Laparoscopic Management of Complicated Ulcer Disease

Laparoscopic surgery for complicated ulcer disease has to be tailored to the specific needs imposed by the pathology and clinical state of the patient. In the elective situation, patients with concomitant reflux esophagitis and duodenal ulcer disease are best treated by partial crurally-fixed posterior fundoplication and highly selective vagotomy. Patients with resistant prepyloric ulcers and those on long-term medication with ulcerogenic drugs require truncal vagotomy and antrectomy. Because many patients with benign pyloric stenosis are elderly and exhibit hypochlorhydria, a drainage procedure without vagotomy is sufficient. The type of drainage performed, gastrojejunostomy or pyloroplasty, depends on the extent of scarring of antroduodenal segment. In the emergency situation, patients with perforated ulcer disease are best treated by simple closure with adequate peritoneal toilet. A definitive procedure should be reserved for fit patients with prior symptoms and limited chemical peritonitis of less than 6 to 8 hours duration. All perforated gastric ulcers should be biopsied at the time of laparoscopic closure. New endogastric techniques are being evaluated for the treatment of patients with bleeding gastroesophageal lesions.