Patients with peptic ulcer occasionally develop complications that require surgical intervention, despite the advances in medical treatment and changes in the natural history of disease. The clinical surgeon must make...
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Patients with peptic ulcer occasionally develop complications that require surgical intervention, despite the advances in medical treatment and changes in the natural history of disease. The clinical surgeon must make a decision about performing "selective vagotomy antrectomy versus highly selective vagotomy," based on the information discussed herein. The goals for operative treatment remain safe correction of the presenting problem, avoidance of perioperative morbidity and mortality, and freedom from disabling postoperative side effects. This paper addresses broad aspects of the details of surgical interventions;because most operative procedures are performed in urgent circumstances in patients who often have a variety of conditions, it is not surprising that there is no best operation suited to every complication of ulcer.
The decline in duodenal ulcer disease and the established relation of peptic ulcer to Helicobacter pylori have virtually abolished the need for elective ulcer surgery, However, a substantial proportion of the populati...
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The decline in duodenal ulcer disease and the established relation of peptic ulcer to Helicobacter pylori have virtually abolished the need for elective ulcer surgery, However, a substantial proportion of the population around retirement age has previously been subjected to partial gastric resection due to peptic ulcer, and the long-term outcome of these patients is of continuing relevance, Patients subjected to elective surgery could represent a selected group of healthy subjects with a lower overall morbidity, but reports indicate that patients operated on for peptic ulcer have more advanced disease associated with excess smoking and a different pattern of social behavior, The surgical procedure induces enterogastric reflux, leading to profound changes in the remnant mucosa and the formation of carcinogens in the gastric juice, In addition, metabolic abnormalities are common, especially fat malabsorption. Evaluation of the impact of these factors on morbidity and mortality is difficult. Increased mortality in gastrointestinal tumors (especially gastric stump carcinoma), respiratory diseases and other smoking-related malignancies, and suicide are found in the long-term follow-up after partial gastric resection due to peptic ulcer. However, these hazards to life are offset by a decreased mortality in cardiovascular disease. Preventive measures against suicide and especially tobacco smoking are recommended to improve the outcome for this cohort.
作者：
Johnson, AGUniv Sheffield
Royal Hallamshire Hosp Surg Unit Dept Surg Sheffield S10 2JF S Yorkshire England
Proximal gastric vagotomy (PGV) is a modification of truncal vagotomy, which was introduced by Dragstedt for the treatment of duodenal ulcer (DC) in 1943. It is a technically demanding operation;but when performed by ...
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Proximal gastric vagotomy (PGV) is a modification of truncal vagotomy, which was introduced by Dragstedt for the treatment of duodenal ulcer (DC) in 1943. It is a technically demanding operation;but when performed by an experienced surgeon, it is safe and gives a cure rate for DU of more than 90%, with minimal side effects. The operation permanently alters the natural history of the disease and may be used for gastric ulcer (GU), with ulcer excision;but it is not as effective, Further adaptations, such as posterior truncal vagotomy with anterior seromyotomy, were introduced to simplify and shorten the operation, but they did not receive wide acceptance. Recently, with the identification of Helicobacter, it was found that DU can also be cured by eliminating the infection. PGV is therefore used electively in patients with persistent DU that is not Helicobacter-positive or in the few in whom Helicobacter cannot be eliminated. In patients with bleeding or perforated DUs, PGV may be used in conjunction with underrunning the vessel or patching the perforation. However, few surgeons doing emergency peptic ulcer surgery have experience with PGV, so simple suture followed by medical treatment is the safest option. Because elective PGV is now a rare procedure, patients should be referred to a center with special expertise. If Helicobacter becomes resistant to antibiotics in the future, surgery may be needed regularly again, but the technical nuances would have to be relearned.
The eradication of Helicobacter pylori in patients with peptic ulcer disease has greatly diminished the need for antiulcer surgery. However, in societies where such drug therapy is considered too expensive and because...
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The eradication of Helicobacter pylori in patients with peptic ulcer disease has greatly diminished the need for antiulcer surgery. However, in societies where such drug therapy is considered too expensive and because occasional patients remain refractory to optimal medical therapy, elective surgery for duodenal ulcer disease is still carried out, If the required expertise is available, it can be undertaken laparoscopically. The advent of endoscopic therapies such as heater probe therapy and injection sclerotherapy has also greatly diminished the need for emergency surgery in bleeding peptic ulcer disease. Once again, however, when such therapy fails surgery is still indicated. El en with perforated peptic ulcer disease the role of surgery has receded somewhat, but here not because of changes in drug therapy. Nonoperative management of perforation is indicated in fit patients if the diagnosis is in doubt, in any patient when surgical facilities are unavailable (e.g., remote geographic areas, on board ship), or when a patient is extremely ill either because of comorbidity or late presentation of the disease. Operation should be considered in all patients when the perforation is established to be unsealed, particularly after a trial of conservative management, and in all patients who are otherwise fit.
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