Role of surgery

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Introduction
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Role of surgery

• Despite advances in medical therapy to inhibit
  acid secretion and to eradicate H. pylori,
  surgery remains important in managing these
  patients. Over the last 2 decades, there has been
  an increase in emergency operations performed for
  complications of peptic ulcers while the number
  of operations for elective indications has
  decreased markedly.
• An ulcer by definition extends through the
  muscularis mucosa in contrast to an erosion,
  which is superficial to the muscularis mucosa.

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Etiologies of Duodenal ulcer

• Duodenal ulcer disease is a disease of multiple
  etiologies. The only absolute requirements are
  secretion of acid and pepsin in conjunction with
  either H. pylori infection or ingestion of
  NSAIDs.

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Etiologies of gastric ulcers

• Most of gastric ulcers appear to behave more like
  duodenal ulcers and are associated with excess
  acid.
• Types I and IV gastric ulcers are defects in
  mucosal protection
• types II and III are associated with acid
  hypersecretion and behave like duodenal ulcers
• Gastric cancers ( suspicious ) may ulcerate and
  resemble gastric ulcers.
• Furthermore, ulcers may be caused by nonacid or
  other peptic disorders such as Crohns disease,
  syphilis, Candida infection, or malignant
  diseases such as Kaposis sarcoma, lymphoma,
  carcinoma, or pancreatic carcinoma.

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Clinical Manifestations

• Young and middle-aged patients
• Pain or one of complication ( perforation ,
  bleeding , obstruction pyloric obstruction ,
  hour glass stomach , penetration , malignant
  transformation in gastric ulcer )

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ABDOMINAL PAIN

• The most common symptom is mid-epigastric
  abdominal pain that is usually well localized.
  The pain is usually tolerable and frequently
  relieved by food. Moreover, the pain may be
  episodic, may be seasonal in the spring and fall,
  or may relapse during periods of emotional
  stress. For these reasons and because it is
  relieved, many patients do not seek medical
  attention until they have had the disease for
  many years.
• When the pain becomes constant, deeper
  penetration of the ulcer, and referral of pain to
  the back is usually a sign of penetration into
  the pancreas.
• Diffuse peritoneal irritation is usually a sign
  of perforation.

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PERFORATION

• Acute Vs subacute
• Pathology 3 Stages
• Sudden sever abdominal pain ,assosiated with
  neusia and vomiting , and variable degree of
  shock
• Peritonitis , frequently accompanied by fever,
  tachycardia, dehydration, and ileus .
• Abdominal examination reveals tenderness,
  rigidity, and rebound.
• A hallmark of perforation is the demonstration
  of free air underneath the diaphragm on an
  upright chest radiograph. This complication of
  duodenal ulcer disease represents a surgical
  emergency. Once the diagnosis is made, operation
  should be performed in an expeditious fashion
  following appropriate fluid resuscitation.

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BLEEDING

• The most common cause of death in patients with
  peptic ulcer disease is bleeding in patients who
  have major medical problems or are older than 65
  years of age.
• Because the duodenum has an abundant blood supply
  and the gastroduodenal artery lies directly
  posterior to the duodenum bulb.
• Most duodenal ulcers present with only minor
  bleeding episodes that are detected by the
  presence of Melina

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OBSTRUCTION

• Gastric outlet obstruction manifested by delayed
  gastric emptying, anorexia, or nausea accompanied
  by vomiting.
• In cases of prolonged vomiting, patients may
  become dehydrated and develop a hypochloremic,
  hypokalemic metabolic alkalosis. Fluid
  resuscitation requires replacement of the
  chloride and potassium deficiencies in addition
  to nasogastric suction for relief of the
  obstructed stomach.
• In addition to acute inflammation leading to
  functional gastric outlet obstruction , chronic
  inflammation of the duodenum may lead to
  recurrent episodes of healing followed by repair
  and scarring with ultimately fibrosis and
  stenosis of the duodenal lumen. In this
  situation, the obstruction is accompanied by
  painless vomiting of large volumes of gastric
  contents with similar metabolic abnormalities as
  seen in the acute situation. The stomach can
  become massively dilated in this setting, and it
  rapidly loses its muscular tone. Marked weight
  loss and malnutrition are also common in this
  situation.

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Gastric Ulcer

• Like duodenal ulcers, gastric ulcers are also
  characterized by recurrent episodes of quiescence
  and relapse. They also cause pain, bleeding, and
  obstruction and can perforate. Hemorrhage occurs
  but the most frequent complication is
  perforation. Most perforations occur along the
  anterior aspect of the lesser curvature. Similar
  to duodenal ulcer, gastric outlet obstruction can
  also occur.

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Zollinger-Ellison syndrome

• Zollinger-Ellison syndrome is a clinical triad
  consisting of gastric acid hypersecretion, severe
  peptic ulcer disease, and non-beta islet cell
  tumor of the pancreas. The tumors are known to
  produce gastrin and are referred to as
  gastrinomas.

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Diagnosis

• History and physical examination
• Upper GIT endoscopy
• A serum gastrin level should also be obtained in
  patients with
• ulcers that are refractory to medical therapy or
  require surgery.
• An upright chest radiograph is usually performed
  when ruling out perforation.
• H. pylori testing should also be done in all
  patients with suspected peptic ulcer disease.

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HELICOBACTER PYLORI TESTING

• Serology is the test of choice for initial
  diagnosis when endoscopy is not required.
• If, however, endoscopy is to be performed, the
  rapid urease assay or histology are both
  excellent options.
• After treatment (only if necessary) the urea
  breath test is the method of choice

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Treatment

• Medical Management with exceptions

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Surgical Procedures for Peptic Ulcer Disease

• VAGOTOMY
• TRUNCAL and drainage procedures
  
• SELECTIVE VAGOTOMY
• HIGHLY SELECTIVE VAGOTOMY
• Gastrectomy

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Types of VAGOTOMY
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Heineke-Mikulicz pyloroplasty Vs
gastro-jejunostomy should be associated with
truncal vagotomy or selective vagotomy but not
highly selective vagotomy


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Hemigastrectomy with Billroth 1 (gastroduodenal)
anastomosis
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Hemigastrectomy with Billroth II
GASTROJUJINOSTOMY
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LAPAROSCOPIC PROCEDURES

• Both parietal cell vagotomy and posterior truncal
  vagotomy with anterior seromyotomy (Taylor
  procedure) can be accomplished laparoscopically
  and represent effective antiulcer operations.

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Surgical Indications

• It salvages patients from life-threatening
  complications associated with perforation,
  hemorrhage, and gastric outlet obstruction.

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Approach to the Patient Bleeding from Peptic
Ulcer Disease

• Approximately 80 of upper gastrointestinal
  bleeds are self-limited.
• The initial step in management is adequate
  initial and on going resuscitation.
• Following resuscitation, endoscopy is performed
  to assess the cause and severity of the bleed.
• Mortality increases with age ,the severity of the
  initial bleed is also an adverse prognostic
  factor, and this might include the presence of
  shock, a high transfusion requirement, or bright
  red blood in the nasogastric tube or in the
  stool. Recurrent bleeding, concomitant disease
  increased the mortality rate. Also Visible
  vessel was seen during endoscopy

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• Endoscopy remains the investigation of choice for
  patients with upper gastrointestinal bleeding
  from peptic ulcer disease.
• Not only for diagnosis but also therapy.
• When the bleeding is controlled, long-term
  medical therapy includes antisecretory agents
  usually in the form of a proton-pump inhibitor
  plus testing for H. pylori, with treatment if
  positive.
• If H. pylori is present, documentation of
  eradication should be performed following
  therapy. If the bleeding continues or recurs,
  surgery may be indicated.

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Treatment of Bleeding Duodenal Ulcers

• For those patients who continue to bleed or who
  are referred by the endoscopist , the duodenal
  bleeding is usually controlled by opening the
  duodenum and oversewing the ulcer with a U stitch
  from the vessel, which is usually the
  pancreaticoduodenal artery or gastroduodenal
  artery.
• As most of these patients are elderly, have bled
  a significant amount, and have some degree of
  hypotension, the more time-consuming parietal
  cell vagotomy is usually not performed. Instead,
  a truncal vagotomy with pyloroplasty is performed.

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Bleeding Gastric Ulcers

• For bleeding gastric ulcers, a distal gastrectomy
  with Billroth I anastomosis is usually performed.
  

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Perforated Duodenal Ulcers

• Simple patching of a perforated duodenal ulcer
  followed by medical treatment is all that is
  necessary for patients who present with a
  perforated duodenum secondary to peptic ulcer
  disease. Patch closure of the duodenum can be
  performed by either a laparoscopic or open
  procedure.

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Perforated Gastric Ulcer

• For perforated gastric ulcers that occur in
  hemodynamically stable patients, distal
  gastrectomy with Billroth I reanastomosis is
  usually performed.
• However, simple patching of the gastric ulcer,
  testing for H. pylori, and treatment if positive
  can also be considered. However, the risk of
  malignancy needs to be ruled out therefore,
  biopsy of the ulcer bed also needs to be
  performed.

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Gastric Outlet Obstruction

• The first principle is to categorize the patient
  as either acutely or chronically obstructed.
• If the patient is acutely obstructed, the
  patient should be treated nonoperatively with
  nasogastric decompression, intravenous fluid,
  nutritional support as needed, and acid
  suppressive therapy. H. pylori should be tested
  for and treated.
• if the patient has chronic gastric outlet
  obstruction operative therapy is usually
  indicated to open up the gastric outlet. In
  addition, an acid-reducing procedure is
  necessary.

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Preoperative

• Nasogastric decompression for several days.
• Correction of fluid and electrolyte imbalances.
• Antisecretory therapy.
• Endoscopy with biopsies.

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Operative

• Gastrectomy can be done if technically feasible.
• Alternatively, gastrojejunostomy with truncal
  vagotomy is also an option.

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Postoperative Complications for Peptic Ulcer
surgery

• Early complication bleeding , stomal
  obstruction , duodenal blow-out
• Postgastrectomy Syndromes Secondary to Gastric
  Resection( Dumping SYNDROME, METABOLIC
  DISTURBANCES,AFFERENT LOOP
• and EFFERENT LOOP SYNDROME)
• Postvagotomy Syndromes

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Postgastrectomy Syndromes

• DUMPING SYNDROME
• Dumping syndrome refers to a symptom complex that
  occurs following ingestion of a meal when a
  portion of the stomach has been removed or the
• normal pyloric sphincter mechanism has become
  disrupted.
• Dumping syndrome exists in either a late or an
  early form, with the early form occurring more
  frequently.

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EARLY DUMPING

• The early form of dumping syndrome usually occurs
  within 20 to 30 minutes following ingestion of a
  meal .
• The gastrointestinal symptoms include nausea and
  vomiting, a sense of epigastric fullness,
  eructations, cramping abdominal pain, and often
  explosive diarrhea.
• The cardiovascular symptoms include
  palpitations, tachycardia, diaphoresis, fainting,
  dizziness, flushing, and occasionally blurred
  vision.
• This occurs because gastrectomy or interruption
  of the pyloric sphincteric
• mechanism prevents the stomach from
  preparing its contents and delivering them to the
  proximal bowel in the form of small particles in
  isotonic solution. The resultant hypertonic food
  bolus passes into the small intestine, which
  induces a rapid shift of extracellular fluid into
  the intestinal lumen to achieve isotonicity.
• Following this shift of extracellular fluid,
  luminal distention occurs and induces the
  autonomic responses listed earlier.
• Dietary measures are usually sufficient to manage
  these patients.

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LATE DUMPING

• Appears 2 to 3 hours after a meal.
• The basic defect in this disorder is also rapid
  gastric emptying. When carbohydrates are
  delivered to the small intestine, they are
  quickly absorbed, resulting in hyperglycemia that
  triggers the release of large amounts of insulin
  to control the rising blood sugar. This results
  in an actual overshooting such that a profound
  hypoglycemia occurs in response to the insulin.
  This activates the
• adrenal gland to release catecholamines,
  which results in diaphoresis, tremulousness,
  lightheadedness, tachycardia, and confusion.
• The symptom complex is indistinguishable from
  insulin or hypoglycemic symptom .
• These patients should be advised to ingest
  frequent small meals and to reduce their
  carbohydrate intake.

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METABOLIC DISTURBANCES

• Anemia
• Iron deficiency anemia a combination of decreased
  iron intake, impaired iron absorption, and
  chronic subclinical blood loss secondary to the
  hyperemic, friable gastric mucosa primarily
  involving the margins of the stoma where the
  stomach connects to the small intestine. In
  general, the addition of iron supplements to the
  patients diet corrects this metabolic problem.
  
• Megaloblastic anemiaVitamin B12 deficiency
  occurs secondary to poor absorption ,due to lack
  of intrinsic factor secretion . The patient
  should be treated with intramuscular injections
  of cyanocobalamin every 3 to 4 months
  indefinitely.

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METABOLIC DISTURBANCES

• Impaired absorption of fat. On occasion,
  steatorrhea may be seen after gastrectomy and
  Billroth II reconstruction as a result of
  inadequate mixing of bile salts and pancreatic
  lipase with ingested fat because of the duodenal
  bypass.
• Deficiency in fat-soluble vitamins may also
  occur.
• In the setting of steatorrhea, pancreatic
  replacement enzymes are often effective in
  decreasing fat loss.

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METABOLIC DISTURBANCES

• Both osteoporosis and osteomalacia have also been
  observed following gastric resection and appear
  to be caused by deficiencies in calcium.

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AFFERENT LOOP SYNDROME

• Usually occurs when the afferent limb is longer
  than 30 to 40 cm and has been anastomosed to the
  gastric remnant in an antecolic fashion.
• Following obstruction of the afferent limb, there
  is an accumulation of pancreatic and
  hepatobiliary secretion within the limb,
  resulting in its distention.
• Pancreatic and hepatobiliary secretion occur in
  response to ingestion of food, accumulation of
  these secretions results in distention, which
  causes epigastric discomfort and cramping. In the
  setting of partial obstruction, the intraluminal
  pressure increases to forcefully empty its
  contents into the stomach, resulting in bilious
  vomiting that is often projectile but offers
  immediate relief of symptoms. There is no food
  contained within the vomitus.
• If the obstruction has been present for a long
  period, it can also be aggravated by the
  development of the blind loop syndrome.
• For both forms of afferent loop syndrome, acute
  and chronic, operation is indicated because it is
  a mechanical problem, not a functional problem.

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EFFERENT LOOP OBSTRUCTION

• The most common cause of efferent loop
  obstruction is herniation of the limb behind the
  anastomosis in a right-to-left fashion.
• Operative intervention is almost always necessary
  and consists of reducing the retroanastomotic
  hernia and closing the retroanastomotic space to
  prevent recurrence of this condition.

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POSTVAGOTOMY DIARRHEA

• Approximately 30 or more of patients suffer from
  diarrhea after gastric surgery. For most
  patients, it is not severe and usually disappears
  within the first 3 to 4 months. For some
  patients, the diarrhea is part of the dumping
  syndrome. However, vagotomy is also associated
  with alterations in stool frequency
• Most patients with postvagotomy diarrhea have
  their symptoms resolve over time. In those
  patients who fail to resolve their symptoms,
  cholestyramine, an anionic exchange resin that
  absorbs bile salts and renders them unabsorbable
  and inactive, can significantly diminish the
  severity of diarrhea.

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STRESS GASTRITIS

• Stress gastritis has been referred to as stress
  ulcerations, stress erosive gastritis, and
  hemorrhagic gastritis.
• These lesions may lead to life-threatening
  gastric bleeding and by definition occur after
  physical trauma, shock, sepsis, hemorrhage,
  respiratory failure, or severe burns.
• They are characterized by multiple, superficial
  (non ulcerating) erosions that begin in the
  proximal or acid-secreting portion of the stomach
  and progress distally.
• They may also occur in the setting of central
  nervous system disease such as that seen with a
  Cushing ulcer or as a result of thermal burn
  injury involving more than 30 of the body
  surface area (Curling ulcer).

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Gastric Adenocarcinoma

• H pylori infection increases the risk of gastric
  cancer
• Morphologic types ulcerating (15), polypoid
  (25), superficial spreading (15), linitis
  plastica (10), advanced (35)
• Symptoms and signs include postprandial
  abdominal heaviness early anorexia, with weight
  loss vomiting, often with blood, if pyloric
  obstruction occurs epigastric mass in 25
  hepatomegaly in 10 stool positive for occult
  blood in 50 but melena in a few cases
• Signs of distant spread metastases to the neck
  (Virchow node) or umbilicus (Sister Mary Joseph
  node), metastases anterior to rectum detectable
  on rectal examination (Blumer shelf), metastases
  to ovaries (Krukenberg tumors)
• Laboratory findings carcinoembryonic antigen
  is elevated in 65
• higher levels indicate extensive spread of tumor
• Endoscopy usually identifies gastric carcinomas
  .

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Treatment
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Haematemesis

• GI bleeding is any blood loss from the GI tract
  (from the mouth to the anus), which may present
  with haematemesis, melaena, rectal bleeding or
  anaemia.
• Haematemesis is defined as vomiting blood and is
  usually caused by upper GI disease.
• Melaena is the passage PR of a black
  treacle-like stool that contains altered blood,
  usually as a result of proximal bowel bleeding.

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Haematemesis

• Haematemesis is usually caused by lesions
  proximal to the duodenojejunal junction.
• upper GI lesions can cause frank PR bleeding if
  sever
• Most tumours more commonly cause anaemia than
  frank haematemesis.
• In young adults, peptic ulcer disease (PUD)and
  varices are the common causes.
• In the elderly, tumours, PUD and angiodysplasia
  are the common causes.

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Gastric causes

• Erosive gastritis may follow alcohol or NSAID
  intake/stress, history of dyspeptic symptoms.
• Gastric ulcer possible herald smaller bleeds,
  accompanied by altered blood (coffee grounds),
  history of PUD.
• Gastric cancer anaemia commoner, associated
  weight loss, anorexia, dyspeptic symptoms.
• Gastric leiomyoma (rare)
• Dieulafoys disease (rare) younger patients,
  large bleed.

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Duodenal causes

• Duodenal ulcer past history of duodenal ulcer,
  symptoms of back pain, hunger pains, NSAID use.
• Aortoduodenal fistula (rare) usually infected
  graft post AAA repair, massive haematemesis and
  PR bleed, usually fatal.
• Cancer ampula of Vater

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Esophageal causes

• Bleeding varices sudden onset, painless, large
  volumes, dark red blood, history of (alcoholic)
  liver disease, physical findings of portal
  hypertension.
• Reflux oesophagitis associated with
  regurgitation.
• Oesophageal carcinoma (rare) scanty,
  blood-stained debris, rarely significant volume,
  associated with weight loss, anergia,dysphagia.
• Trauma during vomiting (MalloryWeiss
  syndrome) bright red bloody vomit usually
  preceded by several normal but forceful vomiting
  episodes.

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General (systemic causes)
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MANAGEMENT

• Resuscitation
• Minor bleed observation, scheduled OGD ,monitor
  haemoglobin .
• Major bleed Continued resuscitation, urgent OGD
• VaricesEndoscopic therapy, Sengstaken
  tube.,Surgery
• Peptic ulcer Endoscopic therapy or surgery
• I.V. PPI treatment, correction of coagulation
  profile , protect aganest hepatic coma if LCF is
  present
• Early feeding