Combined Gastric Vagotomy in the Treatment of Patients with Complicated Course of Peptic Ulcer Disease of the Duodenum

The dissertation is devoted to improving the surgical treatment of patients with complicated duodenal ulcer disease. It investigates the application of combined gastric vagotomy (CGV)—a method combining anterior selective proximal vagotomy with posterior truncal vagotomy—to enhance the effectiveness of organ-preserving operations. The work includes intraoperative assessment of local blood flow and gastrointestinal motility, as well as the development of methods for predicting vagotomy efficacy.

Based on clinical and morphofunctional data, indications and contraindications for performing CGV, corrective antireflux operations on the cardia, and pyloroplasty have been established. The author's proposed intraoperative monitoring methods have been patented and have made it possible to reduce the frequency of early postoperative complications, decrease ulcer recurrence rates, and shorten patient periods of temporary disability.

Peptic ulcer disease of the stomach and duodenum remains one of the most common gastroenterological diseases. Statistical data cited in the specialized literature indicate millions of patients in economically developed countries, underscoring a trend toward an increase in the incidence of this disease [56; 145; 31; 103; 104; 37; 228; 249]. Peptic ulcer disease affects 10–15% of the Russian population [11; 4; 167]. Duodenal ulcer disease occurs 4–13 times more frequently than gastric ulcer disease [4; 163], and despite the successes of conservative therapy, it often serves as a cause of prolonged loss of working capacity, disability of patients, and sometimes even death [89; 79; 31; 69; 97; 243; 249]. Although a trend toward a decrease in the number of patients hospitalized for peptic ulcer disease has been observed, there has been a sharp increase in the proportion of complicated forms of this disease that pose a threat to the patient's life [138; 136; 89; 116; 159; 130; 92; 123; 234; 259; 252]. In recent years, a decrease of more than twofold has been noted in the number of elective operations for gastroduodenal ulcers. Accordingly, there has been a 2–3-fold increase in the number of surgical interventions performed on emergency indications due to ulcer perforation and ulcer bleeding [157; 146; 79; 162; 24; 72; 103; 92; 175; 221; 251]. There has been a sharp increase in the number of patients admitted at late stages from the onset of the disease (more than 24 hours). This affects the choice of surgical tactics. In the setting of diffuse peritonitis, when more than 24 hours have elapsed since perforation, or in the setting of hypovolemic shock due to ulcer bleeding, the volume of the operation is reduced to a minimum [87; 97; 182; 225; 252; 228; 249]. There is an increase in both overall and, in particular, postoperative mortality among patients with complicated duodenal ulcers [3; 169; 134; 230; 185; 210; 247; 246].

According to data from the Republican Medical Information and Analytical Center of the Ministry of Health of the Udmurt Republic, the overall morbidity rate for peptic ulcer disease of the stomach and duodenum in the Udmurt Republic (UR) remains at 20.5 per 1,000 population and has shown no tendency toward decline over the past ten years. This rate significantly exceeds the indicators for the Russian Federation (RF) and the Volga Federal District (VFD), where the overall morbidity rate in 2003 was 15.6 and 17.6 per 1,000 population, respectively. The number of elective operations for peptic ulcer disease of the stomach and duodenum decreases each year. If in 1999, 271 elective operations for peptic ulcer disease were performed in the UR, then in 2003 only 82 operations were performed. However, no decline in the number of complicated forms of peptic ulcer disease of the stomach and duodenum has been observed; on the contrary, there is a clear trend toward an increase in complications. It should be noted that the postoperative mortality rate for elective operations in the UR has been 3–4% since 1999, but in 2005 it was only 1.5%. Meanwhile, the postoperative mortality rate during the same period for perforated ulcer was 3.5–5%, and for gastrointestinal bleeding was 9–18% and 21.7% in 2005. Thus, the overall and primary morbidity rate for peptic ulcer disease of the stomach and duodenum in the UR shows no tendency toward decline over the past several years and significantly exceeds comparable indicators for the RF and VFD.

The performance of organ-preserving operations with vagotomy for complicated forms of duodenal ulcer disease is pathogenetically justified and clinically advisable [136]. Truncal vagotomy is the simplest and most rapidly performed variant of organ-preserving operations, but it is less functionally advantageous [136; 187; 191; 211]. Among organ-preserving operations, selective proximal vagotomy (SPV) has gained the widest application. However, in the opinion of some authors, it is a technically complex intervention requiring highly professional surgical technique and significant time expenditure, which is not always possible in urgent surgery [59; 142]. For technical simplification and reduction of the duration of the operation, a number of surgeons propose performing anterior selective proximal vagotomy in combination with posterior truncal vagotomy, which is described in a number of literary sources as combined gastric vagotomy (CGV) [136; 79; 242]. However, studies devoted to the comparative assessment of the morphofunctional state of the operated stomach and duodenum after CGV are few and contradictory. Therefore, clearly defined indications and contraindications for performing this surgical intervention are lacking. In the available literature, we have not found justified indications for performing antireflux operations on the cardia or drainage operations on the stomach during CGV.

Goal of the Study

To improve the results of surgical treatment of patients with complicated course of duodenal ulcer disease through the use of combined gastric vagotomy with methods of predicting vagotomy efficacy.

Research Objectives

1. To conduct intraoperative assessment of local blood flow and motility in the esophagus, stomach, and duodenum in complicated peptic ulcer disease. To refine indications for performing CGV in urgent surgery.

2. To refine indications for performing fundoplication during CGV in patients with complicated duodenal ulcer.

3. To refine indications for performing pyloroplasty during SPV and CGV in patients with complicated duodenal ulcer.

4. To assess the nature of local blood flow, motility, and acid production; to determine the protective properties of gastric mucus; and to characterize Helicobacter infection in the early and late postoperative period after CGV and SPV.

5. To evaluate the immediate and late results of surgical treatment of patients with complicated course of duodenal ulcer disease through the performance of CGV and SPV.

Scientific Novelty

A morphofunctional study of changes in various parts of the stomach and duodenum in the early and late postoperative period in patients who underwent vagotomy for complicated peptic ulcer disease has been conducted. A method for intraoperative prediction of vagotomy efficacy based on the assessment of local motility in the pyloroantral region of the stomach after electrical stimulation of the vagus nerve during organ-preserving operations has been proposed and patented (Russian Patent No. 2261043). A method for diagnosing physiological cardia insufficiency in duodenal ulcer disease has been proposed, which made it possible to intraoperatively justify indications for corrective antireflux operations on the cardia in patients with complicated duodenal ulcer — a positive decision on the issuance of Russian Patent No. 2005114123/14(016213). A correlative dependence between local blood flow in the gastric wall and the production of sialic acids — one of the components of the gastric mucosal barrier — after organ-preserving operations in patients with complicated peptic ulcer disease has been determined. The influence of sialic acid production on the degree of Helicobacter colonization has been studied. Based on the obtained clinical and morphofunctional data, indications and contraindications for performing combined gastric vagotomy in patients with complicated peptic ulcer disease have been established.

Practical Significance

The performance of combined gastric vagotomy for complicated forms of duodenal ulcer disease has made it possible to minimize the frequency of early ischemic intra- and postoperative complications and improve the course of the early postoperative period. The proposed and patented method for determining vagotomy efficacy has made it possible to intraoperatively and atraumatically determine indications and contraindications for performing organ-preserving operations in patients with complicated peptic ulcer disease, as well as to prevent the development of severe manifestations of postsurgical vagotomy syndrome and the occurrence of peptic ulcer recurrence. The proposed and patented method for diagnosing physiological cardia insufficiency in duodenal ulcer disease has made it possible to justify indications for corrective antireflux operations on the cardia in patients with complicated duodenal ulcer. The performance of justified radical organ-preserving operations on emergency indications for complicated duodenal ulcer has ensured a reduction in the recurrence rate of duodenal ulcer. The number of days of temporary disability caused by exacerbation of duodenal ulcer disease has decreased. The number of repeat operations on the stomach and duodenum due to severe complications of peptic ulcer disease in the late period has decreased.

Statements for Defense

1. The use of intraoperative transillumination hemomotorodynamic monitoring with simultaneous electrical stimulation of the vagus nerve makes it possible to determine indications for fundoplication and pyloroplasty, thereby enabling prediction of vagotomy efficacy for the prevention of postoperative complications.

2. The frequency and character of early postsurgical vagotomy disturbances depend on the nature of local gastric blood flow. The frequency of early functional disorders after CGV is lower than after SPV.

3. The late results of surgical treatment of patients with complicated peptic ulcer disease after CGV are comparable to the results of surgical treatment by the SPV method.

Work Dissemination

The main provisions of the work were reported and discussed at a scientific and practical conference dedicated to the 65th anniversary of the Department of Hospital Surgery of IGMA — Izhevsk, 2002; the XIX All-Russian Scientific Conference with International Participation «Physiology and Pathology of Digestion» — Sochi, 2004; the Founding Congress of the Russian Society of Surgeons-Gastroenterologists — Sochi, 2004; the V Congress of the Scientific Society of Gastroenterologists of Russia — Moscow, 2005; at sessions of the republican surgeons' society 2004–2006 at the problem commission on surgery (IGMA, 2004); at a joint interdepartmental meeting of IGMA (29.12.2006); and at a joint interdepartmental meeting of PGMA (10.02.2007).

Implementation of Research Results

The proposed variant of combined gastric vagotomy is applied in the clinic of general surgery at the Medical and Surgical Center «Izhmash», Izhevsk, and in the clinic of hospital surgery at the 2nd City Clinical Hospital, Izhevsk. Based on the research results, an information letter for surgeons has been published. The dissertation materials are used in the lecture course and practical exercises at the Department of General and Hospital Surgery of IGMA and at the Department of Operative Surgery and Topographic Anatomy.

Publications on the Dissertation Topic

Fourteen scientific works have been published, seven of which in Russian print media, including one in a journal peer-reviewed by the Higher Attestation Commission of the Russian Federation. Based on the research results, a Russian invention patent has been obtained: No. 2261043 «Method for Intraoperative Prediction of Vagotomy Efficacy», and a positive decision on the issuance of Russian Patent No. 2005114123/14(016213) «Method for Diagnosing Physiological Cardia Insufficiency». An information letter for surgeons entitled «Combined Gastric Vagotomy for Complicated Duodenal Ulcer» has been published.

Author's Personal Contribution to Obtaining Scientific Results

All clinical studies on the dissertation topic, as well as the analysis, calculation, and statistical processing of the material, were performed by the author personally. More than half of the surgical procedures were performed by the applicant personally; for the remainder, the author served as an assistant. The author personally supervised all patients in the postoperative period.

Structure and Volume of the Work

The dissertation consists of an introduction, a literature review, a chapter on materials and research methods, a chapter on the technique of combined gastric vagotomy based on the author's own research, a chapter on the results of surgical treatment of patients with complicated peptic ulcer disease, a conclusion, findings, practical recommendations, and a reference list. The total volume of the work was 124 pages of typescript. The work includes 22 figures and 33 tables. The reference list contains 270 sources, of which 101 are by foreign authors.