Current role of surgery in the management of peptic ulce (1)

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  • Your lecture is concise and valuable, however many internists deny the presence of refractory ulcer with the recent drugs. I my self strongly agree with You that elective surgery for some medically resistant ulcers is still present.
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Current role of surgery in the management of peptic ulce (1)

  1. 1. <ul><li>“ CURRENT ROLE OF SURGERY IN THE MANAGEMENT OF PEPTIC ULCER DISEASE ” </li></ul><ul><li> Dr.Anil Haripriya </li></ul>
  2. 2. INTRODUCTION <ul><li>INCIDENCE OF PEPTIC ULCER DISEASE HAS DECREASED </li></ul><ul><li>BETTER UNDERSTANDING OF ETIOLOGY: H PYLORI AND NSAIDS </li></ul><ul><li>BETTER CONTROL WITH MEDICAL TREATMENT </li></ul>
  3. 3. HISTORY OF PEPTIC ULCER SURGERY <ul><li>   Billroth 1 </li></ul><ul><li>   Billroth 2 </li></ul><ul><li>Truncal vagotomy with antrectomy </li></ul><ul><li>Truncal vagotomy with drainage procedure </li></ul><ul><li>Highly selective vagotomy </li></ul>
  4. 4. CURRENT INDICATIONS FOR SURGERY <ul><li>FAILURE OF MEDICAL TREATMENT </li></ul><ul><ul><li>REFRACTORY CASE </li></ul></ul><ul><ul><li>RELAPSE </li></ul></ul><ul><ul><li>RECURRENCE </li></ul></ul><ul><ul><li>PATIENTS REQUIRING CONCOMINANT STEROID OR NSAID THERAPY </li></ul></ul>
  5. 5. EMERGENCY INDICATIONS FOR SURGERY <ul><li>BLEEDING ULCER </li></ul><ul><li>PERFORATED ULCER </li></ul><ul><li>GASTRIC OUTLET OBSTRUCTION </li></ul>
  6. 6. BLEEDING PEPTIC ULCER <ul><li>AROUND 70% RESOLVE SPONTANEOUSLY </li></ul><ul><li>RISK FACTOR FOR REBLEED: </li></ul><ul><ul><li>SHOCK </li></ul></ul><ul><ul><li>COAGULOPATHY </li></ul></ul><ul><ul><li>CO-MORBIDITY </li></ul></ul><ul><ul><li>VISIBLE ACTIVE BLEEDER </li></ul></ul>
  7. 7. MANAGEMENT <ul><li>ENDOSCOPIC THERAPY </li></ul><ul><li>3 VESSEL LIGATION </li></ul>
  8. 8. PERFORATION <ul><li>INCIDENCE 5-10% OF ALL PATIENTS WITH DUODENAL ULCER DISEASE </li></ul><ul><li>RISK FACTORS </li></ul><ul><ul><li>PRESENCE OF SEVERE COMORBIDITY </li></ul></ul><ul><ul><li>DURATION OF PERFORATION > 24 HRS </li></ul></ul><ul><ul><li>PRESENCE OF HYPOTENSION (SYSTOLIC < 100 mmHg) ON PRESENTATION </li></ul></ul>
  9. 9. MANAGEMENT <ul><li>CONSERVATIVE MANAGEMENT IN SELECTIVE CASES </li></ul><ul><li>EXPL. LAP WITH SIMPLE CLOSURE OF PERFORATION WITH OMENTAL PATCH </li></ul>
  10. 10. GIANT PERFORATION <ul><li>ARBITARILY DEFINED AS ULCER > 2.5 CM IN DIAMETER </li></ul><ul><li>USUALLY OCCURS LEFT TO THE INCISURA </li></ul>
  11. 11. MANAGEMENT <ul><li>CLOSURE BY OMENTAL IMPLANTATION </li></ul><ul><li>CLOSURE BY OMENTAL PATCH </li></ul><ul><li>CLOSURE USING FALCIFORM LIGAMENT </li></ul><ul><li>JEJUNAL SEROSAL PATCH TECHNIQUE </li></ul><ul><li>ROUX-EN-Y DUODENOJEJUNOSTOMY </li></ul><ul><li>PYLOROPLASTY </li></ul><ul><li>OPERATIONS INVOLVING EXCLUSION OR DIVERTICULIZATION, INCLUDING PARTIAL GASTRECTOMY OR GASTRIC DISSOCITION </li></ul><ul><li>DUODENOSTOMY </li></ul><ul><li>EXPERIMENTAL TECHNIQUES – USE OF BIO REACTIVE MATERIAL, OPEN PEDICLE GRAFTS OF ILEUM, TRAMP FLAP, PTFE PATCH AND PEDICLE GALL BLADDER GRAFT </li></ul><ul><li>RESECTION </li></ul>
  12. 12. GASTRIC OUTLET OBSTRUCTION <ul><li>INCIDENCE 6-8% OF PATIENTS WITH DU </li></ul><ul><li>FIBROTIC PYLORIC STENOSIS CAUSING MECHANICAL OBSTRUCTION IS STRONGLY AN INDICATION OF SURGERY </li></ul>
  13. 13. MANAGEMENT <ul><li>VAGOTOMY AND ANTRECTOMY </li></ul><ul><li>VAGOTOMY AND DRAINAGE </li></ul><ul><li>ENDOSCOPIC BALLON DILATION </li></ul>
  14. 14. FACTORS INFLUENCING CHOICE OF OPERATION IN DU <ul><li>HISTORY </li></ul><ul><ul><li>DURATION OF PREVIOUS DISEASE </li></ul></ul><ul><ul><li>DURATION OF PREVIOUS COMPLICATIONS </li></ul></ul><ul><li>PREVIOUS TREATMENT </li></ul><ul><ul><li>ANTACIDS </li></ul></ul><ul><ul><li>ERADICATION OF H. PYLORI </li></ul></ul><ul><ul><li>PREVIOUS OPERATION </li></ul></ul><ul><li>ASPIRIN OR NSAID’s USE </li></ul><ul><li>CONDITION OF PATIENT </li></ul><ul><ul><li>UNDERLYING MEDICAL ILLNESS </li></ul></ul><ul><ul><li>HEMORRHAGIC SHOCK </li></ul></ul><ul><ul><li>DURATION OF PERFORATION MORE THAN 24 HOURS </li></ul></ul>
  15. 15. CURRENT CHOICE OF SURGERY <ul><li>1.     Truncal vagotomy with drainage </li></ul><ul><li>2.     High selective vagotomy </li></ul><ul><li>3.     Truncal vagotomy and </li></ul><ul><ul><ul><li>antrectomy </li></ul></ul></ul><ul><li>4.     Laproscopic truncal vagotomy or </li></ul><ul><ul><ul><li>high selective vagotomy </li></ul></ul></ul>
  16. 16. INDICATIONS AND OPERATIVE STRATEGY IN DUODENAL ULCER: Indication Preferred operation Alternatives Bleeding Oversew + TV and pyloroplasty Oversew and HSV Perforation Closure and omental patch + HSV Closure and omental patch + TV     Laproscopic closure and omental patch Obstruction TV and anterectomy with Billroth I TV and anterectomy with Billroth II     TV and Finney or Jaboulay pyloroplasty     TV and gastrojejunostomy Intractability Laproscopic HSV Open HSV
  17. 17. RECURRENT ULCER AND POSTGASTRECTOMY SYNDROMES AFTER OPERATIONS FOR DUODENAL ULCER: Operation Incidence of recurrence (%) Incidence of posgastrectomy syndromes (%) Mortality rate (%) HSV vagotomy 10 5 0.1 Truncal vagotomy & drainage 7 20-30 < 1 TV and anterectomy/ Billroth I or Billroth II 1 30-50 0-5 TV and anterectomy/ Roux-en-Y 5-10 50-60 0-5
  18. 18. SIDE EFFECTS OF OPERATIONS FOR DUODENAL ULCER: Early postoperative complications Long-term side effects Afferent loop obstruction Alkaline reflux gastritis Anastomotic leak Anemia Duodenal stump leak Dumping syndrome Efferent loop obstruction Gallstones Gastric atony Gastric remnant cancer Gastric outlet obstruction Malnutrition Hemorrhage Postprandial hypoglycemia Pancreatitis Postvagotomy diarrhea   Reflux esophagitis   Small bowel obstruction
  19. 19. THANK YOU

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