Possibilities of Diagnosing Dumping Syndrome after Operations for Gastric and Duodenal Ulcer Disease

The dissertation is devoted to the problem of diagnosing dumping syndrome that develops in patients after surgical interventions for gastric and duodenal ulcer disease. Based on clinical material, an analysis was carried out of the frequency of occurrence of this complication depending on ulcer localization, sex, age, method of surgery, acid-forming function of the stomach, and the presence of Helicobacter pylori. A set of clinical, instrumental, and laboratory methods for diagnosing dumping syndrome was developed and tested, including ultrasound examination, fluoroscopy, integral rheography, electrocardiography, and determination of serotonin and blood glucose levels. Criteria for assessing the severity and type of dumping reaction are proposed, along with a rational diagnostic algorithm using the standard and extended Fisher-Stafford test, including during fibrogastroduodenoscopy.

The practical significance of the work is associated with the introduction of the proposed diagnostic algorithm into the clinical practice of medical institutions in Saint Petersburg, the Murmansk and Vologda regions, as well as with the use of the results obtained in the educational process for the course on gastric surgery.

Dumping syndrome occurs after gastric resection and various types of vagotomy in 10-30% of observations among patients operated on for gastric and duodenal ulcer disease. In 3-5% of cases it presents in a severe form requiring reoperation (A.F. Chernousov et al., 1996; K.N. Movchan, 1997; L.Ya. Kovalchuk et al., 2002; G.K. Zherlov et al., 2005; J. Svab et al., 2001; J. Schölmerich, 2004).

Currently, alongside a decrease in elective operations due to improvements in drug therapy methods, a 2-2.5-fold increase in the frequency of complicated forms of ulcer disease has been noted—hemorrhage, perforation, and stenosis of the pyloroduodenal region (Petrov V.P., 2001; Peregudov S.I. et al., 2004; Lobankov V.I., 2005). Due to the impossibility of complete preoperative examination during emergency operations, the frequency of postoperative dumping syndrome in this group turned out to be 2 times higher than in elective operations, which determines the significance of this problem at the present stage of gastric surgery (Borisov A.E. et al., 2000; Mikhailov A.P. et al., 2002).

Conservative treatment of patients with mild and moderate dumping syndrome is often successful, whereas patients with the severe form of dumping syndrome undergo reconstructive operations.

The manifestations of dumping syndrome are varied and combined with other postgastroresection and postvagotomy syndromes, which complicates its diagnosis (Mikhailov A.P., 2000; Sazhin V.P. et al., 2004; Chan P.Y. et al., 2003). The methods of detecting dumping syndrome and its assessment that exist in clinical practice (gastric fluoroscopy, various variants of provocative tests) are often difficult to perform, costly, and invasive. At the same time, the interpretation of diagnostic results is often contradictory and complicates the determination of severity, type of reaction, and, as a consequence, the choice of treatment method. The few publications that have appeared in recent years on the use of ultrasound (Sazhin V.P., 2004; Maresca G., 1998), as well as the technical improvement of other methods of examining the gastrointestinal tract, have not yet demonstrated their significance in the diagnosis of diseases of the operated stomach. The factor of radiation exposure when using the radiological method is also important, which becomes particularly relevant when monitoring the effectiveness of treatment over time. An urgent task is also the absence of clear stratification of dumping syndrome across various diagnostic methods, which is decisive in expert evaluation and the choice of treatment tactics. Therefore, we have undertaken the present study.

Aim of the study: to improve the results of treatment of patients with dumping syndrome after various methods of surgical intervention for gastric and duodenal ulcer disease, based on the improvement of methods of its diagnosis.

Objectives of the study:

1. To study the frequency of occurrence of dumping syndrome depending on ulcer localization (stomach, duodenum), age, and sex after various methods of surgery.

2. To evaluate the influence of the acid-forming function of the stomach and Helicobacter pylori on the occurrence of dumping syndrome.

3. To improve the method of ultrasound diagnosis of dumping syndrome.

4. To conduct a comparative analysis of methods for diagnosing dumping syndrome and to stratify the criteria of severity and types of dumping reaction.

5. To develop a rational algorithm for the diagnosis of dumping syndrome.

Scientific novelty of the study

Based on extensive clinical material, a systematic and comparative analysis of new methods of diagnosing dumping syndrome developed and introduced into clinical practice, which determine approaches to its treatment and prevention, has been carried out.

The absence of influence on the frequency of occurrence of dumping syndrome of such factors as age, sex, acid-forming function of the stomach, and the presence of Helicobacter pylori has been proven.

The capabilities of various methods for diagnosing dumping syndrome (ultrasound, rheovasography, fluoroscopy) have been identified, and criteria for assessing the severity and types of dumping reaction with these methods have been determined. A method for determining dumping syndrome during fibrogastroduodenoscopy has been developed, which significantly simplifies and shortens the time of patient examination.

Practical significance of the work

An algorithm for the diagnosis of dumping syndrome has been developed, and characteristics of the dumping reaction during the extended and standard Fisher-Stafford test have been provided. An original method of ultrasound diagnosis for assessing the morphofunctional state of the upper gastrointestinal tract in dumping syndrome has been put into practice, as well as the performance of the Fisher-Stafford test during fibrogastroduodenoscopy, which makes it possible to simplify and facilitate the diagnosis of dumping syndrome, optimize the choice of treatment tactics, and monitor the effectiveness of treatment.

Based on the data obtained, practical recommendations have been formulated for physicians engaged in gastric surgery. The developed principles of diagnosing dumping syndrome help surgeons make optimal tactical decisions taking into account the causes of dumping syndrome, its severity, and the patient's condition.

Main propositions submitted for defense:

1. The frequency of occurrence of dumping syndrome after gastric resection and vagotomy does not depend on ulcer localization, sex and age of patients, method of surgery, acid-producing function of the stomach, and Helicobacter pylori.

2. Ultrasound examination of the upper gastrointestinal tract, along with fluoroscopy, allows qualitative and quantitative diagnosis of disorders of the motor-evacuatory function in dumping syndrome.

3. The Fisher-Stafford test with intrajejunal administration of glucose in the standard technique and during fibrogastroduodenoscopy produces a reaction identical to the clinical manifestation of dumping syndrome in patients after food intake and makes it possible to reliably determine the degree of severity of clinical manifestations. The method is objective and important in the algorithm for diagnosing dumping syndrome.

The personal contribution of the author to the conducted study consists in personal management of patients, performance of and participation in surgical interventions, collection, statistical processing, and analysis of material, and development of new methods for diagnosing dumping syndrome.

Implementation of the work

The results of the research and development have been introduced into the practical activities of the State Healthcare Institution "City Aleksandrovskaya Hospital" (Saint Petersburg); the Federal State Healthcare Institution "Central Medical Sanitary Unit No. 122" of the FMBA (Saint Petersburg); the State Healthcare Institution "Murmansk Regional Clinical Hospital named after P.A. Bayandin"; the Municipal Healthcare Institution "Central District Hospital of ZATO Severomorsk"; and the State Healthcare Institution "Vologda Regional Clinical Hospital No. 1".

The theoretical and practical results obtained in the dissertation work are used in the educational process at the Department of Surgery named after N.D. Monastyrsky of the State Educational Institution of Additional Professional Education "Saint Petersburg Medical Academy of Postgraduate Education" of the Ministry of Health and Social Development of Russia and are included in the thematic course on gastric surgery.

Approbation of the work

The results of the research and the main propositions of the dissertation were reported and discussed at a meeting of the Department of Surgery named after N.D. Monastyrsky of the Saint Petersburg Medical Academy of Postgraduate Education (2009); at a meeting of the problem commission "Surgery and Related Specialties" of the Saint Petersburg Medical Academy of Postgraduate Education (2009); at the scientific-practical conference of young scientists of the Saint Petersburg Medical Academy of Postgraduate Education "Current Issues of Clinical and Experimental Medicine" (Saint Petersburg, 2007, 2008); at the Scientific-Practical Conference dedicated to the 80th anniversary of Professor A.I. Gorbashko "Problems of Surgical Gastroenterology" (Saint Petersburg, 2008); and at the 1st Congress of the Russian Society of Gastrointestinal Surgeons "Current Issues of Surgical Gastroenterology" (Gelendzhik, 2008).

Publications

On the topic of the dissertation, 11 scientific works have been published, including 4 publications in central journals recommended by the Higher Attestation Commission of the Russian Federation.

Scope and structure of the dissertation

The dissertation consists of an introduction, 4 chapters, a conclusion, conclusions, practical recommendations, a bibliography, and is set out on 146 pages of typewritten text. The work contains 30 tables, 15 figures, and a bibliographic index comprising 138 domestic and 125 foreign literature sources.