Vagotomy and Fundoplication

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■ Vagotomy and Pyloroplasty

Vagotomy (truncal vagotomy and selective proximal vagotomy), with or without a Heineke-Mikulicz pyloroplasty, is rarely performed today. The endoscopist is still occasionally confronted with these postoperative states, however. In the Heineke-Mikulicz pyloroplasty, the gastric outlet is incised longitudinally and reapproximated transversely (Fig. 3.126). This produces a semicircular fold in the duodenal bulb, with a typical endo-scopic appearance.

■ Fundoplication

In the classic fundoplication, the fundus is wrapped around the juxtacardial esophagus and secured with sutures, thereby narrowing the cardia and creating an acute angle at the gastric inlet (Fig. 3.127 a). Fundoplication has been and is practiced in a modified form for reflux esophagitis that is refractory to medical therapy.

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Fig. 3.126 Heineke-Mikulicz pyloroplasty. The gastric outlet is incised longitudinally and reapproximated transversely

- Fig. 3.127 Fundoplication

- Fig. 3.127 Fundoplication

a The fundus is wrapped like a cuff around the juxtacardial esophagus and secured with sutures

b Retroflexed view of a plicated fundus a The fundus is wrapped like a cuff around the juxtacardial esophagus and secured with sutures b Retroflexed view of a plicated fundus

Endoscopic Appearance

Endoscopic Appearance

Typical findings

► After vagotomy alone

- Usually no particular findings

► After truncal vagotomy

- Increased incidence of bezoars

► Vagotomy with pyloroplasty

- Gaping pylorus

- Semicircular fold caused by the opened pylorus

Checklist for endoscopic evaluation

► Inspect the enlarged pylorus

Pathological findings

► Mucosal erythema in the proximal pylorus

► Ulcerations

Typical findings (Fig. 3.127 b)

► Deformation of the cardia

► Thickened cardial ring

► Soft, symmetrical mucosal ring

Differential diagnosis

► Submucosal tumor in the cardia region

Checklist for endoscopic evaluation

► Evaluate gastroesophageal junction.

► Check resistance to endoscope passage.

► Evaluate cardial closure with the retroflexed scope.

Pathological findings

► Recurrence of reflux esophagitis

► Cardial closure too tight

■ Definition

Angiodysplasia is a collective term for a heterogeneous group of vascular abnormalities in the gastric mucosa. Angiodysplasias are seen in the absence of a detectable underlying disease, in the setting of hereditary disorders (Osler disease, von WillebrandtJürgen syndrome), and in acquired diseases (chronic renal failure, hepatic cirrhosis, irradiation, connective tissue diseases).

Angiodysplasias appear endoscopically as bright red spots, flat or raised, ranging from a few millimeters to 1 cm in diameter and occasionally larger. They may be solitary, multiple, or numerous and are a source of chronic oozing hemorrhages leading to iron deficiency (Fig. 3.128).

Differentiation is required from suction artifacts, petechial hemorrhages, erosions, and Kaposi sarcoma (Fig. 3.129).

A special form is watermelon stomach (GAVE syndrome) occurring in patients with portal hypertension (see p. 119; Fig. 3.130).

Fig. 3.128a-c Angiodysplasia

Fig. 3.128a-c Angiodysplasia

thrombocytopenia hypertension

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