Perf Gastroduo Ulcers PDF

www.downstatesurgery.
org
Management of perforated
gastric and duodenal ulcers
Joyce Au
SUNY Downstate Grand Rounds
September 27, 2012
www.downstatesurgery.org
CASE
97 F with 2 days of sudden, diffuse, constant
abdominal pain with some lightheadedness
No fevers/chills/N/V/diarrhea/bloody BM
PMH/PSH: HTN, atrial fibrillation, s/p
hysterectomy, right knee surgery, left breast
surgery
Meds: amlodipine, atenolol; no
anticoagulation due to history of falls
Soc hx: lives alone
T=97.6, HR=125, BP=106/77, RR=20

Alert, oriented, responsive
Abdomen soft, mildly distended, very tender
diffusely, + guarding and rebound tenderness,
+ bowel sounds; no mass on DRE, guaiac
negative
RRR, clear breath sounds b/l, no CVA
tenderness, no pedal edema
CBC: 16.2 (91% PMN) / 12 / 34.9 / 330

BMP: 137 / 3.6 / 94 / 30 / 49 / 1.2 / 82
UA negative
Coags normal
EKG atrial fibrillation with HR of 99
CXR large amount of free air
CT - large amount of free air; no contrast
extravasation; no obstruction
OR findings
Turbid fluid in the upper abdomen
5 mm circular perforation on anterior pyloric
channel with clean edges
Extensive adhesions with the omentum
stuck to the abdominal wall
Procedure:
Exploratory laparotomy
Primary repair of ulcer with two interrupted
sutures
Small patch of omentum sutured over the
repair
Cefotetan, vancomycin, diflucan as per ID

Nexium
Return of bowel function on POD#4 diet
started and advanced
Atrial fibrillation - echo negative; metoprolol,
digoxin
Discharged to short-term rehab on POD#13
INTRODUCTION
2-10% peptic ulcers perforate
M>F; trend towards more patients being
female, older, using NSAID, and having
gastric ulcers
Etiology
Acid Mucos
secreti al
on defens
e
H. pylori, NSAID, stress, gastrinoma, crack

Modified Johnsons classification of gastric ulcers
II III
IV V
Giant gastric ulcers >3 cm greater risk of

malignancy (up to 30%) and complications
SIGNS & SYMPTOMS

Pain - sudden, severe, constant, rebound,
guarding, rigid abdomen; radiates to R
scapula with subphrenic abscess
Decreased bowel sounds, fever, tachycardia
Free air
MANAGEMENT
To operate or not?
How sick is patient
Patch?
- Open or laparoscopic
- Role of PPI and H. pylori antibiotics
Need definitive surgery?

- Which definitive surgery
Perforated
ulcer
Nonoperative
Patch
Definitive
Ulcer
Operation
To operate or not
Nonoperative in highly selected patients
Perforation must be sealed
Acute ulcer, or chronic ulcer in high-risk patient

Operate if deteriorate or no improvement in 12
hours
Berne et al. Arch Surg 1989
Donovan et al. Ann Surg 1979
Perforated
ulcer
Nonoperative
Patch
Definitive
Ulcer
Operation
How sick is patient

Emergency surgery for perforated ulcer with
mortality of 6-30%
Definitive ulcer surgery often deferred with
shock, poor-risk patient, age >70, prolonged
perforation, abscess, or generalized peritonitis
Lui et al. Scand J Surg 2010

Boey score
1 point each for
preoperative shock
severe comorbidities
longstanding perforation >24 hr
Boey et al. Ann Surg 1987

Lohsiriwat et al. World J Surg 2009
Open vs. laparoscopic patch

Graham patch popularized by Roscoe Graham,
1937
Laparoscopic omental patch
Variable techniques
Convert to open with: large ulcer, friable ulcer
edge, posterior location of ulcer, unable to
localize ulcer; also shock, delayed presentation
>24 hrs
No significant difference in mortality or morbidity

Conversion rate of 8%
Sanabria et al. Cochrane Database Syst Rev 2005
Sutureless patch with gelatin sponge and

fibrin glue
Gastric ulcers - risk of malignancy biopsy

or excision
PPI and H. pylori antibiotics

About 1/3 patients with just patch closure
have ulcer recurrence
H. pylori tests: serology, urease breath test,
rapid urease assay, biopsy
Treatment of H. pylori
Amoxicillin, clarithromycin, PPI;
metronidazole, bismuth
Able to decrease ulcer recurrence at 1 year
to 5%
Must test for eradication to determine need
for 2nd treatment or definitive ulcer surgery
Feliciano. Surg Clinics North Amer 1992
Ng et al. Ann Surg 2000
Perforated
ulcer
Nonoperative
Patch
Definitive
Ulcer
Operation
Indications
Unable to afford the meds, noncompliance
Intractable, multiple, or large ulcers
Hemorrhage accompanying the perforation
Gastric outlet obstruction
Gastric ulcer
Which definitive ulcer operation
Duodenal perforation
Truncal vagotomy and drainage
Highly selective vagotomy
Gastric perforation
Truncal vagotomy and drainage and ulcer
excision
Truncal vagotomy, antrectomy; gastrectomy
A.) Truncal vagotomy, drainage

L anterior and R posterior vagal trunks; frozen
section
Heineke-Mickulicz pyloroplasty
If scarring of pylorus or duodenum, then

Finney pyloroplasty or Jaboulay
gastroduodenostomy
Advantage: safe and quick

Disadvantage: diarrhea, dumping syndrome
B.) Highly selective vagotomy

Aka parietal cell vagotomy, proximal gastric
vagotomy
Spare nerves of Latarjet, hepatic and celiac
branches
Include criminal nerve of Grassi
Advantage: safe, less side-effects

Disadvantage: highest recurrence, longer
operation, requires more skill
C.) Truncal vagotomy, antrectomy; gastrectomy
Inclusion of vagotomy and extent of surgery
based on type of gastric ulcer
Reconstruction
Billroth I - gastroduodenostomy
Billroth II gastrojejunostomy
Advantage: reduces acid the most, lowest

recurrence rate
Disadvantage: diarrhea, dumping, post-
gastrectomy syndromes, not suitable if
extensive inflammation or scarring which
compromise the anastomosis
TV + PCV TV +
pyloroplast antrectomy
y
Gastrin Increased Increased Decreased
release
Gastric Accelerated No change Slowed
emptying of
solids
Mulholland et al. Surg Clin North Am 1987



CONCLUSIONS
Patients clinical status and type
Perforated
ulcer
of ulcer with important
implications for surgery
Nonoperative
Patch
Pathogenesis of ulcer disease
may alter treatment options
Definitive
Ulcer
Operation
Anatomy and physiology give

clues to effects and
complications of surgery
QUESTIONS
1. A 45 yr old man requires surgery for
intractable duodenal ulcer. Which best
prevents ulcer recurrence?
a. Subtotal gastrectomy
b. Truncal vagotomy and pyloroplasty
c. Truncal vagotomy and antrectomy
d. Parietal cell vagotomy
2. The pathogenesis of benign type I gastric

ulcer is predominantly which?
a. Hypersecretion of acid
b. Hypergastrinemia due to gastric stasis
c. Antral stasis
d. Hyperpepsinogenemia
e. Defective mucosal barrier
3. A 52M has ulcer-like pain 15 years after a highly

selective vagotomy, and EGD shows a recurrent
duodenal ulcer, H. pylori negative. The most likely
explanation for his recurrent ulcer is
a. Incomplete vagotomy
b. Gastrinoma
c. Antral G-cell hyperplasia
d. Bile reflux
e. Occasional NSAID use
Thats all, folks.

Thank you!

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www.downstatesurgery.

T=97.6, HR=125, BP=106/77, RR=20

CBC: 16.2 (91% PMN) / 12 / 34.9 / 330

Cefotetan, vancomycin, diflucan as per ID

H. pylori, NSAID, stress, gastrinoma, crack

Modified Johnsons classification of gastric ulcers

Giant gastric ulcers >3 cm greater risk of

SIGNS & SYMPTOMS

How sick is patient

Need definitive surgery?

Acute ulcer, or chronic ulcer in high-risk patient

How sick is patient

Lui et al. Scand J Surg 2010

Boey et al. Ann Surg 1987

Open vs. laparoscopic patch

Laparoscopic omental patch

No significant difference in mortality or morbidity

Sutureless patch with gelatin sponge and

Gastric ulcers - risk of malignancy biopsy

PPI and H. pylori antibiotics

Which definitive ulcer operation

A.) Truncal vagotomy, drainage

If scarring of pylorus or duodenum, then

Advantage: safe and quick

B.) Highly selective vagotomy

Advantage: safe, less side-effects

Advantage: reduces acid the most, lowest

Mulholland et al. Surg Clin North Am 1987

Mulholland et al. Surg Clin North Am 1987

Mulholland et al. Surg Clin North Am 1987

Anatomy and physiology give

2. The pathogenesis of benign type I gastric

3. A 52M has ulcer-like pain 15 years after a highly

Thats all, folks.

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