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GS18 General Surgery and Thoracic Surgery Stomach and Duodenum Toronto Notes 2019
Billroth I
Billroth II
(II=2 limbs) – distal gastrectomy + gastrojejunostomy
Ligament of Treitz
Roux-en-Y
Ligament of Treitz
© Jerusha Ellis after Sonya Amin 2012
Figure 9. Billroth I and Billroth II with Roux-en-Y reconstruction (gastrojejunostomy)
Kissing Ulcer: combination of perforation and bleeding
Complications of Treatment
• airleak:mayrequirereintubationandmechanicalventilation • arrhythmias, pneumonia
Prognosis
• worseearlymortalitybutbetterexercisecapacityandqualityoflifewithLVRS
Stomach and Duodenum
Peptic Ulcer Disease
GASTRIC ULCERS
• seeGastroenterology,G11
Indications for Surgery
• refractorytomedicalmanagement
• suspicion of malignancy (even if biopsy benign)
• complicationsofPUD:obstruction,perforation,andbleeding(3xgreaterriskcomparedtoduodenalulcers) • surgeryincreasinglyrareduetoH.pylorieradication,medicaltreatmentandendoscopictreatments
(injection therapy with adrenaline, polidocanol or fibrin glue) or coagulation therapy (heater probe or argon plasma)
Procedures
• ligationofbleedingvessels
• distal gastrectomy with ulcer excision: Billroth II, Roux-en-Y gastrojejunostomy or Billroth I (rarely)
reconstruction
• vagotomyandpyloroplastyonlyifacidhypersecretion(rare) • wedgeresectionifpossibleorbiopsywithprimaryrepair
DUODENAL ULCERS
• seeGastroenterology,BleedingPepticUlcer,G12,andPepticUlcerDisease,G11 • mostwithin2cmofpylorus(duodenalbulb)
Indications for Surgery
• hemorrhage,rebleedinhospital,perforation,gastricoutletobstruction • refractorytomedicalandendoscopicmanagement
Procedures
• omental(Graham)patch:plicationofulcersupportedbyoverlyingomentalpatch • oversewingofbleedingulcer±pyloroplasty
• treatwithH.plyorieradicationprotocolpostoperatively
Complications of Gastric Surgery
• retainedantrum
• fistula(gastrocolic/gastrojejunal)
• dumpingsyndrome,postvagotomydiarrhea,afferentloopsyndrome
(I=1 limb) – distal gastrectomy + gastroduodenostomy
Table 5. Complications of Duodenal Ulceration
Complication
Perforated Ulcer
(typically on anterior surface)
Posterior Penetration Hemorrhage (typically
on posterior surface)
Gastric Outlet Obstruction
Clinical Features
Sudden onset of pain (possibly in RLQ due to track down right paracolic gutter)
Acute abdomen: rigid, diffuse guarding
Ileus
Initial chemical peritonitis followed by bacterial peritonitis
Elevated amylase/lipase if penetration into pancreas Constant mid-epigastric pain burrowing into back, unrelated to meals
Gastroduodenal artery involvement
Ulcer can lead to edema, fibrosis of pyloric channel, and neoplasm
N/V (undigested food, non-bilious), dilated stomach, and crampy abdominal pain
Succussion splash (splashing noise heard with stethoscope over the stomach when patient is shaken) Auscultate gas and fluid movement in obstructed organ
Management
Investigation
CXR – free air under diaphragm (70% of patients)
Treatment
Oversew ulcer (plication) and omental (Graham) patch – most common treatment
Resuscitation initially with crystalloids; blood transfusion if necessary Diagnostic and/or therapeutic endoscopy (laser, cautery, or injection); if recurs, may have second scope
Consider interventional radiology: angiography with embolization/ coiling
Surgery if severe or recurrent bleeding, hemodynamically unstable, or failure of endoscopy and IR: oversewing of ulcer, pyloroplasty
NGT decompression and correction of hypochloremic, hypokalemic metabolic alkalosis
Medical management initially: high dose PPI therapy
Surgical resection if obstruction does not resolve: either Billroth I, pyloroplasty, or gastrojejunostomy