Diagnosis and treatment of patients with recurrent gastroduodenal hemorrhage - Shaprynskyi V.O. 2009

Surgical treatment of recurrent ulcerative gastroduodenal hemorrhage
Surgical strategy and indications for various types of surgical interventions

The Treatment of patients with acute gastroduodenal ulcer bleeding remains a subject of intense study for a wide range of surgeons. In discussing the issue of ulcer bleeding, the debate over the choice and comparative efficacy of various management strategies remains highly contentious.

Velyhotskyi M.M. et al., 2001, substantiate the feasibility of an individually tailored active surgical approach, which includes: 1) endoscopic Assessment of the bleeding source, ulcer localization and size, and the degree of hemostasis at its base; 2) assessment of the severity and rate of bleeding, and the number of recurrences; 3) age and comorbidities; 4) risk assessment of urgent surgery. Based on prognostic elements and the severity of the patient's condition, the authors propose the following types of surgical interventions: 1) emergency (at the peak of bleeding); 2) delayed (indicated for unstable hemostasis, threat of recurrent bleeding, or severe Blood loss); 3) early elective.

Fomin P.D., Shepetko Ye.M. et al., 2007, developed a specific algorithm for treating patients with gastroduodenal bleeding based on prognostic factors for early recurrent bleeding. This algorithm includes the following types of surgical interventions: 1) emergency (within the first 6 hours) for ongoing bleeding when endoscopic hemostasis fails; 2) urgent (6–12 hours) for high and moderate risk of recurrent bleeding (according to their developed prognostic scale, see table);

3) early delayed for a low risk of recurrent bleeding. The authors do not define elective surgical interventions for this category of patients at all.

Dziubanovskyi I.Ya. et al., 2007, also base their choice of management strategy for patients with gastrointestinal ulcer bleeding on prognostic elements. However, along with clinical and endoscopic data, they utilize local immunomorphological parameters. In this regard, the authors distinguish: 1) emergency surgical interventions (up to 3 hours) for ongoing bleeding and ineffective endoscopic hemostasis; 2) urgent surgeries (up to 6 hours) in case of recurrent bleeding; 3) early delayed; 4) late delayed; 5) elective surgical interventions.

Undoubtedly, an active surgical strategy based on prognostic elements of recurrent bleeding and an individually tailored, rational approach to the objective assessment of the patient's condition remains the strategy of choice today for treating patients with gastroduodenal ulcer bleeding.

To determine the severity of the patient's condition, V.K. Gostishchev and M.A. Evseev (2007) use the APACHE II integral score—a system with the most objective capabilities for assessing patient severity, which accounts for acute pathophysiological changes, comorbidities, and patient age. Objectifying the assessment of severity in patients with gastrointestinal bleeding limits the performance of emergency surgeries without adequate preoperative preparation. Furthermore, this system allows for monitoring the adequacy of intensive therapy and preoperative preparation.

Thus, Gostishchev V.K. and Evseev M.A. (2007) distinguish a specific tactical approach that allows for individualizing treatment measures in gastrointestinal bleeding depending on the risk of recurrence and taking into account the severity of the patient's condition, calling it a "differentiated approach."

Gostishchev V.K. and Evseev M.A., 2007, identify ongoing bleeding with ineffective endoscopic hemostasis as an indication for surgical intervention. Recurrent bleeding is undoubtedly an indication for emergency surgery. However, even in the event of recurrence, surgery should only be performed if the patient's overall status is adequate for the intervention. Otherwise, repeated endoscopic hemostatic measures must be performed alongside ongoing intensive replacement therapy.

Shaprynskyi V.O., Kaminskyi O.A., and Pavlyk I.V., 2007, developed a treatment strategy for patients with acute recurrent gastrointestinal ulcer bleeding (ARGIB) based not only on predicting recurrence and assessing severity but also on estimating potential mortality risk at admission. We have defined this approach as an active, individually tailored, rational strategy, which consists of the following algorithm:

1) Statistical analysis of Factors influencing the development of ARGIB justifies prioritizing the following diagnostic Procedures: urgent EGD with potential endoscopic hemostasis, red blood Cell laboratory parameters, and consultations with related specialists to assess the presence and severity of comorbidities.

2) Risk assessment of ARGIB development using the developed prognostic model, alongside estimating potential mortality risk using the Rockall score.

3) Alongside urgent diagnostic procedures, the patient is indicated for medical hemostatic and infusion therapy, and, if necessary, anti-Shock therapy and blood transfusion.

4) Indications for Surgical treatment are:

5) Patients with a high risk of recurrent bleeding and high mortality risk are indicated for conservative therapy combined with endoscopic hemostatic therapy. In case of recurrent bleeding, preference is given to repeated endoscopic hemostatic therapy.

The goal of surgical treatment at the peak of recurrent bleeding in gastric and duodenal ulcer disease is to perform the simplest, fastest, and pathogenetically justified surgical intervention that would not only stop the bleeding but also prevent its recurrence in the postoperative period. However, it should be noted that during urgent surgical interventions, complex forms of PEPTIC ULCER DISEASE are often found simultaneously, such as ulcers complicated by both penetration and bleeding, perforation and bleeding, double and multiple ulcers, including "kissing" ulcers; giant subcircular and circular ulcers stenosing the gastric outlet and duodenum, as well as ulcers that impair intestinal motor function.

Given the above, the issue of performing a single-stage radical, pathogenetically justified operation that would simultaneously correct these disorders and achieve stable recovery becomes particularly relevant.

The extent of surgical intervention in gastric ulcer disease complicated by ARGIB depends on the ulcer localization, its size, and the patient's condition. In the presence of a small gastric ulcer (up to 2 cm) with minimal surrounding tissue infiltration, excision of the gastric ulcer within healthy Tissues followed by gastroplasty is recommended; in the case of an ulcer defect larger than 2 cm localized in the gastric body, segmental gastric resection is recommended.

In the presence of a large ulcer (over 2 cm) in the antral and pyloric Regions of the Stomach, as well as other complications of peptic ulcer disease, resection Methods of surgical techniques are recommended, namely performing Billroth I gastric resection, or Billroth II gastric resection, most commonly modified by Hofmeister-Finsterer, Balfour, or Vitebsky.

The greatest technical difficulties arise in patients with gastric ulcer disease when the ulcer is localized in the cardiac and subcardiac regions of The Stomach. In this case, during recurrent gastric bleeding, we use ulcer excision followed by gastroplasty with a double-row suture and devascularization of the ulcer zone (ligation of the left gastric artery). In our view, this extent of surgery meets all the requirements for surgical interventions at the peak of bleeding.

Organ-preserving operations should be considered the primary intervention for duodenal ulcer disease, which include excision and extraterritorialization of the ulcer followed by duodeno- or pyloroduodenoplasty combined with one of the types of vagotomy.

Excision, which means complete removal of the ulcer along with its walls and base, is used when the ulcer is located on the anterior, anterosuperior, or anteroinferior walls, where areas of shallow penetration may be present.

In the case of deeply penetrating ulcers, we perform extraterritorialization of the ulcer outside the lumen of the duodenum. From our point of view, this method is radical, since an ulcer located outside the lumen of the gastrointestinal tract poses no threat of recurrent bleeding. Such ulcers are predominantly located on the posterior wall of the bulb, as well as in the postbulbar region of the duodenum.

In the presence of a giant ulcer, i.e., more than 2 cm in diameter, other complications besides bleeding, as well as multiple ulcers and double-site ulcers, we prefer resection methods of surgical treatment with ulcer removal or exclusion of the ulcer (extraterritorialization of the ulcer).

In rare cases, when the patient's condition is extremely critical, simple undersewing of the vessel at the Base of the ulcer may be appropriate; however, it must be noted that this extent of surgery is not pathogenetically justified, which often leads to recurrent bleeding from the sutured vessel in the postoperative period.

It should be noted that, despite significant advances in conservative hemostatic therapy and endoscopic hemostasis techniques, early preventive surgery in patients at high risk of recurrent bleeding remains to this day the only method for preventing recurrent Hemorrhage.

The Use of endovascular catheter embolization of the bleeding vessel warrants separate mention. Ripoll C. et al., 2000, compared surgical treatment in 39 patients with embolotherapy in 31 patients. However, they found no statistically significant advantage of one method over the other; therefore, the use of embolotherapy should also be based on an individualized approach to patient care.

The choice of elective surgical intervention for chronic duodenal ulcer deserves special attention.

Selecting the optimal surgical Procedure for duodenal ulcer depends on several key factors, the primary being the level and nature of gastric secretion. Each patient should be assigned to one of three groups.

The first group consists of patients indicated for a two-thirds gastric resection or interventions aimed at managing Zollinger-Ellison syndrome. This group includes:

1) patients with complicated ulcers, a nocturnal gastric secretion level above 70 mmol, and a negative medical vagotomy test;

2) patients with uncomplicated, long-standing peptic ulcer disease resistant to conservative therapy, with a nocturnal secretion level above 40 mmol, stimulated secretion above 30 mmol/h regardless of the basal secretion rate, and a negative medical vagotomy test;

3) patients with recurrent ulcers after vagotomy that are complicated or resistant to conservative therapy;

4) patients with Zollinger-Ellison syndrome.

Young, nulliparous women may be an exception to subgroups 1 and 2, as it has been noted that Pregnancy rarely occurs in the vast majority of female patients after extended gastric resection. In cases of hypersecretion and pyloroduodenal stenosis, vagotomy with antrectomy is advisable.

The second group consists of patients in whom vagotomy generally yields excellent and good results. This group includes:

1) men and women over 50 years of age with complicated ulcers, a nocturnal gastric secretion level below 50 mmol, and a positive medical vagotomy test. In this category of patients, the ulcer recurrence rate after vagotomy with a drainage procedure is the lowest, at 3-4%;

2) men and women aged 30 to 50 years with complicated ulcers, a nocturnal gastric secretion level below 70 mmol, a maximal histamine test value of less than 30 mmol/h, and a basal secretion above 5 mmol/h with its suppression by atropine by 55% or more.

Choosing the optimal surgery is most challenging for patients in the third group, which includes:

1) patients of both sexes under 30 years of age with complicated ulcers who are not classified as "hypersecretors" but typically have high histamine levels that stimulate nocturnal secretion to more than 30 mmol/h;

2) men and women of any age with therapy-resistant ulcers, a nocturnal gastric secretion level below 40 mmol, and a Kay's test value below 30 mmol/h.