SURGERIES FOR

PEPTIC ULCER
DISEASE
Pravin
Narkhede
Surgery for peptic ulcers is performed less often
since the advent of the H2 antagonists and
proton pump inhibitors (PPIs) and the
treatments to eradicate Helicobacter pylori
there is a high recurrence rate for peptic
ulcerations after discontinuation of medical
therapy
 Indications for surgery
Intractable ulcers
Haemorrhage
Perforation
Obstruction, usually pyloric stenosis
 Goal of surgery
treatment of anatomic
complications, such as pyloric
stenosis or perforation.
patient safety in the acute setting,
combined with freedom from
undesirable chronic side effects
alteration of the ulcer diathesis so
that ulcer healing is achieved and
recurrence is minimized
Subtotal gastrectomy was considered
optimal management for duodenal and
gastric ulcers until Dragstedt's description of
vagotomy and its impact on ulcer healing and
recurrence.
 goal of ulcer surgery is to prevent gastric
acid secretion.
Vagotomy decreases peak acid output by
about 50%,
vagotomy plus antrectomy, which removes
the gastrin-secreting portion of the stomach,
decreases peak acid output by about 85%
 Surgical procedures
The operations that have been used
traditionally are:
Truncal vagotomy and Pyloroplasty
Highly selective vagotomy
Truncal vagotmoy and Antrectomy
Billroth I gastrectomy
Billroth II or Polya gastrectomy
Roux-n Y anastomosis
Truncal Vagotomy
Truncal vagotomy is probably the
most common operation performed
for duodenal ulcer disease
truncal vagotomy is performed by
division of the left and right vagus
nerves above the hepatic and celiac
branches just above the GE junction
some form of drainage procedure in
association with truncal vagotomy
Heineke-Mikulicz pyloroplasty
Longitudinal incision across pylorus
which is then closed transversly
not feasibile if pylorus thickened or
scarred
Finney pyloroplasty or Jaboulay
gastroduodenostomy
When the duodenal bulb is scarred,
Gastro duodenostomy
Can be performed if pylorus thickened
or scarred
From a technical standpoint, truncal
vagotomy and pyloroplasty represent an
uncomplicated procedure that can be
performed quickly, making it especially
attractive for patients who are
hemodynamically unstable from bleeding
ulcers
little difference in the side effects
associated with the type of drainage
procedure performed, although bile reflux
may be more common after
gastroenterostomy, and diarrhea is more
common after pyloroplasty
Highly Selective Vagotomy
also called the parietal cell vagotomy or
the proximal gastric vagotomy
divides only the vagus nerves supplying
the acid-producing portion of the
stomach within the corpus and fundus
preserves the vagal innervation of the
gastric antrum so that there is no need
for routine drainage procedures
incidence of postoperative
complications is less
the nerves of Latarjet are identified anteriorly and
posteriorly, and the crow's feet innervating the fundus
and body of the stomach are divided.
nerves are divided 7 cm proximal to the pylorus or the
area in the vicinity of the gastric antrum.
Superiorly, division of these nerves is carried to a point at
least 5 cm proximal to the gastroesophageal junction on
the esophagus
The criminal nerve of Grassi very proximal branch of the
posterior trunk of the vagus, and great attention needs to
be taken to avoid missing this branch in the division
process because it is frequently cited as a predisposition
for ulcer recurrence if left intact.
recurrence rates vary depend on
skill of surgeon and
duration of follow up
prepyloric ulcers are more likely to be
associated with recurrence than duodenal
ulcers, for unclear reasons
The moderate ulcer recurrence rate with
highly selective vagotomy is considered
acceptable by many surgeons because
recurrences in this scenario are usually
responsive to medical therapy with proton
pump inhibitors
Truncal Vagotomy and Antrectomy
most common indications
gastric ulcer and large benign gastric
tumors
Relative contraindications
cirrhosis,
extensive scarring of the proximal
duodenum that leaves a difficult or
tenuous duodenal closure, and
previous operations on the proximal
duodenum, as
choledochoduodenostomy
Distal gastrectomy or antrectomy
requires reconstruction of GI
continuity that can be
accomplished by either a
Billroth I procedure;
Billroth II procedure using one of
several modifications
Roux-n Y loop anastomosis
 Billroth I gastrectomy
Proffesor Hans Theodore Billroth first resection
for malignancy in 1881
Describes removal of a distal gastric segment,
followed by primary anastomosis with
preservation of duodenal integrity
Advantage
Preservation of physiological and anatomical
integrity
Lower incidence of post gasrectomy syndrome
Minimal disturbance of pancreatic function
Lower incidence of development of carcinoma
in remaining segment of stomach
Disadvantage
Anastomosis at tension site
It is the standard operation for
benign pathology as very limited
lymphadenopathy is achieved
Billroth II or Polya gastrectomy
Polya gastrectomy described in 1911
Involves distal gastric resection with closure of
duodenal stump and restoration of gastric
continuity with gastrojejunostomy
Advantage
Usefull in case where billroth I have excess
tension at anastomotic site
Easy to perform
In carcinoma allows radical margins of
dissection
Disavdvantage
Maximum rate of complication
the loop of jejunum chosen for anastomosis is
usually brought through the transverse
mesocolon in a retrocolic fashion rather than
in front of the transverse colon in an antecolic
fashion
The retrocolic anastomosis minimizes the
length of the afferent limb and decreases the
likelihood of twisting or kinking that could
potentially lead to afferent loop ob-struction
and predispose to the devastating
complication of a duodenal stump leak
Roux-n Y gastrojejunostomy
Distal divided end of jejunum is
anastomised to stomach usingend
to side anastomosis
Proximal end anastomised to 40-50
cm downstream, thus providing an
outflow pathway for billiary contents
Subtotal Gastrectomy
rarely performed today
reserved for patients with underlying
malignancies or patients who have
developed recurrent ulcerations after
truncal vagotomy and antrectomy.
After subtotal gastrectomy,
restoration of GI continuity can be
accomplished with either a Billroth II
anastomosis or via a Roux-en-Y
gastrojejunostomy
Posterior truncal vagotomy with anterior
seromyotomy (Taylor procedure)
Simpler and quicker operation than HSV
Gastric drainage procedure not equired
Posterior truncal vagotomy done and
anterior seromyotomy doneby dividing
seromuscular layers taking care not to
breach mucosa
Follows along leser curvature at distance
of 2 cm from its starting at angle of His
extending to approximately 5 cm from
pylorus
Surgical therapy serves several purposes. It salvages
patients from life-threatening complications associated
with perforation, hemorrhage, and gastric outlet
obstruction
For all patients with ulcers being considered for
elective surgery, antisecretory agents should probably
be discontinued for about 72 hours before operation in
order to allow gastric acidity to return to normal values,
which minimizes bacterial overgrowth and the extent of
contamination
In patients undergoing surgery for PUD, it is
recommended that all have H. pylori testing and, if
positive, treatment and documentation of eradication
In patients undergoing surgery for
PUD, it is recommended that all have
H. pylori testing and, if positive,
treatment and documentation of
eradication
NSAIDs should be discontinued
 Recommendations for
Complications Related to Peptic
Ulcer Disease
 Duodenal Ulcer   
Intractable:- parietal cell vagotomy   
Bleeding:- truncal vagotomy with
pyloroplasty and oversewing of bleeding
vessel   
Perforation:- patch closure with treatment of
H. pylori with or without parietal cell
vagotomy   
Obstruction:- rule out malignancy and
parietal cell vagotomy with
gastrojejunostomy
 Recommendations for
Complications Related to Peptic
Ulcer Disease
 Gastric ulcer
Intractable     
Type I:- distal gastrectomy with Billroth I   
Type II or III:- distal gastrectomy with truncal
vagotomy
Bleeding     
Type I: distal gastrectomy with Billroth I  
Type II or III: distal gastrectomy with truncal
vagotomy
 Perforated      
Type I, stable:- distal gastrectomy with
Billroth I  
Type I, unstable:- biopsy, patch, and
treatment for H. pylori       
Type II or III:- patch closure with treatment
of H. pylori   

 Obstruction:- rule out malignancy and

antrectomy with vagotomy   
 Type IV:- depends on ulcer size,
distance from the
gastroesophageal junction, and
degree of surrounding
inflammation   
 Giant gastric ulcers: distal
gastrectomy, with vagotomy
reserved for type II and III gastric
ulcers
 Recommended Operative Procedures
for Recurrent Postoperative Ulcers
Initial Operation Recommended Operation
Local procedure Truncal vagotomy and
antrectomy
Gastrectomy Truncal vagotomy and resection
of retained antrum if present

Vagotomy and pyloroplasty Re-vagotomy and antrectomy

Vagotomy and antrectomy Re-vagotomy and resection of
retained antrum
Proximal gastric vagotomy Truncal vagotomy and
antrectomy
Subtotal gastrectomy Truncal vagotomy and resection
of retained antrum if present
POST GASTRECTOMY
SYNDROME

POST VAGOTOMY SYNDROME

 Postgastrectomy Syndromes
gastric surgery results in a number of
physiologic derangements due
to loss of reservoir function,
interruption of the pyloric sphincter
mechanism,
the type of gastric reconstruction,
and
vagal nerve transection
When these postgastrectomy
symptoms develop, it has become
more apparent that every attempt
should be made to avoid
reoperation because many of these
patients lack a clearly definable
mechanical or physiologic defect
and many of the problems persist
despite reoperation
 Postgastrectomy Syndromes
Secondary to Gastric Resection
 Dumping Syndrome
symptom complex that occurs
following ingestion of a meal when a
portion of the stomach has been
removed or the normal pyloric
sphincter mechanism has become
disrupted
• Early Dumping
• more common after partial gastrectomy with the
Billroth II reconstruction
• 20 to 30 minutes after ingestion of a meal and is
accompanied by both GI and cardiovascular symptoms
• G I Symptoms :- nausea and vomiting, a sense of
epigastric fullness, eructations, cramping abdominal
pain, and often explosive diarrhea
• cardiovascular symptoms :- palpitations, tachycardia,
diaphoresis, fainting, dizziness, flushing, and
occasionally blurred vision
• occurs because hypertonic food delivered to
small intestines
• The resultant hypertonic food bolus passes into
the small intestine, which induces a rapid shift
of extracellular fluid into the intestinal lumen to
achieve isotonicity.
• After this shift of extracellular fluid, luminal
distention occurs and induces the autonomic
responses
• the release of several humoral agents, such as
serotonin, bradykinin-like substances,
neurotensin, and enteroglucagon
Treatment
Most, however, experience
spontaneous relief and require no
specific therapy
When symptoms are prolonged
dietary measures include
avoiding foods containing large
amounts of sugar,
 frequent feeding of small meals rich
in protein and fat, and
 separating liquids from solids during
a meal
Medical
Somatostatin analogue octreotide
acetate highly effective in
preventing the development of
both vasomotor and GI symptoms,
inhibit the hormonal responses
associated with this syndrome and
completely abolish the associated
diarrhea
Increase intestinal transit time
Costly
Surgery
< 1% required
Purpose
 to improve the gastric reservoir
function,
 decrease rapid gastric emptying,
or
 ideally accomplish both goals.
use of isoperistaltic or antiperistaltic
jejunal segments
Iso peristalsis
done using a 10- to 20-cm loop of jejunum
and interposing it between the stomach and
small intestine in an isoperistaltic fashion
Anti peristalsis
jejunal segment 10 cm in length is used,
and the jejunum is twisted on its mesentery
so that its distal end is anastomosed to the
stomach and its proximal end to the small
intestine
creation of a long-limb Roux-en-Y
anastomosis to delay gastric emptying.
Late Dumping
less common
2 to 3 hours after a meal
related specifically to carbohydrates
When carbohydrates are delivered to the
small intestine, they are quickly absorbed,
resulting in hyperglycemia, which triggers the
release of large amounts of insulin to control
the rising blood sugar. This results in an actual
overshooting such that a profound
hypoglycemia
This activates the adrenal gland to release
catecholamines, which results in diaphoresis,
tremulousness, light-headedness, tachycardia,
and confusion
Treatment
to ingest frequent small meals and
to reduce their carbohydrate intake
Medical
patients have found benefit with
pectin either alone or in
combination with acarbose
Surgery
Same like early dumping
Metabolic Disturbances
more common and serious after partial
gastrectomy than after vagotomy
Greater in Billroth II as opposed to a
Billroth I
Anaemia
Most common
Iron deficiency :- more common
30% of patients undergoing gastrectomy
suffer from iron deficiency anemia
related to a
combination of decreased iron
intake,
impaired iron absorption, and
chronic subliminal blood loss
secondary to the hyperemic,
 friable gastric mucosa primarily
involving the margins of the stoma
addition of iron supplements to the
patient's diet corrects this metabolic
problem
Megaloblastic anemia
especially when more than 50% of the
stomach is removed
secondary to poor absorption of the
substance owing to lack of intrinsic factor
secretion in the gastric juice
Serum B-12 level obtained, if less treated
with intramuscular injection every 3 to 4
months indefinitely because its
administration orally is not a reliable route
folate deficiency may coexist oral
supplimentation is sufficient
impaired absorption of fat.
steatorrhea :-
result of inadequate mixing of bile salts and
pancreatic lipase with ingested fat because of the
duodenal bypass pancreatic replacement enzymes
are often effective in decreasing fat loss.
osteoporosis and osteomalacia
caused by deficiencies in calcium
occurs about 4 to 5 years after surgery.
Treatment of this disorder usually requires calcium
supplements (1-2 g/day) in conjunction with vitamin
D (500-5000 units daily).
Postgastrectomy Syndromes Related to Gastric
Reconstruction
More common with Billroth II procedures
Afferent Loop Syndrome
result of partial obstruction of the afferent limb that is
unable then to empty its contents
It can arise secondary to
 kinking and angulation of the afferent limb,
internal herniation behind the efferent limb,
stenosis of the gastrojejunal anastomosis,
a redundant twisting of the afferent limb with a
resultant volvulus, or
adhesions involving the afferent limb
occurs when the afferent limb is greater than 30 to 40
cm in length and has been anastomosed to the gastric
remnant in an antecolic fashion
Chronic presentation common than acute
there is an accumulation of pancreatic and hepatobiliary
secretion within the limb, resulting in its distention which
causes epigastric discomfort and cramping
partial obstruction :-intraluminal pressure increases ,
projectile billous vomiting no food contained within the
vomitus
complete obstruction,
necrosis and perforation of the loop can occur as
the obstruction is a closed loop because the
duodenum proximally has already been closed
constant abdominal pain, more pronounced in
the right upper quadrant with radiation into the
interscapular area.
surgical emergency and requires immediate
attention
In closed loop, bacterial overgrowth occurs in the
static loop, and the bacteria bind with vitamin B12
and deconjugated bile acids
Although symptoms may suggest this
diagnosis, it is sometimes difficult to
establish the diagnosis
plain films of the abdomen dilated
afferent loop may be seen
contrast barium study of the stomach
may delineate the presence of an
obstructed loop
Failure to visualize the afferent limb
on upper endoscopy is also suggestive
of the diagnosis
Radionuclide studies imaging
Treatment
Acute or chronic
A long afferent limb is usually the underlying
problem, and treatment therefore involves
the elimination of this loop
converting the Billroth II construction into a
Billroth I anastomosis
enteroenterostomy below the stoma, which is
technically easier.
Creation of a Roux-en-Y can also be done, but
a concomitant vagotomy should also be
performed to prevent marginal ulceration
from the diversion of duodenal contents from
the gastroenteric stoma.
Efferent Loop Obstruction
rare.
The most common cause of efferent loop
obstruction is herniation of the limb behind the
anastomosis in a right-to-left fashion.
can occur with both antecolic and retrocolic
gastrojejunostomies.
occur anytime after surgery; however, more than
50% of cases do so within the first postoperative
month
complaints may include left upper quadrant
abdominal pain that is colicky in nature, bilious
vomiting, and abdominal distention
Establishing a diagnosis is difficult
contrast barium study of the
stomach with failure of barium to
enter the efferent limb
Surgery
reducing the retroanastomotic
hernia and closing the
retroanastomotic space to prevent
recurrence of this condition.
Alkaline Reflux Gastritis
fairly common
severe epigastric abdominal pain
accompanied by bilious vomiting and
weight loss not relieved by food or
antacids, anaemia weight loss common
diagnosis
careful history,
HIDA scans are usually diagnostic
:-demonstrating biliary secretion into
the stomach and even into the
esophagus in severe cases
Upper endoscopy
performed with multiple biopsy
samples taken away from the
stoma, and the gastric fluid can
be analyzed for bile acid
concentrations
mucosa is frequently friable and
beefy-red, and superficial
mucosal ulcerations may be
apparent on microscopy.
Common with billroth II
there is no clear correlation between
the volume of bile or its composition
and the subsequent development of
alkaline reflux gastritis
Treatment
Medical not satisfactory
Surgery for intractable cases
converting the Billroth II anastomosis
into a Roux-en-Y gastrojejunostomy in
which the Roux limb has been
lengthened to 41 to 46 cm
Retained Antrum Syndrome
Normally, antral mucosa may extend past the pyloric
muscle for a distance of 0.5 cm,
Common with billroth II
retained antrum is continually bathed in alkaline pH
from the duodenal, pancreatic, and biliary secretions
that, in turn, stimulate the release of large amounts of
gastrin with a resultant increase in acid secretion
responsible for about 9% of recurrent ulcers after
previous surgery for PUD and is associated with an
incidence of recurrent ulceration as high as 80%
can be eliminated if biopsy confirmation of duodenal
mucosa is obtained after resection of the proximal
duodenum at the time of the Billroth II gastrectomy.
Diagnosis
technetium scan may prove helpful in diagnosing
retained antrum , demonstrates a hot spot that is
adjacent to the area where normal uptake of
technetium by the gastric mucosa of the remaining
stomach occurs
Medical
H2-receptor blockade or proton pump inhibitors may
prove helpful in controlling acid hypersecretion
Surgery
If medical ineffective
conversion of the Billroth II to a
Billroth I reconstruction or
excision of the retained antral
tissue in the duodenal stump is
indicated
Postvagotomy Syndromes
 Postvagotomy Diarrhea
30% or more of patients suffer
not severe and usually disappears
within the first 3 to 4 months
occur 2 to 3 times weekly or manifest
itself once or twice a month.
explosive diarrhea and result in soiled
clothing
Most patients symptoms resolve over
time
Medical
Cholestyramine
Four grams with meals three times daily followed by
an adjustment to a maintenance dosage should
decrease bowel movements to once or twice a day
improvement within 1 to 4 weeks of initiation
Surgery
Persistent diarrhea for 1 year after surgery
fails to respond to cholestyramine therapy, and
other causes have been ruled out,
operative procedure of choice is to interpose a 10-cm
segment of reverse jejunum 70 to 100 cm from the
ligament of Treitz
 Postvagotomy Gastric Atony
After vagotomy, gastric emptying is delayed
true for both truncal and selective vagotomies but
not in the case of highly selective or parietal cell
vagotomy
With selective or truncal vagotomy, patients lose
antral pump function and therefore have a
reduction in their ability to empty solids
In contrast, emptying of liquids is accelerated
feeling of fullness and occasionally abdominal pain
functional gastric outlet obstruction
Diagnosis
confirmed on scintigraphic
assessment of gastric emptying.
Endoscopic examination of the
stomach also needs to be
performed to rule out any
anastomotic obstructions
Medical
Prokinetic drugs
metoclopramide and erythromycin
 Incomplete Vagal Transection
predisposes the patient to the
possible development of recurrent
ulcer formation
Truncal vagotomy more common
right vagus nerve is frequently buried
in the periesophageal tissue,
potentially leading to incomplete
transection
Histologic confirmation of vagal
transection decreases the incidence of
incomplete vagotomy