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I. ХИРУРГИЯ
MODERN APPROACHES OF SURGICAL TREATMENT OF ELDER AND SENILE PATIENTS WITH PEPTIC ULCER COMPLICATED WITH PERFORATION
UDC 616.342+616.33]-06-089
Mamakeev K.M., Alybaev E.U., Alybaev M.E., Ashirkulov Z.T.
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
In the last decade it has been a significant increase in the number of emergency operations on complicated forms of peptic ulcer in patients, as well as an increase in mortality during this period by 30-40%.
In the age group older than 60 years, surgeons are faced only with complicated forms of peptic ulcer disease, which undoubtedly affects the results of surgical treatment.
Surgery in patients with peptic ulcer complicated with perforation is the only way to save lives. The choice of method of surgery in patients of elderly age is essential to reduce the postoperative complications and mortality and improve quality of life in the immediate and long-term period after surgery.
Перфорациямен аскынган егде жэне картжасындагы ойьщжара ауруына шалдьщкан наукастарга колданылатын хирургиялык емдеудщ заманауи жолдары
Мамакеев K.M., Алыбаев Э.У., Алыбаев М.Э., Аширкулов З.Т.
И. К. Ахунбаев атында?ы Кдеыз Мемлекетпк медициналык, академиясыньщ myFbm хирургия курсымен госпитальдык, хирургия кафедрасы. К,Р ДС Улттык, хирургиялык, орталь™
Аннотация
Софы онжылдыкта ойыкжара ауруына шалдыккан наукастарга жедел v/рде жасалатын оталардыц саны айтарлыкгай квбейд1. Сонымен катар осы мерз1мде вл1м-жтм керсетш130-40% - fa квтершдг
60 жастан аскан ересек топта хирурггар тек язвалык, аурудын аскынган тур1мен faHa кездесед1. Ол эрине хирургиялык емдеуд1ц нэтижелер1н темендетедг Аскынган перфорациясы бар ойыкжара ауруына шалдыккан ау-руларына карсы отаныц кдтысуы eMipfli сакгап калудыц жалгыз жолы болып табылады.
Егде жэне карт жасындагы наукастарга операциядан кей1нп аскыну мен ел1м-жтм окигаларын азайту жэне eMip cypyi отаныц катысуынан кей1н телей немесе узаргатын кезецтде eMip суру сапасын жогарылату ушш хирургиялык араласу efliciH тацдаудыц зор манызы бар.
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
peptic ulcer, elderly and senile age, perforated ulcer, laparotomy.
АВТОРЛАРТУРАЛЫ
Алыбаев Эрнио Урбаевич -KP YXO-ныц хирургия бел1мшео1н1ц мен/еруш'ю!, м.р.д., профессор, e-mail: ealybaev@esc.kg, тел. 0312218890
Туйш сездер
ойыкжара ауруына шалдьщкан ауру, егде жэне картжас, перфоративл ойыкжара, лапаротомия.
Современные подходы хирургического лечения больных язвенной болезнью пожилого и старческого возраста, осложненной перфорацией
Мамакеев K.M., Алыбаев Э.У., Алыбаев М.Э., Аширкулов З.Т.
Кафедра госпитальной хирургии с курсом оперативной хирургии Кыргызской Государственной медицинской академии им. И.К. Ахунбаева. Национальныйхирургический центр МЗ KP
Аннотация
В последнее десятилетие отмечается значительное увеличение числа экстренных операций по поводу осложненных форм язвенной болезни у больных, а так же повышение летальности за этот срок на 30-40%.
В возрастной группе старше 60 лет хирурги сталкиваются исключительно с осложненными формами язвенной болезни, что, несомненно, ухудшает результаты хирургического лечения.
Оперативное вмешательство у больных с язвенной болезнью осложненной перфорацией язвы является единственным методом спасения жизни.
Выбор метода хирургического вмешательства у больных пожилого и старческого возраста имеет принципиальное значение для уменьшения послеоперационных осложнений и летальности и улучшения качества жизни в непосредственном и отдаленном периоде после оперативных вмешательств.
ОБ АВТОРАХ
Алыбаев Эрнис Урбаевич -заведующий хирургическим отделением НЦХ КР, д.м.н., профессор,
e-mail: ealybaev@esc.kg, тел. 0312218890
Ключевые слова
язвенная болезнь, пожилой и старческий возраст, перфора-тивная язва, лапаротомия.
Table 1.
Time of hospitalizations since the perforation of ulcerinthetwogroups.
According to the WHO classification (2000) at the age of people who have reached 60 years or older it is allocated 3 groups: elderly age (60-75 years), senile age (76-90 years) and long-livers (over90 years).
In the last decade it has been a significant increase in the number of emergency operations on complicated forms of peptic ulcer in patients, as well as an increase in mortality during this period by 30-40%.
In the age group older than 60 years, surgeons are faced only with complicated forms of peptic ulcer disease, which undoubtedly affects the results of surgical treatment.
Surgery in patients with peptic ulcer complicated with perforation is the only way to save lives. However, the choice of method of operation and improvement of surgical treatment of patients of elderly and senile age continues to be debated in the literature [1,2,4,7,8].
The choice of method of surgery in patients of elderly age is essential to reduce the postoperative complications and mortality and improve quality of life in the immediate and long-term period after surgery [1,3,15].
Materials and methods
Clinical analyzes have been the results of surgical treatment of patients with perforated pyloroduo-denal ulcers among 158 elder and senile people operated in the clinic of the National Surgical Centre of the Ministry of Health of the Kyrgyz Republic from January 2007 - till January 2014.
The patients were divided into 2 groups - the main and control, the lineup was comparable by sex, age, nosology forms, severity of illness and complications.
All patients, in addition to general clinical research methods, were performed fiberoptic gastro-duodenoscopy, were investigated basal and stimulated gastric acid production by aspiration-titration method, evacuation function of the stomach with the help of X-ray burst. There was determines the degree of contamination of Helicobacterpilori mucous membrane.
The age of patients ranged from 60 to 87 years. During this period, suturing of perforated pyloro-duodenal ulcers was produced in 75 patients. Exci-
sion of perforated pyloroduodenal ulcer followed by pyloro- or duodenoplasty has been produced in 83 patients.
Among those of elderly and senile age while completing the questionnaire data in 37 patients there was perforation of dumb ulcer. We enrolled 121 patients in the clinic registered ulcerous anamnesis, among them 35 patients regularly received anti-ulcer treatment by a local therapeutist, and the rest were not treated or occasionally took an anti-ulcer drugs while recrudescence. In connection with the elderly and senile age concomitant diseases were diagnosed in 90% of patients of the total number of patients.
Thus, all 158 studied patients were admitted to the hospital on an emergency basis to the emergency room of the NCS MH KR in Bishkek, 133 (84.1%) patients were taken with ambulances, 34 patients -by self (14.3%) and 3 patients were sent from other medical institutions, which accounted for 1.3%.
Important thing in the diagnosis as well as surgical tactics and the development of postoperative complications is period of hospitalization. Time from perforation of ulcer till hospitalization ranged from 30 minutes to 24 hours, in accordance with Table 1.
In the first 6 hours of onset of the disease 50 (31.6%) patients of 158 were hospitalized.
In the period from 6 to 12 hours from the onset of the disease - 84 (53.2%). Since 12 to 24 hours hospital received 17 patients, representing 10.7% of the total patients. In terms of more than 24 hours it received 7 patients, 4.5% of these 8 patients, 4 patients were admitted to the hospital within 72 hours of onset.
Complex issue is presented by diagnosis of a covered perforation of ulcer. Receipt of the contents of the stomach or duodenum into the peritoneal cavity is terminated due to obstruction of perforated hole with food mass or adjacent organs -omentum, liver, gall bladder, especially at the small diameterofthe ulcer.
Against the background of the chronic ulcer disease in many patients of elderly and senile age combined complications arise. The most dangerous complication is the combination of perforation of ulcer with bleeding. Among 158 patients with perforated ulcer bleeding was detected in 3 people
Time of hospitalizations since the perforation of ulcer Number of patients, %
Up to 6 hours 50/31,6%
from 6to12 hours 84/53,2%
from 12 to 24 hours 17/10,7%
More than 24 hours 7/4,5%
Total 158/ 100%
Prevalence of peritonitis Total, %
Localized peritonitis 9/5,69%
Diffuse peritonitis 139/87,97%
General peritonitis 10/6,32%
Total 158/ 100%
Surgical interventions Total/ %
Laparotomy, suturing of perforated ulcer 75/47,46%
Laparotomy, resection of perforated ulcerwith duodenoplasty 68/43,0%
Laparotomy, resection of perforated ulcerwith pyloroplasty 15/9,49%
Total 158/ 100%
Table 2.
Distribution of patients with perforated ulcer of stomach and duodenum on prevalence of peritonitis.
Table 3.
Surgical interventions in patients with perforated ulcer of stomach and duodenum.
Nature of surgical interventions Patients
quantity %
Suturing of perforation by Ostrovsky 61 81,3%
Suturing of perforation by Oppel-Polikarpov 9 12,0%
Othertypes of suturing of perforated holes 5 6,6%
Total: 75 100%
Table 4.
Distribution of patients by the nature of surgical interventions.
(1.9%). Among them - 2 (1.26%) patients under the age of 70, and - 4 (2.52%) patients under the age of85years.
All 158 patients were admitted with peritonitis of different prevalence and different phase, in accordance with the table 2.
Classification of peritonitis on the prevalence and evolution of phases, the most appropriate and convenient in practical terms, in connection with whichwe usethem.
Of 158 patients, the greatest number of patients have been noted a diffuse peritonitis 139 (87.97%). Local peritonitis was observed in 9 patients (5.69%) of the total patients. General peritonitis in patients with perforated ulcer of the stomach and duodenum was observed in 10 patients (6.32%).
Types of surgery performed in studied patients are shown in table 3.
In studied patients of elderly and senile age multiple comorbidities, and peritonitis did not allow us to make radical surgery (resection of the stomach).
By the nature of the executed types of suturing of perforated ulcer patients are presented in Table 4.
The table 4 shows that the main part of the patients underwent suturing of perforated ulcer by interrupted sutures with greater omentum flap sutured to the place of sutured perforated ulcer by Ostrovsky.
In 9 patients because of the rough edges of the ulcer callous changes there was performed tamponade of perforated hole with the lock of the greater omentum by Oppel-Polikarpov.
With age there is a decrease in physiological reserves that has some influence on the course of
the postoperative period, but the main role in the development of postoperative complications play chronic disease.
There were a variety of comorbidities of operated patients of elderly andsenile ages, and at the same patients there had been multiple comorbidities (Table 5).
In the control group comorbidities were observed in 75 (47.6%) patients, in the main group comorbidities were observed in 83 (52.4%) patients.
Cardio - vascular and respiratory diseases prevailed. Pathology of the cardiovascular system was observed in 31 patients (41.3%) in the control and 33 patients (39.7%) in the study group, respectively.
Respiratory diseases, such as chronic bronchitis in the acute phase, bronchial asthma, pleurisy, lower lobe pneumonia were observed in 16 (21.3%) patients in the control group and in 19 (22.9%) patients ofthe main group.
Digestive system diseases such as cirrhosis of the liver; alcoholic hepatitis; infectious hepatitis; portal hypertension; chronic pancreatitis in the control and main groups in its amount had the same number: 10 (13.3%) - in the control, and 11 (13.2%) in the studygroup.
Urinary system diseases ranked last with the number of 2 (2.6%) - in the control group and 3 (3.6%) - in the main group.
Nervous system disorders, such as encephalopathy, condition after Acute Cerebrovascular Event (ACE) were observed in 5 (6.6%) patients in the control group and 4 (4.8%) patients in the study group.
An important role in the course of disease in patients of elderly and senile ages with perforated pyloroduodenal ulcer plays diabetes.
Table 5.
Structure of comorbidities.
Control group Main group
Comorbidities quantity % quantity %
Heart and vascular diseases
- Valvular heart disease;
- Myocardial infarction; - Atrial fibrillation; 31 41,3% 33 39,7%
- Circulatory failure; - coronary artery disease; - hypertonic disease.
Respiratory diseases - Chronic obstructive bronchitis;
- Restrictive lung disease; - Chronic pneumonia; - bronchial asthma; 16 21,3% 19 22,9%
- Tuberculosis in remission.
Diseases of the digestive system - cirrhosis ofthe liver;
- Alcoholic hepatitis; - Infectious hepatitis; 10 13,3% 11 13,2%
- portal hypertension; - chronic pancreatitis.
Kidney diseases - chronic pyelonephritis; 2 2,6% 3 3,6%
- renal insufficiency.
Nervous System Disorders
- ACE in anamnesis; 5 6,6% 4 4,8%
- encephalopathy.
Other
- Diabetes;
- Obesity; - Diseases ofthe blood; 5 6,6% 5 6,0%
- Chronic alcoholism.
Patients without comorbidities 6 8% 7 8,5%
Total 75 100% 83 100%
Table 6.
Postoperative complications and mortality in the two groups.
Complications Total, % Control group quan., % Main group quan., %
Eventration 3(2)/1,9% 2(1)/2,6% 1(1)/0,63%
Insolvency of seams of sutured defect 4(3)/2,5% 4 (3)/ 5,3% -
Suppuration of postoperative wound 5/3,16% 3/4% 2/2,4%
Suppurative complications of internal organs (pneumonia, pleurisy, pyelonephritis, and others.) 9 (5)/ 5,7% 6(3)/8% 3(2)/3,6%
Acute cardiovascular insufficiency 6 (6) / 3,8% 3 (3)/ 4% 3(3)/3,61%
Thromboembolia of the pulmonary artery 2(2)/1,26% 1(1)/1,3% 1(1)/1,2%
Sepsis 5(5)/3,16% 3 (3)/ 4% 2(2)/2,4%
Total complications 34/21,5% 22/ 29,3% 12/14,4%
Postoperative mortality 23 /14,5% 10/13,3% 5 /6,2%
Total: 158/ 100% 75/ 100% 83/100%
Postoperative complications directly related to the surgery occurred in 12 patients, which accounted for 7.6%, other complications in 22 patients (13.9%) are not related to surgery (Table 6).
In the postoperative period in 3 patients (3.9%) there was an eventration (wound dehiscence), including 1 (1.3%) in the main group and 2 (2.6%) in the control group.
Insolvency of seams in sutured perforated hole due to their eruption (control group) was observed in 4 patients, which accounted for 2.5%, relaparotomy and re-suturing of the perforation were performed. Postoperative wound suppuration occurred in 5 patients (3.16%) in the control group 3 (4%), in the main group - 2 (2.4%) patients.
Complications of the internal organs (pneumonia, pleurisy, pyelonephritis, Acute cardiovascular insufficiency) occurred in the postoperative period were observed in 9 patients, 9.5% of all patients with perforated pyloroduodenal ulcer. In the control, and the main groups 6 and 3 patients, what accounted for 8.0% and 3.6%, respectively.
Such complication as sepsis in combination with toxic encephalopathy, determined the severity of the patients was observed in 5 (3.16%) patients with general peritonitis in the terminal phase, in the control group - 3 (4%), in the study group - 2 (2.4%).
Thromboembolia of the pulmonary artery was observed in 2 patients (1.26%) in the control 1 patient (1.3%) and in the main group 1 patient (1.2%). Postoperative complications and subsequent mortality in the control group after sutured perforated ulcer, in contrast to the main group were associated
References
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with the eruption of seams of stitched ulcers. Total postoperative mortality of patients studied (158) of elderly and senile age was 14.5%.
Conclusion
The proposed surgical tactics of choice of the method of surgical intervention at the perforated pyloroduodenal ulcer in elder and senile patients can reduce the immediate postoperative results of operations.
Analysis of the immediate results of patients of elder and senile age shows that the option of pylo-roduodenoplasty with excision of perforated ulcer of pyloroduodenal zone is accompanied by significantly fewer postoperative morbidity and mortality compared with suturing of perforated pyloroduodenal ulcer.
In older age groups, with perforated pyloroduodenal ulcers and severe comorbidities and the presence of diffuse peritonitis it is advisable to carry local excision of perforated ulcer within healthy tissue, followed by pyloro- or duodenoplasty with anti-ulcer therapy. In addition, this method, having a small injury rate, is technically simple, it can be recommended for general surgical practice.
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