أسئلة العاشرة جراحة ثالثة الدلتا

• This lecture discusses the treatment of peptic ulcers
• It covers both acute and chronic duodenal ulcers, as well as chronic gastric ulcers

Treatment of Acute Peptic Ulcer

• Stop taking any drugs that caused the ulcer
• Correct any shock the patient is experiencing

Treatment of Chronic Duodenal Ulcer

• Conservative treatment includes physical and mental rest
• Adopt a diet of frequent small meals, including a midnight snack
• Avoid irritating foods, excess milk, and milk products
• Avoid the "5 S's": smoking, spirits, spices, stimulants (coffee, tea, cola), and steroids and non-steroidal anti-inflammatories

Drug Therapy

• Focuses on inhibitors of acid secretion

Histamine H2 Antagonists

• Cimetidine, Ranitidine, and Famotidine are examples
• Famotidine is more effective and has fewer complications
• MOA: Block H2 receptors of parietal cells, which decreases histamine stimulation and acid secretion
• Side effects of cimetidine include antiandrogenic effects (impotence, oligospermia, gynecomastia, and galactorrhea) and inhibition of drug metabolism

Proton Pump Blockers (Omeprazole or Gastrozole)

• Inhibit gastric acid secretion by blocking the H+/K+ ATPase enzyme in parietal cells
• Disadvantages:
  • A 99% reduction in acid secretion can lead to bacterial overgrowth
  • Conversion of nitrates to carcinogenic compounds
  • Increased gastrin levels, which can lead to atrophic gastritis and increase the risk of malignancy

M-Receptor Antagonists (Anti-Cholinergic Drugs)

• Pirenzepine (Gastrozepine): A tricyclic antidepressant
• Selectively block muscarinic (M) receptors to decrease vagal stimulation of parietal cells, reducing acid secretion

Antacids

• Aluminum hydroxide gel (Al(OH): Can cause constipation
• Magnesium oxide (MgO): Can cause diarrhea
• Usually combined to balance their opposing effects
• Sodium bicarbonate (NaHCO3) is not used

Cytoprotective Agents

• Carbenoxolone Sodium (extracted from liquorice) inhibits prostaglandin dehydrogenase, increasing cytoprotective prostaglandins
• It has mineralocorticoid-like action, leading to hypernatremia and hypokalemia, potentially causing edema, hypertension, and heart failure
• Colloidal Bismuth forms a protective coat on the mucosa, preventing hydrogen back diffusion and affecting Helicobacter pylori
• Adheres to ulcer areas and has anti-pepsin activity

Sucralfate

• Pepsin antagonist
• Increases the mucosal biosynthesis of PGE2 & PGF, which protect the gastroduodenal mucosa
• Best used in an acidic environment, so avoid taking antacids together

Prostaglandins

• High doses reduce acid secretion
• Low doses have a cytoprotective effect, increasing gastric mucus rich in HCO3, and reducing mucosal blood flow

Eradication Treatment for Helicobacter Pylori

• Consists of a proton pump inhibitor or Bismuth plus amoxicillin or tetracycline, and metronidazole

Surgical Treatment

• Indicated if medical treatment fails (intractable or recurrent ulcer for at least one year)
• Also indicated in cases with complications
• Indicated in Combined duodenal ulcer & gastric ulcer
• Indicated when Ulcer present in 2nd part of duodenum or jejunum

Aim of Surgery

• Reduce acidity
• Prevent complications

Procedures to Reduce Acidity

• Vagotomy: removes the nervous phase of gastric secretion
• Antrectomy + vagotomy: removes both hormonal and nervous phases of gastric secretion (procedure of choice in some regions)
• Subtotal gastrectomy: reduces the parietal cell mass and acidity

Vagotomy Types

Truncal Vagotomy

• Excision of 1-2cm of both anterior and posterior vagus trunks, reducing acidity by 50%
• Can lead to pylorospasm and pyloric antrum stasis, predisposing the patient to gastrin release and ulcer recurrence
• Requires combination with drainage procedures such as pyloroplasty or gastrojejunostomy

Complications of Post-Vagotomy Syndrome

• Dysphagia due to reflux esophagitis
• Distension due to division of the coeliac branch to the intestine
• Diarrhea due to decreased HCL and bacterial overgrowth
• Dyskinasia of the sphincter of Oddi
• Damage to the pleura and diaphragm
• Duodenal ulcer recurrence

Selective Vagotomy

• Spares the hepatic and coeliac branches, dividing only the gastric branches
• Still requires drainage procedures

Highly Selective Vagotomy

• Preserves the anterior and posterior nerves of Laterjet
• Doesn't need drainage procedures

Lesser Curve Seromyotomy

• Involves anterior lesser curve seromyotomy with posterior truncal vagotomy, or seromyotomy of both anterior and posterior aspects of the lesser curvature
• It is a simple and rapid method of achieving denervation
• Avoids damage to the criminal nerve of Grassi (responsible for recurrence)

Gastric Drainage Procedures with Vagotomy

Pyloroplasty

• Heineke-Mikulicz pyloroplasty (most popular)
• Finney pyloroplasty
• Jaboulay pyloroplasty
• Partial pylorectomy

Gastrojejunostomy

Antrectomy + Vagotomy

• The antrum is resected because it is responsible for gastrin hormone production
• 50% of the stomach is resected, known as hemigastrectomy
• This procedure leads to less recurrence but higher mortality
• Followed by gastroduodenal anastomosis: Billroth I (antrectomy + end-to-end gastroduodenostomy) or a modification of Billroth I (Schoemaker operation) to avoid leakage

Value of Antrectomy with Vagotomy Combination

• Antrectomy acts as a drainage operation for vagotomy, so no additional drainage procedure is needed
• Removes G-cells which reduces HCI by 40%, so vagotomy and antrectomy together
• Decreases HCI by 90%, leading to the least recurrence

Subtotal Gastrectomy

• 85% of the distal stomach is resected

Methods of Anastomosis After Subtotal Gastrectomy

• Billroth II: Partial or subtotal gastrectomy + side-to-side gastrojejunostomy
• Polya Gastrectomy: Gastrectomy + end-to-side gastrojejunostomy
• Polya Finistre's Gastrectomy: Like Polya, with the formation of an upper valve to avoid dumping; the valve is made by closing the upper 2/3 of the gastric stump
• Hofmeister Gastrectomy: Like Polya, with partial closure of the lesser curvature

Treatment of Chronic Gastric Ulcer

• Conservative treatment is given for one month
• This is followed up with a fibre-optic gastroscopy, this is if conservative treatment is not enough

Surgical Treatment

• Indicated when medical treatment fails after 6 weeks
• Also indicated due to Complications, combined duodenal ulcer and gastric ulcer
• Indicated in Suspicious of malignancy
• Aims to excise the ulcer and ulcer-bearing area + biopsy to prevent complications

Operations

• Partial Gastrectomy: This is where 65% of the distal part of the stomach is resected and followed by gastroduodenal anastomosis using Billroth I (more preferred) or Billroth II
• Subtotal Gastrectomy: This is where 85% of the stomach is resected and indicated in high gastric ulcers or combined gastric & duodenal ulcers

Summary of Common Surgical Treatments for Peptic Ulcer

• Duodenal ulcer: truncal vagotomy + drainage, highly selective vagotomy, or antrectomy + vagotomy
• Gastric ulcer: partial or subtotal gastrectomy