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.     

One-stage combined operations in cholelithiasis

Immediate results of one-stage combined operations in 509 patients aged 16 to 90 years with cholelithiasis performed in 1981-2005 were analyzed. Main indications for one-stage combined operations in these patients in urgent and elective surgery are listed. The operation was elective in 457 (89.8%) cases and urgent -- in 52 (10.2%). Laparotomy and cholecystectomy with hernioplasty were performed in 180 (35.4%) patients, resection of the stomach in patients with duodenal and gastric ulcer -- in 89 (17.5%), extirpation of the stomach for cancer -- in 89 (17.5%) patients. Retroperitoneal surgeries were performed in 13 (2.6%) patients. The operations were performed under general anesthesia in all the 509 patients. Postoperative lethality was 0.8% (4 patients).     

Modification of gastrectomy by the Roux and Ridiger methods

The author recommends a more effective operative method after Roux-Ridiger with an invagination intestinal anastomosis in the management of severe complications of gastric and duodenal ulcer, particularly in duodenostasis and reconstructive operations for a disease of an operated stomach, and in the postvagotomy syndrome. He carried out 340 economical resections of the stomach after Roux-Ridiger with an invagination intestinal anastomosis in various complications of gastric and duodenal ulcer and the post-gastrectomy and postvagotomy syndromes. The immediate and late-term results of the operation were good. Modified gastric resection after Roux and Ridiger with invagination techniques was performed in 26 experimental dose to study the secretory and motor-emptying function of the gastric stump in the immediate and late-term periods after the operation; the results were good.     

Treatment of peptic ulcer hemorrhages

The article analyses experience in treatment of 297 patients with gastroduodenal bleeding of ulcerous etiology. Operative interventions after arrest of bleeding and the appropriate preoperative management produce better results (the mortality rate, 3.3%) than those of emergency operations (the mortality rate, 15.7%). It is therefore advisable to start treatment of patients with gastroduodenal bleeding by means of nonoperative measures which proved effective in 61.6% of cases. In doubtful reliability of hemostasis, patients with moderate and severe bleeding should be operated on in the immediate days after hospitalization without waiting for a possible recurrent bleeding. Gastric resection is the main type of operative intervention in bleeding from a gastric ulcer. In a bleeding duodenal ulcer both resection of the stomach and economical operations--vagotomy, excision or closure of the ulcer, pyloroplasty--are equally competent.     

Endoscopic evaluation of reflux gastritis in patients operated on for stomach and duodenal ulcers

An analysis of results of the endoscopic examination of 320 patients who had been subjected to various operations for ulcer disease of the stomach and duodenum has shown that sphincter-preserving operations (selective proximal vagotomy without drainage of the stomach and pylorus-preserving resection of the stomach) in treatment of ulcer disease of the stomach and duodenum with correction of disturbances of duodenal passability is the most reliable method for prevention of duodeno-gastric reflux and reflux-gastritis.     

Extended selective proximal vagotomy in the treatment of duodenal ulcer complicated by hemorrhage and perforation

The article analyses surgical treatment of 280 patients, aged from 19 to 20 years, with duodenal ulcer complicated by hemorrhage (36.1%) and perforation (63.9%). Closure of the perforating ulcer with sutures was performed in 15%, resection of the stomach in 12.8%, truncal vagotomy in 7.5%, and expanded selective proximal vagotomy in 64.7% of patients. Comparative analysis of the immediate and late-term results of closure of the perforating ulcer, resection of the stomach, and organ-preserving operations showed that expanded selective proximal vagotomy has unquestionable advantages over the other operations mentioned above. It is not marked by mortality and severe postoperative complications, it leads to stable suppression of acid production by the stomach, has a minimal effect on its motor-evacuation activity, shortens the time needed for healing of the ulcer by 16.3 +/- 1.7 days, and leads to rare (2.2%) recurrences of the disease.     

Surgical treatment of patients with duodenal ulcer]

Ulcer incidence in the Crimeahas increased during the last 9 years from 118.4 to 185.7 cases per 10,000 of adult population, being higher in South Coast and in mountains. From 125 patients with duodenal ulcer after conservative treatment only 12.8% have recovered (follow up for 8-10 years). 29.6% of patients underwent surgery; 1.6%--died without operations of ulcer, 35.2%--needed elective treatment. From 97 patients who died during 4 years of ulcer in Simferopol, 25 (25.8%) were not operated. They were aged and very old patients with long history of the disease. Among 9412 operations for ulcer there were 4.17% of lethal outcomes in perforated ulcer and 11.5%--in bleeding (22.18% being at the peak of hemorrhage); 1.45%--after elective resection of the stomach, 0.79%--after organ-saving operations with vagotomy, in SPV--0.56%. According to general hospital surgery data, there were no lethal outcomes after SPV and SPV with pyloroplasty (295 patients). As a conclusion it is stated, that surgery in ulcer should be made earlier, before complications.     

Choice of the method of stomach resection

The authors studied the causes of the recurrence of peptic ulcer in 142 patients after various types of operations on the stomach for peptic ulcer. They came to the conclusion that operations which are characterized by alkalization of the gastrointestinal anastomosis, on condition that free hydrochloric acid is maintained in the gastric juice after the operation, may be a factor predisposing the development of peptic ulcer of the anastomosis and jejunum. Hofmeister-Finsterer gastroenterostomy must be performed in resection of the stomach for duodenal ulcers which are characterized by high acidity. Balfour's anastomosis is preferable in achlorhydria or marked hypoacidity of the gastric juice before the operation.     

Morphofunctional features of the gastric stump after different kinds of resection for ulcer disease

Morphofunctional alterations in the stomach and its stump after resection of 2/3 of the stomach in modifications of Billroth-1, Hofmeister-Finsterer and Roux operations were analyzed in 127 patients with ulcer disease. Chronic experiments were carried out in 5 mongrel dogs. A comparative analysis has revealed functional and organic advantages of gastroenteroanastomoses after Roux and Billroth-I. The Roux resection is an effective operative intervention in patients with ulcer disease of the stomach, for chronic duodenal obstruction, and in patients with post- gastroresectional pathology. It has an anti-dumping effect, provides portional emptying of the gastric stump, improves the life quality of the patients.     

Status of the emptying function of the stomach in patients with duodenal ulcer after vagotomy with draining operations

Choice of draining operations for treatment of duodenal ulcer by vagotomy is greatly responsible for the evacuatory function of the stomach in the early and remote periods after operation. In patients with stenosis of the duodenum, low localization of ulcer and considerable scarring process in the ulcer area pyloroplasty after Finney and gastroduodenoanastomosis after Jaboulay are considered to be most advantageous draining operations of the stomach. If the operations are not possible technically, shortloop gastrojejunostomy is expedient. Pyloroplasty after Heinicke-Mikulicz is admissible in patients with ulcer of the duodenal bulb in patients with not disturbed evacuation from the stomach.     

Acute surgical treatment of bleeding peptic ulcer. A retrospective analysis of 193 patients.

A retrospective analysis of 193 consecutive patients over an 11 year period operated on for continued bleeding from gastric or duodenal ulcer is presented. All patients were operated on within the first 48 hours after hospitalization. Preoperative endoscopic examination was performed in 108 patients and it was diagnostic in 79% of the cases. A sole duodenal ulcer was responsible for bleeding in 59 patients (31%) and in 50 patients (26%) the bleeding ulcer was located in the lesser curvature of the stomach. Other gastric ulcerations were scattered irregularly in different parts of the stomach. Gastric resection and Billroth II reconstruction were the most common procedures performed. Vagotomy, either truncal or gastric, was added to the resection in 31 (16%) cases. Primary mortality rate within 45 days from the operation was 15%. The survivors were on the average ten years younger (mean 58 years) than those who died. Forty one (21%) of the patients were operated on as emergency cases. These patients survived significantly better than those operated on after an observation period. It is concluded, that aggressive surgical treatment immediately after fluid resuscitation was associated with a reduction in mortality and morbidity rates in patients with bleeding peptic ulcer.     

Surgical treatment of duodenal ulcers

Selective proximal vagotomy (SPV) was fulfilled in 440 patients with ulcer of the duodenum, 30.0% of them being operated upon for relative indications, and 70.0% for different complications of the ulcer. Different draining operations were made in 219 patients with stenosis. Draining operations were made in 10.6% of 254 patients without stenosis of the pylorus who had big and deep penetrating ulcers which could disturb duodenal passage on their healing. Resections of the stomach after Billroth-I were fulfilled in 20 of 43 patients with combined gastric and duodenal ulcers, and after Hofmeister-Finsterer in 23 patients in view of a danger of malignization. The best results were obtained after proper SPV and after operations eliminating stenosis and saving the evacuating mechanism of the pylorus (transversal duodeno-duodenostomy in 10 patients and duodenoplasty--in 22). Resection of the stomach should be performed by the Billroth-I method.     

Pylorus-reconstructing operations in complicated gastric and duodenal ulcer]

The results of treatment of 185 patients with complicated gastric and duodenal ulcer disease have been analysed. The results of operative treatment in 132 patients followed up for the period of from 1 to 7 years were studied. In gastric ulcer, resection of the stomach with preservation of the pyloric sphincter, or its reconstruction by means of the flaps taken from the antrum, is indicated; in duodenal ulcer--vagotomy, ulcer excision added by pylorus-preserving and pylorus-reconstructing methods of drainage operations.     

Sphincter-valve gastroduodenal anastomosis in surgery of stomach ulcer

A method of gastroduodenoanastomosis has been developed which allows exclusion or considerable reduction of the pathological effect of the duodenogastric reflux upon the gastric stump mucosa after distal resection of the stomach in patients with gastric ulcer. Complex examinations of the patients after operations have shown that the developed by the authors sphincter-valvular gastroduodenoanastomosis facilitates the rhythmic-portion evacuation of the gastric contents and prevents the reflux of the duodenal contents into the gastric stump.     

Possibilities of gastroscopy after the surgical treatment of peptic ulcer

A considerable diagnostic value of endoscopy for the detection of recurrent ulcers and other postoperative syndromes was shown on the basis of the experience with endoscopies in 21 patients after gastroenterostomies , 281 patients after gastric resection and 96 patients after vagotomies performed for the ulcer disease of the stomach and duodenum. The methods of examining and the endoscopic picture after different operations are found to be of particular character. To study the state of the afferent loop after Bilroth -II resection of the stomach it is expedient to associate endoscopy with rentgenological examination. Endoscopy can be also used for some postoperative complications.     

Corrective and reconstructive operations in post-vagotomy syndromes

Among 322 patients with postvagotomy syndromes who were examined by the authors, 133 were subjected to reconstructive and corrective operations. Most of the patients (73.7%) who underwent surgery for the second time suffered from peptic, recurrent, and persisting ulcers due to vagotomy. The authors give preference to resection methods in recurrent ulcer after vagotomy and do not resort to revagotomy in an isolated form. The authors propose a new method for resection of the stomach in peptic ulcers after vagotomy with gastroduodenoanastomosis by the Jaboulay procedure. In the authors' opinion, the choice of method for reconstructive operations should be made with due regard for the pattern of a complication, the type of a primary surgery, and causes of their development.     

Results of gastrectomy in uncomplicated duodenal ulcer 10 years after the operation]

An analysis of long-term results of surgical treatment (resection of the stomach) of 92 patients with noncomplicated ulcer of the duodenum has been made 10 years after the operative procedure. Peptic ulcer of the gastroenteroanastomosis was found to develop in 1 of 92 patients. The first group (after Vizik) included 23 patients (25%); the second group--22 patients (23.9%), the third one--44 (47.8%) and the fourth--3 patients (3.3%). As a whole, excellent and good results of gastric resection for noncomplicated duodenal ulcer were noted but in half of the patients.     

Distal antrectomy with vagectomy for duodenal ulcer: results in 611 cases.

Distal antrectomy (25% or less) resection of the distal stomach with bilateral vagectomy, Billroth II, antecolic, Polya or Hofmeister gastrojejunostomy, continues to be our operation of choice for chronic duodenal ulcer. This is based upon our experience in 611 operations and as a result of careful complete repeat in-patient followup studies conducted since our original operation which was devised and performed in July 1953. This procedure controls or eliminates the two major gastric acid stimulatory phases responsible in the pathogenesis and chronicity of a duodenal ulcer: neurogenic (cephalic phase) via the vagel gastric pathways, and the humoral (gastrin) phase via antral stimulation. Even though part of the antrum may remain in the gastric remnant in some patients, antral control is maintained because the antrum remains in the gastric acid stream, there is no stasis, and it is vagectomized. The ulcer diathesis is controlled with a minimal disturbance in gastric physiology, in function, and in gastric reservoir capacity; the procedure will almost eliminate all of the undesirable postoperative gastrointestinal sequelase associated with other operations for duodenal ulcer. It insures the least chance for marginal, gastric, or recurrent ulcer formation, and a low morbidity rate.     

Gastroduodenoscopy: a routine examination of 2,800 patients before laparoscopic cholecystectomy

Background Unrecognized gastric and duodenal peptic ulcer is a common cause of epigastric pains for patients with cholelithiasis qualified for laparoscopic cholecystectomy. Undiagnosed gastric or duodenal ulcer may be the cause of persistent pains after cholecystectomy. The purpose of the study was to assess the value of a routine preoperative panendoscopy for qualifying patients to undergo laparoscopic cholecystectomy. Methods The study enrolled 2,800 patients treated for cholelithiasis from May 1993 to December 2002. Endoscopic examination was performed for all treated patients 1 to 4 days before their operations. Results Preoperative endoscopy showed pathologic changes in the stomach or duodenum in 1,187 (42%) of 2,800 patients qualified for laparoscopic cholecystectomy. Gastric ulcer was found in 179 patients (6.4%) duodenal ulcer in 127 patients (4.5%), gastritis in 735 patients (26.3%), polyps in 143 patients (5.1%), and cancer in 3 patients (0.1%). The surgery was postponed for patients with ulcer, and antiulcer treatment was started. In 16 patients, the symptoms associated with cholelithiasis subsided after healing of the ulcer. Cholelithiasis in these patients was asymptomatic, and a cholecystectomy was not performed. Conclusions Panendoscopy should be a routine examination performed for each patient qualified to undergo laparoscopic cholecystectomy. For some patients with asymptomatic cholelithiasis, pain in fact is caused by peptic ulcer.     

Means of improving the surgical treatment of gastric and duodenal peptic ulcer

Based upon the experience with the treatment of 2312 patients with ulcer disease of the stomach and duodenum the authors analysed the major tasks which must be solved for obtaining better immediate and long-term results of the surgical treatment. In 1880 (81,3%) of the patients with a gastric ulcer and a complicated ulcer of the duodenum the stomach resection gave favorable outcomes in 98,6%. In 432 patients (18,7%) organ-preserving operations were made, in 185 of them it was vagotomy. The vagotomy was followed by recovery of 99,5% of the patients. Longterm results were studied in 1486 patients. Bad outcomes were noted in 34 patients (2,4%) after stomach resections and in 16 patients (11%) after vagotomy.