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
| Surgical options for peptic ulcer disease |
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| Oversew |
| 3-point ligation of gastroduodenal artery |
| Vagotomy and pyloroplasty |
| Vagotomy and antrectomy |
| Highly selective vagotomy |
Bleeding 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 treated according to the location of ulcers.They 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.
- 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 difficult because of the rich arcade of vessels from the left gastric artery, wedge excision of these ulcers is more difficult and the subsequent closure of the gastric defect result in deformation of the stomach and either luminal obstruction or gastric volvulus of the resulting J-shaped stomach
- 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 the common method of excising the ulcer and restoring GI continuity.
- Proximal gastric ulcer near the gastroesophageal (GE) junction. Csendes procedure, a distal gastrectomy with the tongue-shaped extension of the lesser curve resection margin to include the ulcer and subsequent Roux-Y esophagogastrojenjunostomy is an excellent option.
Bleeding duodenal ulcers
The standard approach to a bleeding duodenal ulcer is to perform an anterior longitudinal duodenotomy Classically a truncal vagotomy is then performed to reduce the risk of recurrent ulceration.
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.