Surgical treatment of gastric and duodenal ulcer

LUGANSK , 2010.

MINESTRY OF HEALTH CARELUGANSK STATE MEDICAL UNIVERSITY

DEPARTMENT OF SURGERY & PROFPATHOLOGY

Brief Anatomy and physiology of the stomach and duodenum

The stomach is located in the upper floor of the abdomen, above the mesentery of transverse colon.In the stomach distinguishis the following divisions:cardial (cardia ventriculi), bottom (fundus ventriculi),body (corpus ventriculi)pyloric division (pars pylorica), in which isolated antrum pyloricum and canalis pyloricum.

Blood supply of the stomach • Blood supply of the stomach is provided by three

arteries, celiac trunk, yielding: the left and right gastric artery, left and right gastroepiploic artery and short gastric artery.

• In addition, there are small branches of the diaphragmatic artery, sometimes from the superior mesenteric artery.

• Venous outflow veins carried the same name in the portal vein system, partly through the veins of the esophagus into the superior vena cava.

• Lymph thru Ruveru-Carina performed in the course of the three main branches of the celiac trunk.

Innervation

• The stomach like the esophagus, has its own neural apparatus (submucosal and intermuscular nerve plexus).

• Double autonomic innervation is carried by the sympathetic and parasympathetic nerve fibers.

• Parasympathetic motor innervation is carried by the vagus nerves.

• Sympathetic innervation (motor and sensory), is by celiac plexus.

Innervation• Extrinsic & intrinsic innervation gastric secretory & motor function⇒• Extrinsic parasympathetic innervation Vagus (acetylcholine)⇒• – Left (anterior) vagus• – Right (posterior) vagus• The nerves of Latarjet• “crow’s foot”• The ciriminal nerves of Grassi• Fully 75% of the axons contained in the vagal trunks are afferent!• Extrinsic sympathetic innervation from T5-T10, splanchnic nerves →⇒• celiac ganglion → postganglionic sympathetic nerves along the blood• Vessels• Intrinsic nervous system• – Myenteric plexus (Auerbach)• – Submucosal plexus (Meissner)

Lymphatic drainage of the stomach• Gastric lymphatics parallel to the blood vessels• Cardia + medial half of corpus

nodes along the left gastric & ⇒celiac axis• Lesser curvature side of antrum right gastric & pyloric ⇒nodes• Greater curvature half of distal stomach nodes along the ⇒rightgastroepiploic chain• Proximal greater curvature side of stomach nodes along ⇒the leftgastroepiploic or splenic hilum• Nodes along greater & lesser curvatures celiac nodal basin⇒

Component parts of the gastric juice are:

• Hydrochloric acid - parietal cells, the body, the bottom of the stomach;

• protease (pepsin, parapepsin, cathepsin, Gelatinose, chemozin) - the main cell body, the bottom of the stomach;

• mucin (complex mucoprotein), gastrin - extensions, principal cells of antrum;

• lipase, gastromucoprotein (intrinsic factor K, necessary for intestinal absorption of vitamin B12).

Secretory function of stomach• There are two periods of gastric secretion: without food and

with food, or stimulatory. Secretion of the first period is called as the basic. The food (stimulated) secretion has three phases:

• 1) First phase - the neuro-reflex (cephalic) In this phase of digestion is allocated approximately 45% hydrochloric acid gastric juice. At the intersection of the vagus nerves this phase of gastric secretion is absent.

• 2) Second phase - neurohumoral (stomach), is regulated by the hormone gastrin. In this phase is allocated 45% hydrochloric acid gastric juice..

• 3) Third phase - intestinal. Food entering the race intestine reflex and humoral influences on the secretion of hydrochloric acid (10%). At the end of allocated inhibitory hormone in the stomach: enterogastrin, secretin and other.

DUODENUM (duodenum) • Anatomically divided into four parts of the duodenum.

. upper horizontal

. descending part

. lower horizontal part

. ascending part.• Blood and lymph

Arterial blood to the duodenum comes from the branches of the liver (upper pancreatoduodenal artery) and superior mesenteric (lower pancreatoduodenal artery) arteries.

GASTRIC AND DUODENAL ULCER DISEASE(GPUD AND DPUD)

• Latin term - Ulcus pepticum gastrici, up duodeniThe terms - “gastric ulcer", “duodenal ulcer", "peptic ulcer of the stomach" is used against a group of diseases of the digestive tract, characterized by the formation of sites of degradation of the mucous membrane under the action of hydrochloric acid and pepsin

BACKGROUND• Incidence GPUD and DPUD adult population in developed

countries is far 2,1-7,6%. • Up to 10-15% of the population during the life of sick PUD. • Among the urgent surgical diseases in frequency only one

complication of PUD –i.e. perforation is in the third - fourth place.

AETIOPATHOGENESIS OF PEPTIC ULCER DISEASE

• Mechanism of PUD as in the stomach and the duodenum is reduced to a breach of the interaction between the factors of aggression and defense (resistance) mucosa gastroduodenal.

FACTORS OF DEFENSE & AGGRESSION• PUD is in essence polyateological chronically occurring

disease, emerging disease, arising as a result of imbalance between protective factors and factors of aggression in favor of the latter.

• Defense Factors:Resistance of mucous membraneantroduodenal Acid brake

alkaline secretion food

• Aggressive Factors:HCLGastrodeodenal dismotorisationMucous traumaNutrition factorsEnviromental factors

Proposed number of theories of PUD:

1.Vascular theory R. Vihrova (1852g.)2. Mechanical theory prev Aschoff (1912g.)3. Peptic theory Bernard (1856g.) and Quincke (1878g.)4. Inflammatory theory Konyani (1925g.)5. Neuroreflexive theory Resle (1912g.)6. Neurovegetative Bergman (1913g.) dysfunction of the 7. Autonomic nervous system leads to PUD.8.A Neurotrophic theory. D. Speransky (1913g.).9.Kortikovistseralnaya theory of KM Bykov and

IT Kurtsin (1948).10.The theory of stress Selye H. (1953).11.Theory of mucosal barrier Hollander (1954)

CLASSIFICATION OF PUDBY А.А. SHALIMOV, V.F. SAYENKO

Distinguish ulcers :1. Localization:

Duodenum.Pyleroantral part of the stomach.Lesser curvature of stomach.Fundus of stomach.Other locations (greater curvature of the stomach, esophagus, small intestine).Peptic ulcer and intestinal anastomosis.?

2. By the nature of gastric secretion:normal secretion in both its phases;normal secretion in the first phase and increased in the second;with increased secretion in the first and normal second phase; with increased secretion in both phases.

• 3. By their corse:

• Uncomplicated.• Complications:

a) collosum with increased proliferative-sclerotic processes of the connective tissue;b) penetrating;c) perforating;g) bleeding;d) malignant;e) stenosing or distorting the stomach with a violation of the evacuation.

CLASSIFICATION OF PUD BY JHONSON

• Type I. Most of the ulcers I type appear in the body of the stomach, namely in a region called the place of least resistance (locus minimus resistentiae) - the so-called transition zone, located between the body and gastric antral.

• Type II. Ulcers arising with a duodenal ulcer.• Type III. Ulcers pyloric canal. In its flow and clinical

manifestations are more similar to duodenal ulcers than gastric ulcer.

• Type IV. High ulcers, localized near Gastro-oesophageal junction.

Laboratory diagnostic methods for PUD and its complications

1.Study of gastric secretion fractional method (the method of Kay)

2.Study non stimulated basal secretion.3.Investigation of stimulated secretion

Interpretation of the results Basal secretion of hydrochloric acid for 1 hour:

less than 2 mEq - normal, gastric ulcer, gastric cancer.2.5 mEq - normal, gastric ulcer or duodenal ulcer.more than 5 mEq - usually duodenal ulcer.20 mEq or more - Zollinger-Ellison syndrome.

Stimulation seceration of hydrochloric acid in 1 hour:0 mEq - true achlorhydria, atrophic gastritis or gastric cancer.1-20 mEq - usually stomach ulcer.20-35 mEq - usually duodenal ulcer.35-60 mEq - duodenal ulcer, possible Zollinger-Ellison syndrome.More than 60 mEq - syndrome Zollinger-Ellison.

INSTRUMENTAL DIAGNOSIS• Upper gastrointestinal X-rays can detect an ulcer in about

70% of cases. But motorevacuation function of the stomach, its size, shape can be studied only in this way the study. Direct indication of the presence of peptic ulcer is considered a niche in the form of a crater in the wall of the stomach or duodenum, which penetrates barium, as well as changes in terrain folds that converge radially in the ulcer. Indirect signs of peptic ulcer include: finger indrawing greater curvature opposite the ulcer located on the lesser curvature; improve motor function of the stomach, pyloric spasm; local tenderness to palpation, respectively, X-ray projection ulcers; dyskinesia bulbs of duodenum and others? Fibrogastroduodenoscopy (Endoscopy) 

TREATMENT OF PUDINDICATION OF SURGICAL INTERVENTION

TREATMENT OF PATIENTS WITH PUDAbsolute and relative (AA Shalimov, Vladimir Saenko,

1972, 1987).Absolute: 1.perforated ulcer; 2.cicatricial pyleroduodenostenosis; 3.profuznoe and non stop gastrointestinal bleeding; 4.malignizatsiya.?

Relative indications: 1.Collusum ulcers; 2.ulcer penetration into adjacent organs and tissues 3.without any tendency towards healing; 4.giant ulcers; 5.recurrent ulcer bleeding; 6.ulcerative long history of frequent relapses; 7.ineffectiveness of conservative therapy for 4-6 weeks.

RESECTION METHODS OF TREATMENT

• Resection of today are the method of choice for the localization of ulcers in the stomach. 

• The proximal resection performed very rarely, in view of rare localization of ulcers in the gastric cardia. Therefore, most performed distal resection with pathogenetically justified removal of at least 2 / 3 of the stomach. 

• There are dozens of modifications to the method of stomach resection Billroth I and Billroth I.

BILIROTH-I

• 1) Classic - Billroth I - anastomosis end of the stump with the end of the duodenum;

• 2) BILIROTH-I WITH MODIFICATION OF MAKI- SHALIMOVA.- Preserving the pyloric excision of left antral mucosa of the stomach 3-3,5 cm from the pyloric and fistulization proximal end of the stump with the distal stump of antral part.

BLIROTH-II• Resection of the stomach by Billroth second

method is that after the removal of the distal part of the stomach stump KDP take in tight, and the continuity of the gastrointestinal tract is restored with the help connect the stump with the initial division jejunum.

• Of the many variants of gastric resection by Billroth-II the most widespread modification Chamberlain-Finsterera, Roux, Balfour.

The dashed line denotes the sectional curvature of the small skeleton of the stomach and dissection of the peritoneum above the esophagus with the gastric branches of the vagus nerves.

• Cut off the front piece of a small gland with anterior nerve of latterjet.

• Cut off the rear piece of the small omentum, together with the rear nerve latterjet.

• Stitched resected lesser curvature of the stomach

VAGOTOMY With the localization of ulcers in the duodenum by the method of choice are vagotomy - organ-preserving surgery.TYPES OF VAGOTOMY:1. Stem vagotomy (pyloroplasty Jaboulay's, Finn, Haynekefon Mikupicha, gastrojejunostomy)2. SELECTIVE VAGOTOMY.

• SELECTIVE PROXIMAL VAGOTOMY. • INCIDENCE OF OPERATIVE MESURES

The immediate results of surgical treatment of PUD-postgastrectomy lethality - from 1% to 5%, after vagotomy - 0,1% -0,5%. Disability after gastric resection 2,5 months 1,5 months after vagotomy.However, long-term results in the investigation of diseases of operated stomach and in one in both cases are found in 10-15% of poor.

COMPLICATIONS OF PUD. PERFORATED ULCERS OF STOMACH AND DEODENUM

CLASSIFICATION

1. On the etiology of perforation are (By Chuhrienko):perforation of peptic ulcer;perforation of gastric cancer;perforation in violation of local circulation in the gastric wall;perforation in the defeat of the body wall by parasites.2. BY LOCALISATION (SAVELEV):perforated duodenal ulcers;perforation of peptic ulcers of anastomosis;perforated ulcers of the small intestine.

3. BY CLINICAL COURSE:• perforation into the free abdominal cavity;

covered by a perforation;atypical perforation;Some authors identify:erased perforation;reperforatsiyu stitched ulcers;perforation in the treatment of opportunistic diseases.4. BY PATHOLOGICAL CAUSES:

• perforations of acute ulcers;perforation of chronic ulcers;5. BY COURSE OF CLINICAL STAGES :

• Stage I - the initial shock (up to 6 hours);Stage II - an imaginary being (6-12 hours);Stage III - diffuse peritonitis (after 12 hours).

CLINICS• Mondors trais is among the main symptoms of Perforated

ulcer:1) stabbing pain2) tension of the muscles of the abdominal wall,3) ulcerative historyThe functional sign of Mondor (1938) classifies vomiting, delayed stool and gas, thirst.

Физические признаки• symptom SHCHetkina-Bljumberga,

symptom Razdolsky,symptom of the disappearance of hepatic dullness in semi sitting position Spizharnogo.

• Zhobvra - lying on the left side of mid clavicular line on the right.during rectal examination determine tenderness to palpation of the anterior rectal wall (Kulenkampfa).

Diagnosis of perforated gastroduodenal ulcer

• In clinical blood analysis detected high leukocytosis, increased ESR, leukocyte formula shift to the left. 

• X-ray diagnosis is mainly in the detection of free gas in the peritoneal cavity (pneumoperitoneum) for X-rays or X-ray. In the absence of pneumoperitoneum use special methods of research: pneumogastrography, the study of the stomach with sterile water-soluble contrast agents. 

• Pneumogastrography is the introduction through a tube into the stomach of 600-700 ml of air. Passing through the perforated hole, the air accumulates on the liver or diaphragm, so that there is a characteristic X-ray picture (see.serpa). 

• In doubtful cases, apply laparosentesis, laparoscopy, sometimes fibrogastroduodenoscopy, pneumogastromanometry.

TREATMENT • Tactics preoperatively 

If you can not perform the operation can be applied conservative treatment method according to Taylor. The method of the operation. 

• There are palliative surgery (suturing Perforated holes) and radical (resection of the stomach, vagotomy with sparing resection or excision of ulcer). 

• Indications for resection: large collesive gastric ulcers, suspicion of malignancy, malignancy, re-perforation, the combination of perforation with bleeding. 

• Under the old ulcers of the duodenum shows execution stem vagotomy with draining operation and the excision of ulcers. When combined perforation and bleeding removal or flashing a bleeding ulcer required. In the absence of indications for radical surgery or the absence of conditions for its execution is suturing Perforated holes. 

• Suturing shown in acute ulcers in patients aged 30 years, the presence of diffuse peritonitis after perforation of the term of more than 8 hours, severe concomitant diseases. 

• Operation was performed under general anesthesia endotracheal. The mandatory element of the operation - careful sanitation and drainage of the abdominal cavity.

PYLERODUODENAL STENOSIS (Ulcus stenosant)

• Stenosis, or narrowing (from the Greek. Stenos - narrow) is a very common complication of peptic ulcer (13%). In the course of ulcerative stenosis distinguish three stages of compensation, subcompensation and decompensation. 

• When compensating the general condition of stenosis patients suffered enough. In these patients a sense of repletion after a meal. The main sign of the disease is episodic vomiting (1-2 times per week). In some patients, is belching sour. As a result, developing compensatory hypertrophy of the muscular elements stomach overcomes the increased resistance in the area of narrowing, the evacuation takes place in a timely manner. 

• When X-ray study: the stomach of normal size or somewhat expanded, enhanced peristalsis. The evacuation of barium suspension is timely or delayed for up to 6-12 hours. After 24 hours the stomach is free from the contrast.

• Under subcompensation: Vomiting usually daily in the evening. There disability, emaciation, dehydration patients. An objective study, "splashing" in the stomach on an empty stomach, a moderate increase in the size of the stomach.

• X-Ray study: stomach expanded, on an empty stomach is defined by fluid.Piloroduodenalny channel narrowed. Peristalsis weakened. Expressed slow evacuation of up to 12-24 hours, but after 24 hours of barium in the stomach no. In klinikobiohimicheskih blood analyzes expressed protein-electrolyte imbalance.

• In the stage of decompensation:of the stomach wall becomes thinner, hypertrophy followed by atony, the stomach is stretched and under pressure from a large number of content coming down in a small basin. Vomiting (vomiting) after each meal, liquid.

• Objective data: a sharp loss of weight, skin is dry, turgor dramatically reduced. Can be heard fasting "splashing" in the stomach.

• Since vomiting patient loses a lot of fluids, electrolytes, enzymes. There comes a thickening of the blood, increases its viscosity, increased hematocrit, decreased plasma volume. The content of chlorides in blood and urine drops. Developed azotemia. Profound metabolic cause dystrophic changes in vital organs.

• Dehydration, chloropenia, azotemia, hypokalemia, hypoproteinemia, violations of calcium metabolism may lead to the development gastrogenic tetany (gastric tetany, chloropenic tetany), and coma.

• X-ray picture is very characteristic. It entails four classic symptoms:large amount of liquid on an empty stomach;increased size of the stomach, the omission of it;slowing down the evacuation, the weakening of peristalsis;delay of barium in excess of 24 hours.

TREATMENT• Ulcerative gastroduodenal cicatricial stenosis - an

absolute indication for surgery.• The duration, scope and nature of preoperative

preparation depend on the degree of stenosis and the resulting violations of homeostasis.

• For this purpose, is:gastric lavage;correction fluid and electrolyte composition of blood;Correction of carbohydrate metabolism;Correction of protein balance;volemicheskih correction of violations;correction of violations of the cardiovascular system and other violations..

The method operationsWhen compensated and subcompensated stenosis operation of choice is selective proximal vagotomy with

draining the stomach surgeryWith decompensated stenosis - resection of the stomach.

GASTRO-INTESTINAL BLEEDING (GIB)

• GIB is the most frequent complication of BU, observed in 20% of patients suffering from peptic ulcer.

CLASSIFICATION• 1) On the etiology:• Ulcer bleeding:• Nonulcer bleeding:

– varicose veins of the esophagus and stomach in portal– hypertension; – strangulated hiatal hernia; – Mallory-Weiss syndrome (mucosal fissures gastric cardia); – erosive hemorrhagic gastritis; – benign and malignant tumors of the stomach and intestines; – diverticula of the digestive tract; – chemical burns of the stomach; – foreign bodies of the esophagus and stomach.

1. By localizing the source of bleeding: esophageal, gastric, intestinal, intestinal.

2. By the degree of blood loss:- chronic - capillary bleeding (up to 500 ml of blood loss);- I acute low degree (up to 1.0 liters);- acute moderate II degree (up to 1.5 liters);- Severe Acute III degree (over 1.5 liters).

When I degree - blood loss up to 20% on TBC;When II degree - blood loss up to 30% TBC;In III degree - blood loss over 30% TBC.

CLINICS OF GI-BLEEDING• Clinical picture develops with symptoms of internal bleeding. 

• Second manifestation of the GIB - the symptoms of external bleeding: hematemesis (haematemesis) and , black tarry stools (malena).

•  • Mild. Total patient's condition was satisfactory. Pulse satisfactory filling. 90-100

bpm. in 1 min Blood pressure is not below 100/70 mm Hg. Art. Increased shock index Algoveri to 1. Total loss of blood - 1000 ml. Reduction Hp to 100 g / l, Ht to 0.35. 

• Modrate degree of blood loss. A large pale skin. Pulse 100-120 bpm. in 1 min, a weak filling.Blood pressure falls to 80/90 mm Hg. st .. Shock index Algoveri 1-1,5, Hp-reduced to 80 g / l, Ht - 0,25. The total blood loss 1000-1500 ml. 

• Severe degree of blood loss. Pulse 130-140 bpm. in I min, a weak filling, sometimes not detectable. Systolic blood pressure - below 60 mmHg Hp - below 80 g / l, Ht - below 0,25. The total blood loss - 1500-2500 ml or more. Of the additional studies required is determined by blood group and resus factor, Coagulogram, biochemical blood tests. However, the most informative has emergency fibrogastroduodenoscopy, less informative gastrointestinal fluoroscopy.

TREATMENT-GIB• When first aid is necessary to remember - these patients are

classified as extremely serious and require immediate hospitalization, even for suspected FCC centers for gastrointestinal bleeding. Transportation only on a stretcher with the implementation of venous access with infusion dextran, permanent urinary catheter to monitor hourly diuresis.

•  In the hospital in order to select treatment strategy should be to establish: 

• presence of GIB; • source of bleeding and its localization; • stopped or continued bleeding; • the degree of hemostasis; • degree of blood loss.

• Simultaneously begin healing activities: 

• catheterization of the subclavian vein; • gastric lavage, fibrogastroduodenoscopy; • Retrieving the TCB deficit; • hemostatic therapy; • permanent nosogastric probe for monitoring• hemostasis; • oxygen therapy; • permanent urinary catheter; 

• According to fibrogastroscopy distinguish three groups of patients: 

• I with continues bleeding; • II with stopped bleeding, but with unstable hemostasis

(clot in the bottom of ulcers); • III with stopped bleeding with persistent hemostasis (no

bleeding, clots, blood clots).

COMPLEX HEMOSTATIC THERAPY

• INFUSION. • LOCAL. • Therapeutic Endoscopy. • Endovascular embolization of a bleeding

vessel.• Making for the lost TCB. • Stabilizing hemodynamics. • Elimination of metabolic acidosis.• Restoration microcirculation.

INDICATIONS FOR OPERATION

• Emergency immediate operation - up to 2 h: the continuing hemorrhage grade 2-3 severity, recurrence of bleeding. 

• Urgent operation (1,0-1,5 days) - stop the bleeding in the presence of clots in the ulcer, unstable hemostasis, recurrence of bleeding in the hospital. 

• Routine operations are performed in the stabilization of hemostasis, small ulcers in the presence of these blood clots and mild bleeding. 

• When bleeding from ulcers gastric localization preferred gastric resection. When duodenal ulcers - excision of the ulcer or flashing it with selective proximal vagotomy.

• In Mzllori-Weiss syndrome performed gastrotomy and stitching bleeding vessels crack (the operation Beye). 

• When bleeding from varicose veins of the esophagus and cardia in the absence of effect of compression by the tube and then indicated is the usage of tube of Blekmora with haemostatic therapy suturing of vein in chain-like stitch from the mucosa. 

• Bleeding gastric tumors - indication for radical or palliative care (with metastases), resection or gastrectomy. 

• Results of surgical treatment at an hight of uncontrollable bleeding. Postoperative mortality reaches 10% and above.