Integral Assessment of the Severity of the Condition of Patients with Perforated Gastric Ulcer

The dissertation is devoted to improving the effectiveness of surgical treatment of patients with perforated gastric ulcer — a severe complication of peptic ulcer disease associated with high postoperative mortality and a considerable number of complications. The author substantiates the need for a systematic approach to choosing the extent and type of surgical intervention, taking into account an objective assessment of the severity of the patient's physiological state.

The work proposes an improved diagnostic and therapeutic algorithm based on the use of the disease severity index (DSI), the integral assessment of the severity of the physiological state (SAPS), and elements of the mathematical theory of pattern recognition. A retrospective analysis of treatment outcomes in a control group (1990–1997) was carried out, and the short-term results of applying the improved tactics in the second period of observations (1998–2004) were evaluated. The practical implementation of the algorithm makes it possible to individualize the choice of surgical care and to improve the immediate outcomes of treatment.

The history of surgical treatment of perforated ulcers spans more than a hundred years and attests to persistent searches for the optimal method of operative treatment. Currently, surgeons have at their disposal such methods as suture closure of the perforated ulcer, truncal and selective vagotomy, gastric resection, as well as suture closure and resection of the perforated ulcer using endovideo laparoscopy. However, the number of postoperative complications and mortality rates with the above-listed methods of surgical interventions remain high (B.I. Marfin et al., 1998).

In emergency gastric surgery, large perforated openings and pronounced inflammatory infiltration, callous ulcers, stenosis and penetration into adjacent organs, multiple ulcers, suspected malignancy, and other complications require radical methods of surgical treatment of the stomach. Performing gastric resection on emergency indications is associated with a high risk to the patient's life. Postoperative mortality in early gastric resections, even when carried out by surgeons with extensive experience, amounts to 4.4–5% (A.A. Sheptulin, 1995; A.A. Kurygin, 1999; G.E. Sokolovich, 2001) and increases progressively with delayed operative treatment. The accompanying peritonitis should also be kept in mind. Under all these conditions, the choice of the optimal method of surgical care for perforated gastric ulcer is a highly complex task and demands considerable knowledge, qualifications, and experience on the part of the surgeon.

At various periods in the formation and development of surgery, a number of authors (V.S. Savel'yev, 2000), in order to assess the general condition of patients with acute diseases of the abdominal organs and to choose treatment tactics, employed various prognostic indices based on risk factors and thereby predicted the possible outcome of surgical intervention. At the same time, the proposed methods for predicting the outcomes of surgical intervention do not sufficiently reflect the degree of severity of the patient's physiological state and changes in organs and systems. In addition, many of them are labour-intensive and inapplicable in emergency surgery, as they require appropriate conditions and sophisticated modern technical equipment.

The choice of the optimal type and extent of surgical intervention for perforated gastric ulcer dictates the need for the daily use of a system for predicting surgical outcomes that should be widely accessible and at the same time objectively reflect the severity of the patient's physiological state.

Aim of the work: to improve the results of surgical treatment of patients with perforated gastric ulcer by refining the diagnostic and therapeutic algorithm based on the introduction of the disease severity index (DSI) and the integral assessment of the severity of the physiological state of patients with this pathology.

Objectives of the work:

1. To analyse the therapeutic tactics employed in the clinic for perforated gastric ulcer during the period 1990–1997 and to identify their positive and negative aspects.

2. To refine and implement in clinical practice a method for assessing the severity of the physiological state of patients with perforated gastric ulcer, based on the mathematical theory of "pattern recognition".

3. To develop and introduce into surgical practice an improved diagnostic and therapeutic algorithm for perforated gastric ulcer, employing the disease severity index and the integral assessment of the severity of the physiological state of patients (SAPS).

4. To study the short-term results of applying the improved diagnostic and therapeutic algorithm of surgical tactics for perforated gastric ulcer, based on determining the disease severity index (DSI), in the second period of observations (1998–2004).

The scientific novelty of the work consists in refining and introducing a diagnostic and therapeutic algorithm for the surgical treatment of patients with perforated gastric ulcer, based on the introduction of the disease severity index (DSI), which makes it possible to select the optimal type and extent of surgical intervention individually for each patient.

Practical significance of the work. With the aid of the recommended diagnostic and therapeutic algorithm, based on an objective assessment of indications for surgical intervention using the disease severity index (DSI) and the integral assessment of the severity of the physiological state of patients (SAPS) in perforated gastric ulcer, the indications for choosing the type and extent of the surgical operation have been clarified. The application of the improved surgical therapeutic tactics in perforated gastric ulcer resulted in improved short-term outcomes of surgical treatment of patients with this severe complication of peptic ulcer disease.

Implementation of the research results.

The obtained results have been implemented in the routine clinical practice of the surgical departments of the Republican Hospital No. 2 – Emergency Medical Care Centre (RH No. 2 – EMCC) of Yakutsk and RH No. 1 – National Centre of Medicine of the Republic of Sakha (Yakutia).

The main propositions of the study are used in the educational process of 4th–6th-year students at the surgical departments of the Medical Institute of Yakutsk State University.

Approval of the work: the main propositions of the dissertation were reported and discussed at the annual scientific and practical conference of the Medical Institute of Yakutsk State University named after M.K. Ammosov (2004, 2005); at the V Russian Scientific Medical Forum "Surgery-2004" (Moscow, 2004); the IX and X Russo-Japanese International Medical Symposium (Yakutsk, 2003; Niigata, Japan, 2004); the II, III, IV, and V Republican scientific and practical conferences of surgeons "Actual Problems of Emergency Medical Care" (Yakutsk, 2001, 2002, 2003, 2005); and at a joint meeting of the departments of hospital, faculty, and general surgery of the Medical Institute of Yakutsk State University, the Academic Council of the Yakutsk Scientific Centre of the Russian Academy of Medical Sciences and the Government of the Republic of Sakha (Yakutia), and physicians of the 1st and 2nd surgical and intensive care departments of the Republican Centre of Emergency Medical Care (Republican Hospital No. 2), and the departments of surgical gastroenterology, surgical hepatopancreatology, and endosurgery of the National Centre of Medicine (Republican Hospital No. 1) (Yakutsk, 14 December 2005).

Publications:

Fourteen scientific works have been published on the topic of the dissertation.

Volume and structure of the dissertation

The dissertation is set out on 133 pages of typewritten text and consists of an introduction, 5 chapters, a conclusion, conclusions, practical recommendations, and a list of references; it is illustrated with 11 diagrams, 16 tables, and 14 figures. The bibliography includes 203 domestic and 68 foreign sources.