A PowerPoint presentation reviewing gastric perforation for peptic ulcer disease and a review of the surgical treatment options. Intended for medical professionals and students.

1. Gastric Perforation from Ulcers:
Review of Surgical Treatment
Dr. Joseph A. Di Como

2. Introduction
- Elective and emergency operations for benign gastric ulcer disease has decreased over the
decades.
- Annual incidence of peptic ulcer disease 0.1-.3% (300,000 new cases per year), ⅓ gastric ulcers
- Pharmacologic therapy for acid hypersecretion and H. pylori treatment is the primary reason for
reduction in surgical intervention.

3. Etiology
- Multifactorial and is best described in the context of each ulcer type.
- H. pylori infection and nonsteroidal antiinflammatory drug (NSAID) usage contribute to a great
majority of cases; thus, nonoperative management of the disease is indicated in nearly all cases,
with the exceptions of hemorrhage, perforation, obstruction, and refractory disease.
- Direct Helicobacter treatment and eradication is paramount because complete mucosal healing
occurs less than 0.5% of the time with persistent infection.
- Other notable sources implicated in benign disease include smoking, steroid usage, and
Zollinger-Ellison syndrome.

4. Presentation and Diagnosis
- Epigastric pain. Most often, this pain is relieved with the ingestion of food or antacids and recurs
after a short interval.
- Evaluation of the patient generally involves multiple modalities.
- Esophagogastroduodenoscopy provides definitive diagnosis, allows for characterization of the
lesion’s location and extent, and provides tissue for detection of microorganisms and malignant
disease.
- Failure of medical therapy is typically considered persistence of disease beyond 12 weeks.

6. Gastric Ulcers: Type and Location
Type I
- Located near the incisura on the lesser curvature, most common, approximately 60%.
- Etiology fully understood; these lesions are not associated with acid hypersecretion and, in some
cases, are noted in the setting of low levels of gastric acid production. H. pylori infection can be
found in most patients with type I disease, but it also occurs in those whose infections have been
eradicated or who have no history of infection.
- Most are treated successfully with conservative therapy.
- Refractory disease, antrectomy and vagotomy with Billroth I reconstruction is the procedure of
choice when possible.
- Rationale for vagotomy arises from the unclear nature of these ulcers and in general the addition
of minimal, if any, morbidity.
- Billroth II or Roux-en-Y technique when the anatomy is such that gastroduodenostomy is not
feasible

7. Gastric Ulcers: Type and Location
Type II and III
- Type II disease involves concomitant ulcers along the lesser curvature near the incisura and a
duodenal ulcer
- Type III ulcerations are prepyloric.
- Distal gastrectomy that includes the ulcer is the preferred surgical resection, again with Billroth I
reconstruction when possible.
- Duodenal involvement in the type II and the distal location of type III ulcers, sufficient
mobilization of the duodenum may prove difficult, necessitating Billroth II or Roux-en-Y
creation.
- These ulcers are associated with acid hypersecretion, when resection is performed, a vagotomy is
recommended because conservative acid reduction therapy has already failed.

8. Gastric Ulcers: Type and Location
Type IV
- IV ulcers are not related to acid hypersecretion
- Pose a particular surgical challenge because of their proximal location along the lesser curvature
near the gastroesophageal junction.
- Resection is directed at preserving a maximal length of healthy stomach such that a
gastroduodenostomy may be possible even after such a proximal ulcer is removed.
- The Pauchet’s and Csendes’ techniques described subsequently, facilitate this goal.
- A Kelling-Madlener resection, in which total gastrectomy is avoided for very proximal locations
with the ulcer left in place and an antrectomy with vagotomy performed, is not recommended
given the unclear etiology of these ulcers and lack of association with acid production.
- In general, total gastrectomy is rarely necessary for gastroesophageal junction ulcers.

10. Gastric Ulcers: Type and Location
Type V
- Diffuse nature of type V ulceration makes surgical intervention difficult; fortunately, the need for operation is rare.
- The use of NSAIDs or steroids is the primary etiology, and resolution is generally facilitated with cessation of the
offending agent and the addition of a proton pump inhibitor (PPI) or histamine blocker.
- Bleeding is the most common indication for operation in this setting.
- Should intervention become necessary, the initial therapy is endoscopic with injection or cautery of significant points
of hemorrhage. Endoscopic treatment may be inadequate.
- The localization of bleeding vessels and subsequent coiling or embolization via interventional radiology can be
attempted next. Surgical approaches should be reserved for cases refractory to other measures. In that situation, an
anterior gastrostomy facilitates inspection of the gastric mucosa with the goal of oversewing major sites of bleeding.
If this is unsuccessful, one should be prepared to perform a total gastrectomy because it may prove to be a life-saving
measure. Gastric devascularization has been described in small studies in the past, whereby the major vessels are
ligated and the short gastric vessels remain as the primary blood supply. This approach has been virtually replaced
with interventional radiology and is uncommon.

11. Stage V Ulcers
- Surgical approaches should be reserved for cases refractory to other measures.
- In that situation, an anterior gastrostomy facilitates inspection of the gastric mucosa with the
goal of oversewing major sites of bleeding.
- If this is unsuccessful, one should be prepared to perform a total gastrectomy because it may
prove to be a life-saving measure.
- Gastric devascularization has been described in small studies in the past, whereby the major
vessels are ligated and the short gastric vessels remain as the primary blood supply.

12. Stress Ulcers
- Generally encountered in the critical care setting and can occur as early as 12 hours after
admission.
- Relative mucosal ischemia appears to play a principal role, with acid secretion likely a secondary
association.
- Risk Factors: acute respiratory distress syndrome, multiple long bone fractures, transfusion
requirements greater than 6 units, sepsis, acute renal failure, and specific associated trauma,
such as central nervous system (CNS) injury (Cushing’s ulcer) and extensive burns over 35%
body surface area (Curling’s ulcer).
- Patients at risk of clinically significant hemorrhage seem to be those who need mechanical
ventilation for greater than 48 hours or with coagulopathy, defined as a platelet count less than
50,000/mm3 or international normalized ratio (INR) of more than 1.5.
- Prevention of gastritis with addition of pharmaceutical prophylaxis is paramount.
- Treat like type V ulcers

13. Cancer Risk after Resection
- Data regarding the risk of gastric malignant disease after partial resection are conflicting, in
regards to both the time course and the actual (if any) extent of increase.
- Malignant disease usually appears 15 to 30 years after surgery and may in fact be less common
than in the general population during the first 10 years.
- Significant variability in the literature is also present as to the ultimate risk conferred by
resection, anywhere from no additional risk to five times that of normal.
- On the basis of the largely inconsistent information, no strong recommendations can be made
for routine surveillance of these patients.
- Rather, a strong suspicion and low threshold for workup of upper gastrointestinal symptoms
should be maintained, particularly as time from resection elapses.

14. Giant Ulcers
- Giant ulcers are those that are more than 3 cm in diameter. T
- These ulcers have an increased association with cancer: 30% of those larger than 3 cm harbor
malignant disease.
- Earlier surgical intervention is generally warranted given this association. Endoscopy with
multiple biopsies (at least four with jumbo forceps and eight with regular) to include both the
ulcer base and edge usually provide sufficient tissue for diagnosis to guide therapy, with
treatment of nonmalignant ulcers adhering to guidelines as outlined previously, depending on
the location.

15. Obstruction
- Obstruction is the least common complication of gastric ulcer disease.
- It is not an emergency, and initial management involves nasogastric decompression and fluid
and electrolyte replacement.
- This nonoperative therapy can result in at least temporary resolution of a significant percentage
of obstructions, which may be the result of edema or acute inflammation.
- Subsequent definitive management usually rests with resection and reconstruction, ideally as a
Billroth I procedure.
- If chronic scarring and local derangement of tissues prevents safe resection or a tension-free
gastroduodenostomy, then vagotomy and diversion with gastrojejunostomy is appropriate.
- Dilation may be preferable in those patients who are poor surgical candidates.

16. Perforation
- Perforation is the most common complication of gastric ulcers, and the patients tend to be older
and have more debilitated conditions than those with perforated duodenal ulcers.
- Surgical intervention is usually necessary, ideally with a partial gastrectomy to include the ulcer
and reconstruction.
- Rarely, in the setting of a patient with a hemodynamically stable condition without signs of
peritonitis, nonoperative treatment may be considered.
- If the patient cannot tolerate a resection, then full-thickness excision of the ulcer is appropriate,
with care to send that tissue as a specimen to rule out malignant disease.
- Redundancy of the gastric walls generally allows for reapproximation of healthy tissue edges,
without the need for an omental patch.
- In type II or III ulcer, a vagotomy and drainage procedure can be considered.
- If before the perforation, however, the patient has never had a period of medical management to
include eradication of H. pylori, if present, and PPI or H2 antagonist medications, it is
reasonable to attempt these first, assuming close follow-up evaluation is possible.

17. Surgical Technique: Vagotomy and Drainage
- Ulcers are associated with acid hypersecretion and are refractory to medical management, a
vagotomy is recommended at the time of definitive surgical therapy.
- Generally three approaches to vagotomy are recognized.
- Ultimate goal is parasympathetic denervation of any remaining acid-producing stomach tissue, a
feat best accomplished with the technique the operating surgeon is most familiar with and
comfortable pursuing.

18. Surgical Technique: Vagotomy and Drainage

19. - Truncal vagotomy, anterior and posterior nerves are divided at the level of the distal esophagus,
ideally approximately 4 cm proximal to the gastroesophageal junction.
- At this level, one has the best chance of finding a single trunk for both branches: 90% of anterior
and 75% of posterior vagi.
- This requires mobilization of approximately 5 to 6 cm of the esophagus to provide adequate
exposure for complete nerve identification because those that are branching by this point form
several smaller cords.
- Clips are placed proximally and distally on each vagal trunk and then transected, with the
segment sent for pathologic confirmation.
- The so-called “criminal” nerve of Grassi, the first gastric branch of the posterior vagus, is of
particular importance because its separation point can be proximal to the celiac division of the
posterior nerve. It travels to the posterior fundus, running past the angle of His, and failure to
identify and divide it can result in a higher rate of failure; two thirds of cases with ulcer
recurrence after an initial antisecretory operation have evidence of incomplete vagotomy.

20. - Selective vagotomy spares the posterior branches that innervate the pancreas and small
intestine, and the anterior branches that course to the liver and gallbladder.
- Preservation of these distal sites of innervation is directed at decreasing the potential morbidity
of vagotomy; the incidence of postoperative diarrhea and dumping has in some cases proven to
be less with a properly performed selective versus truncal vagotomy, and the recurrence rate of
ulceration is equivalent.
- Selective vagotomy is performed more frequently for refractory duodenal ulcers in the setting of
a concomitant drainage procedure; when used after a gastric resection for benign ulcer disease,
its benefit over truncal vagotomy is less clear.

21. - Highly selective (parietal cell) vagotomy that seeks to preserve Latarjet’s nerves that terminate
on, and provide motor function to, the pylorus.
- This makes it distinct from the other denervation techniques in that no drainage procedure is
necessary.
- Successful completion requires substantial familiarity with the technique; in most cases of
refractory benign gastric ulcer, it is unnecessary because a resection of the pylorus is often a part
of the procedure.
- Involves identification of the terminal fronds of both the anterior and the posterior branches;
these are located at the junction of the corpus and antrum and have a characteristic “crow’s foot”
configuration with three divisions.
- This point is generally 6 cm proximal to the pylorus, and these terminal branches are left intact.
The individual neurovascular bundles originating from the vagal trunks and running within the
anterior and posterior leaves of the lesser omentum to the stomach are divided up to and
including the distal esophagus for approximately 5 cm, with the integrity of the trunks preserved.

22. - In those cases in which a truncal or selective vagotomy is executed but no resection is done,
usually because of extensive scar tissue or an emergent situation, a procedure to allow drainage
through the pylorus is warranted.
- Most commonly, a pyloroplasty is performed in the manner described by Heineke-Mikulicz,
whereby a longitudinal incision is created through the pylorus and closed transversely.
- In cases in which the duodenum is heavily scarred, the Finney and Jaboulay techniques may
afford more mobility to allow closure.
- If a pyloroplasty is not possible via these methods, then a gastrojejunostomy is appropriate.

23. Resection
- In general, an antrectomy with resection of less than 50% of the stomach is suitable for most
benign gastric ulcer disease treatment.
- Minor variations usually enable the surgeon to remove the ulcer itself and all of the gastrin-
secreting tissue without significantly compromising the remaining gastric volume.
- Some gross anatomic landmarks help delineate the approximate area of removal.
- The antrum-body physiologic junction is estimated by a line drawn from 2/5 the distance from
pylorus to the cardia on the lesser curvature to 1/8 the same distance on the greater curve.
- This corresponds to about 7 cm on the lesser curve (2 to 3 cm from the aforementioned crow’s
foot) and 5 cm on the greater curve, although it becomes more proximal with advancing age. If
the resources are available, intraoperative frozen section to determine the presence of antral
glands containing G cells in remaining tissue can be obtained, thus directing further resection.

24. Resection
- As the ulcer location (or proximal extent of a large ulcer) moves progressively more proximal,
principally on the lesser curve, the ability to preserve enough length to create a tension-free
gastroduodenostomy becomes challenging.
- Pauchet’s procedure addresses this issue by starting proximal to the ulcer on the lesser curve and
extending distally to increase the distance along the greater curve.
- Those ulcers within approximately 2 cm of the esophagus are particularly difficult and may
necessitate a subtotal gastrectomy with Roux-en-Y reconstruction, even when saving as much
stomach as possible (Csendes’ procedure). The need for a total gastrectomy, however, is rare and
should be avoided.

25. Resection
- The distal extent of resection is usually straightforward with a transection through healthy
duodenal tissue just distal to the pylorus.
- When the local inflammatory reaction of a gastric ulcer or the ulcer itself creates an ill-defined
margin, determination of the point at which to stop can be difficult.
- This is particularly troubling when the ulcer is posterior and involves the surface of the pancreas.
It is best to avoid attempting complete resection of the ulcer base; perform the antrectomy as
usual, leaving the base in place , and reconstruct overtop the area.
- With the source of inflammation removed, the area heals without adversely affecting the
anastomosis, which generally lies just proximal to the ulcer base.

27. Billroth I
- The reconstruction via anastomosis of the end of the duodenum to the distal greater curvature of
the stomach is the preferred technique for most benign gastric ulcer disease.
- Kocher’s maneuver not always necessary but can provide additional length if anastomosis is
under tension.
- Use of an EEA stapler through an anterior gastrotomy is acceptable. Gastrotomy is then closed
with another staple line or hand sewn.
- -NGT left in to monitor for bleeding, typically removed postoperative day 1 and CLD started and
maintained until bowel recovery.

28. Billroth II
- Performed when BI is not feasible (inability of the duodenum and greater
curvature to approximate without tension)
- Afferent limb should be as short as possible ( no longer than 20cm) to decrease
the incidence of afferent loop syndrome. (Mobilization of the ligament of Treitz
can be performed to provide an even shorter limb)
- Gastroenterostomy should be performed in a retrocolic position with the
anastomosis placed through and lying below the colonic mesentery. This
location helps prevent kinking of both the afferent and efferent limbs. Placement
of sutures from the gastric wall to the transverse colon mesentery is important
to maintain this setting.

29. Billroth II
- Retrogastric location facilitates drainage of stomach.
- Isoperistaltic orientation takes advantage of the natural course of the small
intestine and permits a shorter afferent limb.

31. Roux-en-Y
- Roux limb of at least 40cm helps prevent bile reflux.
- Both retrocolic and antecolic positions are equivalent in terms of outcome,
(more length can be gained with retrocolic version)
- -Some comparisons have shown it to be superior to Billroth II in terms of
subjective symptoms and objective endoscopic evidence of bile reflux.