pyloric exclusion in pud management
TRANSCRIPT
PYLORIC EXCLUSION INPUD MANAGEMENT
dr. Agi Satria Putranto, SPB(K)BD
Pyloric exclusion often is used to divert the GI steam and followed by gastro jejunostomy anastomostic
Current Indications for Surgical PUD
1. Bleeding
2. Perforations
3. Obstruction
4. Failed medical therapy
5. Risk of malignancy
The goals of PUD Surgical Procedure
1. Permit ulcer healing
2. Prevent of treat ulcer complications
3. Address the underlying ulcer etiology
4. Minimize postoperative digestive consequences
To choose the best operation, the surgeon must consider :
1. The characetistic of the ulcer (location, chronicity, type of complication)
2. Etiology (acid hypersecretion, drug-induced, possible role of H. pyloric)
3. The patient (age, nutrition, comorbid illnesses, condition on presentation)
4. The operation (mortality rate, side effects)
Simple Ulcus
Perforated duodenal ulcer
Peritonitis
Operative
• Omental pastching with truncal vagotomy
• Pyloroplasty or omentalpatching with HSV • Omental patching/plug
• H. pylori testing and treatment
“Unusuall” condition of Duodenal Ulcer
• OmentalPatching/plug
• T-tube inserted • Pyloric Exclusion
• Perforation >24h• Contrast study
confirms sealed perforation
Conservative Theraphy
Pyloric Exclusion Procedure
There are two ways to close the pylorus :
1. Suture from within the stomach
2. Stapled closure
Find the pyloric ring make an suturing with ‘O’ technique or interact suturing with absordable
suture
Construct an anterior gastrojejunostomy by bringing up a loop of jejenum and suturing it at the site of the gastrotomy
Place omentum over the duodenal suture line and place drains in close proximity to it
Create an anterior gastrotomy
Repair duodenal ulcer
The indication of Pyloric exclusion common use in complex duodenal repair especially injury and rare in duodenal ulcer
Pyloric exclusion is recommend for severe injure Grade II and Grade III
Anatomic Complication – Pyloric Exclusion
1. Leakage from duodenal closure
2. Duodenal obstruction
3. Failure of pylorus to reopen Alternatively pylorus may reopen before repair is healed
PYLORIC EXCLUSION IN RSCM1. Diagnose : Duodenum perforation (Pars 2, Iatrogenik)
Treatment : Laparatomy
Duodenorraphy
Pyloric exclusion, Gastrojejenumstomy
2. Diagnose : Penetrating abdominal gunshot wounds with abdominal peritonitis, region of the
corpus alineum
Treatment : Laparotomy – exploration
Duodenorraphy
Pyloric exclusion, Gastrujejenumstomy
Double barrel transversum colostomy
3. Diagnose : Residif Pseumiksoma + Insisional hernia + Duodenum perforation (Iatrogenik)
Treatment : Pyloric exclusion
Primer suturing duodenum perforation
Gastojejenumstomy
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