Surgical treatment of complicated gastroduodenal ulcers

Results of surgical treatment of complicated forms of gastroduodenal ulcers in 225 patients were summed up. The patients were operated upon using different variants of gastric resection. Results of the surgical treatment were followed-up during the period from 2-3 months up to 3-5 years. Promising results of the operative treatment of patients with complicated forms of gastroduodenal ulcers using tubular resections of the stomach allow to widely recommend them for surgical practice.     

Surgical treatment of postbulbar ulcers, complicated by penetration into pancreatic head

The results of surgical treatment of 293 patients with postbulbar duodenal ulcers (PBU) have been analysed. It was established that PBU in the majority of cases are associated with several complications of the ulcer, the main of which being penetration of the ulcer into the pancreatic head. Comparing the results of resections of the stomach and organ-saving procedures in PBU, the author suggests that organ-saving methods in combination with vagotomy have some advantages over resectional methods.     

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 cancer of the cardia

The authors report about their experience over 7 years with 258 cancers of the cardia, including 218 operated and 208 resected lesions, the 50 inoperable cases having been treated by laser and curietherapy or with an endoprosthesis. The hospital mortality rate is unrelated to the stage of the tumor, but differs according to the extent of exeresis: 8.6% after total gastrectomy and partial esophagectomy, 10.5% after upper polar esogastrectomy without thoracotomy, 14.8% after total esogastrectomy. There is no difference in the survival rates between the various types, which are defined according to the location of the lesion relative to the cardia. There is an obvious correlation between the survival rate and the stage of the tumor, as well as the involvement of the lymph nodes, both assessed individually and gathered into TNM stages.     

Surgical treatment of cancer of the cardia

Adeno-carcinoma of the cardia corresponds to an accurate definition. During a period of 20 years we have operated on 114 such tumours, and resected 88 of them, 44 by esophageal and proximal gastric resection (group I), and 44 by esophageal and total gastric resection (group II). The resection rate was 77%. Hospital mortality was 20 p. cent in group I and 27 p. cent in group II. There were 1 T1, 8 T2 and 77 T3 (on 86 specimens); 14 p. cent of tumour invasions were observed on the esophageal section (18 p. cent in group I, 9 p. cent in group II); 90 p. cent had lymphatic nodes invasion. Five year's survival was nil in group I, 5 patients survived in group II. Five year's cure can be obtained only in stages I et II (NO MO or NI MO) with total gastrectomy associated with omentectomy, lymphatic curettage of the three coeliac chains, resection of 8 cm of esophagus, and mediastinal lymphatic curettage. When the condition of the patient is poor, or for more evolved stages, proximal gastric resection associated with terminal esophagectomy is the best palliative treatment.     

Surgical treatment of "silent" ulcers of the stomach and duodenum complicated by perforation

Patients with perforating "silent" ulcers and patients with continuous ulcer histories must be subjected to similar surgical treatment. In most cases it may be truncal vagotomy with draining operation on the stomach. Operation of suturing the perforating ulcer is thought to be expedient in patients with acute ulcers (they make up not more than 25%), with severe concomitant diseases, in the terminal phase of diffuse peritonitis and when performed by surgeons with insufficient experience.     

Surgical treatment of stress ulcers

Fifty-six patients underwent surgery because of massive gastrointestinal hemorrhage apparently caused by stress ulcers. Twenty-five of these patients had subtotal gastrectomy as the initial procedure. The over-all mortality was 36 per cent. Twenty-eight patients had pyloroplasty and vagectomy as the initial surgical procedure. The associated over-all mortality was 35 per cent. Three patients had hemigastrectomy and vagectomy with a mortality of 33 per cent.A closer review of these figures indicates that if pyloroplasty and vagectomy were the first operation and the patient continued to bleed, operation should be performed immediately. This gave us our lowest mortality in the series (23 per cent). Second best results were obtained when subtotal gastrectomy was the initial operation but no operation was performed in patients who continued to bleed (31 per cent mortality). These data, however, have no statistical significance and only indicate a trend in a certain direction. There is no clear-cut evidence that one type of operation is preferred to the other.     

Surgical treatment of acute erosions and ulcers of the digestive organs complicated by profuse hemorrhage

Under analysis were results of the surgical treatment of 32 patients with bleeding acute ulcers and erosions of organs of digestion. The analysis has shown that the most effective procedures for this pathology are devascularization of the stomach and vagotomy in combination with suturing and ligation of sources of the bleeding.     

Surgical treatment of carcinoma of the oesophagus and cardia

A clinical series of 216 patients with carcinoma of the oesophagus or cardia, who underwent surgical resection of the oesophagus, is presented. There were 104 patients with oesophageal carcinoma and 112 patients with carcinoma of the cardia. Histologically, there were 102 squamous cell carcinomas, 98 adenocarcinomas, 11 anaplastic carcinomas and 7 non-differentiated carcinomas. Oesophago-gastrotomy was the procedure mostly used; colon interposition was done in only 13 cases. The hospital mortality was 21%. The 5-year survival rate for the whole series after oesophageal resection was 23%. The duration of symptoms, location of the tumour, age and sex of the patients, pre- or postoperative radiotherapy and the histological type of the tumour had only a minor bearing on survival. The two most important prognostic factors were the spread of the tumour at time of operation and a preceding lye stricture. The 5-year survival rate was 34% for the patients with a local tumour at operation and 44% for those in whom the carcinoma developed at the site of a previous lye stricture. The variance of the results in the literature is discussed. Surgical approach to the carcinoma of the oesophagus and cardia is recommended in all the cases in which the patient and tumour seem to be eligible for resection.     

Surgical treatment of the adenocarcinoma of the cardia

Adenocarcinomas of the esophagogastric junction?should be classified into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II), and subcardial carcinoma (Type III) in a pathogenic and therapeutic point of view. During a 15-year period (1995 - 2009), 117 surgical laparotomies for adenocarcinoma of the cardia were performed in elective surgery in the First Clinic of General Surgery UHC "Mother Theresa" in Tirana. The classification was performed by summarizing the information obtained from oral contrast radiography, endoscopy, and intra-operative findings. There were 54 (46%) patients of Type I, 40 (34%) of Type II and 23 (20%) of Type III . Surgical procedures included "subtotal esophagectomy and proximal gastrectomy", "distal esophagectomy and proximal gastrectomy", "total gastrectomy and distal esophagectomy".?All anastomoses performed in the above mentioned procedures were hand sewn. Thirty-seven patients (32%) resulted inoperable at the time of laparotomy and 80 (68%) patients were treated with curative intent, those resulting in an operability index of 68%. The overall morbidity and mortality rates of 29% and 4,3% respectively.