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0RESULTS OF USING LASER THERAPY IN SURGERY FOR STOMACH AND DUODENAL ULCERS
1Nishanov M.F., 2KhoJimetov D.Sh., 3Usmonov Kh.A., 4Abdurakhmadov A.A.
1,2,3,4Andijan State Medical Institute https://doi.org/10.5281/zenodo.11080037
Abstract. In the given article the authors analyze various degrees of physiological anastomositis in 131 patients, and conclude that for the treatment of late anastomositis after surgical interventions on the stomach and duodenum, it is recommended to include laser exposure of the anastomosis zone with two types of low-energy lasers in a comprehensive program. The authors argue that the integrated use of low-energy laser exposure through endoscopic and percutaneous irradiation will improve the effectiveness of treatment of late anastomositis.
Keywords: laser therapy, endoscopy, excision, probe, resection, anastomositis, ulcer, stomach, duodenum.
Relevance. Despite the progress in the development of drug and endoscopic treatment methods, surgery for ulcerative disease in its complicated course remains a subject of interest in terms of developing or improving various options for surgical approaches, the essence of which is aimed at reducing the incidence of various postoperative complications [2,5,7,14]. This applies to both resection technologies, among which the Billroth-I or II resection options are constantly being modified, and organ-preserving interventions - excision of ulcers, suturing of perforations, etc. [3,8,10,12,]. In this regard, the frequency and range of complications certainly depend on both the surgical technique and other factors: the type of suture material, the initial condition of the patients and others [6,11].
Factors associated with pathology include pathological features (size and location of the ulcer, presence of perforation, local tissue inflammation, suspicion of malignancy, peritonitis and sepsis) [4,9]. Patient-related factors include age, gender, and comorbidities, while health-related factors include the availability of medical facilities and skilled surgeon [1]. Each factor itself and their relationship, reflecting the surgical extent, are important when deciding on the choice of surgical strategy [13].
As a rule, postoperative anastomositis is considered as a physiological process and develops in all patients as a result of the intervention. However, it is considered physiological only in the next 5-7 days after surgery, while according to morphological criteria, the anastomositis should be catarrhal. With the development of clinical signs of anastomositis and its duration of more than 7 days, the rehabilitation process will be lengthened, since in these cases such a complication is no longer physiological and requires additional therapeutic measures.
Target. To improve the results of surgical treatment of patients with duodenal ulcer by introducing laser technology.
Materials and methods of research. The satisfactory course of the early postoperative period was characterized by only mild general clinical manifestations, which generally correspond to the severity of the operation. The intra- and postoperative measures proposed against the background of standard recommendations made it possible to increase in the main group the frequency of postoperative "physiological" anastomositis within 6-7 days after surgery from 68.5% (in 50 patients in the comparison group) to 89.7% (in 52 out of 58 patients; x2=9.202;
p=0.011). The average severity of anastomositis was verified in 19 (26%) and 6 (10.3%) patients, respectively, while the severe degree developed only in the comparison group in 4 (5.5%) patients (Table 1).
Table 1
Distribution of patients according to clinical severity of postoperative "physiological"
anastomositis
Severity Comparison group Main group
Abs % abs. %
Light 50 68,5% 52 89,7%
Average 19 26,0% 6 10,3%
Heavy 4 5,5% 0 0,0%
Total 73 100,0% 58 100,0%
x2 9,202; df=2; p=0,011
Accordingly, a lower frequency of clinical manifestations was noted. Thus, symptoms of nausea were noted by 8 (11%) patients in the comparison group, while in the main group only 3 (5.2%). Periodic vomiting occurred in 5 (6.8%) and 1 (1.7%) patients, respectively. Pain symptoms persisted by day 7 in 12.3% (9) in the comparison group and in 3.4% (2) in the main group (Table 2).
Table 2
Frequency of various manifestations of anastomositis on the 7th day after surgery
Abs% abs. % Nausea 811.0% 3 5.2% Vomiting 5 6.8% 11.7% Belching 13 17.8% 4 6.9% 6 8.2% 2 3.4%
Pain or heaviness in the epigastrium 9 12.3% 2 3.4% Decreased appetite 19 26.0% 610.3%
Complaints Comparison group Main group
Abs. % Abs. %
Nausea 8 11,0% 3 5,2%
Vomiting 5 6,8% 1 1,7%
Belching 13 17,8% 4 6,9%
Heartburn 6 8,2% 2 3,4%
Pain or heaviness in the epigastrium 9 12,3% 2 3,4%
Decreased appetite 19 26,0% 6 10,3%
Control endoscopy on days 7-8 due to the development of clinically significant anastomositis was performed on 37 patients in the comparison group and only 8 patients in the main group (Fig. 1).
80% 60% 40% 20% 0%
75,7% 87,5% Форма выраженности воспаления
1
Катарально-отечная Эрозивно-фибринозная Язвенно-некротическая
I Группа сравнения (n=37) ■ Основная группа (n=8)
87,5% 87,5% / о Степень нарушения проходимости
64,9%
2 9,7% 9,7% 12,5% 12,5%
5,4% 0,0% 0,0% 0,0%
Без стеноза Стеноз I степени
Группа сравнения (n=37)
Стеноз II степени Стеноз III степени ■ Основная группа (n=8)
100,0%
По наличию лигатур
80% 60% 40% 20% 0%
100% 80% 60% 40% 20% 0%
Без лигатур С лигатурами
■ Группа сравнения (n=37) ■ Основная группа (n=8)
Fig. 1. Verified form of early prolonged postoperative anastomositis according to endoscopy Results and their discussions. The most frequently verified form of inflammation severity was catarrhal-edematous degree - 28 (75.7%) in the comparison group and 7 (87.5%) in the main group. In 8 (21.6%) and 1 (12.5%) cases, respectively, the erosive-fibrinous form was determined. The ulcerative-necrotic form was detected in 1 (2.7%) patient in the comparison group. Endoscopically, first degree anastomotic stenosis was determined in 11 (29.7%) patients in the comparison group and 1 (12.5%) in the main group; second degree in 2 (5.4%) patients in the comparison group, normal patency of the anastomosis was in 24 (64.9%) and 7 (87.5%) patients. Already in the early postoperative period, in 6 (16.2% of patients in the comparison group,
16,2%
0,0%
_
ligatures were identified in the area of inflammatory infiltrate, which during this period were not subject to excision due to the risk of subsequent failure of the sutures.
In general, 6 (8.2%) patients in the comparison group (after gastric cancer according to BI - 3; gastric cancer according to B-II - 1 and ulcer excision - 2) and only 1 (1.7%) in the main group (after GC according to B-I), clinical and endoscopically, the development of clinically significant anastomositis was noted in the immediate period (Table 3).
Table 3
Frequency of development of clinically significant anastomositis in the near future
Type of operation Comparison group Main group
Abs % Abs. %
RJ according to B-I 3 11,5% 1 5,3%
RJ according to B-II 1 7,7% 0 0,0%
Excision of ulcer 2 5,9% 0 0,0%
Total 6 8,2% 1 1,7%
All these patients underwent a radiocontrast study with a barium suspension. During dynamic examination, normal evacuation (45-60 minutes) after GC according to B-I was determined in 3 (18.8%) cases in the comparison group and 2 (50%) in the main group, accelerated evacuation (less than 45 minutes) in 4 ( 25%) and 1 (25%) patients, slow (more than 60 minutes) in 9 (56.3%) and 1 (25%) patients (Table 4). After GC according to B-II, the norm was determined in 2 (28.6%) cases in the comparison group and 1 (50%) in the main group, accelerated evacuation in 5 (71.4%) and 1 (50%) patients. After excision of the ulcer, normal evacuation was in 5 (35.7%) in the comparison group and 1 (50%) in the main group, accelerated evacuation in 1 (7.1%) patient in the comparison group, slow in 8 (57.1%) ) and 1 (50%) patients.
Table 4
Distribution of patients according to contrast evacuation time (X-ray contrast study)
vacuation time Comparison group Main group
Abs % Abs. %
RJ according to B-I
Norm (45-60 min) 3 18,8% 2 50,0%
Accelerated (up to 45 min) 4 25,0% 1 25,0%
Slow (more than 60 minutes) 9 56,3% 1 25,0%
Total 16 100,0% 4 100,0%
RJ according to B-I
Norm (45-60 min) 2 28,6% 1 50,0%
Accelerated (up to 45 min) 5 71,4% 1 50,0%
Slow (more than 60 minutes) 0 0,0% 0 0,0%
Total 7 100,0% 2 100,0%
Ulcer excision
Norm (45-60 min) 5 35,7% 1 50,0%
Accelerated (up 45 min) 1 7,1% 0 0,0%
Slow (more than 60 min) 8 57,1% 1 50,0%
Total 14 100,0% 2 100,0%
In general, for all types of operations, normal evacuation was determined in 10 (27%) cases in the comparison group and 4 (50%) in the main group, accelerated evacuation in 10 (27%) and 2 (25%) patients, slow in 17 (45.9%) and 2 (25%) patients (Fig. 2).
60%
40%
20%
0%
Норма (45-60 мин)
Ускоренное(до 45 мин) Замедленное(более 60 мин)
■ Группа сравнения ■ Основная группа
Fig. 2. Summary distribution of patients by contrast evacuation time
(X-ray contrast study)
The quality of postoperative rehabilitation also varied over time. Thus, within up to 7 days after surgery, the clinical manifestations of anastomositis were stopped after GC according to B-I in 10 of 26 patients (38.5%) in the comparison group and 15 (78.9%) of 19 patients in the main group.
In the period of 7-10 days, regression of anastomositis was verified in 13 (50%) and 3 (15.8%) patients, and in periods of more than 10 days in 3 (11.5%) and only 1 (5.3%) patient in main group (x2=7.339; df=2; p=0.026) (Table 5).
After GC according to B-II, by 7 days the anastomositis was stopped in 6 of 13 patients (46.2%) in the comparison group and 9 (81.8%) of 11 patients in the main group.
In the period of 7-10 days, regression of anastomositis was verified in 6 (46.2%) and 2 (18.2%) patients, and in periods of more than 10 days in 1 (7.7%) patient in the comparison group (x2 = 3.457; df=2; p=0.178; the difference was not significant).
After excision of the ulcer, by 7 days the anastomositis was relieved in 20 of 34 patients (58.8%) in the comparison group and 26 (92.9%) of 28 patients in the main group.
In the period of 7-10 days, regression of anastomositis was verified in 12 (35.3%) and 2 (7.1%) patients, and in periods of more than 10 days in 2 (5.9%) patients in the comparison group (X2 = 9.433; df=2; p=0.009).
Table 5
Distribution of patients according to the timing of relief of clinical manifestations of
anastomositis
Evacuation time Comparison group Main group
Abs % abs. %
RJ according to B-I
Up to 7 days 10 38,5% 15 78,9%
7-10 days 13 50,0% 3 15,8%
More than 10 days 3 11,5% 1 5,3%
Total 26 100,0% 19 100,0%
x2 7,339; df=2; p=0,026
RJ according to B-II
Up to 7 days 6 46,2% 9 81,8%
7-10 days 6 46,2% 2 18,2%
More than 10 days 1 7,7% 0 0,0%
Total 13 100,0% 11 100,0%
x2 3,457; df=2; p=0,178
Ulcer excision
Up to 7 days 20 58,8% 26 92,9%
7-10 days 12 35,3% 2 7,1%
More than 10 days 2 5,9% 0 0,0%
Total 34 100,0% 28 100,0%
x2 9,433; df=2; p=0,009
In general, for all operations, within 7 days after the interventions, the clinical manifestations of anastomositis were relieved in 36 of 73 patients (49.3%) in the comparison group and 50 (86.2%) of 58 patients in the main group.
In the period of 7-10 days, regression of anastomositis was verified in 31 (42.5%) and 7 (12.1%) patients, and in periods of more than 10 days in 6 (8.2%) and 1 (1.7%) patient in the main group (x2= 19.547; df=2; p<0.001) (Fig. 3).
100%
20% 0%
До 7 суток
7-10 суток
1,7% Более 10 суток
■ Группа сравнения ■ Основная группа
Fig. 3. Summary distribution of patients according to the timing of relief of clinical
manifestations of anastomositis
In the structure of postoperative complications, in addition to erosive anastomositis in 9 (12.3%) patients in the comparison group and 2 (3.4%) patients in the main group, leakage of anastomotic sutures after GC using the first Billroth method developed in 1 (1.4%) patient in the comparison group. The phenomena of gastrostasis were generally observed in 3 (4.1%) and 1 (1.7%) patients (Table 6).
Table 6
Frequency of various early postoperative complications in the compared groups
Complications Comparison Group Main Group
abs. % abs. %
Leakage of anastomotic sutures 1 1,4% 0 0,0%
Anastomositis (erosive process) 9 12,3% 2 3,4%
Gastrostasis 3 4,1% 1 1,7%
Bleeding 1 1,4% 0 0,0%
Acute pancreatitis 1 1,4% 0 0,0%
Больных с осложнениями Больных без осложнений
■ Группа сравнения ■ Основная группа
Fig. 4. Cumulative incidence of complications after surgery
Bleeding and acute pancreatitis were noted in 1 case (1.4%) in the comparison group. In general, in the comparison group there were 10 (13.7%) patients with various complications and 63 (86.3%) were discharged without complications. In the main group there were 2 (3.4%) patients with complications and 56 (96.6%) without complications (x2=4.081; df=1; p=0.044) (Fig. 4).
It should be noted that in the control group there were 2 (2.7%) with severe complications. In the case of suture failure, repeated intervention was required with suturing of the area of suture failure, and in the case of bleeding due to anastomositis, endoscopic hemostasis was required.
According to clinical characteristics, the beginning of regression of anastomositis manifestations in the comparison group after GC according to B-I was noted on 8.2±2.6 days after surgery, in the main group on 6.3±1.3 days (t=2.74; p< 0.05). After GC according to B-II, this indicator was 8.1±2.2 versus 6.1±1.3 days (t=2.36; p<0.05), after excision 7.5±2.2 versus 6 .1±1.3 days (t=3.11; p<0.05) (Table 7).
The duration of the entire hospital period after GC according to B-I was 13.0±3.0 days in the comparison group, in the main group 10.5±1.9 days (t=3.45; p<0.05). After GC according to B-II, this indicator was 12.8±2.1 versus 10.6±1.5 days (t=2.90; p<0.05), after excision of the ulcer - 11.6±2.2 versus 9.9±1.5 days (t=3.71; p<0.05).
Table 7
Duration of various stages of the hospital period (days)
Period Comparison group Main group T
n M Ô n M A Value P
Beginning of regression of anastomositis manifestations (day p.o.)
RJ according to B-I 26 8,19 2,56 19 6,32 2,03 - 2,74 <0,05
RJ according to B-II 13 8,08 2,22 11 6,36 1,29 - 2,36 <0,05
Excision of ulcer 34 7,47 2,22 28 6,07 1,27 - 3,11 <0,05
Duration of hospital p/o period (day p/o)
RJ according to B-I 26 11,04 2,54 19 8,53 1,58 - 4,08 <0,05
RJ according to B-II 13 10,92 2,36 11 8,82 1,08 - 2,88 <0,05
Excision of ulcer 34 10,29 2,29 28 8,64 1,45 - 3,45 <0,05
Duration of hospital stay (days per day)
RJ according to B-I 26 1,92 0,80 19 1,95 0,71 0,11 >0,05
RJ according to B-II 13 1,85 0,80 11 1,82 0,75 - 0,09 >0,05
Excision of ulcer 34 1,32 0,53 28 1,21 0,42 - 0,90 >0,05
Duration of the entire hospital period (daily days)
RJ according to B-I 26 12,96 2,96 19 10,47 1,87 - 3,45 <0,05
RJ according to B-II 13 12,77 2,09 11 10,64 1,50 - 2,90 <0,05
Excision of ulcer 34 11,62 2,23 28 9,86 1,48 - 3,71 <0,05
In general, for all interventions, the duration of t he period before surgery in both groups
was 1.6 ± 0.7 days. The beginning of regression of anastomositis manifestations in the comparison group was noted on 7.8±2.4 days after surgery, in the main group on 6.2±1.6 days (t=4.64; p<0.05). The duration of the postoperative period was 10.63±2.4 versus 8.9±1.7 days (t=4.88; p<0.05). The duration of the entire hospital period was 12.3±2.5 days in the comparison group, in the main group 10.5±1.9 days (t=4.64; p<0.05) (Table 8).
Table 8
Cumulative duration of various stages of the hospital period
Periods Comparison Group Main Group t
M 5 M 5 Value P
Beginning of regression of anastomositis manifestations (day p.°0 7,81 2,35 6,22 1,55 - 4,64 <0,05
Duration of hospital p/o period (day p/o) 10,63 2,39 8,88 1,71 - 4,88 <0,05
Duration of hospital stay (days per day) 1,63 0,74 1,57 0,68 - 0,49 <0,05
Duration of the entire hospital period (daily days) 12,26 2,53 10,45 1,94 - 4,64 <0,05
Conclusion. Thus, the inclusion of the proposed laser technique in a comprehensive program of early rehabilitation after surgical treatment of complicated duodenal ulcer made it possible to reduce the incidence of clinically significant anastomositis from 8.2% (in 6 patients in the comparison group) to 1.7% (in 1 patient in the main group). group) and in general specific complications that required additional measures from 13.7% (in 10 patients) to 3.4% (in 2 patients; X2 = 4.081; df = 1; p = 0.044), increase the proportion of the physiological course of the postoperative period already by 7 days from 49.3% (36 patients) to 86.2% (50 patients; x2=19.547; df=2; p<0.001), and also reduce the duration of the hospital period from 12.3±2, 5 to 10.5±2.0 days (t=4.64; p<0.05).
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