The Surgical Management of Complicated Peptic Ulcer Disease: An EAST Video Presentation

Abstract

Background:

Peptic ulcer disease (PUD), once primary a surgical problem, is now medically managed in the majority of patients. The surgical treatment of PUD is now strictly reserved for life-threatening complications. Free perforation, refractory bleeding and gastric outlet obstruction, although rare in the age of medical management of PUD, are several of the indications for surgical intervention. The acute care surgeon caring for patients with PUD should be facile in techniques required for bleeding control, bypass of peptic strictures, and vagotomy with resection and reconstruction. This video procedures and techniques paper demonstrates these infrequently encountered, but critical operations.

Content (Video Description):

A combination of anatomic representations and videos of step-by-step instructions on perfused cadavers will demonstrate the key steps in the following critical operations. Graham patch repair of perforated peptic ulcer is demonstrated in both open and laparoscopic fashion. The choice to perform open versus laparoscopic repair is based on individual surgeon comfort. Oversewing of a bleeding duodenal ulcer via duodenotomy and ligation of the gastroduodenal artery is infrequent in the age of advanced endoscopy and interventional radiology techniques, yet this once familiar procedure can be lifesaving. Repair of giant duodenal or gastric ulcers can present a challenging operative dilemma on how to best repair or exclude the defect. Vagotomy and antrectomy, perhaps the least common of all the aforementioned surgical interventions, may require more complex reconstruction than other techniques making it challenging for inexperienced surgeons. A brief demonstration on reconstruction options will be shown and includes Roux-en-Y gastrojejunostomy.

Conclusions:

Surgical management of PUD is reserved today for life-threatening complications for which the acute care surgeon must be prepared. This presentation provides demonstration of key surgical principles in management of bleeding and free perforation as well as gastric resection, vagotomy and reconstruction.

Study Type:

Video Procedure and Technique

Level of Evidence:

Not applicable

Background

Peptic ulcer disease (PUD), once predominantly a surgical problem, is now primarily medically managed. Medications including histamine (H2) blockers and proton pump inhibitors (PPI) along with the treatment of Helicobacter pylori (H. pylori) have resulted in a steady decline in incidence and prevalence of PUD.¹ As medical management has proliferated, hospitalization rates for PUD complications have decreased significantly. Complicated PUD (bleeding, perforation, obstruction, or intractable ulcers) decreased 21% from 1998 to 2005.² With current medical and minimally invasive treatments, patients with complicated PUD rarely require surgery. Only 2–14% of patients with complicated PUD will have a perforation, and up to half of these patients may be treated non-operatively due to spontaneous sealing.³

Surgical treatment of PUD is reserved for refractory or severe complications, such as life-threatening bleeding, uncontained perforation, or stricture causing obstruction.^1,4 This EAST Video Presentation demonstrates Procedures and Techniques used in infrequent but critical operations for surgical management of complicated PUD. Procedures demonstrated include Graham patch (open and laparoscopic); ligation of gastroduodenal artery (GDA); vagotomy and antrectomy with Roux-en-Y reconstruction. Supplemental online videos demonstrate key steps and principles of these procedures as performed on fresh perfused cadavers in accordance with the policies of our institution’s Fresh Tissue Training Program and Human Gift Registry.

Clinical Presentation and Initial Resuscitation

Complicated PUD varies in presentation and severity. Initial evaluation includes pertinent history and physical examination, hemodynamic monitoring, imaging and laboratory investigation. Perforated PUD frequently demonstrates free air on x-ray. Patients with contained perforation commonly display focal tenderness, while those with free perforation typically present with severe, diffuse abdominal tenderness, peritonitis, or hemodynamic instability. For patients with perforation, laboratory values may indicate intraabdominal infection (marked leukocytosis). Hemoglobin value may not reveal the true degree of anemia in early hemorrhage. A multi-disciplinary approach involving surgeons, critical care, gastroenterology, and interventional radiology is appropriate, if available, for initial resuscitation, prompt evaluation and early intervention.

Initial resuscitation in patients with hemorrhage or sepsis, includes need for large-bore venous access, fluid administration or blood transfusion for intravascular repletion, and critical care environment especially for consideration of early endotracheal intubation.^5,6 Patients with suspected ulcer perforation should receive intravenous antibiotics and antifungals and an intravenous proton-pump inhibitor.⁷ Those presenting with emesis from gastric outlet obstruction or blood in the stomach may benefit from placement of gastric tubes for evacuation.

Preoperative Considerations

Complicated PUD includes inflamed tissues, distorted anatomy, potential bleeding, and hemodynamic instability. Open laparotomy allows for more expedient control of intraabdominal sepsis or hemorrhage. We only consider laparoscopy in patients with suspected perforation and in hemodynamically stable patients that are likely to tolerate pneumoperitoneum. Regardless of choosing to start laparoscopically, all operating rooms should be ready with instruments required for open surgery. Specific equipment for resections such as linear or endoscopic gastrointestinal stapling devices should be available. In cases where the abdomen cannot be closed or a second look laparotomy is indicated, materials required for a temporary abdominal closure should be available. Effective communication with the anesthesia team should include operative findings including ongoing bleeding and clinical signs of coagulopathy.

Operative Techniques

Basic Considerations

An upper midline laparotomy provides rapid access to the stomach and duodenum. For open operative intervention the patient is positioned supine, and the arms extended. The method of gaining abdominal access and achieving pneumoperitoneum depends on patient factors and surgeon preference. Once abdominal access is obtained port configuration should include a large (12 mm) port at the umbilicus and at least two 5 mm ports in the right and left lateral abdomen (Figure 1). An additional 5 mm port can be placed in the subxiphoid or left subcostal region to allow for use as a liver retractor.

Figure 1. Laparoscopic Port Placement.

The patient is positioned supine, with the head toward the top of the picture. A 12 mm port is placed just cephalad to the umbilicus and two 5 mm ports are placed in the left lateral and right lateral abdomen. An additional 5 mm port can be placed in the subxiphoid or left subcostal region for the use of a liver retractor. Once all ports are placed the patient is positioned in reverse Trendelenburg.

Graham patch, open and laparoscopic

Graham patch is useful for emergent repair of gastric or duodenal perforation.^8,9 Steps include safe abdominal access, washout, control of contamination, identification of ulcer(s), mobilization of omentum, primary repair of the ulcer (modified Graham patch), securing omental patch, and drain placement. For laparoscopic Graham patch, bowel graspers, laparoscopic needle drivers and suction-irrigating devices facilitate repair. Similar to open repair, the ulcer can be repaired in either classic or modified Graham patch fashion. Begin with washout and control of contamination. Limited mobilization should be performed, and the ulcer should be assessed. A tongue of viable omentum is mobilized using a laparoscopic energy device. Biopsy all gastric ulcers, however biopsy of duodenal ulcers is not indicated. For small ulcers we perform modified Graham patch repair. First, the ulcer defect is closed primarily with 2–0 silk sutures introduced via 12 mm port. The omental tongue is secured in 3–4 locations. A closed suction drain is placed inferior to the ulcer via one of the 5 mm port sites and secured, Supplemental Digital Content 1, Video 1: Peptic Ulcer Disease Laparoscopic Graham Patch. Consider open conversion based on need for better visualization or inability to control bleeding.

Steps for open Graham patch repair are similar to the laparoscopic approach, Supplemental Digital Content 2, Video 2: Peptic Ulcer Disease Open Graham Patch. The falciform ligament is mobilized allowing it to serve as an additional liver retractor. The stomach and duodenum are inspected to identify all ulcers. A tongue of healthy appearing omentum is mobilized with an energy device. Repair the defect and secure omentum with silk suture (2–0 or 3–0). We leave closed suction drains in place for all cases involving perforated ulcers. A nasogastric tube is placed to decompress the stomach after repair, and distal feeding access is ensured. In the setting of a giant ulcer (> 3 cm), consider resection and reconstruction in lieu of Graham patch repair.

Duodenotomy and Ligation of the Gastroduodenal Artery

For patients with uncontrolled hemorrhage from a duodenal ulcer, surgical therapy can be required and is best approached via laparotomy. Steps for open GDA ligation include longitudinal duodenotomy with stay sutures, ligation of the GDA and transverse pancreatic branch, and closure of the duodenotomy via pyloroplasty with vagotomy.^9,10 See Supplemental Digital Content 3, Video 3: Peptic Ulcer Disease GDA Ligation. After entering the abdomen, perform a longitudinal duodenotomy spanning 2–3 cm crossing the pylorus onto the stomach. Stay sutures are placed on the superior and inferior edge of the duodenotomy to aid in exposure. The base of the bleeding ulcer is located and a 2–0 or heavier absorbable suture is then used to ligate the GDA at superior (12 o’clock) and inferior (6 o’clock) positions using simple or figure of eight stitch. The transverse pancreatic branch is then ligated using a horizontal U-stitch underneath the ulcer (Figure 2). Once hemostasis has been obtained, the duodenotomy is closed transversely in two layers. The mucosa is closed using running absorbable suture, while the serosa is imbricated over the mucosal repair with interrupted silk stitches. In unstable patients, after expeditious control of the bleeding vessel and closure of the duodenotomy, truncal vagotomy is performed. We routinely leave a closed suction drain to aid in control and identification of post-operative leak, and we place a Dobhoff tube for distal feeding access.

Figure 2. Orientation of the Gastroduodenal artery (GDA) and its branches.

Ligation of the GDA and its branches can help control a bleeding ulcer. An open longitudinal duodenotomy is depicted with stay sutures placed on the superior and inferior aspects of the duodenotomy. This image includes a representation of the course of the GDA and its branches beneath the ulcer crater.

Vagotomy and Antrectomy

Vagotomy and antrectomy can be necessary for control of hemorrhage and contamination, in patients with a giant ulcer (> 3 cm) or with ulcers that have failed conventional therapy.¹¹ Steps for vagotomy include opening of the peritoneum at the GE junction, exposing the diaphragmatic crura, dissection of anterior and posterior vagus nerves with resection and pathologic confirmation of nerve tissue. Antrectomy includes opening the gastrocolic and gastrohepatic omentum, gastric transection at the angularis incisura, posterior mobilization of the stomach and duodenum, and safe duodenal resection with identification of the common bile duct/ampulla.

We typically perform a non-selective truncal vagotomy. The triangular ligament of the left lobe of the liver is mobilized facilitating exposure of the esophageal hiatus. The body of the stomach is retracted caudally while the peritoneum overlying the gastroesophageal junction and diaphragmatic crura is incised. The anterior vagus is isolated and dissected off the esophagus for approximately 2 – 5 centimeters (Figure 3, left image). Clips are placed proximal and distal, and the nerve is excised and sent to pathology for confirmation. The posterior vagus is typically more difficult to isolate, however it can generally be palpated behind the esophagus and bluntly dissected. A window is made between the posterior vagus and the esophagus. A Penrose drain is then passed behind the esophagus, but anterior to the posterior vagus and used to retract the esophagus laterally (Figure 3, right image). A vessel loop is used to retract the posterior vagus medially while clips are applied proximal and distal. The nerve is resected and sent to pathology for confirmation. Coordination with pathology may be necessary to ensure their availability for specimen processing, Supplemental Digital Content 4, Video 4: Peptic Ulcer Disease Vagotomy and Antrectomy.

Figure 3. Exposure of anterior and posterior vagus nerves.

Figure 3 (left image) demonstrates the exposure of the esophageal hiatus and mobilization of the anterior vagus nerve as it lies on top of the esophagus at the gastroesophageal junction. A right angle is passed beneath the anterior vagus for demonstration. Figure 3 (right image) depicts the exposure of the posterior vagus nerve with the esophagus retracted laterally and the posterior vagus nerve retracted medially.

Antrectomy begins by taking down the gastrocolic omentum along the greater curve of the stomach to the point of proximal resection. Likewise, the gastrohepatic omentum is also mobilized off the distal lesser curve. The stomach is then resected using a linear stapler at the angularis incisura. Depending on inflammation and edema, linear staplers of appropriate length with bowel (3.0 to 4.0 mm) or gastric loads (4.8 mm) are required for resection with appropriate reloads for multiple firings if needed. The antrum is mobilized posteriorly to the first portion of duodenum. Posterior adhesions are typically very dense in chronic PUD and often require use of an energy device for dissection. The duodenum can be opened anteriorly and longitudinally, and the ampulla can be palpated from inside to aid in choosing the site of duodenal resection. Once the site of duodenal resection has been chosen, it is resected using a linear or transverse anastomosis stapler with an appropriate bowel load. See Supplemental Digital Content 4, Video 4: Peptic Ulcer Disease Vagotomy and Antrectomy.

Reconstruction

We favor Roux-en-Y gastrojejunostomy for reconstruction of the gastrointestinal system. The proximal jejunum, approximately 30 cm distal to the ligament of Treitz, is transected with a linear stapler and delivered as a retro-colic Roux limb. A stapled gastrojejunostomy is created, and the common enterotomy is closed. A Roux limb of 40 cm (minimum) can help decrease the incidence of bile reflux, and creation of a biliopancreatic limb of at least 30 cm past the ligament of Treitz reduces weight loss that can occur after Roux-en-Y reconstruction.¹² See Supplemental Digital Content 5, Video 5: Peptic Ulcer Disease Roux-en-Y Reconstruction. Factors such as tissue quality may influence the decision to perform a hand-sewn or a stapled anastomosis. We prefer a stapled common channel and hand sewn, two-layer closure of the common enterotomy.

Damage Control

Damage control laparotomy (controlling hemorrhage/contamination and temporary closure) should be considered for patients demonstrating signs of severe sepsis and/or hemodynamic instability. Damage control principles can be utilized in patients with large ulcers requiring a skillset beyond the operating surgeon or those not amenable to expeditious repair. Reconstruction can be delayed for up to 24 – 48 hours until the patient has been suitably resuscitated or transferred to a facility with advanced level of care.

Post-operative considerations

We leave enteral access distal to repaired perforated ulcers as well as gastric tubes to decompress the stomach. Gastric decompression is removed expeditiously to promote pulmonary hygiene. Nutritional support can begin early post-operatively. Assessment of the repair occurs post-operative day 3 – 5 with an upper GI series using water soluble contrast. If negative distal feeding access can be removed and the diet advanced as tolerated. For patients with a leak, longer term distal enteral access is required.

All patients will require extended courses of PPIs, H. pylori testing, and future endoscopic evaluation to ensure resolution. When dealing with perforation and contamination, extended courses of antibiotics may be required. H. pylori testing (intra-operative specimen or stool antigen) and treatment are important. Patients require surveillance endoscopy.

Summary

Surgical management of PUD is reserved for life-threatening complications. Acute care surgeons are frequently called upon to manage patients presenting with complicated PUD requiring these rarely performed surgical procedures. This EAST Video Presentation provides useful instructions for key surgical procedures in management of complicated PUD.