SEMINAR

“CURRENT ROLE OF SURGERY IN

THE MANAGEMENT OF PEPTIC
ULCER DISEASE ”

PRESENTED BY : DR. SURAJ JAIN

MODERATOR : PROF. Dr. DHANANJAY SHARMA

 INTRODUCTION
• INCIDENCE OF PEPTIC ULCER
DISEASE HAS DECREASED

• BETTER UNDERSTANDING OF
ETIOLOGY: H PYLORI AND
NSAIDS

• BETTER CONTROL WITH

MEDICAL TREATMENT
 HISTORY OF PEPTIC
ULCER SURGERY
•   Billroth 1
•   Billroth 2
• Truncal vagotomy with
antrectomy
• Truncal vagotomy with
drainage procedure
• Highly selective vagotomy
CURRENT INDICATIONS
FOR SURGERY
• FAILURE OF MEDICAL
TREATMENT
– REFRACTORY CASE
– RELAPSE
– RECURRENCE
– PATIENTS REQUIRING
CONCOMINANT STEROID OR
NSAID THERAPY
 EMERGENCY
INDICATIONS FOR
SURGERY
• BLEEDING ULCER

• PERFORATED ULCER

• GASTRIC OUTLET
OBSTRUCTION
 BLEEDING PEPTIC
ULCER
• AROUND 70% RESOLVE
SPONTANEOUSLY
• RISK FACTOR FOR REBLEED:
– SHOCK
– COAGULOPATHY
– CO-MORBIDITY
– VISIBLE ACTIVE BLEEDER
 MANAGEMENT
• ENDOSCOPIC THERAPY
• 3 VESSEL LIGATION
 PERFORATION
• INCIDENCE 5-10% OF ALL PATIENTS
WITH DUODENAL ULCER DISEASE
• RISK FACTORS
– PRESENCE OF SEVERE COMORBIDITY
– DURATION OF PERFORATION > 24 HRS
– PRESENCE OF HYPOTENSION
(SYSTOLIC < 100 mmHg) ON
PRESENTATION
 MANAGEMENT
• CONSERVATIVE
MANAGEMENT IN SELECTIVE
CASES
• EXPL. LAP WITH SIMPLE
CLOSURE OF PERFORATION
WITH OMENTAL PATCH
 GIANT PERFORATION
• ARBITARILY DEFINED AS
ULCER > 2.5 CM IN DIAMETER
• USUALLY OCCURS LEFT TO
THE INCISURA
 MANAGEMENT
• CLOSURE BY OMENTAL IMPLANTATION
• CLOSURE BY OMENTAL PATCH
• CLOSURE USING FALCIFORM LIGAMENT
• JEJUNAL SEROSAL PATCH TECHNIQUE
• ROUX-EN-Y DUODENOJEJUNOSTOMY
• PYLOROPLASTY
• OPERATIONS INVOLVING EXCLUSION OR
DIVERTICULIZATION, INCLUDING PARTIAL GASTRECTOMY
OR GASTRIC DISSOCITION
• DUODENOSTOMY
• EXPERIMENTAL TECHNIQUES – USE OF BIO REACTIVE
MATERIAL, OPEN PEDICLE GRAFTS OF ILEUM, TRAMP FLAP,
PTFE PATCH AND PEDICLE GALL BLADDER GRAFT
• RESECTION
 GASTRIC OUTLET
OBSTRUCTION
• INCIDENCE 6-8% OF PATIENTS
WITH DU
• FIBROTIC PYLORIC STENOSIS
CAUSING MECHANICAL
OBSTRUCTION IS STRONGLY
AN INDICATION OF SURGERY
 MANAGEMENT
• VAGOTOMY AND
ANTRECTOMY
• VAGOTOMY AND DRAINAGE
• ENDOSCOPIC BALLON
DILATION
 FACTORS INFLUENCING
CHOICE OF OPERATION
• HISTORY IN DU
– DURATION OF PREVIOUS DISEASE
– DURATION OF PREVIOUS COMPLICATIONS

• PREVIOUS TREATMENT
– ANTACIDS
– ERADICATION OF H. PYLORI
– PREVIOUS OPERATION
• ASPIRIN OR NSAID’s USE
• CONDITION OF PATIENT
– UNDERLYING MEDICAL ILLNESS
– HEMORRHAGIC SHOCK
– DURATION OF PERFORATION MORE THAN 24 HOURS
 CURRENT CHOICE OF
SURGERY
• 1.    Truncal vagotomy with drainage
• 2.    High selective vagotomy
• 3.    Truncal vagotomy and
• antrectomy
• 4.    Laproscopic truncal vagotomy or
• high selective vagotomy
INDICATIONS AND OPERATIVE STRATEGY IN
DUODENAL ULCER:
Indication Preferred operation Alternatives

Bleeding Oversew + TV and Oversew and HSV

pyloroplasty

Perforation Closure and omental Closure and omental

patch + HSV patch + TV

    Laproscopic closure
and omental patch

Obstruction TV and anterectomy TV and anterectomy

with Billroth I with Billroth II

    TV and Finney or
Jaboulay pyloroplasty

    TV and
gastrojejunostomy

Intractability Laproscopic HSV Open HSV

RECURRENT ULCER AND POSTGASTRECTOMY SYNDROMES AFTER
OPERATIONS FOR DUODENAL ULCER:

Operation Incidence of Incidence of Mortalit

recurrence posgastrectomy y rate
(%) syndromes (%) (%)
HSV vagotomy 10 5 0.1

Truncal vagotomy & 7 20-30 <1

drainage

TV and 1 30-50 0-5

anterectomy/ Billroth
I or Billroth II
TV and 5-10 50-60 0-5
anterectomy/ Roux-
en-Y
 SIDE EFFECTS OF OPERATIONS FOR DUODENAL ULCER:

Early postoperative complications Long-term side effects

Afferent loop obstruction Alkaline reflux gastritis

Anastomotic leak Anemia

Duodenal stump leak Dumping syndrome

Efferent loop obstruction Gallstones

Gastric atony Gastric remnant cancer

Gastric outlet obstruction Malnutrition

Hemorrhage Postprandial hypoglycemia

Pancreatitis Postvagotomy diarrhea

  Reflux esophagitis

  Small bowel obstruction