This document outlines surgical treatments for peptic ulcer disease. It discusses the relevant anatomy and physiology, classifications of PUD, indications for surgery, and various surgical options like vagotomy, gastrectomy, and ulcer repair. Complications are also reviewed. The prognosis is generally good with over 80% of patients satisfied after surgery, but some risks remain like dumping syndrome or recurrent ulcers.

1. Surgical treatments for peptic
ulcer disease
DR BASHIR YUNUS
GENERAL SURGERY UNIT
AKTH

2. OUTLINE
• INTRODUCTION
• RELEVANT ANATOMY
• TYPES OF PUD
• INDICATIONS FOR SURGICAL TREATMENT
• VARIOUS TREATMENT OPTIONS
• COMPLICATIONS OF TREATMENT
• PROGNOSIS
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• Peptic ulcer disease is an ulcer caused by gastric acid or pepsin. These
secretions overwhelms the gastroduodenal mucosa and there is
colonization of the pyloric antrum by H. pylori.
• The treatment is principally medical. Surgery is indicated when ulcers
are refractory or become complicated.

4. RELEVANT ANATOMY

6. RELEVANT PHYSIOLOGY
• There 3 glandular zones
Cardiac > mucus cells and few
parietal cells
Oxyntic(parietal)> (80% at fundus
and body) parietal cells secretes
HCL and intrinsic factor the chief
cells pepsinogen
Pyloric gland> G-cells secrete
gastrin
Stimulant of Gastric secretion:
• Acetylcholine (vagus) --> G cells
and parietal cells
• Gastrin --> parietal cell and chief
cells
• Histamine (mast cells) ---> parietal
& chief cells
Phases :
• Cephalic - vagus
• Gastric - food
• Intestinal -chyme

7. CLASSIFICATION
Site
• Common sites are the
duodenum and
Gastric(stomach)
• Other sites;
 lower end of oesophagus,
 Meckel’s diverticulum with
ectopic gastric tissue,
 jejunum in gastrojejunostomy.
Modify Johnson’s classification

8. INDICATIONS FOR SURGERY
• Refractory ulcers
• Haemorrhage not responding to endoscopic treatment
• Gastric outlet obstruction
• Perforation
• Suspicious of Malignancy

9. SURGICAL OPTION
• VAGOTOMY
• Truncal and drainage
• Selective
• Highly selective
• Posterior vagotomy and anterior seromyotomy
• GASTRECTOMY
• Billroth I
• Billroth II
• Subtotal gastrectomy
• GRAHAM’S OMENTAL PATCH
• SUTURE LIGATION OF GASTRODUODENAL ARTERY
• UNDRER-RUNNING AN ULCER BASE
• After excision of the edge
• Vagotomy

10. vagotomy

11. • Division of the vagus nerve remove the cephalic stimulus to oxyntic
cells; acid secretion reduce by 60%.
• Types;
• Truncal vagotomy and drainage
• Selective vagotomy
• Highly selective vagotomy
• Posterior Truncal vagotomy and anterior seromyotomy (Taylor’s)

12. Truncal vagotomy and drainage
• The 2 nerve trunks are divided below the diaphragm near the hiatus.
• The gastric tone and mobility are diminished and emptying delayed
• A drainage procedure is done to drain the stomach
• Drainage;
Pyloroplasty; a longitudinal incision about 6cm long is made across the
pylorus at the mid anterior part to involve the adjacent part of the pyloric
antrum and duodenum. (Heineke-Mikuliez) other types are Finney’s and
Jaboulay
Gastrojejunostomy; the jejunum, about 15cm from the duodeno-jejunal
flexure is anastomose usually to the posterior wall of the stomach behind the
transverse colon

13. Selective vagotomy
• Vagotomy with sparing the hepatic branch of anterior vagus and the
coeliac branch of the posterior vagus.
• A drainage procedure is also performed
• Time consuming and it has being abandoned
• Recurrence rate is 10%

14. Highly selective
• It aims at denervating only the acid producing oxyntic gland sparing
nerve to the pyloric antrum(nerve of latarjet) such that drainage
procedure is not required.
• It is difficult to determine the exact area of denervation of oxyntic cell
• Recurrence rate is 10%

15. Taylor’s operation
• Seromyotomy- denervate the fundic parietal mass preserves nerve of
Latarget. The seromyotomy is done 6cm proximal to the pylorus and
1.5cm from the lesser curvature

16. Billroth I
Billroth I – partial gastrectomy gastro-duodenostomy end-to-end
Done for gastric ulcer in the antrum

17. Billroth II
Partial gastro-jejunostomy end-to-side with blind
closure of duodenum
Done for a proximal gastric ulcer

18. Graham’s patch
• Piece of omentum is used to
cover the perforation.
• 3 or 4 interrupted sutures are
inserted through and through
along the long axis.
• Modified Graham’s patch

19. SUTURE LIGATION OF GASTRODUODENAL ARTERY
• Pylorodedontomy
• Non-absorbable suture must
incorporate the artery proximal
and distal to the site of bleeding
• And the transverse pancreatic
branch
• Usually for massive bleeding

20. Under-running an ulcer
• For bleeding gastric and
duodenal ulcers.

21. COMPLICATIONS
• Immediate
• Bleeding
• Gastric retention
• Dysphagia
• Leakage of duodenal stump
• Obstruction of the stoma
• Acute pancreatitis
• Late
• Dumping syndrome
• Diarrhoea
• Steatorhoea
• Enterogastric reflux
• Recurrent ulceration
• Iron deficiency anaemia
• Risk of colorectal and gastric tumours
• Weight loss
• Megaloblastic anaemia
• Osteomalacia
• Anastomotic ulcer
• Gastro-jejunocolic fistula

22. Prognosis
• Overall operative procedure gives satisfactory result in at least 80% of
patients
• Mortality of vagotomy and drainage is <1%
• Partial gastrectomy has overall mortality of 2%, 90% are satisfied with
result, 2% anastomotic ulceration and 5-10% dumping problems.
• Operative mortality for perforated DU is 7%

23. CONCLUSION
•Peptic ulcers requiring surgeries are complicated
and the patients present as emergency which
requires adequate resuscitation.
•Delay in presentation, diagnosis and treatment
increases morbidity and mortality

24. References
• E.A Badoe et al, “Principles and Practice of surgery including
pathology in the tropics” 4th edition, Assembly of God Literature
Center ltd, 2009
• Bailey and Love’s “Short Practice of Surgery” 26th edition CRC press
Taylor and Francis group. 2013
• Farquharson’s textbook of operative general surgery 9th edition
• SRB’s manual of surgery. 4th edition 2013.
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