Stomach

From the 73rd Annual Surgery Course, Advances in Gastrointestinal and GI Laparoscopic Surgery,sponsored by the University of Minnesota Medical School, Minneapolis

Educational Objectives

The purpose of this program is to improve management of conditions affecting the gastrointestinal tract, including perforated and nonperforated peptic ulcers, nonerosive reflux disease, and disorders of gastric empyting. After hear­ing and assimilating this program, the clinician will be better able to:

1.   Describe the surgical options for managing peptic ulcers, including bleeding and perforated ulcers.

2.   Discuss the basic principles of ulcer surgery and the importance of having standardized surgical indications.

3.   List the etiologies of gastroesophageal conditions that do not respond to proton pump inhibitor therapy.

4.   Explain the relationship between rapid gastric emptying and vagotomy, and the best approaches to manage­ment.

5.   Identify the causes and appropriate treatments of delayed gastric emptying.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning com­mittee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Metz is a consultant for AstraZeneca, Ny­comed, Wyeth, and Takeda, is on the Speakers’ Bureau of Sartasus, and has received research support from Repligen (pending), Alba, and Tercica. Drs. Fromm and Sarr and the planning committee reported nothing to disclose. In his lecture, Dr. Metz presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

This program was recorded at 73rd Annual Surgery Course, Advances in Gastrointestinal and GI Laparoscopic Surgery, held June 10-13, 2009, in Minneapolis, MN, and sponsored by the University of Minnesota Medical School. The Audio-Di­gest Foundation thanks the speakers and the University of Minnesota Medical School for their cooperation in the production of this program.

Current Status of Peptic Ulcer Surgery

David G. Fromm, MD, Professor and Chair Emeritus, Department of Surgery, Wayne State University School of Medicine, Detroit, MI

Treating peptic ulcer disease: measurement of serum gastrin recommended (can affect management, even though results not available until after surgery); Helicobacter pylori detection also recommended; with empiric treatment, 5% chance ulcer will recur; measure bleeding time if patient taking nonsteroidal anti-inflammatory drugs or aspirin

Perforation: simple closure recommended; eradication of H pylori associated with better long-term (>1 yr) results than omeprazole alone

Surgical options: simple plication; omentopexy (but scar may create gastric outlet obstruction if perforation adja­cent to pylorus); ulcer excision, especially if markedly inflamed or scarred; excision and pyloroplasty (may lead to dumping syndrome); transverse elliptical excision safer and easier; for large perforation with inflamed edges, use proximal edge of jejunum as serosal patch

Principles of treatment: operate whenever possible; consider nonsurgical therapies for patients with high operative risk; in comparison of patients undergoing surgery with those receiving nonoperative treatment, mortality rates similar, but nonoperative treatment associated with higher complication rate; success of nonoperative treatment age-dependent; no failures in patients aged <40 yr; 67% failure rate in patients >70 yr of age

Bleeding ulcers: gastric  —  current treatment local excision; duodenal  —  control bleeding; establish criteria for tim­ing of surgery (associated with marked reduction in mortality); traps  —  discounting criteria if patient poor surgi­cal candidate (risks of continued bleeding also high); delaying surgery when bleeding occurs at night (delay may induce coagulation problems)

Endoscopy: after initial endoscopic control, incidence of rebleeding 10% to 30%; risk factors associated with fail­ure of second endoscopy include continuing hemodynamic instability, ulcer >2 cm, and vessel >1 mm in diame­ter

Bleeding gastric ulcer: excision preferred; anterior and posterior nerves of Latarjet run along blood vessels of lesser curvature of stomach; excision of ulcer on lesser curvature may damage nerves of Latarjet (associated risk for significant delay in gastric emptying 30%); safer to perform gastrotomy and excise ulcer from within lumen (avoids damaging nerve)

Bleeding duodenal ulcer: opening duodenum and extending excision into stomach means patient will require pylo­roplasty; duodenal transverse incision easier and avoids risk for dumping syndrome; failure to control transverse pancreatic branch of gastroduodenal artery as well as proximal and distal branches often results in postoperative bleeding

Gastric outlet obstruction: operate if clear indication exists, even if etiology undetermined; place jejunostomy feed­ing tube during surgery to begin nutritional repletion immediately; patients hypokalemic; potassium requirement often inordinate (»200 mEq/day); limited trial of nasogastric (NG) suction appropriate for first-time patient; sa­line load test  —  instill 750 mL normal saline through NG tube; clamp tube for 30 min; if aspirate >400 mL, pa­tient has significant gastric outlet obstruction; repeat test at 72 hr; surgery indicated if 30-min aspirate >200 mL

Surgical options: truncal vagotomy and gastrojejunostomy recommended for excessively scarred duodenum; un­known if gastrojejunostomy alone sufficient for patient with H pylori; principles of vagotomy  —  relationship of vagi to esophageal hiatus variable; to bring vagi into field of dissection, start at cardioesophageal junction, dis­sect posteriorly and come out 2 cm to right of esophagus (encompasses all vagal branches); 12% of patients have 4 vagal branches coming through esophageal hiatus; branch of right posterior vagus (criminal nerve of Grassi) originates proximal to hiatus and innervates fundus; present in 90% of patients; doubled in 10% of patients; to ensure complete vagotomy, divide vagal trunks, then strip terminal esophagus of areolar tissue for 2 cm (ablates other vagal branches); in speaker’s opinion, “gastric atony” caused by edema of anastomosis or mucosal rosette in anastomosis (may obstruct gastric outlet; excision of protruding mucosa recommended); after truncal vagot­omy, 25% of patients develop diarrhea; minimize with selective vagotomy (divide anterior nerve of Latarjet distal to hepatic branches, and posterior nerve distal to celiac branch); if performing antrectomy, start dissection adja­cent to pylorus, extend duodenal incision to distal base of ulcer, resulting in pliable duodenal wall that can be closed over ulcer while maintaining pancreatic flow; difficult duodenal stump  —  prevent anastomotic leak with tube duodenostomy

Acid/Nonacid Reflux and Heartburn

David C. Metz, MD, Professor of Medicine, and Associate Chief, Clinical Affairs, Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia

Background: some patients with gastroesophageal reflux disease (GERD) unresponsive to proton pump inhibitors (PPIs); probably have nonerosive disease; nonerosive reflux disease (NERD)  —  reflux symptoms and negative endoscopy; esophageal acid exposure elevated only slightly; PPIs relatively ineffective

Reasons for poor response to PPIs

Undertreatment: abolition of esophageal acid exposure requires continuous high-dose intravenous infusion; symp­toms may persist despite normalization of pH with twice-daily PPI infusion; NERD patients may have different proton pump physiology that limits PPI efficacy; poor overlap between time PPI in bloodstream and time of acid secretion may permit sufficient acid exposure to cause symptoms

Disease other than GERD present: extraesophageal rather than esophageal reflux disease  —  extraesophageal con­founders include postnasal drip, tension dysphonia, and allergic asthma; extraesophageal reflux disease contro­versial; outcomes of reflux surgery best when performed for classic symptoms (heartburn and regurgitation); “the further you get away from the ileus, the less likely you’re going to cause resolution of your patient’s symptoms”; eosinophilic esophagitis  —  may coexist with GERD and occur without endoscopic changes; classic presentation includes ringed esophagus and multiple eosinophils; on endoscopy, may see furrows and microabscesses; diag­nosis requires 5 biopsies in proximal esophagus; responds to swallowed steroids; will not resolve with PPIs alone; achalasia  —  associated with heartburn due to fermentation products in stomach; endoscopy often normal in absence of Barrett’s esophagus or erosive disease; does not respond to PPI therapy; functional esophageal disease  —  in recent study, patients with typical heartburn who did not respond to PPIs, had negative 24-hr impe­dence test and negative endoscopy for erosive disease exhibited greater response to acupuncture than to twice-daily PPIs; suggests that these patients do not have acid-sensitive disease

Nonacidic reflux: patients experience symptoms from bland reflux, despite adequate suppression and reduction in volume of gastric juice; in normal individual with reflux disease, total number of reflux events may be similar, whether off or on PPIs; PPIs may help with classic acid reflux events, but in weakly acidic or nonacidic reflux disease, may simply replace acid events with weakly acidic events which produce symptoms

Speaker’s approach to antisecretory therapy for reflux disease: PPI for symptoms associated with reflux disease; endoscopy recommended for PPI-dependent patients (look for Barrett’s esophagus); if endoscopy negative, use lowest effective maintenance dose of PPI; if Barrett’s esophagus or erosive esophagitis present, once-daily therapy recommended; try twice-daily therapy if symptoms poorly controlled; impedance pH studies helpful; fully con­trolled reflux on impedance pH-metry suggests functional esophageal reflux disease; treat with pain modulators, visceral perception modulators, and antidepressants; if impedance pH-metry shows uncontrolled esophageal acid exposure, rule out noncompliance and gastroparesis; speaker performs fundoplication only on patients with non­acid reflux (abnormal, weakly acidic esophageal acid exposure); before surgery, patient should see gastroenterolo­gist, undergo manometry, have full history taken, and be evaluated for gastroparesis

Motility Disorders of the Small Bowel and Stomach

Michael G. Sarr, MD, Professor of Surgery, Mayo Clinic College of Medicine, Rochester, MN

Gastric emptying: proximal stomach  —  controls emptying of liquids and serves as reservoir for undigested food; mediated by vagal input; normally relaxes, then contracts slowly; distal stomach  —  antropyloric pump controls breakdown and, in part, emptying of solid food; postvagotomy pyloroplasty probably unnecessary; direction of spread of contractions regulates gastric emptying after antrectomy or vagotomy

Rapid emptying syndromes

Dumping: in speaker’s opinion, occurs primarily postvagotomy; patient usually has pyloric disruption; pathogene­sis involves release of vasoactive substances; treatment with octreotide sometimes effective; patients at risk for dumping have undergone antrectomy or partial gastrectomy plus vagotomy (prevents proximal stomach from relaxing and slowly contracting in response to food; gastric tone increases; liquids empty faster); related to va­gotomy in most cases, not to disruption of antropyloric pump

Treatment: delay further intervention (“patience”); dumping usually resolves >1 yr after vagotomy or gastrec­tomy; trial of octreotide recommended for highly symptomatic patients; recommended dose 125 µg 3 times/day; »15% of patients respond; reverse pyloroplasty recommended only if patient has undergone pyloro­plasty and vagotomy (P and V); conversion to Roux-en-Y drainage risks slowing stomach motility

Status post-gastric bypass: dumping “therapeutic forced behavior modification”; short-lived; rarely needs treat­ment; rarely markedly symptomatic

Slow gastric emptying

Postoperative delayed emptying: normal  —  physiologic response to anesthesia and celiotomy (stress due to long in­cision and cytokine response); usually resolves within 2 to 3 days; pathologic  —  prolonged delay (more than 4-5 days); common after diverting gastroenterostomy for management of pancreatic cancer;  pathophysiology unknown; also seen after antrectomy; usually resolves

Treatment: if normal physiologic response, “just wait”; for early pathologic response, decompress stomach, ex­clude downstream obstruction; prokinetic agents (usually ineffective); provide nutritional support (small bowel function normal; insert nasojejunal tube for enteral feeding); wait ³3 mo

Chronic gastroparesis: idiopathic  —  usually occurs in young women (cause unknown); rarely lasts >3 yr; may re­quire enteral nutritional support; treatment consists of “dietary patience”; gastric electrical stimulation may re­lieve nausea; gastrectomy complication  —  very rare; diabetic  —short-lived; intermittent; should resolve with time

Postvagotomy gastroparesis: usually occurs at least several years after vagotomy-gastrectomy; diagnosed clini­cally; patient vomits undigested food hours postprandially; experiences prolonged postprandial fullness (may eat only 1 meal per day); liquids do not induce vomiting; dietary management usually sufficient, unless patient nutritionally challenged; gastroparesis after P and V or antrectomy  —  problem with stomach, not anastomosis; conversion to Roux anatomy exacerbates condition by slowing gastric emptying further; progression to gastro­paresis rare unless patient has had vagotomy; rule out problem with stoma; perform contrast study to rule out obstruction of efferent limb or distal small bowel; if patient vomits food from previous day, gastric emptying studies unnecessary

Treatment: prokinetic agents (eg, metoclopramide; not effective postantrectomy); trial of low-dose erythromycin recommended; if patient responds, treat on alternate weeks (minimizes risk for tachyphylaxis); domperidone (available from Canada) works if antrum intact (acts on distal stomach); surgical treatment involves removal of gastric reservoir (stomach usually not dilated); managing severe symptoms after P and V  —  antrectomy less in­vasive than near-total gastrectomy; if patient severely nutritionally challenged, speaker performs near-total gastrectomy and Roux-type reconstruction with formal tube jejunostomy; in recent series of 62 patients, 57% still required nutritional support after surgery, and 25% required total parenteral nutrition

Roux stasis syndrome: requires Roux-emptying anatomy; similar to postvagotomy gastrectomy; provide nutritional support to patients who cannot eat; problem related to retrograde contractions of Roux limb; no treatment avail­able; speaker places  duodenostomy or jejunostomy tube for feeding

Bile reflux gastritis: speaker rarely sees; if patient postvagotomy, suspect gastric emptying disorder rather than gas­tritis

Chronic idiopathic pseudo-obstruction: suspect if patient has history of negative celiotomy for bowel obstruction, colonic inertia, swallowing disorder, megaduodenum, megaesophagus, megacolon, or dilated ureters; do not con­fuse with superior mesenteric artery syndrome; start enteral feeding if small bowel functional; consider small bowel transplantation; rule out chronic small bowel obstruction, Crohn’s disease, and adhesions related to radiation enteropathy

Suggested Reading

Chiu PW et al: Predictors of peptic ulcer rebleeding after scheduled second endoscopy: clinical or endoscopic factors? Endocs­copy 38:726, 2006; Fass R, Sifrim D: Management of heartburn not responding to proton pump inhibitors. Gut 58:295, 2009; Fass R: Proton pump inhibitor failure—what are the therapeutic options? Am J Gastroenterol 104(2 Suppl):S33, 2009; Forstner-Barthell AW et al: Near-total completion gastrectomy for severe postvagotomy gastric stasis: analysis of early and long-term re­sults in 62 patients. J Gastrointest Surg 3:15, 1999; Freeman ML: New and old methods for endoscopic control of nonvariceal upper gastrointestinal bleeding. Rev Gastroenterol Mex 68 Suppl3:62, 2003; Hejazi RA et al: Dumping syndrome: Establishing criteria for diagnosis and identifying new etiologies. Dig Dis Sci August 28, 2009 [Epub ahead of print]; Khoo J et al: Pathophys­iology and management of gastroparesis. Expert Rev Gastroenterol Hepatol 3:167, 2009; Patton C et al: Dumping syndrome pre­senting three decades after vagotomy. N Z Med J 120:U2807, 2007; Trivedi A, Long JD: Heartburn refractory to proton-pump inhibitors. Curr Treat Options Gastronenterol 10:47, 2007; Tutuian R et al: Nonacid reflux in patients with chronic cough on acid-suppressive therapy. Chest 130:386, 2006; Waseem S et al: Gastroparesis: current diagnostic challenges and management considerations. World J Gastroenterol 15:25, 2009; Zimmerman J, Hershcovici T: Bowel symptoms in nonerosive gastroesoph­ageal reflux disease: nature, prevalence, and relation to acid reflux. J Clin Gastroenterol 42:261, 2008.