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 .
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- 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