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RESULTS OF SURGICAL TREATMENT OF PATIENTS WITH PERFORATED DUODENAL ULCER
Omarov N., Aimagambetov M., Bulegenov T., Mukataeva A., Kaldybek A., Apetova A., Toleuova A., Konopyanova N., Orinbay A.
Department of "Hospital and Pediatric Surgery" Non-Profit Joint Stock Company "Semey Medical University",
Semey, Republic of Kazakhstan DOI: 10.5281/zenodo.6616416
ABSTRACT
The article reflects the types of surgical treatment of perforated ulcers of the stomach and duodenum in the surgical department of the University Hospital non-profit joint stock company «Medical University of Samey». The article presents the experience of treating 19 patients. The analysis of the long-term results of surgical treatment and the quality of life of patients in the period from 2017 to 2022 is given.
Keywords: ulcer suturing, ulcer excision, duodenoplasty, minimally invasive technologies.
Introductions
The relevance of the problem. Gastric ulcer and duodenal ulcer is and remains today one of the urgent health problems [2,3,4] Perforation is a life-threatening complication observed on average in 5% of patients with peptic ulcer disease. However, if patients are overly exposed to adverse factors and do not receive adequate conservative treatment, the risk of perforation may increase significantly. [1,6,8,12,17,18]
In the literature, perforation among ulcerative patients ranges from 5-15%. This complication occurs significantly more often in men than in women aged 2040 years (67.6%). There is evidence that peptic ulcer disease mainly affects men (9:1) aged 30 to 55 years. Currently, perforating ulcers of the stomach and duodenum account for 0.1% of surgical diseases. In acute surgical pathology of abdominal organs, the perforation of ulcers is 1.5-2.6% [5,7,11,13,16,23].
One of the most frequent indications for surgery is the perforation of an ulcer. Duodenal localization of the
ulcer accounts for the majority of cases of perforation (75-85%). This complication is characterized by a fairly high mortality rate (depending on the clinical group of patients - 5%-30%) [4,9,10,20,22,25]. The greatest number of perforations is observed in the autumn and spring season, which coincides with the frequency of exacerbation of peptic ulcer disease. Contributing factors are quite often some external influence: nervous experience, stomach overflow with food, alcohol intake, physical stress and trauma, fatigue and other adverse factors. Perforation occurs in both old and fresh ulcers. Perforation is more often complicated by ulcers located on the anterior surface of the duodenum, small curvature of the stomach. [14,15,19,21,27].
The key issue in the treatment of perforated ulcers is the problem of choosing the optimal surgical tactics, which at the same time allows to reduce the risk of death and achieve the most favorable functional result. This approach should take into account not only the general principles of abdominal surgery, but also the
specific mechanisms that are characteristic of the development of peptic ulcer. So, in a number of experimental and clinical studies, an important role of vascular disorders in the wall of the stomach and duodenum in the pathogenesis of duodenal ulcers was revealed [24,26,28].
MATERIALS AND RESEARCH METHODS
The work was performed at the University Hospital of the Semey State Medical University for the period from 2017 to 2022.
The nature of the study: observational, prospective, longitudinal.
The study is based on the study of the results of surgical treatment of 19 patients with perforated duodenal ulcer, who were in the University Hospital of the State Medical University of Semey. The study was approved by the ethical committee of the Semey State Medical University (protocol No. 15 dated December 18, 2013).
All patients underwent emergency surgery.
Of the 19 operated patients, the overwhelming majority were men - 10 people (52.6%), and 9 (47.4%) women.
Among our patients, 8 (42.1%) were people of working age. The age of the patients varied from 28 to 64 years, the mean age was 38.9±1.0 years.
Concomitant diseases detected in 8 (42.1%) patients, including: bile reflux gastritis - in 1 (5.3%), focal atrophic gastritis - in 1 (5.3%), chronic cholecystitis -in 1 (5.3%), chronic gastritis in 1 (5.3%), pneumoperitoneum in 2 (10.6%), erosive gastritis in 1 (5.3%), coronary heart disease in 1 (5, 3%), gastrostosis - in 1 (5.3%), chronic renal failure - in 1 (5.3%), schizophrenia - in 1 (5.3%), chronic anemia - in 1 (5.3%) sick.
Ulcer perforation was the first sign of peptic ulcer in 7 (36.8%) patients. Against the background of an exacerbation of the disease, it occurred in 2 (10.5%) cases, during the period of clinical remission - in 1 (5.3%) cases.
The duration of the ulcer history was up to 5 years in 5 (26.3%) patients, from 5 to 10 years in 9 (47.36%), over 10 years in 5 (26.3%) patients.
The majority of patients (14 patients, 73.6%) had previously been diagnosed with peptic ulcer with localization of the ulcer in the duodenum. Perforation was repeated in 3 (15.7%) cases, combined with bleeding in 2 cases (10.5%). Within 6 hours after duodenal ulcer perforation, 2 patients (10.5%) were hospitalized, after 6-12 hours - 2 (10.5%), and after 12 hours or more - 5 (26.3%) patients.
The perifocal inflammatory infiltrate was 1.5±0.04 cm. in diameter and did not go beyond the duodenum. The perforation was located at a distance of 1.8±0.03 cm from the pyloric sphincter, and only in 1 (5.3%) patients - near the pylorus with its involvement in the infiltrate. The combination of perforation with duodenal stenosis of I-II degree was detected in 3 (15.9%) patients, with the presence of a second ulcer in 1 (5.3%) and its penetration into the head of the pancreas in 1 patient (5.3%). Covered perforation was detected in 3 (15.9%) cases. The choice of surgical tactics was aimed at the simultaneous solution of the following tasks - the elimination of the source of peritonitis, radical treatment of peptic ulcer, minor trauma.
All patients were divided into two groups. The first group consisted of 10 (52.6%) patients who underwent videolaparoscopy, sanation, suturing of the duodenal perforation (comparison group). The second group consisted of 9 (47.4%) patients who underwent videolaparoscopy, sanitation with excision of the duodenal ulcer with duodenoplasty from a small access (main group).
Technique of surgical interventions
Technique of video laparoscopic sanitation, excision of perforated duodenal ulcers with duodeno-plasty from mini access.
In patients of the second group, after videolaparoscopy and sanitation in the right hypochondrium, the duodenum was mobilized according to Kocher by transrectal access 4 cm long (Figure 1) using the Liga-7 mini-assistant apparatus.
Figure 1 - A video laparoscope was insertedparaumbilically into the abdominal cavity, a transrectal incision 4
cm long was made in the right hypochondrium
Depending on the localization of the ulcer, the perifocal inflammatory ridge, the presence of an ulcer on the posterior wall of the duodenum, the length and degree of narrowing, the severity of the deformity and prestenotic expansion, one or another method of duo-denoplasty was chosen.
When localizing a perforated ulcer on the anterior wall without involving the upper and posterior walls of
the duodenum, we perform a transverse duodenot-omyalong the ulcer or below the perforation. Through this wound, the infiltration zone, the presence of stenosis, the distance to the pyloric sphincter are assessed.
The perforated ulcer is excised in the form of a "petal" (Figure 2).
Figure 2. View of duodenal ulcer after excision
At the same time, we control the pyloric pulp so as not to damage it, we remove scar tissue. Only pathologically altered tissue should be excised, cicatricial deformities should be eliminated. Visually and palpation instrument, we revise the posterior wall of the duodenum for the presence of a "mirror" ulcer.
The wound on the duodenum is sutured with a two-row atraumatic synthetic suture Vikril 3.0, while the first row of sutures should be applied very carefully, without rough capture of the edges of the intestinal wound.Failure to comply with this rule can lead to deformation of the duodenum and dysfunction of the pyloric sphincter (Figure 3)
Figure 3 - View of the ulcer after excision and suturing
When the perforated ulcer was localized on the anterior-upper wall of the duodenum, with the transition to the upper-posterior wall, a wedge-shaped excision of the ulcer was performed. At the same time, the edges of the ulcer, located on the upper-posterior wall, were mobilized over a distance of 0.8-1.0 cm. A single-row at-
raumatic synthetic suture with Vikril 3.0 thread was applied to the posterior wall, and double-row sutures were applied to the anterior wall.
When a "mirror" ulcer was detected on the posterior wall of the duodenum of a small size (up to 1 cm), without penetration into the pancreas and without cica-tricial stenosis, the edges of the ulcer were mobilized with a dissector for 0.5-0.6 cm, after which 2-3 nodal
seam. The anterior wall is restored with two-row sutures with Vikril 3.0 thread. When the second ulcer was localized on the posterior wall of the duodenum, large or giant (more than 3 cm), with penetration into the gland with signs of stenosis, a circular dissection of the duodenum was performed, after mobilization of the stenosis zone, the ends of the duodenum were isolated from the ulcer up and down.
Mobilization from an ulcer and a combination of external and internal approaches, i.e. on the part of the mucous and serous membranes, allows not only to limit the area of intervention to the zone of the pathological process, but also to avoid damage to the pancreas, large vessels and the common bile stream. We select the posterior wall of the intestine up to the pylorus, such mobilization gives the pyloroduodenal segment significant mobility. We select the lower end of the intestine 1.01.5 cm from the edge of the ulcer. Rubtsov, the altered
sections of the intestine are excised. On the back wall of the duodenum we impose single-row interrupted sutures. In this case, the ulcer of the posterior wall is "turned off' from the intestinal lumen. The anterior wall is sutured with two rows of sutures with an atrau-matic synthetic Vikril 3.0 suture.
After the end of this stage of the operation, the abdominal cavity was washed twice with a 1:5000 solution of furacilin up to 800 ml. The operation ended with drainage of the subhepatic space through a trocar in the right hypochondrium and small pelvis with a 1.0 cm PVC tube.
RESULTS OF THE STUDY
Immediate results of operations. Immediate results of surgical treatment of perforated duodenal ulcer were studied in all 19 patients. Data on the duration of surgery in the compared groups are presented in Table 1.
Table 1
Duration of surgical interventions, in groups of examined
Group Indicator P
min. duration max. duration averageduration
Main 123 92 105,0±2,8 <0,05
Comparisons 87 62 69,2±2,5
The average duration of the operation in patients of the main group was 105±2.8 minutes. The duration of the operation in the comparison group averaged 69.2±3.8 minutes. Performing radical duodenoplasty from a mini-access significantly (by 30-40 minutes - by an average of 51.7%, p<0.05) increased the duration of
the operation, which indicates the complexity of the proposed surgical intervention.
Videolaparoscopy, sanitation, suturing of perforated duodenal ulcer.
The data of fluoroscopy of the stomach in patients of the comparison group are presented in Table 2.
Table 2
The results of fluoroscopy of the stomach in patients in the comparison group.
Researched Characteristic Indicator frequency, n=10
parameter n M±m
Stomach size Increased 4 3,5±1,7
Stomach tone Increased 3 2,9±1,2
Decreased 2 1,2±1,6
Gastric contents large amount of liquid 2 1,6±1,7
Deep 4 3,5±1,7
Peristalsis medium depth 4 3,5±1,7
superficial 1 0,9±0,4
absent 1 0,9±0,4
accelerated 2 1,6±1,7
Evacuation timely 5 4,5±0,5
slowed down 2 1,6±1,7
Bariumdepot 6 5,2±1,7
Duodenogastric reflux 4 3,5±1,7
Radiographically, the patients showed delayed evacuation of barium suspension from the stomach and duodenum up to 12 hours, deformation of the duodenal bulb.
With FGDS in the stomach, a moderate amount of gastric juice (150-200 ml), usually with an admixture
of bile, hyperemia, mucosal edema. The pylorus is deformed, reflux of duodenal contents into the stomach. In the area of the sutured wound, fibrous overlays, duodenitis phenomena (table 3).
Table 3
The results of EGD in patients of the group in the comparison group
Parameterunderstudy Results Indicatorfrequency, n=10
n М± m
Gastriccontents Increase in the amount of secretory fluid 1 10,9±4,2
Leftover food on an empty stomach 1 9,1±3,9
Bileadmixture (DGR) 3 34,5±6,4
Changes in the gastric mucosa Superficialgastritis 4 45,5±6,7
Atrophicandmixedgastritis 1 5,5±3,1
Erosivegastritis 1 3,6±2,5
Condition of the area of the sutured ulcer Passablefreely 2 23,6±5,7
Passablewithdifficulty 3 29,1±6,1
Impassable 1 3,6±2,5
Ligatureinflammation 4 40,0±6,6
Mucousduodenum Duodenitissuperficial 2 20,0±5,4
Erosive duodenitis 1 12,7±4,5
Ulcer 9 94,5±3,1
The study of the acid-producing function of the stomach revealed an increased BOD - 6.6 ± 0.3 mmol / h, BMD - 28.2 ± 0.2 mmol / h, pH with basal secretion 1.1 ± 0.2, pH with stimulated secretion - 0 .8±0.1.
After suturing a perforated ulcer, the following complications developed in the postoperative period:
wound suppuration in 2 (20%) patients, acute intestinal obstruction in 1 (10%) patient, bleeding from an ulcer in the posterior intestinal wall in 1 (10%) patient, suture failure of the sutured ulcer, peritonitis with the formation of a subphrenic abscess - in 1 (10%) patient (Table 4).
Table 4
Complication Frequency of the indicator
n M±m
Acute intestinal obstruction 1 1,8±1,8
Failure of sutures in a sutured ulcer 1 1,8±1,8
Bleeding from an ulcer of the posterior wall of the intestine 1 1,8±1,8
Peritonitis with formation of subphrenic abscess 1 1,8±1,8
Suppuration of postoperative wound 2 3,6±2,5
Gastrostasis 4 9,1±3,9
Videolaparoscopy, sanitation with excision of the duodenal ulcer with duodenoplasty from small access.
X-ray studies of the motor-evacuation function of the stomach and duodenum in 1 (11.1%) patient accelerated evacuation from the stomach, in 2 (22.2%) -
slow, while 1 patient had a balance of barium suspension even 24 hours after its administration, although he did not make any complaints (Table 5).
Table 5
The results of fluoroscopy of the stomach in patients in the main group
Researched Characteristic Indicator frequency, n=10
parameter n M±m
Stomach size Increased 2 1,6±
Stomach tone Increased 1 1,9±
Decreased 3 2,3±
Gastric contents large amount of liquid 1 0,7±
Deep 2 1,6±
Peristalsis medium depth 1 0,7±
superficial 3 2,9±
absent 4 3,0±
accelerated 0 0
Evacuation timely 1 0,9±
slowed down 6 54,3±
Bariumdepot 6 2
Duodenogastric reflux 4 0
Endoscopic examination (table 9) in 6 patients along the line of duodenoplasty sutures, superficial gas-(66.6%) revealed inflammation of the duodenal mucosa tritis was noted in 2 (22.2%), reflux of duodenal con-
tents into the stomach in 1 (11.1%) patients.
Table 9
Results of EGD in patients in the main group._
Parameterunderstudy Results Indicatorfrequency, n=10
n M± m
Gastriccontents Increase in the amount of secretory fluid 2 1,1±0,9
Leftover food on an empty stomach 0 0
Bileadmixture (DGR) 6 5,7±0,4
Changes in the gastric mucosa Superficialgastritis 5 4,4±0,8
Atrophicandmixedgastritis 2 1,1±0,9
Erosivegastritis 2 1,1±0,9
Condition of the area of the sutured ulcer Passablefreely 5 4,4±0,8
Passablewithdifficulty 1 0,7±0,4
Impassable 0 0
Ligatureinflammation 3 37,1±8,2
Mucousduodenum Duodenitissuperficial 6 5,7±0,4
Erosive duodenitis 2 1,1±0,9
Ulcer 0 0
Summing up the results of the clinical evaluation of the immediate results of surgical interventions for callous perforated duodenal ulcer, we can note a smaller number of postoperative complications and the absence of deaths after pylorus-preserving duodeno-plasty. It should be emphasized that in preventing the development of postoperative complications, compliance with the correct technology for applying a precision suture is essential.
In the main group, 3 cases (12.3±4.3%) of postoperative complications were registered. Only in 1 of them there was a significant threat to the life of the patient (acute pancreatitis). There were no lethal outcomes.
Evaluation of long-term results of excision of a perforated duodenal ulcer with duodenoplasty suggests that the use of this method leads to an improvement in long-term results of treatment. In 75% of cases, excellent and good results were obtained in the long term. Postoperative complications after this operation are much less common and occur in a milder form, well corrected by conservative therapy.
Drug therapy, adherence to a diet allowed patients of the main group to maintain their ability to work.
Discussion
The technology of video-laparoscopic sanitation of the revision proposed by us and the use of excision of the ulcer from a small access with the performance of duodenoplasty allows:
1. Adequately sanitize the abdominal cavity,
2. Inspect the ulcer crater and establish the presence of stenosis and penetrating ulcer of the posterior wall of the duodenum.
3. Remove the inflammatory shaft around the ulcer, for better healing of the duodenal wound.
Instead of the usual suturing of the ulcer, we perform excision of a perforated ulcer, duodenoplasty, which has several advantages, namely, it eliminates stenosis, makes it possible to diagnose a posterior wall ulcer and promotes better healing of the duodenal wound.
Thus, for the vast majority of patients with perforated duodenal ulcer, it seems possible to perform excision of the ulcer (with "mirror" ulcers, "turning off" the ulcer from the intestinal lumen) with duodenoplasty and save the pyloric sphincter.
Conclusion
The use of videolaparoscopic debridement and excision of a perforated duodenal ulcer from a mini-access is accompanied by a small number of postoperative complications and gives good and excellent results in the long-term period in 75% of patients.
During video-laparoscopic suturing of a prefora-tive duodenal ulcer with callous edges in the early postoperative period, 3.6% developed suture failure. In 1.8% of patients, bleeding from the ulcer and in 5.4% of patients, stenosis of the duodenum was formed.
The main elements of the surgical technology of video-laparoscopic debridement and excision of a perforated duodenal ulcer from a mini-access are: creation of a mini-access in the right hypochondrium, providing the possibility of direct access to the duodenal bulb; excision of only pathologically altered tissues with preservation of the pyloric sphincter, imposition of a precision suture.
Videolaparoscopicsanation with excision of a perforated ulcer of the duodenum from a mini-access allows 74.1% of patients to save pyloric sphincter due to the use of bridge duodenoplasty, which gives the best functional results.
When analyzing the long-term results of video-laparoscopic suturing of a perforated duodenal ulcer with a callous margin and its excision from a mini-access with preservation of the pylorus, a decrease in the frequency of violations of the evacuation function of the stomach and duodenogastric reflux by 4.3 times, the frequency of signs of gastritis - by 3.3 times, superficial and erosive duodenitis - 2.3 times.
Conflict of interest
No conflict of interest declared.
Acknowledgement
We express our sincere gratitude to the Director of the University Hospital AlzhanovSerikNuribekovich
for providing the opportunity to carry out our work. In addition, we would like to express our sincere gratitude to our Chairman of the Board, Rector Dyusupov Altai Akhmetkalievich for his constant support and provision of conditions for the completion of our work.
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