Comprehensive Treatment of Erosive-Ulcerative Lesions of the Stomach and Duodenum in Cardiac Surgery Patients

The investigation is devoted to the development and evaluation of a comprehensive approach to the treatment of erosive-ulcerative lesions of the stomach and duodenum in patients with ischemic heart disease during the preoperative period preparing for myocardial revascularization. The research examined the prevalence and characteristics of gastroduodenal lesions in this category of patients and established the association between erosive-ulcerative lesions and Helicobacter pylori infection. A method of endoscopic treatment using a 5% oxomethyluracil gel formulation was developed and tested, enabling accelerated mucosal healing and shortened preoperative preparation timelines.

The findings support the inclusion of fibrogastroduodenoscopy and testing for pyloric Helicobacter pylori in the standard preoperative workup of patients with ischemic heart disease. It was demonstrated that the presence of erosive-ulcerative lesions of the upper gastrointestinal tract constitutes a contraindication for performing angiocardiac surgical procedures, and the developed endoscopic treatment method contributes to improved outcomes and reduced risk of postoperative complications.

Relevance of the Problem. Cardiovascular diseases occupy a leading place in the structure of morbidity of the Russian population, to a significant extent determining a high level of disability and mortality [18, 163]. Among cardiovascular diseases, a special position belongs to ischemic heart disease (IHD), which ranks first among cardiovascular diseases of the adult population [2, 18]. The working-age population of patients, significant economic costs for their treatment and maintenance, the possibility of developing severe complications and unfavorable outcomes determine the relevance of improving methods of treatment and prevention of this disease.

Currently, surgical myocardial revascularization is considered the treatment of choice for patients with IHD due to the insufficient efficacy of medical treatment [18, 100]. Cardiac surgical interventions, especially those performed under conditions of artificial circulation, are often accompanied by acute ulcerations of the gastric and duodenal mucosa. Gastroduodenal hemorrhages, whose frequency in the postoperative period amounts to 0.2–0.8%, aggravate the severity of the condition of cardiac surgery patients and are a cause of mortality in 9.6–8.0% of cases [17, 122, 123, 177, 203, 210, 219, 227, 254, 266].

It is known that IHD patients belong to a high-risk group for ulcerative lesions of the gastric and duodenal mucosa. According to various authors, the frequency of gastroduodenal erosive-ulcerative lesions among cardiac patients reaches 22–41%, of which 77.5–79.0% are accounted for by IHD patients [104, 113, 115, 129, 142, 143]. At the same time, the diagnosis of acute erosions and ulcers of the upper gastrointestinal tract against the background of the underlying disease is complicated due to scanty symptomatology and the absence of clear clinical signs [210, 254]. In these conditions, one of the important stages of preparation of IHD patients for surgical treatment is diagnostic and therapeutic fibrogastroduodenoscopy (FGDS), since the presence of erosive-ulcerative lesions of the mucosa of the upper digestive tract is an absolute contraindication for performing angiocardiac surgical operations with the application of anticoagulant therapy. However, there are only isolated studies on the investigation of structural and functional changes in the stomach and duodenum in this pathology; the true prevalence and nature of upper gastrointestinal tract lesions in patients with cardiovascular diseases in the preoperative period have not been determined [17].

An important aspect of the problem of surgical treatment of IHD patients with erosive-ulcerative lesions of the upper gastrointestinal tract is the search for and development of new approaches to reducing the duration of preoperative preparation. One of the ways to improve the results of ulcerative disease treatment is endoscopic impact on the ulcer defect, directed at the local link of ulcerogenesis and allowing objective assessment of the efficacy of the conducted therapy and observation of the dynamics of healing [6, 32, 43]. In recent years, researchers' attention has been attracted by the possibility of using a new derivative of the pyrimidine generation to accelerate regeneration processes — oxomethyluracil, possessing an anti-ulcer effect, high antioxidant activity, anti-inflammatory, immunomodulating, antitoxic, and anabolic effects [57, 75]. Meanwhile, information on the use of this drug in the endoscopic treatment of erosive-ulcerative lesions of the stomach and duodenum has not been found by us in the available literature.

Goal of the Investigation. Improvement of the results of treatment of erosive-ulcerative lesions of the stomach and duodenum in the preoperative period in cardiac surgery patients.

Tasks of the Investigation.

1. To study the prevalence and localization of erosive-ulcerative lesions of the stomach and duodenum in patients with ischemic heart disease at the stage of preoperative preparation.

2. To determine the degree of Helicobacter pylori infection in patients with ischemic heart disease at the stage of preoperative preparation.

3. To develop a method for endoscopic treatment of erosive-ulcerative gastroduodenal lesions in cardiac surgery patients using oxomethyluracil.

4. To evaluate the efficacy and results of complex treatment of this pathology at the preoperative preparation stage in cardiac surgery patients.

Scientific Novelty.

The prevalence of erosive-ulcerative lesions of the upper gastrointestinal tract in patients with ischemic heart disease at the stage of preoperative preparation for myocardial revascularization has been studied. Clinical features of gastroduodenal lesions in this category of patients have been determined.

A correlation between erosive-ulcerative lesions of the stomach and duodenum and Helicobacter pylori in ischemic heart disease has been established. A high prevalence of symptomatic gastroduodenal ulcerations not associated with Helicobacter pylori has been demonstrated.

A method for endoscopic treatment of gastroduodenal lesions with a gel form of 5% oxomethyluracil has been developed (invention patent No. 2006115288 RF dated 03.05.2006).

Scientific and Practical Significance.

The results of the investigation justify the advisability of including fibrogastroduodenoscopy as a diagnostic test in the plan of preoperative examination of patients with ischemic heart disease for the detection of concomitant erosive-ulcerative lesions of the mucosa of the upper gastrointestinal tract, which are a contraindication and a cause of postponement of surgical treatment.

The necessity of testing for pyloric Helicobacter pylori in patients with ischemic heart disease and erosive-ulcerative lesions of the gastric and duodenal mucosa at the preoperative stage has been demonstrated, with the aim of determining the association of the disease with Helicobacter pylori.

The developed method of endoscopic treatment of gastroduodenal lesions with a gel form of 5% oxomethyluracil makes it possible to improve the results of treatment of gastroduodenal erosive-ulcerative lesions, thereby reducing the duration of preoperative preparation of patients with ischemic heart disease and decreasing the risk of developing postoperative complications.

Main Propositions of the Dissertation for Defense.

1. Ischemic heart disease is characterized by a high prevalence of erosive-ulcerative lesions of the mucosa of the upper gastrointestinal tract, which is an absolute contraindication for surgical myocardial revascularization.

2. In ischemic heart disease, a high prevalence of symptomatic erosive-ulcerative lesions of the gastric and duodenal mucosa not associated with Helicobacter pylori has been identified.

3. A method for endoscopic treatment of gastroduodenal erosive-ulcerative lesions in cardiac surgery patients has been developed, allowing reduction of the duration of preoperative preparation for myocardial revascularization and lowering the risk of postoperative gastroduodenal complications.

Implementation in Practice.

The results of the investigation have been implemented in clinical practice of the therapeutic and surgical departments of the Republican Cardiology Dispensary (City of Ufa). The dissertation materials are used in the educational process at the Department of Hospital Surgery of the Bashkir State Medical University.

Presentation of the Work.

The main propositions of the dissertation were reported at the IX Congress of Cardiovascular Surgeons (Moscow, 2005), the 7th All-Russian Gastroenterological Week (Moscow, 2005), the XIV Scientific Conference of the Association of Cardiovascular Surgeons with International Participation (Donetsk, 2006), and the XI Annual Session of the National Research Center for Cardiac Surgery named after A.N. Bakulev of the Russian Academy of Medical Sciences (Moscow, 2007).

Publications.

Based on the materials of the dissertation, 13 scientific works have been published, including 2 works in publications indexed by the Higher Attestation Commission, and 1 Russian Federation invention patent.

Volume and Structure of the Dissertation.

The dissertation is presented on 135 pages of typed text, includes 12 tables and 16 figures, and consists of an introduction, a review of literature, a description of materials and methods of investigation, 2 chapters of original research, a conclusion, propositions, practical recommendations, and a reference list comprising 175 domestic and 91 foreign sources.