Surgical management of peptic ulcer disease – Please participate in our 3-minute survey below!

Introduction to a talk about the surgical treatment of gastroduodenal acid disease by Dr. Josh, a fifth-year resident in the department.

Today's talk covers the definition, epidemiology, etiology, physiology, anatomy presentation and workup of peptic ulcer disease. It also discusses indications for surgery and various surgical techniques. The successful development of anti-acid medication and eradication of Helicobacter pylori have made elective surgery for this disease very unusual.

Peptic ulcer disease affects four million people worldwide, with an incidence of 1.5 to 3% in developing countries. The lifetime prevalence of perforation is about 5%, and mortality can be as high as 20-30%. Anti-acid medication and Helicobacter pylori treatment have reduced complications and hospital admissions for peptic ulcers.

The risk factors for peptic ulcer disease have decreased by 20 to 30 percent from 1993 to 2006. The main factors include Helicobacter pylori infection, medications like non-steroidal anti-inflammatory drugs and steroids, lifestyle habits such as smoking and alcohol consumption, malignancy, extreme stress states, head injury neurosurgical cases (Cushing's ulcers), extensive burns.

Dr. Warren and Dr. Marshall discovered Helicobacter pylori, winning the Nobel Prize in 2005 for their findings. They were the first to link biopsy results with the presence of H.pylori in gastritis and peptic ulcer disease.

H. pylori uses flagella to travel from the gastric lumen to the epithelium, produces ammonia as a protective mechanism against stomach acidity, adheres to gastric epithelium using poly lipo saccharides, and releases endotoxins that contribute to cell damage and inflammatory cascade.

The increase in gastric acid production worsens ulcers, creating a vicious cycle. Diagnostic tests for Helicobacter can be invasive or non-invasive. Invasive tests include endoscopy with high sensitivity and specificity, while non-invasive tests involve the carbon-13 breath test and stool analysis.

Triple Chemotherapy Treatment The most effective treatment for peptic ulcer disease is a triple chemotherapy consisting of high dose proton pump inhibitor and two antibiotics. This treatment is suitable for patients allergic to penicillin and should be administered for 7 to 14 days.

Testing and Retesting All patients with peptic ulcer disease need to be tested and treated for H. pylori infection, regardless of symptoms. If the test is positive, the patient should be retested after 4 weeks due to the risk of false negative results.

The key drugs involved are non-steroidal anti-inflammatories (NSAIDs) and steroids. Steroids inhibit phospholipase A2, while NSAIDs inhibit cyclooxygenase type 1 & 2, leading to reduced prostaglandin production. Prostaglandins are important for gastric mucosa and bicarbonate production.

Gastric ulcers usually occur at the lesser curvature of the stomach, where there is a complex arterial arcade. Duodenal ulcers are more common than gastric ulcers and typically arise in the first part of the duodenum.

Understanding the physiology of gastric cells and parietal cells is crucial for surgical treatment. The historical approach involved surgery targeting the antrum, while modern treatments focus on the corpus.

Parietal Cell Acid Production The parietal cell acid production is activated, leading to peptic ulcer disease. Symptoms include epigastric pain, worsened by eating and relieved by antacids. Perforation results in acute abdominal pain and rigidity.

Diagnostic Workup for Peptic Ulcers Blood tests for hemoglobin and urea are useful diagnostic tools. Carbon-13 breath tests can be performed electively, while endoscopy with H. pylori tests and biopsy is the gold standard for diagnosis.

Gastric ulcers are classified into four types based on their location: type 1 in the corpus, type 2 with ulcers in the duodenum and gastric body, type 3 as pre-pyloric ulcers, and type 4 as high-riding ulcers near the lower esophageal sphincter. Surgical management focuses on two common complications: bleeding (73% prevalence) and perforation; other complications include obstruction, intractable disease, and suspected malignancy.

There are four indications for surgery according to the American Society of Gastroenterologist: failed endoscopic therapy, hemodynamic instability despite volume resuscitation exceeding three units, recurrent hemorrhage after two attempts at endoscopic treatment, and continued slow bleeding requiring more than three units a day. Two risk stratification tools mentioned are the Rockall score for rebleeding risk and the Glasgow-Blatchford score.

The Blatchford score assesses the risk of endoscopic intervention. A score less than three has a low chance (less than 6%) of requiring intervention, while a score greater than six indicates a high chance (50%) of needing intervention.

The Rock Hall score indicates a high chance of needing admission to an intensive care unit. Dr. Miller, the Rock Hall scholar, can help stratify the risk of rebleeding based on certain criteria.

Understanding the Forest Classification for Bleeding

After failed endoscopic attempts, the next steps include embolization or surgery. Embolization is suitable for most cases but surgery is best for severe coagulopathy and as a last resort.

Surgical management has three objectives: hemorrhage control, historical acid reduction (now done medically), and location-based surgical approach determination.

Surgical management of bleeding ulcers involves attending endoscopy and achieving exposure using Jewett Anatomy or Judea Dino pile. Direct suture ligation may be used to stop the bleeding, often requiring ligation of the gastroduodenal artery and reinforcement with an omental patch.

Surgical management for bleeding gastric ulcers involves various techniques, such as wedge resection along the larger curvature and distal gastrectomy if the ulcer is lower down. High-lying ulcers are difficult to treat and may require a two-thirds gastrectomy.

Non-Operative Treatment for Perforated Ulcers Patients with duodenum or gastric ulcer perforation can be successfully treated non-operatively if they are stable. Conservative treatment includes bowel rest, nasogastric tube, and intravenous antibiotics. Small perforations may seal off without surgery, and a diagnostic test is needed to rule out extra luminal leakage.

Advantages of Laparoscopy over Open Surgery Laparoscopic approach offers advantages such as reduced surgical site infection risk, incisional hernia risk, and length of stay compared to open laparotomy. However, it is not appropriate for unstable patients who require immediate intervention.

The laparoscopic approach offers additional benefits, including the use of the Bowie score to determine patient sickness based on three factors: severe comorbidity, preoperative shock (systolic pressure under 90), and duration of perforation over 24 hours. The Bowie score helps stratify morbidity.

Gastroduodenal perforation may not be suitable for laparoscopic procedure. It can be closed with primary closure or using a mental patch, such as the Kellen jones repair. The omentum can be used to plug the hole or sutured over.

Surgical techniques for treating perforated gastric ulcers vary based on the operator's experience. Reconstruction provides flexibility, allowing distal gastrectomy and ruined by reconstruction for low-riding ulcers or alternative methods for high-riding ones.

Extensive gastrectomy with Roux-en-Y reconstruction is discussed, emphasizing the prevalence of duodenal ulcers over gastric ulcers and the significance of H. pylori as a major risk factor for peptic ulcer disease. The importance of testing and treating patients for H. pylori when positive, along with first-line treatments such as endoscopy for bleeding and non-operative therapy or open surgery based on patient stability in cases of perforation.

Management of Bleeding Disorders Patients with bleeding disorders should be managed conservatively, with endoscopy as the first attempt to treat bleeding. Major surgery is risky for these patients, and embolization may be recommended over surgery.

Proton Pump Inhibitor Use in Surgery There are differing opinions on prophylactic use of proton pump inhibitors (PPIs) in all surgical patients. It's debated whether PPI therapy should be given to every patient due to cost and potential complications like gastritis and acid reflux disease.

Resistance to Helicobacter pylori Treatment Resistance to medical treatment for Helicobacter pylori (HP) infection is a problem. Retesting after treatment is important, especially if there was initial resistance. Salvage regimens can be used for persistent HP infection.