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Stomach and DuodenumStomach and Duodenum• AnatomyAnatomy
surgically correctable components to reduce the acid secretion
• Cholinergic vagal stimuli
• Parietal cell mass
• Gastrin secretion
Duodenal Ulcer : operative procedures
• Truncal vagotomy and drainage
• Truncal vagotomy and antrectomy
• Parietal cell vagotomy
• Alternative methods
Gastric effects of truncal vagotomy
• Decreased acid secretion
• Increased serum gastrin
• Gastrin cell hyperplasia
• Accelerated liquid emptying
• Altered emptying of solid
Nongastric effects of truncal vagotomy
• Decreased pancreatic exocrine secretion
• Decreased postprandial bile flow
• Increased gallbladder volume
• Diminished release of vagally mediated peptide hormones
Drainage procedures : pyloroplasty
• Heineke-Mikulicz
• Finney
• Jaboulay
Duodenal Ulcer : operative procedures
• Truncal vagotomy and drainage
• Truncal vagotomy and antrectomy
• Parietal cell vagotomy
• Alternative methods
Duodenal Ulcer : operative procedures
• Truncal vagotomy and drainage
• Truncal vagotomy and antrectomy
• Parietal cell vagotomy
• Alternative methods
Duodenal Ulcer : operative procedures
• Truncal vagotomy and drainage
• Truncal vagotomy and antrectomy
• Parietal cell vagotomy
• Alternative methods
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
Duodenal Ulcer : indications for operation
• Intractability
• Perforation
• Obstruction
• Hemorrhage
Duodenal Ulcer : indications for operation
• Intractability
• Perforation
• Obstruction
• Hemorrhage
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
Operative procedures : intractability
• First choice; parietal cell vagotomy
• Alternatives ; truncal vagotomy and antrectomy
laparoscopic vagotmy
Duodenal Ulcer : indications for operation
• Intractability
• Perforation
• Obstruction
• Hemorrhage
Clinical features ; perforated duodenal ulcer
• Symptoms ; sudden onset of severe epigastric pain spreading throughout the abdomen, variable degree of shock