Jeffrey M. Marks

Introduction

Surgery for bleeding duodenal ulcers is required less often now as a result of advances in endoscopic and interventional radiology techniques and acid suppression agents. When these measures fail to control a bleeding ulcer, however, surgical exposure of the intraluminal posterior wall of the duodenum is required to provide hemostasis.

Principles of Treatment

Patients with upper gastrointestinal bleeding (UGIB) may have either hematemesis or melena/hematochezia, depending on the volume and briskness of the bleeding. Multiple sources for UGIB are well described, including esophageal or gastric varices, gastritis or gastric ulcers, and duodenal ulcers. Comorbid diseases such as portal hypertension, renal failure, and chronic pancreatitis, as well as chronic nonsteroidal antiinflammatory drug (NSAID) use, may help to predict the etiology.

Patients who are seen with symptoms of UGIB initially require full clinical assessment and hemodynamic stabilization. Depending on the amount of blood loss, this may include multiple blood transfusions, medical support of blood pressure, and endotracheal intubation. In patients seen with blood per rectum, placement of a nasogastric tube and aspiration of gastric contents may help confirm an upper GI source for bleeding if clear, nonbloody bile is seen. A nonbloody and nonbilious aspirate does not exclude a postpyloric source of bleeding.

Duodenal ulcers that result in bleeding are usually positioned in the posterior duodenal bulb (Fig. 9-1, A). There are numerous submucosal arterial vessels around the duodenum, but invasion of the gastroduodenal artery is the predominant source for massive duodenal ulcer bleeding (Fig. 9-1, B).

After stabilization of the patient, the first diagnostic (and often therapeutic) intervention is upper endoscopy (Fig. 9-1, C). Multiple endoscopic adjuncts for providing hemostasis are available, including clips, cautery, and injection of sclerotherapy agents. If these endoscopic approaches are unsuccessful and the patient continues to have evidence of bleeding from an identified duodenal ulcer, radiologic interventions are typically used. The gastroduodenal artery is accessed with transarterial catheters through the celiac trunk, and the site of bleeding is then identified and treated with a combination of intraluminal coils, foams, and autologous clots. Vasoactive medications can also be delivered by a subselective catheter left in place with its tip into the gastroduodenal artery to assist in hemostasis.

Surgical Approach

The surgical approach to the duodenum is usually performed using an open upper midline or right subcostal abdominal incision. Laparoscopic approaches have also been described. Although the majority of the duodenum is in the retroperitoneum, the duodenal bulb and first portion of the duodenum are intraperitoneal structures. Incising the lateral attachments to the second and third portions of the duodenum allows elevation of the duodenum and pancreas to provide improved exposure of the duodenal bulb region. Mobilization of the hepatic flexure of the colon is sometimes necessary to access the retroperitoneal areas of the duodenum.

Incision of the lateral attachments of the second portion of the duodenum, called a Kocher maneuver, allows better control as well as laxity of tissues at the level of the pylorus. Structures adjacent to the duodenum include the inferior vena cava, common bile duct, pancreas, gastroduodenal artery, and portal vein. The pancreas sits adjacent to the “C loop” of the duodenum, and the other structures are posterior to the duodenum.

Bleeding duodenal ulcers are often located in the posterior pyloric bulb and penetrate into the gastroduodenal artery, which lies just posterior to the duodenum (see Fig. 9-2, A). Access to these ulcers is best achieved using a longitudinal incision across the pylorus, including several centimeters of both the stomach and the duodenum. This procedure is termed a pyloromyotomy (Fig. 9-2, B). Once the duodenum has been entered at this site, control of the bleeding posterior ulcer is achieved by placement of sutures in the four quadrants around the ulcer. It must be remembered that the common bile duct is just lateral and posterior to this site, so sutures should not be placed too deep (Fig. 9-3).

After suture control of a bleeding duodenal ulcer through a pyloromyotomy, the gastroduodenotomy or pyloromyotomy must be closed. To avoid narrowing of this site, as well as to provide adequate drainage if a truncal vagotomy is also performed, the longitudinal incision is closed in a transverse orientation. This repair is called a Heineke-Mikulicz pyloroplasty (Fig. 9-4).

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