Medical Archive

Anatomy

Physiology

Peptic Ulcer Disease

Epidemiology

Pathogenesis

Duodenal ulcer

Body? ulcer? ? ????. ??? ??? cancer ??
?? ???? ??? ?? ???? ??? ?? ???!

Complicated ulcer diseases

Hemorrhage

• m/c complication, 15-20% of duodenal ulcer.
• ????? ?? + truncal vagotomy with pyloroplasty
• ?? ???? ???? massive bleeding
  • Blood loss >1,500~2,000mL (~5pint of pRBC)
  • Hct fall <25% in acute period
  • Shock, syncope
  • Hct. & BP ?? ?? blood 1,000mL/day ?? ??.

Perforation

• 90%? duodenal bulb ?? (??? ???? ??)
• Surgical option
  • Patch closure (most commonly used)
    • Unstable ??? exudative peritonitis? ?? perforation? 24hr ?? ???? ???? ??.
    • 1cm ??? simple closure
    • 1cm ???? patch closure (omentum flap ??)
  • Patch closure and HSV
    • Stable patient without longstanding perforation? ?? ??.
  • Patch closure and V+D

Gastric outlet obstruction

• ??: ulcer healing -> scar formation -> stenosis & obstruction
• ??: prolonged vomiting (3-4L/day), weight loss, heartburn
• ??: truncal vagotomy, antrectomy

Intractable peptic ulcer disease

Surgical procedures for peptic ulcers

• Indication
  • Hemorrhage, perforation, obstruction ???? ????? ??? ?? ??? ?? ?? ??(rare)
• Truncal vagotomy
  • & drainage (pyloroplasty) – most commonly used
    • ??? ?? ?? ??. but ???, ?? ?? ?. ?? ??? ??? ??? ??
  • & anterectomy (Billroth I/II)
    • Anterectomy? gastrin ??? ??.
    • ??? ????? ???? ????. ?? ? ???/??? ?? ? type III? ?????
    • Post vagotomy syndrome: hepatic branch ??? GB stone ??, celiac branch ??? diarrhea ??. -> ???? ???.
• Selective vagotomy
• Highly selective vagotomy (parietal cell vagotomy)
  • ???? ??? ? ?? (?? type III)
  • ??? ??? ??? ?? ???? ??????

Gastric ulcers

Clinical manifestations

Diagnosis and treatment

Duodenal ulcer?? ?? malignant ???? ??? ???? gastrectomy? ????.

• Type I (55%)
  • Near lesser curvature (LC)
  • Distal gastrectomy + Billroth I ??
• Type II (25%) & Type III (15%)
  • LC+duodenal / Prepyloric
  • d/t ????, D
  • Distal gastrectomy + vagotomy
• Type IV (5%)
  • Proximal stomach
  • d/t Aspirin, NSAID
  • Distal gastrectomy + ulcer excision
• Bleeding gastric ulcer
• Perforated gastric ulcer
• Giant gastric ulcer
• Zollinger-Ellison syndrome

Total gastrectomy? ??? (Roux-en-Y) gastro-jejunostomy? ??.

Stress Gastritis

Postgastrectomy Syndromes

# Early Complications

• Anastomotic leakage
  • POD 3-5? ?, stump ischemia ??.
  • Fever, abdominal pain, tachypnea, and tachycardia
  • HR>120/min has been shown to be the most sensitive predictor.
  • Diagnosis: oral contrast-enhanced imaging (either abdominal CT scan or upper GI series)
  • Treatment: urgent surgical repair.

Dumping Syndrome

Symptoms

• Early symptom (?? 15-30?)
  • Vasomotor symptom
    • Rapid hyperosmolar gastric content? rapid emptying -> ?? ?? flulid shift -> intravascular volume? ??.
    • Palpitation, tachycardia, diaphoresis, headache
    • Abdominal discomfort, N/V/D
  • Management
    • ???? ?? ?? ? ?? ??. ??? ??? ???. Ameliorated by recumbence(????) or saline infusion.
• Late symptom (?? 2?? ?)
  • Hypoglycemic symptom
    • hyperinsulinemia ? ???
  • Management
    • ??? ???!
    • The ?-glucosidase inhibitor acarbose may be particularly helpful in ameliorating the symptoms of late dumping.
    • Most patients improve with time (months and even years), dietary management, and medication.
    • Patients with disabling refractory dumping after gastrojejunostomy 
    • Considered for simple takedown of this anastomosis provided that the pyloric channel is open endoscopically.
    • The Roux-en-Y gastrojejunostomy is associated with delayed gastric emptying, probably on the basis of disordered motility in the Roux limb. Taking advantage of this disordered physiology, surgeons have used this operation successfully in the management of the dumping syndrome.

Treatment

• Dietary management
  • ??? volume ??? frequency ?
  • ?? ?? ?? ??. ????? ?? ??? ??? ?? ???.
• If dietary manipulation fails, the patient is started on octreotide.
  • 100 ?g subcutaneously twice daily. 
  • This can be increased up to 500 ?g twice daily if necessary. 
  • The long-acting depot octreotide preparation is useful.
  • Not only ameliorates the abnormal hormonal pattern seen in patients with dumping symptoms, but also promotes restoration of a fasting motility pattern in the small intestine (i.e., restoration of the MMC)
• Surgical option
  • Billroth II -> I
  • Billroth I -> II
  • Reversed jejunal interposition

Metabolic disturbances

• Anemia
  • Megaloblastic anemia (Vit.B12 deficiency)
  • IDA (m/c)
• Osteoporosis and osteomalacia

Afferent loop syndrome

• Etiology
  • s/p Partial gastric resection & gastrojejunostomy (Billroth II)
  • Duodenal portion (afferent loop)? ???? ???? obstruction
• Symptoms
  • Vomiting – ??? O, ?? ????
  • Postprandial epigastric pain – vomiting? ?? ???. ??? ?? ??.
  • Weight loss
• Diagnosis
  • CT: duodenal portion ??
• Management
  • Billroth II -> I
  • Conversion to Roux-en-Y

Efferent loop obstruction

??? ?? – Lt ?? ??, ??, ??? ??

Alkaline reflux gastritis

• Symptoms
  • Vomiting – ???X, ???? ???? ??
  • Postprandial epigastric pain – vomiting? ?? ???? ??. ??? ?? ??.
• Diagnosis
  • Endoscopy with biopsy
• Management
  • ??? ???, cholestyramine, sucralfate
  • ??? ?? ??? Roux-en-Y gastrojejunostomy

Gastric atony

• ???? ??? ??? ?? ? ??? ?; ??? ??? ??? ??.
• Management
  • Dietary modification
  • Promotility agents
  • Subtotal resection -> near-total or total gastric resection with Roux-en-Y reconstruction

# Gallstones

• D/t resulting rapid weight loss
  • ?Bile concentrations of mucin and calcium.
  • Patients who undergo RYGB have up to a 30%-40% chance of developing symptomatic gallstones.
  • Prophylactic UDCA is often administered for 6 months postoperatively to reduce the risk of gallstone development.

Gastric Cancer

Epidemiology

Risk factors

Pathology

Diagnosis and workup

Staging

https://link.springer.com/article/10.1007%2Fs10120-016-0622-4

Treatment

M1? ??? ?? ??. (M1? CTx)

Distal 1/3: Subtotal~total gastrectomy
Middle 1/3: Total gastrectomy
Proximal 1/3: Extended gastrectomy

New approach

Laparoscopy-Assisted Gastrectomy (LAG)
Robot-Assisted Gastrectomy (RAG)

Leakage? ? ??? ? ?
Obstruction, fluid collection, abscess??? ?

Resection ? tumor ??? R0 / R1 / R2 (R1? only palliative Tx. ??? ?)

?? ??? ????

Node (=M1)	Virchow’s node: supraclavicular Sister Mary Joseph’s node: periumbilical Irish’s node: axillary mesenteric, para-aortic, hepato-duodenal, retro-pancreatic
? ?	Malig. Ascites, Plummer’s shelf, abdominal mass, palpable liver, Krukenberg tumor(bilateral ovaries)

Endoscopic resection

Clinical decision making

Adjuvant and neoadjuvant therapy

Palliative therapy and systemic therapy

??? palliative surgery ? CTx ? ?? ?? ??. ??? ??

Outlet obstruction	Endoscopic dilation and stent, Bypass with Billroth type II
Perforation	Closure with healthy omentum, gastrectomy

CTx: ?? ?? ??? 5YSR ??. Routine ?? ??. ?? ?? ???/????? ??
RTx: ??, ?? ?? ?????? ??

Complicated gastric cancer

Complications

Outcomes

Examinations to be considered when needs arise: chest X-ray gastrography, barium enema, colonoscopy, bone scintigram, PET scan

Other surveillance programs should be sought beyond the 5th year

Gastric lymphoma

Mucosa-Associated Lymphoid Tissue Lymphomas

Gastrointestinal Stromal Tumors

Other Neoplasms

Gastric carcinoid

Heterotopic pancreas

Other Gastric Lesions

Hypertrophic Gastritis (Ménétrier Disease)

Mallory-Weiss Tear

Gastric Varices

Gastric Volvulus

Bezoars