Video-Laparoscopic Combined Vagotomy in the Treatment of Patients with Perforative Pyloroduodenal Ulcers

The research is dedicated to the improvement of surgical treatment for patients with peptic ulcer disease of the duodenum complicated by perforation. The relevance of the work is due to the high frequency of perforative complications and the insufficiency of traditional operative treatment methods, such as gastric resection, which are accompanied by significant mortality and post-resection syndromes. A method of video-laparoscopic combined vagotomy during the suturing of perforative pyloroduodenal ulcers has been developed and tested, allowing the minimization of trauma to the ligamentous apparatus and violations of gastric blood supply.

The scientific novelty lies in the creation of a minimally invasive operative intervention that adequately reduces the acid-producing function of the stomach without the development of motor-evacuating disorders. The implementation of the proposed technique is aimed at preventing disease relapse and preserving the quality of life of operated patients in the remote period.

Relevance of the Problem of Surgical Treatment of Patients with Peptic Ulcer Disease of the Duodenum Complicated by Perforation

In the Russian Federation, over a million patients with peptic ulcer disease of the stomach and duodenum (PUD) are under dispensary supervision, with morbidity averaging 5.1-5.7 per 1000 population [1, 4, 20, 119]. Approximately 100,000 planned and emergency operations are performed annually. Currently, there is an increase in the number of patients with PUD [6, 30, 103].

Currently, for comprehensive conservative treatment of patients with PUD, many medicinal preparations are applied that significantly reduce the acid-producing function of the stomach. However, despite the successes of modern conservative treatment of PUD, upon its cessation, a relapse of the disease occurs in 20-85% of patients, and a relapse of ulcer formation is registered in 10-15% of patients even under conducted conservative treatment [16, 141].

Perforation of the ulcer is a formidable and life-threatening complication. According to literature data, the frequency of perforations relative to the total number of patients with peptic ulcer disease ranges from 3 to 30%, averaging 15% [6, 45, 63, 171, 197]. Despite numerous studies, the choice of method and manner of operative treatment of chronic duodenal ulcer remains one of the urgent problems of gastroenterology [46, 119, 128, 133, 184].

Existing methods of surgical intervention for PUD do not always satisfy surgeons. Thus, gastric resection mortality amounts to 2-6% [25, 109].

The level of post-resection syndromes remains high, ranging from 0.8% to 88% according to various authors, significantly reducing the "quality of life" of operated patients [9, 78; 91, 140].

It is considered that among the currently applied methods of operative treatment of PUD, selective proximal vagotomy (SPV) is free from the aforementioned disadvantages [18, 59, 68, 85, 110]. The immediate and early results of SPV were so good that they contributed to the wide spread of the operation, both in planned and emergency orders, making it the method of choice for operations on PUD and its complicated forms [64, 79, 99, 104, 156].

Traditional laparotomy intervention is traumatic to the soft tissues of the anterior abdominal wall, dangerous by the development of purulent complications from the wound, the formation of abdominal wall hernias, and the development of adhesive disease of the abdominal cavity organs [13, 132, 170]. Moreover, even with an uncomplicated course of the postoperative period, recovery periods are quite prolonged, and the cosmetic effect of this operative procedure is quite problematic. The emergence of new surgical technologies, the introduction of minimally invasive endoscopic interventions gave a new direction in the development of surgical treatment of PUD. A small volume of the operation to suture perforative gastroduodenal ulcers allows it to be successfully performed using modern, more advanced techniques; in particular, laparoscopic suturing of the perforative opening with subsequent sanitation of the abdominal cavity [8, 90, 121, 143,158].

The development of new surgical technologies, the introduction of minimally invasive endoscopic interventions, contributed to the improvement of organ-preserving methods of surgical treatment of PUD. Thus, reports appeared in the literature on the application of laparoscopic vagotomy in duodenal ulcer, including its selective proximal modification [50,165,180,202].

However, it should be noted that laparoscopic selective proximal vagotomy is a lengthy, technically complex, expensive operative intervention and can be successfully performed in specialized medical institutions [64,93,94,194].

To simplify the technique of SPV, various modifications have been proposed by a number of authors. Thus, Taylor (1976) developed a new type of selective proximal vagotomy, which he called superficial seromyotomy of the lesser curvature, which he subsequently supplemented with posterior pyloroplasty. The author believes that the gastric branches of the vagus nerves, before being implanted into the muscular layer of the stomach, pass subserosally for 2-4 cm, and proposed to incise the seromuscular layer of the anterior and posterior stomach walls at a distance of 1-1.5 cm from the edge of the lesser curvature and parallel to it, starting from the angular incisure to the angle of His. In this case, the gastric twigs of the vagus nerve are crossed and the large vessels remain intact. The author did not apply sutures to the edges of the incision, considering the scar an insurmountable obstacle for the regrowth of the crossed vagal twigs. V.I. Oskretkov et al. (2003) analyzed the results of treatment of 107 patients with chronic PUD who were performed various types of laparoscopic vagotomy: the best result was obtained after SPV: 0% relapses over 4 years, after the Taylor operation 15.8%, and after selective gastric vagotomy 12.5% relapse of the disease was revealed.

The same goal was pursued by Yokomuchi (1972), who reported the first cryovagotomy. In our country, this method was developed by E.D. Khvorostov (1989) and V.I. Ovchinnikov (1994). The feature of the cryogenic intervention is that due to the high heat capacity, vessels with a diameter greater than 1 mm are not obliterated.

B.K. Shurkalov et al. (1994) use radio waves to destroy nerve fibers, but these interventions are not always applicable due to the inaccessibility of expensive equipment and require special training of the surgical team.

To incise the seromuscular layer of the stomach, P.A. Sadikov et al. (1995) used laser radiation energy, the advantages of the method include its minimally traumatic coagulating effect.

The disadvantages of these methods are deep thermal injury of surrounding tissues with often occurring post-thermal complications, gross destruction of the tissues of the stomach wall with possible necrosis and perforation.

In the development of post-vagotomy complications, a certain role is played by disorganization of regional blood flow due to denervation and devascularization of the stomach wall due to its gross trauma during manipulations. The literature contains reports on the possibility of chemical denervation of the acid-producing zone of the stomach - APZ [2, 63, 80, 123].

V.I. Podoluzhny et al. (2001) experimentally substantiated and clinically tested the most optimal concentration of ethyl alcohol (30% aqueous solution) for SPV by chemoneurolysis method. In the remote period, 87.8% of patients obtained excellent and good results [42].

Worthy of attention is the technique of video-laparoscopic medicament-thermal selective proximal vagotomy in PUD [69]. The specified method is characterized by technical simplicity, minimal trauma, short duration of execution in combination with good immediate and remote treatment results. Complications associated with medicament-thermal SPV, the authors did not observe.

With the introduction of chemical denervation, technically less complex and inexpensive modifications of the Taylor operation were developed.

B.B. Anishchenko and A.B. Pozdnyakov (1999) performed in an experiment and then in clinical practice laparoscopic posterior trunk vagotomy and anterior SPV by chemoneurolysis method. In 17 operated patients with chronic PUD, a sustained decrease in acidity was preserved over 6 months. N.A. Efimenko et al. (2001) performed video-laparoscopic suturing of the perforative ulcer in combination with combined vagotomy according to Taylor and obtained excellent results in the remote period in 69.8% of patients. At the same time, operations to suture ulcers of the pyloroduodenal zone in combination with one of the types of vagotomy have not received wide spread due to the technical complexity and duration of the operation.

Thus, analysis of literary data allows us to conclude that one of the promising directions in the treatment of patients with PUD is the improvement of methods of vagotomy during video-laparoscopic suturing of perforative pyloroduodenal ulcer, which determined the goal and objectives of the present study.

Goal of the Research

To improve the results of surgical treatment of patients with peptic ulcer disease of the duodenum complicated by perforation, by means of video-laparoscopic suturing of the perforative pyloroduodenal ulcer in combination with combined vagotomy.

Objectives of the Research

1. To develop and clinically test a method of video-laparoscopic combined vagotomy during suturing of the perforative pyloroduodenal ulcer.

2. To evaluate the immediate clinical results of video-laparoscopic combined vagotomy during suturing of the perforative pyloroduodenal ulcer.

3. To conduct a comparative analysis of the acid-peptic activity of the gastric body in patients after video-laparoscopic suturing of the perforative pyloroduodenal ulcer in combination with combined vagotomy, isolated suturing, and suturing of the perforative ulcer in combination with selective proximal vagotomy by the skeletalization method of the lesser curvature of the stomach.

4. To conduct a comparative evaluation of the motor-evacuating function of the stomach after video-laparoscopic suturing of the perforative pyloroduodenal ulcer in combination with combined vagotomy and selective proximal vagotomy by the skeletalization method.

5. To evaluate the remote clinical results of video-laparoscopic suturing of the perforative pyloroduodenal ulcer in combination with combined vagotomy in comparison with suturing of the perforative ulcer in combination with selective proximal vagotomy by the skeletalization method and isolated suturing.

Scientific Novelty of the Research

A method of operative treatment of peptic ulcer disease of the pyloroduodenal zone has been developed and clinically tested (Russian Federation Patent No. 2268658 dated April 5, 2004). It has been shown that the application of video-laparoscopic combined vagotomy allows, when suturing perforative pyloroduodenal ulcers, to exclude trauma to the ligamentous apparatus and violations of gastric blood supply, reduce the time of vagotomy execution, and decrease the number of early postoperative complications from 7.0% to 2.5%. It has been established that video-laparoscopic suturing of perforative pyloroduodenal ulcers in combination with combined vagotomy adequately reduces the acid-peptic activity of the gastric body, does not lead to clinically significant motor-evacuating disorders of gastric function, prevents relapse of the disease and a decrease in quality of life for 3 years after the operation.

Main Propositions to be Defended

1. Video-laparoscopic combined vagotomy during suturing of perforative pyloroduodenal ulcers is a minimally invasive operative intervention, allows adequately reducing the acid-producing function of the stomach and does not lead to motor-evacuating disorders of the stomach for 3 years after the operation.

2. The application of video-laparoscopic combined vagotomy during suturing of perforative pyloroduodenal ulcers allows preventing relapse of the disease and a decrease in the quality of life of operated patients.

Practical Significance

A method of video-laparoscopic combined vagotomy during suturing of perforative pyloroduodenal ulcers has been developed and introduced into clinical practice, allowing to avoid trauma to the ligamentous apparatus and gastric blood supply, and improve immediate and remote treatment results.

Implementation of the Results

The main results of the research have been introduced into clinical practice of surgical departments of MUZ "GKБ No. 3 named after M.A. Podgorbunsky", Kemerovo, into the educational process of the department of hospital surgery of GOU VPO KemGMA of Roszdrav and the department of surgery, urology, endoscopy and operative surgery of GOU DPO GIUV of Roszdrav, Novokuznetsk.

Defense of the Work

The main provisions of the dissertation were reported and discussed at the scientific-practical conference "Vedomstvennaya meditsina" (Kemerovo, 2004), the city scientific society of surgeons (Kemerovo, 2004, 2005), the regional scientific-practical conference of young scientists and students with international participation "Problems of Medicine and Biology" (Kemerovo, 2006).

Publications

Based on the materials of the dissertation, 10 printed works have been published, including 1 invention patent and 2 methodological recommendations.

Structure and Volume of the Dissertation

The dissertation is presented on 124 pages of typed text, illustrated with 10 tables and 33 figures, consists of an introduction, a literature review, three chapters containing the results of own research, conclusion, conclusions and practical recommendations. The bibliography list includes 205 titles (120 domestic and 85 foreign authors).