peptic ulcer disease, complications of peptic ulcer, surgical treatment of peptic ulcer

1. Surgical treatments for peptic
ulcer disease
DR BASHIR YUNUS
GENERAL SURGERY UNIT
AKTH

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

3. 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.

4. RELEVANT ANATOMY

6. RELEVANT PHYSIOLOGY
• There 3 glandular zones
Cardiac > mucus cells and few
parietal cells
Oxyntic(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 cells
Phases :
• Cephalic - vagus
• Gastric - food
• Intestinal -chyme

7. 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

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

9. 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

10. vagotomy

11. • 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)

12. 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

13. 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%

14. 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%

15. 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

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

17. Billroth II
Partial gastro-jejunostomy end-to-side with blind
closure of duodenum
Done for a proximal gastric ulcer

18. 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

19. 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

20. Under-running an ulcer
• For bleeding gastric and
duodenal ulcers.

21. 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

22. 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%

23. 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

24. 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.
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