The Surgical Management of The Gastric Ulcers and The Tumors of The Stomach A surgical perspective of stomach cancer Surgical approach to gastric ulcer

1. The Surgical Management of The Gastric
Ulcers and The Tumors of The Stomach
A Surgery II seminar
Bshr Nammouz - 5’th year medical student - SSST

12. Surgical treatment:
The indications for surgery in PUD are bleeding, perforation, obstruction, and
intractability or non healing.
Gastric cancer must always be considered in patients with gastric ulcer or
gastric outlet obstruction.
Simultaneous performance of vagotomy either truncal or highly selective is
increasingly uncommon, insted we give PPIs.

13. Traditionally, the vast majority of peptic ulcers were treated by a variant of one
of the three basic operations:
- parietal cell vagotomy also called highly selective vagotomy or proximal
gastric vagotomy (HSV).
- Vagotomy and drainage (V+D)
- Vagotomy and distal gastrectomy.

14. Truncal vagotomy and pyloroplasty, and
truncal vagotomy and gastrojejunostomy are
the paradigmatic vagotomy and drainage
procedures.
The main disadvantages are the side effect
profile (10% of patients have significant
dumping and/or diarrhea).

15. HSV severs the vagal nerve supply to the
proximal two thirds of the stomach, where
essentially all the parietal cells are located, and
preserves the vagal innervation to the antrum
and pylorus, and the remaining abdominal
viscera.
Thus, the operation decreases total gastric
acid secretion by about 75%, and GI side
effects are rare.

19. Surgical management of peptic perforation
The classic operation was Billroth I gastrectomy, including the whole ulcer in
the resection.
However, local excision of the ulcer and simple closure are safely employed,
provided the ulcer is believed to be benign.
In any case, the ulcer edge must be biopsied in several places to be certain.

20. Carcinoma of stomach

21. Pathology of gastric carcinoma
Two distinct histopathological groups:
- The intestinal type.
- The diffuse type. characteristic signet ring appearance.

22. Morphologically
The intestinal type largely produces fungating tumours and malignant ulcers,
and the diffuse type causes infiltrating carcinomas:
1. Fungating tumours
2. Malignant ulcers
3. Infiltrating carcinomas

23. Aetiology of gastric carcinoma and
premalignant conditions
Atrophic gastritis
Helicobacter pylori infection
Dietary factors

26. Direct spread and metastasis
1. Direct spread into the transverse colon
2. Transperitoneal (or transcoelomic) spread may involve the surface of the
ovaries (Krukenberg tumour) or form masses in the pouch of Douglas
3. Remote lymph node spread
4. Haematogenous spread to involve liver, lungs, brain and bone is common

27. Investigation of suspected gastric
carcinoma

28. Staging
- CT scanning of chest and abdomen
- Laparoscopy improves the accuracy of staging
- Endoscopic ultrasonography for TNM
- PET

29. Management
- Radical Surgery:
- Because: metastasis from gastric cancer is often early, widespread and occult
- Chemotherapy and radiotherapy.
- Palliative procedures (laparoscopic).

32. ENDThanks for listening