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FIGURE 1 • Pyloroplasty. (Figure 46.2 in Mulholland MW. Gastroduodenal
ulceration. In: Mulholland MW, Lillemoe KD, Doherty GM, et al., eds.
Greenfield’s Surgery: Scientific Principles and Practice. 4th ed. Baltimore,
MD: Lippincott Williams & Wilkins, 2006:722–735).
Pitfalls
• Failure to perform careful esophageal dissection and
injuring/perforating the esophagus
• Forgetting to perform biopsies of the vagal nerves for
confirmation of the appropriate resection of nerve tissue
• Causing splenic injury when applying traction on the
stomach
• Causing a postoperative hiatal hernia from not repairing
defects at the esophageal hiatus at the time of vagotomy
b. Vagotomy and antrectomy ( T a b l e 3): The
combination of the vagotomy and antrectomy
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eliminates basal acid secretion and decreases
stimulated acid secretion by 80%. The benefits of a
vagotomy with antrectomy are that the procedure may
be applied to a variety of situations, and that the ulcer
recurrence rate is very low. The disadvantages are
that the operative mortality is higher than with V&D or
highly selective vagotomy (HSV), and that there may
be complications associated with the subsequent
Billroth I or Billroth II reconstructions. In the modern
era, the antrectomy should be reserved for
healthy/stable patients with refractory ulcer disease
and/or anatomic indications (e.g., large antral gastric
ulcers, pyloric scarring).
TABLE 3. Antrectomy
Procedure:
The vagotomy proceeds as described
above.
The antrectomy is begun by separating the distal half
of the greater curvature by dissecting the greater
omentum from the proximal half of the transverse
colon, carefully isolating and ligating the branches
from the gastroepiploic arcade. Then the posterior
wall of the first part of the duodenum is dissected
from the pancreas. The gastrohepatic ligament is
divided proximally along the lesser curvature and the
left gastric vessels along the lesser curvature are
ligated and divided. The stomach is divided with the
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goal to remove all the antral mucosa. The upper
margin of the antrum may be approximated by
identifying the halfway point on the lesser curvature
between the gastroesophageal junction and the
pylorus. The stomach is divided with a GIA-style
linear stapler using 4.8 mm staples. Next, the right
gastric artery is identified above the pylorus, ligated,
and divided. To facilitate manipulation of the
duodenum, dissect approximately 1.5 cm of the
posterior duodenum off of the pancreas. Divide the
duodenum just distal to the pylorus with a GIA-style
linear stapler. Send a frozen section biopsy of the
margin of duodenal stump to confirm the presence of
duodenal Brunner’s glands to avoid retained antrum.
Following the antrectomy, either a Billroth I
gastroduodenal anastomosis or a Billroth II
gastrojejunostomy is constructed. A Billroth I requires
at least 1 cm of healthy duodenum and in the case of
significant scarring it is difficult to perform. A Billroth II
is the default reconstruction and can almost always
be performed. For a Billroth I reconstruction, the
staple line of the transected duodenum is excised
and an end-to-end gastroduodenal anastomosis is
performed in two layers. The inner layer consists of
full-thickness continuous sutures. The outer layer
consists of interrupted seromuscular Lembert
sutures. A crown stitch is placed at the “angle of
sorrow” of the gastroduodenal anastomosis. If a
Billroth II is to be constructed, then the duodenal
stump is closed in two layers. The Billroth II
gastrojejunostomy is begun by choosing a loop of
proximal jejunum and bringing it antecolic or
retrocolic to the stomach. If a retrocolic approach is
chosen, care must be taken to close the mesenteric
defect to reduce the risk of a future internal hernia.
The jejunum is aligned along the gastric pouch and a
two-layered gastrojejunostomy is performed. A crown
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stitch is placed at the “angle of sorrow” at the medial
margin of the gastrojejunal anastomosis. Any
exposed staples from the antrectomy should be
oversewn.
Pitfalls
• Incomplete removal of the antrum increases the risk of
developing a marginal ulcer.
• For the Billroth II reconstruction, it is important to
properly close the duodenal stump to prevent future
leaks that could be complicated by fistula formation or
pancreatitis.
• Splenic injury may occur secondary to downward
traction on the greater curvature of the stomach.
c. Parietal cell/proximal vagotomy (Table 4) (Figure 2):
The goal of the parietal cell vagotomy is to eliminate
vagal stimulation of the acid-secreting portion of the
stomach, while retaining motor innervation to the
antrum and pylorus. The receptive relaxation of the
stomach is still affected by this procedure, and liquid
emptying from the stomach is accelerated, but solid
emptying is normal. This procedure reduces the
basal acid secretion by 75% and the stimulated acid
secretion by 50%. The HSV has low mortality (risk <
0.5%) and morbidity but has a high ulcer recurrence
rate especially with inexperienced surgeons.
TABLE 4. Parietal Cell Vagotomy Key Points
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FIGURE 2 • Truncal and proximal vagotomy. (Figure 46.1 in Mulholland MW.
Gastroduodenal ulceration. In: Mulholland MW, Lillemoe KD, Doherty GM,
et al., eds. Greenfield’s Surgery: Scientific Principles and Practice. 4th ed.
Baltimore, MD: Lippincott Williams & Wilkins, 2006:722–735).
Procedure:
The initial exploration is as described for
truncal vagotomy. The anterior nerve of Latarjet,
which is the termination of the left vagus nerve, is
identified and encircled. Then the lesser sac is
examined for adhesions to the pancreas and then
entered by dividing the gastrocolic ligament, while
preserving the gastroepiploic arcade. Next, the lesser
omentum is divided from the lesser curvature
between the incisura angularis and the cardia, by
dividing all of the blood vessels and nerves that enter
the lesser curvature. The dissection begins just
proximal to the crow’s foot of the nerve of Latarjet and
proceeds proximally along the lesser curvature to the
left side of the gastroesophageal junction. The
neurovascular branches should be ligated with 3-0 or
4-0 silk sutures and divided. Then the stomach is
reflected upward and the posterior denervation is
conducted in a similar manner. Then the nerve fibers
and blood vessels on the lower 5 to 7 cm of the
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esophagus must be dissected and ligated.
Pitfalls
• Recurrent ulcers may be the consequence of an
inadequate proximal vagotomy.
• Careful dissection around the lesser curvature of the
stomach is important to decrease the risk of injury to the
lesser curve.
Special Intraoperative Considerations
Laparoscopic repair:
Omental patch repair of ulcers <1.0
cm may be performed by either an open or laparoscopic
approach. A randomized controlled trial of 121 patients
with perforated peptic ulcers reported that the laparoscopic
group had significantly lower analgesic requirements,
postoperative hospital length of stay, and returned to work
significantly earlier than the open group. There were no
significant differences between the two groups in mortality,
incidence of reoperation, or postoperative intra-abdominal
fluid collections.
Giant perforated ulcers:
There is no standard
management for giant perforated ulcers (>2 to 3 cm).
Recommendations for repair have included omental patch,
controlled tube duodenostomy, jejunal pedicled graft, jejunal
serosal patch, free omental plug, partial gastrectomy, and
pyloric exclusion. The choice of repair will be influenced by
the patient’s status, the size of the perforation, the degree
of intraperitoneal contamination, and the surgeon’s
experience.
Posterior perforation:
Spontaneous posterior
perforation of a duodenal ulcer is rare. A definitive ulcer
operation is typically undertaken, though there is no
standard treatment.
Perforated gastric cancer:
Though perforation is a rare
complication (<1%) of gastric cancer, a biopsy and frozen
section should be taken during surgery for all gastric
perforations. Options for the surgical repair of a perforated
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gastric cancer include omental patch, emergency
gastrectomy, and a two-stage radical gastrectomy.
Perforation at the gastroesophageal junction:
The
operative approach to perforation of an ulcer located next
to the esophagogastric junction may include a subtotal
gastrectomy to include the ulcer with a Roux-en-Y
esophagogastrojejunostomy or a vagotomy with
antrectomy.
Postoperative Management
H.
pylori
infection should be treated with triple therapy for
10 to 14 days; a common treatment regimen is
clarithromycin, amoxicillin, and omeprazole. Following
treatment conclusion,
H. pylori
eradication should be
confirmed. Patients should receive counseling regarding
NSAID use.
Postoperative complications include the following:
1. An early ulcer recurrence with leak is often treated
with reexploration and may require gastric resection
to adequately repair.
2. An uncontained leak after omental patch may require
reexploration and gastric resection with a Billroth II.
3. Subphrenic and subhepatic abscesses are
associated with a surgery delay >12 hours.
4. A patient should be evaluated for duodenal
obstruction if gastric emptying is not normal by the
eighth postoperative day.
5. Wound infection
6. Pneumonia
7. Pancreatitis
In patients following a definitive ulcer surgery there are
also the following risks:
1. Diarrhea following truncal vagotomy occurs in 5% to
10% of patients. It typically occurs 1 to 2 hours
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following a meal. This problem usually resolves
without intervention. Persistent symptoms may be
improved by cholestyramine and/or loperamide. If
medical therapy does not improve symptoms, a
surgical option includes placement of a reversed
jejunal interposition placed 100 cm distal to the
ligament of Treitz.
2. Dumping syndrome occurs in 5% to 10% of patients
following distal gastrectomy, pyloroplasty, or
pyloromyotomy. It is classified as either early
dumping, occurring within 30 to 60 minutes of eating;
or late dumping, occurring 2 to 3 hours following a
meal. Symptoms of early dumping include fatigue,
facial flushing, lightheadedness, diaphoresis,
palpitations, cramping abdominal pain, nausea,
vomiting, and diarrhea. Symptoms of late dumping
are typically limited to vasomotor symptoms.
Treatment of these symptoms with dietary
manipulation is often successful. Octreotide may be
useful in severe cases. Octreotide, administered
prior to meals, has been shown to improve both
gastrointestinal and vasomotor symptoms. Remedial
surgery is an option for patients with dumping
symptoms resistant to medical management;
however, this approach is typically not used because
most patients do eventually respond to conservative
therapy.
3. Following elimination of the pyloric sphincter bile can
reflux into the stomach. Alkaline reflux gastritis
develops in 2% of patients. It is characterized by
epigastric pain and nausea that is provoked by
meals. Medical therapy with cholestyramine may
improve symptoms. Cases resistant to medical
management may be treated surgically with a Billroth
II gastrojejunostomy with Braun enteroenterostomy,
Roux-en-Y gastrojejunostomy, or a Henley loop.
4. Early satiety with epigastric fullness and emesis with
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meals may develop secondary to gastric stasis,
having a small gastric remnant, or from postsurgical
atony. Atony may be confirmed with a solid food
emptying test and then treated with a prokinetic
agent, or if that fails, gastric pacing or completion
gastrectomy. Symptoms of a small gastric remnant
typically improve with small frequent meals.
5. Following Billroth II construction, the limb may
become obstructed and cause afferent and efferent
loop syndromes. Afferent loop syndrome is
characterized by postprandial epigastric pain and
non-bilious vomiting that is relieved following bilious
vomiting. Efferent loop syndrome is characterized by
epigastric pain, distention, and bilious vomiting. Both
syndromes are treated with a surgical approach.
TAKE HOME POINTS
Early diagnosis and operation are associated with
improved outcome.
It is important to identify prior NSAID use.
It is important to identify
H. pylori
infection.
Surgical goals are to control the perforation and
lavage the abdominal cavity.
Although rarely required, definitive ulcer operation
may be required in select patients.
Gastric perforation should prompt consideration of
underlying gastric cancer.
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