What is the most appropriate surgical procedure for a bleeding duodenal ulcer?
- The best option is simple oversew of the bleeding ulcer. Control of the ulcer bed is attained by performing a duodenotomy with direct ligation of the bleeding vessel or complete plication of the ulcer bed.
- Three-point suture ligation takes place in the superior, inferior, and medial aspect of the vessel. If a posterior duodenal ulcer has eroded into the gastroduodenal artery, bleeding may be profuse.
- If a patient has ulcer disease refractory to medical management or is on chronic NSAID therapy, a definitive ulcer operation is then performed. This may consist of either truncal vagotomy and pyloroplasty or a truncal vagotomy and antrectomy.
- An alternative approach is to attain control of the bleeding duodenal ulcer through a pyloroplasty incision, in which case a truncal vagotomy completes the definitive ulcer operation.
- Patients who have not been treated for H. pylori prior to bleeding should undergo ligation of the bleeder only, with postoperative H. pylori eradication therapy, in lieu of a definitive ulcer operation.