Peptic Ulcer Disease
002.5-7125/91 $0.00 + .20
Surgical Treatment of Peptic Ulcer Disease Ajit K. Sachdeva, MD, FRCS(C), FACS,* Howard A. Zaren, MD, FACS,t and Bernard Sige/, MD, FACS:!:
Surgery for peptic ulcer disease has gone through a period of significant change over the past 15 years. The declining incidence of the disease, the introduction of H 2 -receptor antagonists (as well as other effective drugs to control acid secretion), the development of proximal gastric vagotomy, and re-evaluation of older procedures have all contributed to the emergence of a new era in the surgical management of peptic ulcer disease. The incidence of peptic ulcer disease was on the decline even prior to the introduction of H 2 -antagonists in 1977, and the decline in the number of patients hospitalized for uncomplicated peptic ulcer disease has continued since that time. However, hospitalization rates for hemorrhage and perforation have remained constant. 33 In some series, hospital admissions for hemorrhage have even shown an increase. 1 Operations for peptic ulcer disease have followed these general trends. Emergency procedures for hemorrhage have increased and account for from 20% to 50% of all surgical procedures performed for peptic ulcer disease. 22,38, 34 . The use of proximal gastric vagotomy without a drainage procedure for the treatment of peptic ulcer disease was first reported between 1969 and 1970. Since that time, this "physiologic" procedure increased in popularity and then because of the significant ulcer recurrence rate enthusiasm diminished. However, the p;'ocedure is still a viable option in several clinical situations because of its low complication rate. Several age and gender differences in patients with peptic ulcer disease are worthy of note. In recent years, patients requiring surgery for peptic
*Associate
Professor of Surgery, and Director of Surgical Education, Medical College of Pennsylvania; and Chief, Surgical Services, Veterans AfFairs :\ledical Center, Philadelphia, Pennsvlvania tProfessor ~f Surgery, and Interim Chairman, Medical College of Pennsylvania, Philadelphia, Pennsvlvania :j:Professor '01' Surgery, and Director of Surgical Research, J\[edical College of Pennsylvania, Philadelphia, Pennsylvania Medical Clinics of North America-Vol. 7.5, No. 4, July 1991
999
lOOO
AJIT
K.
SACHDEVA ET AL.
ulcer disease have been older and have associated medical problems. Although the majority of candidates for surgery are men, the proportion of women requiring such operations has increased. 22 The prevalence of nonsteroidal anti-inflammatory drug usage in the adult population might account for the increase seen in hospitalizations for bleeding gastric ulcers. 33 The operative mortality following elective surgery is generally from 1% to 2% and depends on the type of procedure as well as the operative risk of the patient. Emergency operations are associated with an almost 10fold increase in operative mortality.22 This underscores the need for earlier identification of patients who might benefit from elective surgery for peptic ulcer disease. OPERATIONS FOR PEPTIC ULCER DISEASE The surgical procedure for peptic ulcer disease must be taiiored to the specific needs of the individual patient. Efficacy of the procedure must be balanced against the risk to the patient. For optimum results, the surgeon should be able to select the appropriate procedure from a variety of available options. Truncal Vagotomy and Drainage Vagotomy remains pivotal in the surgical treatment of duodenal ulcer disease. Vagotomy decreases acid production by diminishing the cholinergic stimulation of the parietal cells and by decreasing the response of parietal cells to gastrin. Reports indicate that basal acid production is reduced by 70% and stimulated acid production is reduced by 50% following truncal vagotomy.40 Due to total denervation of the stomach (along with other intraabdominal viscera), truncal vagotomy alone would result in poor gastric emptying and gastric stasis. Hence, this procedure must be combined with a drainage procedure, either pyloroplasty (Fig. 1) or gastrojejunostomy. Truncal vagotomy and drainage are relatively easy to perform and are associated with low operative mortality and with an ulcer recurrence rate of from 10% to 15% (Table 1). Mild symptoms of diarrhea and dumping are fairly common following this procedure, but they can be managed conser-
Figure 1. Truncal vagotomy and Heineke-Mikulicz pyloroplasty.
1001
SURGICAL TREATMENT OF PEPTIC ULCER DISEASE
Table 1. Results of Operations for Duodenal Ulcer Disease OPERATIVE
ULCER
PROCEDURE
MORTALITY
RECURRENCE
Truncal vagotomy and drainage Truncal vagotomy and antrectomy Subtotal gastrectomy Proximal gastric vagotomy
1% 1-2% 1-2%
002.5-7125/91 $0.00 + .20
Surgical Treatment of Peptic Ulcer Disease Ajit K. Sachdeva, MD, FRCS(C), FACS,* Howard A. Zaren, MD, FACS,t and Bernard Sige/, MD, FACS:!:
Surgery for peptic ulcer disease has gone through a period of significant change over the past 15 years. The declining incidence of the disease, the introduction of H 2 -receptor antagonists (as well as other effective drugs to control acid secretion), the development of proximal gastric vagotomy, and re-evaluation of older procedures have all contributed to the emergence of a new era in the surgical management of peptic ulcer disease. The incidence of peptic ulcer disease was on the decline even prior to the introduction of H 2 -antagonists in 1977, and the decline in the number of patients hospitalized for uncomplicated peptic ulcer disease has continued since that time. However, hospitalization rates for hemorrhage and perforation have remained constant. 33 In some series, hospital admissions for hemorrhage have even shown an increase. 1 Operations for peptic ulcer disease have followed these general trends. Emergency procedures for hemorrhage have increased and account for from 20% to 50% of all surgical procedures performed for peptic ulcer disease. 22,38, 34 . The use of proximal gastric vagotomy without a drainage procedure for the treatment of peptic ulcer disease was first reported between 1969 and 1970. Since that time, this "physiologic" procedure increased in popularity and then because of the significant ulcer recurrence rate enthusiasm diminished. However, the p;'ocedure is still a viable option in several clinical situations because of its low complication rate. Several age and gender differences in patients with peptic ulcer disease are worthy of note. In recent years, patients requiring surgery for peptic
*Associate
Professor of Surgery, and Director of Surgical Education, Medical College of Pennsylvania; and Chief, Surgical Services, Veterans AfFairs :\ledical Center, Philadelphia, Pennsvlvania tProfessor ~f Surgery, and Interim Chairman, Medical College of Pennsylvania, Philadelphia, Pennsvlvania :j:Professor '01' Surgery, and Director of Surgical Research, J\[edical College of Pennsylvania, Philadelphia, Pennsylvania Medical Clinics of North America-Vol. 7.5, No. 4, July 1991
999
lOOO
AJIT
K.
SACHDEVA ET AL.
ulcer disease have been older and have associated medical problems. Although the majority of candidates for surgery are men, the proportion of women requiring such operations has increased. 22 The prevalence of nonsteroidal anti-inflammatory drug usage in the adult population might account for the increase seen in hospitalizations for bleeding gastric ulcers. 33 The operative mortality following elective surgery is generally from 1% to 2% and depends on the type of procedure as well as the operative risk of the patient. Emergency operations are associated with an almost 10fold increase in operative mortality.22 This underscores the need for earlier identification of patients who might benefit from elective surgery for peptic ulcer disease. OPERATIONS FOR PEPTIC ULCER DISEASE The surgical procedure for peptic ulcer disease must be taiiored to the specific needs of the individual patient. Efficacy of the procedure must be balanced against the risk to the patient. For optimum results, the surgeon should be able to select the appropriate procedure from a variety of available options. Truncal Vagotomy and Drainage Vagotomy remains pivotal in the surgical treatment of duodenal ulcer disease. Vagotomy decreases acid production by diminishing the cholinergic stimulation of the parietal cells and by decreasing the response of parietal cells to gastrin. Reports indicate that basal acid production is reduced by 70% and stimulated acid production is reduced by 50% following truncal vagotomy.40 Due to total denervation of the stomach (along with other intraabdominal viscera), truncal vagotomy alone would result in poor gastric emptying and gastric stasis. Hence, this procedure must be combined with a drainage procedure, either pyloroplasty (Fig. 1) or gastrojejunostomy. Truncal vagotomy and drainage are relatively easy to perform and are associated with low operative mortality and with an ulcer recurrence rate of from 10% to 15% (Table 1). Mild symptoms of diarrhea and dumping are fairly common following this procedure, but they can be managed conser-
Figure 1. Truncal vagotomy and Heineke-Mikulicz pyloroplasty.
1001
SURGICAL TREATMENT OF PEPTIC ULCER DISEASE
Table 1. Results of Operations for Duodenal Ulcer Disease OPERATIVE
ULCER
PROCEDURE
MORTALITY
RECURRENCE
Truncal vagotomy and drainage Truncal vagotomy and antrectomy Subtotal gastrectomy Proximal gastric vagotomy
1% 1-2% 1-2%
