DISEASES OF THE OPERATED STOMACH

PYLORUS

1. Distal muscular loop;2. Proximal muscular loop.

AGGRESSIVE FACTORS

hydrochloric acid pepsin reverse diffusion of ions of hydrogen products of lipid hyperoxidation

DEFENSE FACTORS

mucus and alkaline components of gastric juice

property of epithelium of mucous tunic to permanent renewal

local blood flow of mucous tunic and submucous membrane

PATHOMORPHOLOGY

erosion acute ulcers chronic ulcers

CLASSIFICATION by Johnson (1965)

I – ulcers of small curvature (for 3 cm higher from a goalkeeper);

II– double localization of ulcers simultaneously in a stomach and duodenum;

III – ulcers of goalkeeper part of stomach (not farther as 3 cm from a goalkeeper)

CLINICAL MANAGEMENT

Pain Vomiting Heartburn Belching

COMPLICATIONS

Penetration Stenosis Perforation Bleeding Malignization

DIAGNOSIS PROGRAM

1. Anamnesis and physical examination. 2. Endoscopy. 3. X-Ray examination of stomach. 4. Examination of gastric secretion by the method of aspiration of

gastric contents. 5. Gastric pH metry. 6. Multiposition biopsy of edges of ulcer and mucous tunic of

stomach. 7. Gastric Dopplerography. 8. Sonography of abdominal cavity organs. 9. General and biochemical blood analysis. 10. Coagulogram.

X-Ray examination

THE DIRECT SIGNS: symptom of “Haudek's niche” ulcerous billow and convergence of folds of mucous tunic.

INDIRECT SIGNS: symptom of “forefinger” (circular spasm of muscles) segmental hyperperistalsis, pylorospasm, delay of evacuation from a stomach duodenogastric reflux disturbance of function of cardial part (gastroesophageal reflux).

SYMPTOM OF “Haudek's niche”

STENOSIS OF THE GASTRO-ENTERO-ANASTO-MOSIS

GASTROSCOPY

DEVICE FOR GASTRIC DOPPLEROGRAPHY

Endoscopic picture of the normal stomach wall

Endoscopic picture of the peptic ulcer

SURGICAL TREATMEN

a) at the relapse of ulcer after the course of conservative therapy; b) in the cases when the relapses arise during supporting antiulcer

therapy; c) when an ulcer does not heal over during 1,5–2 months of

intensive treatment, especially in families with “ulcerous anamnesis”;

d) ulcer with complications (perforation or bleeding); e) at suspicion on malignization ulcers, in case of negative

cytological analysis.

Classification of the postgastrectomy syndromes

Functional disturbance.– Dumping.– Hypoglycemic syndrome.– Postgastrectomy (agastric) asthenia.– Syndrome of small stomach.– Syndrome of afferent loop (functional origin).– Gastroesophageal reflux.– Alkaline reflux-gastritis.

Organic disturbances.– Pepticulcer of anastomosis.– Gastro-colon fistula.– Syndrome of afferent loop (mechanical variant).– Cicatricial deformation and narrowing of anastomosis.– Mistakes in the technique of operation.– Postgastrectomy accompanying diseases (pancreatitis, enterocolitis,

hepatitis). Mixed disturbances.

– combination with dumping or postvagotomy diarrhea.

Billroth I and Billroth II resection

Billroth II resection

BILLROTH II RESECTION

BILLROTH II RESECTION

BILLROTH I RESECTION

BILLROTH I RESECTION:

Gastrectomy by B-II

Distal resection of the stomach with saving of the perigastral vessels

1

2 4

3

Aiming resection of the ischemic segment of stomach in combination with SPV (by L.J. Kovalchuk)

1. межі резекції перехідного сегмента шлунка;

2. формування гастро-гастроанастомозу: задня і передня губа;

3. остаточний вигляд сформованого гастро-гастроанастомозу.

1

2

3

Proximal resection of the stomach

1. межі резекції;2. завершений вигляд

оперованого шлунка.

Proximal subtotal resection of the somach

1. схема операції;2. перерізання шлунка;3. перерізання

абдомінального відділу стравоходу.

Gastrectomy (А – scheme; Б – end view)

1. Esophago-jejunuanastomosis;

2. Entero-entroanastomosis.

Degrees of weight of the dumping syndrome

I degree – easy

Patients have the periodic attacks of weakness with dizziness, nausea, that appear after the use of carbohydrates and milk food and last no more than 15–20 min. During the attack a pulse becomes more frequent on 10–15 per min., arterial pressure rises or sometimes goes down on 1.3-2 KPa (10–15 mm Hg), the volume of circulatory blood diminishes on 200–300 ml. The deficit of mass of body of patient does not exceed 5 kg.

Degrees of weight of the dumping syndrome

ІІ degree – middle weight

Attacks of weakness with dizziness, pain in the region of heart, hyperhidrosis, diarrhea. Such signs last, usually, 20–40 min., arise up after the use of ordinary portions of some food. During such state a pulse becomes more frequent on 20–30 per min., arterial pressure is rises (sometimes goes down) on 2–2,7 KPa (15–20 mm Hg), the volume of circulatory blood diminishes on 300–500 ml. The deficit of mass of body of patient achieves 5–10 kg. A working capacity is reduced. Conservative treatment sometimes has a positive effect, but brief.

Degrees of weight of the dumping syndrome

ІІІ degree – hard

Patients are disturbed by the permanent, acutely expressed attacks with the collaptoid state, by a fainting fit, by diarrhea, which do not depend on character and amount of the accepted food and last about 1 hour. During the attack is multiplied frequency of pulse on 20–30 per 1 min; arterial pressure goes down on 2,7–4 KPa (20–30 mm Hg), the volume of circulatory blood diminishes more than on 500 ml. The deficit of mass of body exceeds 10 kg.

Dumping syndrome (quick evacuation of the contrast)

Depending on reasons and mechanisms of development of dumping syndrome there are different methods of the repeated reconstructive operations.

All of them can be divided into four basic groups:

Operations which slow evacuation from stump of stomach.

Redoudenization. Redoudenization with deceleration of evacuation

from stump of stomach. Operations on a thin bowel and its nerves.

Basic stages of reconstructive operations

disconnection of adhesions in an abdominal cavity, releasing of gastrointestinal and interintestinal anastomosis and stump of duodenum;

cutting or resection of efferent and afferent loops; renewal of continuity of upper part of digestive tract.

Hypoglycemic syndrome The attacks of weakness at a hypoglycemic syndrome arise up as a

result of decline of content of sugar in a blood.

І stage Signs beghins after 2-2,5 h after food intake, 2-3 times per week. Patients does not feel it.

ІІ stage Signs beghins 2-3 times per week.

ІІІ stage Signs beghins every day. Patients always has sweet food and bread.

Distinguished easy, middle and heavy degrees of afferent loop syndrome

easy vomiting is 1–2 times per a month, and insignificant regurgitation arise up through 20 min – 2 hour after a food, more frequent after the use of milk or sweet food.

middle attacks repeat 2–3 times per week, patients are disturbed by the considerably expressed pain syndrome, and with vomiting up to 200–300 ml of bile is lost.

heavy the daily attacks of pain are typical, that is accompanied by vomiting by a bile (up to 500 ml and more).

All operative methods of treatment of afferent loop syndrome can be divided into three

groups:

Operations, that will liquidate the bends of afferent loop or shorten it.

Drainage operations. Reconstructive operations.

CLASSIFICATION

I. By etiology: А. True duodenal ulcer. B. Symptomatic ulcers.

II. By passing of disease: 1. Acute (first exposed ulcer). 2. Chronic:

a) with the rare exacerbation; b) with the annual exacerbation; c) with the frequent exacerbation (2 times per a year

and more frequent).

CLASSIFICATION

III. By the stages of disease: 1. Exacerbation. 2. Scarring:

a) stage of “red” scar; b) stage of “white” scar.

3. Remission. IV. By localization:

1. Ulcers of bulb of duodenum. 2. Low postbulbar ulcers. 3. Combined ulcers of duodenum and stomach.

CLASSIFICATION

V. By sizes: 1. Small ulcers up to 0,5 cm. 2. Middle — up 1,5 cm. 3. Large — up to 3 cm; 4. Giant ulcers over 3 cm.

VI. By the presence of complications: 1. Bleeding. 2. Perforation. 3. Penetration. 4. Organic stenosis. 5. Periduodenitis.6. Malignization.

CLINICAL MANAGEMENT

Pain Vomiting Heartburn Belching

DUODENOSCOPY

SYMPTOM OF “Haudek's niche”

STENOSIS

DIAGNOSIS PROGRAM

1. Anamnesis and physical examination. 2. Endoscopy. 3. X-Ray examination of stomach and duodenum. 4. General and biochemical blood analysis. 5. Coagulogram.

METHODS OF SURGICAL TREATMENT

organ-saving operations; organ-sparing operations; resection.

TRUNK VAGOTOMY (TrV)

2 4

3SELECTIVE VAGOTOMY (SV)

SELECTIVE PROXIMAL VAGOTOMY (SPV)

SELECTIVE PROXIMAL VAGOTOMY (SPV)

Heineke-Mikulicz pyloroplasty

Heineke-Mikulicz pyloroplasty

GASTRODUODENOSTOMY BY JABOULAY

Finney pyloroplasty

Classification of the postvagotomy syndromes

Relapse of ulcer. Diarrhea. Disturbance of function of esophagocardial transition. Disturbance of emptying of stomach. Dumping syndrome. Reflux-gastritis. Gallstone disease.

Postvagotomy gastrostasis