SELECTION OF THE METHOD OF SURGERY IN PATIENTS WITH COMBINED COMPLICATIONS OF DUODENAL ULCER DISEASE IN EMERGENCY SURGERY

The dissertation is devoted to the selection of the method of surgical intervention in patients with combined complications of duodenal ulcer disease in emergency surgery. On the basis of clinical and anatomical studies, the technically correct variants of truncal, selective, and proximal gastric vagotomy, as well as improved drainage procedures (transverse pyloroplasties and duodenoplasties), have been substantiated. Indications for radical operations in combined complications of perforated ulcers and the tactics of treatment in combined complications of bleeding ulcers have been developed, including a treatment algorithm and models for predicting the risk of recurrent bleeding and lethal outcome. The immediate and long-term results of surgical treatment, the quality of life of patients, and the costs of treatment have been studied.

Relevance of the problem

Surgical treatment of patients with combined complications of duodenal ulcer disease is one of the pressing problems of gastroenterology.

Despite the introduction of new antisecretory drugs that cause a significant reduction in gastric secretion and methods of Helicobacter pylori eradication, in the Russian Federation an increase is observed in the morbidity and complications of ulcer disease — bleeding, ulcer perforation, and stenosis of the pyloroduodenal segment [10, 40, 54, 66, 101].

In recent years, some surgeons have noted an increase in the number of combined complications of duodenal ulcer disease (ulcer perforation and bleeding; dual localization of ulcers; combination of ulcer perforation or bleeding with penetration into the pancreas or lesser omentum; combination of complications with pyloroduodenal stenosis; combination of all complications — ulcer perforation, bleeding, penetration, and stenosis) [69, 77, 78, 135].

In recent years, some surgeons have proposed palliative interventions with subsequent H. pylori eradication in the treatment of complicated duodenal ulcers (HP-positive patients); however, the literature contains only isolated reports that do not permit final conclusions about such a method of treatment [4, 31, 58, 219, 316, 374].

It should be noted that currently palliative surgical interventions in patients with combined complications of duodenal ulcer disease should be applied only to save the patient's life on the basis of a forecast of a high risk of lethal outcome [31, 34, 35, 62, 68, 100, 134].

Operations in patients with combined complications of duodenal ulcer disease should pursue the goal of radical intervention aimed at preventing recurrences of the disease and maintaining a high quality of life of patients in the postoperative period, which is emphasized by national health-care problems.

After the introduction of truncal vagotomy with gastric drainage procedures by L. Dragstedt and F. Owens into clinical practice, a new era in the surgical treatment of ulcer disease began [213, 214, 215, 216, 217, 380].

The improvement of vagotomy contributed to the creation of a new direction in the treatment of ulcer disease and formed the concept of organ-preserving operations (truncal, selective, proximal gastric vagotomy) combined with drainage procedures.

Gastric resection in the treatment of duodenal ulcer disease is only an important historical achievement and does not reflect modern trends in surgical interventions for this disease (high postoperative mortality in emergency interventions reaching 20%, high frequency of diseases of the operated stomach — 16-26%, and a sixfold increase in the incidence of cancer of the gastric stump relative to the general population) [11, 48, 65, 88, 311, 333].

A restraining factor in the application of organ-preserving interventions in patients with duodenal ulcer disease, according to some authors, is the rather high frequency of ulcer recurrences, reaching 15-20% in the long-term period [88, 272, 276, 328, 330, 349].

However, many gastroenterological surgeons believe that the main cause of ulcer recurrences after various variants of vagotomy is incomplete and inadequate vagotomy [73, 75, 117, 279, 284].

The frequency of ulcer recurrences remains the highest after organ-preserving interventions performed by surgeons in the initial period of mastering the technique of various variants of vagotomy — truncal, selective, and proximal gastric vagotomy [280, 314, 315, 326, 345].

The choice of the method of vagotomy and drainage intervention in patients with combined complications of duodenal ulcer disease continues to be discussed in the literature [88, 196, 286, 317].

The effectiveness of surgical interventions in patients with complications of duodenal ulcer disease is assessed by surgeons using quantitative indicators (intraoperative and early postoperative complications, mortality, working capacity, ulcer recurrence, frequency of pathological syndromes, and the A. N. Visick and D. Johnston scoring scales), which do not allow a reliable analysis of surgical results [277, 379].

Currently, to evaluate the results of surgical interventions in patients with complications of duodenal ulcer disease, not only quantitative indicators but also the quality of life of patients should be used, the latter being one of the main criteria of treatment effectiveness.

An important factor in shaping the treatment strategy for patients with complicated duodenal ulcers is the determination of treatment costs.

Thus, the substantiation of the choice of the method of surgical treatment in patients with combined complications of duodenal ulcer disease is of important practical significance, as it may contribute to reducing mortality and improving the quality of life of patients.

Aim of the study

Improvement of the results of surgical treatment of patients with combined complications of duodenal ulcer disease.

To achieve this aim, the following objectives were defined:

1. On the basis of clinical and anatomical studies, to substantiate the technically correct performance of truncal, selective, and proximal gastric vagotomy and its modifications.

2. To improve drainage operations (pyloroplasties and duodenoplasties) in patients with combined complications of duodenal ulcer disease.

3. To substantiate the choice of the method of surgery in patients with combined complications of perforated duodenal ulcers.

4. To substantiate the tactics of surgical treatment in patients with combined complications of bleeding duodenal ulcers.

5. To study the immediate (intraoperative and early postoperative complications, mortality) and long-term results (functional results, pathological syndromes, working capacity, results according to the modified A. N. Visick and D. Johnston scoring scales of the Faculty of Hospital Surgery, Moscow Medical Academy named after I. M. Sechenov), as well as the quality of life (according to the Instrument for Quality of Life Assessment of the Faculty of Hospital Surgery named after N. N. Burdenko, Moscow Medical Academy named after I. M. Sechenov) after surgical interventions in the long-term period in patients with combined complications of duodenal ulcer disease.

Scientific novelty

For the first time, indications for radical surgical interventions in patients with combined complications of perforated duodenal ulcers have been substantiated on the basis of scoring scales for predicting lethal outcome.

An algorithm for the treatment of patients with combined complications of bleeding duodenal ulcers has been developed.

For the first time in patients with combined complications of duodenal ulcers, improved transverse pyloroplasties (of the J. Aust type with reconstruction of the pylorus, of the E. S. Judd and F. W. Rankin type, and of the F. Holle type in various modifications) and transverse duodenoplasties (of the J. Aust pyloroplasty type and of the F. Holle pyloroplasty type) have been substantiated and used.

For the first time, the quality of life has been studied in patients with combined complications of duodenal ulcer disease in the long-term period after various variants of vagotomy combined with drainage procedures.

For the first time, the costs of surgical treatment of patients with combined complications of duodenal ulcer disease have been studied.

Practical significance of the work

The substantiation of the choice of the method of surgical intervention in patients with combined complications of perforated duodenal ulcers and of the tactics of surgical treatment of patients with combined complications of bleeding duodenal ulcers, and the use of posterior truncal vagotomy with anterior seromyotomy of the body and cardia-fundal segment of the stomach together with improved drainage procedures (pyloroplasty or duodenoplasty) in emergency surgery have made it possible to reduce postoperative mortality, improve the results of surgical interventions, and maintain a high quality of life of patients in the long-term postoperative period.

Main points submitted for defense

1. Clinical and anatomical substantiation of vagotomy combined with drainage procedures in patients with combined complications of duodenal ulcer disease.

2. Selection of the method of surgery in patients with combined complications of perforated duodenal ulcers.

3. Tactics of surgical treatment in patients with combined complications of bleeding duodenal ulcers.

4. Long-term results of surgical treatment of patients with combined complications of duodenal ulcer disease.

Implementation of the results of the study into practice

The improved variants of vagotomy combined with transverse pyloroplasties or transverse duodenoplasties in patients with combined complications of duodenal ulcer disease have been implemented in the practice of the Clinic of Hospital Surgery No. 2 of the Medical Faculty of the State Educational Institution of Higher Professional Education Moscow Medical Academy named after I. M. Sechenov, and of City Clinical Hospitals No. 7 and No. 79 of Moscow.

The main points of the work are used in lecturing, conducting practical classes, and holding scientific and practical conferences with hospital surgeons, students, clinical and city interns, and city and clinical residents at the Department of Hospital Surgery No. 2 of the Medical Faculty of the State Educational Institution of Higher Professional Education Moscow Medical Academy named after I. M. Sechenov.

Publications and approbation of the work

The main points of the work were reported and discussed at scientific and practical conferences of the Department of Hospital Surgery No. 2 of the Medical Faculty of the State Educational Institution of Higher Professional Education Moscow Medical Academy named after I. M. Sechenov (Moscow, 2006, 2008), at the I Congress of Surgical Gastroenterologists of Russia (Gelendzhik, 2008), and at the VII and VIII Congresses of Gastroenterologists of Russia (Moscow, 2007, 2008).

Twenty-one works have been published on the topic of the dissertation, of which six are in central publications.

Scope and structure of the dissertation

The dissertation consists of an introduction, a review of the literature, a description of the clinical characteristics of the patients and the methods of the study, four chapters of original research, a conclusion, conclusions, practical recommendations, a bibliography, and appendices.