Methods of Surgical and Medication Correction of Postgastrectomy Disorders in Patients Who Have Undergone Gastrectomy According to Billroth-II

The research is dedicated to the development and evaluation of the effectiveness of comprehensive surgical and medication approaches to the correction of postgastrectomy disorders in patients who have undergone gastrectomy by the Billroth-II method due to complicated peptic ulcer disease. Postgastrectomy syndromes develop in 10–60% of operated patients and substantially impair quality of life, work capacity, and lead to disability. The work comprehensively examines the pathogenic mechanisms, classification, and treatment methods of these disorders, including both conservative therapy and reconstructive surgical interventions, as well as the development of schemes for preoperative preparation and postoperative rehabilitation.

Until the 1990s, gastrectomy (G) remained the operation of choice in the surgical treatment of complicated peptic ulcer disease (PUD) [Askerkhanov G.R., 1999]. However, in many regions, these organ-preserving technologies continue to be applied and refined [Baranskaya E.K., Ivashkin V.T., 2002; Mikhailov A.P. et al., 2002; Khadzhibaev A.M. et al., 2005; Shiroinov Z.T. et al., 2005].

Resection of 2/3 of the stomach, disruption of the neurohumoral links playing an important role in the coordinated self-regulation of the digestive organs [Galperin Yu.M. et al., 1986; Naumov V.F. et al., 2003], exclusion of the duodenum (D) from the passage of food — all this leads to the development in 10–60% of patients who have undergone G, in both the early and remote periods after the operation, of pronounced postresection disorders, which substantially impair quality of life (QoL), reduce work capacity, and result in disability in 3.8 to 32% of operated patients [Kuzin N.M. et al., 2000; Onopriev V.I. et al., 2001; Mikhailov A.P. et al., 2002; Bardakhchyan E.A. et al., 2004; Rudik A.A. et al., 2004; Bilchenko V.B. et al., 2006; Nazarenko P.M. et al., 2006; Scholmerich J., 2004].

Therapeutic treatment of postgastrectomy syndromes (PGS) is a highly complex task [Goldin V.A., 1990; Wechsler J.G. et al., 1989], and in severe forms, as well as in cases of combined postgastrectomy disorders, it is ineffective [Chistov I.B., 1974; Kuznetsov V.A., Fedorov I.V., 1992; Ukleja A., 2005].

To date, the questions of indications for surgical treatment of this category of patients, the choice of reconstructive operation method, and the assessment of its effectiveness remain debatable. The large number of reconstructive operation methods described in the literature [Askerkhanov G.R. et al., 1999; Mikhailov A.M. et al., 2002; Ovchinikov V.A., Menkov A.V., 2002; Gorpinich A.B., Simonenkov A.P., 2006; Zherlov G.K. et al., 2006; McFadden D.W., Zinner M.J., 1991; Rieu P.N. et al., 1992; Hut'an M. et al., 1997; Corsale I. et al., 2000], rather, underscores the dissatisfaction of surgeons with the results of operative treatment of patients with PGS, in connection with which the problem of developing new methods of medication and surgical correction of postresection disorders remains relevant.

At the Russian Center for Functional Surgical Gastroenterology (RCFSG), technologies of reconstructive operations have been developed and implemented that provide for impact on the main pathogenetic links in the development of postgastrectomy disorders [Onopriev V.I. et al., 2006]. However, pathogenetically justified indications for complex reconstructive interventions and the individual direction of surgical correction in patients who have undergone gastrectomy by Billroth-I have not been clarified; the transformation of clinical, morphological, and functional results and QoL parameters in patients with complicated PUD after gastrectomy and complex reconstructive surgical interventions applied at the RCFSG has not been evaluated; the remote results of these operations have not been studied; and schemes of preoperative preparation and postoperative rehabilitation for patients with PGS have not been developed, which constituted the rationale for the present study.

Taking the above into account, the aim of the work was to improve the effectiveness of comprehensive surgical and medication treatment of patients with postgastrectomy disorders who have undergone G by the Billroth-II method due to complicated PUD.

To achieve the stated goal, the following tasks were set:

1. To provide a comprehensive assessment of clinical, morphological, functional results and QoL parameters in patients with postgastrectomy disorders who have undergone primary G by the Billroth-I method.

2. To refine the complex of rehabilitation measures and evaluate their effectiveness in patients who have undergone G by the Billroth-II method.

3. To clarify pathogenetically justified indications for reconstructive operations and determine the individual direction of surgical treatment of patients with PGS.

4. To develop an algorithm of staged preoperative preparation and postoperative rehabilitation of patients who have undergone reconstructive operation according to V.I. Onopriev.

5. To evaluate the remote results of comprehensive (surgical and medication) treatment of patients with PGS.

Novelty of the research results. In this work, for the first time:

1. The relationships between clinical manifestations of PGS, the morphofunctional state of the upper parts of the gastrointestinal tract (GIT), the biliary system, and the duration of the anamnesis after primary G have been evaluated.

2. Indications for reconstructive operation according to V.I. Onopriev have been clarified.

3. A method of surgical treatment of peptic ulcers (PU) of the gastroenterostomy (GEA) after G by Billroth-I has been developed and tested in clinical practice (patent No. 2278620 dated 06/27/06).

4. Clinical, morphological, functional results and QoL parameters of patients with complicated PUD after gastrectomy, rehabilitation measures, and complex reconstructive surgical interventions have been evaluated.

5. Diagnostic criteria for stages of functional motor activity disorders of the small intestine in patients with dumping syndrome (DS) have been established.

6. A complex of rehabilitation measures has been individualized for patients with postgastrectomy disorders, as well as after reconstructive interventions.

Main propositions of the dissertation to be defended

1. A complex of reconstructive surgical interventions, including, depending on the combination of pathological syndromes: selective vagotomy (SV), plastic reconstruction of the gastric stump, creation of anti-reflux constructions in the esophagogastric (anti-reflux cardia) and gastrointestinal transitions (end-to-side gastroenterostomy — EGEA), and duodenal reconstruction, allows restoration of the anti-reflux elements of the cardia, elimination of hiatal hernia (HH), restoration of portionality and optimization of the evacuation rate of food contents from the gastric stump, and contributes to transformation of the morphological structure of the mucosa (M) of the gastric stump due to reduction of the damaging action of intestinal contents and bile components. Inclusion of the D in the digestive conveyor contributes to restoration of the functional relationships of the duodeno-pancreato-biliary complex. The conducted analysis of results of surgical correction of PGS allows expansion of indications for operative treatment at earlier stages, before the development of irreversible atrophic and regenerative changes of the gastroduodenal zone and small intestine.

2. Patients with complicated PUD who have undergone G and, in some cases, reconstructive operation, require medication rehabilitation, which, depending on the clinical situation, includes eradication therapy, prokinetic therapy, selective spasmolytics, replacement enzymotherapy and vitamin therapy, and correction of dysbiosis.

3. Pathogenetically justified preoperative preparation, timely established indications, used surgical technologies, and postoperative rehabilitation measures allow achieving good and excellent results in 87% of patients and improving the QoL level of patients.

Theoretical significance of the research. The results of the conducted studies deepen the representations about clinical, morphological, and functional features of the course of PGS after G by the Billroth-II method. The relationships between clinical manifestations of pathological syndromes, the morphological and functional state of the upper parts of the GIT, the biliary system, and the duration of the anamnesis after primary G have been evaluated.

Based on the representations of anatomo-functional relationships of the digestive organs, a pathogenetically justified complex of reconstructive interventions has been developed, restoring the reservoir function of the gastric stump, the physiological passage of food through the D, and eliminating the main manifestations of postgastrectomy disorders. Pathogenetically justified schemes of preoperative preparation and postoperative rehabilitation of patients with PGS have been developed.

Practical significance of the research. Indications for operative treatment of patients with PGS have been clarified and expanded. A new method of surgical treatment of peptic ulcers of the GEA after G by Billroth-I has been developed, which allows radical elimination of PUs of the operated stomach, exclusion of entero-gastric and pathological gastro-esophageal refluxes through creation of anti-reflux constructions in the esophagogastric (anti-reflux cardia) and gastrointestinal transitions (EGEA), and restoration of the passage of food through the D. Clinical, morphological, and functional results of comprehensive (surgical and medication) treatment of patients with PGS have been studied. Schemes of preoperative preparation and postoperative rehabilitation of patients with PGS have been developed.

Information on practical use of the research results

Based on the dissertation materials, 7 printed works have been published (Appendix No. 1), including a Russian Federation patent for the invention "Method of surgical treatment of peptic ulcers of the gastroenterostomy after G by Billroth-I" No. 2278620 dated 06/27/06.

Materials of own studies were presented at:

1. III regional scientific-practical conference of young scientists and students "Medical Science and Healthcare" (Anapa, April 21–24, 2005);

2. A scientific session dedicated to the 85th anniversary of Kuban State Medical University (KGMU) (Krasnodar, October 25–27, 2005).

The obtained results are used in teaching at the Department of Abdominal Surgery and Gastroenterology of the Faculty of Advanced Training and Professional Retraining of Specialists (ATPRS) of KGMU, the Department of Endoscopy of ATPRS of KGMU, and at the RCFSG (Krasnodar).

I am confident that I would have won much faster as a doctor if he had told me that he was going to remove a large part of the stomach because of a tiny duodenal ulcer.

C.N. Mayo