Optimization of Surgical Treatment of Perforative Gastroduodenal Ulcer
The study is based on results of the treatment of 725 patients (aged from 16 to 85 years old) with perforated gastric and duodenal ulcers. Method of the surgery has been chosen with consideration of the time elapsed from the moment of perforation to admission, the patient’s age, the presence of comorbidity of vital systems, ulcer site, results of pH-metry of the stomach, and the presence of complications of peptic ulcer disease like stenosis of output department of the stomach, penetration into nearby organs, prevalence, nature and phase of peritonitis. Localized peritonitis was detected in 379 patients, diffuse one — in 281 patients, total one — in 65 patients. The ulcer was localized in the stomach in 123 (16.7 %) patients, in the duodenum — in 602 (80.3 %) cases.
Suturing of perforated holes was performed in 121 patients. Indications for its implementation were cases with evident symptoms of peritonitis and severity caused by comorbidities. In 24 patients it was performed in cases of so-called «silent ulcers» — without signs of perifocal inflammation around the ulcer in young people with normal acid-producing function of the stomach. In all operated patients during postoperative period much attention was paid to prevention of the gastric acidity aggression using H2-blockers and proton pump inhibitors and to eliminate Helicobacter pylori antibiotic therapy.
Primary gastric resection was performed in 40 patients with ulcer localization in the lesser curvature or cardia of the stomach, in cases of malignancy, stenosis of the gastric outlet and cases of combination a chronic gastric ulcer with duodenal one. Main contraindications of performing the primary resection were evidence of general peritonitis and severe comorbidity of the patient’s vital systems.
Analyzed the late postoperative period after the primary resection in cases of perforated ulcers allows us to consider this surgery the method of choice for gastric ulcers, especially located in places susceptible to malignancy or combined gastric and duodenal ulcers, in cases with combined perforation, penetration and pyloric stenosis of the stomach.
Organ-preserving surgery was performed in 564 patients. Truncal vagotomy was done in 53 patients. Indications for its implementation were cases of a late admission to the hospital with signs of peritonitis in patients with combination of perforation and bleeding. In all cases, truncal vagotomy followed by excision of the ulcer with applying one of the stomach drainage surgery techniques.
Selective vagotomy was performed in 171 patients. Its implementation is almost cases supplemented by excision of the ulcer with appliance one type of drainage operations. Pyloroplasty by Heineke — Mikulicz was made in 126 patients; in 8 patients the «pure» selective vagotomy was performed with suture plication of perforated ulcer. These were patients with local peritonitis and ulcer size less than 0.2 cm in diameter with smooth edges. In 37 patients with stenosis of the stomach outlet the selective vagotomy was supplemented by pyloroplasty after Finney or Jaboulay’s gastroduodenostomy.
Selective proximal vagotomy was performed in 340 patients. It was indicated in cases of early period after the ulcer perforation with maintaining a normal anatomy and topography of nerve of Latarjet. In cases of a small size ulcer was excised after Judd — Horsley. Excision was supplemented by pyloroplasty in a chronic ulcers with callosum edges or deformity of the stomach outlet.
Based on the study of stomach acid-producing function it was shown in all cases after applying one type of vagotomy the suppression of hydrochloric acid and pepsin secretions down to pH 5,4 ± 0,6 units.
Analysis of the gastrointestinal motility restoration in patients’ undergone one type of vagotomy showed that in the early postoperative period it has a phase character. Earliest recovery of the gastric motility was in patients after the proximal selective vagotomy with excision of a duodenal ulcer located on its frontal wall. These patients had the fewest cases of the postvagotomic gastrostasis.
Authors make the conclusion that contemporary choice of the type of surgery of perforated gastroduodenal ulcer should be based taking into account the patient’s general condition, age, severity and prevalence of peritonitis, ulcer site, duration of the ulcer anamnesis, nature of changes in periulcergenic area, presence of the related complications (penetration, stenosis, malignancy, etc.), according to the phases of a gastric secretion. Organ-preserving surgery with vagotomy corresponds to all the requirements of the ulcer formation pathophysiology and can be individually method of choice for the treatment of perforated gastroduodenal ulcers.
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