Surgical management of complications of peptic ulcer disease

Jeffrey B Matthews, MD Larry Lickstein, MD

Apr 17, 1998

Despite improvements in the medical management of peptic ulcer disease, the incidence of potentially life-threatening ulcer complications has not declined [1,2]. The importance of early surgical consultation in the management of patients with ulcer complications cannot be overemphasized. In addition to aiding in the resuscitation of the unstable patient, collaboration between the gastroenterologist/endoscopist and the surgeon permits the establishment of goals and limits for initial nonoperative therapy. Early consultation also allows more time for preoperative preparation and education of patients and families should urgent surgical intervention become necessary.

At the time of operation, the surgeon must decide whether to proceed with definitive ulcer operation in addition to addressing the specific ulcer complication. This issue has received considerable attention over the past several decades but remains unsettled. Shifting ulcer epidemiology, recognition of the role of H. pylori, improvements in medical pharmacotherapy, and innovations in interventional endoscopic techniques render historical reports of dubious applicability to current practice.

This topic review will discuss the role of surgery including emergency operations, in the management of the major complications of peptic ulcer disease: perforation, gastric outlet obstruction, and bleeding (show table 1). The overall role of elective surgery in peptic ulcer disease, including a discussion of the different surgical techniques, is presented separately. (See "Role of surgery in the management of peptic ulcer disease").

Omission of an acid-reducing ulcer procedure carries a risk of recurrent ulcer symptoms and complications; this risk is variable in the literature but not negligible. On the other hand, inclusion of such a procedure may result in serious gastrointestinal sequelae in patients who may not have required the intervention. In addition, a definitive operation is generally avoided during emergency procedures with major underlying medical illness or intraoperative hemodynamic instability.

Because proximal gastric vagotomy (PGV, also called parietal cell vagotomy and highly selective vagotomy) is associated with few postoperative sequelae [3,4], it is the preferred acid-reducing procedure in patients with ulcer complications. One trial, for example, randomized 248 patients with stable peptic ulcer disease to truncal vagotomy and drainage (TV), selective vagotomy and drainage (SV), or PGV [3]. At 11 to 15 years after surgery, PGV was associated with reductions in the incidence of severe postvagotomy symptoms such as dumping (2.2 versus 5.9 [TV] and 19.6 [SV] percent), diarrhea (4.4 versus 9.8 and 11.8 percent), and dyspepsia (8.6 versus 18.4 and 20.5 percent). Only the reduction in dumping with PGV compared to SV was statistically significant. (See "Role of surgery in the management of peptic ulcer disease", section on Proximal gastric vagotomy)

PERFORATION — For perforation of a duodenal ulcer, surgeons have historically performed either simple patch closure or truncal vagotomy with pyloroplasty (incorporating the perforation). Both approaches are simple and expedient, and the results have generally been good [5,6,7,8,9].

  •  Patch closure is appropriate for patients with acute NSAID-related perforation (provided that the drugs can be discontinued postoperatively) and for patients without a significant (more than three month) history.

  •  Simple closure of the perforation should also be performed in the setting of on-going shock, delayed presentation, considerable comorbid disease, or marked peritoneal contamination.

Some prospective trials suggest that, in the absence of such factors, addition of a definitive ulcer procedure (particularly PGV) is superior to simple patch closure alone [10]. A recent study reported the outcomes in 159 patients who were followed more than 10 years after vagotomy and pyloroplasty for perforated duodenal ulcer [11]. The perioperative mortality was 5.5 percent, ulcers recurred in 8.8 percent, and postoperative digestive sequelae, notably diarrhea and dumping, developed in 16 percent. Nevertheless, the overall results were good to excellent in almost 90 percent of cases.

PGV with patch closure does at least as well. One series of 107 such patients noted minimal morbidity, low mortality, excellent patient satisfaction (103 were Visick 1 or 2), a 7.4 percent recurrence rate (3.7 percent for duodenal ulcer; 16 percent for pyloric and prepyloric ulcer), and a reoperation rate below 2 percent [12]. Chronic pyloroduodenal scarring is considered a relative contraindication to PGV in this setting since it may be associated with delayed gastric emptying after surgery.

Gastric ulcer — Perforated gastric ulcer carries a greater overall mortality that may range from 10 to 40 percent, regardless of treatment policy [13,14,15]. Distal gastrectomy is the preferred approach unless the patient is at unacceptably high risk because of advanced age, comorbid disease, intraoperative instability, or severe peritoneal soilage (show table 1) [16]. Patch closure alone is associated with postoperative gastric obstruction in approximately 15 percent of cases [16].

There is a growing body of literature on laparoscopic suture patch and fibrin glue repair of perforated peptic ulcers that demonstrates the feasibility of minimally invasive approaches [17,18]. However, this technique cannot be recommended outside of a research setting at this time.

GASTRIC OUTLET OBSTRUCTION — Patients with gastric outlet (pyloric) obstruction due to a duodenal ulcer typically present with symptoms of gastric retention including early satiety, bloating, indigestion, anorexia, nausea, vomiting, epigastric pain, and weight loss. (See "Complications of peptic ulcer disease"). These patients are frequently malnourished, dehydrated, and have a metabolic alkalosis, factors that increase the operative risk. Nevertheless, operation is generally indicated if obstruction fails to resolve despite 48 to 72 hours of adequate intravenous fluid replenishment, antisecretory therapy, and nasogastric tube decompression.

Inflammation and scarring may prevent safe antrectomy, which would otherwise be an excellent choice since it resects the ulcer and relieves the obstruction. Thus, truncal vagotomy and gastrojejunostomy is the preferred approach (show table 1). Placement of a feeding jejunostomy tube at the time of surgery is usually recommended, both because of preoperative malnutrition and because the chronic gastric outlet obstruction predisposes to delayed postoperative gastric emptying.

PGV with drainage has also been used in the setting of obstructing ulcer [19,20]. One series evaluated 37 patients who underwent PGV accompanied by pyloroplasty, pyloric resection, duodenoplasty, or gastroenterostomy to address the obstruction [19]. Digestive side effects were infrequent, and no recurrences were identified at follow-up of 4.6 years. Early dumping was mild and frequently only transient.

Although the need for pyloric reconstruction or bypass would theoretically negate several advantages of PGV over other options, preservation of antropyloric innervation may preserve controlled gastric emptying and minimize bile reflux [20]. However, debate persists as to the optimal drainage procedure. The Jabouley side-to-side duodenoplasty has gained popularity because of its technical simplicity  and because the anastomosis is performed in healthy tissue, distinct from the ulcer bed. In one report of 19 patients treated with this procedure, there was a high degree of patient satisfaction (100 percent modified Visick grade 1 or 2), universal weight gain, and no operative mortality or ulcer recurrence at mean follow-up of 31 months [21].

However, these benefits have not been noted in all reports. One trial randomized 90 consecutive patients with gastric outlet obstruction secondary to duodenal ulcer to PGV with gastrojejunostomy, PGV with Jabouley duodenoplasty, or selective vagotomy with antrectomy [22]. There were no differences in the postoperative course or the reduction in gastric acid secretion; however, both PGV with gastrojejunostomy and selective vagotomy with antrectomy produced a superior clinical result to PGV with Jabouley pyloroplasty.

BLEEDING —  Most patients with bleeding ulcers can be managed with resuscitation, medical therapy, and endoscopic intervention. (See "Treatment of bleeding peptic ulcers"). Current indications for surgery for peptic ulcer hemorrhage include:

  •  Hemodynamic instability despite vigorous resuscitation (>3 unit transfusion)
  •  Failure of endoscopic techniques to arrest hemorrhage
  •  Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis)
  •  Shock associated with recurrent hemorrhage
  •  Continued slow bleeding with a transfusion requirement exceeding three units per day

Secondary or relative indications include rare blood type or difficult crossmatch, refusal of transfusion, shock on presentation, advanced age, severe comorbid disease, and bleeding chronic gastric ulcer. These criteria also apply to elderly patients in whom prolonged resuscitation, large volume transfusion, and periods of hypotension are poorly tolerated.

Identification of a so-called "visible vessel" or other stigmata of recent hemorrhage at endoscopy may define a population at high risk for recurrent bleeding [23], although its predictive value depends upon the strictness of definition. It has not been clearly demonstrated that the presence of a visible vessel in and of itself is sufficient to select patients for operation, although endoscopic cauterization and/or injection with vasoconstrictors or sclerosants may be advisable in this setting.

Endoscopy can identify that population of patients who may require more urgent operative intervention since an ulcer's appearance can have prognostic implications [24,25,26]:

  •  Low recurrence rates have been associated with the visualization of a flat pigmented spot or a clean ulcer bed

  •  High recurrence rates have been associated with a spurting vessel, a visible arterial vessel in the ulcer bed, adherent clot, or a large ulcer bed [24,25,26].

Endoscopic localization (ie, in the duodenum or stomach) is also of considerable value in planning surgical therapy.

The first priority during emergency surgery for a bleeding duodenal ulcer is control of the bleeding site. If esophagogastroduodenoscopy has failed to precisely identify the source of hemorrhage, a pyloroduodenotomy may be necessary to inspect the duodenal bulb and gastric antrum. Control is obtained by suture ligature, or less frequently, by identifying and ligating the gastroduodenal artery at the superior aspect of the duodenum. Once the bleeding has been addressed, a definitive acid-reducing operation should generally be performed (show table 1). Because it is simple to open the pylorus in a longitudinal fashion, truncal vagotomy with pyloroplasty is the most frequently used operation for bleeding duodenal ulcer. For bleeding gastric ulcers, distal gastrectomy with Billroth I or II reconstruction is preferred (show figure 1).

In experienced hands, proximal gastric vagotomy may represent the best therapy for a bleeding duodenal ulcer. There is limited published experience with this approach [27,28,29] probably because endoscopic hemostatic techniques have reduced the total number of surgical referrals and many patients who do require surgery are bleeding so massively as to be unstable or have refractory hemorrhage after multiple attempts at endoscopic control. As a result, more traditional, more expedient operations with proven efficacy are often chosen over PGV.

Nevertheless, PGV may represent ideal therapy in properly selected patients. In a report from the Mayo Clinic, for example, PGV was performed 52 low risk patients; there was no postoperative mortality, few complications, and only one recurrent hemorrhage [28]. Another series evaluated 27 patients who were treated similarly, but presented in more critical condition [29]. There was only one death in the perioperative period (in a patient with cirrhosis) and only one recurrence after 2 to 11 years follow-up (in a patient with a gastrinoma).