GASTRIC PERFORATION: A BRIEF SURGICAL MANAGEMNT

In case of gastric perforation, a good emergency surgery with ulcer edge biopsy and follow up is the key for prevention of further complications in the long run.

1. Gastric perforation Dr Reshma Chandrasekaran DNB General Surgery Resident

2. Upcoming slides include INTODUCTION BASIC ANATOMY OF STOMACH GASTRIC SECRETION PHYSIOLOGY APPROACH TO HVP CASE SURGICAL MANAGEMENT OF GASTRIC PERFORATION COMPLICATIONS CONCLUSION

3. Introduction Perforation of the stomach is a full-thickness injury of the wall of the organ. The peritoneum completely covers the stomach and so perforation of the wall creates a communication between the gastric lumen and the peritoneal cavity. If the perforation occurs acutely, there is no time for an inflammatory reaction to wall off the perforation, and the gastric contents freely enter the general peritoneal cavity, causing chemical peritonitis.  Perforations occurring over a prolonged period may be contained locally by the inflammatory reaction.

4. Elective and emergency operations for benign gastric ulcer disease has decreased over the decades. Annual incidence of peptic ulcer disease 0.1-3% (300,000 new cases per year), ½ gastric ulcers Pharmacologic therapy for acid hypersecretion and H. pylori treatment is the primary reason for reduction in surgical intervention.

5. Stomach anatomy

6. Attachments

7. Rich arterial supply

8. Lymphatics

9. Vagus Innervation

10. Gastric secretion physiology

11. ETIOLOGY of gastric perforation MC : Secondary to peptic ulcer disease Other causes: Trauma: Malignancy: I nterventional procedures: I ntrinsic gastric pathology: S pontaneously in the newborn:

12. ULCEROGENIC FACTORS > PROTECTIVE FACTORS

13. Disease progression

14. Fate of h.pylori infection H. pylori, a group 1 carcinogen can lead to gastric adenocarcinoma through a sequence of pathology starting from In patients with mucosa-associated lymphoid tissue (MALT) lymphoma, H. pylori has been seen in more than 75% of cases. H. pylori testing is recommended in children having first-degree relatives with gastric cancer. Gastritis => atrophy => intestinal metaplasia => dysplasia => carcinoma.

15. Ulcer or perforation site prediction with history Peptic ulceration is typically characterized by non-radiating epigastric pain described as burning or stabbing. Referral of pain to the back may indicate posterior penetration of the ulcer. H/O pain in relation to eating: with duodenal ulcer pain relieved by eating, gastric or marginal ulcer pain worsens with food intake.

16. ROLE OF UGIE About 10% of gastric ulcers are malignant or associated with malignancy, so aggressive biopsy and brushings, as well as careful follow-up to demonstrate healing, are mandatory. All gastric ulcers should undergo multiple biopsies, obtained from the perimeter of the lesion. The addition of endoscopic brushings to multiple biopsies increases diagnostic accuracy to approximately 95%.

17. Signs and symptoms IN HVP Perforated Peptic ulcer-Sudden-onset, severe, G eneralised abdominal pain- Tachycardia- Board-like rigidity- Distension- Obstipation- Fever(not initially)- Hypotension (later stage) POSTERIOR WALL PERFORATION USUALLY PRESENT LATER THAN ANTERIOR WALL PERFORATION.

18. POSTERIOR WALL GASTRIC ULCERS PERFORATE AND THEY LEAK GASTRIC CONTENTS INTO THE LESSER SAC, WHICH TENDS TO CONFINE THE PERITONITIS.

19. Investigations: x-ray abdomen erect

20. FOOTBALL SIGN IN NEONATE WITH GASTRIC PERFORATION

21. 37-year-old woman with perforated gastric ulcer. Focal defect in lesser curvature of gastric body is caused by deep ulcer (arrow) associated with surrounding mural thickening. Note small air bubble (arrowhead) on anterior peritoneal surface of liver.

22. Gastric decompression

23. Gastric aspirate

24. Current Indication for Surgical Intervention 1. Bleeding  Most Common Complication  100 per 100.000 population 2. Perforation  11 per 100.000 population  highest rate of mortality 3. Obstruction  scarring of prepyloric and duodenal ulcers 4. Failed Medical therapy  PPIs 5. Risk of Malignancy  large gastric ulcers

25. role of surgical Management The prognosis is improved if treatment is provided within 6 hours of perforation. Delay in treatment beyond 12 hours  an increase in both morbidity and mortality . A prospective study of patients  perforations >48 hours, pre-operative shock, and concurrent medical illness were associated with an increase in mortality. Emergency surgery for a perforated peptic ulcer has a 6–30% risk of mortality.

26. “ Do not stitch the perforation but plug it with viable omentum and patch a perforation ulcer if you can, if you cannot, then you must resect” ( Mosche Schein )

27. Modified Johnson Classification

28. Surgical management Primary repair : The defect is primarily closed with suture, this is appropriate for most traumatic perforations. Cellan -jones repair : The defect is simply plugged with a well-vascularized omental pedicle and suture d. Graham patch repair: The ulcer is closed with omental cut patch (no vascularity). IN BOTH THESE METHODS PERFORTAION SITES ARE NOT CLOSED WITH PRIMARY REPAIR.

29. Karanjia technique: modified Cellan-Jones: omental pedicle is secured to the tip of a NGT passed through the ULCER site. NGT is withdrawn for 5-6 cms before the omentum is secured to healthy serosa Modified Graham patch repair/ omentoplasty : primary closure of the defect and then application of the omental tongue which is secured with same suture thread. Wedge resection : The perforated area may be resected from healthy tissue, particularly if it is on the greater curvature and distant from the gastroesophageal junction or the pylorus

30. THOROUGH PERITONEAL TOILET: Irrigation with warm NS or antibiotics . One of the most Important p ar t s of s urg e ry  6- 10 lit e r s e ve n up t o 30 litres o f warm saline are reco m mended . Contaminated peritoneal cavity

31. Re- leak following omentoplasty Expected in following Patients: 1. Age>60 years 2. Pulse rate >110/minute 3. Blood pressure <90 mmhg 4. Hb < 10 g/dl 5. Serum albumin < 2 . 5 g/dl 6. Total lymphocyte count < 1800 cells/mm3 7. Size of perforation > 0.5 cm

32. Drainage NEEDED or not? Still controversial . 80%  no need . Drain  Will not reduce the incidence of intraabdominal fluid collections or abcesses (Schein.M) 10% can become infected and intestinal obstruction

33. ULCERS GREATER THAN 5 CM: GIANT ULCERS ACID HYPERSECRETION SITES

34. 10mm 5 mm 5 mm OPEN SURGERY UPPER MIDLINE INCISION MINIMALLY INVASIVE LAPAROSCOPIC SURGERY PORT SITES

35. Heineke-Mikulicz pyloroplasty

36. TYPES OF PYLOROPLASTY

37. The Heineke −Mikulicz pyloroplasty consists of a longitudinal incision of the pyloric sphincter extending into the antrum and the duodenum. The incision is closed transversely, eliminating sphincteric closure and increasing the lumen of the pyloric channel.

38. Role of vagotomy and gastric drainage procedures Vagotomy and pyloroplasty has an 10–15% ulcer recurrence rate. Vagotomy with antrectomy : ulcer recurrence rate is very low.

39. when the ulcer is located 5 cm below the cardia, Schoemaker's or Pauchet's procedure should be performed; if the ulcer is located 2 cm or less from the cardia, Csendes' procedure or the Kelling-Madlener procedure should be employed. Csendes procedure is a surgical treatment for gastric ulcers high in the cardia . It involves excising type 4 gastric ulcers near the gastroesophageal junction by removing the distal stomach along the lesser curvature, a small part of the esophageal wall, and the ulcer with Roux-en-Y esophagogastrojejunostomy .

40. Options for reconstruction: Billroth I : Gastroduodenostomy, anastomosis between the gastric remnant and the duodenum Billroth II : Gastrojejunostomy , side to side anastomosis between gastric remnant and loop of jejunum with the closure of duodenal stump Roux-en-Y gastrojejunostomy :  The creation of jejuno-jejunostomy forming y shaped figure of the small bowel.

41. Surgical Reconstruction

42. BEST PROCEDURE WHEN CONSIDERING REVISION SURGERY

43. SUTURING TECHNIQUES Common Suture techniques: Continuous over-and-over suture Lembert's suture Connell suture Cushing suture Double layer anastomosis Posterior outer lembert's sutures Posterior inner → over-and-over continuous sutures Anterior inner connell's sutures Anterior outer → lembert's sutures

44. Lambert suture Connell stitch

45. CIRCULAR ENDO GI STAPLER USAGE

46. Intestinal anastomosis is a common surgery Anastomotic healing is similar to other tissue healing Hand sewn anastomosis is not inferior to stapler Anastomosis must be tension free, with good blood supply and minimal fecal contamination Two main benefits of stapler anastomosis: Takes less time No objective variations – easy to use by all surgeons

47. Surgical Reconstruction Both Billroth reconstruction  lead to bile reflux  5- 35% To avoid that  Roux-en- Y reconstruction (Roux 1897) Roux-en- Y reconstruction  plaqued with a Roux stasis syndrome Braun variaton Billroth (1893)  lower incidence of Bile reflux  some authors recommend this as standard reconstruction.

48. BII BRAUN ANASTOMOSIS SUCCESSFULLY DIVERTED A SUBSTANTIAL AMOUNT OF BILE FROM THE REMNANT STOMACH, THIS METHOD MAY BE A GOOD ALTERNATIVE TO RY RECONSTRUCTION IN PREVENTING BILE REFLUX.

49. Complication of Ulcer Operations 1. Early Satiety 2.postvagotomy syndrome  30% 3. Dumping Syndrome  20% 4. Alkaline Reflux gastritis  10% 5. Afferent and Efferent loop syndrome  Mechanical obstr uction of the limb kinking, anastomosis narrowing, or adhesion 6. Roux stasis syndrome 7. Recurrent Ulceration 8. Anastomo tic leak

50. Post surgical follow-up UGIE WITH HP TEST TO TREAT RESISTANT VARIETY OF H.PYLORI.

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