Transcript History of stomach and duodenum surgery

Tashkent Medical Academy
Deportment of Faculty and hospital surgery.
Postgastroresection syndrome
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History of stomach and
duodenum surgery
History of stomach being start since second half of XIX century. Its
beginning have connect with names of such as scientifics as Pean,
Rydiger, Billrot.
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• J.E.Pean (November, 21, 1830 – January, 20, 1898)
One of the greatest surgeon of France in XIX century
History of stomach and duodenum
surgery
• Students of Billroth Gussenbauer and Winiwarter
(1870) proved securing of resection for human’s
life.
• In 1879 Реаn was the first who performed
resection of stomach at the human, but patient
died after 4 days.
• Billroth in 1881 was carried out resection of
stomach 34 years old patient. Patient lived 4
month after operation.
• In 1885 Billroth invited 2 types of
gastroenteroanastomosis.
History of stomach and duodenum
surgery
• In 1814 Brody’s researches saw, that excision of vagus nerve in dogs
becomes to decreasing alocation of gastric fluid.
• In 1905 Henry Dale and chemist George Barger puts forward a theory of
strengthen action of gastrin to motor activity of stomach.
• In Berlin in 1911 in Congress of surgeons Exner make a report about
positive results of subphrenic vagotomy through abdominal approach
• In 1943 in Chicago University surgeon Leister Dragsted performed
vagotomy many times and met in mone problem – gastrostasis.
• Afterward was offered pyloroplastic to prevent gastroduodenostasis in
patients with vagotomy.
History of stomach and duodenum
surgery
• In 1964 Gregory and Tracy researched content of
gastrin and got it by artificial way.
• In 1972 English scientist James Black for the first
time worked
out medicine which contented
disabling Н2-receptor buramide (cimetidine) and
got Nobel Prize.
• In 1979 Ivana Estkholma created medicine that
abscopal proton pump – omeprasole (Sweden,
Company “Astra Zeneca”)
• In 1988 in Rome on World Congress of
gastroenterologist was recognized omeprasole the
main drug in treatment of ulcer disease
The short history about laparoscopic
intervention in treatment of ulcer
disease
• In 1992 American surgeon McKerman for the first time
used laparoscopic technology in treatment of ulcer
disease complicated by perforation and gave positive
results
• In 1993 Zucker K.A. updated laparoscopic technology
in treatment of perforative ulcers
• In 1994 Peters J.H. wrote the first book about
laparoscopic intervention in cancer of stomach and
ulcer disease.
Actuality of ulcer of stomach and
duodenum
• 4-5 patients to 1000 of population in year.
• Though this disease meets in different aged
groups of people, but it mainly prevalence in 2040 years
• Young patients have duodenal form, and elderlies
have a gastrical form of ulcer.
Actuality of ulcer of stomach and
duodenum
• In 26,4% of cases ulcer of stomach is diagnosted in
bleeding, and for ulcer of duodenum bleeding is cased for
primary diagnostic in 40%.
• In 26% ulcer disease is continuing to grow up into
neighbour organs or penetrate in it.
• Perforation of ulcer occurs in 13,6% cases. From this
more than 30% it is sicks aged 19- 22 year and 60% it is
sicks aged 23-50 years.
• By case of disability ulcer disease take 3-rd place. (after
cardiovascular and oncologist diseases).
Popularity of ulcer disease
• Common among all diseases 12-place
• In the Republic of Uzbekistan by 2013 year 3.8 cases to
1000
Institute of statistics of Ministry of Healthcare of the Republic of Uzbekistan 2013
Popularity of ulcer disease among the
population and primary diagnostic
Institute of statistics of Ministry of Healthcare of the Republic of Uzbekistan 2013
In our republic annually are being done up to 10
000 operations
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Digestion physiology
Secretory gastric
function The cardiac
glands - produce the
mucilage. Fundic, main
glands consist of 4 cells
kind of: main (produce
the pepsinogen), parietal
(hydrochlorid acid and
internal castle factor),
extra (mucilage),
nondifferentiable.
Antral gland - produce
the mucilage
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Defence factors
• Resistance of mucosa
Acidic balance sheet of
antroduodenal department
Alkaline secretion Food
=
Aggression factors
•Pepsin and acid (nsl )
Gastroduodenal infrigement
of motor function
•Damage of mucous cover
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Pathogenesis of ulcer disease
Resistance lowering of mucous stomach cover and
duodenum
Increase of outward diffusion of hydrogen ions
Increase of outward diffusion of hydrogen ions
Stimulation of secretion of solyannoj acid and
pepsin
Ulcer
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Histamine test of Kay
1. On the hungry stomach each 15 minutes shall
be exercised the fence of gastric juice.
2. 2.
Intramuscularly
introduce
0,1%
histamine.
3. 3. Each 15 minutes shall be exercised the
fence of gastric juice.
4. 4. In taken away juice portions determine the
level of chlorohydric acid. In rate "basal"
secretion
5. 5 mM / hour, after stimulation - 16 - 25 mM /
hour.
Insulin test of Kholander’s
1. On the hungry stomach each 15 minutes shall
be exercised the fence of gastric juice
2. Subcutaneous insulin injection.
3. Each 15 minutes shall be exercised the fence of
gastric juice.
4. In taken away juice portions determine the level
of chlorohydric acid. Eslim though in one of
portions after the stimulation the level of
chlorohydric acid are going up on m/M backward
wave tubes the Kholandera test it is considered
positive
Resection of
the stomach by
Billroth-I
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Resection of the
stomach by
Billroth-II
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Development causes of postgastrectomy
syndrome
Technological inaccuracies of performance of
primary operations on stomach (defective
vagotomy) insufficient resection of antral
portion of the stomach, saving the body
resection of stomach, technically defective
fulfilled gastrectomy by Billroth-2 - small
dimension of anastomosis, short or long leading
the loop, short <spur>, temper of gastric mucosa
by the bile and pancreatic juice and so on ).
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Classification of postgastrectomy
syndrome
Organic (the organic
changes when occurs )
Function (functional
impairments when occur )
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Organic
а ) peptic disease of an operated stomach (stomal ulcer of
jejunum, recurrent ulcer, non-treated ulcer )
B ) cancer of the stomach stump
C ) rumen narrowing of gastroenteroanastomosis
D ) afferent loop syndrome
E ) stenosis of leading loop
F ) complications owing to violation of operation technique
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Function
A ) dumping syndrome
B ) gipo-gyperglicemic syndrome
C ) enterogenous syndrome
D ) function afferent loop syndrome
E ) postgastrorezection anaemia
F ) postgastrorezection debility Pulp ) of
gastrostaz Call ) diarrhoea To ) dysphagia
Backward wave tube ) alkaline reflux gastritis
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Method of examination
•Contrast roentgenography
RH-metriya
•Gastric juice analysis
•US investigation
•Catalyst, angiography
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Frequency of occurence
of recurrent ulcers
Resection of the Stomach - 1 - 7%
Saving gastrectomy with vagotomy - 0 - 4%
Drain operations of stomach by the vagotomy - 8 - 12%
Selective proximal vagotomy - 6 - 10%
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Causes of origin of peptic ulcers
• Saving antrumectomy
• Incomplete vagotomy,
• Zollingera syndrome – Allison,
• Primary hyperparathyroidism (thyroid
adenoma )
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Therapeutic algorithm for peptic ulcers
Conservative anti-ulcer therapy
Thoracoscopic epiphrenic vagotomy
Reconstructive resectionof stomach by Ru
When Zollinger-Ellison syndrome operation of
choice is the gastrectomy
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Cancer of the stomach stump
Cause - absence of chlorohydric acid, presence at these
patients atrophic gastritis and regurgitation of B-bile
stump of the stomach.
The diagnosis shall be established on a foundation of
endoscopy and hystological research of biopsy
Treatment - surgical (gastrectomy)
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Syndrome of
adductor loop
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Causes of afferent loop syndrome
Mechanical factors
1 ) too long leading the loop without Brown inosculation;
2 ) far short leading the loop, which due to of additional the
fixation to flatness can produce intestine hogging;
3 ) the horizontal arrangement of lines of gastrointestinal
anastomosis, thanks to what the food part come into leading
loop, and further in 12-perstnuyu intestine, bringing about
they duodenostasis; since contraction force stomach stumps is
greater than 12-perstnoj intestine, that who acted the food can
overstay there more or less long-time;
4 ) fallout of mucous leading B loop stomach or in outlet loop;
5 ) rotation of leading loop around its long axis;
6 ) cicatrices, soldered connection, swelling or ulcerous stenosis
of leading or outlet loops;
7 ) antistatic location of intestine for anastomosis.
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Causes of afferent loop syndrome
Functional factors
1 ) spasms of leading and outlet loops or sphincter of
12-perstnoj intestine;
2 ) violation of nervous regulation of duodenum and
jejunum due to of dissection of nerve branches during
the operation;
3 ) provided in preoperative period of duodenostasis
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Syndrom and pathogenesis of
leading loop
Food receipt in leading
loop
Food fermentation, gases education and
fluid in number, increasing of intraintestinal of pressure, stagnation and
pressure building up in bile ducts and
ducts
pancreas,
violation
of
microcyrculyation
and
reflectory
narrowing or spasm of outlet bowel
segment
Bulge and nipple in projection of
leading loop after food, sense of
heaviness, crushing pain, retching by
the mass with bad smell, fear feeling of
reception, general weakness, belching.
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Clinic of afferent loop syndrome
To 1-st syndrome degree regard sick, at which is the easy
disorders of regurgitations type, vomiting of bile 1-2 once a
month, more often connected with milk reception. Dyspepsia
violation and pain duration almost is not bothering sick, the
systemic condition satisfactory, the employability is not
abused.
2nd the syndrome degree is characterized is
moderately grave of manifestation disease. The retching with
bile arises 2-3 once a week, the amount of emesis achieves 200300 Jr.. Retching initiation precedes the feeling emergence of
completeness on the right below the rib and epigastrii
following meal, especially after liquid food and the milk. The
retching gives relief. At this category of sick are taking place
the work decrement, the weight loss of.
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Clinic of afferent loop syndrome
To 3-rd syndrome degree belong in the event that the retching
arises almost daily, the volume of emesis achieves 400-500
magnetic tape and more. Following meal arise arching pains
on the right below the rib and anticardium. With a view to
facilitating state of the patient independently cause the
retching. The depletion, the great work decrement is typical.
4th the degree disease is characterized, except above signs,
sharp disorders of nutrition and metabolism (the famine
edema, the severe emaciation, the hypoproteinemia, the
anaemia ), and also great the dystrophy changes on the part of
parenchymatous organs.
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Methods of surgical correction of
afferent loop syndrome
1. Reconstructive of gastroeyunoduodenoplastic
2. 2. Reconstructive U-shaped anastomosis by Ru;
3. 3. Duodenoeunoanastomosis;
4. 4. Entero-enteroanastomosis on Brown;
5. 5. Resection of duodemun;
6. 6. Felling of leading loop to lesser curvature;
7. 7. Transfer of gastrectomy by Billrot-2 in by Billrot-1
8. 8. Felling of leading and outlet loops to back parietal
peritoneum.
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Treatment of afferent loop
syndrome
Reconstructive resection of stomach with
gastroenteroanastomosis by Ru
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Stenosis of
adductor loop
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Gastroenteroanastomosis stenosis
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Clinical picture of
gastroenteroanastomosis stenosis
Of a low degree - cross-country capability absence of
rough, hard food
Moderate degree - cross-country capability absence
of usual food
Heavy degree - cross-country capability absence of
liquid food
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Dumping sindrom
(slumping (angl ) - discharge of, failure )
In the patient after gastrectomy the obturative function of pyloric muscle is absent.
The hyperosmolar solutions come into very the brief time and in number (in sight of
failure ) in the elemental department of jejunum, comes discoordination of vasomotor
reactions and overirritation of different intesoretseptors. Hypertonicity in intestine
with flash dispersal of carbohydrate facilitates flow-in increase of blood liver cancer
and receipt intraluminally of small intestine from blood river-bed of component parts
of plasma, that is followed by the spasm of peripheral vascular channel, congestion
lowering of brain
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Symptom complexes in
demping-sindrome
1. Cardiac-vascular and neurovegetative symptoms:
bouts of weakness, tachycardia, inflow feeling, face
pallor and fingers, hands tremor, dizziness, darking
within their sights, cold sticking perspiration.
Dispepticheski and abdominal discomfort: appetite
loss, nausea, retching, abdominal murmur, loose stool
or constipations. Symptoms by the related to violation
metabolic system: exhaustion, dyspepsia complaint.
Inflammation symptoms of system: duodenostaz and
stomach pain connected with adhesive process in
belly. Symptoms characteristics for astenizatsii
violation and psikho-nevrologicheskogo status:
sensibility, tearfulness, insomnia, headache, loss of
balance, nevrosteniya.
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Dumping syndrome clinic
When mild form of dumping syndrome the bouts of weakness,
sweating, palpitation and dizziness arise, as a rule, only after
use of sweet and milk food, they slightly has been expressed
and are going on usually during 10-15 minute. The pulse rate
grows nothing more than on 10-14 blows. Systolic hell in the
middle of dumping attack is going up usually nothing more
than by 10 MM mouth. Art.. and the diastolic pressure
almost does not change. Sick, trudosposobny and does not
call for special treatment, except for diet observance. The
mild form are seen most frequently in morning hours and
almost never arise in the afternoon. In that time of the day
sick can eat even sweet and milk dish.
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Dumping syndrome clinic
When dumping syndrome is moderately grave the attacks of
dumping attack arise not only after sweet and milk food, but as
well after use of flour dishes and potato. The attack duration in
this case achieves 30-40 mine, and the symptoms of cases is
sometimes so has been expressed, that sick are forced to lie, the
pulse rate rises to 90-100 specific. In 1 mine, systolic hell does
not change, and diastolic is reduced. The employability of such
sick falls off precipitously, conservative treatment bring only
the palliation, sick are forced hedge to about itself in food, with
the consequence that breaks down lose weight and.
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Dumping syndrome clinic
The heavy degree of dumping syndrome is
characterized by the emergence attack after use of
any food, the duration by them gets to 2 ch, sick run
in collaptoid condition. The tachycardia achieves 110120 specific. In 1 minute. At a point of dumping
attack appear the cardialgia, the sharp dizziness, the
sweating, the dozy condition, the orientation in time
sometimes are lost. At such patient suffers the
mentality, appear perplexity feeling, despair, fear of
each food intake. In some patient are developing the
diarrhea, is increasing the depletion, and they become
by complete disabled persons. Conservative
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treatment of success don't bring.
Treatment of the dumping
syndrome
1 ) reduction in the size of gastroenteroanastomosis in the operation by
Billroth-2
2 ) superposition of extra interintestinal anastomosis between leading and
outlet loop by Brown;
3 ) education of additional colon reservoir from coupled between them
intestinal loops (perspiration operation );
) fixing of leading loop to lesser curvature;
5 ) reconstruction of gastroenteroanastomosis by Billroth-2 in operation
Billrot-1
6 ) reconstruction with isoperistaltic colon transplant between stomach
stumps and duodenum intestines (operation of Kupriyanova-ZakharovaGenleya;
7 ) reconstruction with anastaltic segment of jejunum between stomach
stumps and 12-perstnoj intestine (operation of Gerringtona;
8 ) reconstruction with colonic of plastikoj
9 ) narrowing of gastroduodenal anastomosis after gastrectomy by
Billroth-1 (operation Makarenko;
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Treatment of the dumping
syndrome
Gastrojejunoplastic by Kupriyanov-ZakharovHenley
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Alkaline syndrom
Syndrom <low> of stomach
Alimentar anaemia
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