Peptic ulcer surgery

Published on 09/04/2015 by admin

Filed under Surgery

Last modified 09/04/2015

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CHAPTER 7 Peptic ulcer surgery

Step 2. Preoperative considerations

Patient preparation

The advent of proton pump inhibitors (PPIs) has greatly diminished the frequency and volume of peptic ulcer surgery for the practicing general surgeon. Conversely, because of the use and availability of PPIs, only the most severe cases of ulcer disease present for surgical evaluation. A cautious and thorough preoperative workup is paramount.

Patient selection may be the most difficult preoperative activity for the physician. PPI medication noncompliance, chronic NSAID use, smoking, and alcohol use are the most common patient factors that aggravate the disease process. Likewise, these patient factors predict poorer clinical outcomes from surgical intervention. All patients should be counseled appropriately.

The ubiquity of proton pump inhibitors (PPIs) has greatly impacted the frequency and volume of peptic ulcer surgery. Additionally, advancements in therapeutic endoscopic techniques, such as pneumatic balloon dilatation, have reduced the need for the classically described antiulcer surgical procedures. Though the frequency of antiulcer operations has dropped, the severity of ulcer disease that prevails often yields the need for surgical evaluation.

The most common indication for vagotomy and pyloroplasty is gastric outlet obstruction caused by chronic and recurring pyloric channel ulcer disease. Most patients will have had one or multiple therapeutic endoscopic procedures, such as pneumatic balloon dilatation. Reviewing the endoscopic procedure history and photographic documentation will enhance not only correct patient selection but also correct procedural selection.

The most common indication for vagotomy and antrectomy is a chronic nonhealing peptic ulcer. In addition to removing any concerning gastric pathology, antrectomy will also improve acid suppression. Depending on the indication, the antrectomy may improve acid suppression and/or remove concerning gastric pathology. Prior to surgical evaluation, patients may have had months of multidrug antiulcer therapy, repeated H. pylori eradication regimens, and numerous ulcer biopsies to rule out occult malignancy. Reviewing the endoscopic procedure history, biopsy pathology results, and procedural photographic documentation will enhance both patient selection and correct procedural selection.

Step 3. Operative steps

Truncal vagotomy with pyloroplasty