Operative Management of Complicated Peptic Ulcer Disease

Educational Objectives

The goal of this program is to improve surgical management of complicated peptic ulcer disease. After hearing and assimilating this program, the clinician will be better able to:

1. Choose an operative technique for the surgical management of complicated peptic ulcer disease.

Summary

Complicated peptic ulcer disease (CPUD): incidence has decreased; the patient who presents for surgical management of CPUD typically is frail and has malnutrition (a risk factor for CPUD)

Operative principles: include identifying the need for operation and limiting surgical intervention to salvage; the patient may present with life-threatening risk factors, including starvation, pain, dehydration, and shock; resuscitate the patient, manage the pain, then operate

Anterior perforation: innovation by Graham — used 3 catgut sutures to tie the free omental graft onto the perforation, which decreased the morbidity rate from 65% to 35%; can be done laparoscopically or with a limited incision

Posterior penetrating ulcers: the gastroduodenal artery is abundantly fed by 5 arterial sources; the gastroduodenal artery is immediately beneath the posterior wall of the duodenum; approaching too laterally endangers the midportion of the common bile duct (CBD); embolization by an interventional radiologist is an option; technique — after a distal linear incision of the distal stomach across the pylorus into the duodenum, the stomach is decompressed with a nasogastric tube; palpate the duodenal ulcer and staunch the hemorrhage; hemostasis is achieved by placing 4 quadrantic sutures, avoiding injury to the midportion of the CBD; close with Heineke-Mikulicz pyloroplasty; the gastroduodenal artery proper may be ligated in continuity

Duodenal blowout: common with giant duodenal ulcers (>2 cm in diameter); technique — in cases of large duodenal blowout with bile and succus, antrectomy with truncal vagotomy should be performed; divide the stomach at the level of the incisura, mobilize the duodenum medially, and dissect down across the anterior and inferior surfaces of the distal stomach, across the pylorus and into the duodenum; although the anterior duodenal wall may lift away from the posterior penetrating ulcer, resection should be performed beyond that point to restore a tubular duodenum; if the ampulla cannot be palpated on the medial wall, perform a cholecystectomy, place a 5-F feeding tube across the cystic duct, and feed it out through the ampulla for identification and reassurance; in most cases, a Billroth 1 procedure can be performed; otherwise, perform a Billroth 2 procedure; the gastrojejunostomy should be posterior and dependent for drainage; the duodenal stump can be closed using a 2-layer Lembert suture (2-0 silk)

Triple-tube option: not always necessary; 3 separate tubes are inserted (a retrograde red rubber tube that extends across the gastrojejunostomy, back to the duodenal stump, a prograde enteral feeding tube inserted into the jejunum, and a standard gastrostomy tube); external drains are placed around the duodenum for any duodenal stump leak; postoperative management — the retrograde duodenal tube is connected to a Foley bag on the floor for 7 days to create low-pressure suction; bile in the bulb suction drains may indicate an early duodenal leak, which can be easily managed; the gastrostomy tube is open to drainage; patients may start eating on postoperative day 1; check all tubes daily

Readings

Agarwal N, Malviya NK, Gupta N, et al. Triple tube drainage for “difficult” gastroduodenal perforations: A prospective study. World J Gastrointest Surg. 2017;9(1):19-24. doi:10.4240/wjgs.v9.i1.19; Graham RR. The treatment of perforated duodenal ulcers. Surg Gynecol Obstet. 1937; (64):235–8; Hudnall A, Bardes JM, Coleman K, et al. The Surgical Management of Complicated Peptic Ulcer Disease: An EAST Video Presentation [published online ahead of print, 2022 Apr 1]. J Trauma Acute Care Surg. 2022; 10.1097/TA.0000000000003636. doi:10.1097/TA.0000000000003636.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Johannigman was recorded at Trauma, Critical Care, & Acute Care Surgery 2022, held March 28-30, 2022, in Las Vegas, NV, and presented by the Trauma and Critical Care Foundation. For information about upcoming CME activities from this presenter, please visit Trauma-criticalcare.com. Audio Digest thanks the speakers and the Trauma and Critical Care Foundation for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification pro

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS691303

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.