1. Risks and Complications

2. HSV/Parietal Cell Vagotomy Mortality risk <0.5% Causes minimal side effects Decreases total gastric acid secretion by about 75% and GI side effects are rare. Elective HSV has been largely supplanted by PPI treatment, but may be useful in the non- compliant or intolerant patient

3. Oversewing One of two most commonly used operations for bleeding duodenal ulcer (the other being Vagotomy + Antrectomy or V+A) This alone results in a higher rebleeding rate but a lower operative mortality rate. When mortality for reoperation for rebleeding is considered, the overall mortality is comparable for the two approaches.

4. Vagotomy + Antrectomy Smaller dudodenal ulcers are resected with the specimen while larger bleeding ulcers must often be left behind in the duodenal stump; suture hemostasis must be attained and a secure duodenal closure accomplished. The anterior wall of the open duodenum can be sutured to either the proximal or distal lip of the posterior ulcer once the bleeding vessel has been sutured

5. Gastric ulcer management is initially the same. Distal gastric resection to include the bleeding ulcer is the procedure of choice for bleeding gastric ulcer., while 2 nd best is V+D with oversewing and biopsy to rule out cancer.

6. Perforation Perforated gastric ulcer results in a higher mortality rate than perforated duodenal ulcer (10 – 40 %) due to – Advanced age – Medical comorbidities – Delay in seeking medical attention – Larger size of gastric ulcers

7. Perforated gastric ulcers in a stable patient without any other disease are best treated with distal gastric resection., while vagotomy is added for type II or III gastric ulcers.

8. Obstructing Peptic Ulcer Least common indication for operation in PUD Acute ulcers associated with obstruction due to edema and/or motor dysfunction may respond to intensive antisecretory therapy and nasogastric suction. Most common procedures are PUD are V+A and V+D