2012.09.10.

Makassar

SURGERY INTERVENTION IN GEH

DISORDER

DR.Dr.Ibrahim Labeda,Sp.B-KBD
Dept of Surgery, DR. Wahidin Sudirohusodo Hospital / Faculty
of Medicine University of Hasanuddin, Makassar
Surgical Management of Obstructive
Jaundice

Ekstra Hepatal Obstrutive Jaundice

(surgical jaundice)
 Classification of Jaundice

Defect in Bilirubin Predominant

Metabolism Hyperbilirubinemia Examples

Increased production Unconjugated Congential hemoglobinopathies, hemolysis, multiple transfusions, sepsis, burns

Impaired hepatocyte uptake Unconjugated Gilbert disease, drug induced

Reduced conjugation Unconjugated Neonatal jaundice, Crigler-Najar syndrome

Impaired transport and excretion Conjugated Hepatitis, cirrhosis, Dubin-Johson syndrome, Rotor’s syndrome

Billiary obstruction Conjugated Choledocholithiasis, benign strictures, chronic

pancreatitis, sclerosing cholangitis, periampullary
cancer,
cholangiocarcinoma
 Lesions Commonly Associated
with Biliary Tract Obstruction

Type I. Complete Obstruction

Head of pancreas tumors

Common bile duct ligation
Cholangiocarcinoma
Parenchymal liver tumors (primary or secondary)
BISMUTH CLASSIFICATION

Cholangiocarcinoma
Type II. Intermittent Obstruction

Choledocholithiasis
Periampullary tumors
Duodenal diverticula
Choledochal cyst
Polycystic liver disease
Biliary parasites
Hemobilia
30 year old man, with jaundice and pruritus

Choledocolithiasis
 Case
21 year old man, with jaundice and pain

USG

CT SCAN
Operation
Operation
Type III. Chronic Incomplete Obstruction

Strictures of the common bile duct

Congential
Traumatic (iatrogenic)
Sclerosing cholangitis
Postradiotherapy

Stenosis of biliary-enteric anastomosis

Chronic pancreatitis
Cystic fibrosis
Sphicter of Oddi stenosis
 Type IV. Segmental Obstruction

Traumatic
Intrahepatic stones
Sclerosing cholangitis
Cholangiocarcinoma
 Management

Before : Operation only

Now : 1. Percutaneus &

Endoscopic stenting
2. Ballon Dilatation
3. Endoskopi Sfingterotomi
The standard Whipple operation
The standard Whipple operation
Pylorus-preserving pancreatic head resection
Bypass operation for unresectable
pancreatic cancer
Bypass operation for unresectable
pancreatic cancer
Table 1: Mortality and 5-year survival after classical
Whipple operation

Author year n mortality Survival

Condie et al; 1989 13 31% 7.7%
Funovics et al; 1989 100 13% 5%
Lygidakis et al; 1989 111 2%
Trede et al; 1990 133 2% 24%
Cameron et al; 1991 52 9% 19%
Roder et al; 1992 31 2% 3%
Beger et al; 1994 101 4% 9%
Baumel et al; 1994 555 8% 15%
Sperti et al; 1996 113 5% 12%
Chou et al; 1996 93 8%
Ven Berge Henderson et al; 1997 100 5%
Bern 1998 52 3.8%
Table 2: Mortality and 5-year survival after pylorus
preserving Whipple operation

Author year n mortality Survival

Grace et al; 1986 13 4% 25%
Braasch et al; 1986 14 2%
Klinkenbijl et al; 1992 25 2%
Roder et al; 1992 22 2% 0%
Buchler et al; 1993 19 5% 9%
Kozuschek et al; 1993 24 8% 19%
Mosca et al; 1994 76 7.5% 12%
Tsao et al; 1994 22 2% 7%
Ven Berge-Henderson et al; 1997 100 1%
Yao et al; 1997 650 1.9%
Bern 1998 59 3.4%
 ACHALASIA ESOFAGUS

ACHALASIA ESOFAGUS  primary abnormal motility,

signs:
- Lower oesophagus spinchter (LES) hypertensive
- Failure of LES relax after swallowing
- Peristaltic dissappeared at corpus

Incidens :
- Male : Female = 1 : 1
- Any age, >30-50 th
- 2/3 distal oesophagus
- Distal oesophagus 2-8 cm
- Narrowing hypertrophy
- Hyperplasia
ETIOLOGI
• Unknown
• Missing of Mientericus Auerbach plexus ganglion cell (Suspicious)

PATOLOGI

• Oesophagus segment 2-8 cm, narrowed at distal

• Dilatation of proximal Oesophagus  Mega-Oesophagus
• Polymorphic
• Hypertropic muscle layer
• Inflammable mucous
CLINICAL APPEARANCE
• Disphagy  Intermitten (at beginning)
 cold food difficult to pass
• Pain / retrosternal discomfort  early stage
• Regurgitation
• Progressive symptom
• Eat slow, drink a lot
• Decrease of body weight
• Aspiration pneumonia
• Ca oesophagus predisposition
 DIAGNOSIS

Mild Moderate Severe

• Oesophagography  Bird beak app., mouse tail app.

• Chest x ray: Dilatation of oesophagus which filled with food & air
• Dilatation of proximal oesophagus  Mega-oesophagus
Bird Beak Appearance
 Manometry : - Increase sphyncter pressure
- Oesophagus lumen > Stomach
- Incomplete relactation LES sphyncter
- Oesophagus peristaltic (-)

 Endoscopy : - Like entering dirty and smell gutter

- Mucous inflammation
- Narrowing distal oesophagus
 THERAPY

• Operative  Failure conservative

– Medicamentosa
» Calsium Channel Blocker : Nifedipine
» Nitrate
» Balloning dilatation
• Operative procedure  Heller’s myotomi
» Trans abdominal
» Trans thoracal
• Approach - Laparoscopy
- Open Surgery
• Complication  - Perforation
- Reflux
Forcefull dilatation
Myotomi Heller’s
 CORROSIVE OESOPHAGITIS

Damage :
• Oesophageal wall due to chemistry
• Depend on types, concentration, quantity,
contact time

ETIOLOGY
Acid or strong base  insectisida
 PHATOLOGY
- Swelling and congestif all layer submucous vessells
- Re-epitelitation (mucous only)
- Scar when deep
- Stenotic / stricture

SYMPTOMS
- Mild till moderate pain
- Combustio at lips,oral cavity, throath, chest
- Disphagy
- Dyspney
- Bleeding
- Emesis
 Therapy
- Early oesophagoscopy
- Late oesophagography

Complication
- Early  antidote
- Antibiotic
- Corticosteroid
- Bouginasi
- Operate

Examination
- Laringeal oedema
- Mediastinitis
- Pneumoni
- Tracheo-oesophageal fistula
 Case Report 1

Female 41 year old.

“Tentamen Suicidii” with
Porstex®
 MD Photo

Follow through Photo

Gastroscopy

Stenotic antrum-pyloric
Operation :
BillrothII (gastro-yeyenostomi)
 OESOPHAGEAL PERFORATION
• Esophageal rupture is rare
– Roughly 300 cases reported per year
– The diagnosis is commonly missed/delayed
• Mortality is high
– Most lethal GI perforation
– Mortality falls with early dx/intervention
Survival depends on rapid dx and surgery
– Within 24 hours of rupture: 70-75% survival
– Within 25-48 hours: 35-50% survival
– Beyond 48 hours: 10% survival
 Etiology
• Traumatic Causes (MORE COMMON) :
– Endoscopy or dilation procedures
• Stent placement most common cause (up to 25% cases)
– Vomiting or severe straining
– Stab wounds / penetrating trauma
– Blunt chest trauma (rarely)
• Non-Traumatic Causes (LESS COMMON) :
– Neoplasm / Ulceration of esophageal wall
– Ingestion of caustic materials
 Pathophysiology
Air, Saliva, and Gastric contents released
– mediastinitis
– pneumomediastinum
– empyema
– can progress to sepsis, shock, resp failure
 Presentation
• Pain
– lower anterior chest / upper abdomen
– may radiate to left shoulder / back
• Vomiting >> Hematemesis
– hematemesis: think Mallory-Weiss/varices
• Dyspnea
• Cough (precipitated by swallowing)
• Fever
Surgical intervention depend on location :
– Neck :
• If asymptomatic, no local sign or systemic symptom
– Observation
– Starvate
– NGT placement
– Antibiotic
• If any local sign or sistemic symptom
– Eksplore and surgery through neck
– Close the wound
– Drainage
– Chest :
• Thoracotomy :
– Close the wound
– Paraesofageal drainage
– Thoracic drainage
– Gastrostomy or jejenostomi for nutrition
– Antibiotic
OESOPHAGOGRAM

Operation
 PEPTIC ULCER
INDICATION FOR OPERATION :
• Failure in medicamentouse:
– Act : Resection and Billroth I / II
• Complication :
• Perforation
• Bleeding
• Stenotic
• Malignancy
– If perforation  excise + simple suture + vagotomy
– If bleeding 
– Endoscopy  for coagulation
– Laparotomi  - Ligation
- Resection + vagotomy
BILLROTH I OPERATION’S  gastric resection + gastroduodenostomi
anastomosis
BILLROTH II OPERATION’S  gastric resection + gastroyeyunostomi
anastomosis
 Vagotomy

Excise perforated peptic ulcer

Simple suture

PEPTIC ULCER PERFORATION

Ligation of peptic ulcer`s bleeding
 SELECTIVE VAGOTOMY TRUNCAL VAGOTOMY

“Crowfoot nerve”

VAGOTOMY
Kugel Procedure

Kugel Mesh
This is the end of the presentation

Thank You