Complex Treatment of Elderly and Senile Patients with Ulcerative Gastroduodenal Bleeding

The dissertation is devoted to the problem of treating elderly and senile patients with ulcerative gastroduodenal bleeding, which remains one of the most complex tasks of emergency abdominal surgery. The high rate of postoperative complications and mortality in this age group determines the relevance of the search for minimally invasive methods of arresting bleeding that do not cause additional tissue damage and promote repair of the ulcer defect.

The author has developed a technique of combined prolonged endoscopic hemostasis using fibrin glue in combination with standard anti-ulcer therapy and low-intensity laser therapy. The morphological changes of the gastric mucosa and the parameters of immunobiological protection in elderly and senile patients during treatment have been studied. An algorithm of complex treatment adapted to the conditions of a standard surgical hospital and aimed at reducing the number of forced operations and the mortality rate is proposed.

Relevance of the problem. The treatment of elderly and senile patients with gastric and duodenal ulcer disease complicated by bleeding remains the most complex and debatable issue of modern surgery (Grinberg A.A., Grishko S.G., 1996; Gostishchev V.K., Yevseyev M.A., 2003).

It should be noted that patients over 60 years of age account for more than 35% of the total number of patients with ulcerative gastroduodenal bleeding, and surgical treatment in this group is associated with a high rate of postoperative complications and adverse outcomes, exceeding the corresponding figure in young and middle-aged patients by 4–7 times (Zatevakhin I.I. et al., 2003; Lutsevich E.V., Belov I.N., 2003). Overall mortality among elderly and senile patients with ulcerative bleeding ranges from 30% to 40%, and during emergency operations performed at the height of bleeding it approaches 55–70% (Zatevakhin I.I., Shchegolev A.I., 2001; Pantsyrev Yu.M., Fedorov E.D., 2002).

One of the most promising directions in improving the results of treatment of patients with acute gastroduodenal ulcerative bleeding is the introduction of minimally invasive technologies (Pantsyrev Yu.M., Fedorov E.D., 2004). At the same time, the hopes placed on endoscopic hemostasis as a method of definitive arrest of bleeding are not fully justified (Gazinge Yu.I. et al., 2003; Kurygin A.A., Bagnenko I.N., 2004). The rate of recurrent ulcerative bleeding reaches 12–40%, and mortality among elderly and senile patients operated on at the height of bleeding reaches 30–70% (Grinberg A.A., Grishko S.G., 1999; Lutsevich E.V., 2003). Therefore, at present, an active surgical tactic prevails, within which endoscopic hemostasis is regarded as a temporary measure that allows preparation of the patient for urgent surgical intervention (Grinberg A.A., Zatevakhin I.I., 2003; Yermolov A.S. et al., 2003; Gostishchev V.K., Yevseyev M.A., 2005). The use of such a tactic led to a decrease in overall mortality to 10–12% (Grubnik Yu.V., 2002; Fedorov E.D., Pantsyrev Yu.M., 2003). However, when the results of treatment of elderly and senile patients with ulcerative bleeding are considered separately, no significant improvement has been observed (Zatevakhin I.I., Shchegolev A.A., 2001; Lutsevich E.V. et al., 2004; Gostishchev V.K., Yevseyev M.A., 2005).

Modern studies on the morphological basis of ulcer formation show that recurrent bleeding is associated with progressive ischemic necrosis in the periulcerous zone, linked to systemic hemodynamic disorders and underlying chronic ischemia, particularly in elderly and senile patients (Vorobyov A.I., Gorodetsky V.M., 2001; Anisimov V.I. et al., 2003; Gostishchev V.K., Yevseyev M.A., 2003). Therefore, all methods of endoscopic hemostasis (physical, injection, mechanical) lead to an inevitable enlargement of the necrosis zone and, consequently, to frequent recurrent bleeding (Fedorov E.D., 2001; Gostishchev V.K., Yevseyev M.A., 2005).

Recently, there have been an increasing number of attempts to develop methods of combined hemostasis based on additional applications of biological agents that indirectly stimulate the coagulation cascade and repair (Kurygin A.A., 1996; Alekbaradze A.V., Lipintsky E.M., 2004). The question of the expediency of such combinations has only begun to be studied (Kurygin A.A., Skryabin O.N., 1996; Lipintsky E.M., 2004), since the isolated use of coagulation cascade stimulators has proven ineffective, as acknowledged by the majority of authors (Savelyev V.S., 1986; Kurygin A.A., Skryabin O.N., 1996; Grubnik Yu.V., Fomenko V.A., 2002).

Aim of the study: improvement of the results of treatment of elderly and senile patients with ulcerative gastroduodenal bleeding.

Tasks of the study:

1. To develop a technique of combined prolonged endoscopic hemostasis using fibrin glue.

2. To study the results of the application of this method in the group of elderly and senile patients with acute gastroduodenal bleeding.

3. To study the morphological features of the gastric mucosa and the dynamics of changes in the parameters of immunobiological protection in elderly and senile patients with ulcerative gastroduodenal bleeding during prolonged endoscopic hemostasis using fibrin glue.

4. To evaluate the results of treatment of patients using the developed technique against the background of standard anti-ulcer therapy and low-intensity laser irradiation.

Scientific novelty:

1. An original method of arresting acute gastroduodenal bleeding has been developed (Patent No. 2217076 of 27.11.2003), based on a combination of injections of 24% ethanol solution and applications of fibrin glue.

2. The features of morphological changes in the gastric mucosa in elderly and senile patients during prolonged endoscopic hemostasis using fibrin glue, against the background of standard anti-ulcer therapy and percutaneous low-frequency laser therapy, have been studied.

3. The parameters of immunobiological protection and natural resistance of the organism in elderly and senile patients under the influence of fibrin glue have been studied.

4. An algorithm of combined treatment of elderly and senile patients with ulcerative gastroduodenal bleeding has been developed.

Practical significance:

1. A method of conducting combined prolonged endoscopic hemostasis adapted to the conditions of a standard surgical hospital has been developed.

2. A combined variant of complex treatment of patients with ulcerative gastroduodenal bleeding has been developed, based on the performance of prolonged endoscopic hemostasis against the background of standard anti-ulcer therapy.

3. The use of the proposed methods of combined treatment of elderly and senile patients with ulcerative gastroduodenal bleeding made it possible to reduce the number of forced operations at the height of bleeding and thereby reduce the mortality rate in this group of patients.

Main propositions submitted for defense:

1. Improvement of the results of treatment of elderly and senile patients with ulcerative gastroduodenal bleeding is associated with the introduction of minimally invasive complex technologies, including variants of endoscopic hemostasis that do not cause additional tissue alteration and stimulate healing of the ulcer defect.

2. The use of this variant of hemostasis made it possible to reduce the number of forced operations at the height of bleeding.

3. The developed scheme of combined treatment makes it possible to improve the results of treatment of elderly and senile patients with ulcerative gastroduodenal bleeding.

Implementation of the work.

The materials of the dissertation were reported:

1. At joint conferences of the staff of the Department of Hospital Surgery No. 2 of the Medical Faculty, the Department of Liver Surgery and Metabolic Surgery of the I.M. Sechenov Moscow Medical Academy and employees of City Clinical Hospital No. 7 in 1999–2005.

2. At the III Russian Gastroenterology Week (Moscow, 1997).

3. At the IX Russian Gastroenterology Week (Moscow, 2003).

4. At the XVIII Interregional Scientific and Practical Conference (Lipetsk, 2005).

5. At the International Congress "New Technologies in Surgery" (Rostov-on-Don, 2005).

Publications.

On the topic of the dissertation, 9 scientific works have been published, 3 of them in central press. An RF patent for invention No. 2217076 of 27.11.03 has been obtained.

Volume and structure of the dissertation.

The dissertation is set out on 117 pages and consists of an introduction, four chapters, a conclusion, conclusions, practical recommendations, and a list of references. The work is illustrated with 16 figures, contains 17 tables; the bibliography includes 197 sources, of which 138 are domestic and 59 foreign.