Surgical Management of Benign
Gastric Disease Processes
Scott Welle, DO, FACOS, FACS
Disclosure:
Consultant Intuitive Surgical
Anatomy
Arterial blood supply
Derived primarily from celiac trunk
hepatic, left gastric, splenic arteries
left gastric found proximal lesser curve
Right gastric originates from common hepatic artery;
contributes to pyloroduodendal blood supply
Right gastroepiploic artery comes fro the gastroduodenal a.,
left gastroepiploic arises from splenic artery
Anatomy
Parasympathetic Innervation
Anterior vagus divides into anterior gastric (anterior nerve of Latarjet) and hepatic
branches.
Separate pyloric nerve (nerve of McCrea) may arise from anterior vagus or its hepatic branch
Posterior vagus divides into posterior gastric (posterior nerve of Laterjet) and celiac
branches
Crow’s foot refers to distal branches of gastric vagal divisions in the pylorantral region where the
nerves of Latarjet terminate
Criminal nerve of Grassi~ proximal branch of posterior vagus.
Selective vagotomy ~ divides nerves of Latarjet below hepatic and celiac branches
Highly selective vagotomy ~ divides individual branches of nerve of Latarjet, preserving
“crow’s foot”
Gastric Mucosa
G cells in antrum are primary source of gastrin
Brunner’s glands in submucosa of proximal
duodenum are source of pepsinogens
Somatostatin synthesized and stored by delta cells
Gastric Mucosa
Antrectomy removes main source of acid stimulating
gastrin. Effectiveness of highly selective vagotomy is
due to denervation of parietal cell mass
Parietal cells have acetylcholine receptors
Vagal cholinergic stimulation directly releases acid from
parietal cells
Antral acidification releases somatostatin
Vagal stimulation, antral distension, and antral chemical
stimulation are all connected
Gastric Emptying
Emptying of solids depends on mechanical action of
the pyloroantral region
Pattern of emptying of solids is linear after an initial
lag period
Gastric emptying of liquids depends primarily on
pressure gradient between proximal stomach and the
pylorus. Largely determined by fundal zone
Abnormalities in gastric emptying
Rapid gastric emptying is associated with Zollinger-Ellison syndrome,
caused by hypergastrinemia and lack of inhibition by duodenal acidification
Changes in gastric emptying result from operative procedures
Resective procedures Billroth I or II reconstruction or sleeve gastrectomy
usually accompanied by more rapid emptying.
Reconstruction by Roux-en-Y gastrojejunostomy can result in impaired
emptying, perhaps in relation to interruption of neural impulses from
duodenal pacemaker
Vagal denervation of the proximal stomach accelerates emptying of liquids
as a result of the loss of receptive relaxation and accommodation
h. pylori
Found in most patients with antral gastritis, duodenal
ulcer, and gastric ulcer
Associated chronic atrophic gastritis, which in turn is
associated with gastric cancer
Gastric cancers below the cardia are approximately 3
times more common in patients with H. Pylori
hypergastrinemia
Conditions associated with elevated serum gastrin
and increases in acid secretion include ZE syndrome,
antral G cell hyperplasia, retained antrum, renal
failure, gastric outlet obstruction, and short gut
Serum gastrin levels during fasting are normal in
patients with uncomplicated duodenal ulcer but may
be excessively elevated postprandially
Surgical therapy for duodenal
ulcer
Partial gastrectomy highest mortality rate
Truncal vagotomy with antrectomy lowest recurrence
rate
Parietal cell vagotomy carries lowest mortality rate,
lowest incidence of side effects, but highest
recurrence rate
Selective vagotomy associated with lower rate of
diarrhea than truncal vagotomy
Anterior duodenal ulcer
After simple closure of perforated ulcer approximately
1/3 of patients have recurrent symptoms that can be
managed medically
Some surgeons advocate routine anti-ulcer operation
in any patient with perforation not more than 24 hours
old
Hemorrhage
Most important endoscopic predictor of persistent or
recurrent bleeding is active bleeding at time or
endoscopy
Bleeding is controlled by suture ligation with attention
to proper suture placement for control of the posterior
complex of gastroduodenal vessels
Definitive anti-ulcer operation should then be
performed
Gastric outlet obstruction
Classic metabolic abnormality resulting from gastric
outlet obstruction is hypochloremic, hypokalemic,
metabolic alkalosis
During initial loss of hydrochloric acid, urine is
alkaline
stress bleeding
H2 receptor antagonists alone not as effective as
antacids alone, but the use of both conjointly may
decrease the volume of buffer required
Gastroscopy demonstrates acute, superficial lesions
that appear first in fundus and spread distally
gastric ulcer classification
Type I ulcers occur along lesser curve
Type II combined with duodenal ulcers
Type III prepyloric
Type II & III associated with increased acid
secretion
Type IV medication associated ie NSAIDS
Surgical therapy
Isolated type I ulcers are usually treated with antrectomy or
hemigastrectomy without vagotomy
Vagotomy is used when the distinction between type I and III may not be
clear
Vagotomy with pyloromyotomy for type I ulcers has been associated with
higher recurrence rate
Parietal cell vagotomy for type I ulcers has yielded good clinical results
Type II and III ulcers are treated as duodenal ulcers
Parietal cell vagotomy is not indicated for prepyloric ulcers
gastric volvulus
Patient presents severe pain and nausea but are
unable to vomit. Strangulation can follow
MesoAxial and OrganoAxial
gastric bezoars
Hair is not digestible, endoscopic removal generally
inadequate
Misc
Leiomyomas are most common submucosal masses
found in the GI tract form an angle of 90 degrees
Ectopic pancreas is a piece of pancreatic tissue
found in the gastric antrum or duodenum