Surgical treatments for peptic ulcer

diseaseDR BASHIR YUNUS

GENERAL SURGERY UNIT AKTH

OUTLINE • INTRODUCTION• RELEVANT ANATOMY• TYPES OF PUD • INDICATIONS FOR SURGICAL TREATMENT• VARIOUS TREATMENT OPTIONS• COMPLICATIONS OF TREATMENT• PROGNOSIS• CONCLUSION• REFERENCES

INTRODUCTION• Peptic ulcer disease is an ulcer caused by gastric acid or pepsin. These

secretions overwhelms the gastroduodenal mucosa and there is colonization of the pyloric antrum by H. pylori. • The treatment is principally medical. Surgery is indicated when ulcers

are refractory or become complicated.

RELEVANT ANATOMY

RELEVANT PHYSIOLOGY• There 3 glandular zones Cardiac > mucus cells and few

parietal cellsOxyntic(parietal)> (80% at

fundus and body) parietal cells secretes HCL and intrinsic factor the chief cells pepsinogen

Pyloric gland> G-cells secrete gastrin

Stimulant of Gastric secretion:• Acetylcholine (vagus) --> G cells and

parietal cells• Gastrin --> parietal cell and chief cells• Histamine (mast cells) ---> parietal &

chief cellsPhases :• Cephalic - vagus• Gastric - food• Intestinal -chyme

CLASSIFICATION

Site • Common sites are the

duodenum and Gastric(stomach)• Other sites;

lower end of oesophagus, Meckel’s diverticulum with

ectopic gastric tissue, jejunum in gastrojejunostomy.

Modify Johnson’s classification

INDICATIONS FOR SURGERY• Refractory ulcers • Haemorrhage not responding to endoscopic treatment• Gastric outlet obstruction• Perforation • Suspicious of Malignancy

SURGICAL OPTION• VAGOTOMY

• Truncal and drainage • Selective • Highly selective • Posterior vagotomy and anterior seromyotomy

• GASTRECTOMY • Billroth I• Billroth II• Subtotal gastrectomy

• GRAHAM’S OMENTAL PATCH• SUTURE LIGATION OF GASTRODUODENAL ARTERY • UNDRER-RUNNING AN ULCER BASE

• After excision of the edge• Vagotomy

vagotomy

• Division of the vagus nerve remove the cephalic stimulus to oxyntic cells; acid secretion reduce by 60%.• Types; • Truncal vagotomy and drainage • Selective vagotomy • Highly selective vagotomy• Posterior Truncal vagotomy and anterior seromyotomy (Taylor’s)

Truncal vagotomy and drainage • The 2 nerve trunks are divided below the diaphragm near the hiatus.• The gastric tone and mobility are diminished and emptying delayed • A drainage procedure is done to drain the stomach• Drainage;

Pyloroplasty; a longitudinal incision about 6cm long is made across the pylorus at the mid anterior part to involve the adjacent part of the pyloric antrum and duodenum. (Heineke-Mikuliez) other types are Finney’s and Jaboulay

Gastrojejunostomy; the jejunum, about 15cm from the duodeno-jejunal flexure is anastomose usually to the posterior wall of the stomach behind the transverse colon

Selective vagotomy • Vagotomy with sparing the hepatic branch of anterior vagus and the

coeliac branch of the posterior vagus.• A drainage procedure is also performed • Time consuming and it has being abandoned • Recurrence rate is 10%

Highly selective • It aims at denervating only the acid producing oxyntic gland sparing

nerve to the pyloric antrum(nerve of latarjet) such that drainage procedure is not required.• It is difficult to determine the exact area of denervation of oxyntic cell• Recurrence rate is 10%

Taylor’s operation

• Seromyotomy- denervate the fundic parietal mass preserves nerve of Latarget. The seromyotomy is done 6cm proximal to the pylorus and 1.5cm from the lesser curvature

Billroth I

Billroth I – partial gastrectomy gastro-duodenostomy end-to-endDone for gastric ulcer in the antrum

Billroth II

Partial gastro-jejunostomy end-to-side with blind closure of duodenumDone for a proximal gastric ulcer

Graham’s patch• Piece of omentum is used to

cover the perforation.• 3 or 4 interrupted sutures are

inserted through and through along the long axis.• Modified Graham’s patch

SUTURE LIGATION OF GASTRODUODENAL ARTERY

• Pylorodedontomy• Non-absorbable suture must

incorporate the artery proximal and distal to the site of bleeding • And the transverse pancreatic

branch • Usually for massive bleeding

Under-running an ulcer• For bleeding gastric and

duodenal ulcers.

COMPLICATIONS• Immediate

• Bleeding • Gastric retention• Dysphagia • Leakage of duodenal stump• Obstruction of the stoma • Acute pancreatitis

• Late • Dumping syndrome • Diarrhoea• Steatorhoea • Enterogastric reflux • Recurrent ulceration • Iron deficiency anaemia • Risk of colorectal and gastric tumours• Weight loss • Megaloblastic anaemia• Osteomalacia• Anastomotic ulcer• Gastro-jejunocolic fistula

Prognosis • Overall operative procedure gives satisfactory result in at least 80% of

patients• Mortality of vagotomy and drainage is <1%• Partial gastrectomy has overall mortality of 2%, 90% are satisfied with

result, 2% anastomotic ulceration and 5-10% dumping problems.• Operative mortality for perforated DU is 7%

CONCLUSION•Peptic ulcers requiring surgeries are complicated and the patients present as emergency which requires adequate resuscitation.

•Delay in presentation, diagnosis and treatment increases morbidity and mortality

References• E.A Badoe et al, “Principles and Practice of surgery including

pathology in the tropics” 4th edition, Assembly of God Literature Center ltd, 2009• Bailey and Love’s “Short Practice of Surgery” 26th edition CRC press

Taylor and Francis group. 2013• Farquharson’s textbook of operative general surgery 9th edition• SRB’s manual of surgery. 4th edition 2013.• www.slideshare .net