Professional Documents
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20
Surgery for peptic ulcer disease has gone through a period of significant
change over the past 15 years. The declining incidence of the disease, the
introduction of H 2 -receptor antagonists (as well as other effective drugs to
control acid secretion), the development of proximal gastric vagotomy, and
re-evaluation of older procedures have all contributed to the emergence of
a new era in the surgical management of peptic ulcer disease.
The incidence of peptic ulcer disease was on the decline even prior to
the introduction of H 2 -antagonists in 1977, and the decline in the number
of patients hospitalized for uncomplicated peptic ulcer disease has continued
since that time. However, hospitalization rates for hemorrhage and perfo-
ration have remained constant. 33 In some series, hospital admissions for
hemorrhage have even shown an increase. 1 Operations for peptic ulcer
disease have followed these general trends. Emergency procedures for
hemorrhage have increased and account for from 20% to 50% of all surgical
procedures performed for peptic ulcer disease. 22,38, 34 .
ulcer disease have been older and have associated medical problems.
Although the majority of candidates for surgery are men, the proportion of
women requiring such operations has increased. 22 The prevalence of non-
steroidal anti-inflammatory drug usage in the adult population might account
for the increase seen in hospitalizations for bleeding gastric ulcers. 33
The operative mortality following elective surgery is generally from
1% to 2% and depends on the type of procedure as well as the operative
risk of the patient. Emergency operations are associated with an almost 10-
fold increase in operative mortality.22 This underscores the need for earlier
identification of patients who might benefit from elective surgery for peptic
ulcer disease.
The surgical procedure for peptic ulcer disease must be taiiored to the
specific needs of the individual patient. Efficacy of the procedure must be
balanced against the risk to the patient. For optimum results, the surgeon
should be able to select the appropriate procedure from a variety of
available options.
Truncal Vagotomy and Drainage
Vagotomy remains pivotal in the surgical treatment of duodenal ulcer
disease. Vagotomy decreases acid production by diminishing the cholinergic
stimulation of the parietal cells and by decreasing the response of parietal
cells to gastrin. Reports indicate that basal acid production is reduced by
70% and stimulated acid production is reduced by 50% following truncal
vagotomy.40 Due to total denervation of the stomach (along with other intra-
abdominal viscera), truncal vagotomy alone would result in poor gastric
emptying and gastric stasis. Hence, this procedure must be combined with
a drainage procedure, either pyloroplasty (Fig. 1) or gastrojejunostomy.
Truncal vagotomy and drainage are relatively easy to perform and are
associated with low operative mortality and with an ulcer recurrence rate
of from 10% to 15% (Table 1). Mild symptoms of diarrhea and dumping are
fairly common following this procedure, but they can be managed conser-
Hemorrhage
The overall mortality for hemorrhage from peptic ulcer disease remains
around 10% to 20%. Although 75% of patients admitted with massive
hemorrhage from peptic ulcer disease will stop bleeding spontaneously
within 48 hours, some patients with life-threatening hemorrhage will
require emergency surgery. Mortality rates are higher for patients who are
older than 60 years, for patients who require more than five units of blood
transfusion, and for patients who have multiple system failure. 35 Hunt20
reported that shock on admission to the hospital was associated with a
significantly greater incidence of re-bleeding in 70% of cases. Also, patients
with endoscopic stigmata of recent hemorrhage and those with hemoglobin
levels of less than 8 g/dL at admission appear to be more likely to have
further bleeding. 7 A visible vessel on endoscopy has been reported to be
associated with up to a 60% chance of further bleeding. 27 Chronic ulcers
that are bleeding from an artery at the time of endoscopy continue to bleed
or re-bleed in 80% to 100% of patients and represent a very high-risk
group.36 Patients with gastric ulcers have a greater risk of re-bleeding than
patients with duodenal ulcers.5 An aggressive approach in these high-risk
groups is indicated in order to decrease mortality.
The use of endoscopic methods to control hemorrhage may be at-
tempted as the first therapeutic step. These methods include monopolar or
bipolar electrocoagulation, laser photocoagulation, and direct application of
heat with a "heater" probe. The results of these treatment modalities have
been mixed and are clearly operator-dependent. 13, 28, 36, 48 If these methods
are unsuccessful or if brisk bleeding precludes the use of these methods,
emergency operation must be performed immediately because delay in
surgical intervention results in higher patient mortality,43 It should also be
pointed out that on occasion, if bleeding is brisk, it may not be possible to
adequately resuscitate the patient prior to the operation. In such cases, the
patient must be taken to the operating room expeditiously, even if vital
signs continue to remain unstable; otherwise, the condition of the patient
will continue to worsen, resulting in increasing transfusion requirements
and a formidable risk of perioperative mortality.
Once the decision to operate has been made, it is very important to
gain control of the bleeding vessel as quickly as possible. For a bleeding
duodenal ulcer, an anterior duodenotomy is performed with suture ligature
of the vessel at the base of the ulcer. Following this step, the choice of
operation depends on several factors: location of the ulcer; age, stability,
and general medical condition of the patient; and preference of the
individual surgeon. For older patients and for those who are hemodynam-
ically unstable, we prefer a truncal vagotomy-pyloroplasty. This procedure
can be performed expeditiously and has a lower mortality rate than
procedures involVing gastric resection. In younger, lower-risk patients, we
recommend truncal vagotomy-antrectomy, with a Billroth I or 11 reconstruc-
tion. However, a very scarred duodenum might make this procedure
hazardous due to the difficulty in dealing with the duodenal stump. A
1006 AJIT K. SAClIDEYA ET AL.
cases. 9 However, the complication rate for this technique remains quite
high, even in experienced hands.
Perforation
If patients with perforated duodenal ulcer are in shock, they require
aggressive resuscitation followed by prompt celiotomy. Preoperatively,
nasogastric aspiration is instituted and broad-spectrum antibiotics started.
There is still some controversy as to whether these patients should
undergo only closure of the perforation with an omental patch or whether
a definitive ulcer operation should be combined with closure of perforation.
It has been claimed that a prior history of duodenal ulcer disease or findings
of chronic ulcer at the time of the operation might identify suitable patients
who will bencfit from immediate definitive surgery. However, this approach
has been challenged because of the problems associated with obtaining an
accurate history and because of the high ulcer recurrence rates reported in
some series, irrespective of the duration of ulcer symptoms. In a series
reported by Boey and associates, ulcer recurrence rates following simple
closure of perforation were 36.6% after 3 years, compared with a 10.6%
recurrence rate after definitive surgery (proximal gastric vagotomy). Recur-
rence rates between 14% and 80% f()lIowing closure of acute ulcers have
been reported.:] Authors have reported comparable operative mortality in
relatively good-risk patients whether simple closure is performed or a
definitive procedure is added. 6 This makes a strong case for the latter
approach in patients with perforated duodenal ulcer. 14 Despite the recom-
mendations of some authors who suggest just closure of the perforation, 4. 30
we recommend a definitive procedure unless the patient is poor-risk and
has significant peritoneal contamination or unless the peIforation is associ-
ated with an acute ulcer caused by drug ingestion or acute stress.
The choice of the definitive operation also remains somewhat contro-
versial. In patients with duodenal ulcer perforation, good results have been
reported with proximal gastric vagotomy. 3. 21 Alternatively, truncal vagot-
omy-pyloroplasty may be peIformed. We have used truncal vagotomy-
pyloroplasty quite frequently because its technical ease reduces operating
time considerably.
Perioperative mortality in patients with perforated duodenal ulcer has
been found to be related to preoperative shock, severe concurrent medical
illness, and presentation for treatment 24 hours after peIforation. 2 If all
three risk factors were present, Boey and associates 2 reported mortality of
100%. Koness and associates 31 reported that patients with perforated ulcer
who were older than 5,5 years and those with intraoperative hypotension
had a higher mortality.
For perforated gastric ulcers, a distal gastrectomy with Billroth I or 11
anastomosis should be undertaken if the ulcer is in the distal stomach and
the patient is a good risk. .39 Unlike duodenal ulcers, gastric ulcers present
the risk of malignancy. Hence, this procedure has the additional advantage
of enabling excision of the ulcer for pathologic diagnosis. In high-risk
patients, biopsy of the ulcer should be performed and the ulcer closed with
an omental patch. 34 ..51, 53
1008 AJIT K. SACHDEVA ET AL.
Obstruction
Patients with peptic ulcer disease may present with acute gastric outlet
obstruction because of inflammation and edema around a pyloric channel
ulcer. Other patients present with a chronic history of ulcer disease that
has resulted in scarring of the pyloroduodenal region and thus permanent
narrowing. Many patients with permanent narrowing have a long history
of ulcer disease, with periodic exacerbations.
When thc diagnosis of gastric outlet obstruction is made, the patient
should be placed on a regimen of nasogastric decompression, intravenous
fluid and electrolyte replacement, and Hz-receptor antagonists. In patients
with acute obstructions, improvement is generally seen within 72 hours. If
the patient does not improve, operation should be performed. A slightly
longer period of preoperative management may be required if the patient
has been significantly depleted of fluid and electrolytes (resulting in severe
metabolic problems), or if the patient needs parenteral nutritional support.
In younger, better-risk patients, we recommend truncal vagotomy-
antrectomy, with a Billroth 11 reconstruction. This procedure is very
effective and has a low ulcer recurrence rate. In older patients, truncal
vagotomy and a drainage procedure should be considered. Delayed gastric
emptying following operative procedures has been reported by some
authors, but has not been found to be a significant problem by others. 11
Adequate preoperative nasogastric decompression helps to diminish gastric
atony and facilitates postoperative gastric emptying.
Several recent reports note good results with proximal gastric vagotomy
and drainage. b . .37 Also, proximal gastric vagotomy with dilatation has been
performed in patients with gastric outlet obstruction. 26 However, the long-
term results of dilatation are still questionable. Kozarepz reported imme-
diate symptomatic relief in 67% of patients following endoscopic dilatation.
However, objective improvement (radiologically or endoscopically) at 3
months was seen in only 38% of patients. Restricturing after dilatation
(surgical or endoscopic) continues to remain a concern.
Intractability
The availability of effective medication has led to high rates of healing
of duodenal ulcers; for example, it is stated that over 80% of patients heal
after 4 weeks of starting medical therapy and over 90% of patients heal
after 8 weeks. 45 However, once treatment is stopped, 50% to 90% of
patients will have a recurrence. 46 Thus, long-term maintenance therapy
with H 2 -receptor antagonists is recommended. Medication does not, how-
ever, cure the underlying ulcer diathesis, and about 10% of patients will
ultimately develop complications (hemorrhage, perforation, or stenosis).46
In some patients, ulcer recurrences are frequent, or ulcers do not respond
to the usual medical management. These patients should be considered
intractable and therefore candidates for elective surgery.40 Persistence with
long-term medical treatment in these cases may result in a high complication
rate. Also, a few patients will continue to be noncompliant with medical
therapy, and they too should be considered candidates for elective surgical
treatment. The cost of long-term maintenance therapy in comparison to the
cost of surgery must be considered during treatment of duodenal ulcer
SURCICAL TI\EAT\IE]\;T OF PEPTIC CLCEI\ DISL\SE 1009
disease. 'Neighing all these f~lctors, if electivc surgery for duodenal ulcer
disease is indicated, we recommcnd proximal gastric vagotomy because of
its very low complication rate coupled with a very low incidence of
undesirable postoperative side effects (such as dumping or diarrheal. If
proximal gastric vagotomy is not advisable for technical reasons, another
procedure may be selected.
Prior to initiation of medical therapy, a gastric ulcer must be evaluated
endoscopically and biopsy perfcmned to assess for possible malignancy.
Once medical treatment is begun, close follow-up is required. If the gastric
ulcer does not heal within 6 to 8 weeks of placing the patient on medical
therapy, we recommend elective surgery. For distal gastric ulcers, a distal
gastrectomy should be performed. . .
Recurrent Ulceration
Recurrent ulceration may occur after a surgical procedure for peptic
ulcer disease. The incidence varies according to the type of procedure
performed and may be a result of technical error during the original
procedure. Examples of technical errors resulting in recurrent ulceration
include incomplete vagotomy, inadequate gastric resection, and retained
gastric antrum in the duodenal stump following a Billroth 11 reconstruction.
If recurrence occurs, other causes such as Zollinger-Ellison syndrome and
hyperparathyroidism must also be considered. The recurrence rate after
operations for benign gastric ulcers has been reported to be between 2%
and 4%Y
Once Zollinger-Ellison syndrome and hyperparathyroidism have been
excluded, the patient may be placed initially on medical treatment. Hoff-
mann reported an 80% rate of healing of recurrent ulcers in patients on
H 2 -receptor antagonist therapy after 4 weeks and a 95% rate of healing
after 12 weeks of therapy. However, 30% to 75% of patients will develop
a new ulcer within 9 months of stopping this treatment. Even on mainte-
nance therapy, up to 50% of patients will develop ulcer recurrence.
Generally, 50% of the patients who develop recurrent ulceration will
require a second operation. 1R
A variety of surgical options must be considered, depending upon the
type of original procedure that was performed, the operative findings at
the time of that first procedure, the pathology reports fi'om the first
procedure, and other diagnostic studies that might provide information on
a possible technical error that may have contributed to the recurrence. If
the initial procedure was vagotomy and drainage or proximal gastric
vagotomy, re-vagotomy and antrectomy should be considered. If the initial
procedure was vagotomy-antrectomy, re-vagotomy or further gastric resec-
tion may have to be performed.1.5 If there is stenosis of the gastroenteric
anastomosis, this should be revised at the time of reoperation. If there is
no reason to go into the abdomen other than to perform re-vagotomy, it is
technically much easier and safer to perform the vagotomy through the
transthoracic route, away from adhesions from previous surgery.49 For
recurrent gastric ulceration, further gastric resection may need to be
performed. The specific operative procedure for recurrent ulceration de-
pends on the requirements of the individual patient.
1010 AJIT K. SACHDEYA ET AL.
SUMMARY
ACKNOWLEDCl\IEKTS
The authors wish to acknowledge the contributions of Juliette K. Smith, who prepared
the illustrations for Figures 1 through 4, and Maureen Benzing, who assisted in preparation
of the manuscript and provided technical editing.
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