الفهرس 
Anatomy of the duodenumOnly 14 pages are availabe for public view
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Abstract
Peptic ulcer disease can be divided into gastric and duodenal ulcers. Both types tend to occur near mucosal junctions. Duodenal ulcers usually occur at the duodenal pyloric junction.
It is now believed that 90% of duodenal ulcers are associated with H. pylori infection. If this organism is eradicated as part of ulcer treatment, ulcer recurrence is extremely rare.
After H. pylori infection, ingestion of NSAIDs is the most common cause of peptic ulcer disease.Most of the increased NSAID utilization has occurred in patients older than 50 years of age, which is also the group with the increase in bleeding gastric ulcers. Consequently, the ingestion of NSAIDs remains an important factor in ulcer pathogenesis, especially in relationship to the development of complications and death.
The safety of a laparoscopic procedure relies upon a careful preoperative patient assessment, with recognition of any contraindication to the laparoscopic approach.
Although recent advances in technology have made the use of laparoscopic procedures more widely practicable, the benefits of these minimally invasive operations must be weighed against the unique complications associated with laparoscopic instrumentation and techniques.
Complications can be divided into intraoperative and postoperative complications. Intraoperative complications include anesthesia complications, pneumoperitoneum or due to instrumentation injury.Postoperative complications in the form of peritonitis or wound infection, delayed hemorrhage, incisional hernia, tumor metastases and azotemia.
In operations as laparoscopic partial gastrectomy, a more conservative approach to resumption of feedings is often taken after distal gastrectomy and reanastomosis, starting clear liquids on postoperative day 3 or 4 and advancing as tolerated. Some groups advocate obtaining radiographic studies to evaluate for leaks before feeding.
Following discharge, patients can begin normal light activities according to comfort level and are usually able to resume unrestricted activities within 7 to 10 days of surgery. A follow-up office visit is scheduled for 2 to 3 weeks.
In laparoscopic highly selective vagotomy, when compared to other open procedures like vagotomy/antrectomy or vagotomy/pyloroplasty, a highly selective vagotomy has been shown to have a decreased morbidity and a negligible mortality. Highly selective vagotomy has the added benefit of preserving vagally mediated motor function to the antrum and pylorus. This preservation of innervation to the antrum and pylorus, via the crow’s foot, eliminates the need for a drainage procedure, which results in a decreased incidence of postoperative dumping, diarrhea, bilious emesis, and steatorrhea.
In laparoscopic management of duodenal perforation, the approach most often used to close duodenal perforation involves suture plication of the perforation incorporating an omental overlay patch (Graham patch).Interrupted 3-0 or 2-0 silk sutures are placed 5-10 mm to either side of the perforation and sequentially tied either intra- or extracorporeally, leaving the tails long. A tongue of omentum is then mobilized from a convenient location and placed over the repair. The tails are then tied over the omental patch, securing it in place.
In laparoscopic truncal vagotomy and pyloroplasty, a 1 cm window is made to the right of the esophagus and carried around circumferentially. Once the vagal trunks are identified, they are divided between clips and excised performing an approximately 1cm vagectomy.
In laparoscopic distal gastrectomy and Billroth II reconstruction, a Billroth II reconstruction is appropriate in cases of significant duodenal inflammation making mobilization dangerous or if there is undue tension at the proposed BI anastomotic site.
Laparoscopic gastrojejunostomy is useful in the chronically scarred duodenum, which causes obstruction and with any form of truncal vagotomy, or a selective but not highly selective vagotomy, a drainage procedure is usually necessary.
Long-term follow up is necessary to assess the function and physiologic effects of this laparoscopic approach.