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

IN DU• HISTORY – 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 pyloroplasty

Oversew and HSV

Perforation Closure and omental patch + HSV

Closure and omental patch + TV

    Laproscopic closure and omental patch

Obstruction TV and anterectomy with Billroth I

TV and anterectomy 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 recurrence (%)

Incidence of posgastrectomy syndromes (%)

Mortality rate (%)

HSV vagotomy 10 5 0.1

Truncal vagotomy & drainage

7 20-30 < 1

TV and anterectomy/ Billroth I or Billroth II

1 30-50 0-5

TV and anterectomy/ Roux-en-Y

5-10 50-60 0-5

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