Monday, June 30, 2008
In this day and age of everyone and their brother being on protonix or nexium or some variant thereof, we rarely see patients present with peptic ulcer disease to such a degree that surgical intervention is necessary. The glory days of general surgery had to be back in the late seventies when guys like Phil Donahue MD (not Marlo Thomas' husband) were snipping vagus nerves in a highly selective fashion left and right. The old surgical textbooks had throngs of chapters on all the permutations of ulcer surgery. Vagotomies and Billroth I and Billroth II and roux-en-Y gatrojejunostomies and all the post-gastrectomy complications like dumping syndrome and gastroparesis and roux stasis. My god, I killed myself trying to memorize everything as a junior resident. And then.... I find out no one ever does surgery like that anymore except for the occasional graham patch for a perforated duodenal ulcer. Looking through the old Cameron and Schwartz textbook chapters on peptic ulcer diease is like reading an old scroll from Galen or Hippocrates. Interesting but not particularly relevant to modern surgical practice.
But every once in a while we see someone like Patient X. 50 years old, alcoholic, non-compliant with previous medical interventions. He smokes 2 packs a day and said that whenever he would "cough up blood" he could usually treat it by running out to Walgreens and scarfing down a bunch of Tagamet and/or Pepcid. He was admitted for weakness and his hemoglobin in the ER was noted to be 4.6. The upper endoscopy confirmed a large gastric ulcer (3x6cm) on the lesser curve of the stomach that was not actively bleeding. Further questioning found that he had a first degree relative who had died from a "stomach tumor". So he got transfused up to a normal level and was placed on a Protonix IV drip. Then what?
Peptic ulcer disease (PUD) encompasses ulcers in two distinct locations: duodenal and gastric. Duodenal ulcers are much more common. 95% of duodenal ulcers are associated with chronic H Pylori infection and nearly all are observed in the setting of acid hypersecretion.
Gastric ulcers are a slightly different animal. Gastric ulcers are further broken down into 4 categories:
Type I- Most common type, usually a single ulcer on the lesser curve, not typically associated with hypersecretion of acid, seen in patients infected with H Pylori or NSAID abusers.
Type II- Two ulcers present (duodenal and lesser curve of stomach), strong association with hypersecretion of acid.
Type III- Prepyloric ulcers, also have an association with hypersecretion of acid
Type IV- ulcers near the gastroesophageal junction, not associated with acid hypersecretion.
The classic indications for surgery for gastric ulcers are similar to those for duodenal ulcers: perforation, bleeding, obstruction, and intractability. In addition, gastric ulcers are a risk factor for the development of gastric adenocarcinoma. Therefore, all gastric ulcers need to be biopsied and followed over the course of time. Giant gastric ulcers (>3cm) have a 30% incidence of harboring a cancer.
Back to my patient. Non compliant borderline alcoholic male. Giant gastric ulcer. Strong family history of stomach cancer. Presents with significant blood loss and massive transfusion requirements....what would you do?
Well I did a distal gastrectomy with Billroth II reconstruction. No need for vagotomy because his was a true Type I ulcer (non-dependent on acid hypersecretion). He's doing well so far. The ulcer seemed smooth and rounded (more consistent with a benign etiology) but we'll have to see what the pathology shows in a few days. Surgery on the stomach is actually quite fun. You feel like a goddam surgeon when you're in there doing it. Sometimes futzing around with laparoscopes and tiny instruments all the time can be tiresome. Good to get your hands dirty every now and then....
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Great image and review of perforated ulcers. How long does a B2 take to do? I haven't ever had the pleasure of sitting through one.
Wow, Buckeye that brings back memories from 1986, gonna wear my Miami Vice jacket to work today. I memorized the operations to, as a 3rd year medical student who wanted to be a Surgeon. I still remember getting lectured to because I didn't know the different kinds of incisions you have to make on the Pylorus so the stomach will empty properly.
in our setting we still do some gastrectomies, but all in complex patients. i remember one i did in the state hospital. the junior asked me to explain the anatomy nicely as i went. i laughed. i then explained to him that in general, if there is still anatomy, we don't do gastrectomies.
sure enough, the ulcer had eroded into the liver, the mesocolon of the transverse and the anterior abdominal wall. i kid you not. also the galbladder had been destroyed and its remnant protruded into the stomach. i basically had to leave the ulcer bed, cut the stomach above and do some sort of repair (i think i did a roux-y).
also, in our setting duodenal ulcer is becoming a scarce monster. this may be because of hp eradication or possibly the african variant of the organism. gastric ulcers are far more common.
Great stuff, as usual, Bongi. Is gastric cancer seen very often, as in Asian countries?
no. i think our gastric cancer is about the same as yours would be. nothing like the asians or japanese.
Did you consult Chris Johnson M.D. for the post-operative care?
Very nice patient presentation. Your management is well supported by all the surgery texts, but I still don't understand why he will not get a marginal ulcer with a BII and intact vagi. Can you explain it?
Good question. He may very well get a marginal ulcer but I don't feel the risk (1-5% ??) warrants a vagotomy and all the attendant complications (high esophageal dissection, long term motility issues). I saw a lady a few months ago with a perforated marginal ulcer a year out from a roux-n-Y gastric bypass. It will be interesting to see if someone compiles data on marginal ulcers for gastric bypass because none of those patients get routine vagotomies either.
Did you do a Heinike-Mikulitz incision?
I believe that the argument for why people don't routinely get marginal ulcers after RYGB is that the gastric pouch it is so small. Though of course I have operated for it 2-3 times in training. The same rationale states that a vagotomy is not necessary after a subtotal gastrectomy with 2/3 removal. (To cut and paste from an old grand rounds) "Phemister (1944) described 2/3 distal gastrectomy or subtotal gastrectomy without vagotomy as there was a permanent reduction of acid without recurrent or marginal ulcer--abandoned for a 20-50% morbidity with the treatment believed worse than the problem." Did you biopsy it first or try PPI/conservative mgmt?
GI consultant was nervous about biopsying it because of bleeding concerns. He required 7 units of blood and there was a strong family history of gastric cancer. So i recommended surgery.
Youre right about the marginal ulcers. The problem with a type I gastric ulcer is one of decreased mucosal defenses (NSAIDS/H Pylori) rather than hypersecretion of acid. Vagotomy simply isn't justified.
(the same anon as before) Thanks for your reply. I am a newly minted surgeon of 1 week post residency and so I appreciate the opportunity to learn from your experience. I would be paranoid to do a B2 because a) though straightforward, I never did one in training and b) all the classic complications inherent in the post-op such as reflux gastritis and afferent/efferent limb syndromes. Question-I assume you did a B2 because the resection was such the it was not possible to simply remove it and stitch it back up. Also I would assume that it precluded a B1 mechanically for the same reason. Would you have considered those options however? I would probably have done a roux limb as that is my familiarity--having scrubbed many RYGB. What do you think of that option?
A BII is actually the easiest anastomosis to do, of the three. The only problem with the roux is that youve now created two anastomoses. If something happens (marginal ulcer/stricture, etc) to the BII, you can always do the Roux later on. If the roux fails for whatever reason, you're sort of screwed.
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