Complications of Peptic Ulcer

Disease: Surgical Management

John D. Mellinger MD, FACS

Associate Professor of Surgery
Residency Program Director
Chief, Gastrointestinal Surgery
Medical College of Georgia
 Complications of PUD
Bleeding

Gastric outlet obstruction

Perforation
Hospitalization per 100,000 for
duodenal ulcer disease
100
90
80
70
60
Uncomplicated
50
Hemorrhage
40
Perforation
30
20
10
0
1970 1975 1980 1985
Hospitalizations per 100,000 for
gastric ulcer disease
40
35 Influence of
30
NSAIDS
25
Uncomplicated
20
Hemorrhage
15 Perforation
10
5
0
1970 1975 1980 1985
 More recent demographics
222 ulcer operations 1981-1998 (UCLA)
No change in mortality (13%)
Decrease in annual number of operations (24 to
11.3)
Increased percentage of patients needing urgent
surgery
No change in percentage of patients explored
for uncontrolled hemorrhage despite endoscopy
Towfigh et al, American Surgeon, 2002
 Poland, 1977-81 vs. 1992-96
Decreased surgery overall (360 vs. 246)
Increased operative patient age and
percentage of women in later period
Decreased number of patients with
obstruction
No change in number of patients needing
surgery for bleeding or perforation
Janik, et al, Medical Science Monitor, 2000
 UT San Antonio 1980-1999
80 % decrease in number of ulcer
operations performed
70/year early 1980s, 14/year late 1990s
Decreased need for surgery most
pronounced for intractability (95%), but
also diminished for complicated peptic
disease (86% hemorrhage and 36%
perforation)
Schwesinger et al, J Gastrointest Surg, 2001
 Bleeding

When should operation be performed?

What operation should be done?

 Clinical predictors of
continued/recurrent bleeding
Shock (SBP < 100 mmHg)
Anemia (hemoglobin <7, <10)
High transfusion requirement (2000 cc/24, 5
units total)
Age > 60 (comorbidities)
Bleeding rate of > 600cc/hour as measured
hematemesis
Forrest Classification of Bleeding
Activity (Endoscopy, 1989)
Type of bleeding Forrest Type Description

Active bleeding Ia Spurting bleed

Ib Oozing bleed

Recent bleeding IIa Nonbleeding

visible vessel
IIb Adherent clot

No bleeding III Clean, no stigmata

Endoscopic predictors of
rebleeding
Finding(freq%) Rebleeding Surgery

Clean, dark spot, 10% 5%

clot(60)

Nonbleeding 50% 40%

visible vessel(20)

Active 80% 70%

bleeding(15)

Shock, 100% 100%

inaccessible(5)
Kovacs, Jensen 1987 Ann Rev Med
 Relative value of predictors of
rebleeding

Endoscopic stigmata more predictive than

shock (Hsu, Gut, 1994)

Stigmata>shock>hematemesis>age
(Jaramillo, Am J Gastroenterol 1994)
 Risk factors effect on mortality
Other Ulcer Tx > 5 # survive/ Predicted
illness >1cm units mortalities mortality
- - - 181/0 0.1%
- + - 28/0 2.4%
+ + - 13/0 3.5%
- + + 6/0 5.5%
+ - + 15/2 17.9%
+ + + 5/6 46.7%
Branicki, Ann Surg, 1990
Summary of rebleeding risk data
Clinical and endoscopic features can predict
rebleeding and mortality
Early operation an appropriate
consideration, ideally after stabilization, if
rebleeding risk is high
Availability of endoscopic hemostatic
techniques can greatly diminish need for
urgent surgery in many, but not all cases
Value of endoscopic rx and re-rx
80-100% initial hemostasis rates
75% success with endoscopic retreatment
Slight increased risk of perforation with
thermal re-rx
Randomized trial for rebleeding shows decrease in
overall complications and need for surgery with
endoscopic re-rx, with no increase in mortality
Hypotension at randomization and ulcer size>2
cm predictive of higher failure with endo re-rx
Lau et al, NEJM, 1999
 Does Endoscopic Rx Affect
Outcome?
Metanalysis all randomized controlled trials
62% reduction rebleeding
64% reduction need for operative intervention
45% reduction mortality

Cook et al., Gastroenterology 1992;102:139

 Choice of operation--gastric
ulcers
Generally higher rebleeding rate with
gastric lesions (30% with simple oversew),
also increased risk of neoplasia (10%)
compared to duodenal
Location and setting influence choice of
operation
 Gastric ulcer typology
(Modified Johnson Classification)

Type I: incisura, lesser curve

Type II: associated duodenal ulcer disease
Type III: antral/prepyloric
Type IV: high lesser
curve/gastroesophageal junction
Type V: associated with NSAID use
Choice of operation--type I, II, III
Distal gastrectomy incorporating ulcer and
Billroth I reconstruction
no vagotomy necessary in pure type I setting
add vagotomy if type II, ongoing ulcerogenic
stimulus (alcohol, steroids, NSAIDs), type III
within 3 cm of pylorus
Consider vagotomy and pyloroplasty with bx
and oversew or wedge excision if unacceptable
risk for gastrectomy, accept 15% higher risk of
rebleeding
Billroth I (gastroduodenostomy)
Billroth II (gastrojejunostomy)
 Choice of operation--type IV
Pauchet procedure (distal gastectomy with
lesser curve tongue-extension to incorporate
higher ulcer and Billroth I reconstruction)
Csendes operation (gastrectomy
incorporating portion of GE junction on
lesser curve side and
esophagogastrojejunostomy)
Kelling-Madlener procedure (antrectomy
with oversew/bx of ulcer left in situ)
Csendes operation
 What about parietal cell
vagotomy?
Acceptably documented in elective setting
for gastric ulcers (with ulcer excision)
Caveats in bleeding setting:
experience/time issue in emergent setting
risk of damage to nerves of Laterjet with
oversew/biopsy of lesser curve ulcer
higher recurrence rates with type III, can
decrease with addition of pyloroplasty
 A few thoughts on
reconstruction...
Billroth I most anatomic
No afferent loop or retained antrum issues
Billroth II if inadequate length, duodenal
status marginal
Roux en Y if reflux a major concern; risk of
Roux stasis/emptying difficulty must be
considered--best if very small gastric
remnant
Operation for bleeding duodenal
ulcer
Support for PCV with oversewing of ulcer
bed in this setting, particularly in stable,
younger, healthier patient population
Miedema, Jordan (both 1991): one death in 79
patients, 1.3% rebleeding risk (combined
series)
Caveat that relatively few patients in era of
endoscopic hemostasis come to surgery
with above credentials
Operation for bleeding duodenal
ulcer
Truncal vagotomy and pyloroplasty with
oversew most attested and efficient
operation in less stable patient
Antrectomy a useful alternative in stable
patient with large ulcers (>2 cm)
Increased bleeding and rebleeding with giant
ulcers
Nissen closure technique can be a helpful
adjunct with large posterior ulcers into pancreas
or adjacent structures
Nissen closure of duodenal stump
 Conservative vs. conventional
surgery
Prospective, randomized multicenter trial
Simple oversew and ranitidine vs. TV&P or
T&A
Similar mortalities (13-16%)
High rebleeding (11%) in simple oversew
group with attendant high mortality (86%)--trial
stopped

Poxon et al., Br J Surg 1991

 Technique of oversew
Four deep circular suture technique may
miss vessel entering posteriorly
Superior, inferior, posterior mattress
technique
Superior ligature
Mattress ligature, Inferior ligature
incorporating vessel
entering posteriorly
Ulcer bed
Vessel in ulcer bed
Oversew technique
 What about H. pylori?
Clear data available showing lower
rebleeding rates with H. pylori eradication
Rokkas, Gastrointest Endosc 1995;41:1-4
Jaspersen, Gastrointest Endosc 1995;41:5-7
 Counterargument
Conversely, only 10% of HP+ patients
develop PUD, of those only 20% bleed, and
only 10% of those come to surgery for
bleeding (0.2% of total infected
population)--may be other factors which
need to be considered before accepting
minimal surgical approaches
 Is bleeding different?
Decreased rapid urease sensitivity with bleeding
False negative CLO 18% with bleeding, only 1% w/o
Lee et al, Am J Gastroenterol 2000; 95:1166-1170
Surgical bleeding patients HP + only 40-55% of
time in most studies
U. Tennessee study: emergency surgery for
bleeding 1993-1998
H. pylori positive (specimen histology) 68% duodenal
and 19% gastric (<usual ulcer pop.)
No correlation NSAID use with H. pylori status
No patient rebled (33 V&A, 6 V&oversew)
Callicutt et al, J Gastrointest Surg, 2001
 Gastric outlet obstruction
Acute vs. chronic, natural history

Nonsurgical options

Surgical options
 Natural history--peptic gastric
outlet obstruction

68% of acute obstructions and 98% chronic

obstructions ultimately require surgery

Weiland, 1982
 ? Nonoperative strategies for
peptic GOO
Balloon dilation
ASGE survey: 76% immediate improvement,
but only 38% objective improvement at 3 mos.
Kozarek: 70% asymptomatic over mean follow
up of 2.5 years, however 52% had active/acute
component when dilated and included patients
with anastomotic and NSAID-induced GOO as
well as peptic (Gastrointest Endosc, 1990)
Technique: 15mm balloon, 2 one-minute
inflations
 GOO--? Just do the antibiotics
22 consecutive patients with benign peptic
stenosis (16 duodenal, 6 pyloric)
Eradicative triple therapy followed by 8
weeks PPI
20/22 fully resolved clinically and
endoscopically within 2 months
No recurrence at mean follow up of 12
months
Brandimarte et al, Eur J Gastroenterol Hepatol, 1999
 GOO--surgical options
Issues
Parietal cell vs. truncal vagotomy
Dilation vs. drainage
Type of drainage procedure
pyloroplasty/duodenoplasty (Heineke-Mikulicz,
Finney)
gastroduodenostomy (Jaboulay)
gastrojejunostomy
antrectomy/anastomosis
Pyloroplasties
 GOO--vagotomy
Multiple studies attest PCV minimizes
recurrence when accompanied by drainage
procedure (decreased gastrin), with less
delayed emptying/postgastrectomy sequelae
than seen with TV
Recurrence 0-5%, 95+% of patients Visick I or
II--Bowden, Donahue
Delayed emptying 0 (PCV) vs. 33% (TV)--
Gleysteen
 Dilation vs. drainage
Operative dilation (digitally or with Hegar
dilator) has 7% recurrent stenosis rate with
relatively short follow up, even when
combined with parietal cell vagotomy
Drainage procedures therefore more
appropriate

Mentes, Ann Surg, 1990

GOO--type of drainage procedure
Duodenal status limits procedures which
directly approach site of obstruction
Extended pyloroplasties and Jaboulay make
reoperation more challenging, if required
Antrectomy irreversible, contributes to
higher incidence postgastrectomy sequelae
Overall, gastrojejunostomy appears to be
best choice for GOO due to duodenal ulcer
Csendes, Am J Surg 1993
 Gastrojejunostomy--where and
how?
Near greater curve, retrocolic, with distal
aspect approximately 3 cm proximal to
pylorus
Posterior and near antroduodenal pump for
emptying, short and undistorted afferent limb

Expert opinion
 Peptic perforation

Nonoperative treatment
Operative treatment
risk status
definitive surgery vs. simple closure
? laparoscopy
What about H. pylori?
 Nonoperative treatment
Water soluble contrast study documenting
sealed perforation
Age<70
NG tube, antibiotics, acid suppression, IVF
Improving exam and clinical signs within
12 hours
70% success rate in avoiding surgery, 35%
longer hospital stay
Crofts, NEJM 1989; Berne, Arch Surg 1989
 Operative treatment--risk
assessment
Multiple studies show mortality a function
of risk status, independent of operation
performed
Age>70, perforation>24 hours, SBP<100,
poorly controlled comorbid conditions define
high risk patient

Hamby, Am Surg 1993

Graham patch
 Benefits of definitive operation
High risk of recurrent ulcer disease (48-
60%) if simple closure done, though this
can be lowered by longterm acid
suppression
PCV lowers above to 3-7%, can be
combined with patch closure
Not advised in setting of shock, significant
comorbidity, gross peritonitis
Griffin, Ann Surg 1976
Jordan, Thornby Ann Surg 1995
Feliciano Surg Clin N Am 1992
Parietal Cell Vagotomy
 What about laparoscopy?
Small series published detailing feasibility
and efficacy of laparoscopic (and combined
endoscopic/laparoscopic) patch procedures
in selected patients
Laparoscopic vagotomies also described
and reported in small series (Taylor, truncal,
true PCV)
Remember for gastric lesions, excision or
biopsy as a minimum advised
 and H. pylori?
83 patients with perforated DU
47% H. pylori + (similar to non-ulcer controls)
No differences in age, smoking, EtOH, prior hx
DU, and NSAID use
Concluded that unlike chronic uncomplicated
DU, perforation has no correlation with H.
pylori positive status

Reinbach, Gut 1993

 An opposing view...
47 consecutive perforated ulcer patients
73% H. pylori +
38% closed laparoscopically, all treated with
simple closure
Morbidity and mortality significantly higher in
laparoscopic group
Eradicative rx successful in 96% (triple rx)
No recurrence or delayed mortality at median
of 43.5 month follow up
Metzger et al, Swiss Medical Weekly, 2001
Randomized trial, Ng et al, Ann Surg
2000; 231:153-158
104 patients with 90%
perforated DU and HP 80%
70%
+ on biopsy at time of 60%
50%
simple patch closure 40%
30%
HP rx
Omeprazole
Randomized to either 20%
10%
eradicative therapy or 0%
HP - at Recur
4 weeks omeprazole 8
weeks
at 1
year
 Is H. pylori a risk factor after
definitive ulcer surgery in general?
93 patients with dyspepsia after prior ulcer
surgery (78% partial gastrectomy, 22%
vagotomy and drainage)
Prevalence of H. pylori not statistically
different in patients with or without ulcer
recurrence

Lee et al, Am J Gastroenterol, 1998

 Concluding comments
Know your patient (risk status, chronicity,
compliance)
Know your self (training, competence)
Know your setting (resources, support,
endoscopy, blood bank, monitoring
capability)
Questions?