Preoperative and Postoperative Management of Elderly and Geriatric Patients with Complicated Forms of Gastric and Duodenal Ulcer Disease

The dissertation addresses the problem of preoperative and postoperative management of elderly and geriatric patients with complicated forms of gastric and duodenal ulcer disease. The work covers the etiopathogenesis and geriatric aspects of complicated ulcer disease, the characteristics of the coagulation system in ulcerative bleeding, as well as the features of the perioperative period and postoperative complications in elderly and geriatric patients. Special attention is given to the assessment of coagulation system function in patients younger and older than 60 years with ulcerative gastroduodenal bleeding, the analysis of examination results, and the characterization of postoperative complications. A method for preventing and treating postoperative complications using controlled novocaine sympathetic denervation and magnetotherapy is proposed, and an algorithm for preoperative and postoperative management of patients is developed. The practical significance of the work lies in the implementation of the proposed methods in clinical practice to improve surgical treatment outcomes and reduce mortality in elderly and geriatric patients.

Relevance of the topic. Gastric ulcer disease is one of the most common chronic gastroenterological diseases and occupies leading positions in the structure of overall morbidity and mortality in many developed countries. Up to 5% of the world's population suffers from gastric and duodenal ulcer disease [Vakhidov V.V., 1992; Gorbashko A.I., 1993; Babalich A.K., 1999; Velieva N.A., 2003; Herrington J.L., 1989]. According to V.I. Onopriev (1995), in the 1990s the world witnessed a real "ulcer epidemic": the morbidity of gastric ulcer disease is constantly and steadily increasing. In cases of the development of complications of this nosology, various difficulties in diagnosis, management tactics, as well as significant financial costs are encountered [Boytsov N.I.*, 1984; Chechurin N.S., 1999; Gostishev V.K., 2004; Waisbren S.J., 1990].

Analysis of literary data shows that with modern conservative treatment of duodenal ulcers, healing can be achieved in 90% of patients. However, stable results of conservative treatment, even against the background of modern anti-ulcer therapy, are observed in only 40% of patients, and disease recurrence occurs in 60% of patients [Almazkin V.Yu., 2000; Isaev G.B., 2004; Osipov V.V., 2004; Bucur A., 1996]. With age, a significant decrease in positive treatment outcomes is observed. Complicated forms of gastric ulcer disease develop in 50–60% of patients, and this percentage increases significantly in older age groups [Tkachenko B.I., 1994; Yarema I.V., 1996; Bardakhanoev E.T., 1997; Lebedev N.V., 2007; Zuccaro G.I., 1993].

Aging is a universal process of natural involution of the organism, extending to the physiological mechanisms of homeostasis, forming a set of metabolic, structural-functional, and dysregulatory changes that limit the adaptive-compensatory capabilities of the organism. Involutional destabilization of adaptation causes decompensation of existing chronic diseases, which in turn intensify the aging processes, closing a vicious circle [Tkachenko B.I., 1994; Miroshnikov B.I., 2000; Lebedev N.V., 2007; Biggs R.L., 1987].

The features of the physiology of the aging organism are reflected in the mechanisms of development, course, and outcomes of treatment of complicated gastric and duodenal ulcer disease in patients of advanced age. On the one hand, patients in this category poorly tolerate acute blood loss or perforation, which dictates the need for earlier emergency assistance in stopping bleeding or suturing the ulcer perforation; on the other hand, such assistance, in particular surgical intervention, can lead to no less severe consequences, which limits the range of possibilities for the surgeon [Gorbunov V.N., 1998; Filkov A.P., 1999; Briskin B.S., 2006; Dousset V., 1995].

In recent years, there has been a trend toward an increase in the number of patients with ulcerative bleeding and perforated ulcers, particularly in the elderly age [Greenberg A.A., 1995; Chechurin N.S., 1999; Kasyan D.A., 1999; Romanov M.D., 2007; Choudari S.R., 1995]. Thus, in Moscow in 1987, there were 1,879 patients with ulcerative gastroduodenal bleeding (UGDB), and in 2005, respectively, 3,267 [Shchegolev A.A., 2006]. According to the same author, in Moscow, the number of emergency operations in patients with this pathology increased from 1,758 in 1987 to 2,290 in 2005, while the number of planned operations decreased from 1,771 in 1987 to 609 in 2005. Postoperative mortality at the height of bleeding ranges from 4% to 35%, and in elderly and geriatric patients it exceeds 50% [Vakhidov V.V., 1990; Pantserev Yu.M., 2003; Gostishev V.I., 2007; Panos M.Z., 1993].

A similar trend is observed in other complications of gastric ulcer disease (GUD) and duodenal ulcer disease (DUD). In the postoperative period, a large number of complications are identified; thus, the incidence of acute pancreatitis after gastrectomy is registered in 2.3–19.6% of patients [Zelentsovsky E.B., 1984; Serova L.S., 1996; Filin V.I., 1998; Kuznetsov N.A., 2003; Thompson J., 1980].

In the majority of patients over 60 years of age, DIC syndrome develops [Makarovich Ya.A., 1988; Korymasov E.A., 1992; Hunt P.S., 1984; Langman M.S., 1990]. Compared with young patients, with blood loss of less than 20% of circulating blood volume in an otherwise healthy adult, the risk of DIC syndrome development is virtually absent [Stolyarov E.A., 1999]. Hypercoagulation is a natural compensatory mechanism in bleeding and the development of acute blood loss, and the risk of thromboembolic complications significantly increases against the background of atherosclerotic vascular damage, which creates conditions for constant activation of the vascular and macrocirculatory hemostasis system (Stolyarov E.A. et al., 1999), which is often present in elderly and geriatric patients. This point of view is shared by N.S. Chechurin (1999), D.A. Kasyan (1999), A.A. Baeshko (2000), V.E. Gostishev (2004).

R.Z. Losev et al. (1996), A.I. Fetyukov et al. (1997) consider that the main cause of postoperative complications and death in elderly patients is thromboembolic complications. According to the study by Baeshko A.A. et al. (2000), the incidence of fatal pulmonary embolism (PE) after gastric surgery ranged from 0.2% to 0.7%. During life, the diagnosis of PE was established in only 32% of the 803 surgical patients whose cause of death was PE. According to the U.S. National Institutes of Health, annually only on 1,200,000 abdominal organ operations in patients aged 40 years and older, 600 deaths caused by PE are registered, and PE accounts for 10% to 21% of in-hospital and 6% to 25% of postoperative mortality [Baeshko A.A., 2000; Dehring D.E., 1990; Anderson F.A., 1991].

Aging, affecting all organs and systems of the body, also causes disturbances in the hemostasis system. An involutional shift in coagulation system parameters toward increased procoagulant activity and intensity of intravascular thrombus formation, together with microcirculatory changes and local immune disorders characteristic of the elderly, increases the risk of postoperative thromboembolic complications and further complicates the surgeon's task [Davydovsky I.V., 1966; Litvitsky P.F., 1995; Butenko G.M., 1999; Briskin B.S., 2006; Manegold V., 1994].

All of this indicates the need to search for new, more effective methods of treating complicated forms of gastric and duodenal ulcer disease in elderly and geriatric patients, which would allow achieving optimal results with minimal risk of complications.

Goal of the study

To improve the results of surgical treatment of elderly and geriatric patients with complicated forms of gastric and duodenal ulcer disease through the use of controlled novocaine sympathetic denervation and magnetotherapy.

Research objectives

1. To investigate the state of the coagulation system in ulcerative gastroduodenal bleeding in elderly and geriatric patients depending on the degree of blood loss and the type of hemostatic therapy performed.

2. To evaluate the effectiveness of controlled novocaine sympathetic denervation in the prevention of postoperative complications in patients over 60 years of age with complicated gastric ulcer disease.

3. To evaluate the combined effect of controlled novocaine sympathetic denervation and magnetotherapy on the results of surgical treatment of gastric and duodenal ulcer disease in patients of older age groups.

4. To develop an algorithm for preoperative and postoperative management of elderly and geriatric patients with complicated forms of gastric and duodenal ulcer disease.

Scientific novelty

A method for preventing and treating complications after surgery for gastric and duodenal ulcer disease using controlled novocaine sympathetic denervation and magnetotherapy in elderly and geriatric patients has been developed.

An algorithm for preoperative and postoperative management of elderly and geriatric patients with complicated forms of gastric and duodenal ulcer disease has been developed.

Practical significance

A methodology of controlled novocaine sympathetic denervation and magnetotherapy has been proposed and implemented in clinical practice, which allows improving the results of surgical treatment of complicated forms of gastric and duodenal ulcer disease and reducing postoperative and overall mortality in elderly and geriatric patients.

Main findings for defense

1. The use of controlled novocaine sympathetic denervation in the preoperative period significantly reduces the development of complications after surgery on the stomach and duodenum in patients over 60 years of age with complicated gastric ulcer disease. 2. The use of controlled novocaine sympathetic denervation in combination with magnetotherapy in the pre- and postoperative periods contributes to improving the results of surgical treatment of gastric and duodenal ulcer disease in elderly and geriatric patients.

Implementation of research results in practice

The results of the conducted studies have been implemented in clinical practice in the 5th and 6th surgical departments of MUZ UGKB SMP, in the surgical department of GUZ UOKB, in the surgical department of GUZ KOB No. 2, and in the 1st and 2nd surgical departments of MUZ TGKB. The materials of the work are used in the educational process at the department of hospital surgery of the medical faculty of UlSU.

Presentation of the work

The main findings and results of the dissertation were reported and published at the All-Russian Conference "Modern Problems of Emergency and Planned Surgical Treatment of Patients with Gastric and Duodenal Ulcer Disease" (Saratov, 2003), at scientific and practical conferences of physicians of the Ulyanovsk region (Ulyanovsk, 2004, 2005, 2006, 2007), at the Russian Gastroenterological Week (Moscow, 2004), at the International Surgical Congress "New Technologies in Surgery" (Rostov-on-Don, 2005), at a scientific and practical conference of young scientists in Tomsk (2005), and at the All-Russian Conference with international participation "Medico-physiological problems of human ecology" (Ulyanovsk, 2007).

11

Publications

Based on the dissertation materials, 18 scientific works have been published in central and local press, including 2 in publications recommended by the VAK of the Russian Federation.

Structure and volume of the dissertation

The dissertation consists of an introduction, a literature review, a description of materials and research methods, the results of original studies presented in two chapters, their discussion, conclusions, and practical recommendations. The work is written on 113 typewritten pages, illustrated with 14 figures and 27 tables. The bibliography contains 215 sources, of which 48 are foreign authors.