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II. ДИАГНОСТИКА
UDC 616.866-003.7
ABOUT THE AUTHORS: Ernis U. Alybaev - head of the surgical department of the NSC of KR, dr. med., prof., e-mail: ealybaev@esc.kg, tel. 0312218890.
Keywords
ventricle, endoscopy, stenosing ulcer, pyloroduodenoplasty, perforation.
ENDOSCOPIC PICTURE OF VENTRICLE OPERATED WITH COMPLICATED PERFORATION AFTER VARIOUS OPTIONS OF OPERATIVE INTERVENTION IN THE EARLY POSTOPERATIVE PERIOD
Alybaev E.U., AshirkulovZ.T., Alybaev M.E.
National Surgery Center of MOH KR
Department of Hospital Surgerywith the course of operative surgery ofthe KSMA named after I.K. Ahunbaev, Bishkek, Kyrgyz Republic
Abstract
The results of endoscopic assessment of state of the operated ventricle in patients with stenosing ulcer, combined with perforations, in the early stages after surgery showed that one of the main reasons for motor-evacuation function of the stomach after palliative and radical surgery is the development of an acute inflammatory response in the area of pyloroduodenoplasty or sutured ulcer. Therefore, the technique and choice of operating patients in this group have a great influence on the postoperative course and condition of evacuation function of the stomach.
Ерте операциядан кейшп мерз1мде жедел хирургиялык араласудьщ турл! нускаларынан соц аскынган перфорациялаубойынша отажасалган асказанньщ эндоскопиялык KepiHici
АВТОРЛАРТУРАЛЫ:
Алыбаев Эрнис Урбаевич - К,Р
¥ХО-ньщ хирургия бел1мшес1нщ Meqrepyiuici, м.г.д., профессор, e-mail: ealybaev@esc.kg, тел. 0312218890
Туйш сездер
асказан, эндоскопия, стеноздж жара, пилородуоденопластика, перфорация.
Алыбаев Э.У., Аширкулов З.Т., Алыбаев М.Э.
КР ДСЭДМ Хирургиялык орталь™, K,npFH3 Республикасы, Бшкек к,.
И.К.Ахунбаеватында?ы КММА, Шу?ылхирургияк,курсымен госпиталдыхирургия кафедрасы Ацдатпа
Ерте шугыл хирургияльщ арапасудан кеишп асцазанга ота жасалган аурулардыц перфорациялау-ымен арапас ойыщарасыньщ тарылу ахуапын эндоскопиялык баталау бойынша алынган нэтижелер1 палиативтк жэне тубегет операциядан кеишп асцазаннын, моторлык,-эвакуаторлык, функцияларын керсеткен басты себептершщ 6ipi пилородуоденопластикапык, немесе тшген ойыщара аймашндаш жт кдбынеан реакциясынын, дамуы болып табылатындьрын корсет. Соньщ нэтижес'шде, осы топ ау-руларына ота жасау техникасы мен dfliciH тацдау асцазанныц эвакуаторлык, функциясыныц жардайына жэне ота жасаганнан кеишп арымына эсер 'ш типзед '1.
ОБ АВТОРАХ:
Алыбаев Эрнис Урбаевич - заведующий хирургическим отделением НЦХ КР, д.м.н., профессор, e-mail: ealybaev@esc.kg, тел. 0312218890
Ключевые слова
желудок, эндоскопия, стенози-рующая язва, пилородуодено-пластика, перфорация.
Эндоскопическая картина оперированного желудка осложненной перфорацией после различных вариантов оперативного вмешательств в раннем послеоперационном периоде
Алыбаев Э.У., Аширкулов З.Т., Алыбаев М.Э.
Национальный хирургический центр МЗ КР
Кафедра госпитальной хирургии с курсом оперативной хирургии КГМА им И.К. Ахунбаева Кыргызской Республики г. Бишкек
Аннотация
Полученные результаты эндоскопической оценки состояния оперированного желудка у больных стенозирующей язвой, сочетающейся с перфорацией, в ранние сроки после оперативного вмешательства показали, что одной из главных причин моторно-эвакуаторной функции желудка после пали-ативных и радикальных операций является развитие острой воспалительной реакции в зоне пилоро-дуоденопластики или ушитой язвы. Следовательно, техника и выбор метода оперирование у больных этой группы оказывают большое влияние на послеоперационное течение и состояние эвакуаторной функции желудка.
The diagnostic value of endoscopic examinations lies primarily in the fact that it makes available (visual and physical) examination of the gastric mucosa and duodenal ulcers, and if necessary can be a biopsy.
Normal functioning operated ventricle should have somehow the optimal level of the secretory and motor-evacuation activities that provide an adequate digestion in the absence of relapse of peptic ulcer and complaints of the patient [2,3,5,7].
Evaluation of post-operative state of the operated ventricle can not be considered sufficient without data of endoscopy. Some authors consider endoscopic techniques as leading in the diagnosis of major diseases of operated ventricle. [2,4,5,8].
In the NSC of MOH KR in Bishkek during the period 2012 to 2015 in the early postoperative period we have examined 67 patients with endoscopic studies: 17 patients with sutured perforations, 9 - after pyloroplasty of perforative ulcer of pyloroduodenal zone, and 41 patients after transverse duodenoplasty of perforative duodenal ulcer [1,5,8,11].
The data of endoscopy of patients with stenotic perforated duodenal ulcers who underwent suturing of the perforation on the background-existing ulcerative stenosis, showed that in the first three days after surgery, all patients have delayed the evacuation of the contents of the ventricle. Its quantity ranged from 500 to 1000 ml. Ventricle is atonic, peristalsis is sharply weakened. During this period a pronounced inflammation of the mucosa of the stomach and duodenum with a picture of acute gastroduodenitis is revealed. The folds of the stomach are thickened, edematous mucosa with multiple submucosal hemorrhages. Almost all of these patients on the third day after the operation output of the stomach is narrowed and hardly passable for endoscope diameter 8mm, of whom 2 patients operated on pass the endoscope through the zone of suturing failed due to severe deformation of the duodenal bulb or pyloric, as well as an acute inflammation of the mucosa.
By the end of the 5-th day after the suturing of the perforation all patients preserve endoscopic picture of acute gastroduodenitis. Number of fasting gastric contents is significant and reaches an average of 500 ml. The contents of the ventricle in some patients attended the bile. In these terms considerable edema and hyperemia of the gastric mucosa with punctate foci of hemorrhage retain. Peristalsis of the stomach is determined, but peristaltic wave is interrupted at sutured ulcer. Swelling in the area retains and its
patency of endoscope is still difficult.
All patients by the end of the second week remained stasis of gastric contents, despite considerable peristaltic activity of the stomach. The reason of it was a narrowing of the duodenum at the level of suturing the perforation. At the time of discharge in three patients moderate gastrostasis and severe deformation of pyloroduodenal zone remain [2,3,4,5,9].
In 9 patients who underwent pyloroplasty of perforated ulcer of pyloroduodenal area in the first three days after surgery it was observed in the lumen of the stomach contents of a large number of stagnant greenish color with flakes of fibrin, bile and hemolyzed blood.
Endoscopic picture of operated ventricle was tonin folds of mucosa were swelling, hyperemic, with the air insufflation bad disposed. In the majority of patients in these terms it was revealed a pronounced acute gastritis. Almost all of these patients on the third day after the operation the pyloric part of the stomach occurred, multiple erosions and areas covered with a touch of fibrin. Output from the stomach is slit-like shape, and a width of 5-10 mm to pass the endoscope with diameter of 8 mm. Line pyloroplasty joints in all the cases presented a rough roller invaginate due to swelling in the lumen of the stomach tissue. In the duodenum it was noted endoscopic picture of acute bulbitis.
By the end of the 5-th day the amount of gastric contents of empty stomach decreased, reaching an average of 300 ml. In the operated patients in this period there was a superficial peristaltic contractions of the ventricle. The mucosa was still swollen, friable, hyperemia remained with individual portions of erosions in the antrum. Fabrics along the line of joints are swollen, inflamed, sometimes with necrotic changes. Peristaltic waves deepened to the 8-9 th day after the surgery, but most patients experienced frequent antiperistaltic reduction in pyloroduodenal area with abundant reflux of duodenal contents into the gastric lumen. In 2 patients of this group in the early postoperative period due to persistent delays of gastric emptying it had to resort to probing of pyloroplasty zone with endoscope [4,7,8,10].
In 41 patients with perforated duodenal ulcer who underwent an adequate cross duodenoplasty in the early period after surgery, when viewed on the 3rd day the tone of the stomach was reduced, but most of them had clearly defined separate peristaltic waves. The mucous membrane was moderate swelling and hyperemic, superficial gastritis was observed, which was caused by reflux of bile and intestinal contents into the
BULLETIN OF SURGERY IN KAZAKHSTAN № 3-2015
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stomach, and slow evacuation of food due to hypotension of ventricle. In 4 patients operated at decompensated stenosis, the stomach was atonic, its mucosa was atrophic, its folds easily dealt with the air insufflation. Signs of acute superficial gastritis were found in 20 (49%) patients. The most pronounced inflammation of the gastric mucosa was observed in the antrum, which also determines the unit of erosion. Output in the stomach of the anastomosis from the first day had an oval shape, width of about 1-1.2 cm.
Hyperemia of the zone with edema, hemorrhage, and individual portions of fibrin deposition is usually observed only after excision of perforated ulcer by implementation of transverse duodenoplasty with double row seams. By the end of 6 th day inflammation of the stomach and duodenum was reduced, all patients recovered their motility. Swelling and redness of joints of duodenoplasty areas in the early stages after surgery of most patients
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The results of endoscopic assessment of state of the operated ventricle in patients with stenosing ulcer, combined with perforations, in the early stages after surgery showed that one of the main reasons for motor-evacuation function of the stomach after palliative and radical surgery is the development of an acute inflammatory response in the area of pyloroduodenoplasty or sutured ulcer. Therefore, the technique and choice of operating patients in this group have a great influence on the postoperative course and condition of evacuation function of the stomach.
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