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General

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

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Vagotomy for Bleeding Duodenal Ulcer

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  • 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.

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Absolute

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  • Inability to tolerate general anesthesia.
  • Uncorrectable coagulopathy.

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Relative

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  • 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.

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

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  • All patients with complicated duodenal or gastric ulcers should undergo workup for H pylori by serum, fecal testing, urease testing, or biopsy. Those who are positive for H pylori should undergo 14 days of triple therapy. Endoscopy may be performed 4–6 weeks post-procedure to document ulcer response to therapy.
  • All patients with duodenal, type II, or type III gastric ulcers should receive aggressive anti-acid pharmacologic therapies with proton pump inhibitors or H2 blockers.
  • NSAIDs should be avoided when possible. The synthetic prostaglandin analogue misoprostol decreases the incidence of recurrent bleeding when NSAIDs cannot be discontinued.
  • Generally, the nasogastric tube may be left in place until the output is < 1 L/day. Subsequently the diet may be advanced accordingly. Postvagotomy patients are not routinely placed on antidumping diets.
  • If the patient continues to have severe pain, fevers, or persistent gastric ileus, CT scan with oral contrast should be considered to evaluate for leak or undrained abscess. Alternatively, a water-soluble upper gastrointestinal contrast study may be performed to evaluate for an anastomotic leak.

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  • Anastomotic leak.
  • Duodenal leak.
  • Injury to the common bile duct.
  • Bleeding (splenic injury or suture line bleeding).
  • Postsurgical gastroparesis.
  • Gastric outlet obstruction.
  • Small bowel obstruction after Billroth II reconstruction (migration of the jejunal limbs above the transverse mesentery).
  • Dumping syndrome.
  • Afferent loop syndrome, intussusception.
  • Cancer in the gastric remnant.

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