Surgical Treatment of Ulcers
Anatomy
Introduction
 Number
of admissions for
uncomplicated disease is falling
 Incidence of complications related to
NSAID use is increasing
 Incidence has declined by 50% in last
25 years
 Surgical intervention is rare now for
elective treatment
Medical Treatment
 Biaxin
500 BID and Amoxacillin 1g BID
plus Prilosec BID all for 2 weeks.
 Flagyl 250 QID and Tetracyclin 500 QID
and Prilosec BID all for 2 weeks.
 80% heal over 6 weeks.
 80% recur after 1 year if H.Pylori not
treated at same time.
Bleeding Ulcer
Laser Coagulation of Bleeding
Ulcer
Coil Embolization of Bleeding
Ulcer
Pyloroplasty for Bleeding
Ulcer
Indications For Surgery
 Bleeding
 Perforation
 Obstruction
 Intractability
 Surgical
treatment is aimed at reduction
of acid production one way or another
 Cure with lowest risk of complications
History of Peptic Ulcer
Surgery

Harberer 1882- first gastric resection for ulcer
 Billroth 1885- Billroth II gastrectomy
 Hofmeister 1896- Retrocolic anastamosis
 Dragstedt 1943- Truncal vagotomy
 Visick 1948- vagotomy and drainage
 Johnson 1970- highly selective vagotomy
Open Surgical Procedures
 Truncal
vagotomy and pyloroplasty
 Truncal vagotomy and
gastrojejunostomy
 Truncal vagotomy and antrectomy
 Highly selective vagotomy
Billroth I Gastrectomy
 Originally
described for resection of
distal gastric ulcers.
 Still used in gastric cancers if radical
gastrectomy is inappropriate.
 Later applied in treatment of benign
ulcers.
 Useful for ulcers high on lesser curve,
or bleeding ulcer that needs resection.
Antrectomy and Truncal
Vagotomy with BI
Billroth II Gastrectomy
 Initially
described for duodenal ulcers.
 Some form of vagotomy is treatment of
choice for uncomplicated DU.
 Ulcer heals after surgery.
 Useful in recurrent ulcers following
previous vagotomy.
 Antecolic vs retrocolic.
Antecolic and Retrocolic BII
Truncal Vagotomy

Resect 1-2cm of each vagal trunk on distal
esophagus.
 Reduces acid by 80%.
 Denervates parietal cells, antral pump, pyloric
sphincter mechanism.
 Delays gastric emptying, so need drainage.
 With pyloroplasty recurrence 3-10%
 With pyloroplasty morbidity 1-2%
Pyloroplasty for Bleeding
Ulcer
Pyloroplasty and Oversew of
Ulcer
Truncal Vagotomy and
Antrectomy
 Entails
distal gastrectomy of 50-60% of
stomach.
 Removes parietal cell mass.
 Requires a BI or BII reconstruction.
 Recurrence rate 0.6-4%
 Morbidity rate 0.9-1.6%
Selective Vagotomy
 Total
denervation of the stomach from
diaphragmatic crus to pylorus.
 Procedure still needs drainage, but
advantage is other organs are spared,
liver, gallbladder, small bowel, colon.
Highly Selective Vagotomy
 Spares
nerves of Latarjet, but divides
vagal branches to proximal 2/3 of
stomach.
 Antral innervation is thus preserved,
gastric emptying preserved, so drainage
procedure unnecessary.
 Recurrence rate 10-15%
 Lowest morbidity of all
Types of Vagotomies
Post Gastrectomy
Complications

Gastric atony 50%
 Alkaline gastritis
 Recurrent ulcers 2%
 Diarrhea 16%
 Dumping 14%
 Bilious vomit 10%
 Anemia 12%
 B12 deficiency 14%
 Folate deficiency 32%
Roux -en -Y Reconstruction
Post Vagotomy Complications
 Diarrhea
2%
 Dumping 2%
 Bilious vomiting <2%
Penetrating Gastric Ulcer