Surgical management of peptic ulcer disease
- Ashley H Vernon, MD
Ashley H Vernon, MD
- Instructor in Surgery
- Brigham and Women’s Hospital/Harvard Medical School
- Stephen J Ferzoco, MD
Stephen J Ferzoco, MD
- Lecturer, Department of Surgery
- Tufts University School of Medicine
- Stanley W Ashley, MD
Stanley W Ashley, MD
- Section Editor — Pancreatic and Hepatobiliary Surgery
- Chief Medical Officer and Senior Vice President for Clinical Affairs
- Brigham and Women’s Hospital
- Frank Sawyer Professor of Surgery
- Harvard Medical School
- Section Editors
- David I Soybel, MD
David I Soybel, MD
- Editor-in-Chief — General Surgery
- Section Editor — Upper GI Surgery
- David L. Nahrwold Professor
- Penn State Hershey Medical Center
- Mark Feldman, MD, MACP, AGAF, FACG
Mark Feldman, MD, MACP, AGAF, FACG
- Section Editor — Acid Peptic Disease
- Texas Health Presbyterian Hospital Dallas
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical School at Dallas
Once the most common indications for gastric surgery, peptic ulcer disease, now only infrequently requires operation. Over the last several decades, the development of potent antisecretory agents (H2 blockers and proton pump inhibitors) and the recognition that treatment for Helicobacter pylori infection can eliminate most ulcer recurrences have essentially eliminated the need for elective surgery [1,2]. However, complications related to peptic ulcer disease continue to occur and include bleeding, perforation, and gastric outlet obstruction. An understanding of surgical management remains important since surgery is the mainstay of emergency treatment of these life-threatening complications, and for disease that is refractory to medical management. Also, there remain a significant number of patients who underwent surgery prior to the development of current standard medical therapies, who continue to have issues related to their original operation.
The indications for surgery, general principles of ulcer surgery, as well as respective treatments for duodenal and gastric ulcers will be reviewed here. The technical aspects of gastrectomy and vagotomy and their complications are reviewed elsewhere. (See "Partial gastrectomy and gastrointestinal reconstruction" and "Total gastrectomy and gastrointestinal reconstruction" and "Vagotomy" and "Postgastrectomy complications".)
NATURAL HISTORY OF PEPTIC ULCER DISEASE
There has been a significant decline in the incidence of hospitalization for peptic ulcer disease (PUD) since 1990 [3,4]. In a study of the Nationwide Inpatient Sample (NIS), hospitalizations for PUD decreased 30 percent from 1993 to 2006, with the decline being greater for duodenal compared with gastric ulcers (37 versus 20 percent, respectively) . These declines are attributed to better medical therapy, including proton pump inhibitors and regimens that eradicate Helicobacter pylori (H. pylori). The natural history and treatment of PUD are discussed elsewhere. (See "Peptic ulcer disease: Management".)
Because of the decrease in the hospitalization rate for PUD, surgeons-in-training now have less exposure to the overall management of peptic ulcer disease, including complications, as well as some of the more technically demanding procedures for treating peptic ulcer disease, such as highly selective vagotomy (parietal cell vagotomy) [5,6]. (See "Vagotomy", section on 'Highly selective vagotomy' and "Postgastrectomy duodenal leak".)
INDICATIONS FOR SURGERY
Elective surgery is uncommonly needed for peptic ulcer disease in current medical practice. Currently accepted indications, elective and emergent, for surgery in the management of peptic ulcer disease include bleeding, perforation, obstruction, intractable disease, and suspected malignancy .
- Kauffman GL Jr. Duodenal ulcer disease: treatment by surgery, antibiotics, or both. Adv Surg 2000; 34:121.
- Lickstein, LH, Matthews, JB. Elective surgical management of peptic ulcer disease. Probl General Surgery 1997; 14:37.
- Gustavsson S, Kelly KA, Melton LJ 3rd, Zinsmeister AR. Trends in peptic ulcer surgery. A population-based study in Rochester, Minnesota, 1956-1985. Gastroenterology 1988; 94:688.
- Wang YR, Richter JE, Dempsey DT. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Ann Surg 2010; 251:51.
- Towfigh S, Chandler C, Hines OJ, McFadden DW. Outcomes from peptic ulcer surgery have not benefited from advances in medical therapy. Am Surg 2002; 68:385.
- Rockall TA. Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for the National Audit of Acute Upper Gastrointestinal Haemorrhage. J R Soc Med 1998; 91:518.
- Sánchez-Delgado J, Gené E, Suárez D, et al. Has H. pylori prevalence in bleeding peptic ulcer been underestimated? A meta-regression. Am J Gastroenterol 2011; 106:398.
- Gunshefski L, Flancbaum L, Brolin RE, Frankel A. Changing patterns in perforated peptic ulcer disease. Am Surg 1990; 56:270.
- Graham DY. Ulcer complications and their nonoperative treatment. In: Gastrointestinal Disease, 5th ed, Sleisenger M, Fordtran J (Eds), WB Saunders, Philadelphia 1993. p.698.
- Leontiadis GI, Sreedharan A, Dorward S, et al. Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding. Health Technol Assess 2007; 11:iii.
- Søreide K, Thorsen K, Søreide JA. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg 2014; 101:e51.
- Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy 2011; 43:950.
- Simeone DM, Hassan A, Scheiman JM. Giant peptic ulcer: a surgical or medical disease? Surgery 1999; 126:474.
- Csendes A, Maluenda F, Braghetto I, et al. Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Am J Surg 1993; 166:45.
- Hoffmann J, Jensen HE, Christiansen J, et al. Prospective controlled vagotomy trial for duodenal ulcer. Results after 11-15 years. Ann Surg 1989; 209:40.
- Amdrup E, Andersen D, Høstrup H. The Aarhus County vagotomy trial. I. An interim report on primary results and incidence of sequelae following parietal cell vagotomy and selective gastric vagotomy in 748 patients. World J Surg 1978; 2:85.
- Donahue PE, Yoshida J, Richter HM, et al. Proximal gastric vagotomy with drainage for obstructing duodenal ulcer. Surgery 1988; 104:757.
- Donahue PE, Griffith C, Richter HM. A 50-year perspective upon selective gastric vagotomy. Am J Surg 1996; 172:9.
- Millat B, Fingerhut A, Borie F. Surgical treatment of complicated duodenal ulcers: controlled trials. World J Surg 2000; 24:299.
- Spivak, H, Hunter, JG. Laparoscopic gastric surgery. Probl Gen Surg 1997; 14:82.
- Weerts JM, Dallemagne B, Jehaes C, Markiewicz S. Laparoscopic gastric vagotomies. Ann Chir Gynaecol 1994; 83:118.
- Cadiére GB, Himpens J, Bruyns J. Laparoscopic proximal gastric vagotomy. Endosc Surg Allied Technol 1994; 2:105.
- Croce E, Azzola M, Golia M, et al. Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy. Endosc Surg Allied Technol 1994; 2:113.
- Katkhouda N, Heimbucher J, Mouiel J. Laparoscopic posterior vagotomy and anterior seromyotomy. Endosc Surg Allied Technol 1994; 2:95.
- Gomez-Ferrar, F. Gastrectomie lineaire anterieure et vagotomie tronculaire posteriere una nouvelle technique laparocopique dans le traitment de líulcere duodenal. J Chir (Paris) 1992; 4:35.
- Lau WY, Leung KL, Zhu XL, et al. Laparoscopic repair of perforated peptic ulcer. Br J Surg 1995; 82:814.
- Lau WY, Leung KL, Kwong KH, et al. A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique. Ann Surg 1996; 224:131.
- Zittel TT, Jehle EC, Becker HD. Surgical management of peptic ulcer disease today--indication, technique and outcome. Langenbecks Arch Surg 2000; 385:84.
- Nakamura T, Yoshida M, Otani Y, et al. Twelve years' progress in surgery for perforated gastric and duodenal ulcers: a retrospective study of indications for laparoscopic surgery, post-operative course and the influence of Candida infection. Alimentary Pharmacology & Therapeutics Symposium Series 2006; 2:297.
- Lunevicius R, Morkevicius M. Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. Br J Surg 2005; 92:1195.
- Ashley SW, Evoy D, Daly JM. Stomach. In: Principles of Surgery, 7th ed, Schwartz SS (Ed), McGraw-Hill, New York 1999. p.1181.
- Hoffmann J, Devantier A, Koelle T, Jensen HE. Parietal cell vagotomy as an emergency procedure for bleeding peptic ulcer. Ann Surg 1987; 206:583.
- Miedema BW, Torres PR, Farnell MB, et al. Proximal gastric vagotomy in the emergency treatment of bleeding duodenal ulcer. Am J Surg 1991; 161:64.
- Kay PH, Moore KT, Clark RG. The treatment of perforated duodenal ulcer. Br J Surg 1978; 65:801.
- Playforth MJ, McMahon MJ. The indications for simple closure of perforated duodenal ulcers. Br J Surg 1978; 65:699.
- Boey J, Lee NW, Koo J, et al. Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial. Ann Surg 1982; 196:338.
- Hay JM, Lacaine F, Kohlmann G, Fingerhut A. Immediate definitive surgery for perforated duodenal ulcer does not increase operative mortality: a prospective controlled trial. World J Surg 1988; 12:705.
- Tanphiphat C, Tanprayoon T, Na Thalang A. Surgical treatment of perforated duodenal ulcer: a prospective trial between simple closure and definitive surgery. Br J Surg 1985; 72:370.
- Ng EK, Lam YH, Sung JJ, et al. Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial. Ann Surg 2000; 231:153.
- Datsis AC, Rogdakis A, Kekelos S, et al. Simple closure of chronic duodenal ulcer perforation in the era of Helicobacter pylori: an old procedure, today's solution. Hepatogastroenterology 2003; 50:1396.
- Wara P, Kristensen ES, Sørensen FH, et al. The value of parietal cell vagotomy compared to simple closure in a selective approach to perforated duodenal ulcer. Operative morbidity and recurrence rate. Acta Chir Scand 1983; 149:585.
- Robles R, Parrilla P, Lujan JA, et al. Long-term follow-up of bilateral truncal vagotomy and pyloroplasty for perforated duodenal ulcer. Br J Surg 1995; 82:665.
- Jordan PH Jr, Thornby J. Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy. Ann Surg 1995; 221:479.
- Yusuf TE, Brugge WR. Endoscopic therapy of benign pyloric stenosis and gastric outlet obstruction. Curr Opin Gastroenterol 2006; 22:570.
- Holle FK. The physiopathologic background and standard technique of selective proximal vagotomy and pyloroplasty. Surg Gynecol Obstet 1977; 145:853.
- Dittrich K, Blauensteiner W, Schrutka-Kölbl C, et al. Highly selective vagotomy plus Jaboulay: a possible alternative in patients with benign stenosis secondary to duodenal ulceration. J Am Coll Surg 1995; 180:654.
- Johnson HD. Gastric ulcer: classification, blood group characteristics, secretion patterns and pathogenesis. Ann Surg 1965; 162:996.
- Jordan, PH Jr. Gastric ulcer. In: Surgery of the Stomach, Duodenum, and Small Intestine, Scott, H Jr, Sawyers, JL (Eds), Blackwell Scientific Publications, Boston 1991. p.309.
- McDonald MP, Broughan TA, Hermann RE, et al. Operations for gastric ulcer: a long-term study. Am Surg 1996; 62:673.
- Jordan PH Jr. Type I gastric ulcer treated by parietal cell vagotomy and mucosal ulcerectomy. J Am Coll Surg 1996; 182:388.
- Tekant Y, Goh P, Low C, Ngoi SS. Pyloric channel ulcers: management and three-year follow-up. Am Surg 1995; 61:237.
- Herrington JL Jr, Sawyers JL. Gastric ulcer. Curr Probl Surg 1987; 24:759.
- Jordan PH Jr. Surgery for peptic ulcer disease. Curr Probl Surg 1991; 28:265.
- Matthews JB, Silen W. Operations for peptic ulcer disease and early postoperative complications. In: Gastrointestinal Disease, Sleisenger MH, Fordtran JS (Eds), WB Saunders, Philadelphia 1993. p.713.
- Hodnett RM, Gonzalez F, Lee WC, et al. The need for definitive therapy in the management of perforated gastric ulcers. Review of 202 cases. Ann Surg 1989; 209:36.
- NATURAL HISTORY OF PEPTIC ULCER DISEASE
- INDICATIONS FOR SURGERY
- Management of peptic ulcer disease complications
- - Bleeding peptic ulcer
- - Perforated peptic ulcer
- - Gastric outlet obstruction
- Peptic ulcer disease refractory to medical management
- Suspicion of malignancy
- Controversial indications
- GENERAL PRINCIPLES OF ULCER SURGERY
- General considerations
- Preoperative evaluation
- Surgical options
- - Ulcer bed management
- - Vagotomy
- - Gastric drainage
- - Gastrectomy and reconstruction
- Open versus laparoscopic approach
- DUODENAL ULCER
- Elective surgery for duodenal ulcer
- Bleeding duodenal ulcer
- Perforated duodenal ulcer
- Gastric outlet obstruction
- GASTRIC ULCER
- Elective surgery for gastric ulcer
- - Type I gastric ulcer
- - Type II gastric ulcer
- - Type III gastric ulcer
- - Type IV gastric ulcer
- - Recurrent gastric ulcer
- Bleeding gastric ulcer
- Perforated gastric ulcer
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS