ppt
DESCRIPTION
TRANSCRIPT
![Page 1: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/1.jpg)
Preoperative Case Presentation & Sharing of Information on Vomiting
Preoperative Case Presentation & Sharing of Information on Vomiting
Jeffy G. Guerra, MD
Level III Surgery Resident
OMMC-Surgery
053006
![Page 2: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/2.jpg)
General Data:
C.P., 68F
SAB, Mla
![Page 3: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/3.jpg)
Chief Complaint:
Vomiting
![Page 4: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/4.jpg)
History of Present Illness:
8 years PTA epigastric pain, on/off, moderate, slightly relieved by antacid
consult : ulcer
![Page 5: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/5.jpg)
1 year PTA Persistence of Ssx, consultRx: Cimetidine
lost to follow-up
![Page 6: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/6.jpg)
8 months PTA episodes of regurgitation,
gastrointestinal reflux
![Page 7: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/7.jpg)
1 month PTA (+) black tarry stool
no consult
![Page 8: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/8.jpg)
25 days PTA epigastric pain vomiting
unrelieved by antacid,
admitted: IV started, H2 block and BT, 2 units,
apparently d/c well
![Page 9: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/9.jpg)
2 days PTA vomiting, 3x, nonprojectile, postprandial, partially digested food
![Page 10: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/10.jpg)
Few hours PTA persistence, consult-admitted IM-ERDx: UGIB 2 PUDR/O Gastric MalignancyCBC, PC, BT, CXR electrolytes done(+) Saline loading testBT, 2 u PRBC ordered
![Page 11: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/11.jpg)
Course in the Ward: IM
• NPO, NGT
• Meds:– FeSO4 tab, TID– Ranitidine 50mg TIV, q12
• No Subjective complaints
• PPE: E/N
• Plan: EGD
• Referred to Surgery
![Page 12: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/12.jpg)
Past Medical History: NSAID use
Family History: no history of cancer in the family
Personal Social History: non-smoker non-alcoholic
beverage drinker
![Page 13: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/13.jpg)
Physical Examination:
• Conscious, coherent, ambulatory, NICRD• BP:110/70 CR:75 RR:21
T:37ºC• Pale palpebral conjunctiva, anicteric sclerae• Supple neck, (-) cervical LAD• Symmetrical chest expansion, clear breath sounds• Adynamic precordium, normal rate & regular rhythm• Flat, NABS, soft, (+) slight Direct tenderness,
epigastric area, no mass• DRE: (+) yellow feces on tactating finger
![Page 14: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/14.jpg)
Salient Features:• 68F
• Known case of PUD
• Epigastric pain,
• Gastrointestinal reflux, regurgitation
• Vomiting
• Slight tenderness Epigastric area
• DRE: E/N
![Page 15: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/15.jpg)
VOMITING
Systemic Mechanical
NeurologicInfectious
UGIT LGIT
Stomach Small BowelEsophagus Duodenum Colon
Sphincter Fnxn
Mechanical Obstruction
Mechanical ObstructionA. StrictureB. Mass
![Page 16: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/16.jpg)
Clinical Diagnosis:
Diagnosis Certainty Treatment
Gastric outlet obstruction 2 stenosis 2 PUD
70% Medical/Surgical
Gastric Outlet obstruction 2 to gastric mass
30% Surgical
![Page 17: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/17.jpg)
Do I need a para-clinical diagnostic procedure?Yes.• To increase the certainty of my primary
diagnosis.• To determine my treatment plan
![Page 18: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/18.jpg)
Para-clinical Diagnostic ProcedureBenefit Risk Cost Availability
UGIS Sn rate: 80-85%
SP rate: 82%
radiation 2k /
Endoscopy with Biopsy
Sn rate: 95%
SP rate: 98%
perforation 5k /
CT scan Sn rate: 88%
SP rate: 85%
radiation 3k /
![Page 19: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/19.jpg)
Endoscopy Result:
Gastric Outlet Obstruction; pyloric channel, secondary to healed pyloric ulcer, 98% obstructing
No Biopsy done
![Page 20: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/20.jpg)
Pre-Treatment Diagnosis:
Diagnosis Certainty Treatment
Gastric outlet obstruction 2 stenosis 2 healed PUD
95% Surgical
Gastric Outlet obstruction 2 to stenosis 2 malignancy
5% Surgical
![Page 21: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/21.jpg)
Goals of Treatment:
• Resolution of the obstruction• Maintenance of bowel continuity • No recurrence• No complications
![Page 22: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/22.jpg)
TREATMENT OPTIONS BENEFIT RISK COST AVAILABI
LITY
Resolution of obstruction
Bowel continuity Local recurrence
Vagotomy + Antrectomy
/// /// MR: 5%
RR: 2%
3k /
Vagotomy + Jaboulay gastroduodenostomy
/// /// MR:1%
RR: 10%
3k /
Vagotomy + gastrojejunostomy*
/// /// MR: 1%
RR: 1%
3k /
Endoscopic baloon dilatation
/ /// MR: 1%
RR: 50%
15k x
*Csendes A. et al. RCT on three techniques for GOO treatment.*Millat B. Surgical treatment of complicated Duodenal ulcer: RCT
![Page 23: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/23.jpg)
Pre-op preparation: what I will do • Informed consent secured• Psychosocial support provided• Optimized patient’s physical health
– Correction of anemia/electrolytes– Nutritional build-up
• Patient screened for any health condition• Operative materials secured
![Page 24: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/24.jpg)
Intra-op Management: How I will do It (Vagotomy, Gastrojejunostomy)
• Patient supine under GETA
• Asepsis and antisepsis technique
• Sterile drapes place
• Long vertical incision from xyphoid to supraumbilical area
![Page 25: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/25.jpg)
Mobilization of left lateral segment of the liver
![Page 26: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/26.jpg)
Division of triangular ligament
![Page 27: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/27.jpg)
Exposure of esophagogastric junction
![Page 28: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/28.jpg)
Exposure of anterior vagus nerve
![Page 29: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/29.jpg)
Isolation/ligation of nerve trunk, anterior, posterior and esophageal
branches• Anterior vagal trunk is encircled with hook
and dissected sharply from esophageal musculature
• Nerve trunk is ligated proximally and distally
![Page 30: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/30.jpg)
Drainage via Gastrojejunostomy
![Page 31: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/31.jpg)
Anastomotic site
![Page 32: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/32.jpg)
Posterior serosal suture
![Page 33: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/33.jpg)
Gastric incision
![Page 34: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/34.jpg)
Posterior mucosal suture
![Page 35: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/35.jpg)
Anterior mucosal suture
![Page 36: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/36.jpg)
Completion of anastomotic defect
![Page 37: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/37.jpg)
Post-op Care
![Page 38: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/38.jpg)
• Postoperative care: – Intravenous fluids– nasogastric decompression – Analgesics– hemodynamics
• The nasogastric tube is removed upon return of gastrointestinal transit, and feeding is slowly begun.
![Page 39: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/39.jpg)
Outcome:
• Resolution of obstruction• Live patient• No complications• Satisfied patient• No medico-legal suit
![Page 40: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/40.jpg)
Sharing of information
![Page 41: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/41.jpg)
SURGERY FOR PEPTIC ULCER DISEASE(PUD)
• Ulcer in the GIT is characterized by an
interruption in the mucosa stretching through the muscularis mucosa into the submucosa or deeper
• Location - in order of decreasing frequency
– Duodenum – Stomach – Esophagus
![Page 42: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/42.jpg)
Epidemiology
Gastric ulcer Duodenal ulcer
Age 40 – 60 20 – 45
Sex M : V = 1.5 : 1 M : V = 3 : 1
Socio-economic Lower Higher
Blood group A O
![Page 43: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/43.jpg)
Classification of Gastric Ulcers(GU) ( Gaintree – Johnson )
• Type 1 = incisura on the lesser curvature.
No increased acid secretion. Mucosal resistance problem.
• Type 2 = Gastric and duodenal ulcer. Gastric ulcer secondary to gastric stases caused by duodenal ulcer.
• Type 3 = Prepyloric ulcer within 2-3cm of the pylorus. Often acid hypersecretors. Association with blood group O. Treated like duodenal ulcer.
![Page 44: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/44.jpg)
• Type 4(Csendes) = High on lesser curvature near gastro-esophageal junction. As Type 1.
• Type 5 = Secondary to chronic use of non-steroidal anti-inflammatory drugs (NSAID). Can occur anywhere in the stomach.
![Page 45: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/45.jpg)
Pathogenesis
• Still debated
• Traditionally duodenal ulcers are seen as a problem with acid hypersecretion and gastric ulcers as a mucosal resistance problem
![Page 46: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/46.jpg)
Gastric acid. Central in pathogenesis – no benign ulceration occurs without gastric acid
Gastric stases. Delayed emptying of normal amounts of acid with increased exposure
![Page 47: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/47.jpg)
Enviromental factors are very important.a) Helicobacter pylori infection. 90% of
patients with DU and 50% of patients with GU
b) NSAID use. The mucus gel layer contains bicarbonate. This layer adheres to the gastric mucosa. It protects the mucosa against back diffusion of hydrogen ions. NSAID’s suppress mucus cell function.
c) Smoking
![Page 48: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/48.jpg)
4) Mucosal resistance
5) Genetic predisposition
![Page 49: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/49.jpg)
Clinical Picture
![Page 50: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/50.jpg)
DUODENAL ULCER
1) Epigastric pain – Central or slightly to the right
Burning or gnawing
Can spread to the back
Relieved by ingestion of food or anti-acid
Pain occurs when patient is hungry
![Page 51: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/51.jpg)
2) Different degrees of nausea and vomiting
3) Weight gain ( Pain relieved by ingestion of food)
4) Epigastric tenderness just to the right of the midline, may be absent.
![Page 52: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/52.jpg)
GASTRIC ULCER
1) Epigastric pain – Brought on by meals often within 30 minutes
2) Nausea and vomiting
3) Weight loss
4) Epigastric tenderness
![Page 53: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/53.jpg)
Complications
1) Bleeding
2) Perforation
3) Gastric outlet obstruction
4) Penetration
![Page 54: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/54.jpg)
Management
• Surgery is indicated and for the following:
1) Non-healing ulcer ( 8 – 12 weeks for GU, DU can be managed conservatively for longer since the risk for malignancy is low)
2) Complications • a) Perforation
b) Bleeding if massive,
c) Gastric outlet obstruction that does not clear up on conservative management.
![Page 55: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/55.jpg)
Surgical principle for definitive ulcer surgery
![Page 56: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/56.jpg)
Definitive ulcer operations for GU
• Type 1 GU partial gastrectomy. Vagotomy not done.
• Type 2 and 3 GU treated as DU. HSV contra-indicated due to high ulcer recurrence with prepyloric ulcers.
• Type 4 GU treated with partial gastrectomy and excision of a long tongue of lesser curvature including the ulcer(Pauchet procedure).
![Page 57: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/57.jpg)
Gastric outlet obstruction
• Cycles of inflammation and repair may cause obstruction at the gastroduodenal junction as a result of edema, muscular spasm and fibroses.
![Page 58: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/58.jpg)
• Edema and spasm can resolve with medical treatment.
• Obstruction is mainly caused by DU and prepiloric GU.
• Malignant tumors is the other important cause of gastric outlet obstruction.
![Page 59: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/59.jpg)
• normal pylorus is about 20 mm in diameter and can distend to 25 mm
• gastric outlet obstruction occur when the diameter of the antroduodenal segment is below 10 mm
• A saline load test can be utilized in the objective measurement of outlet obstruction or gastric atony and the assessment of response to therapy
![Page 60: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/60.jpg)
• The major benign causes of GOO are PUD, gastric polyps, ingestion of caustics, pyloric stenosis, congenital duodenal webs, gallstone obstruction (Bouveret syndrome), pancreatic pseudocysts, and bezoars
![Page 61: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/61.jpg)
Clinical picture
• Longstanding history of PUD
• Progressive worsening of ulcer pain and early satiety.
• Vomiting after meals of partially digested food without bile ( food eaten earlier the day or the previous day).
• Dehydration and severe weight loss.
![Page 62: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/62.jpg)
• Visible peristalses of the dilated stomach (rarely).
• Succussion splash audible with to and fro movement of abdomen.
• Tetany in cases of advanced alkaloses.
• Develop hyponatremic, hypokalemic, hypochloremic metabolic alkaloses
![Page 63: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/63.jpg)
Management
1) Resussitation initially with 0.9% sodium chloride. Potassium supplementation only after good urine output is established.
2) Gastric lavage with thick stomach tube ( 32 F) to remove food residue.
3) Diagnostic tests after gastric lavage : Gastroscopy with biopsies with or without barium meal to rule out malignancy.
![Page 64: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/64.jpg)
4) IV H2-blockers or proton pump inhibitors.
5) A nasogastric tube is passed. The patient may drink water. The amount of oral intake and drainage is charted. This gives an impression whether the obstruction is resolving.
6) Balloon dilatation of pyloric channel is possible but seldom produces a final solution.
![Page 65: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/65.jpg)
7) Surgery is indicated if the obstruction does not resolve after one week of conservative treatment. Mostly a truncal vagotomy and antrectomy is done although truncal vagotomy with a drainage procedure is sometimes performed.
![Page 66: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/66.jpg)
Complications of PUD surgery
![Page 67: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/67.jpg)
Complications due to vagotomy
• Intraoperative complications can occur with injury to adjacent structures.
• Early post-operative complication – delayed gastric emptying – dysphagia and lesser curve necroses( lesser
curve necroses specific to HSV).
• Late complications include postvagotomy diarrhea, reflux esophagitis and gallstones
![Page 68: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/68.jpg)
Complications of gastrectomy
• Early complications – bleeding– anastomotic leakage– obstruction – hepatobiliary-pancreatic complications
(pancreatitis, bile duct injury)
![Page 69: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/69.jpg)
• Late complications are classified as follows :
– 1) Ulcer recurrence
a) Recurrent ulcer (anastomotic,stomal,marginal)
b) gastrojejenocolic fistula
![Page 70: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/70.jpg)
2) Mechanical problemsa) Chronic afferent loop obstruction after BII
anastomoses – abdominal pain relieved by vomiting , vomit mainly bile without food.
b) Chronic efferent loop obstruction
c) Internal herniation, jejenogastric intussusception and late gastroduodenal obstruction
![Page 71: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/71.jpg)
3) Pathophysiologic problemsa) Alkaline reflux gastritis – reflux of bile into stomach.
Pain not relieved with vomiting. Vomitus contains food and bile.
b) Dumping(I)Early dumping – symptoms within 20 minutes after meal. Gastro-intestinal : Abdominal cramps, satiety, nausea, vomiting and explosive diarrhea. Cardiovascular : sweating, dizziness, weakness,dyspnea, palpitations and flushing.
![Page 72: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/72.jpg)
– Due to sudden release of high osmolality chyme into duodenum with fluid shifts and release of gastro-intestinal hormones.
• (II) Late dumping – only vasomotor symptoms. Caused by enteroglucagon secretion which leads to increased and prolonged insulin secretion with resultant hypoglycaemia.
![Page 73: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/73.jpg)
4) Malabsorption and Nutritional problems
a) Malabsorption of protein, carbohydrates and fat
b) Early satiety
c) Anemia : Fe, folate and B12 deficiency. B12 problems mostly after total or near total gastrectomy.
d) Osteopmalacia
![Page 74: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/74.jpg)
References:1. Csendes A. Maluenda F. et al. Prospective randomized controlled trial
comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Am J Surg. 1993 Jul 166:45-49
2. Edwards LW, Herrington JL Jr. Vagotomy and gastroenterostomy—vagotomy and conservative gastrectomy. Ann Surg, 1953; 137: 873– 83.
3. Emas S, Fernstrom M. Prospective, randomized trial of selective vagotomy with pyloroplasty and selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric and prepyloric ulcers. Am J Surg, 1985; 149: 236–43.
4. Fischer AB. Twenty-five years after Billroth II gastrectomy for duodenal ulcer. World J Surg, 1984; 8: 293–302.
5. Kuwada, S et al. Long-term outcome of endoscopic dilation of nonmalignant pyloric stenosis. Gastrointestinal Endoscopy 1995; 41(1) 15-17.
6. Gibson JB, Behrman SW, Fabian TC: Gastric outlet obstruction resulting from peptic ulcer disease requiring surgical intervention is infrequently associated with Helicobacter pylori infection. J Am Coll Surg 2000 Jul; 191(1): 32-7[Medline].
![Page 75: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/75.jpg)
7.Millat B, Fingerhut A et al. surgical treatment of complicated duodenal ulcer. Controlled trial. World J Surg. 2000 Mar. 24(3) 299-306.
8. Siu WT, Tang CN, Law BK, et al: Vagotomy and gastrojejunostomy for benign gastric outlet obstruction. J Laparoendosc Adv Surg Tech A 2004 Oct; 14(5): 266-9[Medline].
9. Haglund UH, Jansson RL, Lindhagen JG, Lundell LR, Svartholm EG, Olbe LC.Primary Roux-Y gastrojejunostomy versus gastroduodenostomy after antrectomy and selective vagotomy.Am J Surg. 1992 Apr;163(4):457-8.
![Page 76: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/76.jpg)
Questions
1. Gastric Outlet Obstruction secondary to healed pyloric ulcer may present with which of the following?
a. vomiting
b. hyponatremia
c. hypochloremia
d. epigastric pain
e. All of the above
![Page 77: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/77.jpg)
2. What is the most common complication of peptic ulcer disease?
a. bleeding
b. perforation
c. intractability
d. obstruction
![Page 78: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/78.jpg)
3. The following statements is/are true regarding gastric outlet obstruction.
1. Cycles of inflammation and repair may cause obstruction at the gastroduodenal junction as a result of edema, muscular spasm and fibroses.
2. Edema and spasm can resolve with medical treatment.3. Obstruction is mainly caused by DU and prepiloric GU. 4. Malignant tumors is the other important cause of
gastric outlet obstruction.
![Page 79: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/79.jpg)
4. Which of the following choices is/are late complication/s of vagotomy?
1. postvagotomy diarrhea,
2. reflux esophagitis and
3. Gallstones
4. Delayed gastric emptying
![Page 80: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/80.jpg)
5. Which of the following is/are not early complication of gastric surgery ?
6. Bleeding
7. anastomotic leakage
8. hepatobiliary-pancreatic complications (pancreatitis, bile duct injury)
9. gastrojejenocolic fistula
![Page 81: ppt](https://reader033.vdocument.in/reader033/viewer/2022061119/5464df3daf7959cf288b608d/html5/thumbnails/81.jpg)
Thank you!