Surgery for uncomplicated peptic ulcer disease is rarely performed since the advent of proton pump inhibitors to reduce acid production and the discovery of H. pylori. However in life-threatening upper gastrointestinal bleeding, if gastric outflow obstruction develops or for malignant gastric ulcers surgery is still indicated.
Vagotomy was previously used to reduce acid secretion but caused decreased motility and thus a drainage procedure is required:
· Pyloroplasty in which a longitudinal cut is made in the pylorus, which is then closed transversely, establishing an enlarged outlet from the stomach into the intestine.
· Gastro-enterostomy in which a loop of small bowel is linked to the stomach (the normal pyloric passage remains intact).
The side effects of the procedure are operative mortality, ulcer recurrence, dumping syndrome (see later) and diarrhoea.
Partial gastrectomy is usual (total gastrectomy is uncommon):
· Bilroth I in which the distal part of the stomach is removed and the stomach remnant connected to the duodenum.
· Bilroth II differs in that the stomach remnant is connected to the first loop of the jejunum and the duodenal stump is closed.
Complications following surgery:
· Duodenogastric reflux, may lead to chronic gastritis. Vomiting due to stoma narrowing.
· Recurrence of the original disease (gastric ulcer, gastric carcinoma).
· Nutritional consequences include weight loss, iron deficiency anaemia, vitamin B12 deficiency and malabsorption.
· The dumping syndrome is due to the uncontrolled rapid emptying of hyperosmolar solution into the small bowel characterised by a feeling of epigastric fullness after food associated with flushing, sweating 15–30 minutes after eating. This syndrome may improve with regular small frequent meals. Surgical revision may be indicated.
· Reactive hypoglycaemia is due to rapid absorption of glucose from the upper small bowel, causing a reactive hyperinsulinaemic state and then hypoglycaemia.
· Small increased risk of gastric cancer following partial gastrectomy after a latent period of 20 years possibly due to bacterial overgrowth with the generation of carcinogenic nitrosamines from nitrates in food.