1. Complications of Peptic Ulcer
Disease: Surgical Management
John D. Mellinger MD, FACS
Associate Professor of Surgery
Residency Program Director
Chief, Gastrointestinal Surgery
Medical College of Georgia
4. Hospitalizations per 100,000 for
gastric ulcer disease
0
5
10
15
20
25
30
35
40
1970 1975 1980 1985
Uncomplicated
Hemorrhage
Perforation
Influence of
NSAIDS
5. More recent demographics
• 222 ulcer operations 1981-1998 (UCLA)
– No change in mortality (13%)
– Decrease in annual number of operations (24 to
11.3)
– Increased percentage of patients needing urgent
surgery
– No change in percentage of patients explored
for uncontrolled hemorrhage despite endoscopy
Towfigh et al, American Surgeon, 2002
6. Poland, 1977-81 vs. 1992-96
• Decreased surgery overall (360 vs. 246)
• Increased operative patient age and
percentage of women in later period
• Decreased number of patients with
obstruction
• No change in number of patients needing
surgery for bleeding or perforation
Janik, et al, Medical Science Monitor, 2000
7. UT San Antonio 1980-1999
• 80 % decrease in number of ulcer
operations performed
– 70/year early 1980’s, 14/year late 1990’s
• Decreased need for surgery most
pronounced for intractability (95%), but
also diminished for complicated peptic
disease (86% hemorrhage and 36%
perforation)
Schwesinger et al, J Gastrointest Surg, 2001
9. Clinical predictors of
continued/recurrent bleeding
• Shock (SBP < 100 mmHg)
• Anemia (hemoglobin <7, <10)
• High transfusion requirement (2000 cc/24,
5 units total)
• Age > 60 (comorbidities)
• Bleeding rate of > 600cc/hour as measured
hematemesis
10. Forrest Classification of Bleeding
Activity (Endoscopy, 1989)
Type of bleeding Forrest Type Description
Active bleeding Ia Spurting bleed
Ib Oozing bleed
Recent bleeding IIa Nonbleeding
visible vessel
IIb Adherent clot
No bleeding III Clean, no stigmata
11. Endoscopic predictors of
rebleeding
Finding(freq%) Rebleeding Surgery
Clean, dark spot,
clot(60)
10% 5%
Nonbleeding
visible vessel(20)
50% 40%
Active
bleeding(15)
80% 70%
Shock,
inaccessible(5)
100% 100%
Kovacs, Jensen 1987 Ann Rev Med
12. Relative value of predictors of
rebleeding
• Endoscopic stigmata more predictive than
shock (Hsu, Gut, 1994)
• Stigmata>shock>hematemesis>age
(Jaramillo, Am J Gastroenterol 1994)
14. Summary of rebleeding risk data
• Clinical and endoscopic features can predict
rebleeding and mortality
• Early operation an appropriate
consideration, ideally after stabilization, if
rebleeding risk is high
• Availability of endoscopic hemostatic
techniques can greatly diminish need for
urgent surgery in many, but not all cases
15. Value of endoscopic rx and re-rx
• 80-100% initial hemostasis rates
• 75% success with endoscopic retreatment
– Slight increased risk of perforation with
thermal re-rx
• Randomized trial for rebleeding shows decrease in
overall complications and need for surgery with
endoscopic re-rx, with no increase in mortality
– Hypotension at randomization and ulcer size>2
cm predictive of higher failure with endo re-rx
Lau et al, NEJM, 1999
16. Does Endoscopic Rx Affect
Outcome?
• Metanalysis all randomized controlled trials
– 62% reduction rebleeding
– 64% reduction need for operative intervention
– 45% reduction mortality
– Cook et al., Gastroenterology 1992;102:139
17. Choice of operation--gastric
ulcers
• Generally higher rebleeding rate with
gastric lesions (30% with simple oversew),
also increased risk of neoplasia (10%)
compared to duodenal
• Location and setting influence choice of
operation
18. Gastric ulcer typology
(Modified Johnson Classification)
• Type I: incisura, lesser curve
• Type II: associated duodenal ulcer disease
• Type III: antral/prepyloric
• Type IV: high lesser
curve/gastroesophageal junction
• Type V: associated with NSAID use
19. Choice of operation--type I, II,
III
• Distal gastrectomy incorporating ulcer and
Billroth I reconstruction
– no vagotomy necessary in pure type I setting
– add vagotomy if type II, ongoing ulcerogenic
stimulus (alcohol, steroids, NSAID’s), type III
within 3 cm of pylorus
– Consider vagotomy and pyloroplasty with bx
and oversew or wedge excision if unacceptable
risk for gastrectomy, accept 15% higher risk of
rebleeding
22. Choice of operation--type IV
• Pauchet procedure (distal gastectomy with
lesser curve tongue-extension to incorporate
higher ulcer and Billroth I reconstruction)
• Csendes operation (gastrectomy
incorporating portion of GE junction on
lesser curve side and
esophagogastrojejunostomy)
• Kelling-Madlener procedure (antrectomy
with oversew/bx of ulcer left in situ)
24. What about parietal cell
vagotomy?
• Acceptably documented in elective setting
for gastric ulcers (with ulcer excision)
• Caveats in bleeding setting:
– experience/time issue in emergent setting
– risk of damage to nerves of Laterjet with
oversew/biopsy of lesser curve ulcer
– higher recurrence rates with type III, can
decrease with addition of pyloroplasty
25. A few thoughts on
reconstruction...
• Billroth I most “anatomic”
– No afferent loop or retained antrum issues
• Billroth II if inadequate length, duodenal
status marginal
• Roux en Y if reflux a major concern; risk of
Roux stasis/emptying difficulty must be
considered--best if very small gastric
remnant
26. Operation for bleeding duodenal
ulcer
• Support for PCV with oversewing of ulcer
bed in this setting, particularly in stable,
younger, healthier patient population
– Miedema, Jordan (both 1991): one death in 79
patients, 1.3% rebleeding risk (combined
series)
• Caveat that relatively few patients in era of
endoscopic hemostasis come to surgery
with above credentials
27. Operation for bleeding duodenal
ulcer
• Truncal vagotomy and pyloroplasty with
oversew most attested and efficient
operation in less stable patient
• Antrectomy a useful alternative in stable
patient with large ulcers (>2 cm)
– Increased bleeding and rebleeding with giant
ulcers
– Nissen closure technique can be a helpful
adjunct with large posterior ulcers into pancreas
or adjacent structures
29. Conservative vs. conventional
surgery
• Prospective, randomized multicenter trial
• Simple oversew and ranitidine vs. TV&P or
T&A
– Similar mortalities (13-16%)
– High rebleeding (11%) in simple oversew
group with attendant high mortality (86%)--
trial stopped
Poxon et al., Br J Surg 1991
30. Technique of oversew
• Four deep circular suture technique may
miss vessel entering posteriorly
• Superior, inferior, posterior mattress
technique
Superior ligature
Inferior ligatureMattress ligature,
incorporating vessel
entering posteriorly
Ulcer bed
Vessel in ulcer bed
32. What about H. pylori?
• Clear data available showing lower
rebleeding rates with H. pylori eradication
– Rokkas, Gastrointest Endosc 1995;41:1-4
– Jaspersen, Gastrointest Endosc 1995;41:5-7
33. Counterargument
• Conversely, only 10% of HP+ patients
develop PUD, of those only 20% bleed, and
only 10% of those come to surgery for
bleeding (0.2% of total infected
population)--may be other factors which
need to be considered before accepting
minimal surgical approaches
34. Is bleeding different?
• Decreased rapid urease sensitivity with bleeding
– False negative CLO 18% with bleeding, only 1% w/o
• Lee et al, Am J Gastroenterol 2000; 95:1166-1170
• Surgical bleeding patients HP + only 40-55% of
time in most studies
• U. Tennessee study: emergency surgery for
bleeding 1993-1998
– H. pylori positive (specimen histology) 68% duodenal
and 19% gastric (<usual ulcer pop.)
– No correlation NSAID use with H. pylori status
– No patient rebled (33 V&A, 6 V&oversew)
Callicutt et al, J Gastrointest Surg, 2001
37. ? Nonoperative strategies for
peptic GOO
• Balloon dilation
– ASGE survey: 76% immediate improvement,
but only 38% objective improvement at 3 mos.
– Kozarek: 70% asymptomatic over mean follow
up of 2.5 years, however 52% had active/acute
component when dilated and included patients
with anastomotic and NSAID-induced GOO as
well as peptic (Gastrointest Endosc, 1990)
– Technique: 15mm balloon, 2 one-minute
inflations
38. GOO--? Just do the antibiotics
• 22 consecutive patients with benign peptic
stenosis (16 duodenal, 6 pyloric)
• Eradicative triple therapy followed by 8
weeks PPI
• 20/22 fully resolved clinically and
endoscopically within 2 months
• No recurrence at mean follow up of 12
months
Brandimarte et al, Eur J Gastroenterol Hepatol, 1999
39. GOO--surgical options
• Issues
– Parietal cell vs. truncal vagotomy
– Dilation vs. drainage
– Type of drainage procedure
• pyloroplasty/duodenoplasty (Heineke-Mikulicz,
Finney)
• gastroduodenostomy (Jaboulay)
• gastrojejunostomy
• antrectomy/anastomosis
41. GOO--vagotomy
• Multiple studies attest PCV minimizes
recurrence when accompanied by drainage
procedure (decreased gastrin), with less
delayed emptying/postgastrectomy sequelae
than seen with TV
– Recurrence 0-5%, 95+% of patients Visick I or
II--Bowden, Donahue
– Delayed emptying 0 (PCV) vs. 33% (TV)--
Gleysteen
42. Dilation vs. drainage
• Operative dilation (digitally or with Hegar
dilator) has 7% recurrent stenosis rate with
relatively short follow up, even when
combined with parietal cell vagotomy
• Drainage procedures therefore more
appropriate
Mentes, Ann Surg, 1990
43. GOO--type of drainage
procedure
• Duodenal status limits procedures which
directly approach site of obstruction
• Extended pyloroplasties and Jaboulay make
reoperation more challenging, if required
• Antrectomy irreversible, contributes to
higher incidence postgastrectomy sequelae
• Overall, gastrojejunostomy appears to be
best choice for GOO due to duodenal ulcer
Csendes, Am J Surg 1993
44. Gastrojejunostomy--where and
how?
• Near greater curve, retrocolic, with distal
aspect approximately 3 cm proximal to
pylorus
– Posterior and near antroduodenal pump for
emptying, short and undistorted afferent limb
“Expert” opinion
45. Peptic perforation
• Nonoperative treatment
• Operative treatment
– risk status
– definitive surgery vs. simple closure
– ? laparoscopy
• What about H. pylori?
46. Nonoperative treatment
• Water soluble contrast study documenting
sealed perforation
• Age<70
• NG tube, antibiotics, acid suppression, IVF
• Improving exam and clinical signs within
12 hours
• 70% success rate in avoiding surgery, 35%
longer hospital stay
Crofts, NEJM 1989; Berne, Arch Surg 1989
47. Operative treatment--risk
assessment
• Multiple studies show mortality a function
of risk status, independent of operation
performed
– Age>70, perforation>24 hours, SBP<100,
poorly controlled comorbid conditions define
high risk patient
Hamby, Am Surg 1993
49. Benefits of definitive operation
• High risk of recurrent ulcer disease (48-
60%) if simple closure done, though this
can be lowered by longterm acid
suppression
• PCV lowers above to 3-7%, can be
combined with patch closure
• Not advised in setting of shock, significant
comorbidity, gross peritonitis
Griffin, Ann Surg 1976
Jordan, Thornby Ann Surg 1995
Feliciano Surg Clin N Am 1992
51. What about laparoscopy?
• Small series published detailing feasibility
and efficacy of laparoscopic (and combined
endoscopic/laparoscopic) patch procedures
in selected patients
• Laparoscopic vagotomies also described
and reported in small series (Taylor,
truncal, true PCV)
• Remember for gastric lesions, excision or
biopsy as a minimum advised
52. …and H. pylori?
• 83 patients with perforated DU
– 47% H. pylori + (similar to non-ulcer controls)
– No differences in age, smoking, EtOH, prior hx
DU, and NSAID use
– Concluded that unlike chronic uncomplicated
DU, perforation has no correlation with H.
pylori positive status
Reinbach, Gut 1993
53. An opposing view...
• 47 consecutive perforated ulcer patients
– 73% H. pylori +
– 38% closed laparoscopically, all treated with
simple closure
• Morbidity and mortality significantly higher in
laparoscopic group
– Eradicative rx successful in 96% (triple rx)
– No recurrence or delayed mortality at median
of 43.5 month follow up
Metzger et al, Swiss Medical Weekly, 2001
54. Randomized trial, Ng et al, Ann
Surg 2000; 231:153-158
• 104 patients with
perforated DU and HP
+ on biopsy at time of
simple patch closure
• Randomized to either
eradicative therapy or
4 weeks omeprazole
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
HP - at
8
weeks
Recur
at 1
year
HP rx
Omeprazole
55. Is H. pylori a risk factor after
definitive ulcer surgery in general?
• 93 patients with dyspepsia after prior ulcer
surgery (78% partial gastrectomy, 22%
vagotomy and drainage)
– Prevalence of H. pylori not statistically
different in patients with or without ulcer
recurrence
Lee et al, Am J Gastroenterol, 1998
56. Concluding comments
• Know your patient (risk status, chronicity,
compliance)
• Know your self (training, competence)
• Know your setting (resources, support,
endoscopy, blood bank, monitoring
capability)
