TREATMENT OPTIONS *Csendes A. et al. RCT on three techniques for GOO treatment. *Millat B. Surgical treatment of complicated Duodenal ulcer: RCT x 15k MR: 1% RR: 50% /// / Endoscopic baloon dilatation / 3k MR: 1% RR: 1% /// /// Vagotomy + gastrojejunostomy* / 3k MR: 5% RR: 2% /// /// Vagotomy + Antrectomy / 3k MR:1% RR: 10% /// /// Vagotomy + Jaboulay gastroduodenostomy Bowel continuity Local recurrence Resolution of obstruction AVAILABILITY COST RISK BENEFIT
Pre-op preparation: what I will do
Informed consent secured
Psychosocial support provided
Optimized patient’s physical health
Correction of anemia/electrolytes
Patient screened for any health condition
Operative materials secured
Intra-op Management: How I will do It (Vagotomy, Gastrojejunostomy)
Patient supine under GETA
Asepsis and antisepsis technique
Sterile drapes place
Long vertical incision from xyphoid to supraumbilical area
Mobilization of left lateral segment of the liver
Division of triangular ligament
Exposure of esophagogastric junction
Exposure of anterior vagus nerve
Isolation/ligation of nerve trunk, anterior, posterior and esophageal branches
Anterior vagal trunk is encircled with hook and dissected sharply from esophageal musculature
Nerve trunk is ligated proximally and distally
Drainage via Gastrojejunostomy
Posterior serosal suture
Posterior mucosal suture
Anterior mucosal suture
Completion of anastomotic defect
The nasogastric tube is removed upon return of gastrointestinal transit, and feeding is slowly begun.
Resolution of obstruction
No medico-legal suit
Sharing of information
SURGERY FOR PEPTIC ULCER DISEASE(PUD)
Ulcer in the GIT is characterized by an interruption in the mucosa stretching through the muscularis mucosa into the submucosa or deeper
Location - in order of decreasing frequency
Epidemiology O A Blood group Higher Lower Socio-economic M : V = 3 : 1 M : V = 1.5 : 1 Sex 20 – 45 40 – 60 Age Duodenal ulcer Gastric ulcer
Classification of Gastric Ulcers(GU ) ( Gaintree – Johnson )
Type 1 = incisura on the lesser curvature. No increased acid secretion. Mucosal resistance problem.
Type 2 = Gastric and duodenal ulcer. Gastric ulcer secondary to gastric stases caused by duodenal ulcer.
Type 3 = Prepyloric ulcer within 2-3cm of the pylorus. Often acid hypersecretors. Association with blood group O. Treated like duodenal ulcer.
Type 4(Csendes ) = High on lesser curvature near gastro-esophageal junction. As Type 1.
Type 5 = Secondary to chronic use of non-steroidal anti-inflammatory drugs (NSAID). Can occur anywhere in the stomach.
Traditionally duodenal ulcers are seen as a problem with acid hypersecretion and gastric ulcers as a mucosal resistance problem
Gastric acid. Central in pathogenesis – no benign ulceration occurs without gastric acid
Gastric stases. Delayed emptying of normal amounts of acid with increased exposure
Enviromental factors are very important.
a) Helicobacter pylori infection. 90% of patients with DU and 50% of patients with GU
b) NSAID use. The mucus gel layer contains bicarbonate. This layer adheres to the gastric mucosa. It protects the mucosa against back diffusion of hydrogen ions. NSAID’s suppress mucus cell function.
4) Mucosal resistance
5) Genetic predisposition
1) Epigastric pain – Central or slightly to the right
Burning or gnawing
Can spread to the back
Relieved by ingestion of food or anti-acid
Pain occurs when patient is hungry
2) Different degrees of nausea and vomiting
3) Weight gain ( Pain relieved by ingestion of food)
4) Epigastric tenderness just to the right of the midline, may be absent.
1) Epigastric pain – Brought on by meals often within 30 minutes
2) Nausea and vomiting
3) Weight loss
4) Epigastric tenderness
3) Gastric outlet obstruction
Surgery is indicated and for the following:
1) Non-healing ulcer ( 8 – 12 weeks for GU, DU can be managed conservatively for longer since the risk for malignancy is low)
b) Bleeding if massive,
c) Gastric outlet obstruction that does not clear up on conservative management.
Surgical principle for definitive ulcer surgery
Definitive ulcer operations for GU
Type 1 GU partial gastrectomy . Vagotomy not done.
Type 2 and 3 GU treated as DU. HSV contra-indicated due to high ulcer recurrence with prepyloric ulcers.
Type 4 GU treated with partial gastrectomy and excision of a long tongue of lesser curvature including the ulcer(Pauchet procedure).
Gastric outlet obstruction
Cycles of inflammation and repair may cause obstruction at the gastroduodenal junction as a result of edema, muscular spasm and fibroses.
Edema and spasm can resolve with medical treatment.
Obstruction is mainly caused by DU and prepiloric GU.
Malignant tumors is the other important cause of gastric outlet obstruction.
normal pylorus is about 20 mm in diameter and can distend to 25 mm
gastric outlet obstruction occur when the diameter of the antroduodenal segment is below 10 mm
A saline load test can be utilized in the objective measurement of outlet obstruction or gastric atony and the assessment of response to therapy
The major benign causes of GOO are PUD, gastric polyps, ingestion of caustics, pyloric stenosis, congenital duodenal webs, gallstone obstruction (Bouveret syndrome), pancreatic pseudocysts, and bezoars
Longstanding history of PUD
Progressive worsening of ulcer pain and early satiety.
Vomiting after meals of partially digested food without bile ( food eaten earlier the day or the previous day).
Dehydration and severe weight loss.
Visible peristalses of the dilated stomach (rarely).
Succussion splash audible with to and fro movement of abdomen.
1) Resussitation initially with 0.9% sodium chloride. Potassium supplementation only after good urine output is established.
2) Gastric lavage with thick stomach tube ( 32 F) to remove food residue.
3) Diagnostic tests after gastric lavage : Gastroscopy with biopsies with or without barium meal to rule out malignancy.
4) IV H2-blockers or proton pump inhibitors.
5) A nasogastric tube is passed. The patient may drink water. The amount of oral intake and drainage is charted. This gives an impression whether the obstruction is resolving.
6) Balloon dilatation of pyloric channel is possible but seldom produces a final solution.
7) Surgery is indicated if the obstruction does not resolve after one week of conservative treatment. Mostly a truncal vagotomy and antrectomy is done although truncal vagotomy with a drainage procedure is sometimes performed.
Complications of PUD surgery
Complications due to vagotomy
Intraoperative complications can occur with injury to adjacent structures.
Early post-operative complication
delayed gastric emptying
dysphagia and lesser curve necroses( lesser curve necroses specific to HSV).
Late complications include postvagotomy diarrhea , reflux esophagitis and gallstones
Complications of gastrectomy
hepatobiliary-pancreatic complications (pancreatitis, bile duct injury)
Late complications are classified as follows :
1) Ulcer recurrence
a) Recurrent ulcer (anastomotic,stomal,marginal)
b) gastrojejenocolic fistula
2) Mechanical problems
a) Chronic afferent loop obstruction after BII anastomoses – abdominal pain relieved by vomiting , vomit mainly bile without food.
b) Chronic efferent loop obstruction
c) Internal herniation, jejenogastric intussusception and late gastroduodenal obstruction
3) Pathophysiologic problems
a) Alkaline reflux gastritis – reflux of bile into stomach. Pain not relieved with vomiting. Vomitus contains food and bile.
b) Dumping (I)Early dumping – symptoms within 20 minutes after meal. Gastro-intestinal : Abdominal cramps, satiety, nausea, vomiting and explosive diarrhea. Cardiovascular : sweating, dizziness, weakness,dyspnea, palpitations and flushing.
Due to sudden release of high osmolality chyme into duodenum with fluid shifts and release of gastro-intestinal hormones.
(II) Late dumping – only vasomotor symptoms. Caused by enteroglucagon secretion which leads to increased and prolonged insulin secretion with resultant hypoglycaemia.
4) Malabsorption and Nutritional problems
a) Malabsorption of protein, carbohydrates and fat
b) Early satiety
c) Anemia : Fe, folate and B12 deficiency. B12 problems mostly after total or near total gastrectomy.
Csendes A. Maluenda F. et al. Prospective randomized controlled trial comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Am J Surg. 1993 Jul 166:45-49
Edwards LW, Herrington JL Jr. Vagotomy and gastroenterostomy—vagotomy and conservative gastrectomy. Ann Surg, 1953; 137: 873– 83.
Emas S, Fernstrom M. Prospective, randomized trial of selective vagotomy with pyloroplasty and selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric and prepyloric ulcers. Am J Surg, 1985; 149: 236–43.
Fischer AB. Twenty-five years after Billroth II gastrectomy for duodenal ulcer. World J Surg, 1984; 8: 293–302.
Kuwada, S et al. Long-term outcome of endoscopic dilation of nonmalignant pyloric stenosis. Gastrointestinal Endoscopy 1995; 41(1) 15-17.
Gibson JB, Behrman SW, Fabian TC: Gastric outlet obstruction resulting from peptic ulcer disease requiring surgical intervention is infrequently associated with Helicobacter pylori infection. J Am Coll Surg 2000 Jul; 191(1): 32-7 [Medline] .
7.Millat B, Fingerhut A et al. surgical treatment of complicated duodenal ulcer. Controlled trial. World J Surg. 2000 Mar. 24(3) 299-306.
8. Siu WT, Tang CN, Law BK, et al: Vagotomy and gastrojejunostomy for benign gastric outlet obstruction. J Laparoendosc Adv Surg Tech A 2004 Oct; 14(5): 266-9 [Medline] .
9. Haglund UH , Jansson RL , Lindhagen JG , Lundell LR , Svartholm EG , Olbe LC . Primary Roux-Y gastrojejunostomy versus gastroduodenostomy after antrectomy and selective vagotomy. Am J Surg . 1992 Apr;163(4):457-8.
Gastric Outlet Obstruction secondary to healed pyloric ulcer may present with which of the following?
All of the above
2. What is the most common complication of peptic ulcer disease?
3. The following statements is/are true regarding gastric outlet obstruction.
1. Cycles of inflammation and repair may cause obstruction at the gastroduodenal junction as a result of edema, muscular spasm and fibroses.
2. Edema and spasm can resolve with medical treatment.
3. Obstruction is mainly caused by DU and prepiloric GU.
4. Malignant tumors is the other important cause of gastric outlet obstruction.
4. Which of the following choices is/are late complication/s of vagotomy?
postvagotomy diarrhea ,
reflux esophagitis and
Delayed gastric emptying
Which of the following is/are not early complication of gastric surgery ?
hepatobiliary-pancreatic complications (pancreatitis, bile duct injury)