Оncogenesis of chronic gastric ulcer and pathogenetic principles of surgical treatment of patients

Abstract

The role of peptic ulcer disease (PUD) and dysregenerative changes (DC) in gastrocarcinogenesis is still not fully defined [1], the rates of malignancy of chronic gastric ulcer (CGU) vary widely (0-44.4%) [3]. There are serious problems in the differential diagnosis of CGU and gastric cancer at the clinical, instrumental and morphological stages. The oncologist gave surgeons all the grounds for immediate intervention on the ulcer, taking into account all the rules of ablastics. In planned surgery, classic gastric resection (CGR) was accompanied by a high mortality - 2 - 4%, with perforated ulcer - 5.1 - 12.3% with bleeding - 2.5 - 30% [4,6]. 6 - 80% of patients developed postgastroresection complications [2], which caused disability in 20 - 30% of patients operated within first year after surgery, and 10 - 15% - within later periods. 20 years after CGR in 10-70% of cases recorded the development of gastric stump cancer and in 15 - 20% of cases - cancer of other organs [2,5]. The aim of the work is to determine the frequency of true malignancy of CGU and to improve the results of surgical treatment of patients. Materials and methods. We analyzed the results of treatment of 129 patients with PUD (CGU type 1 by Johnson) in the period from 1990 to 2021. Men accounted for 71.3% and women for 28.7%. The age of patients ranged from 16 to 98 years, averaging 53.5 ± 2.2 years. 77 patients with large and giant CGU (59.7%) were admitted to the clinic as planned and 52 patients were admitted to the clinic by ambulance (40.3%). In 59 patients (45.7%) histological examination of polypositional endoscopic gastrobiopsy (PEGB) revealed CGU on the background of DC in the gastric mucosa in varying degrees of differentiation: in 32 (62.7%) patients epithelial dysplasia (ED) was mild and moderate, in 28 (37.3%) patients - severe. Of the 52 patients admitted to the clinic in an urgent manner, ulcer perforation was found in 13 patients (25%), ulcer penetration - 7 patients (13.5%), gastric bleeding - in 32 patients (61.5%). Several ulcer complications were registered in 8 patients with CGU (15.4%). 25 patients (32.5%) were referred from the outpatient department with a previous diagnosis of “Malignant gastric ulcer”. Results of the research. We studied the nature of DC in the gastric mucosa, both in the area of ulcerative infiltrate and at a distance from it (chromogastroscopy). In the course of the study it was found that in the field of chronic ulcers DC (intestinal metaplasia (IM) and ED), are usually rare and are mostly mild. It has been proven that true malignancy of CGU occurs in 0.78% of cases, and the data on the high incidence of CGU in cancer (up to 44.4%) in the literature are nothing but misinterpreted cases of primary gastric cancer. The choice of treatment for patients with PUD depends on a number of reasons, the main of which is to establish the nature of gastric lesions. All patients with CGU, except for cases of emergency surgery, underwent preoperative medical treatment, which included the use of modern schemes of antiulcer therapy. In case of gastrointestinal bleeding were used endoscopic methods to arrest it. Stable clinical and endoscopic remission of the disease was achieved in 50.4% of cases, which made it possible to avoid performing a surgery in this category of patients. 64 patients with PUD (49.6%) were operated. It should be noted that the preservation after 4-6 weeks of conservative treatment in patients with PUD severe ED is an absolute indication for the carring out of CGR, the amount of which depends on the prevalence of these changes - 21 patients (32.8%). In the absence of severe precancerous changes in the gastric mucosa, the operation of choice for CGU type 1 is considered one of the options for economy (plastic) resection - 43 patients (67.2%). The development of postgastroresection complications during the year after CGR surgery was registered in 3 patients (14.3%), including recurrent ulcer (one case). After economy (plastic) resection , these complications were not detected in any patient. Three nonoperated patients died as a result of profuse gastric bleeding (2.3%). Conclusion. 1. The role of PUD in gastric carcinogenesis is exaggerated (true malignancy of CGU occurs in about 0.78% of cases), and data on the high incidence of ulcer malignization is nothing but misinterpreted cases of primary gastric cancer. 2. The operation of choice for complicated PUD (type 1) is economy (plastic) resection. 3. 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