Benign gastric ulcers

Question 1

Risk of malignant ulcer

Answer 1

• Giant Ulcer (>2cm), 1/3 harbor malignancy
• Ulcers that do not heal at 12 weeks
• perforated more at risk than obstructing ulcers

Question 2

Johnson classification

Answer 2

Type Location Acid Hypersecretion
I, Lesser curvature, incisura, No (60% of benign gastic ulcers)
II, Body of stomach, incisura, and duodenal ulcer (active or healed), Yes
III, Prepyloric, Yes
IV, High on lesser curve, near gastroesophageal junction No
V, Anywhere (medication induced) No

Question 3

Preferred type of reconstruction if resection

Answer 3

Billroth I : gastroduodenostomie along greater curvature

Question 4

If distal ulcer (prepyloric type III)

Answer 4

Billroth II (gastrojejunostomy) or Roux-en-Y

Question 5

If proximal ulver (type IV)

Answer 5

Pauchet’s procedure to preserve as much stomach as possible.

Question 6

Perforation

Answer 6

Primary suture with patch plastik (Graham patch)

If H pylori eradication and PPI, consider primary resection.

Question 7

Vagotomy and antrectomy

Answer 7

Vagotomy : reduce peak acid output by 50%
Vagotomy + antrectomy : reduce peak acid output by 85%
If non selective - perform pyloroplasty because of Laterjet denervation

Question 8

Roux en Y

Answer 8

Always an alternative to a Billroth II, results in less reflux but patient can develop gastric atony and bloating (Roux Stasis syndrome, even more at risk after vagotomy)
Needs at least 40 cm of limb to prevent bile reflux.
Retrocolic provides greater lenth but same outcome as antecolic.