Current role of surgery in the management of peptic ulce (1)

Current role of surgery in the management of peptic ulce (1)

• 1.
  “ CURRENT ROLEOF SURGERY IN THE MANAGEMENT OF PEPTIC ULCER DISEASE ” Dr.Anil Haripriya
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  INTRODUCTION INCIDENCE OFPEPTIC ULCER DISEASE HAS DECREASED BETTER UNDERSTANDING OF ETIOLOGY: H PYLORI AND NSAIDS BETTER CONTROL WITH MEDICAL TREATMENT
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  HISTORY OF PEPTICULCER SURGERY    Billroth 1    Billroth 2 Truncal vagotomy with antrectomy Truncal vagotomy with drainage procedure Highly selective vagotomy
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  CURRENT INDICATIONS FORSURGERY FAILURE OF MEDICAL TREATMENT REFRACTORY CASE RELAPSE RECURRENCE PATIENTS REQUIRING CONCOMINANT STEROID OR NSAID THERAPY
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  EMERGENCY INDICATIONS FORSURGERY BLEEDING ULCER PERFORATED ULCER GASTRIC OUTLET OBSTRUCTION
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  BLEEDING PEPTIC ULCERAROUND 70% RESOLVE SPONTANEOUSLY RISK FACTOR FOR REBLEED: SHOCK COAGULOPATHY CO-MORBIDITY VISIBLE ACTIVE BLEEDER
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  MANAGEMENT ENDOSCOPIC THERAPY3 VESSEL LIGATION
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  PERFORATION INCIDENCE 5-10%OF ALL PATIENTS WITH DUODENAL ULCER DISEASE RISK FACTORS PRESENCE OF SEVERE COMORBIDITY DURATION OF PERFORATION > 24 HRS PRESENCE OF HYPOTENSION (SYSTOLIC < 100 mmHg) ON PRESENTATION
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  MANAGEMENT CONSERVATIVE MANAGEMENTIN SELECTIVE CASES EXPL. LAP WITH SIMPLE CLOSURE OF PERFORATION WITH OMENTAL PATCH
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  GIANT PERFORATION ARBITARILYDEFINED AS ULCER > 2.5 CM IN DIAMETER USUALLY OCCURS LEFT TO THE INCISURA
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  MANAGEMENT CLOSURE BYOMENTAL IMPLANTATION CLOSURE BY OMENTAL PATCH CLOSURE USING FALCIFORM LIGAMENT JEJUNAL SEROSAL PATCH TECHNIQUE ROUX-EN-Y DUODENOJEJUNOSTOMY PYLOROPLASTY OPERATIONS INVOLVING EXCLUSION OR DIVERTICULIZATION, INCLUDING PARTIAL GASTRECTOMY OR GASTRIC DISSOCITION DUODENOSTOMY EXPERIMENTAL TECHNIQUES – USE OF BIO REACTIVE MATERIAL, OPEN PEDICLE GRAFTS OF ILEUM, TRAMP FLAP, PTFE PATCH AND PEDICLE GALL BLADDER GRAFT RESECTION
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  GASTRIC OUTLET OBSTRUCTIONINCIDENCE 6-8% OF PATIENTS WITH DU FIBROTIC PYLORIC STENOSIS CAUSING MECHANICAL OBSTRUCTION IS STRONGLY AN INDICATION OF SURGERY
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  MANAGEMENT VAGOTOMY ANDANTRECTOMY VAGOTOMY AND DRAINAGE ENDOSCOPIC BALLON DILATION
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  FACTORS INFLUENCING CHOICEOF OPERATION IN DU HISTORY DURATION OF PREVIOUS DISEASE DURATION OF PREVIOUS COMPLICATIONS PREVIOUS TREATMENT ANTACIDS ERADICATION OF H. PYLORI PREVIOUS OPERATION ASPIRIN OR NSAID’s USE CONDITION OF PATIENT UNDERLYING MEDICAL ILLNESS HEMORRHAGIC SHOCK DURATION OF PERFORATION MORE THAN 24 HOURS
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  CURRENT CHOICE OFSURGERY 1.     Truncal vagotomy with drainage 2.     High selective vagotomy 3.     Truncal vagotomy and antrectomy 4.     Laproscopic truncal vagotomy or high selective vagotomy
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  INDICATIONS AND OPERATIVESTRATEGY IN DUODENAL ULCER: Indication Preferred operation Alternatives Bleeding Oversew + TV and pyloroplasty Oversew and HSV Perforation Closure and omental patch + HSV Closure and omental patch + TV     Laproscopic closure and omental patch Obstruction TV and anterectomy with Billroth I TV and anterectomy with Billroth II     TV and Finney or Jaboulay pyloroplasty     TV and gastrojejunostomy Intractability Laproscopic HSV Open HSV
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  RECURRENT ULCER ANDPOSTGASTRECTOMY SYNDROMES AFTER OPERATIONS FOR DUODENAL ULCER: Operation Incidence of recurrence (%) Incidence of posgastrectomy syndromes (%) Mortality rate (%) HSV vagotomy 10 5 0.1 Truncal vagotomy & drainage 7 20-30 < 1 TV and anterectomy/ Billroth I or Billroth II 1 30-50 0-5 TV and anterectomy/ Roux-en-Y 5-10 50-60 0-5
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  SIDE EFFECTS OFOPERATIONS FOR DUODENAL ULCER: Early postoperative complications Long-term side effects Afferent loop obstruction Alkaline reflux gastritis Anastomotic leak Anemia Duodenal stump leak Dumping syndrome Efferent loop obstruction Gallstones Gastric atony Gastric remnant cancer Gastric outlet obstruction Malnutrition Hemorrhage Postprandial hypoglycemia Pancreatitis Postvagotomy diarrhea   Reflux esophagitis   Small bowel obstruction
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  THANK YOU