19 September 2018 Surgery of the stomach and duodenum: Peptic ulcer disease *- Congenital hypertrophic pyloric Nature stenosis Sites of peptic ulcer disease Etiology *- Acute gastric dilatation Types: *- Peptic ulcer disease (acute erosions – *- Gastric erosions (erosive gastritis) chronic peptic ulcer) *- Stress ulcers e.g. ICU patients, trauma patients, intra- *- Gastric volvulus cranial trauma or operations (Cushing ulcer), burned patients (Curling ulcer) *- Bezoars Clinical presentations *- Gastric neoplasms Diagnosis *- Gastrectomy, and its complications Treatment: Medical treatment *- Gastrostomy Endosc. treatment ( injections , Laser, or thermal ttt ) *- Gastric role in bariatric surgery Surgical treatment Gastrectomy ?? 1 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 *- Chronic peptic ulcer Etiology: Increased gastric acidity is the main association, multifactorial by * Genetic predisposition (large parietal cell mass) * Increased vagal tone mainly by night may be by worry or stress * Abnormality in gastrin release and inhibition * Helicobacter pylori causing gastritis, duodenal ulcer and sometimes MALT lymphoma. * Hypergastrinaemia by pancreatic gastrinoma (Zollinger Ellison syndrome) * Spicy meals, drinks, smoking, alcohol , drugs, 2 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 Clinical presentation: Incidence: *- Pain (post prandial , localized , deep, severe, Decreasing incidence of ulcer disease with 50-60% increased by codiments, wores by night) increased GE reflux and gastritis More common in males (5:1), age is around middle *- Nausea and vomiting age (??) *- Periodicity (periods of activity followed by DU : GU = 25 : 1 period of quiescence),loss of periodicity signats 15-20% 15-20% complications , penetration, or spastic pyloric Pathology: stenosis Site gastric , duodenal (Kissing ulcers) Size Single or multiple *- Complications as bleeding (hematemesis, or Shape Edge Floor Base melena, hematochasia?? ), penetration (pancreatitis), perforation (peritonitis), or ?10% pyloric obstruction. Investigations *- Endoscopy (diagnosis, Biopsy) *- Barium meal *- CT scan, Multislice CT scan *- MRI scan, Scientigraphy scan *- Laboratory investigations 3 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 ? 4 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 Treatment: (Peptic ulcer treatment is mainly medical, *- Mucosal protective drugs: surgery has selective indications only) ( Sucralfait, or prostaglandin analogue,) I- Medical treatment *- Antacids: *- Complete physical and mental rest. (Aluminum hydroxide, …..) *- Dietary regimens. *- Anti HP drugs, and their regimens. *- H2 receptor antagonists: (Dual therapy, Triple therapy, or Quadruple (Cimetidine 800 mg, Ranitidine 300 mg, Famotidine therapy). 40 mg, Nizatidine 300 mg, or Ruxatidine ??) *- Other drugs *- Proton pump inhibitors (No acid-No ulcer): Sedative tranquilizers, prokinetics, digestants,.. (Omeprazole 20 mg, Lanzoprazole, Pantoprazole, Rapeprazole, or Esomprazole) II- Surgical treatment Initial treatment Recurrent ← (4-6 or 8 weeks) ulcer Gastric ulcer: Mainly caused by local defect in mucosal ↘ ↓ Once ulcer Intractable ulcer barrier, or local insult, so the treatment is by Re-endoscopy → Non healed ulcer gastrectomy (remove the ulcer or the bearing area, and ensure gastric emptying). ↓ ↘ ↘ Surgical ↓ Duodenal ulcer: Bad patient treatment Healed ulcer → Mainly caused by hypersecretion either due to compliance ↑ increased vagal tone (treated by vagotomy ± ↓ Always ulcer drainage procedure), increased gastrin level Maintenance therapy Complicated → Follow up (treated by anterectomy), or large parietal cell Interval therapy ulcer mass (treated by gastrectomy). 5 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 Vagotomy: abolishing entirely the pathway of gastric secretion with immediate reduction of HCL secretion in 80 %, with time it decreased to 50 %. *- Truncal vagotomy + drainage procedure *- Selective vagotomy + drainage procedure *- Highly selective vagotomy (parietal cell vagotomy) (proximal gastric vagotomy) *- lesser curve seromyotomy (+posterior truncal vagotomy) (Taylor operation) 6 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 Drainage procedures: *- Pyloomyotomy (Rammstedt) *- Heineke-Mikulicz pyloroplasty *- Finney pyloroplasty *- Jaboulay pyloroplasty *- Antrectomy + reconstruction ( Billroth I, Billroth II, Polya , or others) *- Gastrojejunostomy ( loop with or without enteroenterostomy, antecolic or retrocolic, isoprestaltic or antiprestaltic, short afferent or ultrashort afferent limb, Roux-en-Y loop. 7 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 8 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 9 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 10 Prof. Alaa Ahmad Redwan, 2017 19 September 2018 11 Prof. Alaa Ahmad Redwan, 2017.