tag:blogger.com,1999:blog-2760353953251845523.post2386021763172405665..comments2024-02-10T02:14:39.898-05:00Comments on Buckeye Surgeon: Gastric UlcerJeffrey Parks MD FACShttp://www.blogger.com/profile/15650563299849196122noreply@blogger.comBlogger13125tag:blogger.com,1999:blog-2760353953251845523.post-13469665746646312992008-07-07T20:31:00.000-04:002008-07-07T20:31:00.000-04:00Anon-A BII is actually the easiest anastomosis to ...Anon-<BR/>A BII is actually the easiest anastomosis to do, of the three. The only problem with the roux is that youve now created two anastomoses. If something happens (marginal ulcer/stricture, etc) to the BII, you can always do the Roux later on. If the roux fails for whatever reason, you're sort of screwed.Jeffrey Parks MD FACShttps://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-51852044714882705572008-07-06T00:06:00.000-04:002008-07-06T00:06:00.000-04:00(the same anon as before) Thanks for your reply. ...(the same anon as before) Thanks for your reply. I am a newly minted surgeon of 1 week post residency and so I appreciate the opportunity to learn from your experience. I would be paranoid to do a B2 because a) though straightforward, I never did one in training and b) all the classic complications inherent in the post-op such as reflux gastritis and afferent/efferent limb syndromes. Question-I assume you did a B2 because the resection was such the it was not possible to simply remove it and stitch it back up. Also I would assume that it precluded a B1 mechanically for the same reason. Would you have considered those options however? I would probably have done a roux limb as that is my familiarity--having scrubbed many RYGB. What do you think of that option?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-89920314278418107732008-07-05T05:21:00.000-04:002008-07-05T05:21:00.000-04:00Anon-GI consultant was nervous about biopsying it ...Anon-<BR/>GI consultant was nervous about biopsying it because of bleeding concerns. He required 7 units of blood and there was a strong family history of gastric cancer. So i recommended surgery. <BR/><BR/>Youre right about the marginal ulcers. The problem with a type I gastric ulcer is one of decreased mucosal defenses (NSAIDS/H Pylori) rather than hypersecretion of acid. Vagotomy simply isn't justified.Jeffrey Parks MD FACShttps://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-64928860356659466822008-07-04T22:57:00.000-04:002008-07-04T22:57:00.000-04:00I believe that the argument for why people don't r...I believe that the argument for why people don't routinely get marginal ulcers after RYGB is that the gastric pouch it is so small. Though of course I have operated for it 2-3 times in training. The same rationale states that a vagotomy is not necessary after a subtotal gastrectomy with 2/3 removal. (To cut and paste from an old grand rounds) "Phemister (1944) described 2/3 distal gastrectomy or subtotal gastrectomy without vagotomy as there was a permanent reduction of acid without recurrent or marginal ulcer--abandoned for a 20-50% morbidity with the treatment believed worse than the problem." Did you biopsy it first or try PPI/conservative mgmt?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-64748606053204946332008-07-04T10:51:00.000-04:002008-07-04T10:51:00.000-04:00Did you do a Heinike-Mikulitz incision?Did you do a Heinike-Mikulitz incision?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-75535860126953299932008-07-04T10:18:00.000-04:002008-07-04T10:18:00.000-04:00jb-Good question. He may very well get a marginal...jb-<BR/>Good question. He may very well get a marginal ulcer but I don't feel the risk (1-5% ??) warrants a vagotomy and all the attendant complications (high esophageal dissection, long term motility issues). I saw a lady a few months ago with a perforated marginal ulcer a year out from a roux-n-Y gastric bypass. It will be interesting to see if someone compiles data on marginal ulcers for gastric bypass because none of those patients get routine vagotomies either.Jeffrey Parks MD FACShttps://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-20378558995900151462008-07-04T00:09:00.000-04:002008-07-04T00:09:00.000-04:00Very nice patient presentation. Your management i...Very nice patient presentation. Your management is well supported by all the surgery texts, but I still don't understand why he will not get a marginal ulcer with a BII and intact vagi. Can you explain it?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-25757860875950265702008-07-03T07:44:00.000-04:002008-07-03T07:44:00.000-04:00Did you consult Chris Johnson M.D. for the post-op...Did you consult Chris Johnson M.D. for the post-operative care?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-25891181076880919702008-07-02T15:46:00.000-04:002008-07-02T15:46:00.000-04:00no. i think our gastric cancer is about the same a...no. i think our gastric cancer is about the same as yours would be. nothing like the asians or japanese.Bongihttps://www.blogger.com/profile/12918640034313468627noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-37068161143870491112008-07-02T09:48:00.000-04:002008-07-02T09:48:00.000-04:00Great stuff, as usual, Bongi. Is gastric cancer s...Great stuff, as usual, Bongi. Is gastric cancer seen very often, as in Asian countries?Jeffrey Parks MD FACShttps://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-51202519223151842612008-07-02T09:00:00.000-04:002008-07-02T09:00:00.000-04:00in our setting we still do some gastrectomies, but...in our setting we still do some gastrectomies, but all in complex patients. i remember one i did in the state hospital. the junior asked me to explain the anatomy nicely as i went. i laughed. i then explained to him that in general, if there is still anatomy, we don't do gastrectomies.<BR/><BR/>sure enough, the ulcer had eroded into the liver, the mesocolon of the transverse and the anterior abdominal wall. i kid you not. also the galbladder had been destroyed and its remnant protruded into the stomach. i basically had to leave the ulcer bed, cut the stomach above and do some sort of repair (i think i did a roux-y).<BR/><BR/>also, in our setting duodenal ulcer is becoming a scarce monster. this may be because of hp eradication or possibly the african variant of the organism. gastric ulcers are far more common.Bongihttps://www.blogger.com/profile/12918640034313468627noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-44342375913280161762008-07-02T06:59:00.000-04:002008-07-02T06:59:00.000-04:00Wow, Buckeye that brings back memories from 1986, ...Wow, Buckeye that brings back memories from 1986, gonna wear my Miami Vice jacket to work today. I memorized the operations to, as a 3rd year medical student who wanted to be a Surgeon. I still remember getting lectured to because I didn't know the different kinds of incisions you have to make on the Pylorus so the stomach will empty properly.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-63648201897450764562008-07-01T21:57:00.000-04:002008-07-01T21:57:00.000-04:00Great image and review of perforated ulcers. How l...Great image and review of perforated ulcers. How long does a B2 take to do? I haven't ever had the pleasure of sitting through one.Rural Doctoringhttps://www.blogger.com/profile/02675577069641479392noreply@blogger.com