Surgical treatment for peptic ulcer disease

peptic ulcer disease, complications of peptic ulcer, surgical treatment of peptic ulcer

1. Surgical treatments for peptic ulcer disease DR BASHIR YUNUS GENERAL SURGERY UNIT AKTH

2. OUTLINE INTRODUCTION RELEVANT ANATOMY TYPES OF PUD INDICATIONS FOR SURGICAL TREATMENT VARIOUS TREATMENT OPTIONS COMPLICATIONS OF TREATMENT PROGNOSIS CONCLUSION REFERENCES

3. INTRODUCTION Peptic ulcer disease is an ulcer caused by gastric acid or pepsin. These secretions overwhelms the gastroduodenal mucosa and there is colonization of the pyloric antrum by H. pylori. The treatment is principally medical. Surgery is indicated when ulcers are refractory or become complicated.

4. RELEVANT ANATOMY

5. RELEVANT PHYSIOLOGY There 3 glandular zones Cardiac > mucus cells and few parietal cells Oxyntic (parietal)> (80% at fundus and body) parietal cells secretes HCL and intrinsic factor the chief cells pepsinogen Pyloric gland > G-cells secrete gastrin Stimulant of Gastric secretion: Acetylcholine (vagus) --> G cells and parietal cells Gastrin --> parietal cell and chief cells Histamine (mast cells) ---> parietal & chief cells Phases : Cephalic - vagus Gastric - food Intestinal - chyme

6. CLASSIFICATION Site Common sites are the duodenum and Gastric (stomach) Other sites; lower end of oesophagus, Meckel’s diverticulum with ectopic gastric tissue, jejunum in gastrojejunostomy . Modify Johnson’s classification

7. INDICATIONS FOR SURGERY Refractory ulcers Haemorrhage not responding to endoscopic treatment Gastric outlet obstruction Perforation Suspicious of Malignancy

8. SURGICAL OPTION VAGOTOMY Truncal and drainage Selective Highly selective Posterior vagotomy and anterior seromyotomy GASTRECTOMY Billroth I Billroth II Subtotal gastrectomy GRAHAM’S OMENTAL PATCH SUTURE LIGATION OF GASTRODUODENAL ARTERY UNDRER-RUNNING AN ULCER BASE After excision of the edge Vagotomy

9. vagotomy

10. Division of the vagus nerve remove the cephalic stimulus to oxyntic cells; acid secretion reduce by 60%. Types; Truncal vagotomy and drainage Selective vagotomy Highly selective vagotomy Posterior Truncal vagotomy and anterior seromyotomy (Taylor’s)

11. Truncal vagotomy and drainage The 2 nerve trunks are divided below the diaphragm near the hiatus. The gastric tone and mobility are diminished and emptying delayed A drainage procedure is done to drain the stomach Drainage; Pyloroplasty ; a longitudinal incision about 6cm long is made across the pylorus at the mid anterior part to involve the adjacent part of the pyloric antrum and duodenum. ( Heineke-Mikuliez ) other types are Finney’ s and Jaboulay Gastrojejunostomy ; the jejunum, about 15cm from the duodeno-jejunal flexure is anastomose usually to the posterior wall of the stomach behind the transverse colon

12. Selective vagotomy Vagotomy with sparing the hepatic branch of anterior vagus and the coeliac branch of the posterior vagus. A drainage procedure is also performed Time consuming and it has being abandoned Recurrence rate is 10%

13. Highly selective It aims at denervating only the acid producing oxyntic gland sparing nerve to the pyloric antrum(nerve of latarjet ) such that drainage procedure is not required. It is difficult to determine the exact area of denervation of oxyntic cell Recurrence rate is 10%

14. Taylor’s operation Seromyotomy- denervate the fundic parietal mass preserves nerve of L atarget . The seromyotomy is done 6cm proximal to the pylorus and 1.5cm from the lesser curvature

15. Billroth I Billroth I – partial gastrectomy gastro- duodenostomy end-to-end Done for gastric ulcer in the antrum

16. Billroth II Partial gastro- jejunostomy end-to-side with blind closure of duodenum Done for a proximal gastric ulcer

17. Graham’s patch Piece of omentum is used to cover the perforation. 3 or 4 interrupted sutures are inserted through and through along the long axis. Modified Graham’s patch

18. SUTURE LIGATION OF GASTRODUODENAL ARTERY Pylorodedontomy Non-absorbable suture must incorporate the artery proximal and distal to the site of bleeding And the transverse pancreatic branch Usually for massive bleeding

19. Under-running an ulcer For bleeding gastric and duodenal ulcers.

20. COMPLICATIONS Immediate Bleeding Gastric retention Dysphagia Leakage of duodenal stump Obstruction of the stoma Acute pancreatitis Late Dumping syndrome Diarrhoea Steatorhoea Enterogastric reflux Recurrent ulceration Iron deficiency anaemia Risk of colorectal and gastric tumours Weight loss Megaloblastic anaemia Osteomalacia Anastomotic ulcer Gastro- jejunocolic fistula

21. Prognosis Overall operative procedure gives satisfactory result in at least 80% of patients Mortality of vagotomy and drainage is <1% Partial gastrectomy has overall mortality of 2%, 90% are satisfied with result, 2% anastomotic ulceration and 5-10% dumping problems. Operative mortality for perforated DU is 7%

22. CONCLUSION Peptic ulcers requiring surgeries are complicated and the patients present as emergency which requires adequate resuscitation. Delay in presentation, diagnosis and treatment increases morbidity and mortality

23. References E.A Badoe et al, “Principles and Practice of surgery including pathology in the tropics” 4th edition, Assembly of God Literature Center ltd, 2009 Bailey and Love’s “Short Practice of Surgery” 26th edition CRC press Taylor and Francis group. 2013 Farquharson’s textbook of operative general surgery 9th edition SRB’s manual of surgery. 4 th edition 2013. www.slideshare .net