Surgical treatment of peptic
ulcer
Hemorrhagic ulcer therapy
Assess
severity
Resuscitate
Stop
the bleeding
Therapeutic endoscopy
Surgery
Hemorrhagic ulcer therapy
Vasopressors
Endoscopy
Surgery
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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
After Yamada T. Textbook of gastroenterology
Vagotomy- types
Vagus nerves anatomy
and vagotomy types
VP posterior vagus, VA
anterior vagus, R. H-B
hepato-biliary r., R. C.
celiac r., N.A.M.C.
Lesser curvature
anterior nerve (Latarjet),
N.P.M.C. great
curvature anterior nerve,
VT troncular
vagotomy, VS selective
vagotomy, VSS parietal
cell vagotomy (limit - 5-7
cm)
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
After Yamada T. Textbook of
gastroenterology
Hemostasis in situ
Nyhus et al.
Gastric resection (R),
hemigastrectomy (H) and
antrectomy (A);
a. Gastroduodenoansto
my (Pan-Billroth I),
b. Gastrojejunostomy Billroth II
Billroth II operation and some of its modifications. (From Soybel DI, Zinner MJ: Stomach and duodenum:
Operative procedures. In Zinner MJ, Schwartz SI, Ellis H [eds]: Maingot's Abdominal Operations, vol I, 10th
ed. Stamford, CT, Appleton & Lange, 1997.)
After Yamada T. Textbook of gastroenterology
After Yamada T. Textbook of gastroenterology
After Yamada T. Textbook of gastroenterology
JA Myers, JW Millikan, TJ Saclarides - Common Surgical Diseases, Springer 2008
COMPLICATIONS OF SURGERY FOR
PEPTIC ULCER
Early Complications
7%
incidence of major complications
and a 1.5% mortality rate
Bleeding,
infection, and
thromboembolism are potential
complications after any abdominal
procedure.
Early Complications
Leak
Acute
afferent limb obstruction with
potential duodenal stump leak after
Billroth II reconstructions remains a
feared complication
Dumping syndrome
Rapid
emptying from the stomach
Early
Late
It
consists of a group of
cardiovascular and gastrointestinal
symptoms:
faintness, sweating, tachycardia, bloating,
nausea, and cramping abdominal pain.
Early dumping
Gastric
emptying is normally regulated by
duodenal osmoreceptors, but if the pylorus is
divided or bypassed, hypertonic fluids can be
'dumped' into the upper small intestine. This
leads to an outpouring of fluid into the small
intestine to dilute the bowel contents, thereby
reducing the blood volume.
Whether
or not a particular patient experiences
cardiovascular symptoms may depend on how
sensitive he/she is to slight changes in plasma
volume.
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, 10% -milder
symptoms.
Symptoms
tend to improve with the time.
Early dumping
Vasomotor and gastrointestinal
symptoms which typically occur 15 to
30 minutes after eating:
dizziness,
flushing,
nausea
Early dumping - 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.
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,
the patient can also carry a
glucose sweet, which can be taken as soon
as the symptoms start, to prevent a severe
hypoglycaemia
Dumping syndrome surgical
treatment
If
the patient has a gastroenterostomy
and a patent, intact pylorus, 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.
After Yamada T. Textbook of gastroenterology
After Yamada T. Textbook of gastroenterology
Postvagotomy diarrhoea
Severe
diarrhoea may affect 10 % of
patients after truncal vagotomy and
drainage, but only 1% after proximal
gastric vagotomy.
Loperamide or
diphenoxylate/atropine are required
for adequate relief.
After Yamada T. Textbook of gastroenterology
Afferent limb syndrome
After
Billroth II gastrojejunostomy
Cause
- the limb of duodenum and jejunum
responsible for proximal intestinal, biliary, and
pancreatic drainage becomes partially or
completely obstructed proximal to the gastric
anastomosis.
Two
forms:
Acute
chronic
Acute afferent limb syndrome
Obstruction
of the afferent limb leads
to accumulation of secretions within
the proximal jejunal lumen. As
lumenal pressure increases, venous
pressures are quickly exceeded,
resulting in ischemia and pressure
necrosis of the intestinal mucosa.
Disruption
result.
of the duodenal stump may
Acute afferent limb syndrome
Is
a surgical emergency.
Mortality
rates associated with acute
afferent limb syndrome approach 50%
Chronic afferent limb syndrome
It
results from intermittent, partial
mechanical obstruction of the afferent
limb.
Symptoms:
postprandial epigastric
discomfort, pain, and fullness and,
later bilious vomiting, usually void of
foodstuff.
Treatment
remedial surgery
Chronic afferent limb syndrome treatment
Conversion
to a Roux-en-Y
gastrojejunostomy
Alternatively,
a Braun
enteroenterostomy between the
afferent and efferent limbs is effective
in decompressing the obstructed
afferent limb.
After Yamada T. Textbook of gastroenterology
Efferent limb syndrome
In
patients treated with Billroth II
gastrectomy, obstruction of the
gastrojejunostomy distal to the
anastomosis is termed the efferent
limb syndrome.
The
causes of obstruction include
postoperative adhesions, internal
herniation, and jejunogastric
intussusception.
Efferent limb syndrome
Colicky
abdominal pain, distension, diffuse
tenderness, and frequent bilious emesis.
The
diagnosis is confirmed by either barium
swallow or computed tomography scan with
oral contrast.
Upper
endoscopy should be performed
when recurrent ulcer, gastric stump
carcinoma, or intussusception are
suspected.
Alkaline reflux gastritis
Nausea,
burning epigastric pain,
bilious vomiting, and weight loss
because of reflux of bile and
pancreatic juice.
Prokinetic
drugs are useful
metoclopramide
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.
After a Polya (Billroth II) gastrectomy, a
Roux-en-Y reconstruction or Tanner Roux
procedure
Tanner-Roux procedure
After Yamada T. Textbook of gastroenterology
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.
After
vagotomy, especially if there has been some
obstruction of the antral outlet.
Patients,
therefore, are advised to keep their meals
as dry as possible and drink between meals, and to
bite their meals up well.
Delayed gastric emptying
Prokinetic
drugs are helpful, for
example metoclopramide or
erythromycin have even been found to
give some benefit on the gastric
remnant when the antrum has been
removed.
Stomal ulcer
Cause:
H. pylori infection
Billroth II gastrojejunostomy
Completeness of previous vagotomy
Unsuspected gastrinoma (rare)
Nutritional problems
Loss
of weight
Iron,
folate and vitamin B12 deficiency
Hypocalcaemia
and malabsorption of fat
and fat-soluble vitamins, especially when
the duodenum is bypassed and the mixing
of food with bile and pancreatic secretion is
poor because of persistent diarrhoea as
steatorrhoea
After Yamada T. Textbook of gastroenterology
Gastric remnant carcinoma
1-4%
incidence
Twenty
years after a gastric resection for benign
disease, a patient has a 3.7-fold increased risk of
developing carcinoma of the gastric remnant
More
than 10-20 years to appear
Possible
causative factors
hypochlorhydria,
alkaline reflux,
diminished gastrin production,
uneradicated H pylori infection
nitrosation
Gastric remnant carcinoma
Patients
undergoing antrectomy with
Billroth II reconstruction appear to
have a two to sixfold increased risk of
developing gastric remnant carcinoma.
Patients
with gastric remnant
carcinomas tend to present late in their
course, with more advanced disease,
and tend to be elderly.
Gastric remnant carcinoma
Gastric
remnant carcinoma usually
requires completion gastrectomy with
Roux-en-Y reconstruction.
