Various types of vagotomy

Three types of vagotomy require consideration. Bilateral truncal vagotomy denervates the entire stomach and the gastrointestinal tract to the left colon. When combined with other operations it is extremely effective in reducing the number of recurrent ulcers.

However it does carry some deleterious side effects, reducing the ability of the stomach to empty and being followed by other late motility disturbances, occasional vagus diarrhoea, and reflux alkaline gastritis.

Selective vagotomy denervates the entire stomach but leaves nerves to the gallbladder, pylorus, and bowel intact. From a practical point of view this operation is more difficult and time-consuming than truncal vagotomy, appears to have nearly equivalent results, and has attracted few supporters. Proximal gastric vagotomy can be used without pyloroplasty.

Partial gastrectomy

The usual procedure involves resection of the distal two-thirds of the stomach followed by either a Billroth I or a Billroth II anastomosis. In our opinion the operation is neater and more accurate when sutures are inserted by hand, although stapling instruments can be used. Partial gastrectomies are usually performed for type 1 gastric ulcer and for combination of duodenal ulcer perforation with decompensate stenosis.

Postoperative treatment

Administer intravenous antibiotics postoperatively. The length of administration is based on the operative findings and the recovery of the patient.

Antiemetics and analgesics are administered to patients experiencing nausea and wound pain.

A liquid diet may be started when bowel function returns.

To prevent gastric and duodenal ulcer recurrence and their complications proton pump inhibitor or H2 – receptors antagonist is administered.

Follow-up care

After hospital discharge, patients must have a light diet and limit their physical activity for a period of 4 weeks – 3 months based on the surgical approach (i.e., laparoscopic or open procedure).

The patient should be evaluated by the surgeon in the clinic to determine improvement and to detect any possible complications.

Continuous supportive therapy (for a month or even years) with half the dose of proton pump inhibitors or H2 receptors antagonists is administered.

Prognosis

For uncomplicated surgery, the prognosis is excellent, with a very low mortality rate.

Chapter 5 Peptic ulcer acute haemorrhage

Peptic ulcer acute haemorrhage is a common occurrence throughout the world. In France, a recent report concludes that the mortality from peptic ulcer acute haemorrhage has decreased from about 11 to 7%; however, a similar report from Greece finds no decrease in mortality.

Patients typically present with an ulcer that has bled or is actively bleeding. Approximately 80% of ulcers stop bleeding. The overall mortality rate is approximately 10%. Rebleeding or continued bleeding is associated with increased mortality. Comorbidities increase the probability of rebleeding in patients after endoscopic therapy. An increasing amount of evidence in the literature states that therapy with high-dose proton pump inhibitors may decrease the rate of rebleeding after endoscopic therapy. By increasing the gastric pH above 6, the clot is stabilized.

This patient population has become progressively older, with significant comorbidities that increase mortality.