Gastric surgery and NOTES

Péter LUKOVICH M.D.

Semmelweis University, Faculty of Medicine, 1st Department of Surgery

Blood supply of the stomach

and the duodenum

Celiac trunk - a. gastrica sin.

- a hepatica comm. - a. gastroepiploica d.

- a. hepatica comm. - a. gastrica d.

- a. lienalis - a. gastroepiploica sin.

- a lienalis - a. gastricae breves

Anamnesis (familiar: ulcer,cancer)

Complains (vomitus, haematemesis, anaemia (iron deficiency) disgust of meat)

Physical examination (palpable mass, Wirchow lymph node)

Contrast X-ray

Endoscopy

Endoscopic Ultrasound (EUS)

CT

Virtual endoscopy

Capsule endoscopy

Helicobacter pylori test

Scintigraphy

Lab test: Gastrin level (Zollinger-Ellison syndrome) >50-100 pg/ml

Laparoscopy, laparotomy

Examination of the stomach

Congenital dieseases of the stomach

and the duodenum

Duodenum atresia Rare, double bubble sign : X-ray

Congenital pylorus stenosis

Pancreas annulare Frequency 1:6-7000

Meckel diverticulum

Congenital hypertrophic pylorus stenosis

- Frequency: 500-700/1 birth

- First-born male infants (male/female ratio: 4-5/1)

- One of the more common causes of gastric outlet

obstruction in the neonatal period

- Manifest by projectile nonbilious vomiting between the 4th and 6th weeks

- The antiperistaltic movement of the stomach can be visualised and the hypertrophied

pylorus is palpable

Operation: Weber-Ramstedt pyloro-myotomy

Pancreas anulare

1818 Tiedemann discribed at the first time

1862 Ecker gave the name: pancreas anulare

Drey classified: (neonatal, child age,

asymptomatic and symptomatic in the adult age

Rare disease: 20 000/3

(boncolt esetek)

Male/female ratio : 1/1

In 75% with other congenital diseaeses

Down syndrom

Tracheo-oesophageal fistula

Oesophageal atresia

Anus imperforatus

Hirchsprung disease

Duodenal atresia

Meckel diverticulum

Pancreas anulare

Ulcer of the stomach and the duodenum

Etiology

1., Familiar

2., Hyperacidity (Schwartz 1910 - "Ohne saure kein Ulcus”)

Peptic ulcer is not peptic, Zollinger-Ellison syndrome

3., Decreased level of the protective factors

(pepsin and bicarbonat, prostaglandin level)

4., Blood group - "O" blood group

5., Non steroid antiinflammatory drugs (aspirin)

6., Steroid therapy

7., Helicobacter pylori infection

8., Stress

9., Damage of the blood supply of the duodenum

10., Others Curling ulcer - after burning

Cushing ulcer - after trauma of the brain

Complication of the ulcer

of the stomach and the duodenum

Perforation

Pylorus stenosis

Bleeding

Perforation of the ulcer

Complains: Usually the ulcer on the anterior wall could perforate

Epigastrial pain like thrust of the knife -

later pain in the right lower quadrant (Moynihan tunnel)

Differential diagnosis: Appendicitis!!!

Examinations:

Physical examination: free air in the abdominal cavity,

loss of the blunt of the liver (Chilaiditi syndrome!)

defanse musculaire - peritonitis

no movement of the the bowels

Nativ abdominal X-ray:

air in the abdominal cavity (under the diaphragma)

Operation: suture of the perforation (+covering with omentum)

Neumann

resection of the stomach

Minimal invasiv technic: laparo-gastroscopy

P. Lukovich

Heinecke-Mikulicz

Finney

Jaboulay

Pyloromyotomy (Aust)

Pyloroplasty

Forrest classification of the ulcer

I. active bleeding Ia: spuring bleeding

Ib: oozing bleeding

II. signs of the previous bleeding

IIa: black surface

IIb: visible stump of vessel

IIc: coagulum

III. without any sign of bleeding

Bleeding of the ulcer

Surgery: vagotomy

1. Truncal vagotomy

2. Selectiv vagotomy

3. Superselectiv vagotomy

Now it is a history!

Surgery: resection of the stomach

Billroth-I resection Billroth-II resection

Surgery: resection of the stomach (Billroth-I)

of the stomach

and

the small bowel

Surgery: resection of the stomach (Billroth II)

Gastric cancer:

Incidence of the gastric cancer

decreased in USA

increase in Japan, Chile, Iceland

Peak of incidence in the 5th decade in the life

Male/female ratio: 2/1

Gastric cancer: epidemiology

Feeding: salt, qualitiy of the drinking water

Smoking

Precancerous diseases:

Polyps: hyperplastic adenomatous polyps

suggested:endoscopic polypectomy or surgical resection

Ulcus chronicum

Atrophic gastritis: Type A (anaemia perniciosa)

antibody against the parietal cells

localized into the fundus

Type B (local irratation of the foods)

localized into the fundus and the antrum

Dysplasia

Menetrier gastritis: suggested: preventiv gastrectomy

After Billroth II resection: bile reflux - after 15-20 yrs of the op

Gastric cancer: clinical presentation

Abdominal pain 66%

Weight loss more than 10% 50%

Nausea, vomiting 32%

GI bleeding 23%

Dysphagia 23%

Mass 36%

Tenderness 20%

Anaemia 42%

Hypoproteinaemia 26%

Gastric cancer: lymphnode metasteses

Kompartment I Kompartment II Kompartment III

Gastric cancer: pathology

Macroscopical appareance:

Bormann calssification

Histological classification:

adenocarcinoma

mucinous adenocarcinoma

round cell carcinoma

planocellular carcinoma

Localisation: antrum: 55%

corpus 35%

cardia 5%

linitis plastica 5%

Gastric cancer: TNM classification

T (primer tumor)T1 infiltration of the lamina propria

T2 infiltration of the subserosa

T3 involve the serosa

T4 involve the surronding organs (pancreas, colon, spleen, diaph)

N (regional lymph nodes)N0 no lymph node metastasis

N1 metastasis in the perigastric lymph nodes(distance <3 cm)

N2 metastasis in the perigastric lymph nodes(distance >3 cm)

Wirchow lymph node

M (distant metastases)Krukenberg tumor

Operation of the stomach cancer

Gastrectomy and - regional lyphadenectomy

- omentectomy

- splenectomy (if there is metastasis in the hilum)

- if it is necessery resection of the colon or pancreas

Antrectomy: small tumor

Reconstruction

after gastrectomy

Gastric cancer: 5 year survival rates

Carcinoma in situ (2%) 100%

Stage I (6%) 43%

Stage II (9%) 42%

Stage III (17%) 6%

Stage IV (67%) 0%

Liver 35-40%

Colon 35-40%

Klatskin 20-30%

Oesophagus 10-20%

Pancreas 8-15%

Gallbladder 0-5%

Stomach 20-25%

Gastro-entero anastomosis (GEA)

Indication: Gastric outlet obstruction

Antecolic – retrocolic

Anterior – posterior

wall of the stomach

P. Lukovich

Indications:

- obstruction of the oesophagus

- feeding problem

(coma, muscle diseases)

Local anaesthesia (high risk patients!)

Surgical gastrostomy

Witzel (1891)

Kader (1896) (Stamm-Senn)

Percutan endoscopic gastrostomy (PEG)