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"TYPOLOGICAL" FEATURES OF ULCER GASTRODUODENAL
BLEEDING IN THE ELDERLY
Abdullazhanov B.R.
Akhmadbekov B.O.
Botirov A.K.
Botirov Zh.A.
Khamidov F.Sh.
Andijan State Medical Institute
https://doi.org/10.5281/zenodo.15282247
Relevance of the problem.
This problem in urgent surgery continues to be
the subject of large-scale scientific research conducted in clinics and
laboratories of our Republic, in the CIS countries and abroad [2;3].
In our opinion, in case of UGDB, age-related features of the organism are not
given due attention. This puts the clinician in a difficult position due to the
impossibility of unambiguous interpretation of the obtained results. Meanwhile,
without solving these issues, recommendations to practical medicine regarding
the choice of one or another surgical tactic are not fully substantiated. All this
served as a reason for conducting this study.
Material and methods of the study.
The work is based on a clinical
analysis of the results of 326 patients with ulcerative gastroduodenal bleeding
who were hospitalized in the 3rd surgery of the Otabekov Clinic.
Yu.O. at the
Department of Surgical Diseases of the Andijan State Medical Institute
and
at the
Andijan branch of the Republican Scientific Center for Emergency Medical Care
for the period from 2019 to 2023.
According to the purpose and objectives, the study is divided into two
stages:
The first stage
is
the determination of some “typological” features of the
course of the ulcerative process in acute (drug ulcers) and chronic (peptic ulcer)
ulcers of the stomach and duodenum and ulcerations in gastroduodenal ulcers in
the elderly compared with similar patients under 60 years of age.
For this purpose, following the WHO classification [1], we have
conditionally identified two groups:
- control group (234 patients with UGDB) - from 2019 to 2021, aged 18-59
years, i.e. patients of adolescence, young and mature ages (the average age was
35.3±0.5, p< 0.001);
- the study group (92 patients with UGDB) – 2022-2023, in old age (the
average age was 67.2±0.5, p< 0.001).
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2) the second stage
-
after determining some "typological" features of the
course of UGD in the elderly compared to patients under 60 years of age, the
study group of patients is also conditionally divided into two groups:
- comparison group - (51 patients with UGDB) - 2022, elderly, where they
adhered to “traditional approaches to surgical treatment;
- the main group - (41 patients with UGDB) - 2023, elderly, where optimized
surgical tactics were followed.
To solve the tasks set, general clinical, laboratory, instrumental and
statistical research methods were used in accordance with the protocols
approved by the Ministry of Health of the Republic of Uzbekistan.
Results and their discussion.
Method of excision of a bleeding gastric
ulcer complicated by penetration into the pancreas ( IAP 20240286 dated
16.05.2024 ).
The purpose of the invention
is the reduction of the duration of the
operation and the decrease of the frequency of postvagotomy disorders, which is
achieved by the fact that when the ulcer is located on the anterior wall of the
stomach, a gastrotomy is performed, longitudinally retreating 1.5 cm from the
lesser curvature with simultaneous excision of the ulcer. The length of the
incision is from the cardia to the angle of the stomach with preservation of the
motor branches of the Latarjet nerve. The dissected wall of the stomach is
sutured with a two-row suture, then a posterior trunk vagotomy and serotomy
are performed in the cardiac section, starting from the upper end of the
gastrotomy. When the ulcer is localized on the posterior wall of the stomach, a
gastrotomy is performed in the specified manner, the ulcer is sutured with
suturing and ligation of the bleeding vessels or excised.
Objective of the invention:
- to develop an organ-preserving technology for precision excision of a
bleeding gastric ulcer, accompanied by penetration into the pancreas, which
allows for simplifying the surgical technique and preventing injury to the
pancreas with the development of postoperative pancreatic necrosis;
- ensure reliable hemostasis;
- remove the edges of the ulcer (the affected edges of the layers of stomach
tissue) to its bottom, as a source of possible recurrent bleeding;
- preserve all parts of the stomach and its innervation;
- to achieve optimal plastic restoration of the gastric wall and, consequently,
the natural shape and function of the stomach.
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The set task is solved by the fact that in the method of excision of a bleeding
gastric ulcer complicated by penetration into the pancreas , including
gastrotomy up to 5 cm long , assessment of the size of the ulcer infiltrate, its
location, presence of penetration, degree of prevalence, relationship of the ulcer
process with important topographic-anatomical and functional structures, active
aspiration of gastric contents, excision of the edges of the bleeding ulcer,
installation and control of a nasogastric duodenal tube for gastric sanitation,
restoration of the ulcer defect of the stomach, control of hemostasis, suturing of
the gastrotomy opening, after active aspiration of gastric contents, the edges of
the bleeding ulcer are excised precisely, with two bordering incisions including
the mucomuscular layers, within healthy tissues to its bottom in the direction of
muscle fibers, leaving the bottom of the ulcer penetrating into the thickness of
the tissue pancreas, intact, then the specified ulcer bottom is treated with
alcohol and electrocautery, after installation and control of the nasogastric tube,
the edges of the stomach defect are restored with interrupted single-row
sutures on an atraumatic needle to achieve extragastric ulcer bottom, the
operation is completed in the generally accepted manner.
The technical essence, novelty and inventive level of the claimed method
consist in the fact that in the projection of a bleeding gastric ulcer, accompanied
by penetration into the pancreas, the lumen of the stomach is opened by a
gastrotomy up to 5 cm long. The size of the ulcer infiltrate, its location, the
presence of penetration, the degree of prevalence, as well as the relationship of
the ulcer process with important topographic-anatomical and functional
structures are assessed. Establishing the exact localization of cicatricial-
ulcerative lesions of the stomach relative to the most important topographic-
anatomical formations is the most important and necessary condition for
performing an organ-preserving operation.
After active aspiration of gastric contents, the edges of the bleeding ulcer
are excised precisely by two bordering incisions taking into account the
direction of muscle fibers, including the mucous-muscular layers, within healthy
tissues to its bottom. The bottom of the ulcer, which penetrates and is located in
the thickness of the pancreatic tissue, is left intact (since it is the desire to
remove it that leads to the development of pancreatic necrosis with a fatal
outcome), which is treated with alcohol and electrocautery. A nasogastric
duodenal tube is installed and controlled for gastric sanitation, and the edges of
the gastric defect are restored with interrupted single-row sutures on an
atraumatic needle, which achieves extragastration of the ulcer bottom (the ulcer
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bottom is outside the digestive tract, thereby eliminating the pathological
substrate, i.e. the ulcer bottom) and excluding trauma to the pancreas with the
development of postoperative pancreatic necrosis. Hemostasis control. The
gastrotomy opening is sutured using the generally accepted technique.
The shape of the stomach is restored without visible deformation, which is
achieved by using precision technology, as well as excision of the ulcer edges
taking into account the direction of muscle fibers (in their direction) and using
single-row interrupted sutures on an atraumatic needle. All this allows avoiding
local areas of tension and dilation of the gastric wall in the sutures when
performing gastroplasty.
Optimal conditions for the regeneration of adapted tissues of the combined
gastric suture are provided by gastrointestinal decompression and, if necessary,
gastric mucosal lavage. Intraoperatively, a polyvinyl chloride tube from a blood
transfusion system with lateral microperforation holes is installed through the
gastrotomy opening. During the first day after the operation, gastric lavage is
performed every 3-4 hours to evacuate stagnant gastric contents. We have not
observed cases of suture failure.
In the period from 2019 to 2022, this method was used in 10 patients with
gastric ulcer complicated by bleeding accompanied by penetration into
surrounding organs (mainly into the pancreas).
Conclusion.
The developed method of excision of a bleeding gastric ulcer
with penetration into the pancreas allows avoiding injury to the pancreas (due
to extragastration), with the development of postoperative pancreatic necrosis
with a fatal outcome. The shape of the stomach is restored without visible
deformation, which is achieved by using precision technology, as well as single-
row interrupted sutures on an atraumatic needle to restore the edges of the
defect, which eliminates the effect of gastric juice and pain syndrome. The
technical implementation of this method does not cause difficulties, reliable
hemostasis is achieved and special medical equipment is not required. All this
allows avoiding local areas of tension and dilation of the gastric wall in the
sutures when performing gastroplasty.
We did not observe any cases of postoperative pancreatitis or suture
failure.
Bibliography:
1.
Age classification of the World Health Organization (WHO). 2021. April 4.
https://glavkniga.ru/forum/topic/6904#.
2.
Ivashkin V.T., Maev I.V., Tsarkov P.V., et al. Diagnosis and treatment of
peptic ulcer in adults (Clinical guidelines of the Russian Gastroenterological
ACADEMIC RESEARCH IN MODERN SCIENCE
International scientific-online conference
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Association, Russian Society of Colorectal Surgeons and Russian Endoscopic
Society). Russian Journal of Gastroenterology, Hepatology, Coloproctology.
2020;30(1):49–70.
3.
Ismailov B.A., Sadykov R.A., Palymbetova D.N. Delivery device for the use
of hemostatic coating Geprocel in minimally invasive surgery // Problems of
biology and medicine. - Samarkand - 2018. - No. 4 (104) - P. 160 - 163.
