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Back to Topics<<<< (Operated Gastric Diseases) Recurrence One of the commonest post-operative long term complications of partial gastrectomy due to gastric ulcers is the recurrence of ulcers. Recurrence occurs as a rule, after gastric resection due to duodenal ulcers in 90-95%. Ulcer recurrence occurs as: 1 – 7 % ------------ after 2/3rd of gastric resection 0 – 4 % ------------ after gastric economic resection with vagotomy 8 -12 % ------------ after truncal vagotomy with drainage procedure 0 – 7 % ------------ after proximal selective vagotomy Complains: Severe pain occurs in the epigastric region of higher intensivity than that of the previous attacks of pain, which doesn’t disappear after taking antacids. This pain also radiates to the back and right hypochondrial region. Post gastric resective ulcers after Billroth I-type resection usually are localized on the line of gastrojejunal anastomosis. In Billroth II- type, recurrence of ulcers occurs on the gastrojejunal junction as well as on the afferent loop of the intestine. Treatment: Treatment of choice is TRUNCAL VAGOTOMY, if the previous operation was performed in accordance of Billroth-I. If the recurrence occurs after Billroth-I operation, after secondary resection, we can transform Billroth-I to Billroth-II. The etiology of Post-Resective Peptic Ulcers are due to:
If the large area of ventricle is left which can produce HCl, it leads to peptic ulcer recurrence. Remaining HCl high activity affects on the mucous membrane of anastomosis especially on the weak areas or junctions. Investigations: X-ray reveals large areas of gastric stump or remnants. Treatment: Secondary gastric resection is a method of choice. 2. Antral Syndrome: G hormonally active cells are incorporated in the large antral part of the stomach. These G cells belong to APUD (Amine-Precursor uptake and decarboxylation) and secrete gastrin. The gastrin in turn affects the parietal and chief cells of the ventricle humorally and as result the HCl and Pepsin concentration increases. Post gastric resectional peptic ulcers on the basis of antral syndrome occur in short period of time than in case of economic resection. These ulcers are also complicated with bleeding, perforation and penetration to the adjacent organs. Treatment: Antrumectomy is a method of choice 3. Hypertonic Vagus: Evaluation: Vagal hypertony should be evaluated with Hollander’s test, in which insulin is used as a hypoglycemic agent. We can evaluate basal and stimulated HCl production or their output or their ratio. Treatment: Bilateral truncal vagotomy 4. Afferent Loop Syndrome Afferent loop syndrome is caused by intermittent mechanical obstruction of the afferent loop of a gastrojejunostomy. Symptom: Symptoms include early postprandial distension, pain and nausea. These symptoms are relieved by the ultimate vomiting of bilious material not mixed with food. Treatment: Treatment includes the drainage of the afferent loop usually done through the Roux-en-Y anastomosis. 5. Zollinger-Ellison Syndrome This syndrome results due to the high level of gastrin in the blood stream. Normal level of gastrin in blood is about 0-200pg (pictogram). Signs: Gastrinoma and multiple ulcer appearance in different areas of GIT, diarrhea and tendency to bleeding are most prominent signs. Zollinger-Ellison Syndrome is of two types:
Treatment: Gastrectomy and enucleation of the gastrinoma of the pancreas is an ideal method. By gastrectomy we remove plaster on which gaster acts. This article has been written by Dr. M. Javed Abbas. If you have any comments please do not hesitate to sign my Guest Book. 00:48 08/02/2003 |