pud management

8/14/2019 Pud Management

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PravinNarkhede

SURGERIES FORPEPTIC ULCER

DISEASE


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Surgery for peptic ulcers is performed less oftensince the advent of the H2 antagonists andproton pump inhibitors (PPIs) and the

treatments to eradicate Helicobacter pylori

there is a high recurrence rate for pepticulcerations after discontinuation of medicaltherapy

Indications for surgery

Intractable ulcers

Haemorrhage

Perforation

Obstruction, usually pyloric stenosis


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Goal of surgerytreatment of anatomic

complications, such as pyloricstenosis or perforation.patient safety in the acute setting,

combined with freedom fromundesirable chronic side effectsalteration of the ulcer diathesis so

that ulcer healing is achieved andrecurrence is minimized


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Subtotal gastrectomy was consideredoptimal management for duodenal andgastric ulcers until Dragstedt's description of

vagotomy and its impact on ulcer healing andrecurrence.

goal of ulcer surgery is to prevent gastricacid secretion.

Vagotomy decreases peak acid output byabout 50%,

vagotomy plus antrectomy, which removesthe gastrin-secreting portion of the stomach,decreases peak acid output by about 85%


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Surgical procedures

The operations that have been usedtraditionally are:

Truncal vagotomy and Pyloroplasty

Highly selective vagotomyTruncal vagotmoy and AntrectomyBillroth I gastrectomy

Billroth II or Polya gastrectomyRoux-n Y anastomosis


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Truncal VagotomyTruncal vagotomy is probably the

most common operation performedfor duodenal ulcer diseasetruncal vagotomy is performed by

division of the left and right vagusnerves above the hepatic and celiacbranches just above the GE junction

some form of drainage procedure inassociation with truncal vagotomy


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Heineke-Mikulicz pyloroplasty

Longitudinal incision across pylorus

which is then closed transverslynot feasibile if pylorus thickened orscarred

Finney pyloroplasty or JaboulaygastroduodenostomyWhen the duodenal bulb is scarred,Gastro duodenostomy

Can be performed if pylorus thickenedor scarred


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From a technical standpoint, truncalvagotomy and pyloroplasty represent anuncomplicated procedure that can beperformed quickly, making it especiallyattractive for patients who arehemodynamically unstable from bleeding

ulcerslittle difference in the side effects

associated with the type of drainageprocedure performed, although bile reflux

may be more common aftergastroenterostomy, and diarrhea is morecommon after pyloroplasty


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Highly Selective Vagotomy

also called theparietal cell vagotomyor

theproximal gastric vagotomydivides only the vagus nerves supplying

the acid-producing portion of thestomach within the corpus and fundus

preserves the vagal innervation of thegastric antrum so that there is no needfor routine drainage procedures

incidence of postoperativecomplications is less


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the nerves of Latarjet are identified anteriorly andposteriorly, and the crow's feet innervating the fundusand body of the stomach are divided.

nerves are divided 7 cm proximal to the pylorus or the

area in the vicinity of the gastric antrum.

Superiorly, division of these nerves is carried to a point atleast 5 cm proximal to the gastroesophageal junction onthe esophagus

The criminal nerve of Grassi very proximal branch of theposterior trunk of the vagus, and great attention needs tobe taken to avoid missing this branch in the divisionprocess because it is frequently cited as a predispositionfor ulcer recurrence if left intact.


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recurrence rates vary depend on

skill of surgeon and

duration of follow upprepyloric ulcers are more likely to be

associated with recurrence than duodenalulcers, for unclear reasons

The moderate ulcer recurrence rate withhighly selective vagotomy is consideredacceptable by many surgeons becauserecurrences in this scenario are usuallyresponsive to medical therapy with protonpump inhibitors


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Truncal Vagotomy and Antrectomy

most common indications

gastric ulcer and large benign gastrictumorsRelative contraindicationscirrhosis,extensive scarring of the proximalduodenum that leaves a difficult ortenuous duodenal closure, and

previous operations on the proximalduodenum, ascholedochoduodenostomy


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Distal gastrectomy or antrectomyrequires reconstruction of GIcontinuity that can be

accomplished by either aBillroth I procedure;Billroth II procedure using one of

several modificationsRoux-n Y loop anastomosis


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Billroth I gastrectomy

Proffesor Hans Theodore Billroth first resectionfor malignancy in 1881Describes removal of a distal gastric segment,followed by primary anastomosis withpreservation of duodenal integrityAdvantagePreservation of physiological and anatomical

integrityLower incidence of post gasrectomy syndromeMinimal disturbance of pancreatic functionLower incidence of development of carcinomain remaining segment of stomach


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DisadvantageAnastomosis at tension site

It is the standard operation forbenign pathology as very limitedlymphadenopathy is achieved


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Billroth II or Polya gastrectomy

Polya gastrectomy described in 1911

Involves distal gastric resection with closure of

duodenal stump and restoration of gastriccontinuity with gastrojejunostomy

Advantage

Usefull in case where billroth I have excess

tension at anastomotic siteEasy to perform

In carcinoma allows radical margins ofdissection

Disavdvantage

Maximum rate of complication


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the loop of jejunum chosen for anastomosis isusually brought through the transversemesocolon in a retrocolic fashion rather thanin front of the transverse colon in an antecolicfashion

The retrocolic anastomosis minimizes thelength of the afferent limb and decreases thelikelihood of twisting or kinking that couldpotentially lead to afferent loop ob-structionand predispose to the devastating

complication of a duodenal stump leak


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Roux-n Y gastrojejunostomy

Distal divided end of jejunum is

anastomised to stomach usingendto side anastomosisProximal end anastomised to 40-50

cm downstream, thus providing anoutflow pathway for billiary contents


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Subtotal Gastrectomy

rarely performed today

reserved for patients with underlyingmalignancies or patients who havedeveloped recurrent ulcerations aftertruncal vagotomy and antrectomy.After subtotal gastrectomy,restoration of GI continuity can beaccomplished with either a Billroth II

anastomosis or via a Roux-en-Ygastrojejunostomy


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Posterior truncal vagotomy with anteriorseromyotomy (Taylor procedure)

Simpler and quicker operation than HSV

Gastric drainage procedure not equiredPosterior truncal vagotomy done andanterior seromyotomy doneby dividingseromuscular layers taking care not to

breach mucosaFollows along leser curvature at distanceof 2 cm from its starting at angle of Hisextending to approximately 5 cm frompylorus


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Surgical therapy serves several purposes. It salvagespatients from life-threatening complications associatedwith perforation, hemorrhage, and gastric outlet

obstructionFor all patients with ulcers being considered for

elective surgery, antisecretory agents should probablybe discontinued for about 72 hours before operation in

order to allow gastric acidity to return to normal values,which minimizes bacterial overgrowth and the extent ofcontamination

In patients undergoing surgery for PUD, it is

recommended that all have H. pylori testing and, ifpositive, treatment and documentation of eradication


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In patients undergoing surgery forPUD, it is recommended that all have

H. pylori testing and, if positive,treatment and documentation oferadication

NSAIDs should be discontinued

Recommendations for


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Recommendations forComplications Related to PepticUlcer Disease

Duodenal UlcerIntractable:- parietal cell vagotomy

Bleeding:- truncal vagotomy withpyloroplasty and oversewing of bleeding

vesselPerforation:- patch closure with treatment of

H. pylori with or without parietal cellvagotomy

Obstruction:- rule out malignancy andparietal cell vagotomy withgastrojejunostomy

Recommendations for


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Recommendations forComplications Related to PepticUlcer Disease

Gastric ulcerIntractable

Type I:- distal gastrectomy with Billroth I

Type II or III:- distal gastrectomy with truncalvagotomy

Bleeding

Type I: distal gastrectomy with Billroth IType II or III: distal gastrectomy with truncal

vagotomy


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Perforated

Type I, stable:- distal gastrectomy withBillroth I

Type I, unstable:- biopsy, patch, and

treatment for H. pyloriType II or III:- patch closure with treatment

ofH. pylori

Obstruction:- rule out malignancy andantrectomy with vagotomy


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Type IV:- depends on ulcer size,distance from the

gastroesophageal junction, anddegree of surroundinginflammation

Giant gastric ulcers: distalgastrectomy, with vagotomyreserved for type II and III gastriculcers


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Recommended Operative Procedures

for Recurrent Postoperative Ulcers

Initial Operation Recommended OperationLocal procedure Truncal vagotomy and

antrectomy

Gastrectomy Truncal vagotomy and resection

of retained antrum if present

Vagotomy and pyloroplasty Re-vagotomy and antrectomy

Vagotomy and antrectomy Re-vagotomy and resection ofretained antrum

Proximal gastric vagotomy Truncal vagotomy andantrectomy

Subtotal gastrectomy Truncal vagotomy and resectionof retained antrum if present


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POST GASTRECTOMY

SYNDROME

POST VAGOTOMY SYNDROME


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Postgastrectomy Syndromes

gastric surgery results in a number of

physiologic derangements dueto loss of reservoir function,interruption of the pyloric sphincter

mechanism,the type of gastric reconstruction,and

vagal nerve transection


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When these postgastrectomysymptoms develop, it has becomemore apparent that every attempt

should be made to avoidreoperation because many of thesepatients lack a clearly definable

mechanical or physiologic defectand many of the problems persistdespite reoperation


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Postgastrectomy SyndromesSecondary to Gastric Resection

Dumping Syndromesymptom complex that occurs

following ingestion of a meal when a

portion of the stomach has beenremoved or the normal pyloricsphincter mechanism has becomedisrupted


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Early Dumping

more common after partial gastrectomy with theBillroth II reconstruction

20 to 30 minutes after ingestion of a meal and isaccompanied by both GI and cardiovascular symptoms

G I Symptoms :- nausea and vomiting, a sense ofepigastric fullness, eructations, cramping abdominalpain, and often explosive diarrhea

cardiovascular symptoms :- palpitations, tachycardia,diaphoresis, fainting, dizziness, flushing, andoccasionally blurred vision

b h t i f d d li d t


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occurs because hypertonic food delivered tosmall intestines

The resultant hypertonic food bolus passes into

the small intestine, which induces a rapid shiftof extracellular fluid into the intestinal lumen toachieve isotonicity.

After this shift of extracellular fluid, luminal

distention occurs and induces the autonomicresponses

the release of several humoral agents, such asserotonin, bradykinin-like substances,neurotensin, and enteroglucagon

T


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TreatmentMost, however, experience

spontaneous relief and require nospecific therapyWhen symptoms are prolongeddietary measures include

avoiding foods containing largeamounts of sugar, frequent feeding of small meals rich

in protein and fat, andseparating liquids from solids duringa meal


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MedicalSomatostatin analogue octreotide

acetate highly effective inpreventing the development ofboth vasomotor and GI symptoms,

inhibit the hormonal responsesassociated with this syndrome andcompletely abolish the associateddiarrheaIncrease intestinal transit timeCostly

S


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Surgery< 1% required

Purpose to improve the gastric reservoirfunction, decrease rapid gastric emptying,

or ideally accomplish both goals.use of isoperistaltic or antiperistaltic

jejunal segments


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Iso peristalsis

done using a 10- to 20-cm loop of jejunumand interposing it between the stomach and

small intestine in an isoperistaltic fashionAnti peristalsis

jejunal segment 10 cm in length is used,and the jejunum is twisted on its mesentery

so that its distal end is anastomosed to thestomach and its proximal end to the smallintestine

creation of a long-limb Roux-en-Y

anastomosis to delay gastric emptying.

Late Dumping


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p gless common

2 to 3 hours after a meal

related specifically to carbohydratesWhen carbohydrates are delivered to thesmall intestine, they are quickly absorbed,resulting in hyperglycemia, which triggers therelease of large amounts of insulin to controlthe rising blood sugar. This results in an actualovershooting such that a profound

hypoglycemiaThis activates the adrenal gland to releasecatecholamines, which results in diaphoresis,tremulousness, light-headedness, tachycardia,

and confusion


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Treatmentto ingest frequent small meals and

to reduce their carbohydrate intakeMedicalpatients have found benefit with

pectin either alone or incombination with acarbose

Surgery

Same like early dumping

b li i b


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Metabolic Disturbances

more common and serious after partialgastrectomy than after vagotomy

Greater in Billroth II as opposed to aBillroth I

Anaemia

Most commonIron deficiency :- more common

30% of patients undergoing gastrectomysuffer from iron deficiency anemia


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related to acombination of decreased iron

intake,impaired iron absorption, andchronic subliminal blood loss

secondary to the hyperemic, friable gastric mucosa primarilyinvolving the margins of the stoma

addition of iron supplements to thepatient's diet corrects this metabolicproblem

M l bl i i


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Megaloblastic anemia

especially when more than 50% of thestomach is removed

secondary to poor absorption of thesubstance owing to lack of intrinsic factorsecretion in the gastric juice

Serum B-12 level obtained, if less treatedwith intramuscular injection every 3 to 4months indefinitely because itsadministration orally is not a reliable route

folate deficiency may coexist oralsupplimentation is sufficient

impaired absorption of fat


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impaired absorption of fat.

steatorrhea :-

result of inadequate mixing of bile salts and

pancreatic lipase with ingested fat because of theduodenal bypass pancreatic replacement enzymesare often effective in decreasing fat loss.

osteoporosis and osteomalacia

caused by deficiencies in calcium

occurs about 4 to 5 years after surgery.

Treatment of this disorder usually requires calciumsupplements (1-2 g/day) in conjunction with vitaminD (500-5000 units daily).

Postgastrectomy Syndromes Related to Gastric


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Postgastrectomy Syndromes Related to GastricReconstruction

More common with Billroth II procedures

Afferent Loop Syndrome

result of partial obstruction of the afferent limb that isunable then to empty its contents

It can arise secondary to

kinking and angulation of the afferent limb,

internal herniation behind the efferent limb,

stenosis of the gastrojejunal anastomosis,a redundant twisting of the afferent limb with aresultant volvulus, or

adhesions involving the afferent limb


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occurs when the afferent limb is greater than 30 to 40


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occurs when the afferent limb is greater than 30 to 40cm in length and has been anastomosed to the gastricremnant in an antecolic fashion

Chronic presentation common than acute

there is an accumulation of pancreatic and hepatobiliarysecretion within the limb, resulting in its distention whichcauses epigastric discomfort and cramping

partial obstruction :-intraluminal pressure increases ,projectile billous vomiting no food contained within the

vomitus

complete obstruction


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complete obstruction,

necrosis and perforation of the loop can occur asthe obstruction is a closed loop because the

duodenum proximally has already been closedconstant abdominal pain, more pronounced inthe right upper quadrant with radiation into theinterscapular area.

surgical emergency and requires immediateattention

In closed loop, bacterial overgrowth occurs in thestatic loop, and the bacteria bind with vitamin B12

and deconjugated bile acids

Alth h t t thi


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Although symptoms may suggest thisdiagnosis, it is sometimes difficult to

establish the diagnosisplain films of the abdomen dilatedafferent loop may be seencontrast barium study of the stomach

may delineate the presence of anobstructed loopFailure to visualize the afferent limb

on upper endoscopy is also suggestiveof the diagnosisRadionuclide studies imaging

Treatment


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Acute or chronic

A long afferent limb is usually the underlying

problem, and treatment therefore involvesthe elimination of this loop

converting the Billroth II construction into aBillroth I anastomosis

enteroenterostomy below the stoma, which istechnically easier.

Creation of a Roux-en-Y can also be done, buta concomitant vagotomy should also be

performed to prevent marginal ulcerationfrom the diversion of duodenal contents fromthe gastroenteric stoma.

Efferent Loop Obstruction


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Efferent Loop Obstruction

rare.

The most common cause of efferent loop

obstruction is herniation of the limb behind theanastomosis in a right-to-left fashion.

can occur with both antecolic and retrocolicgastrojejunostomies.

occur anytime after surgery; however, more than50% of cases do so within the first postoperativemonth

complaints may include left upper quadrantabdominal pain that is colicky in nature, biliousvomiting, and abdominal distention

Establishing a diagnosis is difficult


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Establishing a diagnosis is difficultcontrast barium study of the

stomach with failure of barium toenter the efferent limbSurgery

reducing the retroanastomotichernia and closing theretroanastomotic space to preventrecurrence of this condition.

Alkaline Reflux Gastritis


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Alkaline Reflux Gastritis

fairly common

severe epigastric abdominal painaccompanied by bilious vomiting andweight loss not relieved by food orantacids, anaemia weight loss common

diagnosiscareful history,

HIDA scans are usually diagnostic:-demonstrating biliary secretion into

the stomach and even into theesophagus in severe cases

Upper endoscopy


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Upper endoscopyperformed with multiple biopsy

samples taken away from thestoma, and the gastric fluid canbe analyzed for bile acidconcentrationsmucosa is frequently friable andbeefy-red, and superficialmucosal ulcerations may be

apparent on microscopy.

Common with billroth II


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Common with billroth IIthere is no clear correlation between

the volume of bile or its compositionand the subsequent development ofalkaline reflux gastritisTreatmentMedical not satisfactorySurgery for intractable casesconverting the Billroth II anastomosis

into a Roux-en-Y gastrojejunostomy inwhich the Roux limb has beenlengthened to 41 to 46 cm

Retained Antrum Syndrome


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Retained Antrum Syndrome

Normally, antral mucosa may extend past the pyloricmuscle for a distance of 0.5 cm,

Common with billroth II

retained antrum is continually bathed in alkaline pHfrom the duodenal, pancreatic, and biliary secretionsthat, in turn, stimulate the release of large amounts ofgastrin with a resultant increase in acid secretion

responsible for about 9% of recurrent ulcers afterprevious surgery for PUD and is associated with anincidence of recurrent ulceration as high as 80%

can be eliminated if biopsy confirmation of duodenal


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can be eliminated if biopsy confirmation of duodenalmucosa is obtained after resection of the proximalduodenum at the time of the Billroth II gastrectomy.

Diagnosistechnetium scan may prove helpful in diagnosingretained antrum , demonstrates a hot spot that isadjacent to the area where normal uptake oftechnetium by the gastric mucosa of the remaining

stomach occurs

Medical

H2-receptor blockade or proton pump inhibitors may

prove helpful in controlling acid hypersecretion

Surgery


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SurgeryIf medical ineffective

conversion of the Billroth II to aBillroth I reconstruction orexcision of the retained antral

tissue in the duodenal stump isindicated

Postvagotomy Syndromes


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Postvagotomy Syndromes

Postvagotomy Diarrhea

30% or more of patients suffernot severe and usually disappearswithin the first 3 to 4 monthsoccur 2 to 3 times weekly or manifestitself once or twice a month.explosive diarrhea and result in soiledclothing

Most patients symptoms resolve overtime

MedicalCh l t i


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Cholestyramine

Four grams with meals three times daily followed byan adjustment to a maintenance dosage should

decrease bowel movements to once or twice a dayimprovement within 1 to 4 weeks of initiation

Surgery

Persistent diarrhea for 1 year after surgery

fails to respond to cholestyramine therapy, and

other causes have been ruled out,operative procedure of choice is to interpose a 10-cmsegment of reverse jejunum 70 to 100 cm from theligament of Treitz

Postvagotomy Gastric Atony


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g y y

After vagotomy, gastric emptying is delayed

true for both truncal and selective vagotomies butnot in the case of highly selective or parietal cellvagotomy

With selective or truncal vagotomy, patients loseantral pump function and therefore have areduction in their ability to empty solids

In contrast, emptying of liquids is acceleratedfeeling of fullness and occasionally abdominal painfunctional gastric outlet obstruction

Diagnosis


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Diagnosisconfirmed on scintigraphic

assessment of gastric emptying.Endoscopic examination of thestomach also needs to be

performed to rule out anyanastomotic obstructionsMedicalProkinetic drugsmetoclopramide and erythromycin

Incomplete Vagal Transection


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Incomplete Vagal Transectionpredisposes the patient to the

possible development of recurrentulcer formationTruncal vagotomy more commonright vagus nerve is frequently buried

in the periesophageal tissue,potentially leading to incompletetransection

Histologic confirmation of vagaltransection decreases the incidence ofincomplete vagotomy

pud management

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