Sachdeva A K, Zaren H A, Sigel B
Medical College of Pennsylvania, Philadelphia.
Med Clin North Am. 1991 Jul;75(4):999-1012. doi: 10.1016/s0025-7125(16)30426-6.
Elective surgery for peptic ulcer disease has diminished significantly over the past 15 years. However, emergency surgery has not shown a decline. Some series have even reported an increase in hospitalizations and operations for hemorrhage. The appropriate surgical procedure for peptic ulcer disease must be tailored to the specific needs of the individual patient. During emergency operations for hemorrhage from duodenal ulcer, we recommend suture ligature of the bleeding vessel and vagotomy-pyloroplasty for high-risk patients, or vagotomy-antrectomy for the lower-risk patient. Bleeding gastric ulcers should be resected, if possible. For massive hemorrhage from stress ulceration requiring surgery, near-total or total gastrectomy should be performed. Perforated duodenal ulcers are best managed by closure and a definitive ulcer operation, such as vagotomy-pyloroplasty. Perforated gastric ulcers are best excised but may be simply closed if conditions do not favor resection. In these situations, biopsy should be performed. We recommend truncal vagotomy-antrectomy for patients presenting with obstruction. Vagotomy (truncal or proximal gastric) with drainage is an acceptable alternative in this situation. For patients with intractable ulcer disease or for those who are noncompliant, proximal gastric vagotomy is the preferred operation. However, other operations may need to be considered, depending on the specific situation. Recurrent ulceration needs appropriate work-up to determine the possible cause. Although patients with ulcer recurrence initially may be placed on medical treatment, about 50% will require reoperation. The most effective procedure for peptic ulcer disease is truncal vagotomy-antrectomy, which has a recurrence rate of less than 1%. The procedure with the least morbidity and the fewest undesirable side effects is proximal gastric vagotomy. Ulcer recurrence after proximal gastric vagotomy or truncal vagotomy-pyloroplasty is in the range of 10% to 15%.
在过去15年中，消化性溃疡疾病的择期手术显著减少。然而，急诊手术并未呈现下降趋势。一些系列报道甚至显示因出血导致的住院和手术数量有所增加。消化性溃疡疾病的合适手术方式必须根据个体患者的具体需求来定制。在十二指肠溃疡出血的急诊手术中，对于高危患者，我们建议缝合结扎出血血管并进行迷走神经切断术 - 幽门成形术；对于低危患者，则建议进行迷走神经切断术 - 胃窦切除术。如果可能，出血性胃溃疡应进行切除。对于因应激性溃疡大出血而需要手术的情况，应进行近全胃或全胃切除术。穿孔性十二指肠溃疡最好通过缝合和确定性溃疡手术（如迷走神经切断术 - 幽门成形术）来处理。穿孔性胃溃疡最好进行切除，但如果情况不适合切除，也可简单缝合。在这些情况下，应进行活检。对于出现梗阻的患者，我们建议进行全胃迷走神经切断术 - 胃窦切除术。在这种情况下，迷走神经切断术（全胃或近端胃）加引流术也是一种可接受的替代方案。对于患有顽固性溃疡疾病或不依从的患者，近端胃迷走神经切断术是首选手术。然而，根据具体情况可能需要考虑其他手术。复发性溃疡需要进行适当的检查以确定可能的原因。虽然溃疡复发的患者最初可能接受药物治疗，但约50%将需要再次手术。消化性溃疡疾病最有效的手术是全胃迷走神经切断术 - 胃窦切除术，其复发率低于1%。发病率最低且不良副作用最少的手术是近端胃迷走神经切断术。近端胃迷走神经切断术或全胃迷走神经切断术 - 幽门成形术后的溃疡复发率在10%至15%之间。
