Reoperations in ulcer recurrence after surgical treatment of peptic ulcer

Operations were carried out on 60 patients with recurrent ulcers after closure of perforated gastroduodenal ulcers (49), resection of the stomach (9), and gastroenterostomy (2). Various complications of the ulcer were encountered in 46 of them. A relationship was found between the recurrence and the inadequacy of antiulcerative therapy after closure of the perforated ulcers. The reoperations consisted in resection (48) and reresection (6) of the stomach and other operations (6). Two (3.3%) patients died after the operation. Resection and reresection of the stomach are the operations of choice in recurrent ulcers.     

Improvement in the immediate and late results of gastric resection in patients with gastroduodenal ulcers]

An analysis of treatment of 420 patients following distal (406) and proximal (14) resections of the stomach for gastroduodenal ulcers was made. No incompetence of the stump sutures of the duodenum, stomach and anastomoses was noted. The dumping syndrome was observed in 2.8%, reflux gastritis in 5.1% of the patients. Results of the surgical treatment of ulcer disease were improved by using original methods of distal resection of the stomach with the formation of an artificial constrictor of the gastric stump and a reflux esophagogastric anastomosis.     

Decision on the operative treatment of gastroduodenal ulcers in patients with large perforated openings and with associated ulcerogenic complications

Optimal kinds of surgical treatment were developed for perforated gastroduodeal ulcers and associated complications (stenosis, bleeding), with large perforated openings in patients with high risk of radical operative treatment. The method was used in operations on 30 patients. The second group consisted of 30 patients after suturing perforated gastroduodenal ulcers. Healing of ulcer defects after plasty of the perforated gastroduodenal ulcers by tunneling was noted 9 days earlier on average as compared with suturing.     

Operations on the stomach with a Roux anastomosis]

In order to prevent complications such as reflux gastritis, reflux esophagitis, erosions, ulcers and tumors of the gastric stump the Roux anastomosis was used in 497 patients. Among them there were 194 patients after distal resection of the stomach, 239--after extirpation of the stomach, 45 after vagotomy, antrumectomy, 19 after reconstructive operations on the stomach. These patients had organic complications much more rarely: 3.7% had reflux esophagitis (after resection of the stomach on the short loop and with Brown anastomosis--in 50.5%), 12.5% (85.4%) had reflux gastritis, 3.66% (23.7%) had erosions and ulcers of the gastric stump, 2.1% (21.5%) had polyps and carcinomas of the gastric stump. Postoperative lethality was 3.09 and 7.12%.     

Characteristics of stomach-draining operations in organ-sparing interventions in duodenal ulcer

The incidence of duodenogastric reflux (DGR) was studied in 241 of 376 patients operated upon for duodenal ulcers. Rentgenological, endoscopic and laboratory examinations were performed prior to and after vagotomy and vagotomy with draining operations. A great number of DGR was established in all variants of operations. With the help of multifactorial analysis it was shown that the Finney pyloroplasty was followed by greater amount of postvagotomy complications than gastroduodenal anastomosis (GDA) after Jaboulay. A new variant of the transverse GDA between the stomach and duodenum is proposed. The operative technique is described giving better results than GDA after the Jaboulay and Finney pyloroplasty. Choice of the method of draining operation is dependent on certain conditions. Recommendations are given.     

Assessment of effectiveness of gastroduodenal anastomosis in the surgery of gastric cancer

An analysis of results of surgical treatment was made on the basis of experiences of performing 260 operations with gastroduodenal anastomosis for distal gastric cancer under conditions of the same hospital for 20 years. Postoperative lethality was 2.69%. Different complications after surgery were noted in 34.2% of the patients. Dumping syndrome after Billroth-1 operations developed in 12.3%. The 5 and 10 year survival after operations among 215 followed-up patients was 65.1% and 24.7% respectively. Original methods of operations were developed and introduced into practice for the improvement of immediate and long-term functional results of the surgery on the stomach.     

The late results of surgical treatment in patients with perforated gastroduodenal ulcers]

It was shown that suturing perforative ulcers of the stomach and duodenum gives bad outcomes in more than 52% of the patients. More than half of such patients continue suffering from the ulcer and its complications, every fifth patient needs future radical reoperation. The most frequent indication for reoperation is a recurrent ulcer and stenosis of the pyloric area of the stomach. Somewhat better results of simple suturing the ulcer are observed in patients aged 15-20 years. The maximum amount of unfavourable results (60%) are noted in young patients aged 21-30 years. Perforation of "dumb" gastroduodenal ulcers was followed by a considerable amount (43.5%) of unsatisfactory results of treatment which often required reoperations. Truncal vagotomy with the dissection of the ulcer and pyloroplasty cures the disease and its complications in 85.2% of patients with perforative gastroduodenal ulcers. Somewhat worse results of this operation are noted in patients aged 21-30, considerably better outcomes in patients older than 50. In them the amount of excellent and good results is 67% and 94.2% correspondingly.     

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.     

Surgical treatment in chronic gastroduodenal ulcers

Operative treatment was carried out in 1197 patients with chronic gastroduodenal ulcers. Among the most frequent complications of the ulcers there were penetration of the III-IV degree, compensated, subcompensated and decompensated pyloroduodenal stenosis. The operative interventions included Billroth-II resections of the stomach in modification of Hofmeister-Finsterer, Billroth-I, with saving the pyloric sphincter, after Roux and gastrectomies. Postoperative complications developed in 127 (10.6%) patients, postoperative lethality was 0.7%. Excellent and good long-term results were noted in 846 (94.5%) patients, in 14 (1.6%) patients they were estimated as satisfactory and in 35 (3.9%) as unsatisfactory. The causes of unsatisfactory results were recurrent ulcers (0.7%), peptic ulcer of the gastroenteroanastomosis (0.6%), dumping-syndrome of a severe and medium degree (1.5%), diarrhea of a severe degree (0.3%) and erosive-ulcerous reflux-esophagitis (0.3%).     

Bleedings from ulcers after resection of stomach and vagotomy

Overall 162 patients with recurrent ulcers after previous operations for ulcer disease were treated. Resection of stomach was performed in 69 (42.6%) of them, vagotomy--in 93 (57.4%). Episodes of bleeding were revealed in anamnesis at 56 (81.2%) patients with peptic ulcers after stomach resection, and at 15 (16.1%)--with ulcers after vagotomy. Bleeding was the cause of urgent hospitalization at 39 (28.1%) patients. One hundred and thirty-six from 162 patients have been operated (including 52 patients after primary resection and 81--after primary vagotomy). Vagotomy at the patients with ulcers after primary resections demonstrates good results. Repeated resection of gastric stump with vagotomy is indicated in great penetrating ulcers. Resection of stomach is the operation of choice in majority cases of recurrent ulcers after primary vagotomy. Stem re-vagotomy demonstrates good result an the patients with ulcers of gastro-intestinal anastomosis after primary selective proximal vagotomy.     

Methods for reducing risk of complications after Billroth-1 resection of the stomach

An analysis of surgical treatment of 102 patients with complicated pyloroduodenal ulcers has shown that vast infiltration and scary alterations in the ulcer area, its penetration, stenosis as well as the presence of tension of gastroduodenal anastomosis are risk factors for performing resection of the stomach after Billroth-1. In order to eliminate these factors the author used a technically correct elimination of the deformity of the duodenum. The additional application of extraorganic traction sutures and intraoperative dystopia of the duodenum allowed to complete the operation of resection of the stomach in most patients by putting a direct gastroduodenal anastomosis. In 29.4% of cases it was not possible to eliminate the risk factors in question by the well-known methods. So, the patients underwent resection of the stomach by Billroth-II method.     

The immediate and late results of Billroth-I gastric resection with the application of the single-row suture]

An experience with gastric resections in 942 patients with ulcer disease of the duodenum is presented. Billroth-I resection was used in 760 patients (81%). The posterior wall of the gastroduodenal anastomosis was formed with the help of a one-row blanket catgut suture in 118 of these patients. Complications at the postoperative period were noted in 10 patients (8.5%). No lethal outcomes followed. Good long-term results in patients with Billroth-I resection of the stomach with a one-row suture of the posterior wall of the gastroduodenal anastomosis were noted in 98.6% of the cases.     

Surgical treatment of perforative gastroduodenal ulcers in elderly and senile patients

The work is based on experiences with surgical treatment of 206 elderly and senile patients with perforating gastroduodenal ulcers. In 67.5% of cases the perforations took place in duodenal ulcers, in 16%--in the pyloric canal. The gastric body and antral portion ulcers were perforative more rarely--9.8% and 4.8% respectively. Perforations of the cardial and retrobulbar ulcers were found in 1.9% and 1% respectively. At early terms after operation 67 patients (33.5%) died. After suturing the perforative opening 38 out of 98 patients died (38.8%), after dissection and suturing the ulcers died 7 out of 19 patients, after Oppel-Polikarpov operation died 7 out of 11, after resection of the stomach died 4 out of 6, after truncal vagotomy with pyloroplasty died 11 out of 72 patients (15.3%). The main cause of lethal outcomes is thought to be complications of the coexistent diseases, totally responsible for 46.2% of deaths. Truncal vagotomy with a dissection of the ulcer and pyloroplasty performed in 60-70 year old patients gave the least indices of lethality and early postoperative complications, so the indications to radical organ-saving operations in patients of this age must be wider. This method of treatment for perforative ulcers in patients of 71-80 years of age should be used with restrictions due to not bad long-term results of suturing the ulcers (good and excellent results took place in 53.8% of cases). In patients older than 80 radical operations are not indicated. In such cases the ulcer should be better dissected and sutured, the posterior wall of the organ being examined for a "mirror" 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.     

Gastric resection after the suturing of perforated ulcers]

The article deals with the authors' experience in reoperations for complications of peptic ulcer occurring after suturing of a perforation. The stomach was resected in 237 patients, after Billroth I in 71.3 and after Billroth II in 28.7% of cases. The indications for operation were as follows: recurrent perforation, stenosis, penetration, bleeding from the ulcer, as well as peptic ulcer of the gastroenteroanastomosis. Total mortality rate was 1.26%; it was higher in the Billroth II operation (3%). The authors analyse the specific features of surgical interventions after closed penetrating ulcers, which make performance of the principal moments of gastric resection and prevention of possible complications easier. Preference is given to the first method of gastric resection which was applied in 70% of cases. The peculiarities of formation of the gastroduodenal anastomosis during a adhesive process and the main contraindications for its establishment are described.     

Current principles of the use of laparoscopic surgery in gastroduodenal ulcer

Comparative assessment of treatment results in 618 patients with gastroduodenal ulcer (GDU) was carried out. 3 groups of patients were compared. Different combinations of drugs were used in 384 patients, 234 patients have undergone open resections of the stomach or organsaving operations, 83 patients--analogous laparoscopic operations. Immediate and long-term results of the treatment were studied. After drug therapy, including antihelicobacter drugs, healing of ulcers was achieved in 96.9-97.9% cases. 1 year after drug therapy the recurrence of CDU is revealed in 16.2-20.3% patients, rate of the recurrence increases with years. After surgical treatment of CDU (more often in complicated course of the disease) rate of recurrences is 2-3 times lower (6.5-7.4% cases). Laparoscopic resections of the stomach and organsaving operations are atraumatic, accompanied by physiologic course of postoperative period and reduction of postoperative complication rate.     

Surgical strategy for juxtapapillary ulcers of the duodenum

Results of surgical treatment of 89 patients with ulcer of the duodenum with postbulbar localization were studied. A classification of postbulbar ulcers was proposed taking into consideration the degree of involvement of bile-excreting pathways and major duodenal papilla into the periulcerous process. In extrapapillary ulcers without involvement of bile-excreting pathways in the cicatricial-ulcerous process resection of the stomach after Bilroth I is recommended with performing gastroduodenal anastomosis with a single layer suture. Resection of the stomach supplemented with biliodigestive anastomosis is recommended in cases with suprapapillary ulcers with the involvement of choledochus. Mechanical jaundice complicated by juxtapapillary ulcer can be cut off by endoscopic papillosphincterotomy. Fulfillment of pancreatoduodenal resection is possible in cases of deep injury of the pancreatic head.     

A comparative evaluation of the results of traditional and laser stomach resection]

Comparative evaluation of immediate and long-term results of gastric resection was made in 89 patients operated upon by a traditional method and in 69 patients after laser operations. It was found that laser scalpel used in gastric resection gives reliable hemostasis, reduces the intraoperative blood loss and the time of creation of gastroenteric anastomosis. At the same time 2 times greater amount of inflammatory complications of the anastomosis was noted. The cause of the development of anastomosis after laser resection of the stomach is discussed.     

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.     

Split stoma in resectional surgery of high‐risk patients with ileocolonic Crohn’s disease

Aim The aim of this retrospective study of ileocolonic resection in patients with Crohn’s disease was to compare the outcome of primary anastomosis with that of split stoma and delayed anastomosis in a high‐risk setting. Method From 1995 to 2006, 132 patients had 146 operations for ileocolonic Crohn’s disease. Preoperative data, including risk factors for complications, were obtained from a prospectively registered database. Operations on patients who had two or more preoperative risk factors (n = 76) were considered to be high‐risk operations and formed the main study. Primary outcome variables were postoperative anastomotic complications and the alteration in the number of preoperative risk factors achieved by a delayed anastomosis. Secondary outcome was time in hospital and the number of operations performed. Results Early anastomotic complications were diagnosed in 19% (11/57) of patients receiving a primary anastomosis compared with 0% (0/19) of patients after a delayed anastomosis (P = 0.038). The mean number of risk factors in the split stoma group was 3.5 at the time of resection and 0.2 when the split stoma was reversed (P < 0.0001). The total number of operations was 1.9 ± 1.5 (mean ± SD) after a primary anastomosis and 2.0 ± 0.2 after a split stoma (P = 0.70). Total in‐hospital time for all operations was 20.9 ± 35.6 days after a primary anastomosis and 17.8 ± 10.4 days after a delayed anastomosis (P = 0.74). Conclusion Delayed anastomosis after ileocolonic resection in high‐risk Crohn’s disease patients was associated with a reduction in the number of preoperative risk factors and fewer anastomotic complications. Hospital stay and number of operations were similar after delayed and primary anastomosis in high‐risk patients.