SURGERY OF STOMACH AND DUODENUM
Surgical Anatomy
Arterial blood supply
1—left gastric artery 2—right gastric artery 3—gastroduodenal
artery ( from hepatic artery) divide a –superior pancreatico –
duodenal artery, b- right gastroepiploic artery
4-inferior pancreatico-duodenal artey artery abranch of superior
mesenteric artery
5-left gastroepiploic artery a branch of splenic artery..
6-short gastric arteries from splenic artery
Venous drainage
1—right & left gastric veins draine into portal vein
2-left gastro epiploic vein & vasa bevia join solenic vein
3-right gastro epiploic vein join superior mesenteric vein
4- vein of mayo
Nerve supply
1-intrinsic, a- myenteric plexus of Auerbach,, b- submucosal
plexus of Meissner
2-Extrensic, a ant. Vagus, b- post vagus
3-sympathetic
Physiology
1-parietal cells secrete HCL 2-chief cells secrete pepsin 3endocrine cells secrete gastrin
1
Investigations of stomach & duodenum
1-OGD
2-Endoscopic ultrasound
3-barium meal
4-ultrasound
5-computerised tomography scanning CT Scan
6-laparoscopy
7-Angiography
SURGICAL PATHOLOGY
1-Congenital hypertrophic pyloric stenosis
2-Duodenal atresia
HELICOBACTER PYLORI
It is important in the aetiology of gastroduodenal diseases such as
1- chronic gastritis
2-peptic ulceration 3-gastric cancer
Types of Gastritis
Type A gastritis;it is an autoimmune condition there is circulationg
antibody against parietal cell mass resulting in hypochlorhydria
then to achlorhydria a premalignant condition..also no secretion of
intrinsic factor by parietal cell lead to malabsorbtion of vitamine
B12 which if not treated will lead to pernicious anaemia which is
again premalignant condition.both might cause gastric cancer.
Type B Gastritis
This type of gastritis is associated with Helicobacter pylori.,,affect
the antrum such patients are prone to develop peptic ulcer
,,pangastritis due to H ,pylori is associated with gastric cancer..
2
Intestinal metaplasia is associated with chronic
pangastritis,,intestinal metaplagia is pre malignant condition it
need regular follow up.
Reflux Gastritis
Occur after gastric surgery ,treatment medical very rare surgical..
Erosive Gastritis
Caused by NSAID & alcohol,,treatment medical.
Stress Gstritis
after serious illness or injury characterized by reduction to blood
supply of the superficial mucosa of the stomach some time
associated with stress ulcer or bleeding ,treatment by H2 antagonist
for bleeding is by blood transfusion.some times we give
prophylactic anti ulcer treatment.
Menetriers Disease
Gross hypertrophy gastric mucosa it is premalignant condition
,only treatment is gastrectomy..
PEPTIC ULCER
Common sites;1-first part duodenum. 2-lesser curve stomach. 3oesophagus. 4- stoma following gastric surgery. 5- meckls
diverticulum.
1-Acute peptic ( gastric & duodenal ) ulcer.& acute stress
ulcer.causes are major illness,uraemia,,food
poisoning,,bacteraemia ,,burn,,asirin,,steroid & NSAID.
Pathology
Some times it is single & some times are multiple as diagnosed by
OGD.it involve the mucous membrane & does not penetrate the
muscles,,some times it bleed,,or perforate..
3
Treatment.
Treat the cause plus anti ulcer treatment.
2-Chronic peptic ulcer. A-Gastric ulcer having relatively normal
level or below normal gastric acid secretion.B-Duodenal ulcer
occur in presence of very high acid level.also occur in zollinger
Ellison syndrome,,geneticfactors may be involved, H pylori
,,social stress..,emotional.,smoking,,NSAIDs
DUODENAL ULCER
Incidence
There have been marked changes in the last 2 decades in the
domography of patients presenting with duodenal ulcer first by the
use of OGD second the introduction of H2 receptor antagonists
(wide spread use of anti ulcer drugs & eradication therapy ) , SO
,the incidence of duodenal ulcer & the frequency of elective
surgery are falling. ( except in cases of complications of peptic
ulcer ) commoner in male than female
Pathology
Occur in first part duodenum it involve the mucosa,,muscle
coat,leading to fibrosis and pyloric stenosis,,it may penetrate post.
To pancreas & invade gastro duodenal artery,
Some times there is multiple ulcers,,or ANT,& POST.ulcer called
kissing ulcers,,
ANT.ulcer tend to perforate while POST.ulcer tend to bleed.
Big ulcer called GIANT ulcer.(more than 2 cm.)
Chronic duodenal ulcer never become malignant.
Chronic gastric & chronic duodenal ulcer may co exist at same
time.
GASTRIC ULCER
Incidence
Same etiological factors
Gastric ulcer is less common than D.U.sex are equal male to
female,population is older than d.u. patient,,it is more prevalent in
low socioeconomic patients,,.
4
Pathology
Usually on the lesser curve stomach,,but it is larger than du.,also
invade mucosa & muscle coat & fibrosis,may cause stomach
deformity hour glass stomach or tea pot deformity,,may penetrate
to pancreas or blood vessel or invade transverse colon ..
Malignancy in gastric ulcer
1-On the long run ch. G.U.might become malignant so on OGD.
To take multiple biopsies
2-other type of g.u is malignant g.u from the start.
Other types of peptic ulcer
1-stomal ulcer at jujunal site of gastrojejunostomy.
2-Billroth 2 (polya) gastrectomy.
3- prepyloric gastric ulcer it carry risk of cancer so it need biopsy.
The clinical features of gastric & duodenal ulcers
PAIN;;in the epigastric region ,,may radiate to the back,it is
intermittent ;may last weeks or monthes with interval of pain
free,,.some time patient do not eat cause of pain & some time
patient eat to relieve pain .
PERIODICITY; attack of pain last from 2—6 weeks, attack is
more in spring & autum
VOMITING ;;absent unless there is pyloric stenosis .
ALTERATION IN WEIGHT ;;
BLEEDING;;either chronic presented as anaemia;;or fresh as
haematemasis & melaena.
CLINICAL EXAMINATION
Tenderness at epigastric region,,stomach splash in case of pyloric
stenosis.
5
INVESTIGATIONS OF PEPTIC ULCER
1--OGD with or without multiple biopsy (CHECK ESOPHAGUS
,,, STOMACH,,DUODENUM),,& STOMA OF
GASTROJEJUNOSTOMY to exclude stomal ulcer.
2—BARIUM MEAL
3—C.B.P.
TREATMENT OF CHRONIC PEPTIC ULCER
The vast majority of uncomplicated peptic ulcer are treated
medically ,,surgical treatment of uncomplicated peptic ulcer has
decreased markedly since 1990.due to the use of H2 recepter
antagonist or proton pump inhibitor &eradication therapy.
The aim of surgical treatment is to reduce gastric acid
secretion,(now it is reserved for the complicated P.U.)
MEDICAL TREATMENT
1-cessation of cigarette smoking ,,NSAIDs & Cortisone.
2-H2 receptor antagonist a-cemetidine (tagamet)---b—ranetidine (
zantac ).—c sucralphate (ulcar).
3-Proton pump inhibiter (omeprazole )
4-Eradication therapy.either give flagyl 3times aday plus amoxil
500mg cap,3 times aday for 2 weeks or to give flagyl plus
klarethromycin 500mg twice a day for 2 weeks.
SURGICAL TREATMENT OF UNCOMPLICATED PEPTIC
ULCER
Although it is rare now ,but some time it need to be performed if
there is failer of medical treatment.
Operations for D. U. aim is excluding the damage effect of acid to
the duodenum by diversion of the acid away from duodenum,
HISTORICAL SURGICAL PROCEDURES
1-BILLROTH I & BILLROTH II ( or called polya)
GASTRECTOMY,by billroth in 1881.
2-OR TO DO ONLY GASTRO JEJUNOSTOMY (by wolfler in
1881)will end with high rate of stomal ulcer.
At present time the operation of choice in cases of D.U.are the
followings:
6
1—Truncal vagotomy(first introduced1943 by Dragstedt) plus
drainage procedure
Types of drainage procedure:
A—PYLOROPLSTY types :1—finnys pyloroplasty. 2—HeinekeMikulicz pyloroplasty.
3-Jaboulays pyloroplsty. 4-Ramstedts pyloroplasty.
B—GASTROJEJUNOSTOMY post.,,isoperistaltic.at antrum post.
2- OR –Selective vagotomy plus drainage procedure.
3-or highly selective vagotomy only ( with preservation to the
nerve of latarjet that supply the pylorus ).no need to do drainage
procedure.
4—OR Truncal vagotomy and antrectomy.(billroth I)
Operations for gastric ulcer
1—BILLROTH I OR BILLROTH II OPERATION PLUS
EXCISION TO GASTRIC ULCER FOR HISTOPATHOLOGY
TO EXCLUDE MALIGNANCY
2—Or to do vagotomy plus drainage procedure plus excision
biopsy to the ulcer..
COMPLICATIONS OF PEPTIC ULCER SURGERY
1-Recurrent ulceration –a-either same ulcer, or b-stomal ulcer
(complication may cause gastrojejunocolic fistula).
2-bile vomiting.
3-small stomach syndrome.
4-Dumping,due to rapid gastric emptying a—early dumping. B—
late dumping.
5-Post vagotomy diarrhea .
6-Malignant changes.bile reflux gastritis then intestinal metaplagia
then malignancy.
7-Gallstones formation.
8-Nutritional disorder ,wt. loss.,,anaemia,,vit.b12 deficiency.
7
COMPLICATIONS OF PEPTIC ULCER
1-PERFORATION PEPTIC ULCER: 1-Perforation ant. First pert
duodenum most common,,2-perforation gastric ulcer, 3perforation in to prepyloric ulcer.
SYMPTOMS
Some give history of D.U. or silent ulcer ,,there will be Sever
sudden onset epigastric pain then generalized.due to irritant effect
of gastric acid & gastric contents of food on the peritoneum, first
chemical peritonitis then bacterial peritonitis,
SIGNS
At first temp.subnormal or normal then temp. increase (pyrexia by
bacterial peritonitis),pulse increases,abdomen moves little or not
move with respiration ,by palpation sever abdominal tenderness,
abdominal rigiditity called board like rigidity,,
On percussion dull on Auscaltation first bowel sound +ve then
become –ve. some time the perforation is small,which is sealed by
omentum,patient will have epigastric pain,,by P.R. elicit
tenderness at rectovesical pouch,This emergency condition needs
emergency surgery,, other wise if not there will be advanced
peritonitis,, then septicemia & septic shock & mortality will be
high.
INVESTIGATIONS
Xray abdomen in erect ,,supine & lateral position,,, shows gas
under diaphragm in 70% & chest xray,,
Blood tests ,serum amylase,,abdomen ultrasound & C.T.Scan
abdomen..
TREATMENT
1-Resuscitation.give antibiotics,,give tagament injection..
2-Emergency laparotomy by upper mid line incision,,localize the
perforation site close the perforation by interrupted sutures with or
without omental patch,, then peritoneal toilet,,then put drain
,nasogastric tube.& close abdomen.on rare occasion it need to do
partial gastrectomy indications :1-perforation in carcinoma 2sever bleeding 3-perforation is big & can not be closed.
8
Post op.period & Follow up.by anti ulcer treatment & O.G.D.
Other types of treatment:
1-conservative, 2- surgical the definitive treatment.
2—PYLORIC STENOSIS Due to fibrosis or cicatrisation of D.O.
OR Some times due to oedema associated with prepyloric ulcer
.or called (GASTRIC OUTLET OBSTRUCTION) or called
(DUODENAL STENOSIS).
Other causes carcinoma pylorus & congenital hypertrophic pyloric
stenosis.
CLINICAL FEATURES
There is a history of long standing peptic ulcer .
SYMPTOMS
1-Pain, 2- Vomiting (foul) no bile,
SIGNS
1-Wt loss, 2 dehydration pale 3-distended epigastric region, 4visible peristalsis from left to right, 5-succussion splash positive
(audible) on shaking abdomen of the patient.
METABOLIC EFFECT
There will be HYPOKALEMIC METABOLIC ALKALOSIS
PLUS DEHYDRATION PLUS ANAEMIA PLUS VITAMINE
DIFICIENCY.
INVESTIGATIONS
1-O.G.D. + BIOPSY. 2- BARIUM MEAL 3BLOOD+ELECTROLYTES TEST.
TREATMENT
1-N.G TUBE 2- I.V.FLUID +NACL + KCL. 3-WATCH
URINE OUT PUT. 4- ANTI ULCER TREATMENT.
MILD CASES DUE TO OEDEMA WILL RESPOND TO
CONSERVATIVE.SEVER CASES WILL NEED SURGERY
1- IF THE ULCER HEALED DO ONLY DRAINAGE BY
GASTROJEJUNOSTOMY ONLY.
9
2-IF THERE IS ACTIVE ULCER DO TRUCAL VAGOTOMY
PLUS GASTROJEJUNOSTOMY(SOME TIMES CAN DO
PYLOROPLSTY IN STEAD)
FOLLOW-UP A PATIENT WITH
PERFORATED PEPTIC ULCER
3—BLEEDING (HAEMATEMESIS & MELAENA)OF
PEPTIC ULCER
Either 1- slight 2- major bleeding. Some times there is history
of peptic ulcer,,some PATHOLOGY
times there is history of drug intake like NAIDs &ASPIRIN.
THERE IS EROSION OF AN ARTERY IN THE FLOOR OF
AN ULCER ,LIKE GASTRODUODENAL OR SPLENIC
ARTERY,IF PATIENT ABOVE 40 YS THERE IS
ATHEROSCLEROSIS SO THE ARTERY WILL NOT
CONTRACT TO ARREST BLEEDING
.
SYMPTOMS & SIGNS
FEATURES OF BLEEDING
INVESTIGATIONS
TREATMENT
1—RESUSCITATION
I.V.CANNULA,,CVP LINE,,BLOOD SAMPLE FOR BLOOD
TEST,,I.V. FLUID ,BLOOD TRASFUSION,, INJACTABLE
ANTI ULCER TREATMENT ,,NG TUBE,,FOLYS
CATHETER,,PULSE & BP CHART,,OXYGEN,,
2—SPECIFIC INVESTIGATIONS FOR DIAGNOSIS
DO O.G.D.
3—TREATMENT BY I.V. FLUID ,,BLOOD
TRANSFUSION,,ANTI ULCER TREATMENT.
10
1-CONSERVATIVE MEDICAL TREATMENT WITH
BLOOD TRANSFUSION,IF BLEEDING STOP CONTINUE
(MEDICAL TREATMENT),,WITH OR WITHOUT
MINIMAL INTERVENTION.
MINIMAL INTERVENTION
MANY O.G.D. DEVICES ARE AVAILABLE CAN
ACHIEVE HAEMESTASIS EXAMPLE INJECTION
DILUTED ADRENALINE ,,OR NACL INJECTION ,OR BY
ANGIOGRAPHY TO FIND THE SITE OF THE BLEEDER
AND EMBOLIZATION.
2—IF BEEDING STOPPED BUT REOCCUR AGAIN AFTER
ADMISSION TO HOSPITAL THIS PATIENT IS A
CANDIDAT FOR SURGICAL INTERVENTION
3—IF BLEEDING NEVER STOP SINCE ADMISSION TO
HOSPITAL & PATIENT RECEIVE MORE THAN 6 UNITS
BLOOD ,THIS PATIENT IS A CANDIDAT FOR SURGICAL
INTERVENTION.
SURGICAL TREATMENT
AIM OF SURGERY IS TO STOP THE BLEEDING.
IN BLEEDING POST. D.U. WHICH IS THE MOST
COMMON
DO LAPARATOMY BY UPPER MID LINE
INCISION,,MOBILIZE THE DUODENUM,,DO
LONGITUDINAL INCISION 3,5 CM STOMACH SITE,2,5
CM DUODENUM SITE, BY CUTTIND PYLORIC
SPHINCTOR
WE ARREST BLEEDER BY MULTIPLE INTERRUPTED
UNDERRUNING SILK SUTURES,,BLEEDING WILL STOP
,,ANASTHETIST WILL SAY B.P.IS RISING. ON RARE
OCCASION THERE WILL BE A NEED TO DO LIGATURE
11
TO GASTRODUODENAL ARTERY OR TO DO PARTIAL
GASTRECTOMY.
THEN DO PYLOROPLASTY,,
ALSO TO COMPLETE THE OPERATION DO TRUNCAL
VAGOTOMY IF YOU DO NOT DO VAGOTOMY
CONTINUE GIVING ANTI ULCER TREATMENT
IN BLEEDING GASTRIC ULCER PROCEDURE THE SAME
1-EITHER ARREST BLEEDING +BIOPSY,, OR, 2—
EXCISION BIOPSY TO THE ULCER AND CLOSE
STOMACH.
HAEMATEMESISS & MELAENA (UPPER
GASTROINTESTINAL BLEEDING)
CAUSES
1—CHRONIC PEPTIC ULCER 60% A—OESOPHAGEAL
B-GASTRIC C-DUODENUM.
2-ACUTE PEPTIC ULCER 26% (EROSION)AOESOPHAGUS, B-GASTRIC. C-DUODENUM.
3-OESOPHAGEAL VARICES 4%
4-MALLORY –WEISS TEAR (SYNDROME) 4%
5-TUMOUR O.5%
6-VASCULAR e.g.DIEULAFAYS DISEASE O.5%
7-OTHERS 5% e.g.PURPURA,,HAEMOPHILIA
MANAGEMENT
SAME RESUSCITATION PLUS INVESTIGATIONS
SPECIFIC TREATMENT ACCORDING TO THE CAUSE
12
GASTRIC NEOPLASMS
BENIGN TUMOURS.
LEIOMYOMA ,,NEUROFIBROMA ,,POLYP( S)
GASTRIC CANCER
GASTRIC CANCER IS ONE OF THE MOST COMMON
CAUSES OF DEATH IN THE WORLD.
THE OUTCOME IS GENERALY POOR, OWING TO THE
ADVANCED STAGE AT TIME OF PRESENTATION.
BETTER RESULT ARE OBTAINED IN JAPAN ,,WHICH
HAS A HIGH POPULATION INCIDENCE ,DUE TO
SCREENING PROGRAM.
AETIOLOGY OF GASTRIC CANCER IS
MULTIFACTORIAL,,H,PYLORI IS IMPORTANT FACTOR..
EARLY PRESENTATION OF GASTRIC CANCER IS
ASSOCIATED WITH VERY HIGH CURE RATE.
GASTRIC CANCER CAN BE CLASSIFIED INTO
INTESTINAL & DIFFUSE TYPE (HAVE BAD PROGNOSIS)
IN THE WEST PROXIMAL GASTRIC CANCER IS MORE
COMMON THAN DISTAL CANCER & IT IS DIFFUSE
TYPE.
SPREAD BY
DIRECT,,LYMHPATICS,,BLOOD,,TRANSCOELOMIC.
TREATMENT OF CURABLE CASES IS BY RADICAL
SURGERY,
GASTRIC CANCER IS CHEMOSENSITIVE.
INCIDENCE
IN U.K. 15 PATIENTS PER 100000 PER YEAR.
IN U.S.A.10 PATIENTS PER 100000 PER YEAR.
EAST EUROPE 40 PATIENTS PER 100000 PER YEAR.
IN JAPAN 70 PATIENTS PER 100000 PER YEAR.
MEN AFFECTED MORE THAN WOMEN.
INCIDENCE INCREASE WITH AGE.
13
IN THE WEST GASTRIC CANCER IS CONTINUING TO
FALL BY 1%PER YEAR.THIS REDUCTION AFFECT
CANCER ARISING FROM BODY &PYLORUS,WHILE
THERE IS INCREASE IN CANCER IN THE PROXIMAL
STOMACH.
CANCER OF BODY ,PYLORUS STOMACH COMMON IN
LOW SOCIOECONOMIC GROUP,,
PROXIMAL GASTRIC CANCER AFFECT HIGH
SOCIOECONOMIC GROUP..
PROXIMAL GASTRIC CANCER NOT ASSOCIATED WITH
H,PYLORI
BODY & PYLORUS CANCER IS ASSOCIATED WITH H.
PYLORI..
AETIOLOGY
1--H.PYLORI ASSOCIATED WITH CARCINOMA DODY &
PYLORUS.
2--H.PYLORI CAUSE GASTRITIS ,,THEN GASTRIC
ATROPHY,,& INTESTINAL METAPLASIA
3—PERNICIOUS ANAEMIA & GASTRIC ATROPHY ARE
RISK FACTOR.
4-GASTRIC POLYP.
5-AFTER GASTRIC SURGERY eg.BILLROTH I, OR
II,,PYLOROPLASTY,,GASTROJEJUNOSTOMY,WILL
INCREASE THE RISK 4 TIMES.
6—REFLUX BILE GASTRITIS.
7—CIGARETTE SMOKING,,DUST INGESTION,,
8—INGESTION SPIRIT CAUSE GASTRITIS ON LONG
RUN CHANGE TO CANCER.
9—GENETIC FACTOR,
CLINICAL FEATURES
SYMPTOMS
1-DYSPEPSIA,,POOR
APPITITE,,DISTENSION,BLEEDING,THEN
14
ANAEMIA,DYSPHAGIA,VOMITING,LUMP AT
EPIGASTRIC REGION
SIGNS
EPIGASTRIC TENDERNESS,,?MASS,,STOMACH
SPLASH,DEHYDRATION,,FEATURES OF PYLORIC
OBSTRUCTION,THROMBOPHLEBITIS
MIGRANE,,D.V.T.ENLARGED LEFT
SUPRACLAVICULAR LYMPH NODES(TROISIERS
SIGN),,LIVER METASTASIS CAUSE
JAUNDICE,,ASCITES,
PATHOLOGY
1—INTESTINAL GASTRIC CANCER
A—CAULIFLOWER.
B—ULCERATIVE
C—COLLOID
2—DIFFUSE GASTRIC CANCER INFILTRATES DEEPLY
IN STOMACH WITHOUT OBVIOUS MASS (LINITIS
PLASTICA) OR CALLED (LEATHER BOTTLE
STOMACH).
3—GASTRIC CANCER SECONDARY TO GASTRIC
ULCER.
MICROSCOPICALLY IT IS COLUMNAR CELL
MOST COMMON SITE IS PYLORU,THEN BODY ,&
CARDIA & FUNDUS.
STAGING CARCINOMA STOMACH
TI TUMOUR INVOLVE LAMINA PROPRIA.
T2- ==
==
MUSCLE LAYER OR SUB SEROSA.
T3-- ===
== SEROSA.
T4--==
== ADJACENT ORGANS.
N0 NO LYMPH NODES.
N1 METASTASIS TO 1----6 REGIONAL NODES.
N2- =========== TO 7----15 ======== ======.
N3—METASTASIS TO MORE THAN 15 NODES.
15
M0 NO DISTANT METASTASIS.
M1- DISTANT METASTASIS.
SPREAD OF GASTRIC CANCER
1-DIRECT INVADE THE WALL THEN
,,LIVER,,PANCREAS,,COLON OMENTUM.
2-LYMPHATIC SPREAD BY PERMIATION &
EMBOLIZATION.
3-BLOOD BORNE METASTASIS.
4-TRANSPERITONEAL SPREAD.
INVESTIGATIONS
TREATMENT OF GASTRIC CANCER
1-PALLIATIVE SURGERY
A-GASTROJEJUNOSTOMY
B-M.B. TUBE.
2-RADICAL RESECTION
A-TOTAL GASTRECTOMY
B-UPPER RADICAL GASTRECTOMY
C-LOWER ===
==
GASTRIC STROMAL TUMOURS (G.S.T.)
GASTRIC LYMPHOMA.
16
17