Ulcer Surgery

Ulcer Surgery

 

Definition

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.

Total gastrectomy

Removing the entire stomach is done only for resistant Zollinger-Ellison syndrome or extensive cancers.

Antrectomy

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
Common sites of ulcers in the human stomach. The need for ulcer surgery has diminished over the past 20-30 years due to the discovery that Helicobacter pylori, an infectious bacterium, plays a major role in causing ulcers. H. pylori can be eliminated from most patients with a combination of antibiotics and bismuth.
Common sites of ulcers in the human stomach. The need for ulcer surgery has diminished over the past 20-30 years due to the discovery that Helicobacter pylori, an infectious bacterium, plays a major role in causing ulcers. H. pylori can be eliminated from most patients with a combination of antibiotics and bismuth.
(Illustration by Electronic Illustrators Group.)
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, lightheadedness, and diarrhea
  • Hypoglycemia after a meal
  • Alkaline reflux gastritis marked by abdominal pain, vomiting of bile, diminished appetite, and irondeficiency anemia
  • Recurrence of an ulcer
  • Malabsorption of necessary nutrients, especially iron, in patients who have had all or part of their stomachs removed

Resources

Books

Moody, Frank G., et al. "Stomach." In Sleisenger & Fordtran's Gastrointestinal and Liver Disease, edited by Mark Feldman, et al. Philadelphia: W. B. Saunders Co., 1998.

Key terms

Gastrin — A type of hormone that produces gastric juice.
Hypoglycemia — An abnormal decrease in blood sugar level.
Jejunum — Section of the small intestine.
Laparoscope — A pencil-thin telescope that allows surgery to be done through half-inch incisions.
Pylorus — The opening from the stomach to the intestine.
Vagus nerve — Cranial nerves that supply the internal organs (viscera).
Zollinger-Ellison syndrome — A syndrome marked by peptic ulcers and gastrinomas in the pancreas.
References in periodicals archive ?
These drugs spare many people the necessity of having to undergo ulcer surgery and as they are also very effective against heartburn they are extremely popular.
A Bosnian man has filed a lawsuit, claiming he was forced to live in pain for nine years after doctors left scissors in his stomach during 2003 ulcer surgery at Mostar Hospital.
The technique of proximal gastric vagotomy represents the culmination of decades of surgical research and appears to have greatly improved the functional outcome of ulcer surgery. There currently exists no pharmacological agent that permanently controls the peptic ulcer diathesis.
Predisposing factors in bezoar formation include systemic diseases that reduce gastrointestinal motility and previous peptic ulcer surgery [2].
Her surgeon did not believe osteoporosis, osteomalacia, and bone pain were risks of peptic ulcer surgery, and so did not discuss those risks with her.
Traditional risk factors for CDI that were investigated included antimicrobial drug use within the past month, age [greater than or equal to] 65 years, serious underlying illness/weakened immune system, history of bowel or ulcer surgery, colon disease, previous CDI, and recent hospitalization.
The $500m, two-movie production has suffered a series of problems including studio funding issues, a threatened actors' boycott and ulcer surgery for Jackson.
Ulcer surgery may trigger pancreatic cancer by reducing the amount of acid the stomach produces - this creates a friendly environment for bacteria which produce chemical compounds called nitrosamines that can be carcinogenic.
Loss of domain is what happened to gastrointestinal surgeons when peptic ulcer surgery, traditionally a big part of what they did every day, all but disappeared as a consequence of pharmacologic eradication of H.
"Peptic Ulcer Surgery During the [H.sub.2]-Receptor Antagonist Era: A Population-based Epidemiological Study of Ulcer Surgery in Helsinki from 1972 to 1987." British Journal of Surgery 78 (1): 23-31.
Although some medical technologies can reduce costs - as with the polio vaccine, or when drug treatment replaces expensive ulcer surgery - too often new medicine brings a greater financial burden.