stomach and duodenum

SURGERY OF STOMACH AND DUODENUM

Surgical Anatomy

Arterial blood supply

1left gastric artery 2right gastric artery 3gastroduodenal artery ( from hepatic artery) divide a superior pancreatico duodenal artery, b- right gastroepiploic artery
4-inferior pancreatico-duodenal artey artery abranch of superior mesenteric artery
5-left gastroepiploic artery a branch of splenic artery..
6-short gastric arteries from splenic artery

Venous drainage

1right & left gastric veins draine into portal vein
2-left gastro epiploic vein & vasa bevia join solenic vein
3-right gastro epiploic vein join superior mesenteric vein
4- vein of mayo

Nerve supply

1-intrinsic, a- myenteric plexus of Auerbach,, b- submucosal plexus of Meissner
2-Extrensic, a ant. Vagus, b- post vagus
3-sympathetic

Physiology

1-parietal cells secrete HCL 2-chief cells secrete pepsin 3- endocrine cells secrete gastrin

Investigations of stomach & duodenum

1-OGD
2-Endoscopic ultrasound
3-barium meal
4-ultrasound
5-computerised tomography scanning CT Scan
6-laparoscopy
7-Angiography

SURGICAL PATHOLOGY

1-Congenital hypertrophic pyloric stenosis


2-Duodenal atresia

HELICOBACTER PYLORI

It is important in the aetiology of gastroduodenal diseases such as 1- chronic gastritis
2-peptic ulceration 3-gastric cancer

Types of Gastritis

Type A gastritis;it is an autoimmune condition there is circulationg antibody against parietal cell mass resulting in hypochlorhydria then to achlorhydria a premalignant condition..also no secretion of intrinsic factor by parietal cell lead to malabsorbtion of vitamine B12 which if not treated will lead to pernicious anaemia which is again premalignant condition.both might cause gastric cancer.

Type B Gastritis

This type of gastritis is associated with Helicobacter pylori.,,affect the antrum such patients are prone to develop peptic ulcer ,,pangastritis due to H ,pylori is associated with gastric cancer..
Intestinal metaplasia is associated with chronic pangastritis,,intestinal metaplagia is pre malignant condition it need regular follow up.

Reflux Gastritis

Occur after gastric surgery ,treatment medical very rare surgical..

Erosive Gastritis

Caused by NSAID & alcohol,,treatment medical.

Stress Gstritis

after serious illness or injury characterized by reduction to blood supply of the superficial mucosa of the stomach some time associated with stress ulcer or bleeding ,treatment by H2 antagonist for bleeding is by blood transfusion.some times we give prophylactic anti ulcer treatment.


Menetriers Disease
Gross hypertrophy gastric mucosa it is premalignant condition ,only treatment is gastrectomy..

PEPTIC ULCER

Common sites;1-first part duodenum. 2-lesser curve stomach. 3- oesophagus. 4- stoma following gastric surgery. 5- meckls diverticulum.

1-Acute peptic ( gastric & duodenal ) ulcer.& acute stress ulcer.causes are major illness,uraemia,,food poisoning,,bacteraemia ,,burn,,asirin,,steroid & NSAID.
Pathology
Some times it is single & some times are multiple as diagnosed by OGD.it involve the mucous membrane & does not penetrate the muscles,,some times it bleed,,or perforate..

Treatment.

Treat the cause plus anti ulcer treatment.
2-Chronic peptic ulcer. A-Gastric ulcer having relatively normal level or below normal gastric acid secretion.B-Duodenal ulcer occur in presence of very high acid level.also occur in zollinger Ellison syndrome,,geneticfactors may be involved, H pylori ,,social stress..,emotional.,smoking,,NSAIDs

DUODENAL ULCER

Incidence
There have been marked changes in the last 2 decades in the domography of patients presenting with duodenal ulcer first by the use of OGD second the introduction of H2 receptor antagonists (wide spread use of anti ulcer drugs & eradication therapy ) , SO ,the incidence of duodenal ulcer & the frequency of elective surgery are falling. ( except in cases of complications of peptic ulcer ) commoner in male than female
Pathology
Occur in first part duodenum it involve the mucosa,,muscle coat,leading to fibrosis and pyloric stenosis,,it may penetrate post. To pancreas & invade gastro duodenal artery,
Some times there is multiple ulcers,,or ANT,& POST.ulcer called kissing ulcers,,
ANT.ulcer tend to perforate while POST.ulcer tend to bleed.
Big ulcer called GIANT ulcer.(more than 2 cm.)
Chronic duodenal ulcer never become malignant.
Chronic gastric & chronic duodenal ulcer may co exist at same time.


GASTRIC ULCER
Incidence
Same etiological factors
Gastric ulcer is less common than D.U.sex are equal male to female,population is older than d.u. patient,,it is more prevalent in low socioeconomic patients,,.
Pathology
Usually on the lesser curve stomach,,but it is larger than du.,also invade mucosa & muscle coat & fibrosis,may cause stomach deformity hour glass stomach or tea pot deformity,,may penetrate to pancreas or blood vessel or invade transverse colon ..

Malignancy in gastric ulcer

1-On the long run ch. G.U.might become malignant so on OGD. To take multiple biopsies
2-other type of g.u is malignant g.u from the start.

Other types of peptic ulcer

1-stomal ulcer at jujunal site of gastrojejunostomy.
2-Billroth 2 (polya) gastrectomy.
3- prepyloric gastric ulcer it carry risk of cancer so it need biopsy.

The clinical features of gastric & duodenal ulcers

PAIN;;in the epigastric region ,,may radiate to the back,it is intermittent ;may last weeks or monthes with interval of pain free,,.some time patient do not eat cause of pain & some time patient eat to relieve pain .
PERIODICITY; attack of pain last from 26 weeks, attack is more in spring & autum
VOMITING ;;absent unless there is pyloric stenosis .
ALTERATION IN WEIGHT ;;
BLEEDING;;either chronic presented as anaemia;;or fresh as haematemasis & melaena.


CLINICAL EXAMINATION
Tenderness at epigastric region,,stomach splash in case of pyloric stenosis.

INVESTIGATIONS OF PEPTIC ULCER

1--OGD with or without multiple biopsy (CHECK ESOPHAGUS ,,, STOMACH,,DUODENUM),,& STOMA OF GASTROJEJUNOSTOMY to exclude stomal ulcer.
2BARIUM MEAL
3C.B.P.
TREATMENT OF CHRONIC PEPTIC ULCER
The vast majority of uncomplicated peptic ulcer are treated medically ,,surgical treatment of uncomplicated peptic ulcer has decreased markedly since 1990.due to the use of H2 recepter antagonist or proton pump inhibitor &eradication therapy.
The aim of surgical treatment is to reduce gastric acid secretion,(now it is reserved for the complicated P.U.)
MEDICAL TREATMENT
1-cessation of cigarette smoking ,,NSAIDs & Cortisone.
2-H2 receptor antagonist a-cemetidine (tagamet)---branetidine ( zantac ).c sucralphate (ulcar).
3-Proton pump inhibiter (omeprazole )
4-Eradication therapy.either give flagyl 3times aday plus amoxil 500mg cap,3 times aday for 2 weeks or to give flagyl plus klarethromycin 500mg twice a day for 2 weeks.

SURGICAL TREATMENT OF UNCOMPLICATED PEPTIC ULCER

Although it is rare now ,but some time it need to be performed if there is failer of medical treatment.
Operations for D. U. aim is excluding the damage effect of acid to the duodenum by diversion of the acid away from duodenum,
HISTORICAL SURGICAL PROCEDURES


1-BILLROTH I & BILLROTH II ( or called polya) GASTRECTOMY,by billroth in 1881.
2-OR TO DO ONLY GASTRO JEJUNOSTOMY (by wolfler in 1881)will end with high rate of stomal ulcer.

At present time the operation of choice in cases of D.U.are the followings:

1Truncal vagotomy(first introduced1943 by Dragstedt) plus drainage procedure
Types of drainage procedure:
APYLOROPLSTY types :1finnys pyloroplasty. 2Heineke-Mikulicz pyloroplasty.
3-Jaboulays pyloroplsty. 4-Ramstedts pyloroplasty.
BGASTROJEJUNOSTOMY post.,,isoperistaltic.at antrum post.
2- OR Selective vagotomy plus drainage procedure.
3-or highly selective vagotomy only ( with preservation to the nerve of latarjet that supply the pylorus ).no need to do drainage procedure.
4OR Truncal vagotomy and antrectomy.(billroth I)

Operations for gastric ulcer

1BILLROTH I OR BILLROTH II OPERATION PLUS EXCISION TO GASTRIC ULCER FOR HISTOPATHOLOGY TO EXCLUDE MALIGNANCY
2Or to do vagotomy plus drainage procedure plus excision biopsy to the ulcer..

COMPLICATIONS OF PEPTIC ULCER SURGERY

1-Recurrent ulceration a-either same ulcer, or b-stomal ulcer (complication may cause gastrojejunocolic fistula).
2-bile vomiting.
3-small stomach syndrome.
4-Dumping,due to rapid gastric emptying aearly dumping. Blate dumping.
5-Post vagotomy diarrhea .
6-Malignant changes.bile reflux gastritis then intestinal metaplagia then malignancy.
7-Gallstones formation.
8-Nutritional disorder ,wt. loss.,,anaemia,,vit.b12 deficiency.

COMPLICATIONS OF PEPTIC ULCER

1-PERFORATION PEPTIC ULCER: 1-Perforation ant. First pert duodenum most common,,2-perforation gastric ulcer, 3- perforation in to prepyloric ulcer.

SYMPTOMS

Some give history of D.U. or silent ulcer ,,there will be Sever sudden onset epigastric pain then generalized.due to irritant effect of gastric acid & gastric contents of food on the peritoneum, first chemical peritonitis then bacterial peritonitis,
SIGNS
At first temp.subnormal or normal then temp. increase (pyrexia by bacterial peritonitis),pulse increases,abdomen moves little or not move with respiration ,by palpation sever abdominal tenderness, abdominal rigiditity called board like rigidity,,
On percussion dull on Auscaltation first bowel sound +ve then become ve. some time the perforation is small,which is sealed by omentum,patient will have epigastric pain,,by P.R. elicit tenderness at rectovesical pouch,This emergency condition needs emergency surgery,, other wise if not there will be advanced peritonitis,, then septicemia & septic shock & mortality will be high.
INVESTIGATIONS
Xray abdomen in erect ,,supine & lateral position,,, shows gas under diaphragm in 70% & chest xray,,
Blood tests ,serum amylase,,abdomen ultrasound & C.T.Scan abdomen..


TREATMENT
1-Resuscitation.give antibiotics,,give tagament injection..
2-Emergency laparotomy by upper mid line incision,,localize the perforation site close the perforation by interrupted sutures with or without omental patch,, then peritoneal toilet,,then put drain ,nasogastric tube.& close abdomen.on rare occasion it need to do partial gastrectomy indications :1-perforation in carcinoma 2-sever bleeding 3-perforation is big & can not be closed.
Post op.period & Follow up.by anti ulcer treatment & O.G.D.
Other types of treatment:
1-conservative, 2- surgical the definitive treatment.

2PYLORIC STENOSIS Due to fibrosis or cicatrisation of D.O. OR Some times due to oedema associated with prepyloric ulcer .or called (GASTRIC OUTLET OBSTRUCTION) or called (DUODENAL STENOSIS).
Other causes carcinoma pylorus & congenital hypertrophic pyloric stenosis.
CLINICAL FEATURES
There is a history of long standing peptic ulcer .
SYMPTOMS
1-Pain, 2- Vomiting (foul) no bile,
SIGNS
1-Wt loss, 2 dehydration pale 3-distended epigastric region, 4-visible peristalsis from left to right, 5-succussion splash positive (audible) on shaking abdomen of the patient.

METABOLIC EFFECT

There will be HYPOKALEMIC METABOLIC ALKALOSIS PLUS DEHYDRATION PLUS ANAEMIA PLUS VITAMINE DIFICIENCY.

INVESTIGATIONS

1-O.G.D. + BIOPSY. 2- BARIUM MEAL 3- BLOOD+ELECTROLYTES TEST.


TREATMENT
1-N.G TUBE 2- I.V.FLUID +NACL + KCL. 3-WATCH URINE OUT PUT. 4- ANTI ULCER TREATMENT.
MILD CASES DUE TO OEDEMA WILL RESPOND TO CONSERVATIVE.SEVER CASES WILL NEED SURGERY
IF THE ULCER HEALED DO ONLY DRAINAGE BY GASTROJEJUNOSTOMY ONLY.
2-IF THERE IS ACTIVE ULCER DO TRUCAL VAGOTOMY PLUS GASTROJEJUNOSTOMY(SOME TIMES CAN DO PYLOROPLSTY IN STEAD)

FOLLOW-UP A PATIENT WITH PERFORATED PEPTIC ULCER

3BLEEDING (HAEMATEMESIS & MELAENA)OF PEPTIC ULCER

Either 1- slight 2- major bleeding. Some times there is history of peptic ulcer,,some PATHOLOGY
times there is history of drug intake like NAIDs &ASPIRIN.

THERE IS EROSION OF AN ARTERY IN THE FLOOR OF AN ULCER ,LIKE GASTRODUODENAL OR SPLENIC ARTERY,IF PATIENT ABOVE 40 YS THERE IS ATHEROSCLEROSIS SO THE ARTERY WILL NOT CONTRACT TO ARREST BLEEDING
.
SYMPTOMS & SIGNS

FEATURES OF BLEEDING

INVESTIGATIONS

TREATMENT

1RESUSCITATION
I.V.CANNULA,,CVP LINE,,BLOOD SAMPLE FOR BLOOD TEST,,I.V. FLUID ,BLOOD TRASFUSION,, INJACTABLE ANTI ULCER TREATMENT ,,NG TUBE,,FOLYS CATHETER,,PULSE & BP CHART,,OXYGEN,,
2SPECIFIC INVESTIGATIONS FOR DIAGNOSIS
DO O.G.D.
3TREATMENT BY I.V. FLUID ,,BLOOD TRANSFUSION,,ANTI ULCER TREATMENT.
1-CONSERVATIVE MEDICAL TREATMENT WITH BLOOD TRANSFUSION,IF BLEEDING STOP CONTINUE (MEDICAL TREATMENT),,WITH OR WITHOUT MINIMAL INTERVENTION.

MINIMAL INTERVENTION

MANY O.G.D. DEVICES ARE AVAILABLE CAN ACHIEVE HAEMESTASIS EXAMPLE INJECTION DILUTED ADRENALINE ,,OR NACL INJECTION ,OR BY ANGIOGRAPHY TO FIND THE SITE OF THE BLEEDER AND EMBOLIZATION.
2IF BEEDING STOPPED BUT REOCCUR AGAIN AFTER ADMISSION TO HOSPITAL THIS PATIENT IS A CANDIDAT FOR SURGICAL INTERVENTION

3IF BLEEDING NEVER STOP SINCE ADMISSION TO HOSPITAL & PATIENT RECEIVE MORE THAN 6 UNITS BLOOD ,THIS PATIENT IS A CANDIDAT FOR SURGICAL INTERVENTION.

SURGICAL TREATMENT

AIM OF SURGERY IS TO STOP THE BLEEDING.
IN BLEEDING POST. D.U. WHICH IS THE MOST COMMON
DO LAPARATOMY BY UPPER MID LINE INCISION,,MOBILIZE THE DUODENUM,,DO LONGITUDINAL INCISION 3,5 CM STOMACH SITE,2,5 CM DUODENUM SITE, BY CUTTIND PYLORIC SPHINCTOR
WE ARREST BLEEDER BY MULTIPLE INTERRUPTED UNDERRUNING SILK SUTURES,,BLEEDING WILL STOP ,,ANASTHETIST WILL SAY B.P.IS RISING. ON RARE OCCASION THERE WILL BE A NEED TO DO LIGATURE TO GASTRODUODENAL ARTERY OR TO DO PARTIAL GASTRECTOMY.
THEN DO PYLOROPLASTY,,
ALSO TO COMPLETE THE OPERATION DO TRUNCAL VAGOTOMY IF YOU DO NOT DO VAGOTOMY CONTINUE GIVING ANTI ULCER TREATMENT


IN BLEEDING GASTRIC ULCER PROCEDURE THE SAME
1-EITHER ARREST BLEEDING +BIOPSY,, OR, 2EXCISION BIOPSY TO THE ULCER AND CLOSE STOMACH.

HAEMATEMESISS & MELAENA (UPPER GASTROINTESTINAL BLEEDING)

CAUSES
1CHRONIC PEPTIC ULCER 60% AOESOPHAGEAL B-GASTRIC C-DUODENUM.
2-ACUTE PEPTIC ULCER 26% (EROSION)A-OESOPHAGUS, B-GASTRIC. C-DUODENUM.
3-OESOPHAGEAL VARICES 4%
4-MALLORY WEISS TEAR (SYNDROME) 4%
5-TUMOUR O.5%
6-VASCULAR e.g.DIEULAFAYS DISEASE O.5%
7-OTHERS 5% e.g.PURPURA,,HAEMOPHILIA

MANAGEMENT

SAME RESUSCITATION PLUS INVESTIGATIONS

SPECIFIC TREATMENT ACCORDING TO THE CAUSE

GASTRIC NEOPLASMS

BENIGN TUMOURS.

LEIOMYOMA ,,NEUROFIBROMA ,,POLYP( S)


GASTRIC CANCER

GASTRIC CANCER IS ONE OF THE MOST COMMON CAUSES OF DEATH IN THE WORLD.

THE OUTCOME IS GENERALY POOR, OWING TO THE ADVANCED STAGE AT TIME OF PRESENTATION.
BETTER RESULT ARE OBTAINED IN JAPAN ,,WHICH HAS A HIGH POPULATION INCIDENCE ,DUE TO SCREENING PROGRAM.
AETIOLOGY OF GASTRIC CANCER IS MULTIFACTORIAL,,H,PYLORI IS IMPORTANT FACTOR..
EARLY PRESENTATION OF GASTRIC CANCER IS ASSOCIATED WITH VERY HIGH CURE RATE.
GASTRIC CANCER CAN BE CLASSIFIED INTO INTESTINAL & DIFFUSE TYPE (HAVE BAD PROGNOSIS)
IN THE WEST PROXIMAL GASTRIC CANCER IS MORE COMMON THAN DISTAL CANCER & IT IS DIFFUSE TYPE.
SPREAD BY DIRECT,,LYMHPATICS,,BLOOD,,TRANSCOELOMIC.
TREATMENT OF CURABLE CASES IS BY RADICAL SURGERY,
GASTRIC CANCER IS CHEMOSENSITIVE.

INCIDENCE

IN U.K. 15 PATIENTS PER 100000 PER YEAR.
IN U.S.A.10 PATIENTS PER 100000 PER YEAR.
EAST EUROPE 40 PATIENTS PER 100000 PER YEAR.
IN JAPAN 70 PATIENTS PER 100000 PER YEAR.
MEN AFFECTED MORE THAN WOMEN.
INCIDENCE INCREASE WITH AGE.
IN THE WEST GASTRIC CANCER IS CONTINUING TO FALL BY 1%PER YEAR.THIS REDUCTION AFFECT CANCER ARISING FROM BODY &PYLORUS,WHILE THERE IS INCREASE IN CANCER IN THE PROXIMAL STOMACH.
CANCER OF BODY ,PYLORUS STOMACH COMMON IN LOW SOCIOECONOMIC GROUP,,
PROXIMAL GASTRIC CANCER AFFECT HIGH SOCIOECONOMIC GROUP..
PROXIMAL GASTRIC CANCER NOT ASSOCIATED WITH H,PYLORI


BODY & PYLORUS CANCER IS ASSOCIATED WITH H. PYLORI..

AETIOLOGY

1--H.PYLORI ASSOCIATED WITH CARCINOMA DODY & PYLORUS.
2--H.PYLORI CAUSE GASTRITIS ,,THEN GASTRIC ATROPHY,,& INTESTINAL METAPLASIA
3PERNICIOUS ANAEMIA & GASTRIC ATROPHY ARE RISK FACTOR.
4-GASTRIC POLYP.
5-AFTER GASTRIC SURGERY eg.BILLROTH I, OR II,,PYLOROPLASTY,,GASTROJEJUNOSTOMY,WILL INCREASE THE RISK 4 TIMES.
6REFLUX BILE GASTRITIS.
7CIGARETTE SMOKING,,DUST INGESTION,,
8INGESTION SPIRIT CAUSE GASTRITIS ON LONG RUN CHANGE TO CANCER.
9GENETIC FACTOR,

CLINICAL FEATURES

SYMPTOMS
1-DYSPEPSIA,,POOR APPITITE,,DISTENSION,BLEEDING,THEN ANAEMIA,DYSPHAGIA,VOMITING,LUMP AT EPIGASTRIC REGION
SIGNS
EPIGASTRIC TENDERNESS,,?MASS,,STOMACH SPLASH,DEHYDRATION,,FEATURES OF PYLORIC OBSTRUCTION,THROMBOPHLEBITIS MIGRANE,,D.V.T.ENLARGED LEFT SUPRACLAVICULAR LYMPH NODES(TROISIERS SIGN),,LIVER METASTASIS CAUSE JAUNDICE,,ASCITES,

PATHOLOGY

1INTESTINAL GASTRIC CANCER
ACAULIFLOWER.
BULCERATIVE
CCOLLOID
2DIFFUSE GASTRIC CANCER INFILTRATES DEEPLY IN STOMACH WITHOUT OBVIOUS MASS (LINITIS PLASTICA) OR CALLED (LEATHER BOTTLE STOMACH).
3GASTRIC CANCER SECONDARY TO GASTRIC ULCER.
MICROSCOPICALLY IT IS COLUMNAR CELL
MOST COMMON SITE IS PYLORU,THEN BODY ,& CARDIA & FUNDUS.


STAGING CARCINOMA STOMACH
TI TUMOUR INVOLVE LAMINA PROPRIA.
T2- == == MUSCLE LAYER OR SUB SEROSA.
T3-- === == SEROSA.
T4--== == ADJACENT ORGANS.

N0 NO LYMPH NODES.

N1 METASTASIS TO 1----6 REGIONAL NODES.
N2- =========== TO 7----15 ======== ======.
N3METASTASIS TO MORE THAN 15 NODES.

M0 NO DISTANT METASTASIS.

M1- DISTANT METASTASIS.

SPREAD OF GASTRIC CANCER

1-DIRECT INVADE THE WALL THEN ,,LIVER,,PANCREAS,,COLON OMENTUM.

2-LYMPHATIC SPREAD BY PERMIATION & EMBOLIZATION.

3-BLOOD BORNE METASTASIS.
4-TRANSPERITONEAL SPREAD.


INVESTIGATIONS

TREATMENT OF GASTRIC CANCER

1-PALLIATIVE SURGERY
A-GASTROJEJUNOSTOMY
B-M.B. TUBE.
2-RADICAL RESECTION
A-TOTAL GASTRECTOMY
B-UPPER RADICAL GASTRECTOMY
C-LOWER === ==

GASTRIC STROMAL TUMOURS (G.S.T.)

GASTRIC LYMPHOMA.










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