DISEASES OF THE OPERATED STOMACH

PYLORUS
1. Distal muscular loop;
2. Proximal muscular loop.
AGGRESSIVE FACTORS
hydrochloric acid
pepsin
reverse diffusion of ions of hydrogen
products of lipid hyperoxidation
DEFENSE FACTORS
mucus and alkaline components of gastric
juice
property of epithelium of mucous tunic to
permanent renewal
local blood flow of mucous tunic and
submucous membrane
PATHOMORPHOLOGY
erosion
acute ulcers
chronic ulcers
CLASSIFICATION by Johnson (1965)
I ulcers of small curvature (for 3 cm higher from
a goalkeeper);
II double localization of ulcers simultaneously in
a stomach and duodenum;
III ulcers of goalkeeper part of stomach (not
farther as 3 cm from a goalkeeper)
CLINICAL MANAGEMENT
Pain
Vomiting
Heartburn
Belching
COMPLICATIONS
Penetration
Stenosis
Perforation
Bleeding
Malignization
DIAGNOSIS PROGRAM
1. Anamnesis and physical examination.
2. Endoscopy.
3. X-Ray examination of stomach.
4. Examination of gastric secretion by the method of aspiration of
gastric contents.
5. Gastric pH metry.
6. Multiposition biopsy of edges of ulcer and mucous tunic of
stomach.
7. Gastric Dopplerography.
8. Sonography of abdominal cavity organs.
9. General and biochemical blood analysis.
10. Coagulogram.
X-Ray examination
THE DIRECT SIGNS:
symptom of Haudek's niche
ulcerous billow and convergence of folds of mucous tunic.

INDIRECT SIGNS:
symptom of forefinger (circular spasm of muscles)
segmental hyperperistalsis,
pylorospasm,
delay of evacuation from a stomach
duodenogastric reflux
disturbance of function of cardial part (gastroesophageal reflux).
SYMPTOM OF
Haudek's
niche
STENOSIS
OF THE
GASTRO-
ENTERO-
ANASTO-
MOSIS
GASTROSCOPY
DEVICE FOR GASTRIC
DOPPLEROGRAPHY
Endoscopic picture of the normal
stomach wall
Endoscopic picture of the peptic ulcer
SURGICAL TREATMEN
a) at the relapse of ulcer after the course of conservative therapy;
b) in the cases when the relapses arise during supporting antiulcer
therapy;
c) when an ulcer does not heal over during 1,52 months of
intensive treatment, especially in families with ulcerous
anamnesis;
d) ulcer with complications (perforation or bleeding);
e) at suspicion on malignization ulcers, in case of negative
cytological analysis.
Classification of the
postgastrectomy syndromes
Functional disturbance.
Dumping.
Hypoglycemic syndrome.
Postgastrectomy (agastric) asthenia.
Syndrome of small stomach.
Syndrome of afferent loop (functional origin).
Gastroesophageal reflux.
Alkaline reflux-gastritis.
Organic disturbances.
Pepticulcer of anastomosis.
Gastro-colon fistula.
Syndrome of afferent loop (mechanical variant).
Cicatricial deformation and narrowing of anastomosis.
Mistakes in the technique of operation.
Postgastrectomy accompanying diseases (pancreatitis, enterocolitis,
hepatitis).
Mixed disturbances.
combination with dumping or postvagotomy diarrhea.
Billroth I and Billroth II resection
Billroth II resection
BILLROTH II RESECTION
BILLROTH II RESECTION
BILLROTH I RESECTION
BILLROTH I RESECTION:
Gastrectomy by B-II
Distal resection of the stomach with saving of the
perigastral vessels
1
2 4
3
Aiming resection of the ischemic
segment of stomach in combination
with SPV (by L.J . Kovalchuk)

1.
;
2. -:
;
3.
-.
1
2
3
Proximal resection of the stomach
1. ;
2.
.
Proximal
subtotal
resection of the somach
1. ;
2. ;
3.

.
Gastrectomy
( scheme; end view)
1. Esophago-
jejunuanastomosis;
2. Entero-entroanastomosis.
Degrees of weight of the dumping syndrome
I degree
easy
Patients have the periodic attacks of weakness with
dizziness, nausea, that appear after the use of
carbohydrates and milk food and last no more than 15
20 min. During the attack a pulse becomes more
frequent on 1015 per min., arterial pressure rises or
sometimes goes down on 1.3-2 KPa (1015 mm Hg),
the volume of circulatory blood diminishes on 200300
ml. The deficit of mass of body of patient does not
exceed 5 kg.
Degrees of weight of the dumping syndrome
degree
middle
weight
Attacks of weakness with dizziness, pain in the region of
heart, hyperhidrosis, diarrhea. Such signs last, usually,
2040 min., arise up after the use of ordinary portions of
some food. During such state a pulse becomes more
frequent on 2030 per min., arterial pressure is rises
(sometimes goes down) on 22,7 KPa (1520 mm Hg),
the volume of circulatory blood diminishes on 300500
ml. The deficit of mass of body of patient achieves 510
kg. A working capacity is reduced. Conservative
treatment sometimes has a positive effect, but brief.
Degrees of weight of the dumping syndrome
degree
hard
Patients are disturbed by the permanent, acutely
expressed attacks with the collaptoid state, by a fainting
fit, by diarrhea, which do not depend on character and
amount of the accepted food and last about 1 hour.
During the attack is multiplied frequency of pulse on 20
30 per 1 min; arterial pressure goes down on 2,74 KPa
(2030 mm Hg), the volume of circulatory blood
diminishes more than on 500 ml. The deficit of mass of
body exceeds 10 kg.
Dumping syndrome (quick evacuation
of the contrast)
Depending on reasons and mechanisms of
development of dumping syndrome there are
different methods of the repeated
reconstructive operations.


All of them can be divided into four basic
groups:
Operations which slow evacuation from stump of
stomach.
Redoudenization.
Redoudenization with deceleration of evacuation
from stump of stomach.
Operations on a thin bowel and its nerves.
Basic stages of reconstructive
operations
disconnection of adhesions in an abdominal cavity,
releasing of gastrointestinal and interintestinal
anastomosis and stump of duodenum;
cutting or resection of efferent and afferent loops;
renewal of continuity of upper part of digestive tract.
Hypoglycemic syndrome
The attacks of weakness at a hypoglycemic syndrome arise up as a
result of decline of content of sugar in a blood.
stage Signs beghins after 2-2,5 h after food intake, 2-3 times
per week. Patients does not feel it.
stage Signs beghins 2-3 times per week.
stage Signs beghins every day. Patients always has sweet
food and bread.
Distinguished easy, middle and heavy
degrees of afferent loop syndrome
easy vomiting is 12 times per a month, and insignificant
regurgitation arise up through 20 min 2 hour after a
food, more frequent after the use of milk or sweet food.
middle attacks repeat 23 times per week, patients are
disturbed by the considerably expressed pain syndrome,
and with vomiting up to 200300 ml of bile is lost.
heavy the daily attacks of pain are typical, that is accompanied
by vomiting by a bile (up to 500 ml and more).
All operative methods of treatment of afferent
loop syndrome can be divided into three
groups:
Operations, that will liquidate the bends of afferent loop
or shorten it.
Drainage operations.
Reconstructive operations.
CLASSIFICATION
I. By etiology:
. True duodenal ulcer.
B. Symptomatic ulcers.
II. By passing of disease:
1. Acute (first exposed ulcer).
2. Chronic:
a) with the rare exacerbation;
b) with the annual exacerbation;
c) with the frequent exacerbation (2 times per a year
and more frequent).
CLASSIFICATION
III. By the stages of disease:
1. Exacerbation.
2. Scarring:
a) stage of red scar;
b) stage of white scar.
3. Remission.
IV. By localization:
1. Ulcers of bulb of duodenum.
2. Low postbulbar ulcers.
3. Combined ulcers of duodenum and stomach.
CLASSIFICATION
V. By sizes:
1. Small ulcers up to 0,5 cm.
2. Middle up 1,5 cm.
3. Large up to 3 cm;
4. Giant ulcers over 3 cm.
VI. By the presence of complications:
1. Bleeding.
2. Perforation.
3. Penetration.
4. Organic stenosis.
5. Periduodenitis.
6. Malignization.
CLINICAL MANAGEMENT
Pain
Vomiting
Heartburn
Belching
DUODENOSCOPY
SYMPTOM OF
Haudek's niche
STENOSIS
DIAGNOSIS PROGRAM
1. Anamnesis and physical examination.
2. Endoscopy.
3. X-Ray examination of stomach and duodenum.
4. General and biochemical blood analysis.
5. Coagulogram.
METHODS OF SURGICAL
TREATMENT
organ-saving operations;
organ-sparing operations;
resection.
TRUNK VAGOTOMY (TrV)
2 4
3
SELECTIVE VAGOTOMY (SV)
SELECTIVE PROXIMAL VAGOTOMY
(SPV)
SELECTIVE PROXIMAL VAGOTOMY
(SPV)
Heineke-Mikulicz
pyloroplasty
Heineke-Mikulicz pyloroplasty
GASTRODUODENOSTOMY BY JABOULAY
Finney pyloroplasty
Classification of the postvagotomy
syndromes
Relapse of ulcer.
Diarrhea.
Disturbance of function of esophagocardial transition.
Disturbance of emptying of stomach.
Dumping syndrome.
Reflux-gastritis.
Gallstone disease.

Postvagotomy gastrostasis