surg-treat-peptic-ulcer

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Surgical management of :

1 Surgical management of peptic ulcer & it’s complications

SURGICAL LINE OF MANAGEMENT:

SURGICAL LINE OF MANAGEMENT INDICATIONS INTRACTABLE PAIN INSPITE OF MEDICAL TREATMENT FREQUENT RELAPSES COMPLICATIONS GASTRIC OUTLET OBSTRUCTION HAEMORRHAGE 2

CHRONIC DUODENAL ULCER:

CHRONIC DUODENAL ULCER RATIONALE TO EXCLUDE THE DAMAGING EFFECTS OF ACID FROM DUODENUM ACHIEVED BY *DIVERSION OF ACID AWAY FROM DUODENUM *REDUCING THE SECRETORY POTENTIAL OF THE STOMACH *(OR) BOTH w 3

CHRONIC DUODENAL ULCER:

CHRONIC DUODENAL ULCER BILLROTH 2 GASTRECTOMY GASTROJEJUNESTOMY TRUNCAL VAGOTOMY AND DRAINAGE SELECTIVE VAGATOMY AND DRAINAGE HIGHLY SELECTIVE VAGOTOMY TRUNCAL VAGOTOMY AND ANTRECTOMY 4

CHRONIC GASTRIC ULCER:

CHRONIC GASTRIC ULCER RATIONALE TO REDUCE DUODENAL ACID EXPOSURE TO REMOVE THE DISEASED TISSUE REMOVAL HAS THE ADVANTAGE THAT THE MALIGNANCY CAN BE CONFIDENTLY EXCLUDED 5

CHONIC GASTRIC ULCER:

CHONIC GASTRIC ULCER BILLROTH 1 GASTRECTOMY BILLROTH 2 GASTRECTOMY VAGOTOMY, PYLOROPLASTY AND ULCER EXCISION 6

PROCEDURES:

PROCEDURES 7

BILLROTH 2 GASTRECTOMY:

BILLROTH 2 GASTRECTOMY POLYA GASTRECTOMY - 2/3 ‘s OF THE STOMACH IS REMOVED, THE DUODENAL STUMP IS CLOSED AND THE STOMACH ANASTOMOSED TO THE JEJENUM. 8

HISTORY:

HISTORY 1 ST SUCCESSFUL GASTRECTOMY WAS PERFORMED IN 1881 BY BILLROTH 1 ST GJ IN 1881 BY WOLFER 9

DESCRIPTION OF GJ:

DESCRIPTION OF GJ PVRING P OSTERIOR V ERTICAL R ETROCOLIC I SOPERISTALYTIC N OLOOP, N OTENSION(MINIMAL) G ASTROJEJUNOSTOMY www.similima.com 10

PowerPoint Presentation:

www.similima.com 11 BILLROTH 2 GASTRECTOMY

GASTROJEJUNOSTOMY:

GASTROJEJUNOSTOMY THE JEJENUM IS ANASTOMOSED TO THE POSTERIOR DEPENDENT, WALL OF THE STOMACH. BECAUSE OF POTENTIAL FOR MORTALITY AFTER GASTRECTOMY REFLUX OF ALKALI FROM SMALL BOWEL INTO STOMACH HEALED THE ULCER COMLICATION IS STOMAL ULCERATION DUE TO DIRECT EXPOSURE OF JEJUNAL LOOP TO ACID www.similima.com 12

PowerPoint Presentation:

www.similima.com 13

TRUNCAL VAGOTOMY AND DRAINAGE:

TRUNCAL VAGOTOMY AND DRAINAGE PRINCIPLE ; SECTION OF VAGUS NERVES , WHICH ARE CRITICALLY INVOLVED IN THE SECRETION OF GASTRIC ACID , REDUCES THE MAXIMAL ACID OUTPUT BY APPROXIMATELY 50 %. 1 ST IN 1943 BY DRAGSTED MOTOR TO STOMACH DENERVATION CAUSES GASTRIC STASIS SHOULD BE COMBINED WITH A DRAINAGE PROCEDURE www.similima.com 14

DRAINAGE PROCEDURE:

DRAINAGE PROCEDURE HEINEKE-MIKULICZ PYLOROPLASTY GASTROJEJUNOSTOMY www.similima.com 15

TRUNCAL VAGOTOMY:

TRUNCAL VAGOTOMY www.similima.com 16

SELECTIVE VAGOTOMY & DRAINAGE:

SELECTIVE VAGOTOMY & DRAINAGE HEPATIC &CELIAC BRANCHES OF ANT. VAGUS ARE PRESERVED BUT THE STOMACH IS STILL COMPLETELY DENERVATED ALL THE DISADVANTAGES OF TRUNCAL VAGOTOMY BUT NOT THE MERIT OF SIMPLICITY www.similima.com 17

HIGHLY SELECTIVE VAGOTOMY :

HIGHLY SELECTIVE VAGOTOMY PARIETAL CELL VAGOTOMY PROXIMAL GASTRIC VAGOTOMY 1968 JOHNSTON & AMDRUP ONLY THE PARIETAL CELL MASS OF THE STOMACH IS DENERVATED. MOST SATISFACTORY OPERATION LOSS OF RECEPTIVE RELAXATION OF STOMACH,EPIGASTRIC FULLNESS RECURRENT ULERATION IS ACHILLE’S HEEL OF THIS OPERATION www.similima.com 18

POINTS TO PONDER:

POINTS TO PONDER NERVES OF LATERJET SUPPLYING THE ANTRUM SHOULD BE PRESERVED COMPLETE NEUROVASCULAR CLEARANCE OF THE PROXIMAL LESSER CURVE& LOWER 7CMS OF THE OESOPHAGUS CRIMINAL NERVE OF GRASSI PASSES POSTERIORLY TO SUPPLY THE GREATER CURVE ,SHOULD BE TAKEN CARE OF www.similima.com 19

VAGOTOMY AND ANTRECTOMY:

VAGOTOMY AND ANTRECTOMY ADDITION TO TRUNCAL VAGOTOMY , THE ANTRUM OF THE STOMACH IS REMOVED , THUS REMOVING THE SOURCE OF GASTRIN. LEAST RECURRENCE RATE 3-4 % MORTALITY RATE TRUNCAL VAGOTOMY+ANTRECTOMY+ GASTRODUODENOSTOMY www.similima.com 20

SURGERIES FOR GU:

SURGERIES FOR GU www.similima.com 21

BILLROTH 1 GASTRECTOMY:

BILLROTH 1 GASTRECTOMY STANDARD OPERATION FOR GASTRIC ULCERATION UNTILL MEDICAL TREATMENT BECAME AVAILABLE PARTIAL GASTRECTOMY IS DONE INCLUDING REMOVAL OF ULCER FOLLOWED BY GASTRODUODENAL ANASTOMOSIS. www.similima.com 22

BILLROTH 2 GASTRECTOMY:

BILLROTH 2 GASTRECTOMY HIGH AND LESSER CURVE GASTRIC ULCERS WHERE A GJ IS TECHNICALLY NOT FEASIBE www.similima.com 23

COMPLICATIONS OF PUD:

COMPLICATIONS OF PUD 1.PERFORATION 2.PERITONITIS 3.PENETRATION 4.BLEEDING 5.GASTRIC OUTLET BOSTRUCTION www.similima.com 24

PERFORATION:

PERFORATION INCIDENCE HAS CHANGED LITTLE EPIDEMIOLOGY PREVIOUSLY MIDDLE AGED , M:F RATIO 2:1 NOW COMMON IN ELDERLY FEMALES MC CAUSE NSAIDS www.similima.com 25

CLINICAL FEATURES:

CLINICAL FEATURES H/O PEPTIC ULCER SUDDEN ONSET SEVERE GENERALISED ABDOMINAL PAIN(IRRITANT EFFECT OF ACID ON PERITONEUM) BACTERIAL PERITONITIS IN FEW HOURS TACHYCARDIA TEMPERATURE HYPOTENSION P/A BOARD LIKE RIGIDITY , NO MOVE MENT WITH RESPIRATION www.similima.com 26

VARIATIONS:

VARIATIONS ELDERLY PT. ON NSAIDS NO CLASSICAL PRESENTATION SMALL LEAK - MAY PRESENT WITH PAIN IN EPIGASTRIUM & RT .ILIAC FOSSA SEALED PERFORATIONS www.similima.com 27

INVESTIGATIONS:

INVESTIGATIONS T.C D.C S.AMYLASE ERECT PLAIN CHEST RADIOGRAPH WATER SOLUBLE CONTRAST SWALLOW DPL CT SCAN www.similima.com 28

TREATMENT:

TREATMENT RESUSCITATION SURGERY OPEN LAPAROSCOPIC www.similima.com 29

PowerPoint Presentation:

30 THANKYOU

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