Stomach and Duodenum 2

Stomach and Duodenum

Dr Aqeel Shakir MahmoodAssistant ProfessorConsultant General and Laparoscopic SurgeonFICMS General SurgeryCABS General SurgeryFICMS-GIT Gastrointestinal Surgery (subspecialty )MRCS –( Ireland) General SurgeryFRCS –( London) General Surgery

Stomach and Duodenum

Anatomy Physiology Pathology Gastritis Peptic ulcer diseases Operative procedures Tumors Carcinoma of the stomach

Duodenal Ulcer : goals of operative therapy

Promotion of ulcer healing Treatment of specific complications Reduction of the possibility of recurrence Minimization of postoperative side effects

Duodenal Ulcer : operative procedures

Truncal vagotomy and drainage Truncal vagotomy and antrectomy Parietal cell vagotomy Alternative methods

Vagotomy

Gastric effects of truncal vagotomy
Decreased acid secretion Increased serum gastrin Gastrin cell hyperplasia Accelerated liquid emptying Altered emptying of solid



Nongastric effects of truncal vagotomy
Decreased pancreatic exocrine secretion Decreased postprandial bile flow Increased gallbladder volume Diminished release of vagally mediated peptide hormones

Truncal vagotomy and drainage Drainage procedures : pyloroplasty

Heineke-Mikulicz Finney Jaboulay

Heineke-Mikulicz pyloroplasty

GASTRODUODENOSTOMY BY JABOULAY

Finney pyloroplasty

Duodenal Ulcer : operative procedures
Truncal vagotomy and drainage Truncal vagotomy and antrectomy Parietal cell vagotomy Alternative methods

Duodenal Ulcer : operative procedures

Truncal vagotomy and drainage Truncal vagotomy and antrectomy Parietal cell vagotomy Alternative methods


Duodenal Ulcer : choice of operation
Location of ulcer Indication for operation Chronicity of the ulcer diathesis Age and sex, nutritional status of the patient Presence of concomitant illness Stability of the patient during the perioperative period Experience and personal preference of the surgeon

Duodenal Ulcer : indications for operation

Intractability Perforation Obstruction Hemorrhage

Duodenal Ulcer : indications for operation

Intractability Perforation Obstruction Hemorrhage

Intractability ; criteria

Initial healing is delayed, so that ulceration persists at 3 months despite active drug therapy Ulcers recur within 1 year of initial healing despite maintenance therapy The ulcer disease is characterized by cycles of prolonged activity with brief or absent remissions

Operative procedures : intractability

First choice; parietal cell vagotomy Alternatives ; truncal vagotomy and antrectomy laparoscopic vagotmy

Duodenal Ulcer : indications for operation

Intractability Perforation Obstruction Hemorrhage

Clinical features ; perforated duodenal ulcer

Symptoms ; sudden onset of severe epigastric pain spreading throughout the abdomen, variable degree of shock Signs ; abdominal tenderness, rigidity Plain X-ray ; peritoneal free air

Differential diagnosis ; perforated duodenal ulcer

Acute cholecystitis Acute pancreatitis Strangulation obstruction Acute appendicitis Perforation of other G-I tract Mesenteric thrombosis

Operative procedures : perforation

Simple closure Definitive surgery parietal cell vagotomy and omental patch truncal vagotomy and pyloroplasty truncal vagotomy and antrectomy

Indications for definitive operation

No preoperative shock No life-threatening medical illness Perforation has been present for less than 48 hours

Duodenal Ulcer : indications for operation

Intractability Perforation Obstruction Hemorrhage

Causes of obstruction in duodenal ulcer

Inflammation and edema Fibrosis

Operative procedures : obstruction

Truncal vagotomy and antrectomy Truncal vagotomy and gastrojejunostomy

Duodenal Ulcer : indications for operation

Intractability Perforation Obstruction Hemorrhage

Indications for operative intervention ; duodenal ulcer bleeding

Massive hemorrhage leading to shock Prolonged blood loss requiring continuing transfusion Recurrent bleeding during medical therapy or after endoscopic therapy Recurrent bleeding requiring hospitalization

Operative procedures : hemorrhage

Truncal vagotomy and pyloroplasty with suture ligation of bleeding vessel Truncal vagotomy and antrectomy including ulcer or suture ligation of bleeding vessel

Timing of operation : hemorrhage

Primary emergency Secondary emergency Early elective surgery

Gastric Ulcer : goals of elective operation

Primary goals ; to excise the ulcer to reduce acid/pepsin output Secondary goals ; to minimize bile reflux and gastric stasis


Stomach resections:Billroth I (BI) – gastro-duodenoanastomosis end-to-endBillroth II (BII) – gastro-jejunoanastomosis end-to-side with blind closure of duodenumProximal selective vagotomy – denervation of parietal gastric cells

Billroth I

Billroth II

Billiroth 1 Gastroduodenostomy Billiroth 2 Gastrojejuenostomy

Gastric ulcer : standard operations
type I ; Distal gastrectomy and B-I anastomosis type II, III ; Distal gastrectomy with vagotomy type IV ; TV and drainage and biopsy/excision of ulcer Proximal gastrectomy

Gastric Ulcer : indications for elective operation

Failure to heal on optimal medical therapy Suspicion of malignancy Distal gastric obstruction Giant gastric ulcer

Gastric Ulcer : emergency operation

Bleeding gastric ulcer Perforated gastric ulcer



Bleeding gastric ulcer : operative procedures
Gastric resection including ulcer simple oversewing excision of ulcer with TV and drainage without TV and drainage

Gastric Ulcer : emergency operation

Bleeding gastric ulcer Perforated gastric ulcer

Perforated gastric ulcer : operative procedures

Gastric resection Biopsy and simple closure

New Surgical Strategy for Gastroduodenal Ulcer : Laparoscopic approach

Truncal vagotomy Thoracoscopic truncal vagotomy Parietal cell vagotomy

Stress Ulcer

Multiple superficial mucosal erosions after major physical trauma, shock, sepsis, hemorrhage, respiratory failure, or severe burns.

Morbid obesity

Morbid obesity Sleeve Gastrectomy

Morbid obesity

Morbid obesity Sleeve Gastrectomy

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