MOD6-SURG2-T2-Surgical Disorders of the Stomach and Duodenum.pdf

SURG2 SURGERY 2 Surgical Disorders of the Stomach and Duodenum TRANS 2...

SURG2 SURGERY 2 Surgical Disorders of the Stomach and Duodenum TRANS 2 MODULE 6 Therese B. Bautista, MD, FPGS, FPCS September 11, 2024 Peptic ulcer is a defect in the gastric or duodenal wall that LECTURE OUTLINE extends through the muscularis mucosa into the deeper layers I Peptic Ulcer Disease of the wall A. Etiology Management of patients with PUD is based on etiology, ulcer B. Symptoms characteristics, and anticipated natural history. C. Management D. Complications A. ETIOLOGY E. Supportive measures PUD is caused by an imbalance in mucosal defenses and acid F. Diagnosis/ Management peptic injury. Body has innate capacity to heal itself but if there is 1. In Bleeding Peptic Ulcer an imbalance, peptic ulcer disease will occur 2. In Perforation PUD is associated with 2 major factors: 3. In Gastric Outlet Obstruction ○ Helicobacter pylori infection II Surgeries in PUD ○ Consumption of non-steroidal anti-inflammatory drugs A. Ulcer Bed Management (NSAIDs) 1. Surgery for Bleeding PUD NSAID use and H.pylori infection represent independent and also 2. Perforation synergistic risk factors for uncomplicated and bleeding PUD. 3. Surgery for Gastric Outlet Obstruction Other risk factors include: B. Definitive Procedures: Acid Reducing ○ Genetic variations in pro-inflammatory cytokines 1. Vagotomy ○ Smoking 2. Resection: Partial Gastrectomy ○ Alcohol 3. Reconstructive Procedure/ Surgery ○ Diet possibly related to toxins generated with storage of certain 4. Complications foods such as kimchi or those with high nitrites C. Procedures for Peptic Ulcer Disease ○ Stress ○ Depressive symptoms III Summary ○ Sleep disturbances, lack of sleep IV APA References ○ ICU admissions Recently reported to be associated with COVID-19 infection. V Review Questions ○ Gastrointestinal bleeding is frequently reported in patients with COVID-19. VI Rationalization ○ Peptic ulcer disease is the most common cause of GI LECTURE OBJECTIVES bleeding. Stomach defense are: 1. Correctly diagnose the complication of the disease ○ Creation of mucus 2. Create appropriate initial management plan ○ Bicarbonate secretion 3. Refer to proper specialty for definitive management ○ Increased blood flow 4. Develop the appropriate surgical definitive procedure There are 5 types of gastric ulcer based on location 🧠 Must Know 📖 Book 📝 Previous Trans ○ Only 2 of 5 are related to acid hypersecretion ○ Type II - ulcer is located at the body of the stomach, concomitantly with duodenal ulcer I. PEPTIC ULCER DISEASE ○ Type III - pyloric in location Studies have shown that the world incidence of uncomplicated All other types located elsewhere are usually NOT related to acid peptic ulcer disease (PUD) is approximately 1 case per 1000 hypersecretion such as individuals in the general population. ○ Type I - antrum, ampullaris incisura Incidence of ulcer complications was approximately 0.7 cases per ○ Type IV - lesser curve 1000 individuals. ○ Type V - ulcers that anywhere in the stomach and is usually In the Philippines, according to the latest WHO data in 2020, PUD medication induced or NSAID induced such as aspirin deaths reached 6, 865 or 1.02% of total deaths, ranking the Philippines 12th in the world with PUD as one of the leading B. SYMPTOMS causes of death Common symptom of PUD are: ○ Pain - burning in character, non radiating, epigastric in location ○ Nausea ○ Bloating ○ Weight Loss - when they eat they have pain so they would rather not eat ○ Anemia - occult bleeding happens in chronic ulcers and that blood loss accumulates causing anemia C. MANAGEMENT Initial management is directed in treating underlying etiology: ○ Eradicating H.pylori ○ Discontinuation of NSAID use Approximately 60% heal spontaneously, but with eradication of H.pylori infection, ulcer healing rates are more than 90%. However, even with continued proton-pump inhibitor use, approximately 5% to 30% of peptic ulcers return within the first Figure 1. Peptic Ulcer Disease year based on whether H. Pylori has been successfully eradicated Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Approximately 5 to 10% of ulcers are refractory anti-secretory Duodenum therapy with a PPI Group 4B | Surgical Disorders of the Stomach and Duodenum 1 of 10  The risk of complications in patients with chronic peptic ulcer 2 Happens in 9% of cases. disease is 2 to 3% per year It should be suspected in patients who ○ If left untreated or unresponsive to medical supportive suddenly develop severe diffuse measures, the peptic ulcer disease will progress and will result abdominal pain. in complications of the disease. Hallmark of peptic ulcer perforation: ○ Sudden onset of abdominal pain O ○ Tachycardia ○ Abdominal rigidity Perforation If the perforation is swallowed up, if the gastric fluid is confined by fibrosis, or if the perforation is retroperitoneal, symptoms may be much less severe as compared with intraperitoneal perforations. In such cases, the upper abdominal pain is more insidious, the presentation often delayed, and the abdominal examination is frequently equivocal. 3 Happens in 3% of cases. Gastric outlet obstruction is caused by narrowing of the pyloric channel or duodenum due to repetitive scarring of Figure 2. Shows the yearly incidence of peptic ulcers as percentage of ulcers located in these areas. total number of yearly upper gastrointestinal endoscopies Symptoms develop slowly and include early Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Obstruction satiety, bloating nausea, vomiting, epigastric Duodenum pain shortly after eating, and weight loss. Patients may develop hypokalemic, hypochloremic (acid is HCl), metabolic alkalosis (high in HCl and acid wont pass thru) due to prolonged vomiting and poor fluid intake. E. SUPPORTIVE MEASURES Fluid resuscitation based on hemodynamic status Correction of electrolyte abnormalities Blood Transfusion (bleeding PUD) Acid suppressive therapy with an IV PPI F. DIAGNOSIS/MANAGEMENT Diagnosis of PUD complications is established by endoscopic evaluation and/or abdominal imaging Figure 3. Time trends in the standardized incidences of annual admissions for gastric ulcer and NSPUD Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Duodenum There has been a consistent decrease in the incidence of bleeding and perforation and hospitalization rates due to complications of PUD presumably reflecting the fall in helicobacter pylori prevalence. Figure 4. Endoscopy and Abdominal Imaging Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Duodenum D. COMPLICATIONS 1 In the united states, bleeding is the most 1. IN BLEEDING PEPTIC ULCER common complication of PUD with 73% Upper endoscopy is the best initial diagnostic and therapeutic Patients with bleeding may present with tool. hematemesis. ○ It is diagnostic as it can localize the ulcer inside the stomach It is either red blood or coffee ground and grade the bleeding. emesis, or melena which are black-tarry Identification of the location of the ulcer will help later on in stools. planning what surgical procedure to perform. ○ Coffee ground emesis: happens due Endoscopy is likewise therapeutic because maneuvers to bleeding from the ulcer in the such as clipping, coagulation, chemical injection can stomach. The stomach naturally has facilitate control of bleeders Bleeding hydrochloric acid, and the acid digests Uses epinephrine to promote vasocontriction the heme of the blood which causes the Use two maneuvers to have high chance of controlling the coagulated thick blood bleeding ○ Melena: If the patient doesnt vomit out the coffee ground, it passes through the entire GIT and goes out as melena In rare cases, patients with massive bleeding may present with hematochezia or red or maroon blood in the stool and orthostatic hypertension Group 4B | Surgical Disorders of the Stomach and Duodenum 2 of 10  2. IN PERFORATION A search for a pneumoperitoneum in an initial chest x-ray upright, patient with symptoms of perforation may support the impression. ○ A pneumoperitoneum is air trapped in the diaphragm. Once this finding is discovered on a chest x-ray together with a history of classic triad of abdominal pain, tachycardia and abdominal rigidity, the patient warrants immediate surgical intervention. Figure 5. Forrest’s Classification for PU Bleeding Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Duodenum Table 1. Forrest’s Classification Type Description I Highest risk of rebleeding because arterial jet and oozing in area of ulcer II Moderate chances of bleeding Figure 7. Chest X-ray with Pneumoperitoneum Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and III Lowest rate of rebleeding because healed Duodenum ulcer 3. IN GASTRIC OUTLET OBSTRUCTION Surgery and transcatheterarteriography are generally reserved A whole abdominal CT scan will demonstrate an enlarged for patients with failed therapeutic endoscopy. distended stomach which may occupy the whole abdomen as Many ulcer-related perforations of the stomach and duodenum shown in the image below. require surgical repair. Succussion splash can also be done during physical examination Figure 8. Enlarged distended abdomen Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Duodenum Doctor’s Notes The figure above shows an abdominal CT scan with enlarged distended stomach occupying almost the entire abdomen. In a normal patient, the stomach should be small. The stomach is highly distensible, the mre things o food inside, it will accommodate that. In a long standing obstruction, it will just accumulate through time, just like a balloon that is filled with air until it reaches the maximal capacity. In you see a CT scan like in the above wherein you cannot appreciate the small bowels and colon, all you can see is the stomach, then think some degree of of obstruction. Figure 6. Transcatheterarteriography Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Duodenum Group 4B | Surgical Disorders of the Stomach and Duodenum 3 of 10  Doctor’s Notes Surgical options of PUD range from local therapy that address only the ulcer bed to more definitive ulcer operations. Gastrotomy: area of bleeding is oversown and open up the anterior wall and locate the area of ulcer and lay stitches around the injury and occlude the vessel that causing the bleeding Figure 9. Long-standing Duodenal ulcer in gastric outlet obstruction Source: Dr. Bautista’s Face to Face Lecture Doctor’s Notes The causes of gastric outlet obstruction includes long standing duodenal ulcers or pre-pyloric ulcers. This induces a lot of edema and subsequent scarring, it obstructs the normal passage of gastric contents. It narrows down the movement and causes gastric outlet obstruction leading to symptoms of nausea and vomiting and eventually, abdominal pain if becomes distended Figure 11. Gastrotomy enough. Source: Dr. Bautista’s Face to Face Lecture [BATCH 2025] NOTES FROM FACE-TO-FACE LECTURE If the patient is unresponsive to conservative management, an endoscopic dilatation may be offered. Treatment of the ulcer bed ○ Surgery is reserved for patients with a complete pyloric Most common site of bleeding: posterior wall of duodenum obstruction that cannot be safely dilated or if the obstruction Gastroduodenal artery is located here, which is also located persists or recurs despite endoscopic management. behind the stomach. If the patient is unstable, close the bleeding vessel. No further procedure. 2. PERFORATION Omentum is mobilized and fixed within the ulcer bed to promote healing Clinical feature: sudden onset of pain Figure 10. Endoscopic dilatation Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Procedure is called Graham's Patching Duodenum Doctor’s Notes Along with endoscopy, you insert a catheter that has a balloon on the tip. The catheter is passed through the obstructions and once have laid down the deflated balloon over the are of constriction, you inflate it with either saline or air and push the constriction to force it to open. What happens here is, you break some scar tissue along the pylorus to widen the lumen to accommodate the passage of food from the stomach to the duodenum. Downside of this treatment is that the effects are usually temporary because even if we cut the scar tissue, it will just scar again. When you cut the scar tissue, you are inducing injury and then the bodyl will heal itself and scar again until it will become obstructed again. II. SURGERIES IN PUD The need for elective surgery for Peptic Ulcer Disease (PUD) has Figure 12. (A) Perforation on stomach. (B) Omentum. (C) Suture placement. markedly decreased over the last several decades because of the (D) Omental patching of the perforated site using the tongue of the omentum. development of potent anti-secretive agents (PPIs) and recognition Original Graham’s patch. Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and and treatment of H. pylori infection. Duodenum However, for complications unresponsive to medical therapy and endoscopic techniques, surgery is the mainstay of emergency treatment of these life-threatening conditions. Doctor’s Notes Surgical options of PUD range from local therapy that address only A flap of omentum is plugged into the perforation. the ulcer bed to more definitive ulcer operations. For example, in the duodenum an omentum is plugged on the perforation and stitches are lay down to hold the omentum in place. A. ULCER BED MANAGEMENT Surgical options of PUD range from local therapy that address only the ulcer bed to more definitive ulcer operations. [BATCH 2025] NOTES FROM FACE-TO-FACE LECTURE Select a viable omentum with good vascularity to prevent the 1. SURGERY FOR BLEEDING PUD necrosis of the flap. Complication is bleeding Debride the edges of the hole of the perforation for clean Bleeding vessel is sutured and ligated coaptation. Modified Graham’s patch: The defect is sutured first then swing Group 4B | Surgical Disorders of the Stomach and Duodenum 4 of 10  omentum to the site and the same sutures are then tied over the omental graft to anchor it. Others say that graham’s patch is more stable than the modified graham’s patch because the modified patch is just laid on the sutured defect which could be floppy and leave the site. 3. SURGERY FOR GASTRIC OUTLET OBSTRUCTION For ulcers producing a gastric outlet obstruction, a bypass procedure is performed. A loop of jejunum is swung up and anastomosed to the greater curve of the stomach, avoiding the narrow lumen of the pyloric Sphincter. This is called the gastrojejunal bypass. Figure 14. Vagotomy Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Duodenum In vagotomy, vagus nerves are severed, leading to denervation of the pyloric sphincter and loss of motor function. A drainage procedure must therefore be performed following vagotomy to permit outflow gastric contents. ○ An exception to this is the highly selective vagotomy because the branches of the vagus nerves in this area are preserved. Doctor’s Notes The more definitive procedures are vagotomy and drainage Vagotomy ○ A procedure that divides the vagus nerve along different parts Figure 13. Gastrojejunostomy of its course Source: Dr. Bautista’s Lecture on Surgical Disorders of the Stomach and Vagus nerve Duodenum ○ Delivers parasympathetic innervation to the pylorus ○ Pylorus is a spinchter composed of longitudinal and circular Doctor’s Notes muscle layers, the circular muscle layers are usually A more definitive treatment is gastrojejunostomy. contracted Only do this as long as you are 100% sure that you are not ○ When vagus nerve fires, it delivers parasymphathetic dealing with malignancy and it is just a benign stricture. innervation; it will relax the pylorus and opens up the channel For example, if you do your endoscopy and see a scarred down ○ If you cut the vagus nerve, function of relaxation of pylorus is pyloric channel, and biopsies are benign, you can perform a loss gastrojejunostomy. ○ When you do a vagotomy/cut the vagus nerve, we also do In gastrojejunostomy, you just attach the lesser curve of the drainage procedures; it is always vagotomy and drainage stomach (Point A) to the jejunum. You bypass the duodenum There are different kinds of drainage procedures: already. When you attach Point A, the lesser curve to the 1. ANTRECTOMY proximal jejunum, you create an ostomy - connection between Remove the antrum or the distal portion of the stomach, two lumen, then eventually the food and other contents will follow usually