1. Stomach and Duodenum • Anatomy • Physiology • Operative procedures • Gastric disorders peptic ulcer diseases tumors structural disorders inflammatory and infectious diseases traumas

6. Peptic ulcer diseases • Major types ; duodenal ulcer gastric ulcer stomal ulcer • Other types ; stress ulcer ulcers caused by gastric irritants steroid induced ulcer

7. Pathogenesis of peptic ulcer • Lack of protection of the mucosa • Acid production

8. Duodenal ulcer ;pathogenetic factors • Increased acid secretion • Environment ; 흡연, NSAIDS, Helicobacter • Mucosal defense ; decreased bicarbonate production, decreased gastric prostaglandin production

9. Duodenal Ulcer : goals of operative therapy • promotion of ulcer healing • treatment of specific complications • reduction of the possibility of recurrence • minimization of postoperative side effects

10. surgically correctable components to reduce the acid secretion • Cholinergic vagal stimuli • Parietal cell mass • Gastrin secretion

11. Duodenal Ulcer : operative procedures • Truncal vagotomy and drainage • Truncal vagotomy and antrectomy • Parietal cell vagotomy • Alternative methods

14. Gastric effects of truncal vagotomy • Decreased acid secretion • Increased serum gastrin • Gastrin cell hyperplasia • Accelerated liquid emptying • Altered emptying of solid

15. Nongastric effects of truncal vagotomy • Decreased pancreatic exocrine secretion • Decreased postprandial bile flow • Increased gallbladder volume • Diminished release of vagally mediated peptide hormones

16. Drainage procedures : pyloroplasty • Heineke-Mikulicz • Finney • Jaboulay

20. Duodenal Ulcer : operative procedures • Truncal vagotomy and drainage • Truncal vagotomy and antrectomy • Parietal cell vagotomy • Alternative methods

23. Duodenal Ulcer : operative procedures • Truncal vagotomy and drainage • Truncal vagotomy and antrectomy • Parietal cell vagotomy • Alternative methods

29. Duodenal Ulcer : operative procedures • Truncal vagotomy and drainage • Truncal vagotomy and antrectomy • Parietal cell vagotomy • Alternative methods

31. 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

32. Duodenal Ulcer : indications for operation • Intractability • Perforation • Obstruction • Hemorrhage

33. Duodenal Ulcer : indications for operation • Intractability • Perforation • Obstruction • Hemorrhage

34. 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

35. Operative procedures : intractability • First choice; parietal cell vagotomy • Alternatives ; truncal vagotomy and antrectomy laparoscopic vagotmy

36. Duodenal Ulcer : indications for operation • Intractability • Perforation • Obstruction • Hemorrhage

37. Clinical features ; perforated duodenal ulcer • Symptoms ; sudden onset of severe epigastric pain spreading throughout the abdomen, variable degree of shock • Signs ; abdominal tenderness, rigidity • Plain X-ray ; peritoneal free air

39. Differential diagnosis ; perforated duodenal ulcer • Acute cholecystitis • Acute pancreatitis • Strangulation obstruction • Acute appendicitis • Perforation of other G-I tract • Mesenteric thrombosis

40. Operative procedures : perforation • Simple closure • Definitive surgery parietal cell vagotomy and omental patch truncal vagotomy and pyloroplasty truncal vagotomy and antrectomy

41. Indications for definitive operation • No preoperative shock • No life-threatening medical illness • Perforation has been present for less than 48 hours

43. Duodenal Ulcer : indications for operation • Intractability • Perforation • Obstruction • Hemorrhage

44. Causes of obstruction in duodenal ulcer • Inflammation and edema • Fibrosis

45. Operative procedures : obstruction • Truncal vagotomy and antrectomy • Truncal vagotomy and gastrojejunostomy • Parietal cell vagotomy with dilatation

47. Duodenal Ulcer : indications for operation • Intractability • Perforation • Obstruction • Hemorrhage

48. Indications for operative intervention ; duodenal ulcer bleeding • Massive hemorrhage leading to shock • Prolonged blood loss requiring continuing transfusion • Recurrent bleeding during medical therapy or after endoscopic therapy • Recurrent bleeding requiring hospitalization

49. Operative procedures : hemorrhage • Truncal vagotomy and pyloroplasty with suture ligation of bleeding vessel • Truncal vagotomy and antrectomy including ulcer or suture ligation of bleeding vessel

50. Timing of operation : hemorrhage • Primary emergency • Secondary emergency • Early elective surgery