Surgical Treatment of Ulcers

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Surgical Treatment of Ulcers

• Vic V. Vernenkar, D.O.
• Department of Surgery
• St. Barnabas Hospital

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Anatomy
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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

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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.

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Bleeding Ulcer
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Laser Coagulation of Bleeding Ulcer
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Coil Embolization of Bleeding Ulcer
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Pyloroplasty for Bleeding Ulcer
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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

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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

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Open Surgical Procedures

• Truncal vagotomy and pyloroplasty
• Truncal vagotomy and gastrojejunostomy
• Truncal vagotomy and antrectomy
• Highly selective vagotomy

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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.

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Antrectomy and Truncal Vagotomy with BI
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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.

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Antecolic and Retrocolic BII
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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

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Pyloroplasty for Bleeding Ulcer
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Pyloroplasty and Oversew of Ulcer
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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 0.9-1.6

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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.

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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

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Types of Vagotomies
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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

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Roux -en -Y Reconstruction
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Post Vagotomy Complications

• Diarrhea 2
• Dumping 2
• Bilious vomiting lt2

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Penetrating Gastric Ulcer