ANALYSIS OF THE RESULTS OF TREATMENT OF PERFORATED DUODENAL ULCERS
Kemerovo State Medical Academy,
Kemerovo, Russia
The modern antisecretory and antibacterial therapy of peptic ulcer on the basis of the leading peptic and infectious concepts of ulcerogenesis has solved only the part of the problem of treatment of this disease [1, 2, 3, 4]. With use of the wide range of pharmaceuticals it is possible to quickly (within 2-3 days) suppress acid production before development of achlorhydria and to remove pain syndrome resulting in quick recovery of peptic ulcer. As result, necessity for planned surgical treatment decreased.
At the same time, past experience shows that despite of short term positive outcomes of drug therapy the number of complications (including perforated duodenal ulcer) of peptic ulcer requiring urgent surgical treatment is still high. Moreover, there are some significant variations in the amount of such operations in various time intervals, and it means availability of some social factors, which influence on appearance and course of duodenal ulcer [5, 6].
Objective – to conduct the analysis of the annual number of operations for perforated duodenal ulcer, the role of acid peptic aggression in ulcerogenesis, the results of acid-reducing interventions and percentage of contamination with helicobacteriosis.
MATERIALS AND METHODS
The retrospective analysis included the annual reports of the regional surgeon and the surgical department of Kemerovo City Clinical Hospital #3 for the period from 1970 till 2015. Also the numbers of operations were compared according to the decades: 1970-1980, 1991-2000 and 2001-2011. The method of overall observation was used for examination of 85 patients 1-14 years after suturing perforated duodenal ulcer and selective proximal vagotomy (SPV). The group 1 (41 patients) received selective proximal vagotomy by means of stomach skeletonization without following eradication therapy (1971-1997). The patients of the second group (n = 44) were operated after 1997: suturing was combined with SPV by means of chemical denervation [7, 8] and the following eradication therapy after identification of helicobacteriosis with use of the available standards (two antibacterial drugs and one antisecretory drug). The patients of the first group were examined 7-14 years after interventions, the patients of the second group – 1-5 years. The group of healthy individuals included the volunteer students of Kemerovo State Medical Academy who had no signs of digestive system pathology.
The examination included fiberoptic gastroduodenoscopy, analysis of proteolysis and levels of hydrochloric acid in the region of the gastric corpus by means of the diffuse technique according to Gorshkov V.A. et al. (1988). Besides, in 2013-2015 the method of overall observation was used for examination of 67 patients for identification of helicobacteriosis before hospital discharge after suturing perforated duodenal ulcer. Helicobacteriosis was diagnosed with the impression smears of the body mucosa and the antrum which were sampled during gastroscopy with mucosal biopsy. After fixation the impression smears were colored according to Gram and Pappenheim-Kryukov. Student’s test and Wilcoxon-Mann-Whitney test were used for estimation of reliability of differences in the intergroup values. Chi-square test and Pearson’s test were used for estimation of statistically significant differences in qualitative values. P < 0.05 was statistically significant.
RESULTS
One may observe the significant increase in the number of operations during 1990s (table 1), i.e. the years of overall instability, closing of enterprises, late payment or non-payment of wages in comparison with the stable and quiet 70s and 80s. The last years demonstrate some trends to decreasing number of patients with perforated duodenal ulcers. So, 547 patients were operated in Kuzbass in 2012, 461 – in 2013, 447 – in 2014; in the surgical unit – 35, 27 and 26 patients correspondingly. In 2015 20 suturing procedures for perforated duodenal ulcers were conducted. The epidemy of perforated duodenal ulcers comes to the end simultaneously with economic stabilizing in absence of significant variations of the number of inhabitants in the city and in the region.
Table 1
|
The minimal and maximal numbers of operated patients with perforative duodenal ulcers per year by decades |
| Notes: * - statistically significant differences from decades (I); ** - statistically significant differences from a decade (II). |
The cardiologists note the similar time trends relating to the mortality as result of myocardial infarction (with the significant increase during 1990s) which are interpreted by them as result of influence of negative psychosomatic and psychosocial factors [9, 10]. It is evident that these factors play either trigger role or intensifying role (for other ulcerogenes) in the origin of perforated duodenal ulcers. Actually, it is difficult to correlate these variations only with the infectious concept of ulcerogenesis. Moreover, helicobacteriosis was not found in the impression smears of antrum mucosa and the gastric corpus in 34.3 % of the cases (23 patients) among 67 examined patients within the nearest time intervals after suturing perforated duodenal ulcers in 2013-2015. Helicobacteriosis was found in 65.7 % of the operated patients. It is difficult to correlate these values with imperfection of the technique of identification of helicobacteriosis. One should note that the operated patients received some antibiotics on a single occasion on the day of surgery, i.e. without previous appropriate eradication therapy at the moment of sampling the impression smears.
Both in prehelicobacter period and at the present time, many authors note the high rate of recurrent peptic ulcers after isolated suturing perforated duodenal ulcer (about 40-80 %) [6, 11, 12, 13, 16, 18]. We have been supplementing selective proximal vagotomy to suturing duodenal ulcer for 44 years (with receiving the informed consent during the past years). Both the skeletization technique and chemical denervation of the acidogenic region of the stomach decrease its acid proteolytic activity (APA) [7, 8, 17]. If patients with perforated duodenal ulcers demonstrate significant increase in digesting activity of gastric acid, then after various types of selective proximal vagotomy APA of the gastric corpus persists within late time intervals of postsurgical period (table 2).
Table 2
|
Acid and proteolytic activity of stomach body in healthy persons and in perforative duodenal ulcer in relation to surgical treatment |
| Notes: * - statistically significant differences in relation to isolated suturing; ** - statistically significant differences in relation to healthy persons. |
Examination of the impression smears in the second group of the operated patients after suturing with vagotomy (n = 15) showed helicobacteriosis. After 2000 the eradication therapy was realized in the hospital or on ambulatory basis after discharge from the surgery unit. According to the literature data, none of the schemes of eradication therapy has efficiency more than 80-90 % [16, 21]. There are some findings about appearance of antibiotic resistant infection and reinfection [19, 20]. Helicobacteriosis was found in 4 impression smears from the gastric mucosa in 10 examined patients in the group of eradication therapy 1-5 years after interventions. Bolotov K.S. (2015) [5] found the high rate of contamination with helicobacteriosis in the late terms after organ-saving operations and outpatient eradication therapy for duodenal peptic ulcer. The facts about negative results of diagnostics of helicobacteriosis in perforated duodenal ulcer suppose its absent role in ulcerogenesis of perforated duodenal ulcer. The problem of such high rate of helicobacteriosis in late terms after eradication therapy requires an individual solution.
We conducted the comparative analysis of the number of recurrent duodenal ulcers in the late terms after interventions without eradication therapy and with it (table 3). There were no statistically significant differences.
Table 3
| The number of disease recurrence in late terms after operation |
CONCLUSION
1. During 1990s one could note the significant increase in the amount of surgical procedures for perforated duodenal ulcers, with the following stabilization of the values after 2001.
2. Perforated duodenal ulcer is characterized with significant increase in acid proteolytic activity of gastric acid. Vagus regulatory mechanisms play the significant role in intensifying peptic aggression. Helicobacter infection presents only in 65.7 % of patients with perforated duodenal ulcers.
3. Selective proximal vagotomy in combination with suturing perforated duodenal ulcer is accompanied by recurrence of the disease in 7.3 % of cases within the period of follow-up up to 14 years.
4. Eradication therapy after suturing with SPV is accompanied by high percentage of contamination of mucosa in late terms after surgery. It is not associated with significant decrease in rates of the recurrent disease.