1. Role/ Indications for surgery

2. Indications for surgery in PUD Bleeding Perforation Obstruction Intractability or nonhealing Schwartz’s Principles of Surgery, 9th ed image: www.hopkins-gi.org

3. Highly Selective Vagotomy (HSV) Parietal Cell Vagotomy –Severs vagal nerve suply to the proximal 2/3 of stomach, where parietal cells are located –Preserves vagal innervation to antrum and pylorus, and the remaining abdominal visera –Decreases gastric acid secretion by 75% Schwartz’s Principles of Surgery, 9th ed image: www.hopkins-gi.org

4. Truncal vagotomy and gastrojejunostomy Truncal vagotomy –Denervates antropyloric mechanism –Another procedure is needed to bypass the pylorus Gastrojejunostomy –if with gastric outlet obstruction or a severely depressed proximal duodenum Schwartz’s Principles of Surgery, 9th ed image: www.hopkins-gi.org

5. Truncal vagotomy and Pyroloplasty Heineke-Mikulicz type Pyroloplasty –Widening of the pyloric canal Schwartz’s Principles of Surgery, 9th ed image: www.hopkins-gi.org

6. Vagotomy and antrectomy GI continuity is re-established using –Billroth I gastroduodenostomy or –Billroth II loop gastrojejunostomy Schwartz’s Principles of Surgery, 9th ed image: www.hopkins-gi.org

7. Choice of Operation Depends on: Type of ulcer –duodenal, gastric, recurrent, marginal Indication for operation Condition of the patient Schwartz’s Principles of Surgery, 9 th ed

8. Surgical options in treatment of duodenal and gastric ulcer IndicationDuodenalGastric BleedingOversew Oversew and biopsy Oversew, V+D Ovesew, biopsy, V+D V+A Distal gastrectomy PerforationPatch Biopsy and patch Patch, HSV Wedge excision, V+D Patch, V+D Distal gastrectomy ObstructionHSV + GJ Biopsy; HSV+GJ V+A Distal gastrectomy Intractability/ nonhealing HSV HSV and wedge excision V+D Distal gastrectomy V+A Schwartz’s Principles of Surgery, 9 th ed

9. image: www.hopkins-gi.org