Сhronic duodenal obstruction and peptic stomach ulcer: interrelation, diagnostics and surgical correction

Abstract

Chronic duodenal obstruction (CDO) or duodenostasis and peptic stomach ulcer (PSU) are interconnected and making more severe each other diseases [1-3]. The conservative treatment renders effect in 61 % of the patients with functional duodenostasis and only in 19 % of the patients with mechanical, rendering at last temporary action [4,5]. The aim of this study was to improve the treatment outcomes of patients with CDO with concomitant PSU. In this regard, we set the following tasks: to identify the relationship between PSU and duodenostasis based on a comprehensive examination of this category of patients and to analyze the results of surgical treatment of comorbidities using a variety of surgical techniques. Materials and methods. The study included 50 patients with concomitant PSU. According to the classification of Nesterenko YA et al. (1990) in 18 patients (36%) functional somatogenous duodenostasis was detected (against the background of severe PSU) and in 32 patients (64%) - mechanical CDO, of which - mechanical congenital (anomalies of duodenum and surrounding vessels) - in 3 patients (9.4%) and mechanically acquired (cicatricial stenosis of the duodenum, cicatricial periduodenitis and connective tissue in the Treitz area) - in 29 patients (90.6%). The presence of CDO was judged from the clinical picture (symptoms of Kellogg, Koenig and Gaius), as well as instrumental research methods - probe duodenography, including and in conditions of hypotension, upper endoscopy. The causes of mechanical CDO were: 1) high fixation of the duodenojejunal junction (4 patients (8%); 2) arterio-mesenteric compression of the horizontal part of the duodenum (2 patients (4%); 3) local permeability of the duodenum (periduodenitis, scars in the duodenoenal transition) (34 patients (68%); 4) total periduodenitis (10 patients (20%). The choice of operative intervention method at the duodenostasis with accompanying PSU depends on a kind of duodenostasis (functional, mechanical), its extension, ulcer type (by Johnson) and character of dysplastic changes of a stomach mucous. Results of the research. In analyzing the relationship between PSU and duodenostasis based on history and patient complaints, we found that this relationship is unconditional. At the same time, an interesting pattern was revealed: the majority of patients with duodenostasis as a result of cicatricial perioduodenitis (75%) had previously suffered from PSU (mostly type 2 by Johnson). Subsequently, 25 of them (75.8%) developed gastric ulcer type 1 by Johnson, and 8 - type 2 (24.2%). In the remaining patients (functional and mechanical CDO) (25%) duodenostasis preceded the development of gastric and duodenal ulcers, and the latter, in turn, complicated the course of the primary disease. Based on clinical and instrumental data, we identified compensated (9 patients (18%), subcompensated (34 patients (67%) and decompensated (7 patients (15%) stages of the disease. We operated on 33 patients (66%). Organ-saving operations with passage preservation in duodenum are effective only at its local disorders (Visick I-II) was observed in 100% of patients). In case of total duodenum defeat with accompanying PSU preference should be given to the resections methods with exclusion duodenum from the passage (economy resection by Roux (Visick I-II) was observed in 100% of patients), Billroth-2(complications were developed in 20% of patients). In mechanical CDO with local duodenal lesions, the best results were recorded after performing one of the duodenoenteroanastomosis variants, supplemented by Strong surgery if necessary (high fixation of the duodenoejunal junction, Treitz ligament scar)(Visick I-ІІ – 83,3%, Visick IV – 16,7%). Isolated execution of Strong's operation is considered ineffective (Visick IV - 50%). At segmental periduodenitis performance of the interventions which restored a normal passage on duodenum was rather effective. Among such interventions we used the methods of duodenolysis (3 patients) and radical duodenoplasty (own development)(12 patients) (Visick I-II - 92%, Visick IV - 4%). In total perioduodenitis, as well as in the case of complications of mechanical CDO active gastric PSU, the operation of choice is gastrectomy for Ru (7 patients) (Visick I-II - 85.7%, Visick IV - 14.3%). Performing gastrectomy by Billroth 2 on a long loop with Braun anastomosis in this type of duodenostasis can also be considered quite acceptable (Visick I-II - 85.7%, Visick IV - 14.3%). It should be noted that the use of surgical interventions that preserve the passage of the duodenum, including gastrectomy by Billroth 1, is contraindicated in total lesions of the duodenum. Conclusion. The choice of operative intervention method at the duodenostasis with accompanying stomach peptic ulcer depends on a kind of duodenostasis (functional, mechanical), its extension, ulcer type (by Johnson). Organ-saving operations with passage preservation in duodenum are effective only at its local disorders. In case of total duodenum defeat with accompanying stomach peptic ulcer preference should be given to the resections methods with exclusion duodenum from the passage (resection by Roux, Billroth-2). References 1. Al Faqeeh AA, Syed MK, Ammar M, Almas T, Syed S. Wilkie's Syndrome as a Rare Cause of Duodenal Obstruction: Perspicacity Is in the Radiological Details. Cureus. 2020 Sep 15;12(9):e10467. doi: 10.7759/cureus.10467. PMID: 33083170; PMCID: PMC7566986. 2. Ji X, Dong A. Duodenal Ulcer-Induced Gastric Outlet Obstruction Showing Pyloric Wall Thickening and Abnormal FDG Uptake Mimicking Malignancy. Clin Nucl Med. 2022 Jan 21. doi: 10.1097/RLU.0000000000004067. 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