Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_595_Библиотеки_им_академика_М_И_Перельмана.pdf
52 Atlas of Complicated Abdominal Emergencies
True aneurysms are best treated with either
proximal and distal embolisation or covered
stents may be used, depending on the aetiology
(Figs. 15 and 16).
The ultimate choice of management options
depends on the pathology, urgency, available expertise, facilities, equipment and overall ancillary support
at that point in time.
References
1. Abbas et al. (2005) Aust NZ J Surg 75: 953–957.
2. Shenker et al. (2001) JVIR 12: 1269–1271.
3. Back et al. (1998) Surg Clin North America 78: 575–591.
4. Gomes et al. (1986) AJR 146: 1031–1037.
5. Nicholson et al. (1998) Gut 43: 79–84.
6. Peck et al. (1998) JVIR 747–751.
Chapter 6
Bleeding Peptic Ulcer — Surgical Management
Ti Thiow Kong*
I. Indications
As described in Chapters 3–5, modern endoscopy
and interventional radiology services provide effective
and less invasive alternative procedures to surgery in
the management of upper gastrointestinal haemorrhage. Surgery is now a stand-by for the dwindling
numbers of patients in whom endoscopy and interventional radiology have failed to arrest life-threatening
haemorrhage. Nevertheless, the challenge for the surgeon has become all the greater as these patients,
exsanguinated by complicated bleeding lesions, are
also frequently old and in poor condition from systemic disease and possibly organ failure.
Besides peptic ulcer disease, a diverse group of
gastro-duodenal conditions can bleed massively,
necessitating emergency surgery.
1. Dieulafoy’s lesion, in which an aberrant vessel in
the mucosa bleeds through a pinpoint ulcer in the
proximal stomach occasionally re-bleeds even
after repeated endoscopic clipping. Haemostasis is
easily accomplished by suture-ligation through
gastrostomy.
2. Local surgical treatment also arrests the occa-
sional severe bleeding from duodenal diverticulum or Mallory–Weiss tear.
3. Gastroduodenal tumours — carcinoma, lym-
phoma, stromal tumour and carcinoid — all have
necessitated urgent resection for life-threatening
haemorrhage.
4. Bleeding stress gastritis/ulcer in ventilatordependent patients is best prevented by appropriate prophylaxis. The role of surgery when massive
bleeding occurs in this condition is uncertain.
5. Variceal haemorrhage, most commonly from portal hypertension in liver cirrhosis, is best managed
by endoscopic ligation/sclerotherapy and, if this
fails, by transjugular intrahepatic portasystemic
shunt (TIPS). Surgical oesophago-gastric devascularisation and emergency porto-caval shunting
have perhaps outlived their role.
To a large extent too, advances in medical treatment, endoscopy and interventional radiology have
diminished the role of surgery in peptic ulcer disease.
Elective surgery for peptic ulcer is virtually extinct, its
role being confined to the treatment of complications
of the disease.
Operative Strategy for Bleeding Peptic
Ulcer
The primary aim of surgery is to identify the lesion
and arrest bleeding expeditiously, and prevent recurrent bleeding. Thus in all patients, suture-ligation of
the bleeder should be performed soonest. With the
availability of PPI and anti-Helicobacter pylori
*T. K. Ti, MD. FRCS, FRACS, FRCSE ad hominen, Emeritus Consultant, Department of Surgery, National University Hospital, and
Professorial Fellow, National University of Singapore, Singapore.
53
54 Atlas of Complicated Abdominal Emergencies
treatment, many surgeons nowadays do not proceed
to definitive ulcer surgery after arresting
haemorrhage.
The secondary aim of ulcer cure by surgery has a
stronger argument in gastric ulcer than in duodenal
ucer. While PPI and anti-Helicobacter medication
heal the majority of duodenal ulcer, gastric ulcer healing has a failure rate of 30–40%.
As ulcer curative surgery increases the magnitude
of the procedure, it should be offered only to fit
patients by experienced gastric surgeons.
*The present author’s selective operative strategy
on bleeding peptic ulcer is along the following
guidelines:
1. Suture-ligation only is performed on a patient
with a short history of ulcer disease, operative
findings of small or non-fibrotic duodenal or gastric ulcer, or who is in a poor general condition.
2. Definitive ulcer surgery is performed on a patient
with a long ulcer history, failed medical treatment, has a large fibrotic duodenal ulcer or
NSAID related giant ulcer (GDA) and is in a
good general condition. Curative surgery is usually by vagotomy with a drainage procedure. It is
however imperative that the surgeon has the
skills to convert from over-sewing to a salvage
gastrectony should operative complications arise.
3. A large bleeding fibrotic gastric ulcer is treated by
excision of the ulcer when a patient is in a poor
condition. Hemigastrectomy is performed in a
patient who is fit.
4. Definitive surgery for peptic ulcer disease would
also be advantageous in poor communities where
cost and distance make continual follow-up care
not always feasible.
II. Preoperative Preparation
1. Ensure adequate infusion of fluids and blood
components to restore and maintain blood volume
and circulation as outlined in Chapter 2.
2. Insert a large-bore nasogastric tube and apply
suction to help empty the stomach.
3. To avert mortality in patients with advanced
age and/or with severe systemic disease, provide maximal supportive peri-operative care in
ICU.
4. In patients with massive bleeding, it is imperative
that endoscopy be performed in the operation
theatre, thus facilitating, when necessary, immediate conversion to surgery.
III. Operative Procedures for
Bleeding Peptic Ulcer
The anatomy of the stomach and upper abdomen is
shown in Fig. 6.1.
A. Laparotomy and Identifi cation of Site
of Haemorrhage
1. Exposure: Upper mid-line incision from the
xiphisternum to the umbilicus. This exposure is
usually adequate without extending the incision
below the umbilicus for all gastro-duodenal procedures. Limitation of exposure occurs when the
incision does not reach the xiphisternal notch.
Goligher retractors are helpful in improving exposure, especially in obese patients undergoing
definitive ulcer surgery.
2. Assessment: Retract the liver and gallbladder.
Massive bleeding is frequently evident in a
stomach grossly distended by blood and clots.
Identify the Vein of Mayo, which separates the
pylorus from the duodenum. Note and feel the
stomach, especially in the antrum and lesser curvature for induration and scarring suggestive of
gastric ulcer. Assess extent of duodenal scarring
and peri-duodenal fibrosis and fixity of the duodenal bulb to the pancreas and hilum of liver, the
presence of which are features of advanced duodenal disease. Correlate with findings at
gastroscopy.
3. Anticipate more technical difficulties when the
duodenal bulb is distorted and fixed.
Figure 6.1.
Chapter 6 Bleeding Peptic Ulcer — Surgical Management 55
Gross anatomy and blood supply of the stomach and duodenum.
B. Over-Sewing a Bleeding Ulcer
1. For duodenal ulcer, Kocherisation facilitates
exposure of the duodenum, especially in obese
patients with severe duodenal disease. The peritoneal reflection on the second part of the duodenum is divided by scissors or diathermy allowing
the proximal part of duodenum with the pancreas
to be lifted forward. The hepatic flexure of colon,
when in the way, requires mobilisation and downward retraction before Kocherisation.
2. In duodenal ulcer haemorrhage, a 5–6 cm inci-
sion is made axially over the pylorus and first part
of duodenum, centred at the Vein of Mayo, which
is diathermised. Blood and clots are evacuated
from the stomach.
3. With adequate retraction, the bleeder and ulcer
are sought. Bleeding may be from a spurter or
ulcer margin or may even have stopped. One or
more figure-of-eight stitches of absorbable sutures
(e.g. vicryl 3-0) are used to stop bleeding from a
spurting vessel or prevent recurrent bleeding from
clotted vessels at the base of the duodenal ulcer.
4. Unless the ulcer is very large and fibrotic, it is
usually possible to appose the ulcer margins with
several interrupted 3-0 vicryl sutures. This reduces
the possibility of recurrent haemorrhage and
expedites healing.
5. The gastro-duodenal incision is sutured
longitudinally — inner continuous vicryl or PDS
3-0, and outer sero-muscular interrupted silk, 3-0.
When vagotomy is anticipated, the gastro-duodenal
incision is closed transversely as a pyloroplasty,
with a single layer of interrupted absorbable 3-0
vicryl or PDS. The gaps between sutures are
checked with the dissecting forceps and, where
found, obliterated by a reinforcing suture (Fig. 6.2).
6. For a small gastric ulcer, a 5–6 cm incision is
made over the anterior mid-stomach and the bleeding ulcer similarly sutured and over-sewn. Following
suture-ligation of gastric bleeder, the gastrostomy is
closed using a full thickness inner layer of continuous 3-0 vicryl or PDS followed by outer seromuscular layer of 3-0 continuous silk sutures.
C. Techniques for Problematical
Duodenal Ulcer Bleeding
Complicated duodenal ulcer disease is manifested
as duodenal distortion and stenosis. Severe periduodenal fibrosis frequently indicates deep penetrating ulcers
56 Atlas of Complicated Abdominal Emergencies
Figure 6.2.
Pyloroplasty.
and duodenal ulcer extending into the second part of
duodenum. Periduodenal oedema and emphysema is
sometimes evident in deep penetrating ulcers that had
undergone attempts at endoscopic sclerotherapy.
Problem 1
Extensive ulceration extending into second
part of duodenum
Severe duodenal ulcer disease may present as
extensive areas of deep ulceration and mucosal denudation extending into the second part of duodenum.
1. To deal with this, duodenostomy is extended after
full Kocherisation.
2. The raw areas are covered over by approximating
remnant adjacent epithelial margins with interrupted or a continuous running stitch of 3-0 vicryl
(Fig. 6.3).
3. This could narrow the lumen considerably, in
which case a gastro-enterostomy is performed
after closing the duodenostomy longitudinally in
two layers.
stitch the bleeding gastroduodenal artery without first slowing down the bleeding.
2. Direct gauze pressure over the bleeding vessel is
applied by the assistant, while the surgeon applies,
through the foramen of Winslow, the left index finger exerting pressure downwards and forward compressing on the origin of the gastro-duodenal artery.
3. If this fails to slow down bleeding to allow figureof-eight suturing of the bleeding artery, the gas-
troduodenal artery is ligated at the superior and
inferior border of the duodenum.
Problem 3
Inability to close duodenum
Deep irregular penetrating duodenal ulcer extending circumferentially with adjacent oozing and
oedematous mucosa defy suturing. Gastro-duodenal
dislocation may occur.
Conversion to salvage gastrectomy becomes
necessary.
Problem 2
Bleeding main gastroduodenal artery
1. When torrential bleeding is found from the posterior wall at duodenostomy, it is impossible to
D. Key Points in Vagotomy-Drainage
for Bleeding Duodenal Ulcer
Should the decision be made to perform an ulcer
curative procedure for a patient with bleeding
Figure 6.3.
Chapter 6 Bleeding Peptic Ulcer — Surgical Management 57
Suturing of giant bleeding duodenal ulcer.
duodenal ulcer, choose vagotomy with drainage after
over-sewing of bleeding ulcer. V-D has fewer complications and a lower operative mortality compared with
gastrectomy. Unlike in the elective setting, vagotomy
is done after completing the drainage procedure.
Pyloroplasty/gastroenterostomy
The drainage procedure is usually a pyloroplasty,
and this has been described earlier and illustrated
(Fig. 6.2).
When severe duodenal ulcer disease has resulted in
gross duodenal distortion, or when an excessively
long gastroduodenal opening has been made, the gastroduodenal opening is closed longitudinally using
two layers of suture. A posterior gastroenterostomy
is performed for gastric drainage (Fig. 6.4).
1. Identify the duodeno-jejunal junction just below
the root of the mesocolon, to the left of the
mid-line.
2. Make a 6–8 cm opening in an avascular part of the
mesocolon to the left of the middle colic vessels.
3. The posterior stomach wall is grasped with
Babcock forceps and brought down through the
opening in the mesocolon.
4. It is convenient to use soft anastomotic clamps for
gastro-enterostomy. One pair of clamps grasps the
posterior wall of stomach and aligned with a similar length of jejunum, 6–8 cm held in an isoperistaltic position by the second clamp. The afferent
jejunal loop should be comfortably positioned and
not excessively long.
5. A standard two-layer anastomosis is performed
— inner full thickness, using 3-0 absorbable running suture (e.g. vicryl or PDS), and outer seromuscular using 3-0 silk. Four stitches anchor the
stomach to the mesocolon.
Truncal vagotomy
1. Exposure of the lower oesophagus is more difficult in obese patients, and in patients with large
fatty left lobe of liver or cirrhosis. As a first step,
ensure that the abdominal mid-line incision
reaches to its maximal superior extent, i.e. the
linea alba is divided up to the notch between the
left or right side of the xiphistenum and the costal
cartilage. Consider using a Goligher retractor to
create more space in the upper abdomen.
2. If exposure of the lower oesophagus appears
insufficient after anterior retraction of the left
58 Atlas of Complicated Abdominal Emergencies
Figure 6.4.
Posterior gastro-jejunostomy.
liver lobe, divide the left triangular ligament with
a long tip diathermy starting from the left free
margin taking care not to traumatise the left
hepatic vein near the mid-line. The left lobe can
then be more easily retracted anteriorly. Folding
of the left lobe of liver on to the right lobe further
improves exposure, but would not be possible
with a cirrhotic or fatty liver.
3. After transversely dividing the peritoneum over
the lower esophagus, the right index finger works
its way behind the oesophagus — the naso-gastric
tube in place helping in its identification. The
posterior vagal trunk, encountered as a cord a few
millimeters behind the oesophagus, is pushed to
the right and lifted up by a nerve hook (Fig. 6.5).
4. Robert arteries are applied on the nerve trunk
1 cm apart and following division; the intermediate segment of nerve is removed and sent for
histological confirmation. The divided nerve is
tied at both ends to prevent bleeding from an
accompanying vessel.
5. The anterior vagus nerve is usually in two
branches, and nerve segments are excised in the
same way.
Figure 6.5.
Truncal vagotomy.
6. By careful inspection of the anterior surface of the
oesophagus, smaller branches of the anterior trunk,
including the criminal nerve of Grassi running from
the left lower oesophagus to the gastric fundus, are
picked up by the nerve hook and diathermised.
Chapter 6 Bleeding Peptic Ulcer — Surgical Management 59
E. Key Points in Billroth II Gastrectomy/
Vagotomy Antrectomy for Bleeding
Duodenal Ulcer
In the heyday of surgery for duodenal ulcer bleeding, gastrectomy had a 20% operative mortality compared to 5% for vagotomy with drainage. Gastrectomy
is a more stressful procedure for both patient and
surgeon; the area of greatest concern — the Achilles’
heel — is duodenal stump leakage.
Ensure safe duodenal stump closure
To ensure safe closure of duodenum, there must be
a healthy duodenal cuff with its posterior wall ½ to
1 cm proximal to the gastro-duodenal artery.
This requires a great deal of patience and determination to achieve in the severely ulcerated duodenum,
indicated by peri-duodenal fibrosis fixing down the
duodenal bulb and pylorus.
1. Start freeing the duodenum by Kocherisation.
2. Isolate and divide the right gastric vessels between
2-0 silk sutures where they approach the lesser
stomach curvature. The right gastro-epiploic vessels are similarly divided near their origin from
the gastro-duodenal vessels, after 2-0 silk ligation
(Fig. 6.6).
3. Free adhesions and fibrosis between the posterior
wall of stomach, duodenal bulb and pancreas. By
lifting up the distal stomach, the posterior wall of
the duodenum is cleared of adhesions and fibrosis
to the pancreatic head until the gastro-duodenal
artery is exposed.
4. Frequently, the most challenging dissection is to
free the superior border of the proximal duodenum without damaging the common hepatic
artery and bile duct (Figs. 6.7 and 6.8).
5. Apply a crushing clamp to the pyloro-duodenal
region and a non-crushing clamp distally to the
duodenum just proximal to the gastro-duodenal
artery. Cut clamped duodenum, leaving an adequate cuff for anastomosis.
6. The duodenal stump is closed as a first all-coats
layer with 3-0 vicryl or PDS running suture.
Check for gaps in the suture line that are reinforced with figure-of-eight stitches. The second
layer is sero-muscular, inverting the two corners
with a half purse-string 3-0 silk suture, together
with two or three interrupted silk between the half
purse-strings (Fig. 6.9).
Figure 6.6.
Gastrectomy — gastro-duodenal dissection.
60 Atlas of Complicated Abdominal Emergencies
Figure 6.7.
Dense scar tissue in severe duodenal ulcer disease.
Figure 6.8.
Separating scar tissue from superior border of duodenum.
7. If the short cuff of the posterior duodenal wall has
not allowed complete inversion of the mucosal
suture line, the closure is reinforced by a third row
of interrupted silk sutures from the anterior duodenal wall to the pancreatic capsule.
Dealing with problems related to the posterior duodenal ulcer penetrating into the pancreas
1. Meticulous dissection to free the duodenal wall
distal to the ulcer is done to obtain a small cuff of
Figure 6.9.
Duodenal stump closure.
posterior duodenal wall to facilitate subsequent
duodenal closure. Lahey’s suggestion of placing a
Bakes dilator into the common bile duct could
help in preventing inadvertent division of the bile
duct (Fig. 6.10).
1
Closure of the duodenal stump is as described
previously, without use of intestinal clamp, and
preserving more of the anterior duodenal wall.
2. However, should a small cuff of posterior duodenum not be available, Norman Tanner’s tech-
2
nique
of three-layer interrupted sutures between
Chapter 6 Bleeding Peptic Ulcer — Surgical Management 61
Figure 6.10.
Bakes dilator in common bile duct.
the duodenal stump and the fibrotic ulcer margin
is an option. Figure 6.11 shows the posterior wall
of the duodenal stump being sutured to the distal
margin of the ulcer base on the pancreas. A second layer of interrupted vicryl stutures closes the
duodenal stump by suturing the anterior wall of
duodenum stump to the proximal margin of the
ulcer base (Fig. 6.12). The third layer of suture is
Figure 6.11.
Posterior wall of duodenum sutured to distal margin of
ulcer base.
sero-muscular from the anterior duodenal wall to
fibrous capsule of pancreas.
3. Performing duodenostomy, i.e. closing the duodenal stump around a tube, is the last resort.
Intraperitoneal leakage, frequently gross in
amount, makes post-operative management difficult to manage successfully in these patients who
are frequently poor operative candidates to start
with.
Mobilisation of distal stomach
The extent of gastric resection for duodenal ulcer
disease depends on whether vagotomy is also performed. With vagotomy, resection of the gastric
antrum, which constitutes about one-third of the stomach, suffices. Without vagotomy, two-thirds of distal
stomach is resected.
1. In antrectomy, following division of the avascu-
lar lesser omentum, the descending branch of the
left gastric vessels near their junction with
the main left gastric vessels is separated from the
lesser curve of stomach and divided after ligation
with 2-0 silk. Along the greater curvature, the
gastro-colic omentum is divided progressively
between sutures until at a point about one-third