GASTRIC SURGERY AND ITS COMPLICATIONS.pptx

gastric surgery and its complicatons

1. GASTRIC SURGERY AND ITS COMPLICTAIONS Dr.Prakash Patel Department of surgery Government Medical College , Surat

2. Objectives To know the various surgeries performed for gastric pathology . To know to basic principle for gastric surgery To know the complications of gastric surgery To know the management of complications

3. GASTRIC SURGERY Common surgeries performed on stomach are: Gastrotomy Gastrostomy Gastrectomy Vagotomy , surgeries for peptic ulcers and perforation Drainage procedures Pyloroplasty Gastrojejunostomy pyloromyotomy

4. Indications for gastric surgery Complicated peptic ulcers Surgical management of duodenal ulcers Ca.stomach Obesity Gastro intestinal stromal tumors (GIST) Corrosive stricture of stomach Zollinger Ellison syndrome

5. Complicated peptic ulcers Indications for Surgical procedures Refractory to medical management Hemorrhage Perforation Obstructive symptoms

6. Surgical procedures for complicated peptic ulcer disease Vagotomy with drainage Billroth II gastrectomy Gastrectomy with hemostasis

7. Surgery for Ca. stomach Radical total gastrectomy Radical partial gastrectomy Palliative resection Bypass

8. Surgery for Obesity Malabsortives types Restrictive types Gastric band Sleeve gastrectomy Gastroplasties Mixed Gastric bypass Biliopancreatic diversion with duodenal switch

9. SURGICAL MANAGEMENT OF DUODENAL ULCERS Principles Reduce acid secretion by dividing vagus nerve- vagotomy Vagotomy denervate stomach and pylorus which will lead to gastric outlet obstruction. So drainage procedure is performed called as pyloroplasty . Two types of surgical procedures Truncal vagotomy with pyloroplasty Selective vagotomy with pyloroplasty

10. Billroth -I Remove of distal part of stomach and anastomosis of stomach with duodenum.

11. Billroth II Remove distal part of stomach and perform gastro – jejunostomy .

12. Roux en Y anastomosis

13. Complications of gastric surgery Early late

14. Early complications Gastrointestinal haemorrhage Anastomotic leak Pulmonary embolism DVT( Deep vein thrombosis) Wound infection Respiratory insufficiency , pneumonia Acute gastroparesis Ischemic necrosis of gastric ramnant or anstomotic site. Duodenal stump blow out

15. Late complications Stomal stenosis Bowel obstruction, small bowel obstruction Internal hernia Cholelithiasis Micronutrient deficiencies Marginal ulcer Staple line disruption Ventral hernia formation Post vagotomy diarrhoea

16. Malabsorption of fat soluble vitamins ( vitamin A, D, E ,K ) Vitamin A deficiency, which causes night blindness Vitamin D deficiency , which causes osteoporosis Iron defiiciency Protein energy malnutrition Afferent loop syndrome Blind loop syndrome

17. Alkaline gastritis Stomal ulcers Gastrojejunocolic fistula

18. Vagotomy complications Decreased acid secretion Faster gastric emptying Diarrhoea Dumping syndrome Gastric outlet obstruction

19. Vagotomy denervates from stomach to distal transverse colon including pancreas and gall bladder. Gall bladder denervations leads to stasis and which increase the chance of gall stones Decrease in pancreatic and gallbladder secretions leads to undigested fat steatorrhoea

20. DUMPING SYNDROME Early Late Cardiovascular and GI symptoms due to vagotomy and pyloroplasty or gastrectomy Early dumping syndrome due to Hypovolemia Late dumping syndrome due to Hypoglycemia

21. Complications of gastrectomy Anaemia ( intrnsic factor essential for binding of vit B12 for absorption in terminal ileum) Early satiety Hypocalcaemia – reduced HCL production interferes with absorption of calcium and Fe in the duodenum Gastric stump carcinoma – due to chronic irritation of stunp by duodenul secretions

22. Early Dumping Syndrome No intact pylorus leads to dumping of large amount of chymes , billiary and pancreatic secretions in to the duodenum at once Results in large amount of fluid shift Occurs within 40 minutes of ingestion Symptoms Tachycardia Diaphoresis Palpitations Diarrhoea Abdominal pain

23. Late Dumping Syndrome Due to rebound hypoglycaemia Occurs 2-4 hours post op Symptoms tachycardia Palpitations Diaphoresis Dizziness

24. Afferent Loop Syndrome Symptoms show immediately after meal Occurs only with billroth II reconstruction. Obstruction of afferent loop adjcent to anastomosis . Cramping pain Vomiting of dark brown bitter tasting material Symptoms resolves with vomiting

25. Blind Loop Syndrome After Billroth II than roux en y gastrojejunostomy , also seen after irradiation or morbid obesity Associated with bacterial overgrowth in the limb of intestine excluded from flow of chyme . This limb has bacteria which proliferate and interfere with folate and vit B12 metabolism, also bacterial overgrowth causes deconjugation of bile salts – steatorrhoea vit B12 deficiency lead to megaloblastic anaemia Diarrhoea Weight loss weakness

26. Treatment of Blind Loop Syndrome Antibiotics Revison surgery or conversion of Billroth I may be required for some patients

27. Reccurent Ulcer Disease Incomplete vagotomy , posterior vagal trunk or a branch of this trunk (Criminal nerve of grassi ) is left intact Truncal vagotomy + antrectomy ( lowest rate 2%) Proximal gastric vagotomy ( highest rate 12%)

28. Treatment – Endoscopy + congo red dye ( to demonstrate area of pH drop in gastric mucosa ) PPI(proton Pump Inhibiter) for long term Re operative vagotomy Recurrent ulceration despite of verified complete vagotomy  look for endocrine etiology like family history of MEN I syndrome , also look for hyperparathyroidism and Gastrinoma as possible cause.

29. Thank you