1. 1 Postgastroresection syndrome Tashkent Medical Academy Deportment of Faculty and hospital surgery.

2. History of stomach and duodenum surgery 2 History of stomach being start since second half of XIX century. Its beginning have connect with names of such as scientifics as Pean, Rydiger, Billrot.

3. J.E.Pean (November, 21, 1830 – January, 20, 1898) One of the greatest surgeon of France in XIX century

4. History of stomach and duodenum surgery Students of Billroth Gussenbauer and Winiwarter (1870) proved securing of resection for human’s life. In 1879 Реаn was the first who performed resection of stomach at the human, but patient died after 4 days. Billroth in 1881 was carried out resection of stomach 34 years old patient. Patient lived 4 month after operation. In 1885 Billroth invited 2 types of gastroenteroanastomosis.

5. In 1814 Brody’s researches saw, that excision of vagus nerve in dogs becomes to decreasing alocation of gastric fluid. In 1905 Henry Dale and chemist George Barger puts forward a theory of strengthen action of gastrin to motor activity of stomach. In Berlin in 1911 in Congress of surgeons Exner make a report about positive results of subphrenic vagotomy through abdominal approach In 1943 in Chicago University surgeon Leister Dragsted performed vagotomy many times and met in mone problem – gastrostasis. Afterward was offered pyloroplastic to prevent gastroduodenostasis in patients with vagotomy. History of stomach and duodenum surgery

6. In 1964 Gregory and Tracy researched content of gastrin and got it by artificial way. In 1972 English scientist James Black for the first time worked out medicine which contented disabling Н2-receptor buramide (cimetidine) and got Nobel Prize. In 1979 Ivana Estkholma created medicine that abscopal proton pump – omeprasole (Sweden, Company “Astra Zeneca”) In 1988 in Rome on World Congress of gastroenterologist was recognized omeprasole the main drug in treatment of ulcer disease History of stomach and duodenum surgery

7. The short history about laparoscopic intervention in treatment of ulcer disease In 1992 American surgeon McKerman for the first time used laparoscopic technology in treatment of ulcer disease complicated by perforation and gave positive results In 1993 Zucker K.A. updated laparoscopic technology in treatment of perforative ulcers In 1994 Peters J.H. wrote the first book about laparoscopic intervention in cancer of stomach and ulcer disease.

8. Actuality of ulcer of stomach and duodenum 4-5 patients to 1000 of population in year. Though this disease meets in different aged groups of people, but it mainly prevalence in 20- 40 years Young patients have duodenal form, and elderlies have a gastrical form of ulcer.

9. Actuality of ulcer of stomach and duodenum In 26,4% of cases ulcer of stomach is diagnosted in bleeding, and for ulcer of duodenum bleeding is cased for primary diagnostic in 40%. In 26% ulcer disease is continuing to grow up into neighbour organs or penetrate in it. Perforation of ulcer occurs in 13,6% cases. From this more than 30% it is sicks aged 19- 22 year and 60% it is sicks aged 23-50 years. By case of disability ulcer disease take 3-rd place. (after cardiovascular and oncologist diseases).

10. Popularity of ulcer disease Common among all diseases 12-place In the Republic of Uzbekistan by 2013 year 3.8 cases to 1000 Institute of statistics of Ministry of Healthcare of the Republic of Uzbekistan 2013

11. Popularity of ulcer disease among the population and primary diagnostic Institute of statistics of Ministry of Healthcare of the Republic of Uzbekistan 2013

12. 12 In our republic annually are being done up to 10 000 operations

13. 13 Digestion physiology Secretory gastric function The cardiac glands - produce the mucilage. Fundic, main glands consist of 4 cells kind of: main (produce the pepsinogen), parietal (hydrochlorid acid and internal castle factor), extra (mucilage), nondifferentiable. Antral gland - produce the mucilage

14. 14 Defence factors Aggression factors Resistance of mucosa Acidic balance sheet of antroduodenal department Alkaline secretion Food Pepsin and acid (nsl ) Gastroduodenal infrigement of motor function Damage of mucous cover =

15. 15 Pathogenesis of ulcer disease Resistance lowering of mucous stomach cover and duodenum Increase of outward diffusion of hydrogen ions Stimulation of secretion of solyannoj acid and pepsin Ulcer

16. Histamine test of Kay 1.On the hungry stomach each 15 minutes shall be exercised the fence of gastric juice. 2. 2. Intramuscularly introduce 0,1% histamine. 3. 3. Each 15 minutes shall be exercised the fence of gastric juice. 4. 4. In taken away juice portions determine the level of chlorohydric acid. In rate "basal" secretion 5.5 mM / hour, after stimulation - 16 - 25 mM / hour.

17. Insulin test of Kholander’s 1.On the hungry stomach each 15 minutes shall be exercised the fence of gastric juice 2. Subcutaneous insulin injection. 3. Each 15 minutes shall be exercised the fence of gastric juice. 4. In taken away juice portions determine the level of chlorohydric acid. Eslim though in one of portions after the stimulation the level of chlorohydric acid are going up on m/M backward wave tubes the Kholandera test it is considered positive

18. 18 Resection of the stomach by Billroth-I

19. 19 Resection of the stomach by Billroth-II

20. 20 Development causes of postgastrectomy syndrome Technological inaccuracies of performance of primary operations on stomach (defective vagotomy) insufficient resection of antral portion of the stomach, saving the body resection of stomach, technically defective fulfilled gastrectomy by Billroth-2 - small dimension of anastomosis, short or long leading the loop, short, temper of gastric mucosa by the bile and pancreatic juice and so on ).

21. 21 Classification of postgastrectomy syndrome Organic (the organic changes when occurs ) Function (functional impairments when occur )

22. 22 Organic а ) peptic disease of an operated stomach (stomal ulcer of jejunum, recurrent ulcer, non-treated ulcer ) B ) cancer of the stomach stump C ) rumen narrowing of gastroenteroanastomosis D ) afferent loop syndrome E ) stenosis of leading loop F ) complications owing to violation of operation technique

23. 23 Function A ) dumping syndrome B ) gipo-gyperglicemic syndrome C ) enterogenous syndrome D ) function afferent loop syndrome E ) postgastrorezection anaemia F ) postgastrorezection debility Pulp ) of gastrostaz Call ) diarrhoea To ) dysphagia Backward wave tube ) alkaline reflux gastritis

24. 24 Method of examination Contrast roentgenography RH-metriya Gastric juice analysis US investigation Catalyst, angiography

25. 25 Frequency of occurence of recurrent ulcers Resection of the Stomach - 1 - 7% Saving gastrectomy with vagotomy - 0 - 4% Drain operations of stomach by the vagotomy - 8 - 12% Selective proximal vagotomy - 6 - 10%

26. 26 Causes of origin of peptic ulcers Saving antrumectomy Incomplete vagotomy, Zollingera syndrome – Allison, Primary hyperparathyroidism (thyroid adenoma )

27. 27 Therapeutic algorithm for peptic ulcers Conservative anti-ulcer therapy Thoracoscopic epiphrenic vagotomy Reconstructive resectionof stomach by Ru When Zollinger-Ellison syndrome operation of choice is the gastrectomy

28. 28 Cancer of the stomach stump Cause - absence of chlorohydric acid, presence at these patients atrophic gastritis and regurgitation of B-bile stump of the stomach. The diagnosis shall be established on a foundation of endoscopy and hystological research of biopsy Treatment - surgical (gastrectomy)

29. 29 Syndrome of adductor loop

30. 30 Causes of afferent loop syndrome Mechanical factors 1 ) too long leading the loop without Brown inosculation; 2 ) far short leading the loop, which due to of additional the fixation to flatness can produce intestine hogging; 3 ) the horizontal arrangement of lines of gastrointestinal anastomosis, thanks to what the food part come into leading loop, and further in 12-perstnuyu intestine, bringing about they duodenostasis; since contraction force stomach stumps is greater than 12-perstnoj intestine, that who acted the food can overstay there more or less long-time; 4 ) fallout of mucous leading B loop stomach or in outlet loop; 5 ) rotation of leading loop around its long axis; 6 ) cicatrices, soldered connection, swelling or ulcerous stenosis of leading or outlet loops; 7 ) antistatic location of intestine for anastomosis.

31. 31 Causes of afferent loop syndrome Functional factors 1 ) spasms of leading and outlet loops or sphincter of 12-perstnoj intestine; 2 ) violation of nervous regulation of duodenum and jejunum due to of dissection of nerve branches during the operation; 3 ) provided in preoperative period of duodenostasis

32. 32 Food receipt in leading loop Food fermentation, gases education and fluid in number, increasing of intra- intestinal of pressure, stagnation and pressure building up in bile ducts and ducts pancreas, violation of microcyrculyation and reflectory narrowing or spasm of outlet bowel segment Bulge and nipple in projection of leading loop after food, sense of heaviness, crushing pain, retching by the mass with bad smell, fear feeling of reception, general weakness, belching. Syndrom and pathogenesis of leading loop

33. 33 Clinic of afferent loop syndrome To 1-st syndrome degree regard sick, at which is the easy disorders of regurgitations type, vomiting of bile 1-2 once a month, more often connected with milk reception. Dyspepsia violation and pain duration almost is not bothering sick, the systemic condition satisfactory, the employability is not abused. 2nd the syndrome degree is characterized is moderately grave of manifestation disease. The retching with bile arises 2-3 once a week, the amount of emesis achieves 200- 300 Jr.. Retching initiation precedes the feeling emergence of completeness on the right below the rib and epigastrii following meal, especially after liquid food and the milk. The retching gives relief. At this category of sick are taking place the work decrement, the weight loss of.

34. 34 Clinic of afferent loop syndrome To 3-rd syndrome degree belong in the event that the retching arises almost daily, the volume of emesis achieves 400-500 magnetic tape and more. Following meal arise arching pains on the right below the rib and anticardium. With a view to facilitating state of the patient independently cause the retching. The depletion, the great work decrement is typical. 4th the degree disease is characterized, except above signs, sharp disorders of nutrition and metabolism (the famine edema, the severe emaciation, the hypoproteinemia, the anaemia ), and also great the dystrophy changes on the part of parenchymatous organs.

35. 35 Methods of surgical correction of afferent loop syndrome 1.Reconstructive of gastroeyunoduodenoplastic 2.2. Reconstructive U-shaped anastomosis by Ru; 3.3. Duodenoeunoanastomosis; 4.4. Entero-enteroanastomosis on Brown; 5.5. Resection of duodemun; 6.6. Felling of leading loop to lesser curvature; 7.7. Transfer of gastrectomy by Billrot-2 in by Billrot-1 8.8. Felling of leading and outlet loops to back parietal peritoneum.

36. 36 Treatment of afferent loop syndrome Reconstructive resection of stomach with gastroenteroanastomosis by Ru

37. 37 Stenosis of adductor loop

38. 38 Gastroenteroanastomosis stenosis

39. 39 Clinical picture of gastroenteroanastomosis stenosis Of a low degree - cross-country capability absence of rough, hard food Moderate degree - cross-country capability absence of usual food Heavy degree - cross-country capability absence of liquid food

40. 40 Dumping sindrom (slumping (angl ) - discharge of, failure ) In the patient after gastrectomy the obturative function of pyloric muscle is absent. The hyperosmolar solutions come into very the brief time and in number (in sight of failure ) in the elemental department of jejunum, comes discoordination of vasomotor reactions and overirritation of different intesoretseptors. Hypertonicity in intestine with flash dispersal of carbohydrate facilitates flow-in increase of blood liver cancer and receipt intraluminally of small intestine from blood river-bed of component parts of plasma, that is followed by the spasm of peripheral vascular channel, congestion lowering of brain

41. 41 Symptom complexes in demping-sindrome 1.Cardiac-vascular and neurovegetative symptoms: bouts of weakness, tachycardia, inflow feeling, face pallor and fingers, hands tremor, dizziness, darking within their sights, cold sticking perspiration. Dispepticheski and abdominal discomfort: appetite loss, nausea, retching, abdominal murmur, loose stool or constipations. Symptoms by the related to violation metabolic system: exhaustion, dyspepsia complaint. Inflammation symptoms of system: duodenostaz and stomach pain connected with adhesive process in belly. Symptoms characteristics for astenizatsii violation and psikho-nevrologicheskogo status: sensibility, tearfulness, insomnia, headache, loss of balance, nevrosteniya.

42. 42 Dumping syndrome clinic When mild form of dumping syndrome the bouts of weakness, sweating, palpitation and dizziness arise, as a rule, only after use of sweet and milk food, they slightly has been expressed and are going on usually during 10-15 minute. The pulse rate grows nothing more than on 10-14 blows. Systolic hell in the middle of dumping attack is going up usually nothing more than by 10 MM mouth. Art.. and the diastolic pressure almost does not change. Sick, trudosposobny and does not call for special treatment, except for diet observance. The mild form are seen most frequently in morning hours and almost never arise in the afternoon. In that time of the day sick can eat even sweet and milk dish.

43. 43 Dumping syndrome clinic When dumping syndrome is moderately grave the attacks of dumping attack arise not only after sweet and milk food, but as well after use of flour dishes and potato. The attack duration in this case achieves 30-40 mine, and the symptoms of cases is sometimes so has been expressed, that sick are forced to lie, the pulse rate rises to 90-100 specific. In 1 mine, systolic hell does not change, and diastolic is reduced. The employability of such sick falls off precipitously, conservative treatment bring only the palliation, sick are forced hedge to about itself in food, with the consequence that breaks down lose weight and.

44. 44 Dumping syndrome clinic The heavy degree of dumping syndrome is characterized by the emergence attack after use of any food, the duration by them gets to 2 ch, sick run in collaptoid condition. The tachycardia achieves 110- 120 specific. In 1 minute. At a point of dumping attack appear the cardialgia, the sharp dizziness, the sweating, the dozy condition, the orientation in time sometimes are lost. At such patient suffers the mentality, appear perplexity feeling, despair, fear of each food intake. In some patient are developing the diarrhea, is increasing the depletion, and they become by complete disabled persons. Conservative treatment of success don't bring.

45. 45 Treatment of the dumping syndrome 1 ) reduction in the size of gastroenteroanastomosis in the operation by Billroth-2 2 ) superposition of extra interintestinal anastomosis between leading and outlet loop by Brown; 3 ) education of additional colon reservoir from coupled between them intestinal loops (perspiration operation ); ) fixing of leading loop to lesser curvature; 5 ) reconstruction of gastroenteroanastomosis by Billroth-2 in operation Billrot-1 6 ) reconstruction with isoperistaltic colon transplant between stomach stumps and duodenum intestines (operation of Kupriyanova-Zakharova- Genleya; 7 ) reconstruction with anastaltic segment of jejunum between stomach stumps and 12-perstnoj intestine (operation of Gerringtona; 8 ) reconstruction with colonic of plastikoj 9 ) narrowing of gastroduodenal anastomosis after gastrectomy by Billroth-1 (operation Makarenko;

46. 46 Treatment of the dumping syndrome Gastrojejunoplastic by Kupriyanov-Zakharov- Henley

47. 47 Alkaline syndrom Syndrom of stomach Alimentar anaemia