Surgical Therapy

In simplest terms, there are three basic operations for uncomplicated peptic ulceration: parietal cell vagotomy, truncal vagotomy with pyloroplasty, and truncal vagotomy with antrectomy. With the advent of H2 receptor antagonists and, more recently, proton pump inhibitors the surgical treatment of peptic ulcer disease has become less common. Surgical treatment is indicated when ulcers fail to heal after 3 months of appropriate medical therapy or when ulcers recur on maintenance therapy. Surgery is also indicated when malignancy cannot be excluded and when complications of disease occur. Complications of peptic ulcer disease include perforation, hemorrhage, and obstruction.

Parietal cell vagotomy selectively inhibits vagal stimulation of parietal cells and smooth muscle cells of the gastric fundus. It spares the vagal enervation to the antrum, pylorus, small bowel, biliary tract, and pancreas. Acid secretion is diminished by the interruption of vagal stimuli to parietal cells. Specifically, basal acid secretion is decreased by about 80% and maximal acid secretion is decreased by about 70%. There is some rebounding of both basal and maximal acid secretion over time but neither rebound to preoperative levels. Vagal denervation of the gastric fundus inhibits receptive relaxation of the fundus. As a result, gastric emptying of liquids is increased. As the antrum and pylorus are spared, there is no effect on the emptying of solids.

Truncal vagotomy has similar efficacy in regards to the reduction of acid secretion. As with parietal cell vagotomy, truncal vagotomy decreases receptive relaxation of the gastric fundus increasing the emptying of liquids. Truncal vagotomy additionally inhibits antral and pyloric motility which results in poor emptying of solids. Pyloroplasty is included to overcome the effect of diminished gastric emptying. It effectively provides a wider gastric outflow tract so that the emptying of solids is increased.

Antrectomy removes the bulk of gastrin producing cells and effectively reduces basal gastrin levels by 50% and postprandial gastrin levels by 67%. Reconstruction of the upper GI tract is via gastroduodenostomy (Billroth I) or loop gastrojejunostomy (Billroth II). Truncal vagotomy and antrectomy results in the reduction of basal and maximal acid secretion by about 85%. Inhibited fundic receptive relaxation again results in the increased emptying of liquids. The emptying of solids is decreased. Both forms of reconstruction are similar in regards to operative mortality, morbidity, and rates of recurrence. Comparison of these three procedures is as follows: (Table 11.5).

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