Robert C. Wright, MD, PS
Informed Consent – Anti-Ulcer Surgery
We have determined that you have a problem with peptic ulcers requiring surgical correction. This condition
is generally treated initially with aggressive medical therapy. Surgery is offered for persistent pain or ulcers
following prolonged medical management, or for emergencies resulting from peptic ulcer disease, including
perforation, bleeding from the ulcer, or obstruction of the stomach from the ulcer. Cancer will occasionally
occur in an ulcer.
Description of the Procedure
The type of procedure performed depends partly on the reason for surgery, and partly on the location and size
of the ulcer. The three most common procedures are as follows:
1. Highly selective vagotomy – just the nerves to the stomach are cut, sparing the nerves to the rest of the
abdomen and to the pylorus. This operation has the lowest complication rate but the highest recurrence rate.
2. Vagotomy/pyloroplasty – the vagus nerves are cut, and the pylorus is sewn to permit the stomach to
empty easily. This operation is usually done for bleeding ulcers, and the ulcer will be oversewn to stop the
bleeding.
3. Vagotomy/antrectomy – the vagus nerves in the abdomen are cut, and the antrum (last part of the
stomach) is removed. The stomach will either be reconnected to the duodenum or jejunum. This operation
has the lowest recurrence rate for ulcers, but the highest complication rate.
Additional Procedures that may be done while in Surgery
1. Splenectomy – the spleen can sometimes get injured in this operation requiring its removal.
2. Cholecystectomy – we will frequently remove the gall bladder if there are stones in the gall bladder. This
is to avoid possible problems following surgery.
3. Biopsy/resection of ulcer – if a cancer is suspected, the ulcer will be either biopsied or removed. This may
result in removal of a potion of the stomach or duodenum.
Alternatives for Treatment
Alternative treatments will depend on the nature and severity of the disease undergoing treatment.
Conservative treatment, consisting of dietary restrictions, anti-ulcer medications, etc. will almost always be
advised before surgery is performed. Surgery is offered after the failure of optimal medical management or
for medical emergencies.
Risks/Complications of Treatment
In any medical treatment, it is impossible to predict all the things that could go wrong. Fortunately,
complications are the exception rather than the rule. Every reasonable effort is made to avoid complications.
The most common possible complications are as follows:
Possible complications following any operation
1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion during or after this operation is uncommon.
2. Infection – we take special care to prevent an infection, but it is always a possibility. An infection
may require prolonged hospitalization and treatment or re-operation to resolve.
3. Reactions to medications – this could be many things from a minor rash to possible death
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia,
sore throat, or potential death, in rare cases.
5. Poor wound healing – breakdown of the incision.
(see other side)
Possible complications following anti-ulcer surgery
1. Persistent pain – Pain may persist after surgery even if ulcers heal.
2. Eating problems/early satiety – this could lead to nausea, vomiting, and inability to eat following
surgery. This may require medications, or another surgery to correct.
3. Weight loss – need for vitamins or a special diet will depend on the individual and the type of
surgery performed.
4. Gastric dumping – this is a condition that results in cramping and diarrhea soon after you eat. This
will usually resolve with time but may require diet modification, medications or surgery to correct.
5. Anastomosis leak – this will require another operation to revise the previous surgery.
6. Recurrence of the ulcer – the surgical treatment may occasionally fail to control the ulcer. This may
require a more extensive operation to correct. It may also require the continued use of medications.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Hospitalization typically extends from four to seven
days. Restrictions on lifting and strenuous physical activity may extend for six weeks. Most people can
return to work for “light duty” in two to three weeks. Dietary restrictions will entail small frequent meals for
several months.
Consent for Treatment
I understand my option for an anti-ulcer operation. I have read and understand the above
explanation of the procedure being proposed. My surgeon has answered my questions, and I choose to
proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act
on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding
that complications may arise from that action.
I understand that while most people receiving an anti-ulcer operation benefit from the operation, I
may not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or
may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment risks;
nonetheless I understand the need for this surgery and grant permission to the surgeon to proceed on
my behalf.
SIGNATURE _____________________________________________________ DATE _________________
04/04rev