Heineke-Mikulicz Pyloroplasty and Duodenotomy for Bleeding Ulcer

Published on 16/04/2015 by admin

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Last modified 16/04/2015

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Heineke-Mikulicz Pyloroplasty and Duodenotomy for Bleeding Ulcer

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).

FIGURE 9–1 Duodenal bulb, blood supply, and endoscopic view.

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