Surgical Treatment of Ulcers

Anatomy

Introduction  Number of admissions for uncomplicated disease is falling  Incidence of complications related to NSAID use is increasing  Incidence has declined by 50% in last 25 years  Surgical intervention is rare now for elective treatment

Medical Treatment  Biaxin 500 BID and Amoxacillin 1g BID plus Prilosec BID all for 2 weeks.  Flagyl 250 QID and Tetracyclin 500 QID and Prilosec BID all for 2 weeks.  80% heal over 6 weeks.  80% recur after 1 year if H.Pylori not treated at same time.

Bleeding Ulcer

Laser Coagulation of Bleeding Ulcer

Coil Embolization of Bleeding Ulcer

Pyloroplasty for Bleeding Ulcer

Indications For Surgery  Bleeding  Perforation  Obstruction  Intractability  Surgical treatment is aimed at reduction of acid production one way or another  Cure with lowest risk of complications

History of Peptic Ulcer Surgery  Harberer first gastric resection for ulcer  Billroth Billroth II gastrectomy  Hofmeister Retrocolic anastamosis  Dragstedt Truncal vagotomy  Visick vagotomy and drainage  Johnson highly selective vagotomy

Open Surgical Procedures  Truncal vagotomy and pyloroplasty  Truncal vagotomy and gastrojejunostomy  Truncal vagotomy and antrectomy  Highly selective vagotomy

Billroth I Gastrectomy  Originally described for resection of distal gastric ulcers.  Still used in gastric cancers if radical gastrectomy is inappropriate.  Later applied in treatment of benign ulcers.  Useful for ulcers high on lesser curve, or bleeding ulcer that needs resection.

Antrectomy and Truncal Vagotomy with BI

Billroth II Gastrectomy  Initially described for duodenal ulcers.  Some form of vagotomy is treatment of choice for uncomplicated DU.  Ulcer heals after surgery.  Useful in recurrent ulcers following previous vagotomy.  Antecolic vs retrocolic.

Antecolic and Retrocolic BII

Truncal Vagotomy  Resect 1-2cm of each vagal trunk on distal esophagus.  Reduces acid by 80%.  Denervates parietal cells, antral pump, pyloric sphincter mechanism.  Delays gastric emptying, so need drainage.  With pyloroplasty recurrence 3-10%  With pyloroplasty morbidity 1-2%

Pyloroplasty for Bleeding Ulcer

Pyloroplasty and Oversew of Ulcer

Truncal Vagotomy and Antrectomy  Entails distal gastrectomy of 50-60% of stomach.  Removes parietal cell mass.  Requires a BI or BII reconstruction.  Recurrence rate 0.6-4%  Morbidity rate %

Selective Vagotomy  Total denervation of the stomach from diaphragmatic crus to pylorus.  Procedure still needs drainage, but advantage is other organs are spared, liver, gallbladder, small bowel, colon.

Highly Selective Vagotomy  Spares nerves of Latarjet, but divides vagal branches to proximal 2/3 of stomach.  Antral innervation is thus preserved, gastric emptying preserved, so drainage procedure unnecessary.  Recurrence rate 10-15%  Lowest morbidity of all

Types of Vagotomies

Post Gastrectomy Complications  Gastric atony 50%  Alkaline gastritis  Recurrent ulcers 2%  Diarrhea 16%  Dumping 14%  Bilious vomit 10%  Anemia 12%  B12 deficiency 14%  Folate deficiency 32%

Roux -en -Y Reconstruction

Post Vagotomy Complications  Diarrhea 2%  Dumping 2%  Bilious vomiting <2%

Penetrating Gastric Ulcer