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محاضرات عين شمس
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بسم الله الرحمن الرحيم
SurgerySurgeryStomach and duodenumStomach and duodenum
Prof. Ismail Kotb
SURGERY OF STOMACH AND DUODENUM
Surgical AnatomyArterial 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 vein2-left gastro epiploic vein & vasa
brevia join splenic vein3-right gastro epiploic vein join
superior mesenteric vein4- vein of mayo
Stomach anatomyStomach anatomy
Stomach anatomyStomach anatomy
Nerve supply1-intrinsic, a- myenteric plexus of Auerbach, , b- submucosal plexus of Meissner2-Extrensic, a ant. Vagus, b- post vagus3-sympathetic
PEPTIC ULCERCommon sites;1-first part duodenum. 2-lesser curve
stomach. 3- oesophagus. 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,,aspirin,,steroid & NSAID.
PathologySome 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..
DUODENAL ULCERIncidenceThere 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 as proton pump ) ,
PathologyOccur 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 ULCERIncidenceSame 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,,.
PathologyUsually 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 ulcer1-On the long run ch. G.U.might become
malignant so on OGD. To take multiple biopsies2-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 EXAMINATIONTenderness at epigastric region,,stomach
splash in case of pyloric stenosis.
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
TREATMENT OF CHRONIC PEPTIC ULCERThe 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 TREATMENT1-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 erthromycin 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:
1—Truncal vagotomy(first introduced1943 by
Dragstedt) plus drainage procedureTypes of drainage procedure:A—PYLOROPLSTY types :1—finnys pyloroplasty. 2—
Heineke-Mikulicz 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..
Comparing Duodenal and Gastric Comparing Duodenal and Gastric UlcersUlcers
DUODENAL ULCER Incidence
Age 30–60Male: female 2–
3:180% of peptic
ulcers are duodenal
GASTRIC ULCER
Usually 50 and over
Male: female 1:115% of peptic
ulcers are gastric
22
Signs, Symptoms, and Clinical Signs, Symptoms, and Clinical Findings Findings
DUODENAL ULCER Hypersecretion of
stomach acid (HCl) May have weight
gain Pain occurs 2–3 hours
after a meal; often awakened between 1–2 AM;
ingestion of food relieves pain
Vomiting uncommon
GASTRIC ULCER Normal—hyposecretion
of stomach acid (HCl) Weight loss may occur Pain occurs 1⁄2 to 1
hour after a meal; rarely occurs at night; may be relieved by vomiting;
ingestion of food does not
help, sometimes increases
pain Vomiting common
23
Comparing Duodenal and Gastric Comparing Duodenal and Gastric UlcersUlcers
DUODENAL ULCER
Malignancy Possibility
RareRisk FactorsH. pylori, alcohol,
smoking, cirrhosis, stress
GASTRIC ULCER
OccasionallyH. pylori,
gastritis, alcohol, smoking, use of NSAIDs, stress
24
Comparing Duodenal and Gastric Comparing Duodenal and Gastric UlcersUlcers
DUODENAL ULCER
Hemorrhage less likely than with gastric ulcer, but if present melena more common than Hematemesis More likely to perforate than
gastric ulcers
GASTRIC ULCER
Hemorrhage more likely to occur than with duodenal
ulcer; hematemesis more common than melena
25
Surgical TreatmentSurgical TreatmentTruncal Vagotomy -- Antrectomy & Truncal Vagotomy -- Antrectomy & Roux-en-Y AnastomosisRoux-en-Y Anastomosis
Surgical TreatmentSurgical TreatmentTruncal Vagotomy -- Heineke-Truncal Vagotomy -- Heineke-Mikulicz PyloroplastyMikulicz Pyloroplasty
Proximal Gastric Proximal Gastric VagotomyVagotomy
Dumping syndromeDumping syndrome
30
Bleeding UlcersBleeding UlcersCommon; seen in 10-20%
patients with active PUD; 6-10% mortality; 50% of UGI bleeding is from ulcers.
May be first sign/symptom vs antecedant ulcer symptoms.
Hematemesis and/or melena vs hematochezia dependent on amount.
31
Treatment: Bleeding UlcerTreatment: Bleeding UlcerVolume expansion (isotonic fluids);
transfuse when needed.Bleeding stops spontaneously in 80%.Endoscopy identifies site, stability of
bleeding site; also used to stop bleeding when necessary (theromocoag, vasoconstricters, clips/staples, etc.).
IV PPI or high dose oral PPI- decrease re-bleeding, need for transfusion or repeat interventions, including surgery.
32
Ulcer Perforation Ulcer Perforation 5% incidence in ulcer patients.Anterior wall of stomach or
duodenum.Results in chemical peritonitis- severe,
generalized abdominal pain, rigid abd, rebound, WBC, free air on KUB/upright.
Laparoscopic perforation closure carries morbidity compared to laparotomy with vagotomy, antrectomy.
Intensive medical Rx also required.
33
Other Complications (IO) Other Complications (IO) Ulcer Penetration of posterior wall of
stomach/duodenum into pancreas, liver or biliary tract.
Symptoms: increase in pain, radiates to back, unresponsive to antacids and other meds; amylase may be elevated. Rx is intensive PPI regimen or IV H2 blocker.
IO- interest only
StomachStomachMallory- Weiss syndromeMallory- Weiss syndrome
Upper GI hemorrhage due to tearing of GEJ.
Repeated retching or vomiting may be responsible for the tears in the mucosa
Significant hemorrhage can occur results from prolonged and forceful
vomiting, coughing or convulsions. It may occur as a result of
excessive alcohol ingestion. This is an acute condition which
usually resolves within 10 days without special treatment.
Mallory-Weiss TearMallory-Weiss Tear
Mallory –Weiss TearMallory –Weiss Tear
StomachStomachMallory-Weiss syndromeMallory-Weiss syndrome Tx:
ConservativeDue to hypovolemia (bleeding) fluid resuscitation
Acid suppressionH2, PPI’sSurgery is last resort
StomachStomachZollinger- Ellison SyndromeZollinger- Ellison SyndromeGastrinomas can be part of an
inherited familial disorder.60 % of gastrinomas are malignant.Hypergastrinemia --- stimulate parietal
cells --- HCL acid is constantly secreted.
50% of pts with malignant variant die within 5 years of Dx.
Due to slow growth long term survival up to 15 years has been seen.
StomachStomachZollinger- Ellison SyndromeZollinger- Ellison Syndrome
multiple duodenal ulcers in atypical places (jejunun or ileum)
Family or personal Hx of refractory PUD or endocrine disease (MEN-1)
Dx: hypergastrinemia (fasting serum gastrin
levels over 1000 pg/ml is a comfirmatory testing + hypersecretion of acid
tumor localization Clinical staging CT scan, MRI and U/S screening for MEN-1
INTRODUCTION - INTRODUCTION - STOMACHSTOMACH
Benign Polyps
◦ Hyperplastic◦ Fundic gland◦ Neoplastic◦ Multiple
Tumors◦ Leiomyomas◦ Lipomas◦ Heterotopic pancreas
Malignant Tumors
◦ Carcinoma◦ Lymphoma◦ Sarcoma◦ Carcinoid
Others Menetriers Disease Bezoar Volvulus
GASTRIC POLYPSGASTRIC POLYPSHyperplastic polyps
◦Most common type of polyp (65 – 90%)◦Inflammatory or regenerative polyps
In reaction to chronic inflammation or regenerative hyperplasia
Often found in HP infections◦Sessile and seldom pedunculated
Mostly in the antrum Multiple in 50% of cases Varying in size but seldom < 2cm
◦Rate of malignant transformation 1 – 3% Usually larger than 2 cm
GASTRIC POLYPSGASTRIC POLYPSFundic Gland
◦Small elisions in the fundus Hyperplasia of the normal fundic glands
◦Often associated with FAP Therefore important as a marker for
disease elsewhere in the GIT tract
GASTRIC POLYPSGASTRIC POLYPSNeoplastic polyps
◦Types Tubular Villous (often larger - > 2cm - and malignant)
◦Macroscopically More often in antrum Pedunculated with malignant potential Solitary, large and ulcerated
◦Treatment Endoscopic removal if no malignancy
identified with surveillance Excision with malignant focus or where
endoscopic removal failed
GASTRIC POLYPSGASTRIC POLYPSMultiple gastric polyps
◦Rare condition Adenomatous and hyperplastic polyps 20% incidence f adenocarcinoma
◦Treatment If confined to corpus and antrum – distal
gastrectomy Otherwise total gastrectomy
◦Sometimes associated with Polyposis syndromes FAP Gardner Peutz-Jeghers
GASTRIC LEIOMYOMAGASTRIC LEIOMYOMAIncidence of 16% at autopsyPathology
◦Arise from smooth muscle of the GIT tract Difficult to distinguish from GIST
◦75% benign Differentiation only on mitotic index
◦Large protruding elisions with central ulcer
Usually presents with bleeding if at all
Treatment is local excision with 2 – 3cm margin
HETEROTOPIC HETEROTOPIC PANCREASPANCREAS
Ectopic pancreas◦Most common found in stomach
Within 6 cm from the pylorus
◦Also in Meckl’s diverticulumRarely larger than 4 cm
◦Sessile and rubbery◦Submucosal in location◦Histological identical to normal
pancreas
ADENOCARCINOMAADENOCARCINOMAOF THE STOMACHOF THE STOMACH
Declining incidence in western world◦HP associated due to chronic atrophic
gastritis◦Also related to
Low dietary intake vegetables and fruit High dietary intake of starches More common in males ( 3 : 1 )
Histology◦ Invariably adeno-carcinoma◦Squamous cell carcinoma from oesophagus
Involves fundus and cardia
ADENOCARCINOMAADENOCARCINOMAOF THE STOMACHOF THE STOMACH
Histological typing◦Ulcerated carcinoma (25%)
Deep penetrated ulcer with shallow edges Usually through all layers of the stomach
◦Polipoid carcinoma (25%) Intraluminal tumors, large in size Late metastasis
◦Superficial spreading carcinomas (15%) Confinement to mucosa and sub-mucosa Metastasis 30% at time of diagnosis Better prognosis stage for stage
ADENOCARCINOMAADENOCARCINOMAOF THE STOMACHOF THE STOMACH
Histological typing◦Linitis plastica (10%)
Varity of SS but involves all layers of the stomach
Early spread with poor prognosis
◦Advanced carcinoma (35%) Partly within and outside the stomach Represents advanced stage of most of
the fore mentioned carcinomas
ADENOCARCINOMAADENOCARCINOMAOF THE STOMACHOF THE STOMACH
Symptoms and signs◦Vague discomfort difficult to distinguish
from dyspepsia◦Anorexia
Meat aversion Pronounced weight loss
◦At late stage Epigastric mass Haematemesis usually coffee ground seldom
severe◦Metastasis
Vircho node in neck
ADENOCARCINOMAADENOCARCINOMAOF THE STOMACHOF THE STOMACH
Surgical resection only cure◦Late presentation makes surgary often
futile◦Palliation controversial for
Haemorrhage Gastric outlet
◦Simple gastrectomy as effective as abdominal block Splenectomy often added due to direct
involvement Only for the very distal partial gestrectomy Rest total gastrectomy
Prognosis overall 12% 5 year survival◦90% for stage I disease
GASTRIC LYMPHOMAGASTRIC LYMPHOMA5% of all primary gastric neoplasm's2 different types of lymphoma
◦Part of systemic lymphoma with gastric involvement (32%)
◦Part of primary involvement of the GIT (MALT Tumors) 10 – 20% of all lymphomas occur in the abdomen 50% of those are gastric in nature
Risk factors◦HP due to chronic stimulation of the MALT ◦ In early stages of disease Rx of HP leads to
regression of the disease
GASTRIC LYMPHOMAGASTRIC LYMPHOMAPrimary MALTPrimary MALT
Early stages also referred to as pseudo-lymphoma◦ Indolent for long periods◦Low incidence of
Spread to lymph nodes Involvement of bone marrow
◦Therefore much better prognosisMostly involves the antrum5 different types according to
appearance◦ Infiltrative - Ulcerative◦Nodular - Polypoid◦Combination
GASTRIC LYMPHOMAGASTRIC LYMPHOMAPrimary MALTPrimary MALT
At time of presentation◦Larger than 10 cm (50%)◦More than 1 focus (25%)◦Ulcerated (30 – 50%)
Pattern of metastasis similar to gastric carcinoma
Signs and symptoms◦Occur late and are vague◦Relieved by anti-secretory drugs◦Diagnosis based on histology
Gastric lymphomaGastric lymphoma
Malignant neoplasm of mucosa associated lymphoid tissue (MALT)
A (usually) low grade B-cell (marginal cell) lymphoma
Gastric lymphoma Gastric lymphoma (maltoma)(maltoma)
Neoplastic cells infiltrate the epithelium (lymphoepithelial lesions)
Strongly associated with H. pylori
Gastrointestinal stromal Gastrointestinal stromal tumours (GIST)tumours (GIST)Mesenchymal neoplasmsDerived from interstitial cells of
Cajal (pacemaker cells controlling peristalsis)
Overexpress c-kit oncogene◦Used as diagnostic aid on tissue◦A target for therapy with tyrosine
kinase inhibitor imatinib (also used in CML)
GIST-spindle cell GIST-spindle cell neoplasm of GI tractneoplasm of GI tract
GISTGIST
Larger tumours with high mitotic rate tend to behave malignantly
Stomach is commonest site
Neuroendocrine tumoursNeuroendocrine tumoursCarcinoids are tumours of
resident neuroendocrine cells in gastric glands
Usually seen in context of chronic atrophic gastritis (driven by gastrin)
Clinical behaviour variable