Surgical treatment of pepticulcer Hemorrhagic ulcer therapy Assess severity Resuscitate Stop the bleeding ◦ Therapeutic endoscopy ◦ Surgery Hemorrhagic ulcer therapy Vasopressors Endoscopy Surgery Click to edit Master text styles Second level Third level Fourth level Fifth level . After Yamada T – Textbook of gastroenterology . Surgery for peptic ulcer Absolute indications ◦ Major hemorrhage ◦ Perforation ◦ Stenosis . Surgical treatment Relative indications ◦ Repeated hemorrhage ◦ Penetration ◦ Arterial hypertension in hemorrhagic ulcer patients ◦ Associated portal hypertension ◦ Postbulbar ulcer ◦ Multiple ulcers ◦ Zollinger-Ellison syndrome ◦ Professional risk patients . After Yamada T – Textbook of gastroenterology . Surgery .goals Excision of the lesion Lowering pH (obtain an hypoacid stomach) Redo tract the continuity of the digestive . – Textbook of gastroenterology .After Yamada T. VS –selective vagotomy.. – great curvature anterior nerve. R. VA –anterior vagus.C.A.M. VSS –parietal cell vagotomy (limit . R.P. –celiac r.C.types Vagus nerves anatomy and vagotomy types VP – posterior vagus.5-7 cm) . N.Vagotomy. VT – troncular vagotomy. H-B –hepato-biliary r.M. – Lesser curvature anterior nerve (Latarjet). C.. N. Posterior troncular vagotomy with anterior seromiotomy (Taylor) . Pyloroplasty Nyhus et al. . Suturing a perforated duodenal ulcer Nyhus et al. . Conservative treatment Pneumoperitoneum in a 26 year old male The niche after conservative treatment . Laparoscopic suture of perforated ulcer . Laparoscopic suture of perforated ulcer Graham patch . – Textbook of gastroenterology .After Yamada T. . . . . . Hemostasis in situ Nyhus et al. hemigastrectomy (H) and antrectomy (A). a.Gastric resection (R). Gastrojejunostomy Billroth II . b. Gastroduodenoansto my (Péan-Billroth I). Ellis H [eds]: Maingot's Abdominal Operations.Billroth II operation and some of its modifications. (From Soybel DI. In Zinner MJ. 1997. Stamford. 10th ed. Zinner MJ: Stomach and duodenum: Operative procedures. Appleton & Lange.) . CT. vol I. Schwartz SI. After Yamada T. – Textbook of gastroenterology . – Textbook of gastroenterology .After Yamada T. – Textbook of gastroenterology .After Yamada T. JA Myers.Common Surgical Diseases. TJ Saclarides . Springer 2008 . JW Millikan. COMPLICATIONS OF SURGERY FOR PEPTIC ULCER . 5% mortality rate Bleeding. . and thromboembolism are potential complications after any abdominal procedure. infection.Early Complications 7% incidence of major complications and a 1. Early Complications Leak Acute afferent limb obstruction with potential duodenal stump leak after Billroth II reconstructions remains a feared complication . nausea. and cramping abdominal pain.Dumping syndrome Rapid emptying from the stomach ◦ Early ◦ Late It consists of a group of cardiovascular and gastrointestinal symptoms: ◦ faintness. . tachycardia. sweating. bloating. thereby reducing the blood volume.Early dumping Gastric emptying is normally regulated by duodenal osmoreceptors. . but if the pylorus is divided or bypassed. This leads to an outpouring of fluid into the small intestine to dilute the bowel contents. hypertonic fluids can be 'dumped' into the upper small intestine. Whether or not a particular patient experiences cardiovascular symptoms may depend on how sensitive he/she is to slight changes in plasma volume. Symptoms tend to improve with the time. 10% -milder symptoms. .Early dumping Gastrointestinal symptoms are due to the sudden release of gastrointestinal peptides such as cholecystokinin and motilin. Symptoms severe enough to interfere with normal activity – 5% per cent after vagotomy and drainage or partial gastrectomy. Early dumping • Vasomotor and gastrointestinal symptoms which typically occur 15 to 30 minutes after eating: ◦ dizziness. ◦ flushing. ◦ nausea . treatment Dietary .avoiding high-osmotic foods and separating drinking and eating. . Octreotide acetate is generally effective in treating severe dumping symptoms that have not responded to appropriate dietary alterations.Early dumping . which can be taken as soon as the symptoms start. to prevent a severe hypoglycaemia . the patient can also carry a glucose sweet.Late dumping Hypoglycaemia occurring about 2 h after a meal because of a large initial secretion of insulin in response to the high sugar load. Less common than early dumping. Same management like early dumping However. then just taking down the gastroenterostomy will probably solve the problem. Reversed jejunal segment Roux-en-Y gastrojejunostomy has been reported to achieve relief of dumping symptoms in 65% of the most severe cases. intact pylorus.Dumping syndrome – surgical treatment If the patient has a gastroenterostomy and a patent. . After Yamada T. – Textbook of gastroenterology . After Yamada T. – Textbook of gastroenterology . but only 1% after proximal gastric vagotomy. .Postvagotomy diarrhoea Severe diarrhoea may affect 10 % of patients after truncal vagotomy and drainage. Loperamide or diphenoxylate/atropine are required for adequate relief. After Yamada T. – Textbook of gastroenterology . biliary. and pancreatic drainage becomes partially or completely obstructed proximal to the gastric anastomosis. Two forms: ◦ Acute ◦ chronic .Afferent limb syndrome After Billroth II gastrojejunostomy Cause .the limb of duodenum and jejunum responsible for proximal intestinal. Acute afferent limb syndrome Obstruction of the afferent limb leads to accumulation of secretions within the proximal jejunal lumen. of the duodenal stump may . venous pressures are quickly exceeded. resulting in ischemia and pressure necrosis of the intestinal mucosa. As lumenal pressure increases. Disruption result. Acute afferent limb syndrome Is a surgical emergency. Mortality rates associated with acute afferent limb syndrome approach 50% . and fullness and. later bilious vomiting. partial mechanical obstruction of the afferent limb. usually void of foodstuff. pain. Symptoms: postprandial epigastric discomfort.Chronic afferent limb syndrome It results from intermittent. Treatment – remedial surgery . a Braun enteroenterostomy between the afferent and efferent limbs is effective in decompressing the obstructed afferent limb. .Chronic afferent limb syndrome treatment Conversion to a Roux-en-Y gastrojejunostomy Alternatively. – Textbook of gastroenterology .After Yamada T. internal herniation. and jejunogastric intussusception. . obstruction of the gastrojejunostomy distal to the anastomosis is termed the efferent limb syndrome.Efferent limb syndrome In patients treated with Billroth II gastrectomy. The causes of obstruction include postoperative adhesions. Efferent limb syndrome Colicky abdominal pain. or intussusception are suspected. The diagnosis is confirmed by either barium swallow or computed tomography scan with oral contrast. distension. gastric stump carcinoma. . Upper endoscopy should be performed when recurrent ulcer. and frequent bilious emesis. diffuse tenderness. and weight loss because of reflux of bile and pancreatic juice. burning epigastric pain. Prokinetic drugs are useful – metoclopramide . bilious vomiting.Alkaline reflux gastritis Nausea. a Roux-en-Y reconstruction or Tanner Roux procedure . ◦ After a Polya (Billroth II) gastrectomy.Alkaline reflux gastritis Revisional surgery ◦ Only in significant reflux disease ◦ Pyloric reconstruction or the closure of a gastrojejunostomy are the first surgical measures if there has been no resection. Tanner-Roux procedure . After Yamada T. – Textbook of gastroenterology . are advised to keep their meals as dry as possible and drink between meals. especially if there has been some obstruction of the antral outlet. Patients. . therefore. After vagotomy. and to bite their meals up well.Delayed gastric emptying Delayed gastric emptying of solids can coexist with rapid emptying of liquids and persists in a few patients long after the early postoperative period. for example metoclopramide or erythromycin have even been found to give some benefit on the gastric remnant when the antrum has been removed.Delayed gastric emptying Prokinetic drugs are helpful. . pylori infection ◦ Billroth II gastrojejunostomy ◦ Completeness of previous vagotomy ◦ Unsuspected gastrinoma (rare) .Stomal ulcer Cause: ◦ H. especially when the duodenum is bypassed and the mixing of food with bile and pancreatic secretion is poor because of persistent diarrhoea as steatorrhoea .Nutritional problems Loss of weight Iron. folate and vitamin B12 deficiency Hypocalcaemia and malabsorption of fat and fat-soluble vitamins. – Textbook of gastroenterology .After Yamada T. 7-fold increased risk of developing carcinoma of the gastric remnant More than 10-20 years to appear Possible causative factors ◦ hypochlorhydria. ◦ uneradicated H pylori infection ◦ nitrosation . ◦ alkaline reflux. ◦ diminished gastrin production. a patient has a 3.Gastric remnant carcinoma 1-4% incidence Twenty years after a gastric resection for benign disease. . and tend to be elderly. Patients with gastric remnant carcinomas tend to present late in their course. with more advanced disease.Gastric remnant carcinoma Patients undergoing antrectomy with Billroth II reconstruction appear to have a two to sixfold increased risk of developing gastric remnant carcinoma. .Gastric remnant carcinoma Gastric remnant carcinoma usually requires completion gastrectomy with Roux-en-Y reconstruction.
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