SEMINAR

³CURRENT ROLE OF SURGERY IN THE MANAGEMENT OF PEPTIC ULCER DISEASE ´
PRESENTED BY : DR. SURAJ JAIN

MODERATOR :

PROF. Dr. DHANANJAY SHARMA

INTRODUCTION
‡ INCIDENCE OF PEPTIC ULCER DISEASE HAS DECREASED ‡ BETTER UNDERSTANDING OF ETIOLOGY: H PYLORI AND NSAIDS ‡ BETTER CONTROL WITH MEDICAL TREATMENT

HISTORY OF PEPTIC ULCER SURGERY
‡ Billroth 1

‡ Billroth 2 ‡ Truncal vagotomy with antrectomy ‡ Truncal vagotomy with drainage procedure ‡ Highly selective vagotomy

CURRENT INDICATIONS FOR SURGERY
‡ FAILURE OF MEDICAL TREATMENT ± REFRACTORY CASE ± RELAPSE ± RECURRENCE ± PATIENTS REQUIRING CONCOMINANT STEROID OR NSAID THERAPY

EMERGENCY INDICATIONS FOR SURGERY
‡ BLEEDING ULCER ‡ PERFORATED ULCER ‡ GASTRIC OUTLET OBSTRUCTION

BLEEDING PEPTIC ULCER
‡ AROUND 70% RESOLVE SPONTANEOUSLY ‡ RISK FACTOR FOR REBLEED: ± SHOCK ± COAGULOPATHY ± CO-MORBIDITY ± VISIBLE ACTIVE BLEEDER

MANAGEMENT
‡ ENDOSCOPIC THERAPY ‡ 3 VESSEL LIGATION

PERFORATION
‡ INCIDENCE 5-10% OF ALL PATIENTS WITH DUODENAL ULCER DISEASE ‡ RISK FACTORS
± PRESENCE OF SEVERE COMORBIDITY ± DURATION OF PERFORATION > 24 HRS ± PRESENCE OF HYPOTENSION (SYSTOLIC < 100 mmHg) ON PRESENTATION

MANAGEMENT
‡ CONSERVATIVE MANAGEMENT IN SELECTIVE CASES ‡ EXPL. LAP WITH SIMPLE CLOSURE OF PERFORATION WITH OMENTAL PATCH

GIANT PERFORATION
‡ ARBITARILY DEFINED AS ULCER > 2.5 CM IN DIAMETER ‡ USUALLY OCCURS LEFT TO THE INCISURA

MANAGEMENT
‡ ‡ ‡ ‡ ‡ ‡ ‡ CLOSURE BY OMENTAL IMPLANTATION CLOSURE BY OMENTAL PATCH CLOSURE USING FALCIFORM LIGAMENT JEJUNAL SEROSAL PATCH TECHNIQUE ROUX-EN-Y DUODENOJEJUNOSTOMY PYLOROPLASTY OPERATIONS INVOLVING EXCLUSION OR DIVERTICULIZATION, INCLUDING PARTIAL GASTRECTOMY OR GASTRIC DISSOCITION ‡ DUODENOSTOMY ‡ EXPERIMENTAL TECHNIQUES ± USE OF BIO REACTIVE MATERIAL, OPEN PEDICLE GRAFTS OF ILEUM, TRAMP FLAP, PTFE PATCH AND PEDICLE GALL BLADDER GRAFT ‡ RESECTION

GASTRIC OUTLET OBSTRUCTION
‡ INCIDENCE 6-8% OF PATIENTS WITH DU ‡ FIBROTIC PYLORIC STENOSIS CAUSING MECHANICAL OBSTRUCTION IS STRONGLY AN INDICATION OF SURGERY

MANAGEMENT
‡ VAGOTOMY AND ANTRECTOMY ‡ VAGOTOMY AND DRAINAGE ‡ ENDOSCOPIC BALLON DILATION

FACTORS INFLUENCING CHOICE OF OPERATION IN DU ‡ HISTORY
± DURATION OF PREVIOUS DISEASE ± DURATION OF PREVIOUS COMPLICATIONS

‡ PREVIOUS TREATMENT
± ANTACIDS ± ERADICATION OF H. PYLORI ± PREVIOUS OPERATION

‡ ASPIRIN OR NSAID¶s USE ‡ CONDITION OF PATIENT
± UNDERLYING MEDICAL ILLNESS ± HEMORRHAGIC SHOCK ± DURATION OF PERFORATION MORE THAN 24 HOURS

CURRENT CHOICE OF SURGERY
‡ 1. Truncal vagotomy with drainage ‡ 2. High selective vagotomy ‡ 3. Truncal vagotomy and
‡ antrectomy

‡ 4. Laproscopic truncal vagotomy or
‡ high selective vagotomy

INDICATIONS AND OPERATIVE STRATEGY IN DUODENAL ULCER:
Indication Bleeding Preferred operation Oversew + TV and pyloroplasty Closure and omental patch + HSV Alternatives Oversew and HSV

Perforation

Closure and omental patch + TV Laproscopic closure and omental patch

Obstruction

TV and anterectomy with Billroth I

TV and anterectomy with Billroth II TV and Finney or Jaboulay pyloroplasty TV and gastrojejunostomy

Intractability

Laproscopic HSV

Open HSV

RECURRENT ULCER AND POSTGASTRECTOMY SYNDROMES AFTER OPERATIONS FOR DUODENAL ULCER: Operation Incidence of recurrence (%) 10 Incidence posgastrectomy syndromes (%) 5 of Mortalit y rate (%) 0.1

HSV vagotomy

Truncal vagotomy & drainage TV and anterectomy/ Billroth I or Billroth II TV and anterectomy/ Rouxen-Y

7

20-30

<1

1

30-50

0-5

5-10

50-60

0-5

SIDE EFFECTS OF OPERATIONS FOR DUODENAL ULCER:
Early postoperative complications Afferent loop obstruction Anastomotic leak Duodenal stump leak Efferent loop obstruction Gastric atony Gastric outlet obstruction Hemorrhage Pancreatitis Long-term side effects Alkaline reflux gastritis Anemia Dumping syndrome Gallstones Gastric remnant cancer Malnutrition Postprandial hypoglycemia Postvagotomy diarrhea Reflux esophagitis Small bowel obstruction

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