Сhronic gastric ulcer and concominant pathology of the abdominal cavity's organs: tactics of surgical treatment

Abstract

So often chronic gastric ulcer (CGU) associated with other diseases of digestive tract, particularly with esophageal hernia (EH) and gallstone disease (GSD). Pathogenic connection was proved between chronic gastric ulcer and accompanying pathology. However, the tactics of treatment and its results do not satisfy clinicians [1-3]. The aim of the study was to improve the results of surgical treatment of patients with CGU with concomitant pathology of the abdominal cavity. Materials and methods. Concomitant gastric ulcers diseases of the abdominal cavity (EH, GSD) were found in 84 people out of 442 patients with CHD (19.0%): ED was registered in 36 patients (26.9%), GSD - 48 patients (35.8%). EH was detected in 15 patients with Johnson type 1 CGU (41.7%), in 6 patients with type 2 CGU (16.6%) and in type 15 CGU patients (41.7%). In 15 patients with concomitant EH ulcers, the onset of ulcers was preceded by symptoms of reflux esophagitis, and in 9 patients a history of diagnosis of EH was established in GERD. Patients complained of burning pain behind the chest, sour belching, vomiting food in a horizontal position and leaning forward. Endoscopically, EH was suspected in 46 patients, but X-ray confirmed the final diagnosis in only 36 patients. One of the cardinal endoscopic features of EH was a change in the ratio of the vertical axis of the esophageal orifice of the diaphragm (EOD) muscle ring to the dentate line. Among 48 patients with concomitant GSD ulcers, 23 patients were diagnosed with type 1 CGU (47.9%), 19 with type 2 CGU (39.6%) and 6 patients with type 3 CGU (12, 5%). The vast majority of patients in this group were women (75%). All patients without exception with concomitant gastric ulcer pathology of the abdominal cavity underwent a course of preoperative pathogenetic drug therapy. In cases where clinical and instrumental manifestations of both diseases were pronounced, and conservative treatment of patients was ineffective, we performed simultaneous surgical interventions. Gastric surgery included classic gastric resection, partial gastrectomy with pyloroplasty, duodenoplasty. Among the surgical interventions for concomitant gastric ulcer EH preferred combined operations (plastic EOD) with cruropexy or esophagofundoplication with cruropexy), including supplemented by gastropexy. With concomitant ulcers of GSD, in cases where the ulcer healed with medication before surgery, patients underwent isolated laparoscopic surgery on the gallbladder and biliary tract. Against the background of active ulcers, simultaneous surgical interventions were used, the nature of which on the stomach depended on the type of ulcer. Results of the research. As a result of therapy in 15 patients (41%) with concomitant EH gastric ulcer completely healed and disappeared clinical and endoscopic manifestations of reflux esophagitis, another 15 patients (41%) gastric ulcer scarred. In the remaining 6 patients (18%) conservative measures were unsuccessful (ulcer did not scar, and the effects of reflux gastritis did not decrease), they underwent simultaneous surgery. Analyzing the immediate and long-term (within 5 years) results of surgical treatment (simultaneous interventions) of this category of patients, it should be noted that a combination of radical surgical interventions on ulcers (classic gastric resection, partial gastrectomy with pyloroplasty, duodenoplasty) with EOD or esophagoplasty cruropexy. We have not registered any recurrence of both EH and CGU. A control clinical and endoscopic study performed in patients with GSD and concomitant ulcers 14 days after the start of therapy revealed complete scarring of the ulcer defect in 17 (35%) patients, and in 14 patients (29%) registered positive dynamics of the disease scarring, reduction of dyspeptic syndrome). The last group of patients (lack of progression of the inflammatory process from the gallbladder) conservative treatment was extended to complete healing of CGU, after which they were operated on for GSD. Isolated laparoscopic surgery on the gallbladder was performed in 31 patients with concomitant gastric ulcer. In 17 patients (35.4%) medical treatment was ineffective (ulcer did not scar, severe dyspeptic syndrome persisted), so all of them underwent simultaneous surgery. Three patients after classic gastric resection (17.6%) were diagnosed with the development of mild dumping syndrome, which continued to be observed in 2 patients for 2 years. Conclusion. The use of long-term and traumatic simultaneous surgical interventions leads to the development of severe postoperative complications in 15% of patients, with the frequency of purulent-septic complications was 8.7%, and postoperative mortality - 4.3%. Preoperative drug treatment of patients with concomitant gastric ulcer and pathogenetically related pathology of the abdominal cavity helps to determine the sequence of the pathological process and in some cases reduce clinical manifestations or eliminate secondary disease. Pathogenetic approach in choosing the method of treatment of peptic ulcer disease (EH, GSD) made it possible to avoid traumatic and long-term simultaneous surgical interventions in favor of isolated, including minimally invasive, in 60.8% of patients. Adequate medical correction of comorbidities made it possible to eliminate the clinical and instrumental manifestations of concomitant pathology of the abdominal cavity and CGU in 23.9% of patients and to abandon their surgical treatment. References 1. Gutt C, Schläfer S, Lammert F. The Treatment of Gallstone Disease. Dtsch Arztebl Int. 2020 Feb 28;117(9):148-158. doi: 10.3238/arztebl.2020.0148. PMID: 32234195. 2. Huerta CT, Plymale M, Barrett P, Davenport DL, Roth JS. Long-term efficacy of laparoscopic Nissen versus Toupet fundoplication for the management of types III and IV hiatal hernias. Surg Endosc. 2019 Sep;33(9):2895-2900. doi: 10.1007/s00464-018-6589-y. Epub 2018 Nov 26. PMID: 30478698. 3. Yu HX, Han CS, Xue JR, Han ZF, Xin H. Esophageal hiatal hernia: risk, diagnosis and management. Expert Rev Gastroenterol Hepatol. 2018 Apr;12(4):319-329. doi: 10.1080/17474124.2018.1441711. Epub 2018 Feb 22. PMID: 29451037.