Surgical treatment of "difficult" gastric ulcers]

In surgical treatment of "difficult" ulcers of the stomach including ulcers of the proximal part of the stomach, giant ulcers (more than 3 cm in diameter) and multiple ulcers it is expedient to use resection of the stomach with the formation of functionally active anastomosis. The choice of the operative method is determined by specific features of the ulcerous process, morphofunctional state of proximal parts of the gastrointestinal tract which determines the individual character of the operative intervention. The use of such operative interventions has reduced the postoperative lethality to 0.9%. Complex examinations have established excellent and good results (by the Visick scale) at remote terms after operation in 95.2% of the patients.     

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.     

Surgical treatment of stenosed duodenal ulcers.

Based on the clinical pattern (case history, radiological, endoscopic and laboratory examinations) four stages of ulcerous stenoses are distinguished (stage I: subclinical; stage II: compensated; stage III: decompensated; stage IV; complete stenosis). Organ-preserving vagotomy is justified only in stages I and II, in which the motoric function and emptying of the stomach is not yet damaged. In stages III and IV resection is the operation of choice. This view is supported by the results of the authors.     

Surgical treatment of large bleeding duodenal ulcers

Results of the surgical treatment of 220 patients are described, in 43 of them the ulcers were more than 2 cm in diameter. The total postoperative lethality was 5.9%, in patients with large size ulcers--11.6%. Specific features of the clinical course, surgical tactics, causes of unfavorable outcomes and methods of prophylactics in patients with large ulcers are discussed.     

Surgical treatment of patients with giant duodenal ulcers

The results of surgical treatment of giant duodenal ulcers in 104 patients are analysed. The peculiarities of the clinical picture and diagnosis of the disease were revealed. In 53 (51.0%) patients, the organ-perserving operations with vagotomy were performed, in 47 (45.2%)--different modifications of gastric resection, in 4 (3.8%)--gastroenterostomy. In treatment of the critically ill patients, the organ-preserving operations are preferable.     

Surgical treatment at combination of duodenal ulcers with reflux-esophagitis

Selective proximal vagotomy (SPV) was performed at 352 patients with duodenal ulcer (DU), 213 of them had reflux-esophagitis (RE). SPV was performed with correcting cardia function operations at all the patients (including ones without RE). It is demonstrated that SPV at combination of RE with DU is safe but effective surgical method and permits to achieve complete recovery from both diseases. SPV is radical if indications are correct and surgical technical requirements are fulfilled.     

Surgical tactics in bleeding duodenal ulcers

The article gives a review of literature on the determination of surgical tactics in patients with duodenal ulcer complicated by bleeding. The authors are supporters of the actively-temporizing tactics. They claim that the period of the delay in the decision should not exceed 24 hours and depends on the intensity of the bleeding, the degree of blood loss, the location and nature of the ulcer, the patient's age, and the concomitant diseases. They believe resection of the stomach to be the operation of choice in bleeding duodenal ulcer. One of the authors suggested a modified method of gastric resection in "difficult" duodenal ulcers which excludes the occurrence of incompetence of the duodenal stump sutures.     

Surgical treatment of duodenal ulcers. When? How? Why?

This report describes a personal experience of 2472 operations carried out for duodenal ulcers between 1964 and 1982 in Athens, Greece. An attempt is made to assess the short- and long-term results after different surgical approaches including truncal vagotomy and antrectomy, truncal vagotomy plus drainage (pyloroplasty or gastrojejunostomy), polya gastrectomy, and proximal gastric vagotomy. All the above procedures were used in dealing with this series of patients. Through a selection process by use of clinical and operative criteria for each individual case, each procedure was carried out to fit the individual demands of each patient. From the above policy our results were satisfactory. We had an overall mortality rate of 0.58 per cent with a late reoperation rate of 4 per cent which included patients with recurrent peptic ulcers, the dumping syndrome, and alkaline reflux gastritis.     

Treatment of "difficult" duodenal stump]

The Plenk method in the author's modification was successfully applied in resection of the stomach "for exclusion" in 22 patients. When there was a threatening incompetence of the duodenal stump sutures, to prevent generalization of peritonitis the stump in 24 patients was covered with a "hood" of the greater omentum and external drainage of this space was installed; the procedure was an alternative of duodenostomy. Incompetence occurred in 3 cases with subsequent recovery. In resection of the stomach for recurrent ulcer after previous vagotomy combined with gastroduodenostomy after Jaboulay, the defects in the duodenal wall were closed with a demucosed antral-pyloric gastric segment after the author's method. The operation was conducted on 4 patients.