Gastric surgical procedures overveiw

1. •Gastrointestinal
Procedures
by
Kamran Akbar

2. RELEVANT ANATOMY

4. RELEVANT PHYSIOLOGY
• There 3 glandular zones
Cardiac > mucus cells and
few parietal cells
Oxyntic(parietal)> (80% at
fundus and body) parietal
cells secretes HCL and
intrinsic factor the chief cells
pepsinogen
Pyloric gland> G-cells
secrete gastrin
Stimulant of Gastric
secretion:
• Acetylcholine (vagus) --> G
cells and parietal cells
• Gastrin --> parietal cell and
chief cells
• Histamine (mast cells) --->
parietal & chief cells
Phases :
• Cephalic - vagus
• Gastric - food
• Intestinal -chyme

5. INDICATIONS FOR SURGERY
• Refractory ulcers
• Haemorrhage not responding to endoscopic treatment
• Gastric outlet obstruction
• Perforation
• Suspicious of Malignancy

6. SURGICAL OPTION
• Gastrostomy
– simple gastrostomy
– Percutaneous gastrostomy
• VAGOTOMY
– Truncal and drainage
– Selective
– Highly selective
– Posterior vagotomy and anterior seromyotomy

7. • GASTRECTOMY
– Total Gastrectomy
• Roux-en-Y jejunojejunostomy
– Subtotal Gastrectomy
• Billroth I
• Billroth II

8. Gastrostomy
• It is the procedure wherein a tube is passed into the
stomach per abdominally for the purpose of enteral
feeding.
Types
– Open gastrostomy
• Stamm’s
• Janeway’s
– Percutaneous endoscopic gastrostomy(PEG)
Could be temporal or permanent ,
8

9. Indications
• Oesophageal stricture
• Oesophageal atreasia
• Any condition which requires prolonged tube feeding for >
4weeks
• Major neck surgeries
• Neurological swallowing disorders
Contraindications
• Previous gastrectomy
• Gastric disease with impaired gastric emptying
• Intestinal obstruction 9

10. Procedure
Open gastrostomy;
• Preoperatively; baseline investigations, plain abd.xray, upper
gi endoscopy, NPO, consent
• Anaesthesia; local, general
• Positioned and Skin prep
• Incision; small upper midline, left subcostal
• The peritoneal cavity is entered and the anterior wall of the
stomach is grasp with two pairs of Babcock forceps and the
stomach drawn unto the surface. The stomach is incised to
allow insertion of a 12 or 14Fr forley catheter whose balloon is
then inflated. Leakage along side the catheter is prevented is10

11. • Stamm’s method; two purses string suture of non-
absorbable material are inserted concentrically around
the tube, the 1st 1cm from the tube. This is then
inverted by a second concentric suture 2cm from the
tube. When drawn tight, these suture invaginate the
catheter.
• Janeway’s; a valve is created by burying the tube in a
short tunnel in the stomach wall.
The tube is brought out through a stab incision on the
anterior abdominal wall. To further prevent leakage, the
anterior gastric wall is sutured to the parietal peritoneum
at the region of the tube. With interrupted sutures. 11

12. Percutaneous endoscopic gastrostomy
• Reduced morbidity and mortality compared to open.
• The fiber optic endoscope is passed into the stomach and
directed towards the anterior abdominal wall.
• The second operator identify it by transillumination and
guide it to the ideal site of placement of the tube.
• A cannula is passed by the abdominal operator
percutaneously into the stomach, he then pass a thread
through the cannula.
• This thread is grasped under direct vision by the
endoscopist using biopsy forceps and drawn back through
the mouth.
• The gastrostomy tube is securely anchored to the thread
which is pulled by the abdominal operator delivering it 12

13. Post-op
• Feeding commened usu within 24hour. When bowel sounds
are heard
• Patient is taught how to care for the tube and to recognize
infection.
Complications;
• Infection
• Trauma to other structures eg colon
• Leakage
• Blockage
• Aspiration pneumonia
• Displacement of tube
bbinyunus2002@gmail.com 13

14. vagotomy

15. • Division of the vagus nerve remove the cephalic
stimulus to oxyntic cells; acid secretion reduce by
60%.
• Types;
– Truncal vagotomy and drainage
– Selective vagotomy
– Highly selective vagotomy
– Posterior Truncal vagotomy and anterior seromyotomy
(Taylor’s)

16. Truncal vagotomy and drainage
The 2 nerve trunks are divided below the diaphragm near the hiatus.
• The gastric tone and mobility are diminished and emptying delayed
• A drainage procedure is done to drain the stomach
• Drainage;
 Pyloroplasty; enlarging the pyloring opening between the stomach and
duodenum, may be performed in patients with an obstructing pyloric ulcer or in
conjuction with vagotomy to treat bleeding duodenal ulcers
 Gastrojejunostomy; the jejunum, about 15cm from the duodeno-jejunal flexure
is anastomose usually to the posterior wall of the stomach behind the transverse
colon

17. Selective vagotomy
• Vagotomy with sparing the hepatic branch of anterior
vagus and the coeliac branch of the posterior vagus.
• A drainage procedure is also performed
• Time consuming and it has being abandoned
• Recurrence rate is 10%

18. Highly selective
• It aims at denervating only the acid producing oxyntic
gland sparing nerve to the pyloric antrum(nerve of latarjet)
such that drainage procedure is not required.
• It is difficult to determine the exact area of denervation of
oxyntic cell
• Recurrence rate is 10%

19. Gastrectomy
• subtotal gastrectomy
– Bilroth 1
– Billroth 2

20. Billroth I
Billroth I – partial gastrectomy gastro-duodenostomy end-to-
end
Done for gastric ulcer in the antrum

21. Billroth II
Partial gastro-jejunostomy end-to-side with
blind closure of duodenum
Done for a proximal gastric ulcer

22. COMPLICATIONS
• Immediate
– Bleeding
– Gastric retention
– Dysphagia
– Leakage of duodenal stump
– Obstruction of the stoma
– Acute pancreatitis
• Late
– Dumping syndrome
– Diarrhoea
– Recurrent ulceration
– Iron deficiency anaemia
– Risk of colorectal and gastric tumours
– Weight loss
– Megaloblastic anaemia
– Osteomalacia

23. Prognosis
• Overall operative procedure gives satisfactory result in at
least 80% of patients
• Mortality of vagotomy and drainage is <1%
• Partial gastrectomy has overall mortality of 2%, 90% are
satisfied with result, 2% anastomotic ulceration and 5-
10% dumping problems.
• Operative mortality for perforated DU is 7%