Surgical Treatment of Ulcers

Anatomy

IntroductionNumber of admissions for

uncomplicated disease is falling Incidence of complications related to

NSAID use is increasing Incidence has declined by 50% in last

25 yearsSurgical intervention is rare now for

elective treatment

Medical TreatmentBiaxin 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 SurgeryBleedingPerforationObstruction IntractabilitySurgical treatment is aimed at reduction

of acid production one way or anotherCure with lowest risk of complications

History of Peptic Ulcer Surgery Harberer 1882- first gastric resection for ulcer Billroth 1885- Billroth II gastrectomy Hofmeister 1896- Retrocolic anastamosis Dragstedt 1943- Truncal vagotomy Visick 1948- vagotomy and drainage Johnson 1970- highly selective vagotomy

Open Surgical ProceduresTruncal vagotomy and pyloroplastyTruncal vagotomy and

gastrojejunostomyTruncal vagotomy and antrectomyHighly selective vagotomy

Billroth I GastrectomyOriginally 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 AntrectomyEntails distal gastrectomy of 50-60% of

stomach.Removes parietal cell mass.Requires a BI or BII reconstruction.Recurrence rate 0.6-4%Morbidity rate 0.9-1.6%

Selective VagotomyTotal 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 VagotomySpares 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 ComplicationsDiarrhea 2%Dumping 2%Bilious vomiting <2%

Penetrating Gastric Ulcer