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A1-G Surg Note Stomach > Duodenal Ulcers > Flashcards

Duodenal Ulcers Flashcards

1
Q

What structures do superficial and deeper duodenal ulcers involve?

A

Superficial ulcers involve the submucosa

deeper ulcers involve the muscularis propria or the serosa

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2
Q

What are common predisposing factors for duodenal ulcers

A

Helicobacter pylori infection
NSAID or aspirin use
smoking
stress.

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3
Q

Name less common causes of duodenal ulcers

A

Gastrinoma (Zollinger-Ellison syndrome)
radiation
Crohn’s disease
cocaine
gastroduodenal dysmotility.

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4
Q

What is the operative mortality rate for emergency peptic ulcer surgery?

A

About 30%.

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5
Q

How can recurrent ulcers after surgery be minimized?

A

By eradicating H. pylori infection
avoiding NSAIDs and aspirin
and abstaining from smoking

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6
Q

When should testing for H. pylori infection be performed?

A

active or a history of peptic ulcer disease
MALT
early gastric cancer
or those requiring long-term aspirin or NSAIDs

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7
Q

What tests can confirm H. pylori eradication?

A

Urea breath test
fecal antigen test
endoscopic biopsy

(H. pylori serology should not be used to confirm cure).

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8
Q

Some Common Helicobacter Treatment Regimens (10– 14 Days)

A

-Clarithromycin triple therapy (PPI, clarithromycin, amoxicillin, or metronidazole)

-Bismuth quadruple therapy (PPI, bismuth, tetracycline, nitroimidazole)

-Sequential therapy (PPI and amoxicillin for 5– 7 days, and then a PPI, clarithromycin, and nitroimidazole for 5– 7 days)

-Hybrid therapy (a PPI and amoxicillin for 7 days, and then a PPI, amoxicillin, clarithromycin, and nitroimidazole for 7 days)

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9
Q

Patients Without Penicillin Allergy With Either Prior Macrolide Exposure or in a Region With >15% Clarithromycin Resistance

A

-Bismuth quadruple therapy
OR
-Levofloxacin triple therapy (PPI, levofloxacin, amoxicillin)

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10
Q

Can daily aspirin for cardiovascular prophylaxis be safely taken in patients with a history of duodenal ulcers?

A

Yes, with daily (PPI)

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11
Q

When is long-term PPI treatment recommended in patients with duodenal ulcers?

A

all patients who have been hospitalized for duodenal ulcers, unless they have undergone a vagotomy.

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12
Q

In which patients should gastrectomy for duodenal ulcers be avoided?

A

avoided in thin or chronically malnourished patients.

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13
Q

What are some early and late findings in a patient with a perforated duodenal ulcer?

A

Early findings include tachycardia

Late Findings: fever, tachypnea, and hypotension

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14
Q

What is the mortality risk for a perforated duodenal ulcer?

A

It is high, up to 30% in some series, especially with delayed treatment.

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15
Q

What is the treatment of choice for most patients with a perforated duodenal ulcer?

A

Laparotomy or laparoscopy with peritoneal washout and omental patch closure of the perforation.

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16
Q

When should a biopsy of a duodenal ulcer be performed during surgery?

A

performed if there is any suspicion of malignancy.

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17
Q

Is antifungal treatment routinely recommended in cases of duodenal ulcer perforation?

A

No

reserved for frail, immunosuppressed, or hospitalized patients, but not routinely used.

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18
Q

What postoperative measures are typically taken after surgery for a perforated duodenal ulcer

A

Placement of at least one closed-suction peritoneal drain and sending peritoneal fluid for culture and sensitivity, including fungal studies

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19
Q

What is the most common method for repairing a perforated duodenal ulcer?

A

Omental patching, also known as Graham patching

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20
Q

How large is the typical perforation in the duodenum when using the omental patch technique?

A

Less than 1 cm.

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21
Q

Why is primary closure of the perforation often avoided in omental patching?

A

The friable duodenal tissue adjacent to the perforation may cause sutures to pull through, enlarging the hole or narrowing a scarred gastric outlet

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22
Q

How is the omental patch held in place?

A

By using interrupted seromuscular Lembert sutures placed into healthy duodenum on either side of the perforation.

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23
Q

How is the adequacy of the seal tested after omental patch placement?

A

By submerging the site under irrigation fluid and injecting air or methylene blue into a nasogastric tube, which remains in place postoperatively

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24
Q

What is a key challenge in repairing large duodenal ulcer perforations (> 2 cm)?

A

They are difficult to securely close using the standard Graham patch technique, and primary repair is prone to breakdown, especially in chronic ulcers.

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25
Q

What is a potential buttress material used to support the closure of a large ulcer perforation?

A

Omentum or falciform ligament can be used to buttress the closure.

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26
Q

How can a Kocher maneuver help in repairing large duodenal ulcer perforations?

A

It facilitates primary closure if it can be done safely

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27
Q

What surgical technique can be used if a large perforation cannot be closed primarily?

A

The perforation can be plugged with omentum or falciform ligament

or a loop of jejunum can be used as a serosal patch.

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28
Q

What is the risk of using direct intubation with or without an omental buttress in treating large perforations?

A

It is prone to ongoing leakage but may be used as a last resort or bailout procedure.

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29
Q

What is the triple-tube technique, and when is it used?

A

It involves placing a gastrostomy, antegrade feeding jejunostomy, and a retrograde jejunostomy tube (in duodenum) for decompression.

It is used in high-risk perforations

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30
Q

What is pyloric exclusion, and when might it be considered?

A

It involves closing the pylorus with heavy absorbable suture and creating a dependent loop gastrojejunostomy, used for tenuous duodenal closures.

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31
Q

What is a surgical option for repairing a large chronic duodenal perforation in a stable low-risk patient?

A

Roux-en-Y duodenojejunostomy, creating a tension-free two-layer anastomosis between the debrided duodenal opening and a Roux limb.

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32
Q

In which patients can definitive ulcer surgery be considered for perforated duodenal ulcers?

A

In stable
low to medium-risk patients (ASA 1 or 2) requiring emergency surgery
with a history of duodenal ulcer
or a large perforation (> 2 cm)

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33
Q

When should definitive ulcer surgery be avoided?

A

It should be avoided
if peritonitis is severe or well-established (exudative).

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34
Q

What are the two current options for definitive ulcer surgery?

A

1) Truncal vagotomy and gastrojejunostomy (V/GJ) with or without temporary pyloric closure

(2) truncal vagotomy and antrectomy (V/A) if the perforated duodenum can be safely resected with the antrum

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35
Q

When should resection be avoided in definitive ulcer surgery?

A

If there is a risk of a tenuous duodenal stump or possible injury to the ampulla or bile duct.

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36
Q

How can the ampulla be protected during definitive ulcer surgery?

A

A biliary Fogarty catheter can be advanced from above via the cystic duct or common bile duct if the ampulla is at risk.

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37
Q

What are the two types of vagotomy that may be considered during laparoscopic surgery for a perforated duodenal ulcer?

A

(1) Bilateral truncal vagotomy
(2) the modified Taylor procedure.

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38
Q

What is the modified Taylor procedure in vagotomy?

A

posterior truncal vagotomy with division of the segmental vagal branches to the anterior stomach, while preserving the anterior innervation to the antropyloric region to facilitate gastric emptying.

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39
Q

Where does postoperative management typically begin for perforated ulcer patients?

A

In the ICU
with continued optimization of critical organ function, fluid management, and treatment of sepsis.

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40
Q

What imaging studies are performed postoperatively to rule out ongoing leaks and demonstrate gastric emptying?

A

Postoperative contrast study, either fluoroscopy or CT.

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41
Q

When are antibiotics typically discontinued after surgery for a perforated duodenal ulcer?

A

On postoperative day 5, unless there is evidence of ongoing infection

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42
Q

When can peritoneal drains be removed postoperatively?

A

Drains can be removed 24 hours after the initiation of oral liquids if drainage is benign and the patient is stable

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43
Q

What may necessitate reoperation in a postoperative perforated duodenal ulcer patient?

A

Persistent leakage from the perforation site
or abdominal wound dehiscence.

44
Q

What is the treatment for localized infected fluid collections postoperatively?

A

Percutaneous drainage can be performed

45
Q

What is the best treatment for multiple fluid collections or extensive peritoneal fluid in the setting of sepsis postoperatively

A

Reoperation and washout.

46
Q

What is recommended for patients after emergency surgery for a perforated duodenal ulcer regarding medication and lifestyle?

A

Chronic PPI therapy
empiric treatment of H. pylori infection
and avoidance of NSAIDs, aspirin (except low-dose with PPI), and smoking

47
Q

What endoscopic hemostatic therapies have decreased the need for surgery in bleeding duodenal ulcers?

A

Cautery, topical agents, epinephrine injection, and clips

48
Q

What percentage of patients with bleeding duodenal ulcers will stop bleeding with only IV fluid and IV PPIs?

A

Three-fourths (75%) of patients.

49
Q

What characteristics are more common in patients with ongoing or recurrent bleeding duodenal ulcers?

A

Hematemesis
hypotension
multiunit transfusion requirement
and endoscopic stigmata such as visible vessels or active bleeding

50
Q

What is the primary purpose of the Rockall score?

A

To predict mortality risk in patients with upper GI bleeding.

51
Q

The Glasgow-Blatchford score (GBS)

A

designed to identify low-risk patients who do not require hospitalization

52
Q

Why are deep posterior bleeding ulcers in the proximal duodenum particularly concerning?

A

may involve the gastroduodenal artery, leading to exsanguinating hemorrhage.

53
Q

What is the usual treatment for high-risk bleeding duodenal ulcer patients?

A

PPI infusion and endoscopic hemostasis.

54
Q

What should be done if a patient rebleeds after initial treatment for a bleeding duodenal ulcer?

A

Repeat endoscopic treatment
and consider arteriography with possible angioembolization

55
Q

When should surgery be considered for patients with bleeding duodenal ulcers?

A

-For persistent or recurrent bleeding in patients with hemodynamic instability
-or requiring more than 6 units of red blood cells.

56
Q

What is the predicted postoperative mortality rate for an older patient with a bleeding duodenal ulcer, hypotension, COPD, and a visible vessel on EGD according to the Rockall score?

A

40%

57
Q

Glasgow-Blatchford Score

A

Elevated BUN 2– 6 points
Low Hgb 1– 6 points
Low BP 1– 3 points
Elevated HR 1 point
Melena 1 point
Syncope 2 points
Liver disease 2 points
Heart failure 2 points

58
Q

What are the three surgical options for treating a bleeding duodenal ulcer?

A

(1) Oversewing alone
(2) oversewing with vagotomy and drainage
(3) vagotomy and antrectomy (V/A).

59
Q

According to clinical trials, how do survival outcomes compare between oversewing with vagotomy and drainage versus vagotomy and antrectomy (V/A)?

A

Survival outcomes are similar, but reoperation for rebleeding is less common after V/A

60
Q

Why is resection for bleeding duodenal ulcer rarely performed nowadays?

A

Most surgical patients are high-risk, and fashioning a secure duodenal stump can be difficult

61
Q

What does the National Surgical Quality Improvement Program data suggest about vagotomy and drainage for bleeding peptic ulcers?

A

Vagotomy and drainage may result in a significantly lower 30-day postoperative mortality rate (12%) compared to vagotomy with resection (23%) or oversewing alone (27%).

62
Q

What is the first step in oversewing a bleeding duodenal ulcer?

A

Exposure of the lesion, usually through a longitudinal duodenotomy or pyloroduodenotomy

63
Q

Why is a Kocher maneuver performed during oversewing of a bleeding duodenal ulcer?

A

It decreases tension on the closure and facilitates manual control of the bleeding gastroduodenal artery

64
Q

How is the gastroduodenal artery manually controlled during oversewing?

A

The surgeon standing on the patient’s left side uses their left hand, with fingers behind the pancreas and thumb in front, to control the artery

65
Q

How are deep posterior ulcers typically managed during oversewing?

A

By placing two or three heavy suture ligatures in a figure-of-8 or over-and-over fashion in the ulcer bed.

66
Q

What is the U-stitch, and when is it used?

A

The U-stitch is a technique well described for securing hemostasis in the ulcer bed

67
Q

Why is extraluminal ligation of the gastroduodenal artery above and below the duodenum typically inadvisable?

A

It is hazardous and misses the pancreatic branch for which the U-stitch is used

68
Q

What step is taken after achieving hemostasis in the ulcer bed?

A

The ulcer bed should be abraded with the sucker tip to prevent rebleeding.

69
Q

How is the anterior incision closed after oversewing a bleeding duodenal ulcer?

A

It can be closed either longitudinally or transversely as a pyloroplasty

70
Q

In which patients may definitive ulcer surgery be appropriate?

A

In patients with a history of ulcer chronicity or those with a large (> 2 cm) deep posterior ulcer

71
Q

In which patients is definitive ulcer surgery contraindicated?

A

It is contraindicated in ASA 4 and 5 patients and should be done selectively in ASA 3 patients

72
Q

What is the preferred definitive surgery for stable patients with bleeding duodenal ulcers?

A

Truncal vagotomy and drainage (pyloroplasty or gastrojejunostomy).

73
Q

How is postoperative management similar to the care following the repair of a perforated duodenal ulcer?

A

High-dose PPIs are used in the early postoperative period to decrease the risk of rebleeding

74
Q

What should be done if early rebleeding occurs after surgery for a bleeding duodenal ulcer?

A

It should be evaluated with upper endoscopy and arteriography (either CT angiography or standard arteriography)

75
Q

What lifestyle change is imperative for patients following surgery for duodenal ulcer complications?

A

Long-term smoking cessation.

76
Q

What is recommended if NSAIDs are medically necessary for patients postoperatively?

A

A selective COX-2 inhibitor should be considered, along with long-term PPI therapy

77
Q

When should long-term PPI therapy be prescribed after surgery for a bleeding duodenal ulcer?

A

If the patient requires chronic aspirin or anticoagulants, or in all patients admitted for duodenal ulcer complications unless definitive surgery has been performed.

78
Q

What is now the second most common indication for duodenal ulcer surgery in some hospitals?

A

Chronic gastric outlet obstruction secondary to chronic inflammation and scarring

79
Q

What physical sign may be present in patients with chronic gastric outlet obstruction?

A

A succussion splash on abdominal auscultation

80
Q

What electrolyte and metabolic disturbance is common in high-grade obstruction with dehydration?

A

Hypokalemic hypochloremic metabolic alkalosis.

81
Q

What major differential diagnosis should be considered in patients with gastric outlet obstruction symptoms?

A

Malignant gastric outlet obstruction, including pancreatic, duodenal, or gastric cancer.

82
Q

What evaluations are typically performed for suspected gastric outlet obstruction?

A

EGD with biopsy, upper gastrointestinal fluoroscopy with oral barium, and CT

83
Q

What is considered the gold standard surgery for obstructing duodenal ulcers?

A

Vagotomy and antrectomy (V/A)

84
Q

What is an alternative to V/A for some patients with obstructing duodenal ulcers?

A

Vagotomy and gastrojejunostomy (V/GJ).

85
Q

What are the advantages of V/A compared to V/GJ?

A

V/A has a lower recurrence rate and confirms that the cause of the obstruction is benign

86
Q

What is an advantage of V/GJ over V/A?

A

lower operative mortality and can be reversed if dumping syndrome becomes intolerable.

87
Q

What is a disadvantage of V/GJ compared to V/A?

A

There is a risk that obstructing cancer may be missed, and marginal ulcers may occur.

88
Q

What is the recommended reconstruction after antrectomy in V/A?

A

Antecolic isoperistaltic Billroth II gastrojejunostomy.

89
Q

Why is Roux-en-Y reconstruction generally avoided in V/A for large gastric remnants?

A

Due to the possibility of marginal ulceration and delayed gastric emptying.

90
Q

How is the duodenal staple line managed during surgery for obstructing duodenal ulcers?

A

The duodenal staple line is typically irrigated and covered with well-vascularized omentum

91
Q

How should patients treated with V/GJ for obstructing chronic duodenal ulcer disease be followed postoperatively?

A

They should be closely followed for 2 years to ensure that an obstructing cancer was not missed

92
Q

What should be considered if a patient is not doing well after V/GJ?

A

Reevaluation and open exploration with conversion of the loop gastrojejunostomy to a distal gastrectomy, including the area of obstruction.

93
Q

Vagotomy and Antrectomy Steps

A

-upper midline or transverse incision
-Exploration of the gastroduodenal area for malignancy
-Truncal vagotomy
-The peritoneum over the abdominal esophagus is incised
-Gastrohepatic ligament is opened above the hepatic vagal branches
-Pulling down on these branches makes the anterior vagal trunk stand out, and it is clipped
-Send for Histopath
-phrenoesophageal ligament opened along the right crus
-retroesophageal space is entered
-posterior vagus is located, clipped, sent for biopsy
-Antrectomy
-The lesser curvature neurovascular bundle is divided at the angularis incisura
-Right gastroepiploic arcade is divided on the greater curvature directly opposite.
-stomach is transected with a green handheld GIA or a purple or black laparoscopic GIA
-The gastrocolic ligament attached to the antrum is taken usually outside the gastroepiploic arcade
-progressing distally to the right gastroepiploic pedicle, which is ligated and divided.
-The right gastric is also ligated and divided
-The pylorus and duodenal bulb are carefully separated from the pancreas
-then the postpyloric duodenum is transected with a GIA or TA stapler
-The outlet obstruction should be resected.
-The surgeon should try hard to rule out cancer if the site of outlet obstruction is left behind

94
Q

Then Cont

A

-Antecolic isoperistaltic Billroth II gastrojejunostomy on the greater curvature side of the gastric remnant
-the afferent loop on the greater curvature side
-the efferent limb on the lesser curvature side.

avoid Roux-en Y reconstruction with a large gastric remnant because of the possibility of marginal ulceration and/ or delayed gastric emptying.

before abdominal closure irrigate the staple line and cover it with well-vascularized omentum held in place by two or three sutures.

95
Q

V/GJ Steps

A

-open or minimally invasive
-evaluation of the stomach and proximal duodenum
-vagotomy is performed
-Either a bilateral truncal or posterior truncal with anterior highly selective technique
-Loop gastrojejunostomy is to the dependent greater gastric curvature
-divide the little branches from the gastroepiploic to the stomach for a length of 6 to 8 cm, creating a target for the handsewn or stapled antecolic isoperistaltic gastrojejunostomy.

96
Q

What must be ruled out before considering surgery for a persistent duodenal ulcer?

A

Gastrinoma and cancer must be ruled out.

97
Q

What conditions must be fulfilled for a duodenal ulcer to heal without surgery?

A

H. pylori infection must be cleared.
The patient must take PPIs as prescribed.
The patient must avoid NSAIDs and aspirin.
The patient must not smoke

98
Q

How is routine closure of the proximal duodenum during Billroth II distal gastrectomy usually accomplished?

A

With a GIA- or TA-type stapler (blue cartridge) or a two-layer suture closure.

99
Q

Why should excessive suturing and imbrication be avoided during duodenal stump closure?

A

It may predispose to stump leakage.

100
Q

What should be done if secure duodenal stump closure is difficult due to ulcer size, location, or inflammation?

A

A distal gastrectomy should be avoided, as operative mortality increases significantly with duodenal leakage

101
Q

How is the integrity of a duodenal closure tested intraoperatively?

A

By placing an NG tube at the ligament of Treitz, distending the duodenum with air, and checking for leaks.

102
Q

What is the role of omentum in difficult duodenal stump closures?

A

Healthy omentum is sewn over the closure to reinforce it.

103
Q

What options are available for duodenal decompression after duodenal stump closure?

A

-Retrograde tube via the proximal jejunum
-Lateral duodenostomy
-NG decompression through the gastrojejunostomy into the duodenum

104
Q

How should postoperative duodenal stump leakage be managed if the patient does not develop diffuse peritonitis or worsening sepsis?

A

It is usually managed nonoperatively with wide drainage and source control.

105
Q

What should be done if suture closure of a leaking duodenal stump fails?

A

A tube is placed into the leak, and the duodenum is snugged around the tube, buttressed with omentum, falciform ligament, or peritoneum/skeletal muscle

106
Q

How is a chronic duodenal fistula treated if it persists after initial management?

A

A definitive repair can be attempted later with Roux-en-Y duodenojejunostomy or resection.

A1-G Surg Note Stomach (11 decks)

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