Stomach and DuodenumStomach and Duodenum• AnatomyAnatomy

• PhysiologyPhysiology

• Operative proceduresOperative procedures

• Gastric disordersGastric disorders

peptic ulcer diseases

tumors

structural disorders

inflammatory and infectious diseases

traumas

Peptic ulcer diseases• Major types ;

duodenal ulcer

gastric ulcer

stomal ulcer

• Other types ;

stress ulcer

ulcers caused by gastric irritants

steroid induced ulcer

Pathogenesis of peptic ulcer

• Lack of protection of the mucosa

• Acid production

Duodenal ulcer ;pathogenetic factors

• Increased acid secretion

• Environment ; 흡연 , NSAIDS, Helicobacter

• Mucosal defense ; decreased bicarbonate production,

decreased gastric prostaglandin production

Duodenal Ulcer : goals of operative therapy

• promotion of ulcer healing

• treatment of specific complications

• reduction of the possibility of recurrence

• minimization of postoperative side effects

surgically correctable components to reduce the acid secretion

• Cholinergic vagal stimuli

• Parietal cell mass

• Gastrin secretion

Duodenal Ulcer : operative procedures

• Truncal vagotomy and drainage

• Truncal vagotomy and antrectomy

• Parietal cell vagotomy

• Alternative methods

Gastric effects of truncal vagotomy

• Decreased acid secretion

• Increased serum gastrin

• Gastrin cell hyperplasia

• Accelerated liquid emptying

• Altered emptying of solid

Nongastric effects of truncal vagotomy

• Decreased pancreatic exocrine secretion

• Decreased postprandial bile flow

• Increased gallbladder volume

• Diminished release of vagally mediated peptide hormones

Drainage procedures : pyloroplasty

• Heineke-Mikulicz

• Finney

• Jaboulay

Duodenal Ulcer : operative procedures

• Truncal vagotomy and drainage

• Truncal vagotomy and antrectomy

• Parietal cell vagotomy

• Alternative methods

Duodenal Ulcer : operative procedures

• Truncal vagotomy and drainage

• Truncal vagotomy and antrectomy

• Parietal cell vagotomy

• Alternative methods

Duodenal Ulcer : operative procedures

• Truncal vagotomy and drainage

• Truncal vagotomy and antrectomy

• Parietal cell vagotomy

• Alternative methods

Duodenal Ulcer : choice of operation

• Location of ulcer• Indication for operation• Chronicity of the ulcer diathesis• Age and sex, nutritional status of the patient• Presence of concomitant illness• Stability of the patient during the perioperative

period• Experience and personal preference of the surgeon

Duodenal Ulcer : indications for operation

• Intractability

• Perforation

• Obstruction

• Hemorrhage

Duodenal Ulcer : indications for operation

• Intractability

• Perforation

• Obstruction

• Hemorrhage

Intractability ; criteria

• Initial healing is delayed, so that ulceration persists at 3

months despite active drug therapy

• Ulcers recur within 1 year of initial healing despite

maintenance therapy

• The ulcer disease is characterized by cycles of prolonged

activity with brief or absent remissions

Operative procedures : intractability

• First choice; parietal cell vagotomy

• Alternatives ; truncal vagotomy and antrectomy

laparoscopic vagotmy

Duodenal Ulcer : indications for operation

• Intractability

• Perforation

• Obstruction

• Hemorrhage

Clinical features ; perforated duodenal ulcer

• Symptoms ; sudden onset of severe epigastric pain spreading throughout the abdomen, variable degree of shock

• Signs ; abdominal tenderness, rigidity

• Plain X-ray ; peritoneal free air

Differential diagnosis ; perforated duodenal ulcer

• Acute cholecystitis

• Acute pancreatitis

• Strangulation obstruction

• Acute appendicitis

• Perforation of other G-I tract

• Mesenteric thrombosis

Operative procedures : perforation

• Simple closure

• Definitive surgery

parietal cell vagotomy and omental patch

truncal vagotomy and pyloroplasty

truncal vagotomy and antrectomy

Indications for definitive operation

• No preoperative shock

• No life-threatening medical illness

• Perforation has been present for less than 48 hours

Duodenal Ulcer : indications for operation

• Intractability

• Perforation

• Obstruction

• Hemorrhage

Causes of obstruction in duodenal ulcer

• Inflammation and edema

• Fibrosis

Operative procedures : obstruction

• Truncal vagotomy and antrectomy

• Truncal vagotomy and gastrojejunostomy

• Parietal cell vagotomy with dilatation

Duodenal Ulcer : indications for operation

• Intractability

• Perforation

• Obstruction

• Hemorrhage

Indications for operative intervention ; duodenal ulcer bleeding

• Massive hemorrhage leading to shock

• Prolonged blood loss requiring continuing transfusion

• Recurrent bleeding during medical therapy or after endoscopic therapy

• Recurrent bleeding requiring hospitalization

Operative procedures : hemorrhage

• Truncal vagotomy and pyloroplasty with

suture ligation of bleeding vessel

• Truncal vagotomy and antrectomy

including ulcer or

suture ligation of bleeding vessel

Timing of operation : hemorrhage

• Primary emergency

• Secondary emergency

• Early elective surgery

Location of gastric ulcers

Type I gastric ulcer

• 60% of GU• Large volume of

secretion with low or normal acid secretion

Type II gastric ulcer

• 25% of GU• Usually acid hypersecretor• DU usually precedes GU

Type III gastric ulcer

• 23% of GU• Prepyloric ulcer• Typically acid hypersecretor

Type IV gastric ulcer

• Less than 10% of GU• High-lying ulcer

Predisposing factors ; gastric conditions

• Acid and pepsin

• Gastric stasis

• Coexisting duodenal ulcer

• Duodenogastric reflux

• Gastritis

• Helicobacter pylori

Predisposing factors ; clinical conditions

• Chronic alcohol use

• NSAIDS

• Smoking

• Long-term steroid therapy

• Infection

• Intraarterial chemotherapy

Gastric Ulcer : goals of elective operation

• Primary goals ;

to excise the ulcer

to reduce acid/pepsin output

• Secondary goals ;

to minimize bile reflux and gastric stasis

Gastric ulcer : standard operations

• type I ; Distal gastrectomy and B-I anastomosis

• type II, III ; Distal gastrectomy with vagotomy

• type IV ;

TV and draiage and biopsy/excision of ulcer

Distal gastrectomy with ulcer excision

Distal gastrectomy with biopsy of ulcer

Proximal gastrectomy

Gastric Ulcer : indications for elective operation

• Failure to heal on optimal medical therapy

• Suspicion of malignancy

• Distal gastric obstruction

• Giant gastric ulcer

Gastric Ulcer : emergency operation

• Bleeding gastric ulcer

• Perforated gastric ulcer

Bleeding gastric ulcer : operative procedures

• Gastric resection including ulcer

• simple oversewing

• excision of ulcer

with TV and drainage

without TV and drainage

Gastric Ulcer : emergency operation

• Bleeding gastric ulcer

• Perforated gastric ulcer

Perforated gastric ulcer : operative procedures

• Gastric resection

• Biopsy and simple closure

New Surgical Strategy for Gastroduodenal Ulcer : New Surgical Strategy for Gastroduodenal Ulcer : Laparoscopic approachLaparoscopic approach

• Truncal vagotomy

• Thoracoscopic truncal vagotomy

• Parietal cell vagotomy

Stress Ulcer

• Multiple superficial mucosal erosions

after major physical trauma, shock,

sepsis, hemorrhage, respiratory failure,

or severe burns.

Surgical therapy

• Truncal vagotomy and drainage

• Truncal vagotomy and antrectomy

• Truncal vagotomy and subtotal gastrectomy

• Total gastrectomy

• Gastric devascularization