Current surgical treatment of ulcer complications

Hemorrhage

The primary treatment of bleeding ulcers is endoscopic control followed by treatment for H. pylori if present. Even rebleeding is best treated by repeat attempts at endoscopic control (4). Surgery is indicated for significant bleeding (requiring over five units of blood) that cannot be controlled by endoscopy. Most uncontrolled bleeding ulcers are from the gastroduodenal artery in the posterior aspect of the duodenal bulb. Treatment is by duodenotomy, and ligation of the bleeding site (Fig. 6). The integrity of the pylorus should be preserved. Gastric ulcers should be treated with ulcer excision if amenable. Ulcers located in regions difficult to excise (cardia, prepyloric) should be biopsied and oversewn. Occasional large or penetrating ulcers may be best treated with distal gastrec-tomy for technical considerations or to rule out cancer.

Duodenotomy
Fig. 6. Controlling bleeding from gastroduodenal artery. (A) A longitudial duodenotomy is made distal to the pylorus. (B) The gastroduodenal artery in the posterior duodenal bulb ulcer is oversewn. (C) The duodenotomy is closed longitudinally.

Certain patients, such as those with arterial bleeding or a visible vessel on endoscopy, are at high risk for rebleeding. Although considered to be surgical indications in past, this is no longer the case. Improved endoscopic techniques and the difficulty of identifying the bleeding risk of individual patients have eliminated the rationale for operating in these patient groups. In H. pylori positive patients, treatment of the H. pylori is highly effective in preventing rebleeding. In H. pylori negative patients, the rebleeding rate is only 10-20%, which is too low to justify an elective surgery to prevent rebleeding. Should rebleeding occur in H. pylori negative patients, oversewing of the bleeder (Fig. 6) and proximal gastric vagotomy can be justified for duodenal ulcers (Fig. 5). In general, surgery has been relegated to controlling ulcer hemorrhage and not treating the ulcer disease.

Perforation

Patients with ulcer perforation should be assumed to be H. pylori positive unless there is evidence to the contrary. Duodenal ulcers and prepyloric gastric ulcers should be treated with omental patches only (Fig. 7). A laparoscopic approach offers a slight decrease in morbidity if such expertise is available. Some controversy exists regarding the treatment of gastric ulcers, especially in the antrum and body of the stomach. If feasible, wedge resection and closure of the defect is best as it rules out malignancy. Perforation that is not amenable to wedge resection requires a distal gastrectomy with inclusion of the ulcer. Reconstruction with a Billroth I (Fig. 4) is the recommended reconstruction as it will result in fewer postgastrectomy side effects.

Recent Approaches Pylori Treatment

Gastric Outlet Obstruction

Gastric outlet obstruction has nearly disappeared in the western world. Ulcers causing pyloric obstruction should be initially treated with endoscopic dilatation and treatment of H. pylori if present. Multiple endoscopic dilations may be needed. This will eventually be successful more than 50% of the time (5). In the remaining patients, surgery is indicated. Truncal vagotomy with gastroenterostomy or antrectomy are both acceptable procedures. Pyloroplasty should not be done because of the increased risk of suture line leak from the fibrotic pylorus, and because patients do not have as good long term outcome (6). As truncal vagotomy and gastroenterostomy are easily accomplished laparoscopically, this will likely become the procedure of choice.

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