2. UPCOMING SLIDES INCLUDE
• INTODUCTION
• BASIC ANATOMY OF STOMACH
• GASTRIC SECRETION PHYSIOLOGY
• APPROACH TO HVP CASE
• SURGICAL MANAGEMENT OF GASTRIC PERFORATION
• COMPLICATIONS
• CONCLUSION
3. INTRODUCTION
• Perforation of the stomach is a full-thickness injury of the wall of the
organ.
• The peritoneum completely covers the stomach and so perforation
of the wall creates a communication between the gastric lumen and
the peritoneal cavity.
• If the perforation occurs acutely, there is no time for an
inflammatory reaction to wall off the perforation, and the gastric
contents freely enter the general peritoneal cavity, causing chemical
peritonitis.
• Perforations occurring over a prolonged period may be contained
locally by the inflammatory reaction.
4. • Elective and emergency operations for benign gastric ulcer disease
has decreased over the decades.
• Annual incidence of peptic ulcer disease 0.1-3% (300,000 new
cases per year), ½ gastric ulcers
• Pharmacologic therapy for acid hypersecretion and H. pylori
treatment is the primary reason for reduction in surgical
intervention.
15. FATE OF H.PYLORI INFECTION
• H. pylori, a group 1 carcinogen can lead to gastric adenocarcinoma
through a sequence of pathology starting from
• In patients with mucosa-associated lymphoid tissue (MALT) lymphoma, H.
pylori has been seen in more than 75% of cases.
• H. pylori testing is recommended in children having first-degree relatives
with gastric cancer.
Gastritis => atrophy => intestinal metaplasia => dysplasia => carcinoma.
16. ULCER OR PERFORATION SITE
PREDICTION WITH HISTORY
• Peptic ulceration is typically characterized by non-radiating epigastric
pain described as burning or stabbing.
• Referral of pain to the back may indicate posterior penetration of the
ulcer.
• H/O pain in relation to eating:
with duodenal ulcer pain relieved by eating,
gastric or marginal ulcer pain worsens with food intake.
17. ROLE OF UGIE
• About 10% of gastric ulcers are malignant or associated with malignancy,
so aggressive biopsy and brushings, as well as careful follow-up to
demonstrate healing, are mandatory.
• All gastric ulcers should undergo multiple biopsies, obtained from the
perimeter of the lesion.
• The addition of endoscopic brushings to multiple biopsies increases
diagnostic accuracy to approximately 95%.
18. SIGNS AND SYMPTOMS IN HVP
• Perforated Peptic ulcer-Sudden-onset, severe,
• Generalised abdominal pain-
• Tachycardia-
• Board-like rigidity-
• Distension-
• Obstipation-
• Fever(not initially)-
• Hypotension (later stage)
• POSTERIOR WALL PERFORATION USUALLY PRESENT LATER
THAN ANTERIOR WALL PERFORATION.
19. POSTERIOR WALL GASTRIC ULCERS PERFORATE AND THEY LEAK GASTRIC CONTENTS
INTO THE LESSER SAC, WHICH TENDS TO CONFINE THE PERITONITIS.
23. • 37-year-old woman with perforated gastric ulcer. Focal defect in lesser curvature of gastric
body is caused by deep ulcer (arrow) associated with surrounding mural thickening. Note
small air bubble (arrowhead) on anterior peritoneal surface of liver.
27. CURRENTINDICATIONFOR SURGICAL
INTERVENTION
1. Bleeding Most Common Complication
• 100 per 100.000 population
2. Perforation 11 per 100.000 population
• highest rate of mortality
3.Obstruction scarring of prepyloric and duodenal ulcers
4. Failed Medical therapy PPIs
5. Risk of Malignancy large gastric ulcers
28. ROLE OF SURGICAL MANAGEMENT
• The prognosis is improved if treatment is provided within 6 hours of
perforation.
• Delay in treatment beyond 12 hours an increase in both morbidity and
mortality.
• A prospective study of patients perforations >48 hours, pre-operative
shock, and concurrent medical illness were associated with an increase in
mortality.
• Emergency surgery for a perforated peptic ulcer has a 6–30% risk of
mortality.
29. “ Do not stitch the perforation but
plug it with viable omentum and
patch a perforation ulcer if you can,
if you cannot, then you must resect”
( Mosche Schein)
32. SURGICAL MANAGEMENT
• Primary repair: The defect is primarily closed with suture, this is
appropriate for most traumatic perforations.
• Cellan-jones repair: The defect is simply plugged with a well-
vascularized omental pedicle and sutured.
• Graham patch repair: The ulcer is closed with omental cut patch
(no vascularity).
IN BOTH THESE METHODS PERFORTAION SITES ARE NOT CLOSED
WITH PRIMARY REPAIR.
33. • Karanjia technique: modified Cellan-Jones: omental pedicle is secured to the
tip of a NGT passed through the ULCER site.
NGT is withdrawn for 5-6 cms before the omentum is secured to healthy
serosa
• Modified Graham patch repair/ omentoplasty: primary closure of the defect
and then application of the omental tongue which is secured with same
suture thread.
• Wedge resection: The perforated area may be resected from healthy tissue,
particularly if it is on the greater curvature and distant from the
gastroesophageal junction or the pylorus
34.
35.
36. THOROUGH PERITONEAL TOILET:
• Irrigation with warm NS or antibiotics.
• One of the most Important parts of surgery
6-10 liters even up to 30 litres of warm saline
are recommended.
CONTAMINATED PERITONEAL CAVITY
37. RE-LEAKFOLLOWINGOMENTOPLASTY
Expected in following Patients:
1.Age>60 years
2. Pulse rate >110/minute
3. Blood pressure <90 mmhg
4. Hb < 10 g/dl
5. Serum albumin < 2.5 g/dl
6.Total lymphocyte count < 1800 cells/mm3
7. Size of perforation> 0.5 cm
38. DRAINAGENEEDEDOR NOT?
• Still controversial.
• 80% no need.
• DrainWill not reduce the incidence of
intraabdominal fluid collections or abcesses
(Schein.M)
• 10% can become infected and intestinal
obstruction
47. The Heineke−Mikulicz pyloroplasty consists of a longitudinal
incision of the pyloric sphincter extending into the antrum and the
duodenum.
The incision is closed transversely, eliminating sphincteric closure and
increasing the lumen of the pyloric channel.
48.
49. ROLE OF VAGOTOMY AND GASTRIC
DRAINAGE PROCEDURES
• Vagotomy and pyloroplasty has an 10–15% ulcer recurrence rate.
• Vagotomy with antrectomy : ulcer recurrence rate is very low.
50.
51. • when the ulcer is located 5 cm below the cardia, Schoemaker's or Pauchet's
procedure should be performed; if the ulcer is located 2 cm or less from the
cardia, Csendes' procedure or the Kelling-Madlener procedure should be
employed.
• Csendes procedure is a surgical treatment for gastric ulcers high in the
cardia.
• It involves excising type 4 gastric ulcers near the gastroesophageal junction
by removing the distal stomach along the lesser curvature, a small part of the
esophageal wall, and the ulcer with Roux-en-Y esophagogastrojejunostomy.
52.
53.
54.
55. OPTIONS FOR RECONSTRUCTION:
• Billroth I: Gastroduodenostomy, anastomosis between
the gastric remnant and the duodenum
• Billroth II: Gastrojejunostomy, side to side anastomosis
between gastric remnant and loop of jejunum with the
closure of duodenal stump
• Roux-en-Y gastrojejunostomy: The creation of jejuno-
jejunostomy forming y shaped figure of the small
bowel.
63. Intestinal anastomosis is a common surgery
• Anastomotic healing is similar to other tissue healing
• Hand sewn anastomosis is not inferior to stapler
• Anastomosis must be tension free, with good blood supply and
minimal fecal contamination
Two main benefits of stapler anastomosis:
• Takes less time
• No objective variations – easy to use by all surgeons
64. SURGICALRECONSTRUCTION
• Both Billroth reconstruction lead to bile reflux 5-35%
• Toavoid that Roux-en-Y reconstruction (Roux1897)
• Roux-en-Yreconstruction plaqued with a Roux stasis syndrome
• Braun variaton Billroth (1893) lower incidence of Bile reflux
some authors recommend this as standard reconstruction.
65.
66. COMPLICATIONOF ULCER OPERATIONS
1. Early Satiety
2.postvagotomy syndrome 30%
3. DumpingSyndrome 20%
4.Alkaline Reflux gastritis 10%
5.Afferent and Efferent loop syndrome
Mechanical obstruction of the limb kinking, anastomosis
narrowing, or adhesion
6. Roux stasis syndrome
7. RecurrentUlceration
8.Anastomotic leak
