Search

The authors analyzed the results of treatment of 965 patients with bleeding from gastroduodenal ulcers. The endoscopic hemostasis was carried out in 20.2% patients, however a recurrence of bleeding was noted in 12.8% cases. The combined endoscopic hemostasis was performed in 76.9% patients, though the relapse of bleeding had only 4.2% and 49 patients were safe. A surgery was required for 3.2% patients.

Based on an experience with treatment of 269 patients with complicated peptic ulcer the authors came to a conclusion that the most sparing and radical operation was subdiaphragmatic truncal vagotomy with Finney pyloroplasty with lethality of 6.8%. Resection of the stomach and forced palliative interventions such as suturing of perforated and bleeding ulcers resulted in lethal outcomes in more than 50% of them.

Treatment of 130 patients with peptic ulcer of the gastroenteroanastomosis after resection of the stomach included operation by the method of videothoracoscopic truncal vagotomy (22 patients), left-side videothoracoscopic truncal vagotomy (19 patients), and operation from the right-side access (3 patients). Cicatrization of the ulcer in the postoperative period was obtained in 16 patients. Recurrent peptic ulcer was revealed in 2 patients. There were no lethal outcomes.

Optimal kinds of surgical treatment were developed for perforated gastroduodeal ulcers and associated complications (stenosis, bleeding), with large perforated openings in patients with high risk of radical operative treatment. The method was used in operations on 30 patients. The second group consisted of 30 patients after suturing perforated gastroduodenal ulcers. Healing of ulcer defects after plasty of the perforated gastroduodenal ulcers by tunneling was noted 9 days earlier on average as compared with suturing.

Results of realization of the protocols of organization of the medico-diagnostic care to patients with bleedings from chronic gastric and duodenal ulcers since 2002 have been analyzed. A simplified scale of the assessment of severity of ulcerous bleedings (UB) at admission including 8 criteria is proposed. Protocols of medical strategy for "severe UB" under conditions of the resuscitation unit are discussed. The principles of rendering the medico-diagnostic care for UB allowed stabilization of total lethality among these patients at the level of 3.4-3.7% at operative activity 27%. The possibility to improve results of the treatment of this pathology in future is associated by the authors with the available and high quality elements of conservative treatment.

The work is based on an analysis of results of treatment of 557 patients with gastro-duodenal bleedings. It was shown that using modem endoscopic methods of bleeding arrest (APC) and antisecretory preparations allowed successful conservative treatment of patients with ulcerous gastroduodenal bleedings, thus minimizing the probability of the development of recurrent bleedings. The proposed medico-diagnostic algorithm allowed total lethality to be decreased from 29.5 to 11.2%, and the number of compulsory operations from 16 to 11.2%.

The article describes a method for minilaparotomic suturing of perforated ulcers in the pylorobulbar zone. The method was successfully used in surgical treatment of 6 patients with perforated ulcers without complications.

A special device--"a low temperature washer"--had been developed and introduced into practice for the improvement of a visual picture in an endoscopic examination of bleeding gastroduodenal ulcers. An estimation of the results of using the device in emergency endoscopic examinations was made in an analysis of results of the diagnosing and treatment of 246 patients (1999-2003). This device allowed almost 100% elevation of the diagnostic and 2.5 times higher medical effectiveness of emergency endoscopy, and 2.5 times less amount of operations performed at highest bleeding.

The state of gastric secretion in ulcer disease patients was investigated. Acidity was estimated by a computed analysis of 24 hour acidogastromonitoring with apparatus AG-24 MP "Gastroscan-24". The examination of 739 patients with chronic duodenal ulcers included 139 (18.8%) patients with exacerbation, 306 (41.1%) with bleeding, 185 (25%) after suturing the perforation, 59 (8%) with stenosis + 50 healthy subjects. A correlation was found between the efficiency of antisecretory drugs and "malignancy" of the course of ulcer disease. An aggressive type of the course of ulcer disease was determined in 178 patients with indications for operation, but the operations were not performed, in 102 out of them long-term results were followed up. The long-term results of operative treatment of uncomplicated ulcer were followed up in 181 (59%) patients.

The investigation is based on an analysis of results of treatment of 102 patients after an emergency resection of the stomach for complicated gastroduodenal ulcers. The probe was inserted into the jejunum intraoperatively. The period of enteral probe nutrition (EPN) was 5-7 days. At the early postoperative period in patients who had undergone the emergency resection of the stomach EPN is an effective method of nutrition maintenance as compared with the infusion-transfusion therapy. The method is simple and open to general use, and is economically advantageous under conditions of any hospital.

An analysis of results of surgical treatment of 107 elderly and senile patients with gastroduodenal ulcer bleedings was made. Emergency operations were fulfilled on 47 patients, urgent operations on 56 patients and planned operations--on 4 patients. Ulcers of large size prevailed. Most of the patients had complications of ulcer disease. Palliative interventions were performed on 27 patients: suturing the vessel--in 20, ablation of the ulcer--in 7. Lethality was 33.3%. Radical operations were performed on 80 patients: resection of the stomach--in 75, vagotomy--in 5. Lethality was 16.3%.

The authors' experiences show that at the present-day stage of the development of mini-invasive surgery the combined method of operating consisting of laparoscopic and mini-laparotomic steps is a perspective alternative. In addition, the authors note high efficiency of combined operations having all advantages of mini-invasive surgical technologies which was confirmed by investigations of the effects of access on microcirculation of the peritoneum in different surgical accesses used in their clinic.

Operative treatment was carried out in 1197 patients with chronic gastroduodenal ulcers. Among the most frequent complications of the ulcers there were penetration of the III-IV degree, compensated, subcompensated and decompensated pyloroduodenal stenosis. The operative interventions included Billroth-II resections of the stomach in modification of Hofmeister-Finsterer, Billroth-I, with saving the pyloric sphincter, after Roux and gastrectomies. Postoperative complications developed in 127 (10.6%) patients, postoperative lethality was 0.7%. Excellent and good long-term results were noted in 846 (94.5%) patients, in 14 (1.6%) patients they were estimated as satisfactory and in 35 (3.9%) as unsatisfactory. The causes of unsatisfactory results were recurrent ulcers (0.7%), peptic ulcer of the gastroenteroanastomosis (0.6%), dumping-syndrome of a severe and medium degree (1.5%), diarrhea of a severe degree (0.3%) and erosive-ulcerous reflux-esophagitis (0.3%).

A method of reduodenization providing the formation of the invagination-valvular jejunoduodenal and sphinctero-valvular esophagojejunoanastomoses has been developed for treatment of patients with postgastroresectional disorders. The method allows the duodenum to be included in the process of digestion by means of creation of the small intestine transplant from the efferent intestinal loop. For prevention of regurgitation at the remote postoperative period the invagination-valvular jejunoduodenal anastomosis was formed by the authors method. Observation of the patients during 5 years following the operation showed good functional results of the operation proposed.

Ceftriaxone was administered intravenously in a single dose of 1.0 g 15 minutes prior to surgical intervention for peptic ulcer and gastric or duodenum tumor in 31 patients at the age of 33 to 74 years. In all the patients primary adhesion of the surgical wound was recorded. No signs of local or general infection were observed. The indices of the total blood count, urinalysis and blood biochemical analysis came to normal by the 5th or the 7th day of the postoperative period. The levels of ceftriaxone in the blood, urine, stomach wall, small intestine tissues and subcutaneous fat were evaluated. The indices of the cellular and humoral immunity in the pre- and postoperative periods in the patients prophylactically treated with ceftriaxone were analyzed.

Peptic ulcers of gastroenterostomies are a serious complication after resection of the stomach or gastrojejunostomy. Their appearance is always associated with the presence of considerable production of hydrochloric acid in the stomach, while the primary operations are performed, as a rule, for chronic ulcers of the duodenum. Choice of an adequate kind of treatment of these patients still remains an actual problem. The authors have obtained convincing data of good results of conservative treatment of patients with peptic ulcer of the anastomosis. However, surgery is considered to be the main method of treatment of this category of patients. Its success depends upon the correct detection of causes of the disease and use of the pathogenetically substantiated surgical interventions aimed at eradication of etiological factors.

A modified method of resection of the stomach after Billroth-II was used in treatment of 26 patients with ulcer disease of the stomach and duodenum and with antral cancer of the stomach. During this procedure the following anastomoses were formed: frontal-colonic, frontal, superior, longitudinal-transversal and antiperistaltic side-to-side anastomosis with interintestinal anastomosis after Braun [correction of Brown] following the dissection of the Treitz ligament. One complication was noted--the incompetent duodenum stump. There were no lethal complications.

An examination of 30 patients against the background of using both the operative and conservative methods of treatment was performed in order to study the rheological properties of blood and selection of the most informative tests for diagnosis of microcirculatory disturbances in diseases of the gastrointestinal tract and gastroduodenal area. The authors propose methods of investigation of deformability and viscosity of erythrocytes in patients with the surgical diseases in question. The methods are simple, quite handy for any surgical hospital and polyclinic laboratories. In addition to being used in investigations of the aggregative ability of erythrocytes and viscosity of the whole blood, these methods can be of use in express diagnosis of rheological disorders. The endogenous intoxication in patients with the diseases in question was found to be accompanied by deep rheological disturbances. The deformability of erythrocytes and their viscosity index which can pass ahead of the shifts in other parameters characterizing the hemocoagulative and rheological properties of blood are changed. A conclusion is drawn that the parameters of the erythrocyte deformability and viscosity can be an additional criteria of the adequacy of therapy used for patients with the diseases in question.

In 78 from 121 patients with peptic ulcers the cause of the appearance of the ulcer was the insufficient volume of resection of the stomach. As a rule resection was performed with transformation of gastrojejunal anastomosis into gastroduodenal one with the abdominal bilateral subdiaphragmatic vagotomy. The isolated vagotomy in peptic ulcers after resection of the stomach was not fulfilled as a rule. Vagotomy was not used for the treatment of peptic ulcers after gastroenteroanastomosis.

Recurrent ulcers after vagotomy make their appearance mainly within the first 2 years after operation. Main causes of recurrences are: not complete vagotomy, disturbance of the motor-evacuatory function of the stomach and duodenum and their combination. Continuous rational antiulcer therapy is expedient for noncomplicated course of the recurrent ulcer. The method of reoperation must be chosen with reference to causes of the recidivation established by findings of special preoperative examinations and suboperative data.

The clinico-experimental investigation has shown high efficiency of the bilateral subdiaphragmatic truncal vagotomy in treatment of patients with acute gastroduodenal ulcers complicated by massive hemorrhage. The haemostatic effect of the operation is related to the inhibited acid gastric secretion, proteolytic activity of the intragastric content as well as to the activation of serotonin-containing cells and increased tonus of the sympathetic nervous system, which is responsible for gastric vessel spasm, shortens time of bleeding, increases the amount of thrombocytes and their aggregation. When vagotomy with interventions draining the stomach is not possible, suturing (dissection) of bleeding acute ulcers is recommended in combination with prolonged novocain blockade of vagus nerves.

Under study were long-term results of forced suturing of perforated ulcers of the stomach and duodenum in 96 patients. It was shown that in patients who were subjected to hyperbaric oxygenation in addition to medicamentous treatment at the early postoperative period excellent and good results were obtained two times more often and there was 1.5 time less amount of bad outcomes as compared with patients who were not given HBO therapy. A conclusion is made that HBO therapy has a positive influence at the early postoperative period on restoration of the disturbed balance in the system "aggression-protection" in ulcer disease which results in greater number of patients who recovered after suturing perforated gastroduodenal ulcers.

Under analysis were results of using intraintestinal electrostimulation with autonomous electrostimulators of gastrointestinal tract and graded enteral probe nutrition under control of intraintestinal pressure in 68 patients after operation on the stomach and duodenum. The method gives more rapid recovery of the intestine mobility, is economically profitable, makes the risk of insufficiency of the duodenal stump after gastric resection considerably less. The method is recommended for clinical practice.

Changes in the acid-base state and acid-transport function of blood were studied in 59 patients with gastroduodenal ulcer bleedings. More than 50% of the changes were more pronounced in patients with a deficient globular volume and its recovery was somewhat slower. In spite of reduced values of the concentration of hemoglobin in blood, 2,3-DPH and ATP of erythrocytes, most patients were found to have satisfactory compensation of the acid-transport function and balanced oxygen affinity for hemoglobin during the whole postoperative period.

An analysis of treatment of 420 patients following distal (406) and proximal (14) resections of the stomach for gastroduodenal ulcers was made. No incompetence of the stump sutures of the duodenum, stomach and anastomoses was noted. The dumping syndrome was observed in 2.8%, reflux gastritis in 5.1% of the patients. Results of the surgical treatment of ulcer disease were improved by using original methods of distal resection of the stomach with the formation of an artificial constrictor of the gastric stump and a reflux esophagogastric anastomosis.

The hormonal status of the endocrine glands (the hypophysis, thyroid, adrenals, pancreas, gastrin-producing cells of the stomach, gonads), was evaluated in patients with gastroduodenal ulcer operated (gastric resection, vagotomy) 6, 12 or 36 months before. Hormonal balance was found affected, the gonads underwent gross changes responsible for gonadal depletion in the long-term postoperative period. Recommendations for relevant correction are provided.

Experimental and clinical data show the zone of hormonal stimulation of gastric juice secretion and that of parietal gastric hydrolysis to have well-defined borders coinciding with anatomical reference points, to be characterized by multidirectional gradient and to be a local mechanism regulating secretory and motor gastric activity. The condition of the lesser curvature ++muco-epithelial complex is one of the factors operable in development of gastroduodenal ulcer. It is hold that resection of hormone--contact zone of the stomach is a preserving, effective and available means of surgical management of gastroduodenal ulcer.

The authors have made an analysis of the frequency of appearance of duodenogastral reflux after resection of the stomach in ulcer disease in 487 patients at remote terms depending on the method of restoration of the gastrointestinal continuity. The results obtained suggest high frequency of the duodenogastral reflux after Billroth-II gastric resection. The method of gastric resection proposed by the authors allowed the frequency of the appearance of duodenogastral reflux to be considerably reduced.

The authors disposing of a great number of observations of patients operated upon for peptic ulcer of the anastomosis (570), give an account of main principles of performing surgical procedures. They are: the detection and elimination of the causes of the anastomosis ulcer, wider use of truncal vagotomy, and for gastro-intestino-colonic fistula a less traumatic intervention should be chosen--the disconnection of the fistula and suturing the colon. The ways of reduction of postoperative lethality of the patients with this severe disease are shown.

Operations for gastric and duodenal ulcers were performed in 1123 patients. Injuries of the spleen were found in 16 patients. Attention is called to special care necessary during manipulations on the upper part of the stomach.

The article presents results of treatment of 219 patients with ulcer disease of the stomach and duodenum operated upon 20-25 years ago. The data presented prove the experience of antrum resection++ with selective vagotomy which may be operation of choice in patients with ulcer disease of the stomach and duodenum.

The data presented show that along with acid-peptic aggression an important role in pathogenesis of stress ulceration in the stomach and duodenum belongs to energy and immune deficiency which makes the correction of these alterations necessary. The timely and valuable conservative therapy including histamine H2-receptor blocking agents in addition to antacids and endoscopic electrocoagulation in case of profuse bleeding from stress ulcers allows to obtain hemostasis and healing of the ulcers more than in 90% of cases. When choosing the surgical method of treatment the preference should be given to atraumatic organ-preserving operations.

The authors have studied results of 228 reinfusions of UV irradiated blood in 75 patients with ulcer disease. It was found that the procedure had a favourable effect on the patient's state, immunostimulating action resulted in a smooth postoperative period and a real reduction of the amount of postoperative complications.

Peculiarities of the action of a single 420 j/m2 dose and two doses of 840 j/m2 and long-wave (315-400 nm) UV radiation on blood were studied in 96 blood samples from patients with ulcer disease. It was found that photomodification of blood caused reduction of the amount of all formed elements in it. The dynamics of changes of the amount of all formed elements depends on the dose. In addition, functional properties of formed elements and some components of blood plasma are dependent on the irradiation dose. The changes found have widened the clinical use of this method of hemosorption.

The authors examined 467 patients at remote terms after different variants of gastric resection for ulcer disease. It was found that most complete information concerning the state of the gastric stump mucosa can be obtained by the endoscopic examination. A comparative assessment of changes of the mucosa has shown advantages of the Billroth-I gastric resection.

A complex examination of 286 patients was performed after gastric resection by the method of Hofmeister-Finsterer, 64 patients after truncal vagotomy with antrum-resection, 14--after selective proximal vagotomy with draining operations and 26--without draining operation. Time for the recovery of motor-evacuatory function of the stomach after organ-preserving operations was considerably shorter than after resection of the stomach. In order to shorten the period of adaptation of the digestion organs after operative treatment of ulcer disease a complex of rehabilitating measures is proposed including percutaneous electrostimulation, diet, balneological and medicamentous therapy. It allowed the terms of temporary invalidity to become average 2 weeks shorter and to improve results of surgical treatment of ulcer disease.