Comparative Evaluation of Methods of Duodenal Stump Closure at Gastrectomy

The dissertation is devoted to a comparative evaluation of methods of duodenal stump closure at gastrectomy. The research is relevant due to the high frequency of postoperative complications, such as insufficiency of the stump sutures, accompanied by disability and mortality. In the work, a modified method of stump closure was developed, and bench and clinical studies were conducted to evaluate the strength of various methods and the effect of duodenal content on suture materials. Data were obtained on the frequency of complications of stump healing after various methods of its closure, and principles were formulated for choosing optimal methods during gastrectomy according to Billroth.

Диссертация посвящена сравнительной оценке способов закрытия культи двенадцатиперстной кишки при резекции желудка. Исследование актуально в связи с высокой частотой послеоперационных осложнений, таких как несостоятельность швов культи, сопровождающихся инвалидизацией и летальностью. В работе разработан модифицированный способ закрытия культи, проведены стендовые и клинические исследования для оценки прочности различных методов и влияния дуоденального содержимого на шовные материалы. Получены данные о частоте осложнений заживления культи после различных способов ее закрытия и сформулированы принципы выбора оптимальных методов при резекции желудка по Бильрот.

Relevance of the research.

The problem of choosing various methods of forming the duodenal stump (DS), choosing methods of intestinal suture and suture materials occupies an important place in the surgery of stomach diseases, as the danger of postoperative complications (insufficiency of DS sutures) accompanied by high disability and mortality is high.

Gastrectomy and antrectomy according to Billroth I in various modifications remains a fairly widely used operation accessible to most surgeons working in clinics, city and district hospitals for gastroduodenal ulcers [Kuzin M.I. et al., 2001; Borisov A.E. et al., 2002] and disease recurrences [Rustamov E.A. et al., 2004].

A large number of methods of DS closure at gastrectomy have been proposed, which indicates surgeons' dissatisfaction with the reliability of numerous variants of methods. Choosing a method of DS closure, especially under difficult conditions - remains an urgent problem for surgeons. Significant difficulties arise in the case of low penetrating duodenal ulcers [Taranov I.I. et al., 1995; 2001; GimezN.A. et al.,2003; TsueiB.J., Schwartz R.W., 2004], especially in urgent surgery of complicated ulcers [Nikitin N.A., 2001; Razicki R. et al., 2005 ]. Mortality after gastrectomy for penetrating duodenal ulcers remains quite high - from 3.1% [Sverdlov V.B.,1975] - 5.2% [Kurbonov K.M. et al., 2001; Sinichenko G.I. et al., 2005] - 6.3%-7.3% [Salikhov I.A. et al.1989; KyzerS. et al., 1997; RadenovskiD. et al., 1998], up to 13.4% [Nikitin N.A.,2001].

According to the consolidated statistics of domestic and foreign authors, insufficiency of DS sutures at gastrectomy according to Billroth II is observed in 2-5% [Godlevsky A.L.,1987; Kyzer S. et al., 1997; Malheiros S.A. et al., 1998; Han Y.M. et al., 2006] and up to 13.5% [Tonus S. et al., 1996]. Insufficiency of duodenal stump sutures is a frequent cause of relaparotomies and determines high mortality [Magomedov A.Z. et al., 1999; Kyzer S. et al., 1997; Radenovski D. et al., 1998].

Despite the improvement of the operation technique, strict determination of indications for performing gastrectomy for peptic ulcer disease of the duodenum, the trend to reduce this complication is not obvious.

Some important aspects of this problem require further research. Various variants of DS closure with a single-row continuous modern suture material and mechanical suture remain insufficiently studied; a search and development of more reliable methods of DS closure at gastrectomy is necessary.

The basis of our hypothesis on increasing the efficiency of stomach operations is the technical aspects of forming the DS, creating the greatest physical hermeticity and optimal conditions for healing. DS closure must ensure sufficient physical hermeticity of the stump, without violating blood circulation in the intestinal wall, forming closed cavities, microabscesses, and granulomas; the choice of methods of intestinal suture of the stump and suture materials should be carried out taking into account the effect of duodenal content on the suture line.

The key link of the hypothesis is that the choice of optimal technical techniques for forming the DS at gastrectomy is one of the determining factors for preventing its insufficiency and improving the results of operations for patients with stomach diseases.

All this determines the relevance of the present research.

The research on the dissertation topic was carried out in accordance with the plan of NIR of Volgograd State Medical University and the Department of Hospital Surgery of VolgSMU, registration number 01.9.90000422.

Goal of the research. To improve the results of stomach operations by choosing optimal methods of forming the duodenal stump to ensure optimal conditions for healing; reducing the frequency of complications and mortality.

Tasks of the research. 1. To develop a modified method of duodenal stump closure;

2. To conduct a comparative evaluation of the strength of various methods of forming the duodenal stump in bench experiments;

3. To study the effect of duodenal content on wall characteristics of various suture materials;

4. To conduct a clinical evaluation of the clinical application of various methods of duodenal stump closure at gastrectomy according to Billroth I.

Scientific novelty.

1. A modified method of DS closure at gastrectomy according to Billroth I has been developed and studied;

2. New data on the effect of methods of DS closure on its physical hermeticity have been obtained;

3. New data on the effect of duodenal content on the strength characteristics of various suture materials have been obtained;

4. New data on the frequency of complications of DS healing after seven different methods of its closure have been obtained;

5. Principles of choosing methods of DS closure at gastrectomy according to Billroth II have been developed.

Practical value.

1. New data on the effect of methods of DS closure on its strength have been obtained and the strength characteristics of various methods of duodenal stump closure have been evaluated;

2. The development of a method of DS closure at gastrectomy according to Billroth I allowed to increase the efficiency of surgical treatment of stomach diseases;

3. The implementation of research results in clinical practice allowed to improve DS healing, reduce the frequency of complications and mortality after gastrectomy according to Billroth II.

Implementation of the research results into practice. The results of the dissertation work have been implemented in the practice of MUZ KB №25, MUZ KB №12 of the city of Volgograd, KB №3 FGU «YuOMTs Roszdrava». The methods developed in the dissertation are used in therapeutic and pedagogical work at the Department of Hospital Surgery and the Department of Surgical Diseases, Pediatric and Stomatological Faculty of Volgograd State Medical University.

Public presentation of the work. The main materials of the work were reported and discussed at the scientific-practical conference «New Technologies in Medicine (morphological, experimental, clinical and social aspects)» (Volgograd, 2005); at the conference of the clinic of hospital surgery of VolgSMU (Volgograd, 2007).

The dissertation public presentation was conducted at a joint interdepartmental conference of employees of the departments of VolgSMU: hospital surgery, the Department of Surgical Diseases with proctology FUV, the Department of Surgical Diseases of the Pediatric and Stomatological Faculty, employees of MUZ №25 KBSMU, MUZ KB №1, №5, №12 of the city of Volgograd, KB №3 FGU «YuOMTs Roszdrava».

Publications. 9 printed works on the dissertation topic have been published, 7 of them at the Russian level, 2 of them in peer-reviewed VAK journals.

Volume and structure of the dissertation. The dissertation is presented on 135 pages of typed text. It consists of an introduction, 4 chapters, conclusion, summaries, practical recommendations and a list of references.