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.

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

• 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.

• 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.