Dynamics of Changes in the Structure and Function of the Gastric Wall after Surgical Treatment of Duodenal Ulcers

The dissertation is dedicated to the study of the dynamics of structural and functional changes in the gastric stump after distal gastrectomy with Billroth-I anastomosis for duodenal ulcers, examining different modifications of gastroduodenostomy formation. The research is based on a comprehensive set of objective examination methods including assessment of secretory and motor-evacuation function, endoscopic examination with quantitative determination of duodenogastric reflux, endoscopic ultrasonography, and morphological analysis with Helicobacter pylori detection. The relevance of the work is due to the need to develop a comprehensive methodology for assessing the operated stomach in order to optimize the choice of anastomosis method and prevent postresective complications, including reflux gastritis and the risk of gastric stump cancer development.

RELEVANCE OF THE RESEARCH

Peptic ulcer disease of the stomach and duodenum occupies one of the leading positions in the structure of diseases of the gastrointestinal tract, affecting up to 6-15% of the population. The last decade is characterized by a sharp reduction in the frequency of elective operations due to gastroduodenal ulcers (more than 2 times), while the number of emergency operations performed due to complications — perforation and bleeding — has increased by 2 and 3 times, respectively [7, 26, 35, 43, 88]. Despite the introduction into clinical practice of various methods of gastric resection, more than 60 different postresective syndromes and pathological conditions associated with digestive decompensation, disease recurrence, so-called "diseases of the operated stomach," have already been described. The frequency of occurrence of disturbances of gastric stump function, according to data from various authors, ranges from 2.2% to 50% [4, 17, 34, 53, 67, 105]:

The most common postgastrectomy syndrome overshadowing the results of surgical treatment of peptic ulcer disease is reflux gastritis. Bile reflux exerts an adverse effect on cellular structures of the gastric stump mucosa, causing inflammatory, atrophic, and degenerative changes [20, 34, 39, 60, 62, 64, 76, 81, 102; 143, 151, 162, 180, 204].

The risk of development of gastric stump cancer after operations for benign diseases exceeds the morbidity rate in the population of the same sex and age by 2-6 times, ranging from 0.85% to 17%, and with increasing postoperative period the frequency further increases [67, 83, 86, 129, 156].

Many researchers studying the pathogenesis of postgastrectomy syndromes identify the main initiating cause in the loss of the antral portion and pylorus, against the background of which simple anastomotic constructions, by their shortcomings, increase the frequency and diversity of postoperative diseases [7, 18, 20, 21, 30, 31, 32, 38, 39, 46, 55, 58, 85, 105].

In this regard, the antireflux anastomosis developed and introduced into practice after distal gastrectomy due to gastroduodenal ulcers allows restoration of the antireflux function of the lost valve apparatus and creation of conditions for normal progression of food through the digestive tract [7, 20, 21, 30, 31, 32, 39, 58, 64, 73].

Despite a large number of works devoted to the study of morphofunctional changes in the gastric stump in remote periods after distal gastrectomy according to Billroth-I, the interest of modern specialists in these questions is due to the appearance of new generations of diagnostic equipment and changes in the concept of performing therapeutic measures [14, 15, 42, 59, 61, 64, 66].

One of the promising directions in improving the diagnosis of "diseases of the operated stomach" is the application of comprehensive objective examination methods. The introduction of these methods into clinical practice allows significantly increasing diagnostic efficiency and expanding the understanding of pathogenetic mechanisms of postoperative complications. Modern treatment standards require not only description of the endoscopic picture, but also knowledge of secretory activity, Helicobacter pylori colonization status, motor-evacuation function status, and morphological verification of diagnosis [14, 16, 23, 29, 33, 54, 58, 61, 70, 83, 122, 123, 139, 148, 149, 159].

In the specialized literature, the effectiveness of this or that additional research method is analyzed, as a rule, in isolation from others; there is no algorithm or methodology for their comprehensive application. This complicates the creation of a unified picture objectively reflecting the state of the gastric stump and reduces treatment efficiency.

Thus, the above indicates the relevance of this problem, the necessity of further study and development, which became the basis for carrying out this research.

OBJECTIVE OF THE RESEARCH

To study using a complex of objective examination methods the dynamics of changes in the structure and function of the gastric stump in patients after distal gastrectomies according to Billroth-I due to peptic ulcer disease of the duodenum against the background of various modifications of gastroduodenostomy formation.

TO ACHIEVE THE STATED OBJECTIVE, THE FOLLOWING TASKS WERE FORMULATED:

1. Based on a complex of modern objective examination methods, to study the dynamics of changes in motor-evacuation function of the gastric stump in patients with various variants of gastroduodenostomy (after operative treatment of duodenal ulcer).

2. To evaluate the acid-producing function of the gastric stump depending on the method of gastroduodenostomy formation.

3. Based on the results of dynamic morphological investigation, to study changes in the mucosa of the operated stomach at various periods after surgical treatment of peptic ulcer disease of the duodenum with various variants of gastroduodenostomy formation.

4. To study the influence of the method of gastroduodenostomy formation on the development of inflammatory changes in the gastric stump mucosa in the context of duodenogastric reflux and/or Helicobacter pylori infection.

SCIENTIFIC NOVELTY

The features of pathological conditions of the gastric stump after resection according to Billroth-I at various variants of gastroduodenostomy formation have been identified for the first time based on data from comprehensive investigation.

A relationship has been established between the method of gastroduodenostomy formation and the arising pathological changes in the gastric stump mucosa, as well as indicators of its secretory and motor-evacuation function.

The influence of Helicobacter pylori on the gastric stump mucosa at various methods of gastroduodenostomy formation has been studied.

Criteria for determining the degree of acute anastomositis of gastroduodenal anastomoses using endoscopic ultrasonography have been developed for the first time, confirmed by Patent of the Russian Federation No. 2277857 dated June 20, 2006.

The role of antireflux gastroduodenostomy in preventing the development of pathological changes in the gastric stump mucosa in the early and remote postoperative periods has been demonstrated.

PRACTICAL SIGNIFICANCE OF THE RESEARCH

As a result of the conducted comprehensive investigation, new data on the dynamics of changes in the structure and function of the gastric wall in patients after distal gastrectomy according to Billroth-I in various modifications due to duodenal ulcers have been obtained, which contribute to the selection of adequate treatment tactics and improvement of remote treatment results for patients with peptic ulcer disease. The proposed highly informative methods for assessing the state of the operated stomach increase the efficiency of diagnosis and prognosis of pathological conditions of the gastric stump mucosa developing in early and remote periods after operative treatment.

POSITIONS SUBMITTED FOR DEFENSE:

1. The application of pylorus-modelling technologies in operative treatment of peptic ulcer disease of the duodenum reduces the risk of developing the most common and severe manifestations of diseases of the operated stomach, including dumping syndrome and reflux gastritis.

2. The character of changes in secretory and motor-evacuation functions of the operated stomach in the early and remote postoperative periods depends on the method of gastroduodenostomy formation and is due to the presence of a mechanism regulating the process of gastric stump content passage into the duodenum and preventing duodenogastric reflux.

3. The use of antireflux gastroduodenostomies brings the structure and function of the wall of the operated stomach closer to the physiological norm, thereby preventing the development of pathological changes in the gastric stump mucosa developing in the postoperative period, including gastric stump cancer.

VALIDATION AND IMPLEMENTATION OF THE RESEARCH

The results of the conducted research were reported and discussed at the all-Russian conference of surgeons "Modern Problems of Surgical Treatment of Peptic Ulcer Disease" (Saratov; 2003), the 8th international scientific-practical conference "Quality — Strategy 21" (Tomsk, 2003), the All-Russian Conference of Surgeons (Tyumen, 2003), the 2nd scientific-practical conference dedicated to the memory of A.F. Rodin "Actual Questions of Clinical Medicine" (Severodvinsk, 2006), the XI all-Russian scientific-practical conference "Young Scientists in Medicine" (Kazan, 2006).

The main results of the dissertation research have been implemented in the work of the NI of Gastroenterology of SibGMU, City Hospital No. 2 of TMSCH-81 (Severodvinsk), and included in the course of lectures on surgical diseases for listeners of the advanced training and postgraduate education faculty of GOU VPO SibGMU of Roszdrav.

PUBLICATIONS

Based on the materials of the dissertation, 17 works have been published, including 3 in central peer-reviewed journals, 2 patents of the Russian Federation for inventions.

VOLUME AND STRUCTURE OF THE RESEARCH

The dissertation is presented on 148 pages of typed text and consists of an introduction, four chapters, conclusion, conclusions, practical recommendations, a bibliography list comprising 226 sources, of which 88 domestic and 138 foreign. The dissertation is illustrated with 11 tables and 33 figures.