Benign Conditions

As alluded to above, surgery for chronic peptic ulceration is now unusual. It aims to remove the gastric ulcer and the gastrin-producing G cells that drive acid secretion. This is accomplished by a Bilroth I distal gastrectomy with a gastroduodenal anastomosis (Figure 2.3). Alternatively, blockage of gastric innervation is achieved by transecting the vagus nerve trunks as they emerge through the diaphragmatic hiatus (truncal vagotomy) resulting in reduced gastric secretions and motility. Because of the latter, a drainage procedure, either pyloroplasty or gastrojejunostomy must also be done. This approach is used in elderly frail patients or for refractory DU. Highly selective vagotomy preserves pyloric innervation, negating the need for a drainage procedure. The now-rare Bilroth II gastrectomy for DU comprises a distal gastrectomy with oversewing of the duodenal stump and fashioning of a gastrojejunal anastomosis of either Polya or Roux-en-Y type. The latter prevents bile reflux as the distal duodenum is joined to the jejunum some 50 cm distal to the gastrojejunal anastomosis.

Bilroth I gastrectomy with gastroduodenal anastomosis

Bilroth I gastrectomy with gastroduodenal anastomosis

Bilroth II gastrectomy with gastrojejunal anastomosis

Figure 2.3. Gastric surgery for gastroduodenal peptic ulceration.

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