Complications of Peptic Ulcer Disease: Surgical Management

John D. Mellinger MD, FACSAssociate Professor of SurgeryResidency Program Director

Chief, Gastrointestinal SurgeryMedical College of Georgia

Complications of PUD

• Bleeding

• Gastric outlet obstruction

• Perforation

Hospitalization per 100,000 for duodenal ulcer disease

010

2030

4050

6070

8090

100

1970 1975 1980 1985

UncomplicatedHemorrhagePerforation

Hospitalizations per 100,000 for gastric ulcer disease

0

5

10

15

20

25

30

35

40

1970 1975 1980 1985

UncomplicatedHemorrhagePerforation

Influence of NSAIDS

More recent demographics

• 222 ulcer operations 1981-1998 (UCLA)– No change in mortality (13%)– Decrease in annual number of operations (24 to

11.3)

– Increased percentage of patients needing urgent surgery

– No change in percentage of patients explored for uncontrolled hemorrhage despite endoscopy

Towfigh et al, American Surgeon, 2002

Poland, 1977-81 vs. 1992-96

• Decreased surgery overall (360 vs. 246)

• Increased operative patient age and percentage of women in later period

• Decreased number of patients with obstruction

• No change in number of patients needing surgery for bleeding or perforation

Janik, et al, Medical Science Monitor, 2000

UT San Antonio 1980-1999

• 80 % decrease in number of ulcer operations performed– 70/year early 1980’s, 14/year late 1990’s

• Decreased need for surgery most pronounced for intractability (95%), but also diminished for complicated peptic disease (86% hemorrhage and 36% perforation)

Schwesinger et al, J Gastrointest Surg, 2001

Bleeding

• When should operation be performed?

• What operation should be done?

Clinical predictors of continued/recurrent bleeding

• Shock (SBP < 100 mmHg)

• Anemia (hemoglobin <7, <10)

• High transfusion requirement (2000 cc/24, 5 units total)

• Age > 60 (comorbidities)

• Bleeding rate of > 600cc/hour as measured hematemesis

Forrest Classification of Bleeding Activity (Endoscopy, 1989)

Type of bleeding Forrest Type Description

Active bleeding Ia Spurting bleed

Ib Oozing bleed

Recent bleeding IIa Nonbleeding visible vessel

IIb Adherent clot

No bleeding III Clean, no stigmata

Endoscopic predictors of rebleeding

Finding(freq%) Rebleeding Surgery

Clean, dark spot, clot(60)

10% 5%

Nonbleeding visible vessel(20)

50% 40%

Active bleeding(15)

80% 70%

Shock, inaccessible(5)

100%

100%

Kovacs, Jensen 1987 Ann Rev Med

Relative value of predictors of rebleeding

• Endoscopic stigmata more predictive than shock (Hsu, Gut, 1994)

• Stigmata>shock>hematemesis>age (Jaramillo, Am J Gastroenterol 1994)

Risk factors effect on mortality

Other illness

Ulcer >1cm

Tx > 5 units

# survive/ mortalities

Predicted mortality

- - - 181/0 0.1% - + - 28/0 2.4% + + - 13/0 3.5% - + + 6/0 5.5% + - + 15/2 17.9% + + + 5/6 46.7%

Branicki, Ann Surg, 1990

Summary of rebleeding risk data

• Clinical and endoscopic features can predict rebleeding and mortality

• Early operation an appropriate consideration, ideally after stabilization, if rebleeding risk is high

• Availability of endoscopic hemostatic techniques can greatly diminish need for urgent surgery in many, but not all cases

Value of endoscopic rx and re-rx• 80-100% initial hemostasis rates• 75% success with endoscopic retreatment

– Slight increased risk of perforation with thermal re-rx

• Randomized trial for rebleeding shows decrease in overall complications and need for surgery with endoscopic re-rx, with no increase in mortality– Hypotension at randomization and ulcer size>2

cm predictive of higher failure with endo re-rxLau et al, NEJM, 1999

Does Endoscopic Rx Affect Outcome?

• Metanalysis all randomized controlled trials– 62% reduction rebleeding– 64% reduction need for operative intervention

– 45% reduction mortality

– Cook et al., Gastroenterology 1992;102:139

Choice of operation--gastric ulcers

• Generally higher rebleeding rate with gastric lesions (30% with simple oversew), also increased risk of neoplasia (10%) compared to duodenal

• Location and setting influence choice of operation

Gastric ulcer typology (Modified Johnson Classification)

• Type I: incisura, lesser curve

• Type II: associated duodenal ulcer disease

• Type III: antral/prepyloric

• Type IV: high lesser curve/gastroesophageal junction

• Type V: associated with NSAID use

Choice of operation--type I, II, III

• Distal gastrectomy incorporating ulcer and Billroth I reconstruction– no vagotomy necessary in pure type I setting– add vagotomy if type II, ongoing ulcerogenic

stimulus (alcohol, steroids, NSAID’s), type III within 3 cm of pylorus

– Consider vagotomy and pyloroplasty with bx and oversew or wedge excision if unacceptable risk for gastrectomy, accept 15% higher risk of rebleeding

Billroth I (gastroduodenostomy)

Billroth II (gastrojejunostomy)

Choice of operation--type IV• Pauchet procedure (distal gastectomy with

lesser curve tongue-extension to incorporate higher ulcer and Billroth I reconstruction)

• Csendes operation (gastrectomy incorporating portion of GE junction on lesser curve side and esophagogastrojejunostomy)

• Kelling-Madlener procedure (antrectomy with oversew/bx of ulcer left in situ)

Csendes operation

What about parietal cell vagotomy?

• Acceptably documented in elective setting for gastric ulcers (with ulcer excision)

• Caveats in bleeding setting:– experience/time issue in emergent setting

– risk of damage to nerves of Laterjet with oversew/biopsy of lesser curve ulcer

– higher recurrence rates with type III, can decrease with addition of pyloroplasty

A few thoughts on reconstruction...

• Billroth I most “anatomic”– No afferent loop or retained antrum issues

• Billroth II if inadequate length, duodenal status marginal

• Roux en Y if reflux a major concern; risk of Roux stasis/emptying difficulty must be considered--best if very small gastric remnant

Operation for bleeding duodenal ulcer

• Support for PCV with oversewing of ulcer bed in this setting, particularly in stable, younger, healthier patient population– Miedema, Jordan (both 1991): one death in 79

patients, 1.3% rebleeding risk (combined series)

• Caveat that relatively few patients in era of endoscopic hemostasis come to surgery with above credentials

Operation for bleeding duodenal ulcer

• Truncal vagotomy and pyloroplasty with oversew most attested and efficient operation in less stable patient

• Antrectomy a useful alternative in stable patient with large ulcers (>2 cm)– Increased bleeding and rebleeding with giant

ulcers– Nissen closure technique can be a helpful

adjunct with large posterior ulcers into pancreas or adjacent structures

Nissen closure of duodenal stump

Conservative vs. conventional surgery

• Prospective, randomized multicenter trial

• Simple oversew and ranitidine vs. TV&P or T&A– Similar mortalities (13-16%)

– High rebleeding (11%) in simple oversew group with attendant high mortality (86%)--trial stopped

Poxon et al., Br J Surg 1991

Technique of oversew

• Four deep circular suture technique may miss vessel entering posteriorly

• Superior, inferior, posterior mattress technique

Superior ligature

Inferior ligatureMattress ligature,incorporating vesselentering posteriorly

Ulcer bed

Vessel in ulcer bed

Oversew technique

What about H. pylori?• Clear data available showing lower

rebleeding rates with H. pylori eradication– Rokkas, Gastrointest Endosc 1995;41:1-4– Jaspersen, Gastrointest Endosc 1995;41:5-7

Counterargument

• Conversely, only 10% of HP+ patients develop PUD, of those only 20% bleed, and only 10% of those come to surgery for bleeding (0.2% of total infected population)--may be other factors which need to be considered before accepting minimal surgical approaches

Is bleeding different?

• Decreased rapid urease sensitivity with bleeding– False negative CLO 18% with bleeding, only 1% w/o

• Lee et al, Am J Gastroenterol 2000; 95:1166-1170

• Surgical bleeding patients HP + only 40-55% of time in most studies

• U. Tennessee study: emergency surgery for bleeding 1993-1998– H. pylori positive (specimen histology) 68% duodenal

and 19% gastric (<usual ulcer pop.)– No correlation NSAID use with H. pylori status– No patient rebled (33 V&A, 6 V&oversew)

Callicutt et al, J Gastrointest Surg, 2001

Gastric outlet obstruction

• Acute vs. chronic, natural history

• Nonsurgical options

• Surgical options

Natural history--peptic gastric outlet obstruction

• 68% of acute obstructions and 98% chronic obstructions ultimately require surgery

Weiland, 1982

? Nonoperative strategies for peptic GOO

• Balloon dilation– ASGE survey: 76% immediate improvement,

but only 38% objective improvement at 3 mos.– Kozarek: 70% asymptomatic over mean follow

up of 2.5 years, however 52% had active/acute component when dilated and included patients with anastomotic and NSAID-induced GOO as well as peptic (Gastrointest Endosc, 1990)

– Technique: 15mm balloon, 2 one-minute inflations

GOO--? Just do the antibiotics

• 22 consecutive patients with benign peptic stenosis (16 duodenal, 6 pyloric)

• Eradicative triple therapy followed by 8 weeks PPI

• 20/22 fully resolved clinically and endoscopically within 2 months

• No recurrence at mean follow up of 12 months

Brandimarte et al, Eur J Gastroenterol Hepatol, 1999

GOO--surgical options

• Issues– Parietal cell vs. truncal vagotomy– Dilation vs. drainage

– Type of drainage procedure • pyloroplasty/duodenoplasty (Heineke-Mikulicz,

Finney)• gastroduodenostomy (Jaboulay)• gastrojejunostomy

• antrectomy/anastomosis

Pyloroplasties

GOO--vagotomy• Multiple studies attest PCV minimizes

recurrence when accompanied by drainage procedure (decreased gastrin), with less delayed emptying/postgastrectomy sequelae than seen with TV– Recurrence 0-5%, 95+% of patients Visick I or

II--Bowden, Donahue– Delayed emptying 0 (PCV) vs. 33% (TV)--

Gleysteen

Dilation vs. drainage

• Operative dilation (digitally or with Hegar dilator) has 7% recurrent stenosis rate with relatively short follow up, even when combined with parietal cell vagotomy

• Drainage procedures therefore more appropriate

Mentes, Ann Surg, 1990

GOO--type of drainage procedure

• Duodenal status limits procedures which directly approach site of obstruction

• Extended pyloroplasties and Jaboulay make reoperation more challenging, if required

• Antrectomy irreversible, contributes to higher incidence postgastrectomy sequelae

• Overall, gastrojejunostomy appears to be best choice for GOO due to duodenal ulcer

Csendes, Am J Surg 1993

Gastrojejunostomy--where and how?

• Near greater curve, retrocolic, with distal aspect approximately 3 cm proximal to pylorus– Posterior and near antroduodenal pump for

emptying, short and undistorted afferent limb

“Expert” opinion

Peptic perforation

• Nonoperative treatment

• Operative treatment– risk status

– definitive surgery vs. simple closure– ? laparoscopy

• What about H. pylori?

Nonoperative treatment• Water soluble contrast study documenting

sealed perforation

• Age<70

• NG tube, antibiotics, acid suppression, IVF

• Improving exam and clinical signs within 12 hours

• 70% success rate in avoiding surgery, 35% longer hospital stay

Crofts, NEJM 1989; Berne, Arch Surg 1989

Operative treatment--risk assessment

• Multiple studies show mortality a function of risk status, independent of operation performed– Age>70, perforation>24 hours, SBP<100,

poorly controlled comorbid conditions define high risk patient

Hamby, Am Surg 1993

Graham patch

Benefits of definitive operation• High risk of recurrent ulcer disease (48-

60%) if simple closure done, though this can be lowered by longterm acid suppression

• PCV lowers above to 3-7%, can be combined with patch closure

• Not advised in setting of shock, significant comorbidity, gross peritonitis

Griffin, Ann Surg 1976Jordan, Thornby Ann Surg 1995Feliciano Surg Clin N Am 1992

Parietal Cell Vagotomy

What about laparoscopy?

• Small series published detailing feasibility and efficacy of laparoscopic (and combined endoscopic/laparoscopic) patch procedures in selected patients

• Laparoscopic vagotomies also described and reported in small series (Taylor, truncal, true PCV)

• Remember for gastric lesions, excision or biopsy as a minimum advised

…and H. pylori?

• 83 patients with perforated DU– 47% H. pylori + (similar to non-ulcer controls)– No differences in age, smoking, EtOH, prior hx

DU, and NSAID use

– Concluded that unlike chronic uncomplicated DU, perforation has no correlation with H. pylori positive status

Reinbach, Gut 1993

An opposing view...

• 47 consecutive perforated ulcer patients– 73% H. pylori +– 38% closed laparoscopically, all treated with

simple closure• Morbidity and mortality significantly higher in

laparoscopic group

– Eradicative rx successful in 96% (triple rx)– No recurrence or delayed mortality at median

of 43.5 month follow upMetzger et al, Swiss Medical Weekly, 2001

Randomized trial, Ng et al, Ann Surg 2000; 231:153-158

• 104 patients with perforated DU and HP + on biopsy at time of simple patch closure

• Randomized to either eradicative therapy or 4 weeks omeprazole

0%10%20%30%40%50%60%70%80%90%

HP - at8

weeks

Recurat 1year

HP rxOmeprazole

Is H. pylori a risk factor after definitive ulcer surgery in general?

• 93 patients with dyspepsia after prior ulcer surgery (78% partial gastrectomy, 22% vagotomy and drainage)– Prevalence of H. pylori not statistically

different in patients with or without ulcer recurrence

Lee et al, Am J Gastroenterol, 1998

Concluding comments

• Know your patient (risk status, chronicity, compliance)

• Know your self (training, competence)

• Know your setting (resources, support, endoscopy, blood bank, monitoring capability)

Questions?