Chapter 8. Emergency Operations for Peptic Ulcer Disease

General

• Duodenal or gastric ulcer.
• Bleeding.
• Perforation.

Vagotomy for Bleeding Duodenal Ulcer

• With current antacid therapies, indications have become more selective.
  • Chronic ulcers that are Helicobacter pylori—negative and have failed medical therapies.
  • NSAID dependence or noncompliance.
  • Previous H pylori treatment failure.
  • Previous ulcer complication.

Absolute

• Inability to tolerate general anesthesia.
• Uncorrectable coagulopathy.

Relative

• Factors that may influence the aggressiveness of the surgical procedure:
  • Age.
  • Preexisting comorbidities.
  • Shock.
  • Delay in diagnosis.
  • Large ulcer size.
  • Noncompliance with medical therapy or risk factor modification.
  • Previous H pylori treatment failure.
  • Failed vagotomy and drainage procedure.

Expected Benefits

• Control of bleeding and repair of perforation may be accomplished by various surgical options; however, with current antacid medication and triple-therapy treatment of H pylori, the surgical options are routinely less radical.
• Historically ulcer recurrence is < 2% for vagotomy and antrectomy, and 10% for vagotomy and pyloroplasty.
• Triple therapy eradicates H pylori in 90% of patients completing therapy.

Potential Risks

• Recurrent ulceration.
• Pancreatitis.
• Leak.
• Wound infection, intra-abdominal abscess.
• Delayed gastric emptying.
• Dumping syndrome.

• General instrumentation set.
• Laparoscopic instrument set including 10-mm 30-degree laparoscope; 5-mm, 10-mm, and 15-mm ports; 5-mm needle holder; 5-mm atraumatic grasper; and clip applier.
• Gastrointestinal anastomosis (GIA) stapler.

• Fluid and electrolyte resuscitation.
• Nasogastric suction or Ewald gastric lavage tube as necessary.
• Systemic antibiotics.
• For bleeding ulcers, surgery is generally preceded by previous attempts at endoscopic therapies.
  • Performance of initial endoscopy within 24 hours of bleeding has been associated with improved outcome.
  • Risk of rebleeding after endoscopic therapy is 10–30%.
  • Endoscopic retreatment has a success rate of 50–70%.
  • Failure of endoscopic therapy has been associated with advanced age, large ulcer, active hemorrhage, and hypotension.
• For perforated ulcers, diagnosis is made by history, physical examination, and radiographic imaging demonstrating free air or fluid. Risk factors associated with operative mortality include medical comorbidities, preoperative shock, and long-standing perforation (> 48 hours).

• After induction of general anesthesia and endotracheal intubation, the patient is placed supine.

Perforated Duodenal Ulcer

Open Graham Patch

• Figure 8–1: The right upper quadrant may be accessed through an upper midline incision.
  • The lesser curvature of the stomach is followed to the pylorus. The perforation is usually along the anterior wall of the duodenum. If this is not the site, the remaining anterior stomach, intra-abdominal esophagus, and lesser sac are explored.
  • Three or four nonabsorbable sutures are placed through the edge of the defect, approximately 0.5–1.0 cm from the edge of the perforation. The suture line should start and stop 0.5 cm from the apices of the perforation.
  • The stitch is brought through the wall on one side and the needle tip should ...