Warm saline increases blood floor too the ulcer,allowing for resolution of edema
Gastric outlet obstruction
STOMACH SAC-LIKE ORGAN LOCATED MOSTLY IN THE LEFT UPPER PART OF THE ABDOMEN HAS 2 SURFACES (ANTERIOR & POSTERIOR), 2 CURVATURES (GREATER & LESSER), & 4 REGIONS (CARDIA, FUNDUS, PYLORUS,& ANTRUM The gastric wall is made up of 4 layers: mucosa, submucosa, muscularis propria, and serosa
STOMACH The mucosa forms thick longitudinally oriented folds or rugae which flatten with distention. The muscularis propria is a combination of 3 muscle layers: inner oblique, middle circular and outer longitudinal
STOMACH It functions primarily as a reservoir to store large quantities of recently ingested food Its volume ranges from about 30ml in a neonate to 1.5 to 2L in adulthood. The gastroesophageal junction generally lies to the left of the 10th thoracic vertebral body, 1-2cm below the diaphragmatic hiatus. The gastroduodenal junction lies at L1 and generally to the right of the midline, but may be lower
STOMACH ANTERIOR RELATIONS – DIAPHRAGM, ANTERIOR ABDOMINAL WALL, LEFT COSTAL MARGIN, & THE LEFT LOBE OF THE LIVER POSTERIOR RELATIONS – LESSER SAC, PANCREAS, LEFT SUPRARENAL GLAND, LEFT KIDNEY, SPLEEN, SPLENIC ARTERY, & THE TRANVERSE COLON SUPERIOR RELATIONS – LEFT DOME OF THE DIAPHRAGM
STOMACH BLOOD SUPPLY: FROM THE COELIAC AXIS – LEFT GASTRIC, SPLENIC (SHORT GASTRIC & LEFT GASTROEPIPLOIC), HEPATIC (GASTRODUODENAL[SUPERIOR PANCREATICODUODENAL & RIGHT EPIPLOIC], CYSTIC, & RIGHT GASTRIC)
STOMACH NERVE SUPPLY: VAGUS (ANTR & POSTR) The vagus constitutes the motor and secretory nerve supply for the stomach. When divided, in the operation of vagotomy, the neurogenic (reflex) gastric acid secretion is abolished but the stomach is, at the same time, rendered atonic so that it empties only with difficulty
STOMACH ; because of this, total vagotomy must always be accompanied by some sort of drainage procedure, either a pyloroplasty (to enlarge the pyloric exit and render the pyloric sphincter incompetent) or by a gastrojejunostomy (to drain the stomach into the proximal small intestine). Drainage can be avoided if the nerve of Latarjet is preserved, thus maintaining the innervation and function of the pyloric antrum (highly selective vagotomy).
STOMACH The sympathetic innervation is derived from preganglionic fibers arising predominantly from T6 to T8 spinal nerves.
STOMACH LYMPHATIC DRAINAGE: DIV INTO 3 AREAS, HOWEVER ALL DRAIN EVENTUALLY TO THE PARAAORTIC NODES
DUODENUMDUODENUM 25cm LONG, C-SHAPED CURVE AROUND THE HEAD OF THE PANCREAS, DIVIDED INTO 4 PARTS 1ST PART 5cm LONG, ASCENDS FROM THE GASTRODUODENAL JUNCTION, OVERLAPPED BY THE LIVER & GALL BLADDER IMMEDIATELY POSTR ARE THE PORTAL VEIN, COMMON BILE DUCT & GASTRODUODENAL ARTERY SEPARATING IT FROM THE INFERIOR VENA CAVA• 2nd PART 7.5CM LONG, DESCENDS IN A CURVE AROUND THE HEAD OF PANCREAS, CROSSED BY THE TRANSVERSE COLON & LIES ON THE RIGHT KIDNEY AND URETER
DUODENUM 3rd PART 10cm LONG, RUNS TRANSVERSELY TO THE LEFT CROSSING THE INFERIOR VENA CAVA, AORTA & L3 VERT• 4th PART ASCENDS UPWARDS & TO THE LEFT TO END AT THE DUODENOJEJUNAL JUNCTION• BLOOD SUPPLY – THE SUPERIOR & INFERIOR PANCREATICODUODENAL ARTERIES
DUODENUM The luminal surface of the duodenum is lined with mucosa, forming circular folds known as the plicae circulares or valvulae conniventes The duodenal bulb has smooth, featureless mucosa The duodenal wall is composed of outer longitudinal and inner circular muscle layers The first few centimeters of the duodenum are intraperitoneal, whereas the remainder is retroperitoneal
PATHOLOGY OF GASTRIC OUTLETOBSTRUCTION FOLLOWINGCHRONIC PEPTIC ULCER DISEASE
INTRODUCTION Gastric outlet obstruction is not a single entity. GOO is the clinical and pathophysiological consequence of any symptom complex that produce a mechanical impediment to gastric emptying. It usually follows chronic PUD
Introduction contd GOO is a common and early complication of DU in Africa and India
Epidemiology Incidence of GOO has been reported to be less than 5% in patients with PUD Though is the leading benign cause GOO Peri-pancreatic malignancy is the leading malignant cause FMC Owerri (jan 2011 – oct 2012) 7 cases of GOO 3 – PUD, all male 4 – gastric ca
Etiology The factors predisposing to chronicity of PUD may include: - persistent imbalance between theaggressive and defensive factors - non eradication of H. pylori infection - non compliance to anti PUDmedication etc.
Etiology contd However, GOO usually occur at the pyloro-duodenal area. It is caused by: - cicatrization - edema - pyloro-duodenal spasm
Pathogenesis/ pathophysiology Obstruction of the stomachhypertrophy of the stomach Dilatation Gastritis &depressed acid secretion
HISTORY AGE:20-45 years with peak 30-35 years Known or suspected case of chronic pud Epigastric and Lt hypochondrial pain : -relieved by alkali, milk +/- food. -gnawing/biting -periodic (spontanous healing) -association with food and time of day -radiates to the back (?pancrease penetration -Generalised (perforation)
Anorexia,nausea. Easy satiety Vomiting: -characteristic unpleasant -copious -projectile -Non bilous -Food taken several days ago.
Feeling of unwell Appetite is maintained but fear of pain often prevent patient from eating Weight loss. Abdominal swelling
Examination Chronically ill looking Wasted Dehydrated may be pale shock
investigation2)To confirm diagnosis Plain x-ray of abdomen:shows large gastric shadow and a large amount of gastric fluid. Gastric aspiration:a wide bore stomach tube is placed early in the morning and the stomach is aspirated of resting juice.if >400ml of juice is obtained a presumptive diagnosis of GOO can be made.
investigation Esophagogastroduodenoscopy + biopsy(histology and bacterioloical investigation). Aim is to viualise the stomach mucosa and any ulcer. Barium meal: -markely dilated stomach with a lot of residue -presence of an ulcer crater -trifoil deformity of the duodenal cap.
.-Hour glass deformity-Tea cup deformity-Abrupt obstruction to barium
3)Pre- op preparation FBC SEUCR Urinalysis RVS
4)Detection of H.pylori Non invasive: serology carbon labelled urea breath test Invasive: Rapid urease test,histology and culture.
OUTLINEINTRODUCTION;PRINCIPLES OF TREATMENT; -Objectives(Goals) of mgt. -Factors influencing choice of rx. -Patient selection.GENERAL MEASURES;SPECIFIC/DEFINITIVE MEASURES;
Outline…COMLICATIONS(& their mgt);FOLLOW UP;PROGNOSIS;CHALLENGES;CONCLUSION.
INTRODUCTION.PUD,largely medically condition.Becomes a surgical pathology when complicated e.g…8-20% of patients developing complications only require surgery.It largely describes a surgically amenable pathology.
Intro…definitions.PUD:Break in acid secreting GIT mucosa; exposed to acid and pepsin secretn; more than 5mm in diameter;heals by granulation tissue formation.Erosion: Break in GI mucosa;not penetrating musclaris mucosa;<5mm in diameter;occuring in both acid secreting and non-acid secreting mucosa; heals rapidly by epithelial bridging.
Intro…Chronic PUDx is characterized by-Presence of chronic inflam cells-Reactive mucosal epithlial changes-Attempt at healing+-malignant changes.
Intro.. GOO 2* Chronic PUDx is a surgically amenable obstructive complication of PUDx.It includes pathologic entities such as:-Chronic PUDx with active edematous ulcer;-Chronic PUDx with antral cicatrisation;-Chronic PUDx with Pyloric stenosis;-Hour glass stomach;-Teapot stomach.
PRINCIPLES. Guiding Principles lies in the recognition of GOO as an emergency, as such, GOAL of treatment include:-1)Resuscitation/stabilization.;-2)Relieve obstruction;-3)Patient selection/categorization;-4)Offer definitive curative care;-5)Prevent recurrence/Follow up care.
Principles…FactorsFactors Influencing Choice Of Tx:Patient-specific Factorsi).Stability:Shock,Fluid and electrolyte imbalance.ii)Obesity:DVT prophylaxis, concomitant bariatric surgeryiii)Age:Better outcome in younger ageiv)Comorbidities:Dm,Htn.
Principles…..Factors cont’d Lesion-related Factors:i)Nature:e.g edema Lavage+H.pylori rxii)Location:Duodenal/Pyloric antral/ Body/Fundus/cardia.iii)Associated Deformity:Resectionsiv)Presence of malignant transformation:Resections Surgeon’s expertise/Materials and manpower available
……Patient selection/category Acutely Obstructed/Chronically Obstructed group:Nonop Tx for acutely obstructed. Frail Elderly:Low life expectant group:Nonop e.g. balloon dilation. Stable/Unstable group:Limited surgical time,extent of resection e.t.c Low/High lying lesion/Deformity.
GENERAL MEASURES. Resuscitation: (Wide bore canular)i).Antishock Therapy:IVF NS/Ringer’s @25ml/kg over 1st 30mins then repeated and reassessii).Urethral catheter:Input/output monitor@30-50ml/hr.(CVP@10-15cmH20)iii).NGT-Decompress,lavage and aspirate
General Measures…cont’d Iv)Correction of electrolyte Imbalance: K+ correction,ensuring urine output,ideally under ECG monitoring. V)Correction of anemia. Vi)Renal challenge after adequate fluid volume resuscitation. Vii)Renal dialysis(resuscitative) in uremia.
General measures..Viii)Calorie-Maintaining with fluid @ 100ml/kg first 10kg,50ml/kg 2nd 10kg, 25ml/kg subsequent kgs. Ensuring at least 100g of glucose is delivered(in 2liters of 5%Dw)Ix)TPN:With period of inanition >7days, marked weight loss
General…X)Antsecretory therapy:IV PPI e.g 40mg of Omeprazole stat then 20mg 12hrlyNB:Should be discontinued 72hrs before surgery(return of g acidity)
SPECIFIC/DEFINITIVE MEASURESNONOPERATIVE MEASURES:i)Warm Saline Lavage+H.Pylori Eradication(usu for acute edematous active ulcer)Recurrence high in chronic active edematous ulcers.ii)Endoscopic Balloon dilation.May be useful in elderly frail patients unfit for surgery.Repeat necessary.
SPECIFIC/DEFINITIVE MEASURE.OPERATIVE MEASURES:Operative Principle:i-Surgically achieving physiologic control of acid production;ii-Ensuring normal gut continuity(Resection and Reconstruction);iii-Minimizing Postgastrectomy &Postvagotomy sequalae.
SPECIFIC MEASURES…1)Antral Oedema with Failure Of Lavage or Recurrence:a)Parietal Cell Vagotomy+ GJ+H.Pylori Eradication.(It maintains antral innervation, prevents ductal motility problems and lesser sequalae).Nb:Criminal nerve of Grassi must be identified and severed.
Specifics..b)Truncal/Selective Vagotomy+ BillrothI/II+ Kocherisation + HPEradication(GJ done should be retrocolic vertical isoperistaltic Nonloop Notension; Mayo’s GJ)TV/SV+Antrectomy+ GJ/GD+ Kocherisation+ HPEradication
Completeness Test(Postvagotomy)Intraop TestsI)Burge Test-Manometer passed via esophagogastric balloon and pylorus is stimulted.Any change in pressure indicates incomplete vagotomy.II)Grassi Test-Glass electrode inserted through an gastrostomy to measure P.H and MAO.A p.H 1.2-2 surrounded by area of 5.5-7,indicate actual area of incomplet.
Postop Testi)Pentagastrin test -Peak acid output reduction of >/50% is indicative of completeness.ii)Insulin (Hollander’s )test. Largely prognostic.Done 1week post vagotomy.If positve in a short time, recurrence risk is high.
Postgastrectomy Synd(Related to Resection)i)Early dumping -Results from disruption of the pyloric sphincter mechanism>Hyperosmolar chyme transit>rapid shift of fluid>luminal distension>autonomic responses. Occurs 20-30mins after ingestion of meal. Characterized by both GI and cardiovascular symptoms.
Cardiovascular symptoms- flushing, diaphoresis, palpitations,dizziness, fainting,blurring of vision.GI- nausea, vomiting,explosive diarrhea, cramping abd.pain.Mgt-Patient informed preop -Spontaneous relief. -Dietary(less sugar),freq. small meals(Most will resolve).
-Long acting somatostatin analogue(octreotide) is highly effecttive for bothGI and CV symptoms in longstandingcases.Its expensive. -<1% fail to respond to conservative tx: +Jejunal 20cm Isoperistaltic loopInterposition(dilates overtime,reservoirfxn) +Jejunal 10cm antiperistaltic loopinterpositn(substitute pylorus,delayingemptying)
ii)Late Dumping -Result from rapid gastric emptying too but specifically for CH2O meal being delivered> quickly absbd>Hyperglycemia> large amt of insulin release>OVERSHOOT > Profound hypoglycemia. Adrenaline release-diaphoresis, tremor ,giddiness ,confusionMgt-Small meals,less CH2O. -Antiperistaltic loop.
Complications…cont’dPostgastrectomy Synd(Related to Reconstruction):iii)Affarent loop synd :May occur within few days of op or years after.Usu when>30-40cm.Xterised by a).RUQ abd.pain radiating to interscapular area. b)Projectile bilious vomiting not containing food and relieves symptoms.
Mgt(a surgical emergency). -A high index of suspicion. -Convert BillrothII to I. -Enteroenterostomy (e.g Braun, easier) below the stoma.-Creation of a Roux-en-Y
iv)Efferent loop synd: Quite rare. >50% occur within 1st mth postop. Usu from herniation of limb behind anastomosis (R-L fashion).Mgt-Reduce retroanastomosis hernia -Close retroanastomosis space.
v)Duodenal Blow out: Usu occurs4-5th day postop.Life threatening.Mgt-Control fistula and sepsis-Enteroenterostomy later.
Vi)Postvagotomy diarrhoea:Occurs in >30% of px.Part of Dumping synd. Usu disappears after 3-4 mths.Mgt-self limiting -Cholestyramine(4g tds) -<1% lasting >1year,Jejunal Interposition.
Vii)Postvagotomy Gastroparesis: Occurs in both TV&SV, not in PCV. Paresis allows liquid(loss of receptive relaxation) not solid(dependent on antral pump mech)Mgt-Prokinetics [Metochlopramide(cholinergic enhancing) and Erythromycin(motilin receptor binding)].Usu suffices.
ix)Alkaline Reflux Gastritis: severe epig pain+bilious vomiting+wgt loss. Usu ffng Billroth II.Diagnosis largely clinical but HIDA scan shows bile reflux into stomach/esoph endoscopy show beefy red ,friable mucosa.Mgt-BillrothII to a Roux-en-Y GJ.
X)Blind Loop synd.:Bacterial overgrowth in static loop causing bind B12 and deconjugate bile acid with resultant Megaloblastic anemia. Xi)Retained Antrum synd:From retained terminal antrum in the duod stump,continually bathed in alkaline secretion>increased gastrin release>increased acid secretion> recurrent ulcer.
FOLLOW UP. Events in the follow up periodi-H.Pylori Eradicationii-H.pylori screening(to document eradication)-serology -CLUB test(4weeks after)iii-BAO output monitoringiv-Yearly upper GI endoscopy+biopsy.v-Nutritional supplementation.vi-Life style modification(alcohol,smoking)
PROGNOSIS Factors affecting Prognosis:i)Age/Physiologic reserve-H.pylori infection load increases by about 1%/year(more in elderly and they present more severe complication.Less physiologic resrve to tolerate homeostatic changes from GOO.ii)Duration of illness:Longer the poorer early presentation is better outcome.
Prognosis..iii)Co-morbidities.Iv)Previous surgeryV)Previously documented failed medical therapy(HPE)Overall prognosis is good with improved surgical and medical therapy.
CHALLENGES i)Poor patient knowledge base/compliance to medical therapy. ii)Substandard medications for HPE iii)Poor status of health facility( screening test,endoscopy) Iv)Financial constraints HPE(PPI) V)Poor life style/socioeconomic status
CONCLUSION:Though PUDx is largely medically managed with the place of the surgeon gradually being relegated to the background following improved medical therapy. However, considering our third world and its attendant constraints,the surgeon’s place can not be overemphasized.