Surgical treatment of peptic

ulcer

Hemorrhagic ulcer therapy

Assess

severity

Resuscitate
Stop

the bleeding

Therapeutic endoscopy
Surgery

Hemorrhagic ulcer therapy

Vasopressors
Endoscopy
Surgery

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Second level
Third level
Fourth level
Fifth level

After Yamada T Textbook of gastroenterology

Surgery for peptic ulcer

Absolute

indications

Major hemorrhage
Perforation
Stenosis

Surgical treatment
Relative

indications

Repeated hemorrhage
Penetration
Arterial hypertension in hemorrhagic ulcer
patients
Associated portal hypertension
Postbulbar ulcer
Multiple ulcers
Zollinger-Ellison syndrome
Professional risk patients

After Yamada T Textbook of gastroenterology

Surgery - goals
Excision

of the lesion

Lowering

pH (obtain an hypoacid

stomach)
Redo

tract

the continuity of the digestive

After Yamada T. Textbook of gastroenterology

Vagotomy- types
Vagus nerves anatomy
and vagotomy types
VP posterior vagus, VA
anterior vagus, R. H-B
hepato-biliary r., R. C.
celiac r., N.A.M.C.
Lesser curvature
anterior nerve (Latarjet),
N.P.M.C. great
curvature anterior nerve,
VT troncular
vagotomy, VS selective
vagotomy, VSS parietal
cell vagotomy (limit - 5-7
cm)

Posterior troncular
vagotomy with
anterior
seromiotomy
(Taylor)

Pyloroplasty

Nyhus et al.

Suturing a
perforated
duodenal ulcer

Nyhus et al.

Conservative treatment

Pneumoperitoneum in a 26 year
old male

The niche after conservative

treatment

Laparoscopic suture of perforated

ulcer

Laparoscopic suture of perforated

ulcer

Graham patch

After Yamada T. Textbook of

gastroenterology

Hemostasis in situ

Nyhus et al.

Gastric resection (R),

hemigastrectomy (H) and
antrectomy (A);
a. Gastroduodenoansto
my (Pan-Billroth I),
b. Gastrojejunostomy Billroth II

Billroth II operation and some of its modifications. (From Soybel DI, Zinner MJ: Stomach and duodenum:
Operative procedures. In Zinner MJ, Schwartz SI, Ellis H [eds]: Maingot's Abdominal Operations, vol I, 10th
ed. Stamford, CT, Appleton & Lange, 1997.)

After Yamada T. Textbook of gastroenterology

After Yamada T. Textbook of gastroenterology

After Yamada T. Textbook of gastroenterology

JA Myers, JW Millikan, TJ Saclarides - Common Surgical Diseases, Springer 2008

COMPLICATIONS OF SURGERY FOR

PEPTIC ULCER

Early Complications
7%

incidence of major complications

and a 1.5% mortality rate

Bleeding,

infection, and
thromboembolism are potential
complications after any abdominal
procedure.

Early Complications
Leak
Acute

afferent limb obstruction with

potential duodenal stump leak after
Billroth II reconstructions remains a
feared complication

Dumping syndrome
Rapid

emptying from the stomach

Early
Late
It

consists of a group of
cardiovascular and gastrointestinal
symptoms:
faintness, sweating, tachycardia, bloating,
nausea, and cramping abdominal pain.

Early dumping
Gastric

emptying is normally regulated by

duodenal osmoreceptors, but if the pylorus is
divided or bypassed, hypertonic fluids can be
'dumped' into the upper small intestine. This
leads to an outpouring of fluid into the small
intestine to dilute the bowel contents, thereby
reducing the blood volume.

Whether

or not a particular patient experiences

cardiovascular symptoms may depend on how
sensitive he/she is to slight changes in plasma
volume.

Early dumping
Gastrointestinal

symptoms are due to the

sudden release of gastrointestinal
peptides such as cholecystokinin and
motilin. Symptoms severe enough to
interfere with normal activity 5% per
cent after vagotomy and drainage or
partial gastrectomy, 10% -milder
symptoms.

Symptoms

tend to improve with the time.

Early dumping
Vasomotor and gastrointestinal
symptoms which typically occur 15 to
30 minutes after eating:
dizziness,
flushing,
nausea

Early dumping - treatment

Dietary

- avoiding high-osmotic foods

and separating drinking and eating.

Octreotide

acetate is generally
effective in treating severe dumping
symptoms that have not responded to
appropriate dietary alterations.

Late dumping
Hypoglycaemia

occurring about 2 h after a

meal because of a large initial secretion of
insulin in response to the high sugar load.

Less

common than early dumping.

Same

management like early dumping

However,

the patient can also carry a

glucose sweet, which can be taken as soon
as the symptoms start, to prevent a severe
hypoglycaemia

Dumping syndrome surgical

treatment
If

the patient has a gastroenterostomy

and a patent, intact pylorus, then just
taking down the gastroenterostomy
will probably solve the problem.

Reversed

jejunal segment Roux-en-Y

gastrojejunostomy has been reported
to achieve relief of dumping
symptoms in 65% of the most severe
cases.

After Yamada T. Textbook of gastroenterology

After Yamada T. Textbook of gastroenterology

Postvagotomy diarrhoea
Severe

diarrhoea may affect 10 % of

patients after truncal vagotomy and
drainage, but only 1% after proximal
gastric vagotomy.
Loperamide or
diphenoxylate/atropine are required
for adequate relief.

After Yamada T. Textbook of gastroenterology

Afferent limb syndrome

After

Billroth II gastrojejunostomy

Cause

- the limb of duodenum and jejunum

responsible for proximal intestinal, biliary, and
pancreatic drainage becomes partially or
completely obstructed proximal to the gastric
anastomosis.

Two

forms:

Acute
chronic

Acute afferent limb syndrome

Obstruction

of the afferent limb leads

to accumulation of secretions within
the proximal jejunal lumen. As
lumenal pressure increases, venous
pressures are quickly exceeded,
resulting in ischemia and pressure
necrosis of the intestinal mucosa.

Disruption

result.

of the duodenal stump may

Acute afferent limb syndrome

Is

a surgical emergency.

Mortality

rates associated with acute

afferent limb syndrome approach 50%

Chronic afferent limb syndrome

It

results from intermittent, partial

mechanical obstruction of the afferent
limb.

Symptoms:

postprandial epigastric
discomfort, pain, and fullness and,
later bilious vomiting, usually void of
foodstuff.

Treatment

remedial surgery

Chronic afferent limb syndrome treatment

Conversion

to a Roux-en-Y
gastrojejunostomy

Alternatively,

a Braun
enteroenterostomy between the
afferent and efferent limbs is effective
in decompressing the obstructed
afferent limb.

After Yamada T. Textbook of gastroenterology

Efferent limb syndrome

In

patients treated with Billroth II

gastrectomy, obstruction of the
gastrojejunostomy distal to the
anastomosis is termed the efferent
limb syndrome.

The

causes of obstruction include

postoperative adhesions, internal
herniation, and jejunogastric
intussusception.

Efferent limb syndrome

Colicky

abdominal pain, distension, diffuse

tenderness, and frequent bilious emesis.

The

diagnosis is confirmed by either barium

swallow or computed tomography scan with
oral contrast.

Upper

endoscopy should be performed

when recurrent ulcer, gastric stump
carcinoma, or intussusception are
suspected.

Alkaline reflux gastritis

Nausea,

burning epigastric pain,

bilious vomiting, and weight loss
because of reflux of bile and
pancreatic juice.

Prokinetic

drugs are useful

metoclopramide

Alkaline reflux gastritis

Revisional

surgery

Only in significant reflux disease

Pyloric reconstruction or the closure of a
gastrojejunostomy are the first surgical
measures if there has been no resection.
After a Polya (Billroth II) gastrectomy, a
Roux-en-Y reconstruction or Tanner Roux
procedure

Tanner-Roux procedure

After Yamada T. Textbook of gastroenterology

Delayed gastric emptying

Delayed

gastric emptying of solids can coexist with

rapid emptying of liquids and persists in a few
patients long after the early postoperative period.

After

vagotomy, especially if there has been some

obstruction of the antral outlet.

Patients,

therefore, are advised to keep their meals

as dry as possible and drink between meals, and to
bite their meals up well.

Delayed gastric emptying

Prokinetic

drugs are helpful, for

example metoclopramide or
erythromycin have even been found to
give some benefit on the gastric
remnant when the antrum has been
removed.

Stomal ulcer
Cause:

H. pylori infection
Billroth II gastrojejunostomy
Completeness of previous vagotomy
Unsuspected gastrinoma (rare)

Nutritional problems
Loss

of weight

Iron,

folate and vitamin B12 deficiency

Hypocalcaemia

and malabsorption of fat

and fat-soluble vitamins, especially when
the duodenum is bypassed and the mixing
of food with bile and pancreatic secretion is
poor because of persistent diarrhoea as
steatorrhoea

After Yamada T. Textbook of gastroenterology

Gastric remnant carcinoma

1-4%

incidence

Twenty

years after a gastric resection for benign

disease, a patient has a 3.7-fold increased risk of
developing carcinoma of the gastric remnant

More

than 10-20 years to appear

Possible

causative factors

hypochlorhydria,
alkaline reflux,
diminished gastrin production,
uneradicated H pylori infection
nitrosation

Gastric remnant carcinoma

Patients

undergoing antrectomy with

Billroth II reconstruction appear to
have a two to sixfold increased risk of
developing gastric remnant carcinoma.

Patients

with gastric remnant

carcinomas tend to present late in their
course, with more advanced disease,
and tend to be elderly.

Gastric remnant carcinoma

Gastric

remnant carcinoma usually

requires completion gastrectomy with
Roux-en-Y reconstruction.