Lec 3 Stomach Surgical Diseases PDF

Lec. 3: Surgical Diseases of Stomach Dr. Ahmed Aly Abdelmotaleb Lecturer of General Surgery Contents 1. Gastric Conditions  Acute Gastric Dilatation  Foreign body ingestion  Gastric volvulous  Trichobezoar 2. Peptic Ulcer Disease 3. Gastric Neoplasms 4. Gastric Operations...

Lec. 3: Surgical Diseases of Stomach Dr. Ahmed Aly Abdelmotaleb Lecturer of General Surgery Contents 1. Gastric Conditions  Acute Gastric Dilatation  Foreign body ingestion  Gastric volvulous  Trichobezoar 2. Peptic Ulcer Disease 3. Gastric Neoplasms 4. Gastric Operations Anatomy, Histology & Physiology of Stomach Stomach is composed of 5 parts: 1. Cardia. 2. Fundus 3. Body. 4. Antrum. 5. Pylorus. Blood supply of the stomach: 1. Lesser curvature:  Right gastric artery: from hepatic artery.  Left gastric artery: from celiac trunk. 2. Greater curvature:  Right gastroepiploic artery: from gastroduodenal artery.  Left gastroepiploic artery: from splenic artery. 3. Pylorus: gastroduodenal artery. 4. Fundus: short gastric arteries. Innervation of the stomach: 1. Sympathetic: T5-T10. 2. Parasympathetic: a) Anterior gastric wall: left vagus nerve (gives hepatic branch). b) Posterior gastric wall: right vagus nerve (gives celiac branch). 1|Page  Acute gastric dilatation  This is a condition where the stomach loses its tone and rapidly dilates to reach an enormous size.  The stomach becomes filled with air and fluid which is dark and foul.  The source of the fluid is mainly from intravascular compartment which is depleted and the patient passes into hypovolaemic shock  This condition can occur postoperatively especially after pelvic operations, splenectomy, and cholecystectomy, but very rarely after gastric surgery. A few cases have been reported during labour and in patients immobilized in plaster casts. Clinical features o 2-3 days after surgery 1. Hiccough 2. Upper abdominal discomfort and distension 3. Tachycardia. 4. Effortless vomiting of dark foul-smelling fluid. 5. Succession splash. The condition should be diagnosed at this stage and gastric decompression by nasogastric tube instituted. 2|Page  Complicaions 1. Dehydration and hypovolaemic shock. 2. Metabolic alkalosis and electolytes embalance 3. Respiratory distress and aspiration pneumonia may occur. Investigations 1. Blood chemistry 2. Never Barium meal as it worsens the condition Treatment 1. Prolyphlactic: The placement of a nasogastric tube after major abdominal surgery prevents acute gastric dilatation 2. Curative: - Stop feeding - Insertion of a nasogastric tube and continuous aspiration. - Correction of fluid, electrolytes and acid-base balance. - Oxygen inhalation Trichobezoar and phytobezoar  Trichobezoar (hair balls) are unusual and are virtually exclusively found in female psychiatric patients, often young.  It is caused by the pathological ingestion of hair, which remains undigested in the stomach.  The hair ball can lead to ulceration and gastrointestinal bleeding, perforation or obstruction.  The diagnosis is made easily at endoscopy or, indeed, from a plain radiograph.  Treatment consists of removal of the bezoar, which may require open surgical treatment.  Phytobezoars are made of vegetable matter and found principally in patients who have gastric stasis. Often this follows gastric surgery. Trichobezoar of the stomach in a girl aged 15 years. 3|Page  Foreign bodies in the stomach  A variety of ingested foreign bodies reach the stomach, and very often these can be seen on a plain radiograph.  If possible, they should be removed endoscopically but, if not, most can be left to pass normally. Even objects such as needles, with which there is understandable anxiety, will seldom cause harm. In general, an object which leaves the stomach will pass spontaneously.  The treatment should therefore be expectant and intervention reserved for patients with symptoms in whom the foreign body is failing to progress. Volvulus of the stomach Rotation of the stomach usually occurs around the axis and between its two fixed points, i.e. the cardia and the pylorus. Types: 1. Horizontal (organoaxial) 65% - Usually associated with a large diaphragmatic defect around the oesophagus (paraoesophageal herniation). - Around a line from pylorus to cardia 2. Vertical (mesenteroaxial) 35% - Idiopathic - Around axis from center of greater curvature to porta hepatis Clinical picture: 1- Acute 2- Chronic (more common) - Severe epigastric pain - Asymptomatic - Vomiting followed by inability to vomit - Distress or bloating after meals followed by - Inability to pass nasogastric tube inability to retch or vomit. - The condition is eased when the patient lies supine Complications: Gangrene, bleeding, respiratory distress and shock Treatment 1- Chronic: o If idiopathic: Gastropexy by stitching the anterior gastric wall to parietal peritoneum o If secondary: Correction of the cause 2- Acute: Emergent operation o Viable: as chronic o Gangrenous: Excision up to total gastrectomy 4|Page  Peptic Ulcer Disease  In the past, peptic ulcer disease (PUD) was the most common indication for gastric surgery.  In more recent times, the recognition that PUD is caused by Helicobacter pylori and the development of highly effective acid-suppressing medications (H2 blockers and PPIs) has dramatically decreased the need for surgical treatment of this condition.  Surgical management of uncomplicated peptic ulcers is rarely necessary because they usually respond well to medical treatment. Indications of surgery for peptic ulcer disease a) Refractory symptoms or recurrence of disease despite appropriate medical treatment b) Diseases that require the continuation of NSAIDs c) Inability to tolerate medical treatment d) Complicated peptic ulcers Surgical procedures 1. Vagotomy:  surgical division of the anterior and posterior vagal trunk of the vagus nerve (truncal vagotomy), both located along the lower esophagus. Denervation through truncal vagotomy results in ∼ 70% reduction of acid production.  As a side effect, delayed gastric emptying occurs  To improve results, truncal vagotomy is combined with one of the following Drainage procedures: o Pyloroplasty o Antrectomy o Subtotal gastrectomy  The anterior and posterior branches of the vagus nerve (CN X) are also known as nerves of Latarjet, which divide into terminal branches that innervate the stomach and the pylorus. The terminal branches on the antropyloric area are sometimes referred to as “crow's foot.”  Selective vagotomy means division of these terminal branches to avoid truncal vagotomy and drainage procedures complications. High risk of recurrence 5|Page  2. Partial gastrectomy (Billroth) and reconstruction: - Billroth I: distal gastrectomy with end-to-end or side-to-end gastroduodenostomy - Billroth II: resection of the distal two-thirds of the stomach with a blind-ending duodenal stump and end-to-side gastrojejunostomy Complications of peptic ulcer 1. Bleeding 2. Perforation 3. Penetration and fistula 4. Malignant transformation (Gastric ulcers) 5. Fibrosis  Gastric outlet obstruction or Hour Glass stomach 6. Recurrence 10% Perforated Peptic Ulcer o More common with DU o More common in males o usually the anterior wall of the first part of the duodenum o Predisposed by NSAIDS, heavy meal, stress Pathology (stages) 1. Stage of chemical peritonitis 2. Stage of illusion 3. Stage of septic peritonitis Clinical Picture:  History of dyspepsia  Epigastric pain then generalized. (may be Rt. iliac pain mimic appendicitis)  Tachycardia, fever, hypotension  Abdominal exam. board-like rigidity with absent bowel sounds, distension.  Dehydration and Shock 6|Page  Investigation: 1. Leucocytosis, increased serum amylase 2. Plain X-ray erect position- Gas under Diaphragm 3. US  Fluid collection 4. Gastrografin meal is indicated only in doubtful cases. Management  Resuscitation: Ryle, I.V fluid, urinary catheter, Antibiotics  Emergent exploration (peritoneal lavage + simple closure of the perforation by omental patch) N.B : Conservative therapy, with percutaneous drain insertion is only indicated in patients with localized / sealed perforation and those too ill for those too ill for surgical intervention. Gastric outlet obstruction Etiology  Cicatrized (healed by fibrosis) duodenal ulcer  Other causes: malignancy, strictures , foreign bodies Pathology  With the slow onset of benign stenosis, compensatory muscular hypertrophy occurs. Ultimately decompensation sets in with gastric dilatation and stasis  Vomiting loss of electrolytes Cl, Ca, metabolic alkalosis Na+ loss in urine,  In advanced cases, as compensatory mechanism loss of H+, K+ in urine  Acidosis Clinical Picture  Long-standing history of dyspepsia and loss of weight.  Anorexia, nausea and vomiting of undigested food - usually non bile stained.  On examination: Dehydration, Upper abdominal distension, Visible peristalsis (left to right), Succussion splash Investigations: 1. Laboratory : decreased serum electrolytes 2. Barium meal: a) Dilated stomach (often reaching the pelvis). b) Soup Dish appearance 3. upper endoscopy : to exclude malignancy 7|Page  Treatment  Correction of the general condition then surgery  (truncal vagotomy + gastrojejunostomy) Gastric Tumours 1.Benign: a) Gastrointestinal stromal tumors (Formely Leiomyoma) b) Neurofibroma & schwannoma. c) Adenomatous polyps:  Multiple polypi are PREMALIGNANT & treated by partial gastrectomy.  Single polyp is excised locally by endoscopy. 2.Malignant: Gastric cancer  High in some Asian countries, most notably Japan, South Korea, and Mongolia  Adenocarcinoma accounts for 95% of gastric cancer. Less frequent gastric cancers include gastric lymphomas, GIST, and neuroendocrine tumors.  prognosis of gastric cancer has remained very bad. The overall 5 years survival rate is about 5%.  Sex: ♂ > ♀ Predisposing factors 1. Exogenous: Diet rich in nitrates and/or salts, H. pylori infection, Nicotine use, Low socioeconomic status ,Obesity 2. Gastric conditions: Chronic atrophic gastritis and pernicious anemia, Gastric ulcers, Partial gastrectomy, Adenomatous gastric polyps, GERD. 3. Hereditary factors: Positive family history, Blood type A, Hereditary nonpolyposis colorectal cancer Pathology:  Adenocarcinoma accounts for ∼ 95% of cases  Arises from glandular cells in the stomach  Most tumours (60%) occur in the pyloric antrum and least of all is type that affects the stomach diffusely. 8|Page  A) Macroscopically B) Microscopically: o (Types):( Japanese classification) : 1. Early gastric cancer: only mucosa or submucosa is infiltrated (protruding, 1) Adenocarcinoma (95 %) superficial or excavating) 2) Colloid carcinoma (bad prognosis) 2. Advanced gastric cancer (common) it may 3) Squamous cell carcinoma (4%) (cardia & fundus) be: 4) Anaplastic carcinoma (1%) Fungating cauliflower mass (body & fundus) ulcer with raised everted edge (pylorus or lesser curve) colloid carcinoma Linitis plastica (thickened wall with intact mucosa) Spread: 1) Direct: To the surrounding organs 2) Blood: -to the liver and rarely to bones. 3) Lymphatic: by permiation or embolization  The proximal stomach drains to the left gastric and to the splenic LNs  The antrum to the right gastric and subpyloric LNs  The greater curvature drains to gastro-epiploic LNs Then drainage to celiac or superior mesenteric LNs 4) Trans-celomic spread: Either seeding or implantation in ovary (Krukenberg's tumor) or Douglas pouch (Blumer's shelf) Clinical pictures: (5 groups) 1) Dyspepsia group: Male patient over 40 years with dyspepsia, anorexia and abdominal pain after meal not responding to treatment. 2) Cachexia group (anemia, asthenia and anorexia): Anemia, unexplained weight loss, 3) Mass group: Epigastric mass (about 30 % of patients are advanced) 4) Obstructive group:  Mass in the cardia (dysphagia)  Mass in the pylorus (vomiting) 5) Metastatic group:  liver secondaries, jaundice, malignant ascites  Enlarged Virchow's LNs (Troisier's sign). 9|Page  Staging Diagnostic approach 1- Diagnostic confirmation: EGD with biopsy (test of choice) 2- Staging: evaluate for lymph node involvement and metastatic disease. - All patients: Obtain CT abdomen, pelvis, and thorax. - Potentially resectable disease (M0): Consider endoscopic ultrasound (EUS)the most accurate for assessment of invasion - Diagnostic laparoscopy for peritoneal metastasis 3- Additional modalities include upper GI series and PET-CT. 4- Laboratory studies: e.g., to identify anemia and biomarkers: e.g. CEA, HER2; , TNF-α Treatment A) Inoperable cases B) Operable cases 1. resectable: 1. Upper 1/3 palliative gastrectomy oesophago-gastrectomy+ OJ 2. irresectable: 2. middle 1/3 a. cardiac obstruction (stent) Total gastrectomy + OJ b. pyloric obstruction (stent or palliative GJ) 3. lower 1/3: Partial gastrectomy+ GJ N.B. Stage 0 or IA can be endoscopically resected with excellent5 years survival rate 80-90%. 10 | P a g e  Gastrointestinal stromal tumor (GIST)  Originated from the interstitial cell of cajal  Age of onset: >40 years of age.  Males = Females  associated with c-KIT gene mutations (tyrosine kinase receptor)  Stomach (60%), Small intestine (35%). Colon, rectum, esophagus, or omentum (5%) Clinical features  Small tumors (< 2 cm): often asymptomatic  Large tumors (> 2 cm)  Ulceration, bleeding → anemia, melena, and hematemesis, Obstruction Diagnosis by Imaging CT, MRI. And Endoscopy with biopsy Treatment: Treatment involves surgical removal and treatment with tyrosine kinase inhibitors such as imatinib (Gleevec). Gastric Operations Gastostomy A gastrostomy is an opening (stoma-mouth) of the stomach on the skin. It may be temporary or permanent. A) Temporary B) Permenant  To feed patients who are undergoing a series of  operations on the mouth and pharynx and cannot with advanced oesophageal ingest food orally for weeks or months. carcinoma.  To decompress the bowel as an alternative to postoperative nasogastric intubation 11 | P a g e  Vagotomy 1. Trunckal vagotomy (+ drainage op.) 2. selective vagotomy 3. highly selective vagotomy 4. Seromyotomy Complications of Vagotomy (Post-Vagotomy Syndromes) 1. Distention: Due to division of the coeliac branch to the intestines. 2. Diarrhea: Due to reduced gastric acidity, the intestinal flora will be overpopulated, lack of mixing food with bile and pancreatic secretions. Cholestyramine improves the post vagotomy diarrhea. 3. Dysphagia: Due to reflux esophagitis from disturbance of the cardio-esophageal junction. 4. Recurrence of ulcer Due to: a. Incomplete vagotomy. b. Very high pre-operative acidity: Zollinger-Ellison's syndrome. c. Inadequate drainage with antral stasis. 5. Damage of important structures at operation: Pleura, diaphragm etc. Gastrectomy Types of gastrectomies: 1. Total gastrectomy 2. Subtotal gastrectomy 3. Partial gastrectomy 4. Antrectomy (hemigastrectomy) (50%) Indications for total gastrectomy in stomach a) For proximal gastric carcinoma b) For extensive tumors (eg. Linitis plastica) c) To obtain negative margins for distal gastric carcinoma d) Roux-en-Y esophagojejunostomyneeds to be done if total gastrectomy is done POST GASTRECTOMY COMPLICATIONS A) Early complications: 1. Hemorrhage: from the anastomotic line 2. Stomal obstruction ( edema or jej-gastric intussuception) 3. Duodenal blow-out (4th day) 12 | P a g e  4. Leakage from the anastomosis: 5. Paralytic ileus, pancreatits 6. Burst abdomen 7. Pulmonary complications B) Late complications: 1. Post gastrectomy Syndromes:  Nutritional Syndrome (weight loss, anemia, steatorrhea & hypocalcemia)  Afferent Loop Syndrome (Bilious vomiting) : It is periodic vomiting of large quantities of bile & pancreatic secretion free of food with sudden relief of epigastric pain & distention due to transient mechanical obstruction, Treated by conversion to Roux en Y  Postcibal Syndrome (Dumping Syndrome): a) Early dumping b) Late dumping 2. Recurrent ulcer (at the stoma site, gastric remnant) 3. Gastro-jejuno-colic fistula 4. Internal herniation and lntestinal Obstruction 5. Biliary Gastritis 6. Diarrhea 7. Gall bladder stones 8. High risk for gastric cancer 13 | P a g e