Surgery for Treating Peptic Ulcer Disease

In This Article

Surgery is not often used in the treatment of peptic ulcer disease. Surgery may, however, be considered when a complication such as an ulcer perforation or bleeding arises.  In such cases, doctors will consider various surgical approaches—Graham's omental patch repair, vagotomy, and others—based on where the peptic ulcer is, the severity of disease, and other factors.

Indications

The following cases, most of which involve complications of peptic ulcer disease, may require surgical treatment:

Perforation

A perforated ulcer occurs when a hole forms in the wall of the stomach or duodenum. This opening may allow digestive juices, food, and bacteria to seep from the stomach or intestines into the abdominal cavity.

The primary symptom of a perforated ulcer is sudden and severe stomach pain. This complication is the most common indication for surgery and requires emergent attention.

Bleeding

A bleeding ulcer may cause blood in the stool (a patient will often report black stool) and/or vomiting. Most of the time, an actively bleeding ulcer can be treated with upper endoscopy performed by a gastroenterologist.

During the upper endoscopy, the bleeding blood vessel is injected with a medication called epinephrine, burned, or clipped. Rarely, if the bleeding cannot be stopped with an upper endoscopy, emergent surgery is required.

Gastric Outlet Obstruction

Gastric outlet obstruction is a rare complication that occurs when an ulcer causes swelling and scarring, which narrows or closes off the part of the stomach that opens into the small intestines. As a result of this blockage, food is then prevented from leaving the stomach, causing severe vomiting after eating and upper abdominal pain.

Gastric outlet obstruction is usually treated with medication and if that is unsuccessful, the gastric outlet can be opened up during an upper endoscopy. If both medication and upper endoscopy do not work, surgery may be a last resort option.

Refractory or Recurrent Disease

Surgery may infrequently be performed to treat ulcers that do not heal with traditional therapies, including proton pump inhibitors (PPIs) and antibiotics to eradicate Helicobacter pylori.

In select cases, people who are dependent on non-steroidal anti-inflammatory drugs (NSAIDs) may also be candidates for surgery.

Prior to surgery, patients with resistant, non-healing ulcers will usually be investigated for rare diseases like Zollinger-Ellison syndrome. In addition, patients with non-healing gastric ulcers will be reassessed for gastric cancer. 

Determining Surgical Approach

There are different types of surgery that may be performed to treat complicated peptic ulcer disease. The type used depends on factors, such as the:

  • Location and size of the ulcer
  • Type and severity of the complication
  • Whether the surgery is emergent or elective
  • Overall health (whether there are underlying illnesses)

Your doctor may consider a few different types of surgical techniques, such as the following.

As you discuss options with your doctor, be sure to ask questions related to possible outcomes, risks, and so on, specifically as they relate to your case and overall health.

Placement of Graham's Omental Patch

This surgical procedure may be used to treat a perforated duodenal ulcer.

In this procedure, a patch of omentum (fatty tissue that covers the stomach and intestines) is used to "plug the hole" (ulcer). This patch, called a Graham's omental patch, is held in place by sutures placed on either side of the perforation.

Placement of a Graham's omental patch can be done by upper abdominal laparotomy or laparoscopically. Although there is debate about which technique is best, research has found that laparoscopic repair may be preferred as it is associated with less postoperative pain and wound infections.

Other surgical procedures are less frequently used to treat ulcer perforations (some of which are described below). These procedures include:

  • A partial gastrectomy (for a perforated gastric ulcer)
  • Converting the perforation into a pyloroplasty
  • Closing the perforation using a jejunal patch (the jejunum is the second part of the small intestines, after the duodenum)

Vagotomy

A vagotomy is a surgical procedure whereby a part or one or more branches of the vagus nerve is removed.

The vagus nerve is a cranial nerve that travels from the bottom of your brain, through your neck, and down to your chest and intestines. While it serves many functions, with regard to the gut, the vagus nerve is responsible for stimulating the release of stomach acid for digestion and for making you feel full after eating.

While a vagotomy may be performed to treat gastric outlet obstruction, bleeding duodenal ulcer, or refractory peptic ulcer disease, it's important to note that it is rarely performed on its own. Instead, this surgery is usually performed along with a drainage procedure, often to prevent the complication of delayed gastric emptying.

For example, vagotomy may be performed with a pyloroplasty, a procedure that entails enlarging the opening between the stomach and the duodenum, allowing stomach contents to pass more freely.

Potential, immediate complications of a vagotomy include bleeding and injury to the esophagus or stomach. Later on, ulcer recurrence, dumping syndrome, or postvagotomy diarrhea may occur.

Partial Gastrectomy

A partial gastrectomy means the part of the stomach that contains the bleeding or perforated gastric ulcer is removed. After a partial gastrectomy, the remaining stomach will need to be surgically re-connected to the small intestines.

Various complications related to both motility (for example, dumping syndrome) and technical aspects of the surgery (how the stomach is cut and reconstructed) may occur after a partial gastrectomy.

A Word From Verywell

The surgical management of peptic ulcer disease is complex, rare, and mostly indicated for a perforated ulcer. If you or a loved one is considering surgery for complicated peptic ulcer disease (assuming it's not emergent), be sure to find a surgeon who has experience with your condition.

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