Perforated gastric cancer - Forum

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Re: Perforated gastric cancer - Ärzteforum

Post#21 »

Many thanks for the clear description of the techniques. For most surgeons today, however, all of this means almost nothing, as modern gastric surgery in most part of the world means subtotal or total gastrectomy for carcinoma. Pauceht, Polya and many names are becoming therefore obscure for our residents.

Only 10 years ago, my unit performed at least 2-3 operation for complicated peptic ulcer disease per week. Spending a few days at that country last week I was told that even there they do not see these problems any more. Operable peptic disease is vanishing from countries in which effective anti-acid and anti-helicobacter therapy is available. Perhaps our English and Ukrainian friends will be "the last Mohikans" in this field. I recall that they love to remove large chunks of stomachs for small ulcers.


Re: Perforated gastric cancer - Ärzteforum

Post#22 »

Effective drugs for peptic ulcer treatement are available. The problem that people do not want to go to gastroenterologist and do not receive any treatment at all (not all but a lot). Thats why we do see mainly complications of peptic ulcer. This year we did about 80 to 100 perforated ulcers (no gastrectomies) and about 12 gastrectomies - half of them for gastric ulcers (usually more then 2 cm and do not responding for medical treatement) and other half for decompensated pylorus stenosis with stomaches enlarged usually to pelvis. In the last case Your words about relatively large pieces of stomach is absolutely true. I would like ask a question about operations for perforated ulcers. What's Your opinion about HSV or truncal vagotomy for that cases in the light of modern unti-ulcer treatement.


Re: Perforated gastric cancer - Ärzteforum

Post#23 »

This obviously is not only a problem of taking or not taking drugs but a socioeconomic status of the population. During WWII the Britons had a huge incidence of ulcers. Balck South Africans moving to large town had an incerased rate of ulcers- stress and new way of life.

Political changes, unemployement, poor nutrition, alcohol consumption, smoking, surely are associated factors in the genesis of the mega-ulcer disease in your practice as is probably Helicobacter.

I believe there are nowdays 2 types of DU's- the one associated with Helicobacter and the one associated with non-steroidal anti-inf drugs (NSAID).

Now, in the poor risk-sick case (APACHE II >10) I would do only omentopexy-starting the patient on acid-reducing and anti-bacterial regimen postop.

In a good risk case depends on the patient: a "nice" chap for example - well insured, non NSAID and reliable- I would do only an omentopexy and erradicate the bacteria postop. Unemployed, non-insured, non-reliable, diffcult to follow up or on NSAID -I would add a HSV to cure the ulcer (in 90%).

Gastic ulcer- here the Helicobater issue is less definitive; large gastric perforations on the lesser curvature are best managed with Bil I gastrectomy.

Basically the choice of the procedure depends on the ULCER (type, size), the PATIENT (his condition) the PERITONEAL CAVITY (established peritonitis versus contamination only) and the SURGEON (is he from Chile or Brazil) (JOKE).

BTW: can we send our residents for an elective? -they may learn how to operatively manage complicated peptic ulcer disease.


Re: Perforated gastric cancer - Ärzteforum

Post#24 »

You are right and wrong simultaneously.
A few words about situation with PUD.
1. Abundance of pharmacologic antiulcer drugs.
2. High level of inpatient care and low level of outpatient care.
3. Agressive gastroenterologists, with conservative treatment of PUD until complications.
4. A great decrease of elective operations for PUD ( long for zero)
5. Enormous increase of emergency operations for PUD.
6. Very, very busy people. (footstep to hospital=footstep from work)
7. Changes in the pathomorphosis of gastric ulcer.

Few lines from the report of our surgical department:

Elective PUD surgery.
45 operations.
Duodenal ulcer - 15 (HSV-2; HSV+pyloroplasty-5; antrumectomy-Roux+selective vagotomy-6; antrumectomy-Roux+truncal vagotomy-2)
Gastric ulcer - 27 (antrumectomy - 21; antrumectomy+truncal vagotomy-3 (III type); partial gastrectomy above 1/2 - 3)
Reconstructive operations - 3

Emergency PUD surgery.
Perforative ulcer.
64 operations.
Perforative duodenal ulcer-58. (sewing - 9; HSV+sewing-2;
HSV+pyloroplasty-4; truncal vagotomy+pyloroplasty-43)
Perforative gastric ulcer-6. (sewing-1; partial gastrectomy-5)

Ulcer bleeding.
Admitted - 172 ! with PUD and bleeding.
99 - conservative treatment.
73 operations.
Duodenal-55: (truncal vagotomy+pyloroplasty-50; antrumectomy+truncal or
selective vagotomy-4; sewing-1)
Gastric: 18 (partial gastrectomies-18)

Almost all pyloroplasties - Finney
Almost all GEA - Roux
The majority of partial gastrectomies - antrumectomy.


Re: Perforated gastric cancer - Ärzteforum

Post#25 »

The issue of operation choise for perforated ulcers now is quite controversial here. First of all we don't do omentopexy (very and very rare). Usual operations on the ulcr site are two layer simple closure (or one layer) or excision of ulcer with pyloroplasty/duodenoplasty. Some surgeons still do truncal vagotomy for perforated ulcers. HSV in poorly prepared and higly stressed urgent patient increase risk and time of operation. Does this risk necessary? My opinion that very rere cases requires emergency HSV.


Re: Perforated gastric cancer - Ärzteforum

Post#26 »

Just to point out something about one statement you make :

"During WWII, the Britons had a huge incidence of ulcers".

It happens to me to remember a report done in the States, a multicentric study done during the years of Viet nam's war ,don't remember where it was published, perhaps I shall later, that demonstrated that during that period, a decrease in incidence of doudenal ulcer in the whole population in the States FELL down in about a 34 %. This was attributed to the fact that stress determined by the war was objectively and externally discharged and reduced the stimuli of autonomic nervous system on the acid output in the stomach, thus reducing the effect of hyperchlorydria as one of the mechanisms in the pathogensis of DU.

This i tell you with an historical perspective rather than an actual surgical discussion.


Re: Perforated gastric cancer - Ärzteforum

Post#27 »

You are absolutely right. Elective surgery in gastroduodenal ulcer has decreased in such a way that I think it tends to almost disappear. We continue to operate the complications, eventhough, these aren't so frequent as they used to be. So,I agree with you that many procedures performed in gastric surgery in the last 80 years, like the ones we've described, belong to the history of surgery but they must be known or recognized by all surgeons because sometime, never know when, you have to appeal to one of them in some very special circumstance.

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Re: Perforated gastric cancer - Ärzteforum

Post#28 »

The incidence of peptic ulcer disease and it's severity has been declining gradually in the Western world over the last 30 years and started declining even before the introduction of modern anti-ulcer medical therapy. Concerning the impact of Vietnam war on the US population versus that of WW II on the Britons- there is a small difference: during Vietnam war most Americans continued playing golf and eating beefy burgers. During WW II on the other hand most Britons were exposed to daily German Blitz-bombing and nasty food. From recent experience I must admit that British food remains nasty.


Re: Perforated gastric cancer - Ärzteforum

Post#29 »

It appears that you and your mates became less aggressive since your previous communication a year ago. Congratulations! But why the routine Roux for GEA? ny evidence that Roux is better than simple GE?

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