Ulcer surgery is a procedure used to cure peptic ulcer disease when medications have failed.
Purpose
Ulcer surgery is used to relieve a present peptic ulcer disease and to prevent recurrence of it.
Surgery is usually required if the ulcer is in one of the following states:
perforated and overflowed into the abdomen
scarred or swelled so much that the bowel is obstructed
acute bleeding
defied all other types of treatment
The need for ulcer surgery has diminished greatly over the past 20–30 years due to the discovery of two new classes of drugs and the presence of the causal germ Helicobacter pylori in the stomach. The drugs are the H2 blockers such as cimetidine and ranitidine and the proton pump inhibitors such as omeprazole. These effectively arrest acid production. H. pylori can be eliminated from most patients with a combination of antibiotics and bismuth.
Precautions
There is a tumor of the pancreas that produces a hormone called gastrin. Gastrin causes ulcers by stimulating acid production. If this disease—Zollinger-Ellison syndrome—does not respond to medical treatment, either the tumor or the entire stomach must be removed.
Description
The two primary goals of ulcer surgery, elimination of the current problem and prevention of future problems bring with them a third problem—to perpetuate the normal function of the bowel. The vagus nerves relax the pylorus, allowing the stomach to empty. Cutting the vagus nerves, while reducing the stomach's acid production, also prevents stomach emptying. Therefore, the procedures described must guarantee stomach emptying along with their other goals.
The lower half of the stomach makes most of the acid and gets all the peptic ulcers above the duodenum. Removing it leaves little place for ulcers to form and little acid to produce them.
Vagotomy
Cutting the vagus nerves can be done in three ways:
The main nerves can be cut completely as they enter the abdomen from the chest.
The branches that go to the stomach can be cut as they leave the main nerves.
The tiny branches that stimulate acid production can be cut on the surface of the stomach.
Pyloroplasty
Opening up the valve at the outlet of the stomach guarantees that the stomach can empty, even without vagus nerve stimulation. Pyloroplasty is ordinarily done by cutting across the muscle that surrounds the outlet. It can also be done by passing a balloon down from the mouth and inflating it forcefully to stretch out the pylorus (opening from the stomach to the intestine).
Close perforation
For some patients all that can be done is to close the hole in the bowel and wait for the patient to recover before initiating corrective surgery.
Billroth I and II
After removing a piece of the stomach, the remainder must be reattached to the rest of the bowel. Simply joining the upper stomach back to the duodenum is called a Billroth I or gastroduodenostomy. It is sometimes better to attach the stomach with another piece of bowel (the jejunum), creating a "y" with the bile drainage and the duodenum forming the second branch of the "y." This part of the procedure is called a gastrojejunostomy. A gastroenterostomy is a more general term for connecting the stomach with any piece of bowel.
A selective vagotomy can be done alone. A complete vagotomy requires either a pyloroplasty or antrectomy. An antrectomy must be reconnected with either a Billroth I or a Billroth II.
Some of these procedures are now being done through a laparoscope.
Risks
All of these procedures carry risks, generally in proportion to their benefits. The more extensive surgeries such as vagotomy and antrectomy with Billroth II reconnection have the highest success rate and the highest complication rate.
Complications include:
Diarrhea after a meal
Dumping syndrome occurring after a meal and characterized by sweating, abdominal pain, vomiting, light-headedness, and diarrhea
Malabsorption of necessary nutrients, especially iron, in patients who have had all or part of their stomachs removed.
BOOKS
Debas, Haile T., and Susan L. Orloff. "Surgical Therapy." In Cecil Textbook of Medicine, ed. J. Claude Bennett and Fred Plum. Philadelphia: W. B. Saunders Co., 1996.
Friedman, Lawrence S., and Walter L. Peterson. "Peptic Ulcer and Related Disorders." In Harrison's Principles of Internal Medicine, ed. Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.
Moody, Frank G., et al. "Stomach." In Sleisenger & Fordtran's Gastrointestinal and Liver Disease, ed. Mark Feldman, et al. Philadelphia: W. B. Saunders Co., 1998.
"Stomach and Duodenum." In Current Surgical Diagnosis and Treatment. 10th ed. Ed. Lawrence W. Way. Stamford: Appleton & Lange, 1994.
J. Ricker Polsdorfer, MD
KEY TERMS
Gastrin—A type of hormone that produces gastric juice.
