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Tactics of Treatment of Patients With Ulcerative Pyloroduodenal Stenosis And High Operational - Anesthesiological Risk

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TACTICS of TREATMENT of PATIENTS With ULCERATIVE

PYLORODUODENAL STENOSIS And HIGH

OPERATIONAL - ANESTHESIOLOGICAL RISK

The Russian centre of science of surgery of Academy of medical sciences of the Russian Federation

A.G. Shertsinger, L.J. Timen, A.I. Cherepanin, S.V. Stonogin.

   Now prevalence of a chronic pyloroduodenal ulcer, resistant to spent conservative treatment and inclined to development of stenosis has increased [8]. The organic ulcerative stenosis and gastrectasia with infringement of evacuation is the absolute indication to operative treatment. At the same time surgical treatment of patients with organic ulcerative pyloroduodenal stenosis, is long not healing ulcerative defect, and also a serious accompanying pathology is accompanied by the big number of postoperative complications and a high lethality. The lethality after realization of emergency operations concerning ulcerative pyloroduodenal stenosis at patients with high operational - anesthesiological risk is connected first of all to absence of high-grade preoperative correction and changes from 10 up to 44.4% [1]. After scheduled operations concerning the given pathology it makes 3,9-5 % [3,10].

Material and methods

   The purpose of the present research was improvement of results of treatment of patients with ulcerative illness of stomach and the duodenal intestine complicated with ulcerative pyloroduodenal stenosis, and having high degree of operational - anesthesiological risk. To research it is subjected 107 patients by peptic ulcer of stomach and the duodenal intestine complicated with ulcerative pyloroduodenal stenosis with high degree of operational - anesthesiological risk for the period with 1986 for 1996. Since 1993 in treatment of the given pathology of the beginnings to be applied the capillary medical probe.
   All patients divided into 2 groups - patients were included in the basic group (43) with a ulcerative pyloroduodenal stenosis in which treatment the capillary medical probe was used. From them at 6 patients the capillary medical probe was used in a combination to enteral tube feed, dietetics, antiulcerous pharmacotherapy and medical endoscopy (the functional compensated pyloroduodenal stenosis on a background of an exacerbation of a peptic ulcer) and operations were not made. 37 patients were subjected an operative measure after correction of albuminous and power failure and infringements of a homeostasis with use of a capillary medical probe (the organic pyloroduodenal stenosis accompanied with expressed motor-evacuational infringements). Middle age ill the basic group has made 50 +1,3 years. Among them patients with peptic ulcer of stomach was - 16 %, with peptic ulcer of duodenal intestine - 77 %, with peptic ulcer of stomach and duodenal intestine - 7 %.
   The control group was made by 64 patients with ulcerative pyloroduodenal stenosis in which treatment the capillary medical probe was not used, and traditional ways of preoperative preparation were applied: infusional therapy and parenteral feed, pharmacotherapy and operative treatment. Middle age ill control group has made 49+ 1,2 years. From them patients with ulcerative illness of stomach of 28 %, with peptic ulcer of duodenal intestine of 67 %, with peptic ulcer of stomach and duodenal intestine of 5 %.
   Authentic differences in the basic and control groups at distribution of patients on a sex, age and localization of ulcerative defect it was not observed. Average terms of ulcerative anamnesis (accordingly 12 +2,0 and 11,5 +1,7 years) and the average sizes of ulcerative defect (accordingly 16 +1,3 and 14 +1,2 mm) at patients of the basic and control groups had no authentic differences. The basic share of patients both basically, and in control groups have made patients with subcompensated ulcerative stenosis (accordingly 33 and 49 patients), with decompensated stenosis accordingly 7 both 10 patients and the least part have made patients with the compensated stenosis - 3 and 5 persons (р<0,01)
   With normal condition of the nutritious status was 2 % of ill both groups.
   Patients with a mild degree of infringement of a feed was 18 %, with an average degree - 69 % and with a serious degree - 11 % of patients. Authentic differences in the basic and control groups on a degree of stenosis and infringement of feed it was not observed. Infringements of aqueous and ionic balance were expressed in hydropenia, downstroke of mass of a body, downstroke of an arterial and central venous pressure, hemoconcentration, hyponatremia, hypokalemia, hyposalemia, metabolic alkalosis.
   Besides infringement of feed 91 % of patients of the basic and control groups had one and more serious attendant disease that rose(elevated, improved, raised) degree of operational - anesthesiological hazard (ischemic illness of heart, renal, pulmonary and hepatic failure, oncologic diseases, diabetes, consequences of acute infringement of cerebral circulation). Operational - anesthesiological hazard estimated by tests of classification of the Moscow scientific society of anaesthesiologists 1988. Among all patients with a high degree of operational - anesthesiological hazard - 66 %, with the highest degree of operational - anesthesiological hazard - 34 % of patients initially prevailed. Reliable differences between patients of both groups on degree of operational - anesthesiological hazard was not.
   Alongside with the standard clinical analyses with the purpose of an estimate of the nutritious status of patients carried out anthropometric gaugings: masses of a body (kg), depth of a dermal crimp of a brachium (sm), volume of muscles and a circle of a medial third of brachium (sm), contents of crude protein and its fractions in Serum of a blood (g\l), quantities of nitrous balance (g), level of creatinine, bilirubin, glucose, Sodium chloridums.
   Tool survey of patients carries out according to the designed program (table 1).
   Diagnostic esophagogastroduodenoscopies combined with examination of stomachal secretion and statement of capillary medical sonde. The capillary medical sonde was erected during esophagogastroduodenoscopy on an original procedure by formation of loops of sonde with the purpose of bracing and augmentation of contacting area of capillary medical sonde with bands of intramural pacemakers of stomach and duodenum (The patent of Russian Federation N 2082326 from 27.06.97.). In the previous reports [2,4] we have presented the concept of pathogenetic therapy of peptic ulcer, based on the neuroreflex mechanism of a cupping be sick, liquidations of motor-evacuational infringements and by that deblocking of healing processes with the help of the capillary medical sonde stacked as loops on reflexogenic bands, responsible for motor-evacuational activity of gastrointestinal path [6] in subcardial-fundal and antropyloric departments of stomach, in the field of the Fateri of a papilla and a sheaf of the Treitz (Drawing 1).

Table 1- Program of survey of patients.

   1. Diagnostic esophagogastroduodenoscopy in 1 day with examination of stomachal secretion and statement of capillary medical sonde
   2. Radionuclid examination and radiographic analysis of stomach with barium on 2-3 day
   3. Control radionuclid and X-ray analysis for 6-8 day on a background of presence of capillary medical sonde
   4. Control esophagogastroduodenoscopy with examination of stomachal secretion for 9-11 day after production of capillary medical sonde and the solution of a question on further tactics
   Motor-evacuational infringements explored a method of radiographic analysis with barium and computer radioisotope scanning of stomach and duodenum with Тх 99 pertechnetat, estimate the shape and the size of members, rate of evacuation of a drug on an effective half-life and residual activity, a degree of a duodenogastral and gastroesophageal reflux, localization of changes.
   We designed the serial plan of complex treatment of peptic ulcer of stomach and duodenum complicated with pyloroduodenal stenosis:
   1 stage - enteral tube feed of 5-7 days;
   2 stage:
   А - transition to a peroral diet with conservation of capillary medical sonde for support of transit of a chyme and
   0x01 graphic
   Bands of a locating of loops of capillary medical sonde:1- cardia, fundal department - Up to middle of a body
   2- Pyloric canal
   3- Fateri papilla
   4-Treitz sheaph
   3 4
   Fig. 1 Plan of a locating of capillary medical sonde
   Groups ill the Degree 5- ^
   Basic
   Operated
   Control
   Operated
   In total
   Operated
   Compensated
   3(7%)
   -
   5(8%)
   1(20%)
   8(7%)
   1(13%)
   Subcompensated
   33(77%)
   30(90,9%)
   49(77%)
   46(93,9%)
   82(77%)
   76(93%)
   Decompensated
   7(16%)
   7(100%)
   10(15%)
   10(100%)
   17(16%)
   17(100%)
   In total
   43(100%)
   37(86%)
   64(100%)
   57(89%)
   107(100%)
   94(88%)
   Relation operated
   больных
   antiulcerous pharmacotherapy for ill with subcancelled or cancelled functional pyloroduodenal stenosis before liquidation of resistant pain set of symptoms for the term of about 5-7 days;
   Б - Operating treatment in case of (organic) cancelled lead(carried out, spent) treatment (organic) cancelled, subcancelled (organic) cancelled, subcancelled or decompensated pyloroduodenal stenosis retained after lead(carried out, spent) treatment after correction of albuminous and energy failure and infringements of homeostasis;
   3 stage - medical endoscopy in case of liquidation of the phenomena of the functional pyloroduodenal stenosis for ill with a delayed adhesion in a band of ulcerative flaw of 10-14 days.

Discussion of results.

   Efficiency of designed tactics of treatment ill with ulcerative pyloroduodenal stenosis and high operationally - anesthesiological hazard was estimated on the following parameters: 1) terms of a cupping of pain set of symptoms and liquidation of motor-evacuational infringements; 2) terms of a cicatrisation of ulcerative flaws; 3) Results of conservative and operating treatment; 4) Duration and cost of course of treatment.
   At estimate of terms of a cupping of a pain set of symptoms it is detected, that they as a whole have coincided with the beginning of correction of motor-evacuational infringements and were on the average in 3 times less in basic group in comparison with control, thus reliability of differences concerned only sub- and a decompensated pyloroduodenal stenosis.
   Other major parameter of treatment ill with a ulcerative pyloroduodenal stenosis was the cicatrisation of ulcerative flaw.
  
   Table 2 - Medial terms of liquidation of pain set of symptoms and the beginning of correction of motor-evacuational function in days (М + м)
   Groups ill
   Basic group
   N=43
   Control group N=64
   Reliability of differences Р(1-2)
   View of a stenosis
   Compensated
   10,5
   32
   р>0,01
   Subcompensated
   21,3
   71,5
   p<o,01
   Decompensated
   31,2
   91,5
   р<0,011
  
   The delay of a cicatrisation or its complete lack fall into to the unfavorable prognostic factors bearing to organic changes in periulcer band. In our observations terms of a cicatrisation of pyloroduodenal ulcers for not operated ill on a background of presence of capillary medical sonde (17 +1,3 day) were reliablly lower than a basic group, than for 7 ill control groups (26 +2,1 day). And, terms of occurrence of the first tags of a cicatrization of ulcerative flaws coincided with terms of liquidation of pain set of symptoms and motor-evacuational infringements.
   Examination рН stomach and duodenum yielded at entering, and also on 6 and 9 day of treatment. For ill both basic, and control group the initial stomachal hyperacidity (рН < 1,5) in a stage of neutralization sub- and decompensations of ulcerative pyloroduodenal stenosis in all cases when they did not gain inhibitors of stomachal secretion was supervised.
   The cicatrization of pyloroduodenal ulcers was not attended by change of oxyntic function of stomach for 72 ill basic and control groups receiving such drugs, as Methacinum, gastrozepin, Nospanum, Almagelum, Vicalinum. In case of usage of more potent blockers of a stomachal secretion of type Ranitidin, Famotidin, Omeprazole response of gastric juice for 35 ill with a cancelled and subcancelled ulcerative pyloroduodenal stenosis increased up to values 1,5<рН>2,1 (hyperacidity with the partial

Table 4

   Postoperative lethality in the basic and control groups ill.
   Groups free
   Basic group
   Control
   Р (1-2)
   N=2
   N=5
   Postoperative lethality

5,4%

8,8%

р<0,01

   or the complete acid removal). After cancelling of drugs in 24 hours per all cases the level рН was returned to reference values рН < 1,5. Thus of change of response of gastric juice in reply to presence of capillary medical sonde it was noted not.
   As a whole the percentage ratio operated ill in the basic and control groups reliablly did not differ. Both in basic, and in control groups the maximum quantity of operations is fulfilled for patients with decompensated pyloroduodenal stenosis (100% ill), minimum - for patients with cancelled pyloroduodenal stenosis (0 and 20 % ill accordingly) in case of subcancelled pyloroduodenal stenosis the share operated ill has constituted accordingly 90,9 % and 93,9 % in the basic and control group.
   In total among patients of a basic group it is operated 37 (86 %) ill. From them the resection of stomach on Rout is fulfilled 3, on Balfur-3, on Bilrot 1 - 7, on the Bilrot 2 - 19, pyloroplasty from SPV - 1, Jabule operation - 3, a gastroenterostomy with truncial vagisection - 1. Terms of preoperative preparation have constituted 8 +2 day, middle age operated ill has constituted 64 +1,3 year.
   In control group it is operated 57 (89 %) ill. From them the resection of stomach on Bilrot 1 is fulfilled 14 ill, on Bilrot 2-29 ill, on Balfur-4 ill, on Rout - 2 ill, erasion of ulcer - 2 ill, gastroduodenostomy on the Jabule - 4 ill, pyloroduodenoplastic with truncial vagisection - 1 ill, a gastroenterostomy with a truncial vagisection - 1 ill. Terms of preoperative preparation have constituted 15+3 day, middle age operated ill 63+1,3 year.
   The data on postoperative lethality represented in table 4.
   The most often reasons of postoperative lethality in the basic and control group were: acute myocardial infarction (accordingly 1 and 2 ill) and the tromboembolism of a pulmonary arteria (accordingly 1 and 4 ill), except for that in control group is noted one mors from a pneumonia, one from acute infringement of a cerebral circulation and the incompetence of gastroenteroanastomosis and peritonitis has served in one case as the reason.
   In basic group less complications - 5,4 %, than for ill control group - 14,1 % were reliable. The number of complications, the bound with acute infringement of a cerebral circulation has constituted 0 % and 1,75 %, postoperative pneumonia 0% and 1,75 %, incompetence of anastomosis 0% and 1,75 % accordingly in the basic and control group.
   Medial terms of treatment ill with ulcerative pyloroduodenal stenosis and high operationally - anesthesiological hazard at usage of designed tactics appeared reliablly smaller, than for ill control group: accordingly 22,6+1,5 and 28,7+1,3 days, and cost of course of treatment has declined in 3,5 times at the expense of a failure from expensive antiulcerous pharmacotherapy.
   At carrying out of preoperative preparation for ill basic and control group reliablly it was possible to lower degree of operationally - anesthesiological hazard, thus the share ill with the highest and high degree of operationally - anesthesiological hazard decreases and number ill with moderate degree of operationally - anesthesiological hazard increased, however, in basic group terms of correction have constituted 9+1,2, and in control 14+1,3 day (р<0,01).

Deductions

   1. Tactics of treatment ill with ulcerative pyloroduodenal stenosis should be under construction with the count of a degree of operationally - anesthesiological hazard and an opportunity of its correction during preoperative preparation.
   2. Usage of capillary medical sonde in a complex of preoperative preparation ill with ulcerative pyloroduodenal stenosis contributes in downstroke of terms of liquidation of pain set of symptoms, cicatrization of ulcerative flaws, correction of motility of stomach and infringements of the nutritious status.
   3. Application of capillary medical sonde under the plan designed by us is an efficient expedient of complex preoperative preparation ill with the ulcerative pyloroduodenal stenosis, permitting to lower degree of operationally - anesthesiological hazard, postoperative lethality and quantity of complications.
   The literature
   l. Baxuдов B.B., Калиш Ю.И.. Хачиев ГЛ. Особенности тече-ния язвенной болезни желудка и двенадцатиперстной кишки и ее хирургическое лечение у лиц пожилого возраста. Хирургия, 1990. N7, стр. 7-11.
   2. Ерамишанцев А.К., Тимен Л.Я., Шерцингер А.Г., Киценко Е.А., Жигалова С.Б. Применение гастроинтестинального зонда в ле-чении язвенной болезни желудка и двенадцатиперстной киш-ки. Клиническая медицина 1994. N2, стр. 36-38.
   3. Попова Т.С., Тамазашвили Т.Ш., Шестопалов А.Е. Хирурги-ческое лечение постбульбарных дуоденальных язв //Паренте-ральное и энтеральное питание в хирургии, Москва, 1996, 221 стр.
   4. Стоногин С.В. Капиллярный лечебный зонд в предоперационной подготовке больных с пилородуоденальным язвенным стенозом, Автореферат на соискание уч. cт. канд. мед. наук, Москва, 1999 год.
   5. Стоногин С.В., А.Г. Шерцингер, Л.Я. Тимен, А.И. Черепанин Капиллярный лечебный зонд в предоперационной подготовке больных с пилородуоденальным язвенным стенозом. http://www.rusmedserv.com/misc/007/stat.htm
   6. Тимен Л.Я. Клинико-эндоскопическое обоснование патогене-тического механизма воздействия гастроинтестинального зонда в терапии язвенной болезни желудка и двенадцатиперстной кишки. Медицинская консультация 1993, N 1, стр.2 J-22.
   7. Тимен Л.Я., Кручинин Е.З., Саввин Ю.Н., Волков А.В. Зна-чение хромоскопии в оценке функционального состояния же-лудка и двенадцатиперстной кишки. Военно-медицинский жур-нал 1984, N12, стр. 53-54.
   6. Cuttat J.F., Ruchat P., Chapuis G. Gastroduodenal ulcer disease: What surgical indications are lift\\ Schweiz Med Wochenchr 1989 May 27, 119 (21): 729-730.
   7. Hermon-Taylor and Cod C.F. Locflisationjfthe duodenal pacemaker and its role in the organisation of the duodenal myelectric activity. Gut, 1971, N12, p 40-47.
   S. Lauven P.M., Stoeckel H., Ebeling B.J. Perioperative morbidity and mortality of geriatric patients. F retrospective study of 3905 cases \ \ Anasth Intensivther Notballmed 1990 Jan;25Suppl 1:3-9.
   The data on writers:
   1) Shertsinger Alexander Georgievich - doctor of medical sciences, the professor of department of the emergency surgery of the Centre of science of surgery of the Russian academy of medical sciences.
   129327 Moscow, Lenskaya 15, 5-th housing, 1 surgical branch.
  
   2) Timen Leonid Jakovlevich - lieutenant colonel of medical service, the term of the American academy of medical sciences, the term of the American academy of sciences, the doctor of the higher category of 20-th city hospital
   Moscow 471-33-62.
   129327 Moscow, Lenskaya 15, 3-rd housing, branch of an endoscopy.
   3) Cherepanin Andrey Igorevich - senior lecturer of stand of surgical illnesses N2 of e Moscow medical academy, candidate of medical sciences
   129327 Moscow, Lenskaya 15, 5 housing, 2 surgical branch 4711135
   4) Stonogin Sergey Vasil'evich - surgeon of contagious housing of the Tooshinskoi children's municipal hospital of Moscow, candidate of medical sciences. 143400 Krasnogorsk, Zheleznodorozhnaja 28A 24.
   E-mail: main70@stk.mmtel.ru,
   http://stonogin.narod.ru/sergeyvs.html
   1
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