Choice of Treatment Strategy in Patients with Perforative Ulcers of the Gastroduodenal Zone

The dissertation is devoted to the development of an evidence-based approach to choosing a treatment strategy for patients with perforative ulcers of the gastroduodenal zone. The issues of applying minimally invasive methods for suturing perforative ulcers and subsequent patient differentiation based on comprehensive morphofunctional examination are investigated. The work substantiates a two-stage treatment strategy combining palliative and radical surgical methods with consideration of individual indications and recurrence risks.

Relevance of the Problem. As demonstrated by studies (Bulgakov G.A. et al. 2002; Rybachkov V.V., Dryzhenko I.G. 2005), in recent years the number of elective surgical interventions for peptic ulcer disease (PUD) has decreased by 1.5-2 times. At the same time, the number of patients with perforated ulcers has increased by 2.6 times. Perforative ulcer of the stomach and duodenal bulb (DU) is a formidable complication of PUD. It occurs in 15-30% of PUD patients (Manevich B.I. et al. 1990; Novikov K.V. et al. 1991; Jordan Jr., Thornby J., 1995), accounts for 5 to 15% of urgent surgical pathology and ranks fourth in frequency (Zaitsev V.T. et al., 1989; Kurygin A.A. et al. 1996). Approximately 7.5-13 patients per 100,000 adult population are surgically treated annually for perforative gastroduodenal ulcers (Myshkin K.I., Lagun M.A., 1983; Pleshov V.G., 1991; Pacyrev Yu.M. et al. 2003). Despite the appearance of H2-histamine blockers, proton pump inhibitors, anti-Helicobacter agents and their widespread use in the treatment of PUD, in recent years, according to some data, the incidence of PUD has somewhat increased (Petrov V.P., Osipov V.V., 1997), thereby increasing the number of patients with complicated forms of PUD in the form of perforation (Nagibeda A.N. et al. 1994; Kurygin A.A. et al. 1998; Kuzin M.I. 2001; Zimmerman Ya.S. 2002; Shirov Z.T. et al. 2005).

Surgical treatment of perforative ulcer began to be developed in the late 19th century. In 1892, Heussner successfully performed suturing of a perforative ulcer, and for over 100 years now this operation has remained the method of choice in many major domestic and foreign surgical hospitals (Belov I.N., Lutshevich E.V., 1994; Peregudov S.I., 1998; Englund R., Fisher R., 1990; Bonati L., Campenella G., 1995; Coluccio G. et al., 1996; Blomgren L.G., 1997). However, the long-term results after this operation did not satisfy a number of surgeons, as the number of PUD recurrences, according to various data, ranges from 15 to 50% (Semenov V.V. et al. 1989; Novikov K.V. et al., 1990; Pleshov V.G., 1991; Bachev I.I. 1992; Kurygin A.A. et al., 1996; Sanzhin V.P., Federov A.F. 2001), and according to N.A. Maistrenko and K.N. Movchan 2000, recurrence was noted in 60-80% of patients, of whom 35 to 60% require repeat operations within the next three years. This prompted surgeons to apply radical operations immediately upon establishing the diagnosis of perforative ulcer of the stomach and DU. Thus, in the 1930-50s, the so-called primary gastrectomy for perforated ulcers appeared (Yudin S.S., 1955), and to this day gastrectomy is considered a radical operation allowing reliable reduction of pathologically elevated gastric secretion, removal of the ulcer as a source of complications together with the zone of possible recurrence (Rusanova A.A., 1981; Gorbashko A.I., 1987; Fineberg H.V. et al., 1981). However, this intervention is accompanied by high mortality, a significant number of early postoperative complications, and the frequency of development of post-gastrectomy syndromes associated with the removal of a significant portion of the organ and the exclusion of the DU from digestion reaches 20-40% (Geller L.I., 1986; Pomelov B.S. et al., 1987; Rychagov G.P., 1988; Shirov Z.T. 2005).

In the 1960-70s, Yu.M. Pancyrev, A.A. Grinberg and others began to widely apply organ-preserving and organ-saving operations in the treatment of perforative ulcer, which allowed improving the short-term and long-term results of surgical treatment of PUD. Postoperative mortality in specialized hospitals decreased to 0.3-0.4% (Kuzin N.M., 1987), the duration of temporary and sustained disability was reduced, and the frequency of development of postoperative digestive disorders significantly decreased (Pancyrev Yu.M., 1983; Pomelov V.S. et al., 1981, 1987; Johnston D.J., 1987). At the same time, the frequency of PUD recurrence after various types of vagotomy ranges from 3 to 25%, and the frequency of development of post-vagotomy syndromes reaches up to 15% (Nesterenko Yu.A. et al., 1985; Shalimov A.A., Saenko V.F., 1986; Nechai A.I. et al., 1987).

At the same time, operations performed via laparotomy have a number of disadvantages: they are accompanied by significant trauma of the anterior abdominal wall soft tissues. This can lead to local wound complications: suppuration, evisceration in the early postoperative period, anterior abdominal wall hernias, complicated by intestinal obstruction in the future. Intestinal complications (postoperative ileus), lung complications (postoperative pneumonia, bronchitis) are largely due to damage to the anterior abdominal wall. Moreover, even with an uncomplicated postoperative period, the recovery period for normal occupational activity is quite prolonged (Chernov V.N., Malakhov S.N. 1997; Levchik E.Yu. 1999; Timirbulatov V.M. 2005). Taking this into account, at present there are all theoretical prerequisites for performing palliative operations using minimally invasive methods. However, as practice shows, only in half of cases is this operation successfully completed without conversion (Savelyev B.S., Krieger A.G. 1999).

In many works (Mayat B.S., Pancyrev Yu.M., 1978, etc.) it is emphasized that gastrectomy or organ-preserving operations performed without strict indications can lead to the development of a large number of pathological conditions requiring persistent conservative treatment and sometimes repeat surgical interventions.

Palliative and radical operations for perforative ulcer of the gastroduodenal zone should not compete with each other; there should be two different stages of treatment for these categories of patients, with the first stage favoring minimally invasive surgery for perforative ulcers when there are clear indications and no contraindications, and radical operations should be performed after complete additional examination and strictly according to indications. Only such an approach will allow eliminating the adverse consequences of either treatment method and obtaining the most favorable long-term functional results.

The absence of clearly substantiated recommendations for the use of minimally invasive methods in perforative ulcers of the gastroduodenal zone, criteria for choosing treatment strategy, and forecasting the course of the ulcerative process in patients who have undergone suturing of a perforative ulcer of the stomach or DU, determined the main goal and objectives of our work.

Goal of the Research: to improve the treatment results for patients with perforative ulcers of the gastroduodenal zone through individualization of indications for the method and volume of surgical intervention and choice of treatment strategy in the postoperative period.

Objectives of the Research:

1. To develop indications and contraindications for the use of minimally invasive methods in suturing perforative ulcers of the gastroduodenal zone.

2. To study the morphofunctional state of the stomach and DU in patients who have undergone suturing of a perforative ulcer using minimally invasive methods (gastric acid-secreting function using automated computer pH-metry, motor-evacuator function of the stomach and DU using gastromanometry with a pressure sensor probe and radiological examination, tone of the autonomic nervous system (ANS) using computer variometric pulsemetry, presence of Helicobacter pylori in the stomach).

3. To substantiate and develop principles of a differentiated approach to choosing treatment strategy for patients who have undergone suturing of a perforative ulcer of the gastroduodenal zone using minimally invasive technologies, taking into account the variant of the clinical course of the disease and morphofunctional changes in the gastroduodenal zone and ANS tone.

Scientific Novelty. In this work, for the first time, one-stage and two-stage methods of combined treatment for patients with perforative ulcer of the gastroduodenal zone have been developed. Indications and contraindications for suturing a perforative ulcer of the stomach or DU using minimally invasive technologies have been developed, as a one-stage or first stage of a two-stage method, which allowed significantly reducing the percentage of conversions and avoiding postoperative complications associated with laparotomy access, as well as reducing rehabilitation terms in the postoperative period. Subsequently, at the second stage, a differentiated approach to choosing treatment strategy for patients who have undergone suturing of a perforative ulcer of the gastroduodenal zone using minimally invasive technologies has been developed, based on a comprehensive, multifactorial analysis of the features of the clinical course of the disease, the state of secretory and motor-evacuator function of the gastroduodenal system, ANS tone using automated computer hardware-software complexes, and the presence of Helicobacter pylori invasion. This allowed dividing patients into two groups. The first group included patients with a low risk of disease recurrence, as therapeutic methods successfully dealt with the existing morphofunctional disorders of the upper digestive tract. The second group with a high risk of disease recurrence and complications should be operated on individually according to the algorithm developed by us.

The Main Provisions of the Dissertation, Presented for Defense:

1. Treatment of a perforated ulcer of the gastroduodenal zone should be two-stage: at the first stage, when there are indications and no contraindications, the perforative ulcer should be sutured using minimally invasive technologies. At the same time, all patients must undergo eradication therapy, treatment with antisecretory and other drugs in the early postoperative period. Then all patients should be examined according to the scheme we proposed, and depending on the obtained results divided into two groups; the first group — patients with a favorable prognosis, without recurrent course of PUD. These patients should be under observation and treatment by a gastroenterologist. Patients of the second group with an unfavorable prognosis of disease recurrence and complications should be under surgical observation.

2. There is a clear correspondence between the variant of the clinical course, the presence of PUD complications in the anamnesis, the nature of morphofunctional changes in the gastroduodenal zone, gastric acid-secreting function, the presence of Helicobacter pylori in the stomach, and the choice of treatment method for patients who have undergone suturing of a perforative ulcer of the gastroduodenal zone using minimally invasive technologies.

3. A differentiated approach to the treatment of patients who have undergone suturing of a perforative ulcer of the gastroduodenal zone using minimally invasive technologies, taking into account the variant of the clinical course and morphofunctional changes in the gastroduodenal system, allows improving the results of surgical treatment in this category of patients.

Practical Significance. The developed indications and contraindications, as well as the technique for using minimally invasive methods in suturing a perforative ulcer of the gastroduodenal zone, allow significantly reducing the number of conversions, which in turn made it possible to avoid a number of complications associated with laparotomy, and significantly reduce the patient's hospital stay and rehabilitation-recovery period. The developed system for examining patients who have undergone suturing of a perforative ulcer of the gastroduodenal zone using minimally invasive methods allows objectively determining the rational treatment and surgical strategy, which makes it possible to achieve improved results of surgical treatment in this category of patients: reduces the percentage of PUD recurrence after surgical treatment, reduces the frequency of development of postoperative reflux gastritis, increases the number of excellent and good treatment results.

Validation of the Work. The main materials of the dissertation were reported at scientific-practical conferences of young scientists and specialists of RostGMU (1997, 1998, 1999, 2000, 2002, 2003, 2004); at the congress of surgical societies (Rostov-on-Don, 1997); at the XVI (I) Russian scientific conference "Physiology and Pathology of Digestion" (Krasnodar, 1997); at the 2nd Moscow International Congress of Endoscopic Surgeons (Moscow, 1997); at the conference of surgeons "Actual Questions of Abdominal Surgery" (Novosibirsk, 1998); at the North Caucasian conference dedicated to the 40th anniversary of the medical and surgical activity of Honored Doctor of the RSFSR V.I. Beruchko (Rostov-on-Don—Peschanokopskoe, 1999); in the collection of medical scientific works "Science and Practice at the Turn of the Centuries", published for the 75th anniversary of TsGB (Rostov-on-Don, 2000); at the All-Russian scientific-practical conference "Organosaving Principles in Surgery of Emergency Conditions" (Yeysk, 2001); at the II All-Russian conference of general surgeons (Rostov-on-Don, 2003); in the journal "Gastroenterology" of St. Petersburg 2003. No. 2-3. Materials of the 5th Slavo-Baltic Scientific Forum "St. Petersburg-Gastro-2003", pp. 187-188; at the IV scientific session of RostGMU (Rostov-on-Don, 2004); at the Congress of Gastroenterologists of Southern Russia (Kislovodsk, 2005); at the Eleventh Russian Gastroenterological Week (Moscow, 2005); at the scientific-practical conference dedicated to the 90th anniversary of P.M. Shorluyan (Rostov-on-Don, 2005).

Publications. 26 scientific works have been published on the dissertation topic, 10 of them in central and 16 in local press.

Implementation of the Work. The main provisions and conclusions of the work have been introduced into the practice of the surgical department of MLPUZ GB No. 1 named after N.A. Semashko in Rostov-on-Don. The results of the dissertation work are read in an elective lecture course for students of grades 3-6, as well as in the process of training doctors in residency, ordination, and postgraduate studies.