dr. k. raghu dissertation

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duodenal ulcer perforation

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HISTORY AND INTRODUCTION

The perforation of duodenal ulcer is one of the commonest abdominal surgical emergencies met with in this part of the country, more so in southern rice eating belt. The incidence of duodenal ulcer perforation is found to be increasing. Nowadays varied views are put forth regarding its treatment. The History of our knowledge of peptic ulcer was reviewed by Jordan in 1985. Rawlingson is credited with the 1st published report of a perforated gastric ulcer in 1727. The first published report of a perforated duodenal ulcer was by Hambergeri in 1746. Although Muralto described a perforated duodenal ulcer in 1688. A report of this case by Lenepneau did not occur until 1839. The frequency of peptic ulceration increases steadily with age: therefore apparent rarity of the disease before twentieth century was due to the generally short life expectancy at that time. In 1857 Brinton was able to collect only 234 reported cases of perforated ulcer, all gastric. During the next 100 years there was an increase in the prevalence of peptic ulceration especially duodenal ulcers. Illing worth and his colleagues showed that the incidence of perforated ulcer in Glasgow doubled between 1924 and 1938 and similar rise was observed in other cities in Great Britain. Braun, Von Mikulicz, Von Herber, Moynihan, Cleave, C.W. Mayo, Zacharycope, Rodney Maingot, De Bekey and others have thrown much light in this subject with their inexhaustible and vast experience and helped one to avoid usual pitfalls in the management of duodenal. Ulcer perforation. It is well said more experience in the causalities. A person is the better surgeon, he is to deal with Abdominal emergencies.

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Since the first report of successful operation for X the perforated duodenal ulcer (Dean 1894) by simple closure, the treatment of this catastrophic abdominal emergency remained the same till today. Many follow-up studies between 1945 to 1965 indicated that simple suture of perforated duodenal ulcer often fall short of being the ideal treatment (IIIing worth et al, 1946; Avery Jones and Doll, 1953; Gilmour, 1953; Hadfield and Hatkins, 1964; Harbecht and Hamilton 1960). Poor results either troublesome dyspepsia or other complications that necessitated further surgical treatment were found in 50-70% patients. Griffin and Organ (1976) in a study of natural history of perforated duodenal ulcer treated by suture placation found that only 17 in 120 patients (14%) were asymptomatic in the long term follow-up. Henessy and associates (1076) in Australia, showed x that almost 90% of the cases subsequently suffered from dyspepsia. They also found that one patient in five bled during follow-up, one in eight developed pysoric stenosis and one in eleven perforated again. On reviewing the literature on duodenal ulcer perforation, I chose this topic for my dissertation work in consultation with my professors and assistant professors.

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SURGICAL ANATOMY OF STOMACH AND DUODENUM 1,2,3,4STOMACH: It is the largest dilatation of the gut and lies between the esophagus and duodenum. It lies in the upper part of the abdomen beneath the diaphragm and mainly to the left of the midline. It has got two surfaces, i.e. anterior and posterior and two curvatures, i.e. lesser and greater. The stomach can be divided into fundus, body and antrum. The fundus is the dome of the stomach to the left and superior to the oesophagogastric junction. An angulation at the midline of the body, approximately 5-6 cm. proximal to the pylorus on the lesser curvature is called the incisura angularis. The body of the stomach is the area between the fundus and line drawn from the incisura angularis to the greater curvature. The gastric anturm is the area distal to the line and proximal to the pylorus. The pylorus is a thick ring of muscle and is externally marked by the vein of Mayo. The oesophagogastric junction, the cardia, is located just to the left of the tenth thoracic vertebra and the gastro duodenal junction, the pylorus, is located to the right of the midline at about the inter space between the first and second lumbar vertebrae (transpyloric plane). The superior margin of the stomach between the cardia and pylorus (12-14 cm) is the lesser curvature, which is suspended from the liver by the gastrohepatic ligament. The inferior and lateral convex border of the stomach is the greater curvature, which is about 3 times as long as the lesser curvature. Gastrocolic ligament is suspended from the major protion of the greater curvature.

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Relations: Anterosuperior surface; it is in contact with the left lobe of the liver and under surface of the diaphragm and some times to the anterior abdominal wall. Posteroinferior surface; it is related to many structures forming stomach bed viz., spleen, left adrenal, left kidney, splenic flexure of colon, anterior surface of the pancreas, upper surface of transverse mesocolon, splenic artery, portal vein and part of the diaphragm. BLOOD SUPPLY: The stomach is endowed with copious blood supply through the branches of coelian axis. The left and right gastric arteries supply the area of lesser curvature. The left gastric artery arises from celiac axis and the right gastric artery is a branch of hepatic artery. The right and left gastro epiploic arteries supply the area of greater curvature. The right is the branch of gastro duodenal artery and left is from splenic artery. The splenic artery supplies the area of fundus through its short gastric arteries. The gastro duodenal artery sends branches to the area of pylorus. VENOUS DRAINAGE: The veins accompany arteries and drain into portal vein either directly of indirectly through splenic or superior mesenteric veins. LYMPHATIC DRAINAGE For the purpose of description of lymphatic drainage, the stomach is divided into three lymphatic areas. It is divided by an imaginary line in its long axis, 2/3rd of the stomach is further divided by an imaginary transverse line at the junction of its upper 1/3rd with lower 2/3rd. (1) The lymphatics of upper right 2/3rds of the stomach along the lesser

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Curvature drain into the superior gastric group of nodes which include paracardiac nodes around the oesophagogastric junction. The supra pyloric nodes receive lymph from the lesser curvature belong to the inferior gastric group and subpyloric group. The receive lymph from the left lower 2/3rds of the stomach along the greater curvature. 3) The lymphatics from the left upper 1/3 of the stomach drain into the pacreaticoleinal group. Efferents from all three groups drain into celiac lymph nodes around the celiac trunk in front of the aorta. NERVE SUPPLY: The stomach derives its parasympathetic (secretomotor) nerve supply from both the vaginas the anterior and posterior gastric nerves which are derived from the left and right vagi respectively. The sympathetic nerve supply is derived from celiac plexus and accompany the arteries. The left vagus passes into the abdomen in front of the esophagus an anterior vagus nerve and supply the anterior wall of stomach. branches to the liver and gall-bladder. It sends The nerve usually divides into

branches at a point 5-7cms. Proximal to the pylorus and supply the pyloric antrum (Crows foot). These terminal branches are preserved in highly selective vagotomy. This nerve supplies the acid-pepsin secreting areas of the stomach. The right vagus passes through the oesophageal hiatus behind the esophagus as posterior vagus nerve and supplies posterior wall of the stomach which sends branch to the celiac axis. The criminal nerve of Grassi is the name given to the branch or branches of posterior vagus that arises at or above the level gastrooesophageal junction and supply the fundus of stomach. It has got an important role in the etiology of the recurrent peptic ulcer, when it is not divided.

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These nerves play major role in intermittent propulsion of gastric contents by the antrum through the pyloric canal into the duodenim. STRUCTURE: The wall of the stomach is composed of four layers, viz. mucosa, submucosa, muscle layer and serosa. The serosal layer (visceral peritoneum) completely invests the stomach except at its curvatures where it passes as double layer as hepatico gastric ligament from lesser curvature and gastro colic ligament from greater curvature and gastro splenic ligament from the left border of the fundus. The muscular coat has got 3 layers, viz., outer longitudinal, middle circular and inner oblique layers. The submucosa is a loose areolar tissue situated in between the mucosa and muscular coats which allows free mobility of mucosa over the muscular later. The mucosa of the stomach is smooth and red. It is thrown into longitudinal folds which disappear when the stomach is greatly distended. Mucosal architecture varies with the area of stomach. The fundic mucosa consists of deep tubular glands lined superficially with epithelial cells and containing in the deeper portions, characteristic parietal cells and chief cells with occasional argentaffin cells. The pyloric and antral mucosa consists of branching tubules lined predominantly with mucous cells and gastric cells. Several types of cells present in the mucosa of stomach with specific functions. Parietal Cells Chief Cells Goblet cells Epithelial Cells Secretion of Hydrochloric acid and intrinsic factor. Synthesize and secrete pepsinogen. Secrete mucus. Probably secrete extra cellular fluid (non-parietal Secretion)

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Gastrin Cells Mast Cells Argentaffin Cells

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Synthesize store and secrete somatostatin. Store heparin, histamine and other vasoactive substances within granules. May Synthesize and store enteroglucagon and other peptide hormones.

The

junction

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antral

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fundic

mucosa

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differentiated on Gross inspection