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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.
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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.
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.
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.
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%
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
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%
Post Vagotomy Complications • Diarrhea 2% • Dumping 2% • Bilious vomiting <2%