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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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■ PepticulcerdiseasereferstoirritationofGImucosafromgastricaciddueto eitherincreasedacidpresenceorweaknessinthemucosalprotectionand typicallypresentswithepigastricpain.

2,4

Pepticulcerscanoccuranywhere intheGItract,butduodenalandgastriculcersaremostcommon. Duodenalulcerstypicallyarisewithin2cmofthepylorus,arehighly associatedwithH.pyloriinfection(>90%),andfrequentlyresolvewith appropriateH.pyloritherapy.Gastriculcersarelesslikelytobeassociated withH.pyloriinfectionandareclassifiedintofivetypesbasedontheir locationandassociationwithacidsecretion(Table2).

■ Thedifferentialdiagnosisofepigastricpainsimilartothatfoundin complicatedpepticulcerdiseaseischroniccholecystitis,acutepancreatitis, chronicpancreatitis,functionalindigestionordyspepsia,gastritis,and refluxesophagitis.Complicatedpepticulcerdiseasecanalsopresentwith upperGIhemorrhage,andadifferentialshouldincludeesophagitis(reflux andinfectious);gastroesophagealvarices,arteriovenousmalformations; Mallory-Weisstear;stressgastritis;andneoplasmoftheesophagus, stomach,duodenum,pancreas,andbiliarytree.

■ Lastly,pyloricobstructionduetochronicinflammationandscarringwill causenausea,emesis,andearlysatiety.Thedifferentialforthesesymptoms includesgastricmotilitydisorders(i.e.,gastroparesis),gastroenteritis,small bowelobstruction,electrolyteabnormalities,andextrinsiccompression frompancreaticpseudocystsorneoplasms.

■ Distalgastricneoplasms—Gastricneoplasmsincludebenignpolyps, adenocarcinoma,neuroendocrinetumors,lymphoma,B-cellmucosaassociatedlymphoidtissue(MALT)lymphomas,GIstromaltumors, leiomyomas,andleiomyosarcomas.Anygastricneoplasticprocesscancause upperGIbleeding,epigastricpain,andluminalobstruction,andadifferential similartopepticulcerdiseaseshouldbeconsidered.

PATIENTHISTORYANDPHYSICALFINDINGS

■ Allpatientsshouldundergoathoroughhistoryandphysicalexamwithquestions focusingonthenatureofthesymptoms,specificallydeterminingthe relationshipbetweensymptomsandeating,decipheringwhethersymptoms areacuteorchronic,anddeterminingtheseverityofthesymptoms.Avast majorityofpatientswillhaveabdominalpain.Painrelatedtopepticulcer diseasethatresultsfromthecorrosiveeffectofgastricacidonvulnerableGI mucosaandtypicallyoccursintheepigastriumisdescribedasgnawingor burningandfollowsadailycycle.Thispaintypicallyarisesshortlyafter eatingbreakfastandpersistsuntillunchatwhichtimetheoralintake alleviatesthepain.Reliefistransientandpainrecursintheearlyafternoon

andagainpersistsuntildinner.Meals,specificallyonesconsistingofmilkand dairyproducts,andantacidsprovidetemporaryrelieffromulcerpain.Acute, severeepigastricpaincansignifyulcerperforation,whereasbackpain suggestsulcerpenetrationintothepancreas.

■ Nauseaandvomitingcanbeseenwithulcerdiseaseevenintheabsenceof pyloricobstruction.Nauseathatischronicinnatureandassociatedwithearly satietyandweightlosssuggestsinflammationandscarringofthepyloric channelduetochroniculceration.

■ ItisnotuncommonforcomplicatedpepticulcerstopresentwithupperGI bleeding,perforation,orobstructioninapatientwithnohistoryofpeptic ulcerdisease.

■ Bleeding—hematemesis,melena,recentdiagnosisofanemia

■ Perforation—acuteonsetupperabdominalpainandperitonitis

■ Obstruction—nausea,emesis,foodregurgitation,earlysatiety,weightloss

■ AcuteorchronicupperGIbleedingcansignifycomplicatedulcerdiseaseand maypresentasmelena,weakness,fatigue,generalmalaise,orarecent diagnosisofanemia.

■ RiskfactorsfordevelopingulcerdiseaseincludeahistoryofH.pyloriinfection; smoking;Zollinger-Ellisonsyndrome;anduseofnonsteroidal antiinflammatorydrugs(NSAIDs),steroids,andotherimmunosuppressive medications.

1,8

Therefore,anaccuratemedicationlistshouldbeobtainedand reviewedwiththepatient.Historyofpreviousulcerdiseaseshouldbeelicited, andthesuccessandtimingofprevioustreatmentmodalitiesshouldbe documented.PresenceofH.pyloriinfection,completionofantibiotictherapy, anddocumentationoferadicationiscrucial(Table3).Ulcersthatpersist despiteappropriatetreatmentofH.pylori,cessationofNSAIDuse,orare foundinH.pylori–negativepatientsshouldraisesuspicionforunderlying

malignancy.

■ Agastriclesioncanalsopresentwithepigastricpainandobstruction.Thispain istypicallyvaguerinnatureandlacksagnawingorburningcomponent. Furthermore,thesepatientsmaydescribeasensationofpersistentfullnessand earlysatietydespitehunger.

■ Asubjectiveassessmentofnutritionandfunctionalstatusisnecessaryto evaluatethepatient’sabilitytotolerateamajorsurgicalprocedure.

IMAGINGANDOTHERDIAGNOSTICSTUDIES

■ DiagnosticevaluationofsuspectedpepticulcerationandupperGIlesionscan includeendoscopy,contrastradiography,andcomputedtomography(CT) (FIG1).

■ Endoscopyisfelttobesuperiorbecauseitallowsfortissuesampling.Sampling ofgastricmucosacanbeusedtoconfirmthepresenceofH.pylori.On endoscopy,ulcersaresharplydemarcated;oftenhaveexposedunderlying submucosa;andfrequentlyoccurinthefirstportionoftheduodenum,the prepyloricarea,andthepyloricchannel.Allgastriculcersshouldbebiopsied atleastsixtimesattheulceredgeandbrushbiopsiedtoevaluatefor underlyingmalignancy.Evenifnegativeformalignancy,repeatendoscopy aftermedicaltreatmentisindicatedtoevaluatefortherapeuticresponse,and ininstancesofpersistentorintractabledisease,ulcerresectionisindicated.

■ OtherrelevantimagingmodalitiesincludecontrastradiographyandCT.Double- contrastradiographyoftheupperGItractdetectsroughly90%ofgastricand duodenalulcersbutdoesnotallowfortissuesampling.Intheacutesetting, CTishelpfulinidentifyinggastricorduodenalulcerperforation. Additionally,CTcanidentifywallthickeninginchroniculcerinflammation orneoplasticsituationsbutagainlackstheabilitytoprovidetissuesampling.

■ Zollinger-Ellisonsyndromeisarareconditionofincreasedserumgastrinlevels secondarytoagastrinomawithresultingsevereulcerdisease.Innonsmoking patientswhoarenegativeforH.pylori,serumfastinggastrinlevelsshouldbe obtainedtoevaluateforZollinger-Ellisonsyndrome.Normalbasalgastrin levelsaverageto50to100pg/mL,andlevelsover200pg/mLcanalmost alwaysbeconsideredhigh.DiagnosisofZollinger-Ellisonsyndromecanalter yourtreatmentapproach.

SURGICALMANAGEMENT

■ TheindicationsforantrectomyarelistedinTable1.Asexplainedearlier,an antrectomyisrarelyperformedforitsoriginalpurposeofremovingthe antrumandreducingacidsecretion.

■ Antrectomyisnottheprimarytreatmentoptionforbleedingorperforatedpeptic

ulcers.Avastmajorityofbleedingulcersiscontrolledendoscopicallyand,in the5%to10%thatrequireoperativeintervention,aformalantrectomyis rarelyneeded.Roughly90%ofperforatedulcerscanbesafelycontrolledwith primaryclosureandomentalpatching.Thus,antrectomyforbleedingor perforatedulcersisreservedforcaseswhenlessinvasivetreatmentoptions areineffective.

PreoperativePlanning

■ Allpatientsshouldundergopreoperativeendoscopytoidentifytheextentof diseaseandpreoperativenutritionalassessment.Allpatientsshouldreceive preoperativeantibioticsinatimelyfashiontoreducetherisksofperioperative infectiouscomplicationsfromgram-positivecocciandentericgram-negative bacillipathogens.

■ SeveralfactorsmustbeconsideredwhendecidingbetweenperformingaBillroth IandBillrothIIprocedure.TheadvantagetoaBillrothIprocedureisthatthe anatomicarrangementoftheGItractispreserved,whichmaintainstheinnate regulatorypathwaysofbicarbonateandpancreaticenzymesandsignificantly decreasestherateofpostprandialdumping.Unfortunately,thelackofa pylorusresultsinbilerefluxgastritisinamajorityofpatients.ABillrothI procedurecannotalwaysbeperformedduetoinflammationandscarringfrom prepyloric,pyloric,orduodenalulcers.Intheseinstances,theBillrothII procedureallowsforatension-freeanastomosisofnoninflamedtissuebut introducestheproblemsofpotentialafferentloopsyndromeandbilereflux gastritis,whereasaRoux-en-Ygastrojejunostomydiminishestheoccurrence ofbilerefluxatthecostofasecondanastomosis.Lastly,incasesofinvasive neoplasmsorconcerninggastricmasses,aBillrothIIprocedurewithor withoutreconstructionwithaRoux-en-Ygastrojejunostomyispreferredasit allowsfordissectionofmuchwidermarginsandislesslikelytoobstructin theunfortunatesettingofrecurrentdisease.

10,11

Positioning

■

Thepatientshouldbepositionedsupinewitharmsout.Aurinarycatheteranda nasogastrictubeshouldbeplacedtodecompressthestomach.Positioning shouldallowforattachmentofaself-retainingretractorsystemtothe operatingroomtable.

TECHNIQUES

EXPOSURE

■ Amidlinesupraumbilicalincisionismadeandcarriedtothelevelofthexiphoid. Thefalciformligamentisdividedandaself-retainingretractorsystemis placedtowidelyexposetheupperabdomen(FIG2).

GASTRICMOBILIZATION

■ Mobilizationofthedistalstomachisbestachievedbystartingonthegreater curvature.Thegastrocolicligamentisidentifiedandincisedtoenterthelesser sac(FIG3).Downwardtractiononthetransversecolonandupwardtraction onthestomachwillhelpexposethisplane(FIG4).Identificationoftheright andleftgastroepiploicvesselsalongthegreatercurvatureisessential.In benigndisease,theplaneofdissectioncanbeveryclosetothestomachinside thegastroepiploicvessels.Alargepartofthisplaneisavascularandcanbe

dividedwithelectrocautery,whereasencounteredvesselsshouldbedivided betweenclampsandligatedwith3-0silkligatures.Oncethelessersacis identified,electrosurgicaldevicescanbeusedtofurthermobilizethegreater curvature(FIG5).Proximally,dissectioniscarriedtothemidpointofthe greatercurvaturepreservingtheleftgastroepiploicartery.Distally,theplane isdevelopedbeyondthepylorustotheduodenumand,onceidentified,the rightgastroepiploicarteryshouldbeclamped,ligatedwith2-0silkligatures, anddivided.Here,oneshouldbeawareoftheunderlyingpancreatictissue anddissectionshouldbemeticulous.

■ Dissectionalongthegreatercurvatureallowsentrancetothelessersac,andthe stomachcanbeliftedsuperiorlyexposingitsposteriorsurfaceandthe congenitalattachmentstotheunderlyingpancreaticcapsule(FIG6).These attachmentsshouldbesharplydivided.Asthisplaneisdevelopedina superiordirection,greatcareshouldbetakentonotinjuretheleftgastric arteryatitsoriginfromtheceliacaxis.Inflammationandscarringcanbe encounteredinthesettingofposteriorgastricwallulcers.

■ Attentionisthenturnedtodivisionofthegastrohepaticligamentalongthelesser

curvature.Retractingthestomachinferiorlyandtothepatient’sleftfacilitates exposureofthelessercurvature.Thisdissectioncanstartinthetransparent parsflaccidaandiscarriedproximallytotheincisuraanddistallytotheright gastricartery,whichshouldbeclamped,ligatedwith2-0silkligatures,and divided(FIG7).Again,electrocauteryorelectrosurgicaldevicescanbeused alongthelessercurvature.Onemustbeawareofanaberrantorreplacedleft hepaticarteryoriginatingfromtheleftgastricarteryandtraversingthe gastrohepaticligament.Ifencountered,attemptsshouldbemadetopreserve thisvessel.Afterclampingbutbeforedivisionoftherightgastricartery, bloodflowtothelivershouldbeconfirmedbypalpationofthe hepatoduodenalligament.

DIVISIONOFTHESTOMACH

■ Astaplingdeviceisusedtodividethestomachalongaplanefromjustproximal totheincisuraangularisonthelessercurvaturetoapointonthegreater curvaturetwo-thirdsofthewayfromthegastroesophagealjunctiontothe pylorus.SomerecommendplacingBabcockforcepsdistaltothestaplelineto preventslidingorrotationofthegastricmucosaasthestaplerisclosed.This willhelpensureaclean,evencutacrosstheanteriorandposteriorlayersof gastricmucosa(FIG8).

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