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II. ХИРУРГИЯ
MPH™ 76 2934 MODERN ASPECTS OF SURGICAL
TREATMENT OF PATIENTS WITH DUODENAL ULCER, COMPLICATED BY BLEEDING (REALITY AND PROSPECTS). LITERATURE REVIEW
about the authors Mehtiev A.G.
MehtievA.G.- Scientific Center of Surgery named M.A. Tothubashov, Baku, Azerbaijan
PhD of the Scientific Center of Surgery named M.A. Tothubashov
Abstract
Bleeding is complicated by both acute and chronic duodenal ulcers. The most severe bleeding is complicated by chronic ulcers, which, as a rule, penetrate deeply into the DNA wall and penetrate into neighboring organs. In these cases, the bleeding can be massive, since the blood vessels, gaping in the ulcer with tight edges and bottom, are poorly thrombosed. Surgical tactics in the treatment of patients with acute bleeding from an ulcer depends largely on the accuracy of the diagnosis, the nature of the ulcer (acute or chronic).
The problems of treating patients with penetrating duodenal ulcer persist. Researchers study the possibilities of different surgical methods for treating patients with pronounced morphological changes in the area of duodenal ulcers, developing during its penetration, and determine the optimal type of operation for this duodenal ulcer, the choice of treatment for patients with duodenal ulcer with pronounced morphological changes attracts special attention of researchers. There are various proposals for its surgical treatment. In K . patients with this category, the question of preference for gastrectomy or vagotomy remains. Moreover, the diiodenaiufar need for surgery in patients with penetrating ulcers, a number of authors questioned. The solution of the bleeding, treatment problems posed was the purpose of the present study.
Он eKi елi шек ойык жарасы кансырап аскынган наукастарды хирургиялык емдеудщ заманауи аспeктiлeрi (^ipri уакыт жэне келешек). Эдеби шолу
авторлар туралы
Мехтиев А.Г. -
М.А. Топчубашев ат. ¥ХИ м.р.к.
Мехтиев А.Г.
М.А. Топчубашев ат. РХИ, Баку, Эзiрбайжан
Туйш сездер
он eKi ел '1 шектщ ойыщ жарасы, щансырау, емдеу
Андатпа
Кансырау жт жэне созылмалы он ек eлi шек ойьщ жараларынын асщынуынан орын алады. Тым асщынган щансырау ДНК щабыргасына жэне квршлес мYшeлeргe терендеп енген созылмалы ойыщ жаралардын щабынуынан болады. Бул жагдайларда щансырау вте аущымды болуы мумкн. Bm^i ойыщ жаранын жщшке жиeктeрi мен тубндеп щан тамырлары нашар тромбтаман.
Ойыщ жарасынын жт щансырауы бар наущастарды емдеу барысында пайдаланылатын хирургиялыщ тэсл квп жатдайда диагноздын нащтылыгына, ойыщ жаранын (жт немесе созылмалы) сипатына байланысты.
Он ек шеЫн ойыщжарасы бар наущастарды емдеу мэселелерi эл'1 де взект.i. Зерттеушлер он екi eлi шек ойыщ жарасынын аймагындагы айщын морфологиялыщ взгерстерi бар наущастарды емдеудщ турлi хирургиялыщ тэс'шдерШ, мYмкiндiктeрiн зерттеп, он ек eлi iшeктiн ойыщ жарасына операция жасаудын онтайлы нусщасын аныщтау устШде. Он ек eлi шек ойыщ жарасынын айщын морфологиялыщ взгер 'ютерi бар наущастарды емдеу тэсшдерш тандауга зерттеушлер ерекше щызыгушылыщ танытып отыр. Бул жараны хирургиялыщ емдеу бойынша турлi усыныстар бар. Осы категория бойынша емделетн наущас гастрэктомияны немесе ваготомияны тандауы тис. Сонымен щатар, ойыщ жарасы бар наущастарга ота жасау цажеттшше б'щатар авторлар кумэн бiлдiрeдi. Бул зерттеу жумысынын мащсаты - осы мэселелерд'щ шешiмiн табу.
Современные аспекты хирургического лечения больных с язвой двенадцатиперстной кишки, осложненной кровотечением (реальность и перспективы). Литературный обзор
Мехтиев А.Г.
НЦХ им. М.А. Топчибашева, Баку, Азербайджан
об авторах
Мехтиев А.Г. - к.м.н., НЦХ им. М.А. Топчибашева
Аннотация
Кровотечение осложняется как острыми, так и хроническими язвами двенадцатиперстной кишки. Наиболее сильное кровотечение осложняется хроническими язвами, которые, как правило, глубоко проникают в стенку ДНК и проникают в соседние органы. В этих случаях кровотечение может быть массивным, поскольку кровеносные сосуды, зияющие в язве с узкими краями и дном, плохо тром-бированы. Хирургическая тактика при лечении больных с острым кровотечением из язвы во многом зависит от точности диагноза, характера язвы (острой или хронической).
Проблемы лечения больных с проникающей язвой двенадцатиперстной кишки сохраняются. Исследователи изучают возможности различных хирургических методов лечения больных с выраженными морфологическими изменениями в области язв двенадцатиперстной кишки, развивающимися при ее проникновении, и определяют оптимальный тип операции при этой язве двенадцатиперстной кишки, выбор метода лечения пациентов с язвой двенадцатиперстной кишки с выраженной Морфологические изменения привлекают особое внимание исследователей. Существуют различные предложения по его хирургическому лечению. У пациентов этой категории остается вопрос о предпочтении гастрэктомии или ваготомии. Более того, необходимость операции у пациентов с проникающими язвами у ряда авторов поставлена под сомнение. Целью настоящего исследования было решение поставленных задач.
Bleeding is complicated by both acute and chronic duodenal ulcers [2, 7, 9, 20, 24]. The most severe bleeding is complicated by chronic ulcers, which, as a rule, penetrate deeply into the DNA wall and penetrate into neighboring organs. In these cases, the bleeding can be massive, since the blood vessels, gaping in the ulcer with tight edges and bottom, are poorly thrombosed. Surgical tactics in the treatment of patients with acute bleeding from an ulcer depends largely on the accuracy of the diagnosis, the nature of the ulcer (acute or chronic).Endoscopic examination is of great practical importance for diagnosing and determining the tactics of treating patients with bleeding duodenal ulcer [10, 11, 14]. Mortality during acute gastrointestinal bleeding ulcerative etiology reaches 20% [3, 5, 9, 25].The number of emergency operations in the treatment of patients with bleeding duodenal ulcer is not reduced [9, 19]. In patients under the age of 50, the risk of bleeding from an ulcer is 11-13%, and at an older age - 24% [8].An early relapse of bleeding from an ulcer after it stops occurs in at least 25% of cases. At the same time, in 90% of cases, early recurrences of bleeding develop within the next 2-3 days after the bleeding stops at first sight. In 30% of cases, recurrence of bleeding develops within the next 5 years after the first hemorrhage from the ulcer.After repeat bleeding from an ulcer, the risk of another recurrence of bleeding
increases to 60% [24, 25].Spontaneously, bleeding stops, on average, in 70% of patients. In 30% of cases, bleeding from the ulcer continues [2.4, 3, 25].Without uniqueanswer, there is still a question about the indications for surgical treatment of patients with acute bleeding from an ulcer [4, 9, 22]. During massive bleeding, when the diagnosis is clear, the blood loss is large and continues, unstable hemodynamic indicators are detected, vomiting with fresh or oxidized blood and tarry feces are noted, the question of surgical tactics is solved simply - after a short preparation or at the same time such patients are subject to urgent surgical treatment [3 ].It is more difficult to decide the timing of surgery in patients whose condition relatively stable during the observation period and hope for the success of conservative treatment is not lost [4, 17, 19, 24]. But in the absence of confidence in the stability of hemostasis, a number of authors consider it necessary to conduct an operative intervention [3, 24]. In patients older than 60 years, mortality during surgery and in the immediate postoperative period with massive bleeding reaches 70% [12, 22, 25]. Some surgeons consider the surgical treatment of ulcer-ative bleeding with severe concomitant diseases in the decompensation stage [12, 20] to be con-traindicated. After a single non-abundant bleeding from a duodenal ulcer durinq satisfactory condition of the patient, many authors prefer to refrain
Ключевые слова
язва двенадцатиперстной кишки, кровотечение, лечение
from emergency surgery [14, 21, 24,]. Thesteady of hemostasis during bleeding duodenal ulcer is one of the most important criteria when determining indications for surgery. Early recurrence of bleeding after its initial stopping is an absolute indication for surgery [25]. The criterion for the intensity of bleeding is hemorrhagic shock, which represents an immediate threat to the life of the patient. Signs of bleeding intensity are bloody vomiting and melena, a decrease in the hemoglobin content below 6 g / l, a hematocrit value below 0.25, and the need for more than 1 liter of blood to be transfused to stabilize hemodynamics [15]. Endoscopy was done soon patient in the hospital, allows for 90 - 95% of patients to clarify the location and nature of the ulcer, as well as to predict the recurrence of bleeding from it [10]. The risk of early recurrence of bleeding from the ulcer in patients in a state of hemorrhagic of shock during the visible thrombus or thrombosed vessel in the bottom of the ulcer is 50 - 79%. In the case of endoscopic signs of stable hemosta-sis in bleeding from chronic ulcers, an early relapse of bleeding was observed in less than 5% of cases [20]. The probability of early recurrence of bleeding also depends on the location of the ulcer, its size and the depth of the defeat of the intestinal wall. With localization of the ulcer on the posterior lower side of the duodenum and the visible vessel in the bottom of the ulcer, the risk of early recurrence of bleeding reaches 77%, with localization of the ulcer on the front wall - 34.7% [21]. Currently, in the treatment of patients with bleeding from the ulcer, endoscopic hemostasis is used (thrombogenic drugs, mechanical methods, electrocoagulation, laser photocoagulation, injection methods, etc.) [19, 21, 25]. These methods for stopping bleeding do not always prevent the development of re-bleeding, but only allow you to quickly and adequately stabilize the patient's condition.
The central link in the treatment of patients with bleeding from duodenal ulcer is an emergency or urgent operation. The choice of surgical intervention in patients with bleeding duodenal ulcer significantly affects the outcome of the disease [3,10]. Surgical intervention for acute bleeding from duodenal ulcer should be "radical" and short-lived [3,10]. The choice of method of operation depends on the nature and localization of the ulcer, the general condition of the patients, their age, the likelihood of early recurrence of bleeding, the risk of operative lethality, complications in the early postoperative period, and is also determined by the qualification of the surgeon [8]. stitching of the ulcer, devascu-larization of the pyloroduodenal zone, gastrectomy, various types of vagotomy with anthrumectomy or stomach draining operations, during which the ulcer is stitched or excised, and pyloro-or duodenoplasty
is performed. In severe conditions of patients with profuse bleeding from ulcers, it is possible to perform only the so-called palliative operations that do not affect the etiological and pathogenetic mechanisms of its development. Stitching and ligation of a bleeding vessel in an ulcer is applicable only in rare cases, since after these interventions the ulcer defect often does not scar, and sometimes (still in the early postoperative period) the bleeding from the ulcer recurs [17]. Stitching or excision of bleeding duodenal ulcer is possible only in those patients in whom the severity of the condition does not allow for surgical intervention with an impact on the etiologi-cal and pathogenetic mechanisms of the disease. The operative lethality at stitching or excision of an ulcer as an independent operation often exceeds 50% [24]. Devascularization of the pyloroduodenal zone by ligation of the gastro-duodenal artery is currently carried out only as an additional method for TV with surgery draining the stomach in combination with flashing of the posterior duodenal ulcer [24].
Gastric resection for bleeding duodenal ulcer is used by many surgeons [18, 19, 23]. But this operation in cases of bleeding from an ulcer is extremely traumatic intervention. Only a few surgeons report a small incidence of operative lethality after gastrectomy performed on duodenal ulcer complicated by massive bleeding [24]. Resection of the stomach can significantly reduce the acid-producing zone and eliminates the antral mechanism of regulation of the acid-forming function of the stomach. After gastrectomy performed for bleeding duodenal ulcer, the frequency of peptic ulcer gas-troenteroanastomosis in the long-term observation of patients does not exceed 3%, but disorders of the functions of the digestive organs are observed more often than when carrying out such an operation in a planned manner [19, 24]. After resection of the stomach according to the Billroth-1 method, dysfunctions are less pronounced than after resection according to the Billroth-II method [12].
During treatment of patients with duodenal ulcer complicated by bleeding, some surgeons consider as an operation of choice an economical resection of the stomach - anthrumectomy with vagotomy. In case of a bleeding ulcer of the posterior wall of the duodenum, antrumectomy is recommended to be supplemented with ligation of the gastro-duodenal artery above and below the ulcer crater with the formation of a C-stitch in the center of the ulcer crater [19]. One of the most dangerous complications of stomach resection according to the Billroth-II method in patients operated on for bleeding duodenal ulcer is the failure of the duodenal stump [3, 12].
At presant various types of vagotomy in combination with stomach draining operations are widely
used in the surgical treatment of patients with bleeding duodenal ulcer [6, 15]. Vagotomy with draining operations of the stomach not only significantly reduces the acid production of the stomach, but also reduces blood flow in the duodenal mucosa, i.e., indirectly affects the blood circulation in the ulcer zone [21. Unfortunately, after vagotomy, the frequency of recurrence of the ulcer is high, which somewhat levels the positive aspects of this operation [10, 25].
For reducing the incidence of adverse gastric dysfunction in patients with a bleeding ulcer after vagotomy, some surgeons suggested performing selective vagotomy with gastric drainage operations [5,9]. With the localization of ulcers on the front wall of the duodenum, it is usually excised, and duodenotomy is transformed into pyloroplasty. When a bleeding ulcer is localized on the posterior wall of the duodenum, duodenotomy is performed, flashing of the vessels in the ulcer or the ulcer itself, as well as covering the ulcer with a shifted mucosa or flap of the duodenum [24]. The operation is completed with pyloroplasty in various modifications; in some cases, single-row suture technique is used. The technical implementation of selective vagotomy is more complicated than the intersection of the trunks of the vagus nerves, therefore, at present, selective vagotomy in the treatment of patients with duodenal ulcer is almost never used.
[12, 13] during treatment of patients with duodenal ulcer complicated by bleeding, it is recommended to perform SST; other authors agree with them [22]. In case of small ulcers of the anterior wall of the duodenum, an ulcer is excised, duode-noplasty, and then SPV [11]. Some authors when performing SPV in patients with bleeding duodenal ulcer do not recommend extraduodenal ligation of the gastro-duodenal artery due to the increased risk of ischemic necrosis of the lesser curvature of the stomach [23].
Despite certain advantages in terms of minimizing the frequency of disorders of the functions of the digestive organs, SST does not find wide application in emergency surgery due to duodenal ulcer due to technical complexity and time-consuming, which does not comply with the principles of emergency surgery. Particularly noteworthy is the use of anterior seriotomy of the body and the fundus of the stomach in patients with a bleeding duodenal ulcer in combination with posterior TV. This operation preserves the positive aspects of the PWV and at the same time is more simple to perform, shortlived and available to most surgeons.
Thus, the search for optimal methods of surgical treatment of duodenal ulcer complicated by bleeding continues. To date, inadequate methods of treatment tactics have been noted in assisting
patients with bleeding duodenal ulcer. In particular, there is no proper consistency in understanding the urgency of surgical treatment of these patients, and there is a striking confusion in the names of operations depending on the timing of admission to the patient in the hospital. A completely different interpretation of an immediate, urgent, emergency, urgent and delayed operation is found, although, from the linguistic point of view, these concepts are synonymous. This state of affairs leads the practical doctor away from understanding the essence of the therapeutic process when patients with a bleeding duodenal ulcer enter the hospital, gives rise to the tactics of passive observation of patients and makes scientific analysis and comparison of data from different authors extremely difficult. The lack of a common understanding of the endoscopic signs of the stability of hemostasis also often leads to unjustified waiting tactics. For various reasons, in many medical institutions, endoscopic methods for stopping bleeding are not used, in which patients are removed from a serious condition and prepared for pathogenetically substantiated surgery. So far, there is no unified point of view on infusion-transfusion therapy programs for acute gastrointestinal bleeding of ulcerative etiology.
Duringe help patients with a bleeding duodenal ulcer, the method of surgical intervention is often chosen because of the surgeon's personal affections, which are often based on little experience. The problem of treatment of acute gastrointestinal bleeding from duodenal ulcer remains relevant and requires a thorough study, both in theoretical and in practical terms. Features of surgical treatment of duodenal ulcer complicated by pyloroduodenal stenosis. Stenosis of the pyloroduodenal zone is one of the most frequent indications for surgical intervention for duodenal ulcer and occurs in 10-54% of all patients with this disease [9,14].
Many surgeons think that surgical treatment is indicated for any degree of ulcerative stenosis of the duodenum, while emphasizing that the results of surgical treatment are better than when the operation is performed [17]. However, in most cases (almost 60%), the operation is performed on patients already with sub- and decompensated degrees of stenosis of the pyloroduodenal zone. After the first operation performed on ulcerative stenosis of the pyloroduodenal zone, more than 100 years have passed. And yet, surgeons are saved and the tasks of treating patients with this complication of duodenal ulcer are not solved.
Planned surgical intervention in the treatment of patients with ulcerative stenosis of the pyloroduodenal zone pursues a number of objectives: restoration of unobstructed patency of the food bolus along the gastrointestinal tract, impact on
the etiological and pathogenetic mechanisms of ulcer formation and creation of conditions for the normalization of the motor-evacuation function of the stomach [9,14 ]. There is no universal method of operation in the treatment of patients with ulcerative stenosis of the pyloroduodenal zone. In case of a serious condition of a patient, surgery that affects the etiological and pathogenetic mechanisms of ulcer formation may be inadequate or difficult to achieve. In these cases, the surgeon primarily seeks to restore the patency of the gastrointestinal tract using only operations draining the stomach, which is accompanied by minimal operational risk.
In determining the surgical tactics in patients with ulcerative stenosis of the pyloroduodenal zone, first of all, take into account information about the degree of stenosis and activity of the ulcerative process. In addition, they take into account the possibility of a combination of duodenal stenosis with other complications of the disease, indices of gastric acid production, clinical features that determine a high degree of risk of surgical intervention [9,14,19]. Drainage operations (in particular, gastroenterostomy), used as independent methods in the treatment of patients with stenosing duodenal ulcer, are undoubtedly effective for restoring the advancement of the food bolus along the gastrointestinal tract and are accompanied by low mortality, especially in elderly and elderly patients.
Stable remission of duodenal ulcer after these operations is rarely observed. Surgical intervention, providing persistent achlorhydria, is a resection of the stomach. However, postoperative mortality after this intervention remains high, reaching 3-5% [3.8], and in about 14-15% of cases, diseases of the operated stomach develop in the form of dumping syndrome, afferent loop syndrome, alimentary dystrophy, etc. [10] . Many of these patients require repeated surgical treatment, and some patients steadily lose their working capacity and are forced to remain on disability [3,8,12,18] think that with decompensated stenosis, it is advisable to perform a particularly extensive stomach resection, as in these cases violated the contractile ability of his muscles.
However, with the decompensated stenosis of the pyloroduodenal zone, the need for resection of an overstretched stomach does not always occur, as with properly performed drainage operations, as a rule, there is a gradual normalization of the muscle tone of the stomach [16, 25]. According to [10,15], the need to remove part of the stomach occurs with a concomitant gastric ulcer, very high rates of acid-forming function of the stomach, chronic obstruction of the duodenum. Moreover, these authors believe that resection of the stomach should be carried out in an economical version (no
more than 1/3 1/2) in combination with vagotomy .. Mortality after gastrectomy performed in a planned manner reaches 4-5% [13, 21 ]. The lack of alternative gastric resection for the treatment of duodenal ulcers complicated by stenosis seems to be very doubtful, and under these conditions the question arises about the use of sparing surgical treatment methods, in particular, vagotomy. But there are concerns that the use of vagotomy, which sometimes causes atony of the stomach, is especially dangerous [9,13].
Published examples of severe postvagotomi-chesky atony of the stomach, necessitating repeated surgery [23]. Some surgeons, using vagotomy with drainage operations of the stomach with duodenal ulcer complicated only with compensated and subcompensated stenosis, object to the use of this operation in patients with decompensated stenosis of the pyloroduodenal zone. Other authors apply vagotomy with any duodenal stenosis [11, 17]. Impaired motor-evacuation function of the stomach in patients with duodenal ulcer complicated by stenosis after vagotomy, as a rule, are associated with insufficiently effective gastric drainage [8, 19]. The standard application of pyloroplasty according to Heinecke - Mikulich with decompensated stenosis is perverse [8, 20]. In these cases, stenosis in the pyloroduodenal zone recurs. The use of a pyloroplasty according to Finney or a gastrojejunostomo-sis on a short loop helps to prevent the violation of motor-evacuation function of the stomach [8,20]. The experience of using vagotomy in treating patients with DIC ulcer complicated by stenosis shows that the long-term results of this operation are favorable [8, 20]. On the other hand, "vagal denervation" of the stomach against the background of a sharply weakened contractile ability of the body previously seemed extremely risky [9, 11].
In most patients, this complication of vagotomy in the early postoperative period is eliminated by conservative treatment and is noted briefly [8,20]. This circumstance, as well as the high incidence of recurrence of the disease in patients undergoing vagotomy [9,16], promoted the introduction of the pyloroduodenal vagotomy with antrumectomy for treatment of patients with ulcerative stenosis [9,19]. A number of authors believe that the best operation for the treatment of patients with ulcer-ative wall pyloroduodenal area is antrumectomy in combination with CB [15, 19]. A new way to consider the surgical treatment of duodenal ulcers, including stenosis of the pyloroduodenal zone, was allowed by the use of SST in clinical practice [22], causing minimal disruption of the motor function of the stomach, preserves the mechanism of antral regulation of its secretion, which ensures secretory processes in the stomach at a level close to physi-
ological [18]. That is why SST, characterized by low postoperative mortality and not having in most cases adverse effects, has been used in the surgical treatment of patients with duodenal ulcer complicated by stenosis [17]. The undoubted advantage of PWV is low operative and postoperative mortality [13]. This circumstance allows its use in exhausted, debilitated patients, especially in patients of elderly and old age. In addition, with the complication of duodenal ulcer stenosis of the pyloroduodenal zone, the frequency of relapses of the disease is less high than with other complications of duodenal ulcer and less frequent disorders of the functions of the digestive organs [19]. Manifestations of dumping syndrome, noted in some patients who underwent SST with pyloroplasty, in most cases are mild and quickly resolved by conservative treatment [17,22]. When treating patients with duodenal ulcer complicated by decompensated stenosis, besides choosing an adequate method of vagotomy, it is also important and determination of the most rational method of stomach draining operation [9,14]. As a rule, pyloroplasty is used as a method of gastric drainage. Gastroenterostomy is used only for special reasons. Currently, the priority are those methods of gastroduodenal anastomosis formation, which allow to reliably drain the expanded stomach and prevent the development of cicatricial changes in the area of the fistula. This is achieved mainly by adhering to its proper size (at least 3 - 3.5 cm). Such is pyloroplasty according to Finney, which has received the most widespread [8]. [11] proved that with duodenoplasty stenosis, duodenoplasty is advisable, while the organ's good permeability is restored, the pylorus musculature and the antrum of the stomach are not damaged, which approximates the functional results of vagotomy with duodeno-plasty to the results of isolated SST. However, duo-denoplasty is not always used. A special problem is the surgical treatment of patients with duodenal ulcer with a combination of stenosis of the pyloro-duodenal zone with an ulcer perforation or acute gastrointestinal bleeding from it [3,4,6].
Thus, in the treatment of patients with duodenal ulcer complicated by pyloroduodenal stenosis, there is no consensus in the choice of the method of surgical treatment. There is no doubt that this choice should be influenced by the degree of viola-
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Thus, the problems of treating patients with penetrating duodenal ulcer persist. Researchers are exploring the possibilities of different surgical methods of treating patients; the question of preference for gastrectomy or vagotomy remains. with pronounced morphological changes in the duodenal ulcer, developing during its penetration
The problems of treating patients with penetrating duodenal ulcer persist. Researchers study the possibilities of different surgical methods for treating patients with pronounced morphological changes in the area of duodenal ulcers, developing during its penetration, and determine the optimal type of operation for this duodenal ulcer, the choice of treatment for patients with duodenal ulcer with pronounced morphological changes attracts special attention of researchers. There are various proposals for its surgical treatment. In patients with this category, the question of preference for gastrectomy or vagotomy remains. Moreover, the need for surgery in patients with penetrating ulcers, a number of authors questioned. The solution of the problems posed was the purpose of the present study
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