Diagnosis and Management of Benign Gastric and Duodenal Disease

The diagnosis of uncomplicated peptic ulcers is difficult to make on a solely clinical basis. Whereas radiographic upper gastrointestinal (UGI) series remain useful, endoscopy is the most accurate method of establishing the diagnosis of peptic ulcer disease. Laboratory tests play an important role in the diagnosis of Helicobacter pylori infection and Zollinger-Ellison syndrome. Figures showing UGI series with double contrast and H. pylori organisms on gastric biopsy samples are provided. The improved medical management of peptic ulcer disease has decreased the need for surgical intervention, which is now largely reserved for urgent management of complications such as hemorrhage, bleeding, and perforation, or the management of obstruction from intractable disease. The appropriate extent of preoperative evaluation for a patient undergoing surgery for a benign gastroduodenal disorder is dictated primarily by the nature of the presenting problem. Endoscopy is the main diagnostic tool to identify the source of bleeding, and in many cases endoscopic therapy can control the bleeding. Angiographic transarterial embolization may be considered following failed endoscopic hemostasis, particularly in high-risk surgical patients. Operative planning is described. The steps of the operative technique, complications, and outcome evaluations are provided for the main surgical interventions for peptic ulcer disease, including vagotomy and pyloroplasty for bleeding duodenal ulcer; resection of bleeding gastric ulcer; omental patch for duodenal perforation (Graham patch); antrectomy; highly selective vagotomy; laparoscopic treatment of peptic ulcer disease; and duodenal diverticulectomy. Operative figures show a Kocher maneuver; omental patch; truncal vagotomy; highly selective vagotomy; Taylor procedure; Heineke-Mikulicz pyloroplasty; Finney pyloroplasty; Billroth I and II antrectomy; Braun enteroenterostomy; and duodenal diverticulectomy. This review contains 15 figures, 2 tables, and 43 references.

Highly selective vagotomy and gastrojejunostomy in the treatment of peptic ulcer induced gastric outlet obstruction

Background/Aim. The incidence of peptic ulcer-induced gastric outlet obstruction is constantly declining. The aim of this study was to present our results in the treatment of gastric outlet obstruction with highly selective vagotomy and gastrojejunostomy. Methods. This retrospective clinical study included 13 patients with peptic ulcer - induced gastric outlet obstruction operated with higly selective vagotomy and gastrojejunostomy. A 3-year follow-up was conducted including clinical interview and upper gastrointestinal endoscopy on 1 and 3 years after the surgery. Results. The most common preoperative symptom was vomiting (in 92.3% of patients). The mean preoperative body mass index was 16.3 ? 3.1 kg/m2, with 9 patients classified preoperatively as underweight. There were no intraoperative complications, nor mortality. At a 3-year follow-up there was no ulcer recurrence. Delayed gastric emptying was present in 1, bile reflux in 2, and erosive gastritis in 1 patient. Two patients suffered from mild ?dumping? syndrome. Conclusion. Higly selective vagotomy combined with gastrojejunostomy is a safe and easily feasible surgical solution of gastric outlet obstruction induced by peptic ulcer. Good functional results and low rate of complications can be expected at a long-term follow-up.

Solid Gastric Emptying after Highly Selective Vagotomy and Pyloroplasty in Patients with Obstructing Duodenal Ulcer

Before being superseded by medical management, highly selective vagotomy (HSV) without drainage was the procedure of choice for uncomplicated duodenal ulcer. It is also justified for complications, including perforation and bleeding in selected cases. This prospective study evaluated the effects of HSV plus drainage on solid gastric emptying in 20 patients with chronic duodenal ulcer and pyloric stenosis. Patients were treated with HSV plus pyloroplasty (Heineke-Mikulicz pyloroplasty in five patients, Finney pyloroplasty in six patients and Jaboulay gastroduodenostomy in nine patients) and underwent solid-phase gastric emptying scintigraphic studies pre-operatively and 2 months and 6 months post-operatively. Results were compared with those from 10 controls. No significant differences were observed between the different types of pyloroplasty, although emptying was slightly faster in the gastroduodenostomy group. Gastric emptying returned to normal by 6 months post-operatively. In conclusion, HSV plus pyloroplasty is effective and can be used for the relief of stenosis in selected cases of duodenal ulcer.