Pravin Narkhede

Surgery for peptic ulcers is performed less often

since the advent of the H2 antagonists and proton pump inhibitors (PPIs) and the treatments to eradicate Helicobacter pylori there is a high recurrence rate for peptic ulcerations after discontinuation of medical therapy  Indications for surgery Intractable ulcers Haemorrhage Perforation Obstruction, usually pyloric stenosis

 Goal of surgery treatment of anatomic

complications, such as pyloric stenosis or perforation. patient safety in the acute setting, combined with freedom from undesirable chronic side effects alteration of the ulcer diathesis so that ulcer healing is achieved and recurrence is minimized

Subtotal gastrectomy was considered

optimal management for duodenal and gastric ulcers until Dragstedt's description of vagotomy and its impact on ulcer healing and recurrence.  goal of ulcer surgery is to prevent gastric acid secretion. Vagotomy decreases peak acid output by about 50%, vagotomy plus antrectomy, which removes the gastrin-secreting portion of the stomach, decreases peak acid output by about 85%

 Surgical procedures

The operations that have been used traditionally are: Truncal vagotomy and Pyloroplasty Highly selective vagotomy Truncal vagotmoy and Antrectomy Billroth I gastrectomy Billroth II or Polya gastrectomy Roux-n Y anastomosis

Truncal Vagotomy Truncal vagotomy is probably the

most common operation performed for duodenal ulcer disease truncal vagotomy is performed by division of the left and right vagus nerves above the hepatic and celiac branches just above the GE junction some form of drainage procedure in association with truncal vagotomy

Heineke-Mikulicz pyloroplasty Longitudinal incision across pylorus

which is then closed transversly not feasibile if pylorus thickened or scarred Finney pyloroplasty or Jaboulay gastroduodenostomy When the duodenal bulb is scarred, Gastro duodenostomy Can be performed if pylorus thickened or scarred

From a technical standpoint, truncal

vagotomy and pyloroplasty represent an uncomplicated procedure that can be performed quickly, making it especially attractive for patients who are hemodynamically unstable from bleeding ulcers little difference in the side effects associated with the type of drainage procedure performed, although bile reflux may be more common after gastroenterostomy, and diarrhea is more common after pyloroplasty

Highly Selective Vagotomy also called the parietal cell vagotomy or

the proximal gastric vagotomy divides only the vagus nerves supplying the acid-producing portion of the stomach within the corpus and fundus preserves the vagal innervation of the gastric antrum so that there is no need for routine drainage procedures incidence of postoperative complications is less

the nerves of Latarjet are identified anteriorly and

posteriorly, and the crow's feet innervating the fundus and body of the stomach are divided. nerves are divided 7 cm proximal to the pylorus or the area in the vicinity of the gastric antrum. Superiorly, division of these nerves is carried to a point at least 5 cm proximal to the gastroesophageal junction on the esophagus The criminal nerve of Grassi very proximal branch of the posterior trunk of the vagus, and great attention needs to be taken to avoid missing this branch in the division process because it is frequently cited as a predisposition for ulcer recurrence if left intact.

recurrence rates vary depend on skill of surgeon and duration of follow up prepyloric ulcers are more likely to be

associated with recurrence than duodenal ulcers, for unclear reasons The moderate ulcer recurrence rate with highly selective vagotomy is considered acceptable by many surgeons because recurrences in this scenario are usually responsive to medical therapy with proton pump inhibitors

Truncal Vagotomy and Antrectomy

most common indications gastric ulcer and large benign gastric

tumors Relative contraindications cirrhosis, extensive scarring of the proximal duodenum that leaves a difficult or tenuous duodenal closure, and previous operations on the proximal duodenum, as choledochoduodenostomy

Distal gastrectomy or antrectomy

requires reconstruction of GI continuity that can be accomplished by either a Billroth I procedure; Billroth II procedure using one of several modifications Roux-n Y loop anastomosis

 Billroth I gastrectomy

Proffesor Hans Theodore Billroth first resection

for malignancy in 1881 Describes removal of a distal gastric segment, followed by primary anastomosis with preservation of duodenal integrity Advantage Preservation of physiological and anatomical integrity Lower incidence of post gasrectomy syndrome Minimal disturbance of pancreatic function Lower incidence of development of carcinoma in remaining segment of stomach

Disadvantage Anastomosis at tension site It is the standard operation for

benign pathology as very limited lymphadenopathy is achieved

Billroth II or Polya gastrectomy

Polya gastrectomy described in 1911 Involves distal gastric resection with closure of

duodenal stump and restoration of gastric continuity with gastrojejunostomy Advantage Usefull in case where billroth I have excess tension at anastomotic site Easy to perform In carcinoma allows radical margins of dissection Disavdvantage Maximum rate of complication

the loop of jejunum chosen for anastomosis is

usually brought through the transverse mesocolon in a retrocolic fashion rather than in front of the transverse colon in an antecolic fashion The retrocolic anastomosis minimizes the length of the afferent limb and decreases the likelihood of twisting or kinking that could potentially lead to afferent loop ob-struction and predispose to the devastating complication of a duodenal stump leak

Roux-n Y gastrojejunostomy

Distal divided end of jejunum is

anastomised to stomach usingend to side anastomosis Proximal end anastomised to 40-50 cm downstream, thus providing an outflow pathway for billiary contents

Subtotal Gastrectomy

rarely performed today reserved for patients with underlying

malignancies or patients who have developed recurrent ulcerations after truncal vagotomy and antrectomy. After subtotal gastrectomy, restoration of GI continuity can be accomplished with either a Billroth II anastomosis or via a Roux-en-Y gastrojejunostomy

Posterior truncal vagotomy with anterior

seromyotomy (Taylor procedure) Simpler and quicker operation

than HSV Gastric drainage procedure not equired Posterior truncal vagotomy done and anterior seromyotomy doneby dividing seromuscular layers taking care not to breach mucosa Follows along leser curvature at distance of 2 cm from its starting at angle of His extending to approximately 5 cm from pylorus

Surgical therapy serves several purposes. It salvages

patients from life-threatening complications associated with perforation, hemorrhage, and gastric outlet obstruction For all patients with ulcers being considered for elective surgery, antisecretory agents should probably be discontinued for about 72 hours before operation in order to allow gastric acidity to return to normal values, which minimizes bacterial overgrowth and the extent of contamination In patients undergoing surgery for PUD, it is recommended that all have H. pylori testing and, if positive, treatment and documentation of eradication

In patients undergoing surgery for

PUD, it is recommended that all have H. pylori testing and, if positive, treatment and documentation of eradication NSAIDs should be discontinued

Recommendations for Complications Related to Peptic Ulcer Disease
Duodenal Ulcer    Intractable:- parietal cell vagotomy    Bleeding:- truncal vagotomy with pyloroplasty and oversewing of bleeding vessel    Perforation:- patch closure with treatment of H. pylori with or without parietal cell vagotomy    Obstruction:- rule out malignancy and parietal cell vagotomy with gastrojejunostomy

Recommendations for Complications Related to Peptic Ulcer Disease
 Gastric ulcer Intractable     

Type I:- distal gastrectomy with Billroth I    Type II or III:- distal gastrectomy with truncal vagotomy Bleeding      Type I: distal gastrectomy with Billroth I   Type II or III: distal gastrectomy with truncal vagotomy

 Perforated      

Type I, stable:- distal gastrectomy with Billroth I   Type I, unstable:- biopsy, patch, and treatment for H. pylori        Type II or III:- patch closure with treatment of H. pylori   
 Obstruction:- rule out malignancy and

antrectomy with vagotomy   

 Type IV:- depends on ulcer size,

distance from the gastroesophageal junction, and degree of surrounding inflammation     Giant gastric ulcers: distal gastrectomy, with vagotomy reserved for type II and III gastric ulcers

Recommended Operative Procedures for Recurrent Postoperative Ulcers
Initial Operation Local procedure Gastrectomy Recommended Operation Truncal vagotomy and antrectomy Truncal vagotomy and resection of retained antrum if present Re-vagotomy and antrectomy Re-vagotomy and resection of retained antrum Truncal vagotomy and antrectomy Truncal vagotomy and resection of retained antrum if present

Vagotomy and pyloroplasty Vagotomy and antrectomy Proximal gastric vagotomy Subtotal gastrectomy


Postgastrectomy Syndromes gastric surgery results in a number of physiologic derangements due to loss of reservoir function, interruption of the pyloric sphincter mechanism, the type of gastric reconstruction, and vagal nerve transection

When these postgastrectomy

symptoms develop, it has become more apparent that every attempt should be made to avoid reoperation because many of these patients lack a clearly definable mechanical or physiologic defect and many of the problems persist despite reoperation

Postgastrectomy Syndromes Secondary to Gastric Resection  Dumping Syndrome symptom complex that occurs following ingestion of a meal when a portion of the stomach has been removed or the normal pyloric sphincter mechanism has become disrupted

• Early Dumping • more common after partial gastrectomy with the

Billroth II reconstruction • 20 to 30 minutes after ingestion of a meal and is accompanied by both GI and cardiovascular symptoms • G I Symptoms :- nausea and vomiting, a sense of epigastric fullness, eructations, cramping abdominal pain, and often explosive diarrhea • cardiovascular symptoms :- palpitations, tachycardia, diaphoresis, fainting, dizziness, flushing, and occasionally blurred vision

• occurs because hypertonic food delivered to

small intestines • The resultant hypertonic food bolus passes into the small intestine, which induces a rapid shift of extracellular fluid into the intestinal lumen to achieve isotonicity. • After this shift of extracellular fluid, luminal distention occurs and induces the autonomic responses • the release of several humoral agents, such as serotonin, bradykinin-like substances, neurotensin, and enteroglucagon

Treatment Most, however, experience

spontaneous relief and require no specific therapy When symptoms are prolonged dietary measures include avoiding foods containing large amounts of sugar,  frequent feeding of small meals rich in protein and fat, and  separating liquids from solids during a meal

Medical Somatostatin analogue octreotide

acetate highly effective in preventing the development of both vasomotor and GI symptoms, inhibit the hormonal responses associated with this syndrome and completely abolish the associated diarrhea Increase intestinal transit time Costly

Surgery < 1% required Purpose

to improve the gastric reservoir function,  decrease rapid gastric emptying, or  ideally accomplish both goals. use of isoperistaltic or antiperistaltic jejunal segments

Iso peristalsis done using a 10- to 20-cm loop of jejunum

and interposing it between the stomach and small intestine in an isoperistaltic fashion Anti peristalsis jejunal segment 10 cm in length is used, and the jejunum is twisted on its mesentery so that its distal end is anastomosed to the stomach and its proximal end to the small intestine creation of a long-limb Roux-en-Y anastomosis to delay gastric emptying.

Late Dumping less common 2 to 3 hours after a meal related specifically to carbohydrates When carbohydrates are delivered to the

small intestine, they are quickly absorbed, resulting in hyperglycemia, which triggers the release of large amounts of insulin to control the rising blood sugar. This results in an actual overshooting such that a profound hypoglycemia This activates the adrenal gland to release catecholamines, which results in diaphoresis, tremulousness, light-headedness, tachycardia, and confusion

Treatment to ingest frequent small meals and

to reduce their carbohydrate intake Medical patients have found benefit with pectin either alone or in combination with acarbose Surgery Same like early dumping

Metabolic Disturbances more common and serious after partial

gastrectomy than after vagotomy Greater in Billroth II as opposed to a Billroth I Anaemia Most common Iron deficiency :- more common 30% of patients undergoing gastrectomy suffer from iron deficiency anemia

related to a combination of decreased iron

intake, impaired iron absorption, and chronic subliminal blood loss secondary to the hyperemic,  friable gastric mucosa primarily involving the margins of the stoma addition of iron supplements to the patient's diet corrects this metabolic problem

Megaloblastic anemia especially when more than 50% of the

stomach is removed secondary to poor absorption of the substance owing to lack of intrinsic factor secretion in the gastric juice Serum B-12 level obtained, if less treated with intramuscular injection every 3 to 4 months indefinitely because its administration orally is not a reliable route folate deficiency may coexist oral supplimentation is sufficient

impaired absorption of fat. steatorrhea :result of inadequate mixing of bile salts and

pancreatic lipase with ingested fat because of the duodenal bypass pancreatic replacement enzymes are often effective in decreasing fat loss. osteoporosis and osteomalacia caused by deficiencies in calcium occurs about 4 to 5 years after surgery. Treatment of this disorder usually requires calcium supplements (1-2 g/day) in conjunction with vitamin D (500-5000 units daily).

Postgastrectomy Syndromes Related to Gastric Reconstruction More common with Billroth II procedures Afferent Loop Syndrome result of partial obstruction of the afferent limb that is unable then to empty its contents It can arise secondary to  kinking and angulation of the afferent limb, internal herniation behind the efferent limb, stenosis of the gastrojejunal anastomosis, a redundant twisting of the afferent limb with a resultant volvulus, or adhesions involving the afferent limb

occurs when the afferent limb is greater than 30 to 40

cm in length and has been anastomosed to the gastric remnant in an antecolic fashion Chronic presentation common than acute there is an accumulation of pancreatic and hepatobiliary secretion within the limb, resulting in its distention which causes epigastric discomfort and cramping partial obstruction :-intraluminal pressure increases , projectile billous vomiting no food contained within the vomitus

complete obstruction, necrosis and perforation of the loop can occur as

the obstruction is a closed loop because the duodenum proximally has already been closed constant abdominal pain, more pronounced in the right upper quadrant with radiation into the interscapular area. surgical emergency and requires immediate attention In closed loop, bacterial overgrowth occurs in the static loop, and the bacteria bind with vitamin B12 and deconjugated bile acids

Although symptoms may suggest this

diagnosis, it is sometimes difficult to establish the diagnosis plain films of the abdomen dilated afferent loop may be seen contrast barium study of the stomach may delineate the presence of an obstructed loop Failure to visualize the afferent limb on upper endoscopy is also suggestive of the diagnosis Radionuclide studies imaging

Treatment Acute or chronic A long afferent limb is usually the underlying

problem, and treatment therefore involves the elimination of this loop converting the Billroth II construction into a Billroth I anastomosis enteroenterostomy below the stoma, which is technically easier. Creation of a Roux-en-Y can also be done, but a concomitant vagotomy should also be performed to prevent marginal ulceration from the diversion of duodenal contents from the gastroenteric stoma.

Efferent Loop Obstruction rare. The most common cause of efferent loop

obstruction is herniation of the limb behind the anastomosis in a right-to-left fashion. can occur with both antecolic and retrocolic gastrojejunostomies. occur anytime after surgery; however, more than 50% of cases do so within the first postoperative month complaints may include left upper quadrant abdominal pain that is colicky in nature, bilious vomiting, and abdominal distention

Establishing a diagnosis is difficult contrast barium study of the

stomach with failure of barium to enter the efferent limb Surgery reducing the retroanastomotic hernia and closing the retroanastomotic space to prevent recurrence of this condition.

Alkaline Reflux Gastritis fairly common severe epigastric abdominal pain

accompanied by bilious vomiting and weight loss not relieved by food or antacids, anaemia weight loss common diagnosis careful history, HIDA scans are usually diagnostic :-demonstrating biliary secretion into the stomach and even into the esophagus in severe cases

Upper endoscopy

with multiple biopsy samples taken away from the stoma, and the gastric fluid can be analyzed for bile acid concentrations mucosa is frequently friable and beefy-red, and superficial mucosal ulcerations may be apparent on microscopy.

Common with billroth II there is no clear correlation between

the volume of bile or its composition and the subsequent development of alkaline reflux gastritis Treatment Medical not satisfactory Surgery for intractable cases converting the Billroth II anastomosis into a Roux-en-Y gastrojejunostomy in which the Roux limb has been lengthened to 41 to 46 cm

Retained Antrum Syndrome Normally, antral mucosa may extend past the pyloric

muscle for a distance of 0.5 cm, Common with billroth II retained antrum is continually bathed in alkaline pH from the duodenal, pancreatic, and biliary secretions that, in turn, stimulate the release of large amounts of gastrin with a resultant increase in acid secretion responsible for about 9% of recurrent ulcers after previous surgery for PUD and is associated with an incidence of recurrent ulceration as high as 80%

can be eliminated if biopsy confirmation of duodenal

mucosa is obtained after resection of the proximal duodenum at the time of the Billroth II gastrectomy. Diagnosis technetium scan may prove helpful in diagnosing retained antrum , demonstrates a hot spot that is adjacent to the area where normal uptake of technetium by the gastric mucosa of the remaining stomach occurs Medical H2-receptor blockade or proton pump inhibitors may prove helpful in controlling acid hypersecretion

Surgery If medical ineffective conversion of the Billroth II to a

Billroth I reconstruction or excision of the retained antral tissue in the duodenal stump is indicated

Postvagotomy Syndromes  Postvagotomy Diarrhea 30% or more of patients suffer not severe and usually disappears within the first 3 to 4 months occur 2 to 3 times weekly or manifest itself once or twice a month. explosive diarrhea and result in soiled clothing Most patients symptoms resolve over time

Medical Cholestyramine Four grams with meals three times daily followed by

an adjustment to a maintenance dosage should decrease bowel movements to once or twice a day improvement within 1 to 4 weeks of initiation Surgery Persistent diarrhea for 1 year after surgery fails to respond to cholestyramine therapy, and other causes have been ruled out, operative procedure of choice is to interpose a 10-cm segment of reverse jejunum 70 to 100 cm from the ligament of Treitz

 Postvagotomy Gastric Atony After vagotomy, gastric emptying is delayed true for both truncal and selective vagotomies but

not in the case of highly selective or parietal cell vagotomy With selective or truncal vagotomy, patients lose antral pump function and therefore have a reduction in their ability to empty solids In contrast, emptying of liquids is accelerated feeling of fullness and occasionally abdominal pain functional gastric outlet obstruction

Diagnosis confirmed on scintigraphic

assessment of gastric emptying. Endoscopic examination of the stomach also needs to be performed to rule out any anastomotic obstructions Medical Prokinetic drugs metoclopramide and erythromycin

 Incomplete Vagal Transection predisposes the patient to the

possible development of recurrent ulcer formation Truncal vagotomy more common right vagus nerve is frequently buried in the periesophageal tissue, potentially leading to incomplete transection Histologic confirmation of vagal transection decreases the incidence of incomplete vagotomy

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