Surgical Treatment Of Benign Gastric Ulcer

With the recognized importance of H. pylori as a cause of gastric ulcer disease, surgical management should be considered only when the ulcer is refractory to nonsurgical therapy or presents with a complication such as perforation, hemorrhage, or obstruction. Gastric ulceration can be considered refractory to nonsurgical treatment if the ulcer fails to heal with optimal medical management, the patient is noncompliant

with or intolerant of the medical management, or early ulcer recurrence supervenes after an initial course of successful treatment. In addition, patients with giant (>3 cm) gastric ulcers should be subjected to elective surgery because of the high complication rate associated with these lesions as well as the high rate of nonhealing with this condition.1 • In the scenario of early recurrence after initial healing, a second course of therapy can be tried, but any patient with a recurrence thereafter should be considered a surgical candidate. In the rare patient in whom an acid-reducing ulcer operation was previously performed for gastric ulceration and a recurrence still occurred, evaluation for the Zollinger-Ellison syndrome should be undertaken. Although

Figure 6-2 Operations for benign gastric ulcer. Options range from simple ulcer excision to more radical approaches for ulcers of the cardia (heavy lines designate resected tissue). Reconstruction after antrectomy is best accomplished with Billroth I method. Roux-en-Y reconstruction is preferable for an anastomosis near the esophagogastric junction. If the ulcer is very high, the anastomosis may have to be brought onto the esophagus to avoid narrowing the lumen. (From Seymour, N.E.: Operations for peptic ulcer and their complications. In Feldman, M., Scharschmidt, B.F., and Sleisenger, M.H. [eds.]: Gastrointestinal and Liver Disease, 6 th ed. Philadelphia, W.B. Saunders, 1998.)

Pauchet Procedure

Ulcer Excision Antrectomy Pauchet Procedure

Gastric Ulcer Elective Surgeries
Figure 6-3 Gastric resecilve procedures. (Modified from Debas, H.T., and Orloff S.L.: Surgery for peptic ulcer disease and postgastrectomy syndromes. In Yamada, / etai feds. ]: Textbook of Gastroenterology, Vol 1, 2nd ed. Philadelphia, J.B. Lippincott, 1995, p. 1524.)
Pauchet Procedure
vagotomy lor duodenal vogue C SENDE S PROCEDURE

9«9tro-j«junoslO<ny • Uttfful in high-lying

Figure 6-4 Proposed pathophysiologic mechanisms responsible for the development of stress ulcer. (From Miller, T.A.: Mechanisms of stress-related mucosal damage. Am. J. Med., 83 (Suppi. 6A):8, 1987. Copyright 1987, with permission from Excerpta Medica Inc.)

Pauchet Gastrectomy

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2. Al-Assi, M.T., and Graham, D.Y.: Peptic ulcer disease, Helicobacter pylori, and the surgeon: Changing of the guard. Curr. Opin. Gen. Surg., 120, 1994.

3. Cowan, W.K.: Genetics of duodenal and gastric ulcer. Clin. Gastroenterol. 2:539, 1973.

4. Csendes, A., Braghetto, I., and Smok, G.: Type IV gastric ulcer: A new hypothesis. Surgery, 101:361, 1987.

5. Dekker, W., and Tytgat, G.N.: Diagnostic accuracy of fiberendoscopy in the detection of upper intestinal malignancy: A follow-up analysis. Gastroenterology, 73:710, 1977.

6. Dewar, E.P., King, R.F.G., and Johnston, D.: Bile acid and lysolecithin concentrations in the stomach of patients by highly selective vagotomy, Billroth I partial gastrectomy and truncal vagotomy and pyloroplasty. Br. J. Surg., 70:401, 1983.

7. Dragstedt, L.R., Oberhelman H.A., Jr., Evans, S.O., et al.: Antrum hyperfunction and gastric ulcer. Ann. Surg. 140:396, 1954.

8. Duthie, H.L., and Kwong, N.K.: Vagotomy or gastrectomy for gastric ulcer. Br. Med. J., 4:79, 1973.

9. Emas, S., Grupcev, G., and Eriksson, B.: Ten-year follow-up of a prospective randomized trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy for treating corporeal gastric ulcer. Am. J. Surg., 167:596, 1994.

10. Fisher, R.S., Cohen, S.: Pyloric sphincter dysfunction in patients with gastric ulcer. N. Engl. J. Med., 288:213, 1973.

11. Go, M.F., and Vakil, N.: Helicobacter pylori infection. Clin. Perspect. Gastroenterol., 2:141, 1999.

12. Graham, D.Y., Schwartz, J.T., Cain, G.D., and Gyorkey, F.: Prospective evaluation of biopsy number in the diagnosis of esophageal and gastric carcinoma. Gastroenterology, 82:228, 1982.

13. Greenall, M.J., and Lehnert, T.: Vagotomy or gastrectomy for elective treatment of benign gastric ulcer. Dig. Dis. Sci., 30:353, 1985.

14. Gustavsson, S. Kelly, K.A., and Hench, V.S.: Giant gastric and duodenal ulcers: A population based study with a comparison to non-giant ulcers. World J. Surg., 11:333, 1987.

15. Hunt, R.H.: Eradication of Helicobacter pylori infection. Am. J. Med., 100:42S, 1996.

Figure 6-4 Proposed pathophysiologic mechanisms responsible for the development of stress ulcer. (From Miller, T.A.: Mechanisms of stress-related mucosal damage. Am. J. Med., 83 (Suppi. 6A):8, 1987. Copyright 1987, with permission from Excerpta Medica Inc.)

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