Peptic ulcer surgery
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Peptic ulcer Microchapters |
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Diagnosis |
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Treatment |
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Surgery |
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Case Studies |
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2017 ACG Guidelines for Peptic Ulcer Disease |
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Guidelines for the Indications to Test for, and to Treat, H. pylori Infection |
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Guidlines for factors that predict the successful eradication when treating H. pylori infection |
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Guidelines to document H. pylori antimicrobial resistance in the North America |
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Guidelines for evaluation and testing of H. pylori antibiotic resistance |
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Guidelines for when to test for treatment success after H. pylori eradication therapy |
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Guidelines for penicillin allergy in patients with H. pylori infection |
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Peptic ulcer surgery On the Web |
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American Roentgen Ray Society Images of Peptic ulcer surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ;Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]
Overview
Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation. Most bleeding ulcers require endoscopy urgently to stop bleeding with cauterizations or injection.
Surgery
Indications for surgical treatment of peptic ulcer:
- Bleeding peptic ulcer
- Perforated peptic ulcer
The primary goal of a bleeding peptic ulcer is hemorrhage control.The preferred operative approach to a peptic ulcer depends on the location of the ulcer, and for this , it is important for the surgeon to be present during upper GI endoscopy to have precise information on the location of the ulcer.It is discussed under two subtypes: Bleeding gastric ulcer and duodenal ulcer.
- Bleeding gastric ulcers
Bleeding gastric ulcers are generally best treated by excision of the ulcer and repair of the resulting gastric defect. Excision or biopsy of the ulcer is important, as 4–5% of benign-appearing ulcers are actually malignant ulcers. For ulcers along the greater curvature of the stomach, antrum or body of the stomach wedge excision of the ulcer and closure of the resulting defect can easily be achieved in most cases without causing significant deformation of the stomach. Gastric ulcers along the lesser curvature of the stomach are more problematic. Because of the rich arcade of vessels from the left gastric artery, wedge excision of these ulcers is more difficult than in other locations, and the subsequent closure of the gastric defect is much more likely to result in deformation of the stomach and ether luminal obstruction or gastric volvulus of the resulting J-shaped stomach. For distal gastric ulcers along the lesser curvature in the area of the incisura angularis, a distal gastrectomy with either a Billroth I or Billroth II reconstruction is often the easiest method of excising the ulcer and restoring GI continuity. A special case is the proximal gastric ulcer near the gastroesophageal (GE) junction. Wedge excision of these ulcers will often result in compromise of the GE junction and leak. In most patients, the easiest approach is an anterior gastrotomy with biopsy and oversewing of the ulcer from inside the gastric lumen. With this approach, it is relatively easy to avoid compromising the GE junction. In the event that ulcer excision is necessary, a Csendes procedure, a distal gastrectomy with tongue shaped extension of the lesser curve resection margin to include the ulcer and subsequent Roux-Y esophagogastrojenjunostomy is an excellent option.
The standard approach to a bleeding duodenal ulcer is to perform an anterior longitudinal duodenotomy extending across the pylorus to the distal stomach. The bleeding vessel, often the gastroduodenal artery is ligated in the ulcer crater by placing a figure of eight suture at the top and the bottom of the ulcer crater to control the artery proximally and distally. A third suture is placed as a U-stitch underneath the ulcer to control the transverse pancreatic branches that enter the GDA posteriorly. The transverse duodenal incision is then closed vertically to construct a Heineke-Mikulicz pyloroplasty. Classically a truncal vagotomy is then performed to reduce the risk of recurrent ulceration. The role of the vagotomy in 2011 is unclear. Our modern understanding of the pathogenesis of peptic ulcer suggests that treatment of H. pylori and elimination of NSAID use should result in cure of the underlying risk of ulcer. Further, with the advent of PPI’s it is now possible to medically eliminate gastric acid production without the side effects of vagotomy. Although level one data exists for perforated duodenal ulcer demonstrating that H. pylori treatment eliminates the need for definitive ulcer surgery, there is to date no trial that confirms this finding in the case of bleeding duodenal ulcer26. Despite the lack of level one evidence, surveys of surgeons in the United Kingdom27, and national data from the United States3 suggest that most surgeons no longer perform a vagotomy as a component of operation for bleeding duodenal ulcer.
Although duodenotomy with direct control of the bleeding site with or without vagotomy is the most commonly used approach for a bleeding duodenal ulcer, there is some data to suggest that a more extensive operation may be associated with a lower re-bleeding rate. In 1993 Millat and colleagues published a randomized controlled trial comparing vagotomy and pyloropasty with gastric resection combined with ulcer excision. The found that the re-bleeding rate was higher (17% vs 3%) with vagotomy and pyloroplasty, but the overall mortality was not different28. The major complication rate, mostly duodenal leaks, was significantly higher after gastric resection. An important caveat to this data is that this study was performed prior to widespread use of PPI’s and H pylori treatment, and it is unclear that there is still a place for aggressive surgical treatment of the underlying ulcer disease now that medical therapy has replaced surgical therapy as the mainstay of ulcer treatment. In patients without significant comorbidities, who are not in shock at the time of operation, a more aggressive surgical approach may be warranted in patients with large posterior duodenal ulcers. Given the challenges of dealing with the difficult duodenal stump in a large posterior duodenal ulcer, this approach should only be undertaken by surgeons with significant experience in ulcer surgery.
Despite the best surgical efforts, re-bleeding after vagotomy and pyloroplasty occurs in between 6–17% of cases28, 29. Endoscopic therapy is generally not an option after a recent duodenotomy, leaving two options either reoperation or transcatherter arterial embolization (TAE). Classically reoperation was the procedure of choice for rebleeding after duodenotomy. In the case of reoperation for recurrent bleeding most surgeons have advocated a more extensive operation, usually distal gastrectomy with or without vagotomy and ulcer excision or exclusion. This approach is unfortunately fraught with complications and associated with high operative mortality28, 29. More recently several authors have advocated TAE as a viable alternative to operative treatment for ulcer bleeding refractory to endoscopy. Without a head to head trial, it is unclear whether TAE should replace surgery as a primary approach to bleeding control, but data from two large series suggest that TAE can achieve long-term hemostasis in roughly 75% of patients with recurrent bleeding after duodentomy and ulcer oversewing30, 31. Given the significant risk of complication or mortality in reoperation for recurrent bleeding, TAE, when available should be the first line therapy for recurrent bleeding after duodenotomy and ulcer oversewing.