Immediate result of surgical treatment of ulcer disease in morbidly obese patients]

From 1975 to 1989, 97 patients with ulcer diseases and concomitant obesity were operated on at the Tashkent branch of the All-Union Scientific Surgical Centre, Academy of Sciences of the USSR. The patients with a gastroduodenal ulcer, II and higher degree of morbid obesity accounted for 2.4% of the total number of patients operated on for ulcer disease. Gastric ulcer was diagnosed in 20 patients, a duodenal one--in 77. All the patients were operated on for disease complications. Of them, 36 underwent Billroth-II gastric resection, the remaining patients--Billroth-I gastric resection and truncal vagotomy with drainage operation. The best immediate result was noted after performance of truncal vagotomy with drainage operation. Use of gastric resection in a given category of patients is accompanied by the development of a large number of local and general complications.     

Surgical treatment of gastroduodenal ulcer hemorrhage

The results of treatment of patients with gastroduodenal ulcerous bleeding over 20-year period were analyzed. From 1997 active individualized policy was used in the treatment of 522 patients. In duodenal ulcer the drug-thermal vagotomy was applied as well as traditional organ-saving operations, in combination with extraduodenisation of ulcer when it penetrates into pancreatic head. In gastric ulcer sparing resection or methods of ulcer's taking outside gastrointestinal tract (extragastration of ulcer) with preservation of gastric angio-, and neuroarchitectonics were preferable. In preoperative period Sandostatin and Hystodil were applied, in postoperative period--Imunofan.     

Status of protective properties of the gastroduodenal mucosa after surgical treatment of duodenal ulcer

The defense properties of the gastroduodenal mucosa (lymphoid system cells secreting immunoglobulins A, M, and G, as well as the secretory component IgA) were studied in 85 patients with duodenal ulcer. The acid-producing function of the stomach was tested at the same time according to the pH value and the basal and maximal acid production. Various types of vagotomy were conducted in 52 patients and resection of the stomach in the remaining patients. The results were followed-up before and after the operation. Peptic ulcer was characterized by secondary immunodeficiency. Selective proximal vagotomy restored the tissue immune defense of the mucosa, gastric resection preserved and even increased immunodeficiency.     

Pylorus-preserving gastric resections in gastroduodenal ulcers]

The article analyses the results of pylorus-preserving resections of the stomach in 116 patients among whom 80 had gastric ulcer, 29 ad duodenal ulcer, and 7 had gastroduodenal ulcers. Changes of acidity and motor-evacuation function of the gastric stump were studied according to the method of pylorus-preserving resection. The late-term results of treatment in follow-up periods of 2 to 5 years are shown, they were found to be good in 96.6% of patients treated by operation and poor in 1.7%. It is noted that the function of the gastric stump is better when the vagus innervation of the pylorus is preserved. Mediogastric resection with selective proximal vagotomy in patients suffering from duodenal ulcer with a superacidic stomach led to stable normalization of acid production, which was a reliable measure for the prevention of a recurrent ulcer.     

Clinical study of a group of vagotomized patients]

The physiopathological premisses underlying vagotomy and its use in the treatment of gastroduodenal ulcer are examined. It is submitted that the inadequacies and risks of the original technique are reflected in the modifications subsequently introduced into truncular vagotomy. A long-term assessment is made of a series of patients operated for duodenal ulcer by different surgeons using different forms of vagotomy. It is felt that superselective vagotomy is most consonant with the therapeutic objectives and associated with the least risk. In addition vagotomy is indicated in subjects with POPU after gastric section whose local and general condition contraindicate more complicated and serious measures, such as degastroenterostomy with further resection.     

Massive haemorrhage from gastroduodenal ulcer. A series of 149 casees operated on.

A series of 149 patients operated on for massive haemorrhage from gastroduodenal ulcer is presented. The patients were divided into two groups, emergency (70 patients) and semi-emergency (79 patients). In the emergency group the cause of bleeding was GU in 67% and DU in 26%; in the semi-emergency group the corresponding figures were GU 30% and DU 63%. In DU vagotomy + antral resection or pyloroplasty were the usual procedures. GU patients usually underwent a classical resection. The operative mortality rate in the emergency group was 14% and in the semi-emergency group 2.5%. In the whole series the mortality rate was 8.0%. Bleeding recurred in 8 patients (5.4%) and of these eight, five died. The causes of death and the postoperative complications were analysed. In the treatment of massively bleeding duodenal ulcer vagotomy + antral resection is recommended in the case of "good risk" patients and vagotomy + pyloroplasty in the case of "poor risk" patients. For treatment of bleeding gastric ulcer, the procedure recommended with "good risk" patients is still antrectomy, but in cases where the ulcer is situated high up near the cardia and for "poor risk" patients, excision, vagotomy and pyloroplasty should be carried out.     

Old and new concepts in surgical therapy of gastroduodenal ulcers complicated or resistant to treatment

This article presents the old and the new therapeutic protocols in the gastroduodenal ulcer. In our opinion, subtotal gastric resection and bilateral subdiafragmatic vagotomy must be considered "historical" without having theoretical support in the era of the antisecretory and anti Helicobacter pylori medication, with similar or superior effects. Is considered as complete the era of the gastric large crippling resection of Péan and Billroth, as the era of Dragstedt's vagotomy and applied the new methods nonaggressive and miniminvasive.     

Complicated postbulbar duodenal ulcer: the characteristics of its diagnosis and surgical technic and management

The paper reports on the authors experience used on 90 patient with complicated postbulbar ulcers (10% of the duodenal ulcers) with hemorrhage (23 cases), perforation (7 cases), duodenal stenosis (19 cases) and penetration pancreatic hepato-biliary (41 cases) period 1987-1996. The frequency of hemorrhagic complication was of 25%. As the hemorrhage due to postbulbar ulcer is favoured by vascular fistula, the sever character of the hemorrhage and the frequency of the recurrence, mainly the cataclysmic one, impose the radical surgery as early as possible. The following were used: large Reichel-Polya's gastrectomy (13 cases) Pean's gastro-duodenectomy + vagotomy (9 cases), gastrectomy for exclusion with hemostasis "in situ" and ligature of gastroduodenal artery + vagotomy (7 case). In 7 cases with perforation: Reichel-Polya's gastrectomy in 2 patients, Pean's gastrectomy in 2 cases, excision pyloroplasty (Judd) and vagotomy (3 cases). In the postbulbar ulcers penetrating into the pancreas or into hepatic pedicle the following were performed: Reichel-Polya's gastrectomy (8 cases), Pean's gastrectomy (11 cases of which 8 with vagotomy) gastrectomy for exclusion of ulcer in 22 cases of which 20 with vagotomy. In 14 patients with stenosed ulcers, Reichel-Polya's gastric resection (4 cases), Pean's gastrectomy (8 cases), gastrectomy for exclusion (7 cases). The conclusions may be drawn that the postbulbar ulcers are complicated ulcers that require differential surgical treatment, as early as possible for diminishing the postsurgical morbidity and mortality (6.6% mortality).     

腹腔镜高选择性迷走神经离断术治疗上消化道溃疡穿孔的临床研究

目的:评价腹腔镜穿孔修补术联合高选择性迷走神经离断术治疗胃十二指肠溃疡穿孔的疗效.方法:回顾分析2003年1月至2007年1月273例胃十二指肠溃疡穿孔患者的临床资料,其中胃穿孔149例,十二指肠穿孔124例.134例行腹腔镜穿孔修补加高选择性迷走神经切断术(研究组),139例行剖腹穿孔修补加高选择性迷走神经切断术(对...     

Resection of the stomach with excision of the small curvature and selective vagotomy in primary and reconstructive surgery of gastroduodenal ulcers

Experience in surgical treatment of 261 patients with complicated gastroduodenal ulcer is summarized. A new improved method of resection with subtotal excision of the small curvature and selective gastric vagotomy, creation of a gastric stump in the form of a proximal reservoir and distal tubular canal was used. In 144 cases this method was performed as repeated or reconstructive surgery in post-vagotomic ulcers. The follow-up was 5 years, long-term results were evaluated in 166 patients with the Visik scale. Excellent and good results were seen in 151 (91%) patients, satisfactory -- in 13 (7.8%), and a poor result (recurrence of ulcer) -- in 2 (1.2%) patients.     

Pharmacotherapeutic aspects of early postoperative period in patients with complicated gastroduodenal ulcer

There were analyzed the immediate and remote results of treatment of 556 patients with complicated gastroduodenal ulcer, in whom radical operation and ulcer excision with various variants of medicinal correction in early postoperative period were performed. The best immediate result was achieved after performance of radical operation (vagotomy, thrifty gastric resection). But in 5-10 years after vagotomy performance the ulcer recurrency have occurred in 11.3% of observations. Excision of the ulcer morphological substratum in combination with antiulcer medicinal therapy in early postoperative period constitutes an alternative method of treatment of such patients. Important role of Helicobacter pylori in the ulcer complications occurrence was established, demanding application of antibacterial preparations. Of many schemes of antibacterial therapy existing preference should be given to combination of macrolides (clarythromycine) with nitroimidazole (tinidazole) and the proton pump inhibitors (pylobact) as most secure and quite effective one.     

Gastric mucosal resection in the treatment of peptic ulcers: a 1-10 year clinical follow-up.

The clinical results of gastric mucosal resection are reported after a 1-10-year follow-up in which 76 per cent of patients were followed up for more than 5 years. There were 3 postopertive deaths in 152 patients. Mucosal antrectomy with vagotomy for duodenal ulcer in 96 patients, and for recurrent ulcer in 9 patients, has not been followed by a single recurrence. Gastric mucosal resection alone for the treatment of gastric ulcer in 21 patients resulted in 1 recurrence. Although vagotomy combined with resection is currently out of fashion for the initial treatment of duodenal ulcer in Britain, mucosal gastric resection has technical advantages in combination with vagotomy for the cure of recurrent ulcers following duodenal ulcer surgery.     

经脐单切口腹腔镜胃大部切除治疗胃、十二指肠溃疡

2010年11月～2011年1月我科对3例胃、十二指肠溃疡疑有恶变,幽门狭窄造成梗阻的患者行经脐单切口腹腔镜胃大部切除术,手术时间分别为250、280、350 min,术中出血量分别为150、200、300 ml,无术后出血、吻合口漏及吻合口梗阻等并发症发生。分别于术后7、8、7 d出院。术后切口愈合良好。3例分别随访7、8、9个月,患者无腹痛、呕吐等症状出现。经脐单切口腹腔镜胃大部切除术治疗良性消化性溃疡安全、可行,有良好的美容效果。     

Surgical treatment in peptic ulcer complicated by acute hemorrhage

Results of the surgical treatment of 168 patients with acute ulcer hemorrhage are analyzed. The main type of operation was gastric resection (87,0%), vagotomy with organ-preserving operations being also used. Total postoperative lethality was 8,3%.     

Surgical treatment of patients with perforated peptic ulcers

Results of surgical treatment of 782 patients with perforated gastric and duodenal ulcers are analyzed. Gastric ulcers of I type were diagnosed at 86 (10.9%) patients, prepyloric and pyloric ulcers - at 441 (56.4%), duodenal ulcers - at 255 (32.6%) patients. Perforation was combined with bleeding and stenosis at 24 (3.1%). Palliative operations have been performed at 172 (22.0%) patients, stem vagotomy with ulcer excision and pyloroplasty - at 58 (7.4%), various types of stomach resection - at 54 (6.9%), proximal gastric vagotomy with excision of gastric, pyloric or duodenal ulcer - at 77 (9.8%), proximal gastric vagotomy with excision or suturing of ulcer and pyloro- or duodenoplasty - at 421 (53.8%) patients. The rate of postoperative complications after proximal gastric vagotomy was 3.6%, after stomach resection - 18.2% (p<0.01). Early postoperative complications after vagotomy with ulcer excision and pyloroplasty were diagnosed at 8.3%, after stomach resection - at 18.2% patients (p<0.01). The quality of patients life was higher after organ-saving operations. Proximal gastric vagotomy with excision of ulcer and pyloro- or duodenoplasty should be regarded as operation of choice at perforated duodenal ulcers.     

Estimation of the results and quality of life indices in patients with gastroduodenal ulcer depending on the method of operative treatment

The results of operative treatment of 261 patients, suffering perforative gastroduodenal ulcer, are analyzed. In 159 patients the ulcer excision with pyloroplasty and without vagotomy was performed and in 102--the ulcer excision with vagotomy. In all the patients the chronic ulcer perforation was noted. In operated patients gastric mucosa have had morphologic peculiarities, characteristic for chronic atrophic gastritis with complete intestinal metaplasia foci. In surgical treatment for perforative gastroduodenal ulcer its excision with pyloroplasty conduction and medicinal correcting therapy are recommended.     

Effect of a drainage operation on gastric secretion in patients with duodenal ulcer after vagotomy

The work analyzes alterations of gastric secretion in 687 patients subjected to various kinds of vagotomy in combination with or without draining operations on the stomach for ulcer of the duodenum. Draining operations were established to decrease activity of gastric secretion. The Jaboulay gastroduodenal anastomosis proved to be less beneficial since 50% of the patients had the positive insulin test and ulcer recurred almost in 11% of the cases. Results were most favorable after vagotomy in combination with pyloroplasty after Finney and Heineke-Mikulicz. The disease recurred after these interventions in 7 and 8% correspondingly.     

MINIMAL ACCESS GASTRODUODENAL SURGERY

Considerable advances are occurring in the application of laparoscopic techniques to gastrointestinal and hepatobiliary disorders. Following studies in experimental animals, surgeons with an interest in gastroduodenal disease have now introduced laparoscopic techniques into current surgical practice. Elective intervention for peptic ulcer disease is currently being established, particularly in patients with proven negative Helicobacter pylori (HP) status, or when eradication has proved unsuccessful with various drug regimens. In addition, emergency laparoscopic intervention for perforation is gaining acceptance, with or without a definitive anti-ulcer procedure. Therapeutic endoscopy for bleeding peptic ulcer may well be followed by anti-ulcer laparoscopic surgery in selected patients. Laparoscopic techniques have been utilized for the treatment of Mallory Weiss tear, congenital hypertrophic pyloric stenosis, Dieulafoy's lesion, gastric trauma or volvulus and benign gastric tumours. More ergonomic instruments are required before laparoscopic gastric resection becomes more widely acceptable. It is essential that objective evaluation of variations on vagotomy themes be undertaken in prospective clinical trials and that the safety and efficacy of gastric resection procedures be substantiated if this renaissance is to revolutionize gastroduodenal surgical practice.     

Vagotomy in the treatment of gastroduodenal ulcers in middle-aged and elderly patients

Experience with the treatment of 190 patients with a complicated ulcer disease of the stomach and duodenum in elderly and senile patients is presented. In 115 of the patients gastric resection was performed. Different kinds of vagotomy were used in 75 patients. Postoperative complications after vagotomy were noted in 9,3% of the cases, after gastric resection in 40%. No lethal outcomes followed vagotomy. Lethality rate after gastric resection was 9,6%.     

Surgical management of acute hemorrhagic postbulbar duodenal ulcer after a previous major surgical procedure

The choice of operation for acute hemorrhagic postbulbar duodenal ulcer after an operation is discussed. Distal partial gastrectomy was performed in six patients. The ulcer was treated by resection, suture, or removal by mucoclasis. Hemostasis was attained in five patients. In another, multiple ulcers were observed in the descending portion of the duodenum and gastrectomy failed to control hemorrhage, resulting in death. Rebleeding was observed in two, one from a newly formed ulcer in the upper part of the papilla of Vater after gastrectomy with truncal vagotomy and which was halted by suture of the ulcer and another was from a newly formed ulcer in the remnant stomach after gastrectomy and which was halted by selective vagotomy and ligation of the left gastric artery. It is recommendable to perform a subtotal gastrectomy and vagotomy combined with removal of the ulcer by mucoclasis or ulcer suture. In some cases, pancreatoduodenectomy may have to be done.