Ulcer Surgery

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Definition

Ulcer surgery is a procedure used to cure peptic ulcer disease when medications have failed.

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.

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

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.

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.

Opening up the valve at the outlet of the stomach guarantees that the stomach can empty, even without 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).

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.

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.

— J. Ricker Polsdorfer, MD