pud management
TRANSCRIPT
-
8/14/2019 Pud Management
1/75
PravinNarkhede
SURGERIES FORPEPTIC ULCER
DISEASE
-
8/14/2019 Pud Management
2/75
Surgery for peptic ulcers is performed less oftensince the advent of the H2 antagonists andproton pump inhibitors (PPIs) and the
treatments to eradicate Helicobacter pylori
there is a high recurrence rate for pepticulcerations after discontinuation of medicaltherapy
Indications for surgery
Intractable ulcers
Haemorrhage
Perforation
Obstruction, usually pyloric stenosis
-
8/14/2019 Pud Management
3/75
Goal of surgerytreatment of anatomic
complications, such as pyloricstenosis or perforation.patient safety in the acute setting,
combined with freedom fromundesirable chronic side effectsalteration of the ulcer diathesis so
that ulcer healing is achieved andrecurrence is minimized
-
8/14/2019 Pud Management
4/75
Subtotal gastrectomy was consideredoptimal management for duodenal andgastric ulcers until Dragstedt's description of
vagotomy and its impact on ulcer healing andrecurrence.
goal of ulcer surgery is to prevent gastricacid secretion.
Vagotomy decreases peak acid output byabout 50%,
vagotomy plus antrectomy, which removesthe gastrin-secreting portion of the stomach,decreases peak acid output by about 85%
-
8/14/2019 Pud Management
5/75
Surgical procedures
The operations that have been usedtraditionally are:
Truncal vagotomy and Pyloroplasty
Highly selective vagotomyTruncal vagotmoy and AntrectomyBillroth I gastrectomy
Billroth II or Polya gastrectomyRoux-n Y anastomosis
-
8/14/2019 Pud Management
6/75
Truncal VagotomyTruncal vagotomy is probably the
most common operation performedfor duodenal ulcer diseasetruncal vagotomy is performed by
division of the left and right vagusnerves above the hepatic and celiacbranches just above the GE junction
some form of drainage procedure inassociation with truncal vagotomy
-
8/14/2019 Pud Management
7/75
-
8/14/2019 Pud Management
8/75
Heineke-Mikulicz pyloroplasty
Longitudinal incision across pylorus
which is then closed transverslynot feasibile if pylorus thickened orscarred
Finney pyloroplasty or JaboulaygastroduodenostomyWhen the duodenal bulb is scarred,Gastro duodenostomy
Can be performed if pylorus thickenedor scarred
-
8/14/2019 Pud Management
9/75
-
8/14/2019 Pud Management
10/75
-
8/14/2019 Pud Management
11/75
-
8/14/2019 Pud Management
12/75
From a technical standpoint, truncalvagotomy and pyloroplasty represent anuncomplicated procedure that can beperformed quickly, making it especiallyattractive for patients who arehemodynamically unstable from bleeding
ulcerslittle difference in the side effects
associated with the type of drainageprocedure performed, although bile reflux
may be more common aftergastroenterostomy, and diarrhea is morecommon after pyloroplasty
-
8/14/2019 Pud Management
13/75
Highly Selective Vagotomy
also called theparietal cell vagotomyor
theproximal gastric vagotomydivides only the vagus nerves supplying
the acid-producing portion of thestomach within the corpus and fundus
preserves the vagal innervation of thegastric antrum so that there is no needfor routine drainage procedures
incidence of postoperativecomplications is less
-
8/14/2019 Pud Management
14/75
the nerves of Latarjet are identified anteriorly andposteriorly, and the crow's feet innervating the fundusand 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 atleast 5 cm proximal to the gastroesophageal junction onthe esophagus
The criminal nerve of Grassi very proximal branch of theposterior trunk of the vagus, and great attention needs tobe taken to avoid missing this branch in the divisionprocess because it is frequently cited as a predispositionfor ulcer recurrence if left intact.
-
8/14/2019 Pud Management
15/75
recurrence rates vary depend on
skill of surgeon and
duration of follow upprepyloric ulcers are more likely to be
associated with recurrence than duodenalulcers, for unclear reasons
The moderate ulcer recurrence rate withhighly selective vagotomy is consideredacceptable by many surgeons becauserecurrences in this scenario are usuallyresponsive to medical therapy with protonpump inhibitors
-
8/14/2019 Pud Management
16/75
-
8/14/2019 Pud Management
17/75
Truncal Vagotomy and Antrectomy
most common indications
gastric ulcer and large benign gastrictumorsRelative contraindicationscirrhosis,extensive scarring of the proximalduodenum that leaves a difficult ortenuous duodenal closure, and
previous operations on the proximalduodenum, ascholedochoduodenostomy
-
8/14/2019 Pud Management
18/75
Distal gastrectomy or antrectomyrequires reconstruction of GIcontinuity that can be
accomplished by either aBillroth I procedure;Billroth II procedure using one of
several modificationsRoux-n Y loop anastomosis
-
8/14/2019 Pud Management
19/75
Billroth I gastrectomy
Proffesor Hans Theodore Billroth first resectionfor malignancy in 1881Describes removal of a distal gastric segment,followed by primary anastomosis withpreservation of duodenal integrityAdvantagePreservation of physiological and anatomical
integrityLower incidence of post gasrectomy syndromeMinimal disturbance of pancreatic functionLower incidence of development of carcinomain remaining segment of stomach
-
8/14/2019 Pud Management
20/75
DisadvantageAnastomosis at tension site
It is the standard operation forbenign pathology as very limitedlymphadenopathy is achieved
-
8/14/2019 Pud Management
21/75
-
8/14/2019 Pud Management
22/75
-
8/14/2019 Pud Management
23/75
Billroth II or Polya gastrectomy
Polya gastrectomy described in 1911
Involves distal gastric resection with closure of
duodenal stump and restoration of gastriccontinuity with gastrojejunostomy
Advantage
Usefull in case where billroth I have excess
tension at anastomotic siteEasy to perform
In carcinoma allows radical margins ofdissection
Disavdvantage
Maximum rate of complication
-
8/14/2019 Pud Management
24/75
the loop of jejunum chosen for anastomosis isusually brought through the transversemesocolon in a retrocolic fashion rather thanin front of the transverse colon in an antecolicfashion
The retrocolic anastomosis minimizes thelength of the afferent limb and decreases thelikelihood of twisting or kinking that couldpotentially lead to afferent loop ob-structionand predispose to the devastating
complication of a duodenal stump leak
-
8/14/2019 Pud Management
25/75
-
8/14/2019 Pud Management
26/75
-
8/14/2019 Pud Management
27/75
Roux-n Y gastrojejunostomy
Distal divided end of jejunum is
anastomised to stomach usingendto side anastomosisProximal end anastomised to 40-50
cm downstream, thus providing anoutflow pathway for billiary contents
-
8/14/2019 Pud Management
28/75
Subtotal Gastrectomy
rarely performed today
reserved for patients with underlyingmalignancies or patients who havedeveloped recurrent ulcerations aftertruncal vagotomy and antrectomy.After subtotal gastrectomy,restoration of GI continuity can beaccomplished with either a Billroth II
anastomosis or via a Roux-en-Ygastrojejunostomy
-
8/14/2019 Pud Management
29/75
Posterior truncal vagotomy with anteriorseromyotomy (Taylor procedure)
Simpler and quicker operation than HSV
Gastric drainage procedure not equiredPosterior truncal vagotomy done andanterior seromyotomy doneby dividingseromuscular layers taking care not to
breach mucosaFollows along leser curvature at distanceof 2 cm from its starting at angle of Hisextending to approximately 5 cm frompylorus
-
8/14/2019 Pud Management
30/75
-
8/14/2019 Pud Management
31/75
Surgical therapy serves several purposes. It salvagespatients from life-threatening complications associatedwith perforation, hemorrhage, and gastric outlet
obstructionFor all patients with ulcers being considered for
elective surgery, antisecretory agents should probablybe 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 ofcontamination
In patients undergoing surgery for PUD, it is
recommended that all have H. pylori testing and, ifpositive, treatment and documentation of eradication
-
8/14/2019 Pud Management
32/75
In patients undergoing surgery forPUD, it is recommended that all have
H. pylori testing and, if positive,treatment and documentation oferadication
NSAIDs should be discontinued
Recommendations for
-
8/14/2019 Pud Management
33/75
Recommendations forComplications Related to PepticUlcer Disease
Duodenal UlcerIntractable:- parietal cell vagotomy
Bleeding:- truncal vagotomy withpyloroplasty and oversewing of bleeding
vesselPerforation:- patch closure with treatment of
H. pylori with or without parietal cellvagotomy
Obstruction:- rule out malignancy andparietal cell vagotomy withgastrojejunostomy
Recommendations for
-
8/14/2019 Pud Management
34/75
Recommendations forComplications Related to PepticUlcer Disease
Gastric ulcerIntractable
Type I:- distal gastrectomy with Billroth I
Type II or III:- distal gastrectomy with truncalvagotomy
Bleeding
Type I: distal gastrectomy with Billroth IType II or III: distal gastrectomy with truncal
vagotomy
-
8/14/2019 Pud Management
35/75
Perforated
Type I, stable:- distal gastrectomy withBillroth I
Type I, unstable:- biopsy, patch, and
treatment for H. pyloriType II or III:- patch closure with treatment
ofH. pylori
Obstruction:- rule out malignancy andantrectomy with vagotomy
-
8/14/2019 Pud Management
36/75
Type IV:- depends on ulcer size,distance from the
gastroesophageal junction, anddegree of surroundinginflammation
Giant gastric ulcers: distalgastrectomy, with vagotomyreserved for type II and III gastriculcers
-
8/14/2019 Pud Management
37/75
-
8/14/2019 Pud Management
38/75
Recommended Operative Procedures
for Recurrent Postoperative Ulcers
Initial Operation Recommended OperationLocal procedure Truncal vagotomy and
antrectomy
Gastrectomy Truncal vagotomy and resection
of retained antrum if present
Vagotomy and pyloroplasty Re-vagotomy and antrectomy
Vagotomy and antrectomy Re-vagotomy and resection ofretained antrum
Proximal gastric vagotomy Truncal vagotomy andantrectomy
Subtotal gastrectomy Truncal vagotomy and resectionof retained antrum if present
-
8/14/2019 Pud Management
39/75
-
8/14/2019 Pud Management
40/75
-
8/14/2019 Pud Management
41/75
POST GASTRECTOMY
SYNDROME
POST VAGOTOMY SYNDROME
-
8/14/2019 Pud Management
42/75
Postgastrectomy Syndromes
gastric surgery results in a number of
physiologic derangements dueto loss of reservoir function,interruption of the pyloric sphincter
mechanism,the type of gastric reconstruction,and
vagal nerve transection
-
8/14/2019 Pud Management
43/75
When these postgastrectomysymptoms develop, it has becomemore apparent that every attempt
should be made to avoidreoperation because many of thesepatients lack a clearly definable
mechanical or physiologic defectand many of the problems persistdespite reoperation
-
8/14/2019 Pud Management
44/75
Postgastrectomy SyndromesSecondary to Gastric Resection
Dumping Syndromesymptom complex that occurs
following ingestion of a meal when a
portion of the stomach has beenremoved or the normal pyloricsphincter mechanism has becomedisrupted
-
8/14/2019 Pud Management
45/75
Early Dumping
more common after partial gastrectomy with theBillroth II reconstruction
20 to 30 minutes after ingestion of a meal and isaccompanied by both GI and cardiovascular symptoms
G I Symptoms :- nausea and vomiting, a sense ofepigastric fullness, eructations, cramping abdominalpain, and often explosive diarrhea
cardiovascular symptoms :- palpitations, tachycardia,diaphoresis, fainting, dizziness, flushing, andoccasionally blurred vision
b h t i f d d li d t
-
8/14/2019 Pud Management
46/75
occurs because hypertonic food delivered tosmall intestines
The resultant hypertonic food bolus passes into
the small intestine, which induces a rapid shiftof extracellular fluid into the intestinal lumen toachieve isotonicity.
After this shift of extracellular fluid, luminal
distention occurs and induces the autonomicresponses
the release of several humoral agents, such asserotonin, bradykinin-like substances,neurotensin, and enteroglucagon
T
-
8/14/2019 Pud Management
47/75
TreatmentMost, however, experience
spontaneous relief and require nospecific therapyWhen symptoms are prolongeddietary measures include
avoiding foods containing largeamounts of sugar, frequent feeding of small meals rich
in protein and fat, andseparating liquids from solids duringa meal
-
8/14/2019 Pud Management
48/75
MedicalSomatostatin analogue octreotide
acetate highly effective inpreventing the development ofboth vasomotor and GI symptoms,
inhibit the hormonal responsesassociated with this syndrome andcompletely abolish the associateddiarrheaIncrease intestinal transit timeCostly
S
-
8/14/2019 Pud Management
49/75
Surgery< 1% required
Purpose to improve the gastric reservoirfunction, decrease rapid gastric emptying,
or ideally accomplish both goals.use of isoperistaltic or antiperistaltic
jejunal segments
-
8/14/2019 Pud Management
50/75
Iso peristalsis
done using a 10- to 20-cm loop of jejunumand interposing it between the stomach and
small intestine in an isoperistaltic fashionAnti 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 thestomach and its proximal end to the smallintestine
creation of a long-limb Roux-en-Y
anastomosis to delay gastric emptying.
Late Dumping
-
8/14/2019 Pud Management
51/75
p gless common
2 to 3 hours after a meal
related specifically to carbohydratesWhen carbohydrates are delivered to thesmall intestine, they are quickly absorbed,resulting in hyperglycemia, which triggers therelease of large amounts of insulin to controlthe rising blood sugar. This results in an actualovershooting such that a profound
hypoglycemiaThis activates the adrenal gland to releasecatecholamines, which results in diaphoresis,tremulousness, light-headedness, tachycardia,
and confusion
-
8/14/2019 Pud Management
52/75
Treatmentto ingest frequent small meals and
to reduce their carbohydrate intakeMedicalpatients have found benefit with
pectin either alone or incombination with acarbose
Surgery
Same like early dumping
b li i b
-
8/14/2019 Pud Management
53/75
Metabolic Disturbances
more common and serious after partialgastrectomy than after vagotomy
Greater in Billroth II as opposed to aBillroth I
Anaemia
Most commonIron deficiency :- more common
30% of patients undergoing gastrectomysuffer from iron deficiency anemia
-
8/14/2019 Pud Management
54/75
related to acombination of decreased iron
intake,impaired iron absorption, andchronic subliminal blood loss
secondary to the hyperemic, friable gastric mucosa primarilyinvolving the margins of the stoma
addition of iron supplements to thepatient's diet corrects this metabolicproblem
M l bl i i
-
8/14/2019 Pud Management
55/75
Megaloblastic anemia
especially when more than 50% of thestomach is removed
secondary to poor absorption of thesubstance owing to lack of intrinsic factorsecretion in the gastric juice
Serum B-12 level obtained, if less treatedwith intramuscular injection every 3 to 4months indefinitely because itsadministration orally is not a reliable route
folate deficiency may coexist oralsupplimentation is sufficient
impaired absorption of fat
-
8/14/2019 Pud Management
56/75
impaired absorption of fat.
steatorrhea :-
result of inadequate mixing of bile salts and
pancreatic lipase with ingested fat because of theduodenal bypass pancreatic replacement enzymesare 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 calciumsupplements (1-2 g/day) in conjunction with vitaminD (500-5000 units daily).
Postgastrectomy Syndromes Related to Gastric
-
8/14/2019 Pud Management
57/75
Postgastrectomy Syndromes Related to GastricReconstruction
More common with Billroth II procedures
Afferent Loop Syndrome
result of partial obstruction of the afferent limb that isunable 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 aresultant volvulus, or
adhesions involving the afferent limb
-
8/14/2019 Pud Management
58/75
occurs when the afferent limb is greater than 30 to 40
-
8/14/2019 Pud Management
59/75
occurs when the afferent limb is greater than 30 to 40cm in length and has been anastomosed to the gastricremnant in an antecolic fashion
Chronic presentation common than acute
there is an accumulation of pancreatic and hepatobiliarysecretion within the limb, resulting in its distention whichcauses epigastric discomfort and cramping
partial obstruction :-intraluminal pressure increases ,projectile billous vomiting no food contained within the
vomitus
complete obstruction
-
8/14/2019 Pud Management
60/75
complete obstruction,
necrosis and perforation of the loop can occur asthe obstruction is a closed loop because the
duodenum proximally has already been closedconstant abdominal pain, more pronounced inthe right upper quadrant with radiation into theinterscapular area.
surgical emergency and requires immediateattention
In closed loop, bacterial overgrowth occurs in thestatic loop, and the bacteria bind with vitamin B12
and deconjugated bile acids
Alth h t t thi
-
8/14/2019 Pud Management
61/75
Although symptoms may suggest thisdiagnosis, it is sometimes difficult to
establish the diagnosisplain films of the abdomen dilatedafferent loop may be seencontrast barium study of the stomach
may delineate the presence of anobstructed loopFailure to visualize the afferent limb
on upper endoscopy is also suggestiveof the diagnosisRadionuclide studies imaging
Treatment
-
8/14/2019 Pud Management
62/75
Acute or chronic
A long afferent limb is usually the underlying
problem, and treatment therefore involvesthe elimination of this loop
converting the Billroth II construction into aBillroth I anastomosis
enteroenterostomy below the stoma, which istechnically easier.
Creation of a Roux-en-Y can also be done, buta concomitant vagotomy should also be
performed to prevent marginal ulcerationfrom the diversion of duodenal contents fromthe gastroenteric stoma.
Efferent Loop Obstruction
-
8/14/2019 Pud Management
63/75
Efferent Loop Obstruction
rare.
The most common cause of efferent loop
obstruction is herniation of the limb behind theanastomosis in a right-to-left fashion.
can occur with both antecolic and retrocolicgastrojejunostomies.
occur anytime after surgery; however, more than50% of cases do so within the first postoperativemonth
complaints may include left upper quadrantabdominal pain that is colicky in nature, biliousvomiting, and abdominal distention
Establishing a diagnosis is difficult
-
8/14/2019 Pud Management
64/75
Establishing a diagnosis is difficultcontrast barium study of the
stomach with failure of barium toenter the efferent limbSurgery
reducing the retroanastomotichernia and closing theretroanastomotic space to preventrecurrence of this condition.
Alkaline Reflux Gastritis
-
8/14/2019 Pud Management
65/75
Alkaline Reflux Gastritis
fairly common
severe epigastric abdominal painaccompanied by bilious vomiting andweight loss not relieved by food orantacids, anaemia weight loss common
diagnosiscareful history,
HIDA scans are usually diagnostic:-demonstrating biliary secretion into
the stomach and even into theesophagus in severe cases
Upper endoscopy
-
8/14/2019 Pud Management
66/75
Upper endoscopyperformed with multiple biopsy
samples taken away from thestoma, and the gastric fluid canbe analyzed for bile acidconcentrationsmucosa is frequently friable andbeefy-red, and superficialmucosal ulcerations may be
apparent on microscopy.
Common with billroth II
-
8/14/2019 Pud Management
67/75
Common with billroth IIthere is no clear correlation between
the volume of bile or its compositionand the subsequent development ofalkaline reflux gastritisTreatmentMedical not satisfactorySurgery for intractable casesconverting the Billroth II anastomosis
into a Roux-en-Y gastrojejunostomy inwhich the Roux limb has beenlengthened to 41 to 46 cm
Retained Antrum Syndrome
-
8/14/2019 Pud Management
68/75
Retained Antrum Syndrome
Normally, antral mucosa may extend past the pyloricmuscle for a distance of 0.5 cm,
Common with billroth II
retained antrum is continually bathed in alkaline pHfrom the duodenal, pancreatic, and biliary secretionsthat, in turn, stimulate the release of large amounts ofgastrin with a resultant increase in acid secretion
responsible for about 9% of recurrent ulcers afterprevious surgery for PUD and is associated with anincidence of recurrent ulceration as high as 80%
can be eliminated if biopsy confirmation of duodenal
-
8/14/2019 Pud Management
69/75
can be eliminated if biopsy confirmation of duodenalmucosa is obtained after resection of the proximalduodenum at the time of the Billroth II gastrectomy.
Diagnosistechnetium scan may prove helpful in diagnosingretained antrum , demonstrates a hot spot that isadjacent to the area where normal uptake oftechnetium 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
-
8/14/2019 Pud Management
70/75
SurgeryIf medical ineffective
conversion of the Billroth II to aBillroth I reconstruction orexcision of the retained antral
tissue in the duodenal stump isindicated
Postvagotomy Syndromes
-
8/14/2019 Pud Management
71/75
Postvagotomy Syndromes
Postvagotomy Diarrhea
30% or more of patients suffernot severe and usually disappearswithin the first 3 to 4 monthsoccur 2 to 3 times weekly or manifestitself once or twice a month.explosive diarrhea and result in soiledclothing
Most patients symptoms resolve overtime
MedicalCh l t i
-
8/14/2019 Pud Management
72/75
Cholestyramine
Four grams with meals three times daily followed byan adjustment to a maintenance dosage should
decrease bowel movements to once or twice a dayimprovement 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-cmsegment of reverse jejunum 70 to 100 cm from theligament of Treitz
Postvagotomy Gastric Atony
-
8/14/2019 Pud Management
73/75
g y y
After vagotomy, gastric emptying is delayed
true for both truncal and selective vagotomies butnot in the case of highly selective or parietal cellvagotomy
With selective or truncal vagotomy, patients loseantral pump function and therefore have areduction in their ability to empty solids
In contrast, emptying of liquids is acceleratedfeeling of fullness and occasionally abdominal painfunctional gastric outlet obstruction
Diagnosis
-
8/14/2019 Pud Management
74/75
Diagnosisconfirmed on scintigraphic
assessment of gastric emptying.Endoscopic examination of thestomach also needs to be
performed to rule out anyanastomotic obstructionsMedicalProkinetic drugsmetoclopramide and erythromycin
Incomplete Vagal Transection
-
8/14/2019 Pud Management
75/75
Incomplete Vagal Transectionpredisposes the patient to the
possible development of recurrentulcer formationTruncal vagotomy more commonright vagus nerve is frequently buried
in the periesophageal tissue,potentially leading to incompletetransection
Histologic confirmation of vagaltransection decreases the incidence ofincomplete vagotomy