1. Dr Aqeel Shakir Mahmood Consultant General and Laparoscopic Surgeon
Stomach and Duodenum
Dr Aqeel Shakir Mahmood
Assistant Professor
Consultant General and Laparoscopic Surgeon
FICMS General Surgery
CABS General Surgery
FICMS-GIT Gastrointestinal Surgery (subspecialty )
MRCS –( Ireland) General Surgery
FRCS –( London) General Surgery

2. Stomach and Duodenum Anatomy Physiology Pathology Gastritis
Peptic ulcer diseases
Operative procedures
Tumors
Carcinoma of the
stomach

3. Duodenal Ulcer : goals of operative therapy
Promotion of ulcer healing
Treatment of specific complications
Reduction of the possibility of recurrence
Minimization of postoperative side effects

4. Duodenal Ulcer : operative procedures
Truncal vagotomy and drainage
Truncal vagotomy and antrectomy
Parietal cell vagotomy
Alternative methods

5. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Vagotomy

8. Gastric effects of truncal vagotomy
Decreased acid secretion
Increased serum gastrin
Gastrin cell hyperplasia
Accelerated liquid emptying
Altered emptying of solid

9. Nongastric effects of truncal vagotomy
Decreased pancreatic exocrine secretion
Decreased postprandial bile flow
Increased gallbladder volume
Diminished release of vagally mediated peptide hormones

10. Truncal vagotomy and drainage Drainage procedures : pyloroplasty
Heineke-Mikulicz
Finney
Jaboulay

11. Heineke-Mikulicz pyloroplasty

12. GASTRODUODENOSTOMY BY JABOULAY

13. Finney pyloroplasty

14. Duodenal Ulcer : operative procedures
Truncal vagotomy and drainage
Truncal vagotomy and antrectomy
Parietal cell vagotomy
Alternative methods

17. Duodenal Ulcer : operative procedures
Truncal vagotomy and drainage
Truncal vagotomy and antrectomy
Parietal cell vagotomy
Alternative methods

24. Duodenal Ulcer : choice of operation
Location of ulcer
Indication for operation
Chronicity of the ulcer diathesis
Age and sex, nutritional status of the patient
Presence of concomitant illness
Stability of the patient during the perioperative period
Experience and personal preference of the surgeon

25. Duodenal Ulcer : indications for operation
Intractability
Perforation
Obstruction
Hemorrhage

26. Duodenal Ulcer : indications for operation
Intractability
Perforation
Obstruction
Hemorrhage

27. Intractability ; criteria
Initial healing is delayed, so that ulceration persists at 3 months despite active drug therapy
Ulcers recur within 1 year of initial healing despite maintenance therapy
The ulcer disease is characterized by cycles of prolonged activity with brief or absent remissions

28. Operative procedures : intractability
First choice; parietal cell vagotomy
Alternatives ; truncal vagotomy and antrectomy
laparoscopic vagotmy

29. Duodenal Ulcer : indications for operation
Intractability
Perforation
Obstruction
Hemorrhage

30. Clinical features ; perforated duodenal ulcer
Symptoms ; sudden onset of severe epigastric pain spreading throughout the abdomen, variable degree of shock
Signs ; abdominal tenderness, rigidity
Plain X-ray ; peritoneal free air

32. Differential diagnosis ; perforated duodenal ulcer
Acute cholecystitis
Acute pancreatitis
Strangulation obstruction
Acute appendicitis
Perforation of other G-I tract
Mesenteric thrombosis

33. Operative procedures : perforation
Simple closure
Definitive surgery
parietal cell vagotomy and omental patch
truncal vagotomy and pyloroplasty
truncal vagotomy and antrectomy

34. Indications for definitive operation
No preoperative shock
No life-threatening medical illness
Perforation has been present for less than 48 hours

36. Duodenal Ulcer : indications for operation
Intractability
Perforation
Obstruction
Hemorrhage

37. Causes of obstruction in duodenal ulcer
Inflammation and edema
Fibrosis

38. Operative procedures : obstruction
Truncal vagotomy and antrectomy
Truncal vagotomy and gastrojejunostomy

40. Duodenal Ulcer : indications for operation
Intractability
Perforation
Obstruction
Hemorrhage

41. Indications for operative intervention ; duodenal ulcer bleeding
Massive hemorrhage leading to shock
Prolonged blood loss requiring continuing transfusion
Recurrent bleeding during medical therapy or after endoscopic therapy
Recurrent bleeding requiring hospitalization

42. Operative procedures : hemorrhage
Truncal vagotomy and pyloroplasty with
suture ligation of bleeding vessel
Truncal vagotomy and antrectomy
including ulcer or suture ligation of bleeding vessel

43. Timing of operation : hemorrhage
Primary emergency
Secondary emergency
Early elective surgery

46. Gastric Ulcer : goals of elective operation
Primary goals ;
to excise the ulcer
to reduce acid/pepsin output
Secondary goals ;
to minimize bile reflux and gastric stasis

47. Stomach resections:
Billroth I (BI) – gastro-duodenoanastomosis end-to-end
Billroth II (BII) – gastro-jejunoanastomosis end-to-side with blind closure of duodenum
Proximal selective vagotomy – denervation of parietal gastric cells

48. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Billroth I

49. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Billroth II

50. Billiroth 1 Gastroduodenostomy Billiroth 2 Gastrojejuenostomy

51. Gastric ulcer : standard operations
type I ; Distal gastrectomy and B-I anastomosis
type II, III ; Distal gastrectomy with vagotomy
type IV ;
TV and drainage and biopsy/excision of ulcer
Proximal gastrectomy

55. Gastric Ulcer : indications for elective operation
Failure to heal on optimal medical therapy
Suspicion of malignancy
Distal gastric obstruction
Giant gastric ulcer

58. Gastric Ulcer : emergency operation
Bleeding gastric ulcer
Perforated gastric ulcer

59. Bleeding gastric ulcer : operative procedures
Gastric resection including ulcer
simple oversewing
excision of ulcer
with TV and drainage
without TV and drainage

60. Gastric Ulcer : emergency operation
Bleeding gastric ulcer
Perforated gastric ulcer

61. Perforated gastric ulcer : operative procedures
Gastric resection
Biopsy and simple closure

62. New Surgical Strategy for Gastroduodenal Ulcer : Laparoscopic approach
Truncal vagotomy
Thoracoscopic truncal vagotomy
Parietal cell vagotomy

63. Stress Ulcer
Multiple superficial mucosal erosions after major physical trauma, shock, sepsis, hemorrhage, respiratory failure, or severe burns.

64. Morbid obesity

65. Morbid obesity Sleeve Gastrectomy

66. Morbid obesity

68. Morbid obesity Sleeve Gastrectomy

69. Thank you