Surgical treatment of peptic ulcer

1

Hemorrhagic ulcer therapyAssess severityResuscitate Stop the bleeding Therapeutic endoscopy

Surgery

2

Hemorrhagic ulcer therapyVasopressors EndoscopySurgery

3

4Click to edit Master text stylesSecond level

Third levelFourth level

Fifth level

5After Yamada T Textbook of gastroenterology

Surgery for peptic ulcerAbsolute indications Major hemorrhagePerforationStenosis

6

Surgical treatmentRelative indications Repeated hemorrhage Penetration Arterial hypertension in hemorrhagic ulcer

patients Associated portal hypertension Postbulbar ulcer Multiple ulcers Zollinger-Ellison syndrome Professional risk patients

7

8After Yamada T Textbook of gastroenterology

Surgery - goalsExcision of the lesionLowering pH (obtain an hypoacid

stomach)Redo the continuity of the digestive

tract

9

10

After Yamada T. Textbook of gastroenterology

Vagus nerves anatomy and vagotomy typesVP 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)

Vagotomy- types

11

Posterior troncular vagotomy with anterior seromiotomy (Taylor)

12

Pyloroplasty

13

Nyhus et al.

Suturing a perforated duodenal ulcer

Nyhus et al.

14

Conservative treatment

Pneumoperitoneum in a 26 year old male

The niche after conservative treatment

15

Laparoscopic suture of perforated ulcer

16

Laparoscopic suture of perforated ulcer

Graham patch

17

18

After Yamada T. Textbook of gastroenterology

19

20

21

22

23

24

Hemostasis in situ

25

Nyhus et al.

26

Gastric resection (R), hemigastrectomy (H) and antrectomy (A); a. Gastroduodenoansto

my (Pan-Billroth I), b. Gastrojejunostomy -

Billroth II

27

28

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.)

29

After Yamada T. Textbook of gastroenterology

30

After Yamada T. Textbook of gastroenterology

31

After Yamada T. Textbook of gastroenterology

32

JA Myers, JW Millikan, TJ Saclarides - Common Surgical Diseases, Springer 2008

COMPLICATIONS OF SURGERY FOR PEPTIC ULCER

33

Early Complications7% incidence of major complications

and a 1.5% mortality rateBleeding, infection, and

thromboembolism are potential complications after any abdominal procedure.

34

Early ComplicationsLeak Acute afferent limb obstruction with

potential duodenal stump leak after Billroth II reconstructions remains a feared complication

35

Dumping syndromeRapid 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.

36

Early dumpingGastric 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.

37

Early dumpingGastrointestinal 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.

38

Early dumping Vasomotor and gastrointestinal

symptoms which typically occur 15 to 30 minutes after eating:

dizziness,

flushing,

nausea

39

Early dumping - treatmentDietary - 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.

40

Late dumpingHypoglycaemia 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

41

Dumping syndrome surgical treatmentIf 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.

42

43

After Yamada T. Textbook of gastroenterology

44

After Yamada T. Textbook of gastroenterology

Postvagotomy diarrhoeaSevere 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.

45

46

After Yamada T. Textbook of gastroenterology

Afferent limb syndromeAfter Billroth II gastrojejunostomyCause - 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

47

Acute afferent limb syndromeObstruction 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 of the duodenal stump may result.

48

Acute afferent limb syndromeIs a surgical emergency.Mortality rates associated with acute

afferent limb syndrome approach 50%

49

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

50

Chronic afferent limb syndrome - treatmentConversion to a Roux-en-Y

gastrojejunostomy Alternatively, a Braun

enteroenterostomy between the afferent and efferent limbs is effective in decompressing the obstructed afferent limb.

51

52

After Yamada T. Textbook of gastroenterology

Efferent limb syndromeIn 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.

53

Efferent limb syndromeColicky 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.

54

Alkaline reflux gastritisNausea, burning epigastric pain,

bilious vomiting, and weight loss because of reflux of bile and pancreatic juice.

Prokinetic drugs are useful metoclopramide

55

Alkaline reflux gastritisRevisional 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

56

Tanner-Roux procedure

57

58

After Yamada T. Textbook of gastroenterology

Delayed gastric emptyingDelayed 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.

59

Delayed gastric emptyingProkinetic 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.

60

Stomal ulcerCause: H. pylori infection

Billroth II gastrojejunostomy

Completeness of previous vagotomy

Unsuspected gastrinoma (rare)

61

Nutritional problemsLoss 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

62

63

After Yamada T. Textbook of gastroenterology

Gastric remnant carcinoma1-4% incidenceTwenty 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 appearPossible causative factors hypochlorhydria,

alkaline reflux,

diminished gastrin production,

uneradicated H pylori infection

nitrosation

64

Gastric remnant carcinomaPatients 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.

65

Gastric remnant carcinomaGastric remnant carcinoma usually

requires completion gastrectomy with Roux-en-Y reconstruction.

66

Slide 1Hemorrhagic ulcer therapyHemorrhagic ulcer therapySlide 4Slide 5Surgery for peptic ulcerSurgical treatmentSlide 8Surgery - goalsSlide 10Vagotomy- typesSlide 12PyloroplastySlide 14Conservative treatmentLaparoscopic suture of perforated ulcerLaparoscopic suture of perforated ulcerSlide 18Slide 19Slide 20Slide 21Slide 22Slide 23Slide 24Hemostasis in situSlide 26Slide 27Slide 28Slide 29Slide 30Slide 31Slide 32Slide 33Early ComplicationsEarly ComplicationsDumping syndromeEarly dumpingEarly dumpingEarly dumpingEarly dumping - treatmentLate dumpingDumping syndrome surgical treatmentSlide 43Slide 44Postvagotomy diarrhoeaSlide 46Afferent limb syndromeAcute afferent limb syndromeAcute afferent limb syndromeChronic afferent limb syndromeChronic afferent limb syndrome - treatmentSlide 52Efferent limb syndromeEfferent limb syndromeAlkaline reflux gastritisAlkaline reflux gastritisTanner-Roux procedureSlide 58Delayed gastric emptyingDelayed gastric emptyingStomal ulcerNutritional problemsSlide 63Gastric remnant carcinomaGastric remnant carcinomaGastric remnant carcinoma