Transcript 17. 8_postgastrorezek

The cathedra of the faculty and hospital surgery of the treatment
faculty of the Tashkent medical academy
Postgastrresection syndrome
Lector
Khakimov M.Sh.
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In our republic about 10 000
operations are performing
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Physiology of digestion
Secretor function of the
stomach
Cardiac glands – product mucin.
Fundal, main glands content from 4
types of cells: main – product
pepsinogen, parietal – solt acis and
internal Kassle’s factor, additional –
mucin and not differentiate.
Antral glands product mucin.
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Factors of protection
• resistance of the wall of the
stomach
• of the antoduodenal part
•Alkaline secretion
•Food
=
Factors of
agression
•Pepsin and acid(НСl)
•Gastroduodenal dysmotoric
•Defeats of the mucous
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Pathogenesis of the ulcer disease
Reducing of the resistance of the mucous of the
stomach and duodenum
Increasing of the by-pass diffusion of the
hydrogenium ions
Liberation of the histamin and acethylcholin
Stimulation of the secretion of the salt acid and
pepsin
ULCER
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Resection of
the stomach by
Bilrot 1
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Resection of the
stomach by Bilrot
2
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The reasons of the development of the
postgastrresection syndrome
Technical defects of the performing of primary
operations at the stomach (inferioity vagotomy,
not enough resection of the antral part of the
stomach, technically inferioity performed
resection of the stomach by Bilrot 2 – small size
of the anastomosis, short of long spur, irritation
of the mucous of the stomach with bile and
pancreatic juice).
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Classification of the postgastrresection
syndrom
ORGANIC
FUNCTIONAL
(when occurs organic
changes)
(when occurs functional
changes)
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Organic
а) peptic disease of operated stomach (peptic ulcer of the
anastomosis of the small intestine, recidive ulcer, not healing
ulcer)
b) cancer of the cult of stomach
c) scar stricture of the gastroenteroanastomosis
d) syndrome of the bringing loop
e) Stenosis of the bringing loop
f) Complications as a result of not correct method of
operation
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FUNCTIONAL
а) dumping-syndrome
b) hypo- hyperglycemic syndrome
c) Enterogenous syndrome
d) Functional syndrome of the bringing loop
e) Postgastrresection anemy
f) Postgastrresection astheny
g) gastrostasis
h) diarrhea
k) dysphagia
l) Alkaline reflux-esophagitis
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METHODS OF THE
RESEARCH
•Esophagogastroduodenofibr
oscopy
•Contrasting X-ray
•рH-metry
•Analysis of the gastric juice
•US research
•CT, angiography
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Frequency of the
appearance of the peptic
ulcers
Resection of the ⅔ of the stomach - 1 – 7%
Economic resection of the stomach with vagotomy - 0 – 4%
Drainage operations at the stomach with vagotomy - 8 – 12%
Селективная проксимальная ваготомия - 6 – 10%
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Reasons of the appearance of the peptic ulcers
• Economic antrumectomy
• Not full vagotomy
• Gastrinoma of the pancreas
(Zollinger-Ellisone syndrome),
• Primary hyperparathyreoidism
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Treatment algorithm at the peptic ulcers
Conservative anti-ulcer therapy
Thoracoscopic subdiaphragmal vagotomy
Reconstructive reresection of the stomach by Ru
At the Zollinger-Ellissone syndrome the operation
of choose is gastrectomy
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Cancer of the cult of the
abdomen
Reason – absence of the salt acid, presence of the
atrophic gastritis and regurgitation of a bile into the
cult of the stomach.
Diagnosis state on the base of endoscopy and
hystoligical researhe of bioptate
Treatment – surgical (gastrectomy)
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Syndrome of the
bringing loop
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Reasons of the syndrome of bringing loop
Mechanical factors
1) too long bringing loop without Brown’s mouth;
2) too short bringing loop, which may create the bend of the intestine as
a result of additional fixing to the small curvature;
3) horizontal location of the lines of gastro-intestinal anastomosis, due to
the part of food comes to the bringing loop, then to the duodenum,
inducting the duodenostasis in it; the strength of constriction of the cult of
the stomach more than duodenum and food may stay there more long;
4) fallout of the mucous of the bringing loop into the stomach or
conducting loop;
5) rotation of the bringing loop around its longitudinal axis;
6) scars, soldering, tumors or ulcerous stenosis of the bringing or
conducting loop;
7) antiperistaltic location of the intestine for the anastomosis.
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Reasons of the bringing loop
Functional factor
1) spasms of the bringing and conducting loops or sphinters
of the duodenum;
2) defeat of the nervous regulation of the duodenum and
small intestine as a result of bandaging of the nervous branches
during the operation;
3) the duodenostasis in the predoperative period.
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Pathogenesis of the bringing loop
syndrome
Coming of the food into
the bringing loop
Fermentation of the food, creation of
gases and liquid in a big volume,
increasing of the intraperitoneal pressure,
sluggishness and increasing of pressure
in the bile ducts and ducts of the
pancreas, defeat of the microcirulation
and reflector narrowing or spasm of the
bringing department of the intestine
Swelling in the projection of the
bringing loop after feeding, sense of
weight, pain, retching with the bad
smelled mass, fair of feeding, general
weakness, belch.
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Clinic of the bringing loop syndrome
The first degree patients, that have light defeats by type of
belch, retching with a bile 1-2 in a month, connected with the
drinking milk. Dyspeptic defeats and pain nearly don’t
disturb the patient, the general status is quite.
The second degree characterized with the middle hard
manifestation of the disease. Retching with a bile 2—3 in a
months, the volume of the retching masses raises to 200-300
ml. The sense of fullnes in the right underrib is prevalence
above the retching. The general status is hard, loss of weight.
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Clinic of the bringing loop syndrome
At the third degree of the syndrome there are those cases
when retching appears every day, the volume of retching
masses is about 400-500 ml and more. After feeding the
ballooned pain in the underrib and epigastria. To relief the
state the patients induct the retching by themselves. The
significant loss of weight and ability to work.
At the forth degree of the disease except these complaints, the
significant defeat of feeding and methabolism appear, and also
dystrophic changes in the parenchimatous organs.
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Methods of the surgical correction of the
bringing loop syndrome
1. Reconstructive gastroejunoduodenoplastic;
2. Reconstructive U-form anastomosis by Ru;
3. duodenoejunoanastomosis;
4. entero-enteroanastomosis by Brown;
5. Resection of the duodenum;
6. Sewing of the bringing loop to the small curvature of the
stomach;
7. Transition of the resection by Bilrote 2 to the Bilrot 1;
8. Sewing of the bringing and conducting loops to the
posterior parietal peritoneum.
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Treatment of the bringing loop
syndrome
Reconstructive reresection of the stomach
with the gastroenteroanastomosis by Ru
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Stenosis of the
bringing loop
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Stenosis of the gastroenteroanastomosis
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Clinic of the stenosis of the
gastroenteroanastomosis
Light degree – absence of the passibility of the hard
food
Middle degree – absence of the passibility of the
ordinary food
Hard degree – absence of the passibility of the fluid
food.
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Dumping syndrome
(сlumping (англ) – сброс, провал)
At the patients after the resection of the stomach the obturate function of the pyloric
muscle. Hyperosmolar solutions come at short time and in a big volume (as a
dumping) into the beginning department of the small intestine, the dyscoordination of
the vasomotor reactions appears. The increasing osmotic pressure in the intestine with
the fast suction of the carbohydrates promotes the increasing of the blood circulatiion
in liver and admit to the intestine the contents of plasma, that conducts with the spasm
of the peripheral vessels, reducing of the brain circulation.
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Symptoms of the dumping syndrome
1. Cardiac-vessels and neurovegetative symptoms: attacks of
weakness, tachycardia, sense of tide, pallor of skin, tremor of
hands, dizziness, cold perspiration.
2. Dyspeptic and abdominal discomfort: loss of appetite, sickness,
retching, liquid excrement or constipation.
3. Symptoms connected with the defeats of methabolic system:
sliding, dyspeptic complaints.
4. Symptoms
of
the
inflammation
of
the
hepatopancreatoduodenal system: duodenostasis and pain in the
abdomen with the soldering process in the abdomen.
5. Symptoms specific to the defeats of asthenisation and psychoneurological status: sensitivity, insomnia, headaches, defeat of
the balance, neurastheny.
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Treatment of the dumping
syndrome
1) reducing of the sizes of the gastroenteral mouth at the operation by
Bilrot 2;
2) putting of the additional intraintestinal anastomosis between the
bringing and conducting loops by Brown;
3) formation of the additional intestinal reservoir from the twiced
between each other intestinal loops (operation of Rotte);
4) fixation of the bringing loop to the small curvature of the stomach;
5) reconstruction of the gastrointestinal mouth by Bilrot 2 inti the
operation Bilrot 1;
6) reconstruction with the isoperistaltic intestinal transplantate
between the cult of the stomach and duodenum (operation of KupriyanovZaharov-Genley);
7) reconstruction with the antiperistaltic segment of the small intestine
between the cult of the stomach and duodenum (operation of
Gerringtone);
8) reconstruction with the thick intestinal с толстокишечной
пластикой;
9) narrowing of the gastroduodenal anastomosis after the resection 30
of
the stomach by Bilrot 1 (operation of Makarenko);
Treatment of the dumping
syndrome
Gastroejunoplastic by Kupriyanov –ZakharovGenley
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Alkaline reflux-esophagitis
Hypoglycemic syndrome
Syndrome of the «small» stomach
Aliment dystrophy
Diarrhea
Postresection anemy
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