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

Historical aspects of the diagnosis and treatment of patients with recurrent gastroduodenal hemorrhage of peptic ulcer etiology

The history of the Treatment of gastric and duodenal ulcers complicated by Hemorrhage dates back to antiquity. Bleeding into the lumen of the digestive tract was known to such ancient physicians as Celsus, Galen, and Avicenna. The first report of a fatal outcome caused by a bleeding gastric ulcer is attributed to Littre (1704). Over many centuries, knowledge about the causes of bleeding accumulated, and in 1816, Fyodor Uden's work "Academic Lectures on Chronic Diseases" was published, describing the manifestations of PEPTIC ULCER DISEASE and its complications: hemorrhage and perforation. Later, in 1829, Cruveilhier described the pathological picture and symptoms of gastric ulcer, identifying pain, vomiting, and hemorrhage as its primary signs.

Over more than a century, the surgery of peptic ulcer disease has followed a complex and contradictory path. The history of this surgical field is marked by key stages that differ in the technical capabilities of Surgical treatment and the tasks set before surgeons, depending on the prevailing views of the time regarding the Etiology AND Pathogenesis of peptic ulcer disease. In our view, the main criterion for periodizing the history of Surgical Treatment of peptic ulcer disease is METABOLISM/2.html">THE CONCEPT OF the "Procedure of choice". Based on this premise, three main periods can be distinguished in the history of surgical treatment of peptic ulcer disease. The first period, from the 1880s to the 1920s, had gastroenterostomy as the method of choice. The second period, from the 1930s to the 1960s, was characterized by gastric resection as the method of choice. The third period, from the 1970s to the present, is characterized by the rapid development of organ-preserving Methods and the Introduction of vagotomy, which expanded the surgeon's arsenal and established THE PRINCIPLE OF an individualized approach: "to each patient, their own operation".

The history of gastric surgery, including in Russia, begins in the mid-19th century. In 1842, V. A. Basov, Doctor of Medicine and Surgery, published a work dedicated to creating an "artificial path into The Stomach" in animal experiments. V. A. Basov published his first report in the "Bulletins de la Société des Naturalistes de Moscou". Subsequently, this type of gastric surgery was named gastrostomy. It was first used clinically in 1849 by the French surgeon Sédillot. Later, gastrostomy became widely used as a symptomatic treatment for esophageal and pyloric obstruction. These were the first attempts to surgically control gastric hemorrhage.

In 1879, the French surgeon Péan, and in 1881, the Viennese surgeon Billroth performed the first gastric resections with gastroduodenal anastomosis. These Procedures later became known as Billroth I operations. In 1881, Wölfler performed the operation currently known as gastroenterostomy.

In 1880, von Eiselsberg first performed the excision of a bleeding gastric ulcer with suturing of the resulting defect. In 1882, Van Kleef first successfully performed a resection of the Cytology/practical/109.html">Pyloric part of the stomach with removal of an ulcer complicated by bleeding in a 16-year-old boy. In 1885, Billroth proposed the operation currently known as Billroth II. In 1886, Heineke, and in 1887, independently, Mikulicz introduced the operation known as "pyloroplasty" into surgical practice.

During the final decades of the 19th century and the early 20th century, numerous modifications of gastric resection, gastroenterostomy, and pyloroplasty were developed. The rapid advancement of gastric surgery was facilitated by the introduction of anesthesia, antisepsis, and asepsis into surgical practice.

The Development of gastric surgery in Russia generally aligned with the progress of global science. The first gastric operations, dating back to the 1870s–1890s, were performed on terminally ill patients when no other treatment options were available.

The first gastrostomy in Russia was performed by V. F. Snegirev. He reported on this operation at a meeting of the Physico-Medical Society on March 7, 1877, in Moscow. A 30-year-old woman was operated on on January 9, 1877. Death occurred 30 hours after the completion of the surgery. From 1877 to 1882, 15 gastrostomies were performed in Russia out of 126 performed worldwide at that time. The first gastric resection in Russia using the Billroth I method was performed on July 16, 1881, by M. K. Kitaevsky in the women's surgical department of the Peter and Paul Hospital in St. Petersburg. The patient, M. Schneider, 52 years old, was operated on for pyloric Cancer complicated by bleeding. By 1895, according to K. Klein, 15 gastric resections had been performed in Russia.

The first gastroenterostomy according to Wölfler's method was performed in Russia on March 13, 1882, by N. D. Monastyrsky. The gastroenterostomy was performed on a 36-year-old patient, Fyodor Petrov. The operation lasted 2 hours, and the patient died 7 hours after its completion. On April 14, 1888, E. M. Goldengorn and S. N. Kolachevsky reported at a meeting of physicians of the Odessa City Hospital on an operation they had performed on April 10, 1888, in the same hospital. The patient was discharged on May 27 of the same year with the Diagnosis "fully recovered".

The first Heineke-Mikulicz pyloroplasty in Russia was performed in the private surgical clinic of Dr. A. D. Kni on May 30, 1890, for pyloric stenosis following the ingestion of crude sulfuric acid. In our historical medical literature, There is a widespread, inaccurate belief that the first pyloroplasty in Russia was performed by K. Klein. In "Essays on Gastric Surgery", S. S. Yudin, referring to K. Klein's dissertation, wrote: "...in Russia, the first pyloroplasty was performed by K. Klein on November 29, 1890, at the Novo-Ekaterininsky Hospital in Moscow." According to S. S. Yudin, 35 pyloroplasties had been performed in Russia by 1895.

In 1892, Doyen first performed an operation for a bleeding gastric ulcer—gastroenterostomy, which became highly popular over the next 40 years. In 1900–1903, S. P. Fedorov proposed combining gastroenterostomy with cauterization of the bleeding ulcer.

In 1896, the first report by I. P. Pavlov on the survival of dogs after bilateral vagotomy appeared, and in 1897, his "Lectures on the Work of the Main Digestive Glands" were published. These works by the Russian genius subsequently became the physiological foundation for the development of gastric surgery worldwide.

The Brief Overview of gastric surgery in Russia up to the end of the 19th century presented above leads to the Conclusion that Russian surgeons by that time had accumulated sufficient clinical experience and mastered the fundamental techniques of gastric operations. Even in the Early stages of gastric surgery, the Main criteria for justifying the advantages of resection, plastic reconstruction, or gastroenterostomy were outlined. In 1897, at the Congress of German Surgeons, Mikulicz expressed the view that the choice of surgical method would be determined not so much by the immediate results of the operations, but by their long-term outcomes. These ideas run like a red thread through the entire history of gastric surgery to the present day. In their 1975 monograph "Gastric Resection and Gastrectomy", V. S. Mayat et al. wrote: "What are the Main Features of the modern period of gastric surgery as it approaches its century-long historical milestone? In our view, this period is characterized primarily by a critical approach of most surgeons to evaluating the long-term Outcomes of surgical interventions on the stomach."

By the late 1880s, the first signs of division among domestic surgeons into supporters of gastroenterostomy and gastric resection for the treatment of peptic ulcer disease emerged. At that time, a strong argument in favor of gastroenterostomy was its lower postoperative mortality rate—47% compared to 71% for gastric resection (according to 1888 data). Gastric operations for ulcers were performed only for life-saving indications at that time and were palliative in nature.

By the beginning of the 20th century, gastric surgery in Russia had accumulated enough experience to develop as an independent branch of surgery. For example, at the First Congress held in 1890, A. D. Birshtein delivered a report titled "On the Casuistry of Surgical Treatment of Pyloric Stenosis". Renowned surgeons such as S. P. Fedorov, V. I. Razumovsky, V. M. Zykov, S. I. Spasokukotsky, A. S. Tauber, K. M. Sapezhko, G. F. Zeidler, and others participated in the Structure/133.html">Discussion of this report. At the Second Congress of Russian Surgeons, the problems of gastric surgery were highlighted in a special program section: "Indications for Gastroenterostomy; Methods of Execution and Its Results".

In 1906, the Sixth Congress of Russian Surgeons took place, where O. A. Yutsevich and I. K. Spizharny expressed the view that patients with a bleeding ulcer required urgent surgery. Preference was given to cauterization and gastroenterostomy. In the same year, at the 35th Congress of German Surgeons, a watchful waiting approach was advocated for bleeding ulcers.

The first attempts to consider gastric resection as a treatment for peptic ulcer disease date back to 1909. In the same year, the Ninth Congress of Russian Surgeons was held, with one of its main sessions dedicated to "Surgical Treatment of Round Ulcer and Its Long-Term Results". The session was held jointly with the First Congress of Russian Internists (at that time, the treatment of bleeding was managed by internists). Proponents of resection criticized the shortcomings of gastroenterostomy. K. M. Sapezhko, defending THE POSITION OF resection, stated that a third approach—"a radical proposal to excise the gastric ulcer"—was joining the two earlier directions in ulcer treatment: medical and palliative-surgical (gastroenterostomy). S. I. Spasokukotsky declared that "gastroenterostomy has not solved The problem of surgical treatment of ulcers and their complications, and the future belongs to resection". At the Tenth Congress of Russian Surgeons, P. S. Babitsky stated that gastric resection would become the "operation of choice in the future".

World War I and the revolutionary events in Russia changed the way of life for millions of people, leading to an "ulcer epidemic" in the 1920s. This circumstance brought the problem of surgical treatment of ulcers to the forefront. It is sufficient to cite the fact that at the 15th Congress of Russian Surgeons in 1922, the keynote topic was "Ulcus ventriculi et ulcus duodeni". Leading Russian surgeons presented reports on this subject. Most of them still favored gastroenterostomy, but the proponents of resection had strong arguments, and their voices sounded more confident than at any previous congress. It should be noted that at the same congress, internist A. I. Bulavinsky spoke, advocating the necessity and feasibility of conservative treatment for bleeding. The same point of view was shared by such renowned internists as N. D. Strazhesko and M. P. Konchalovsky.

At the 16th Congress of Russian Surgeons, S. S. Kuzmin's report concluded that an emergency operation—gastric resection—was necessary in cases of recurrent bleeding. His opinion was supported by V. A. Oppel and P. D. Sokolov.

The confrontation between supporters of gastroenterostomy, which emerged at the 15th Congress, on the one hand, and proponents of gastric resection on the other, became particularly sharp at the 19th Congress, where the keynote topic was reoperations. Reports and presentations at this congress were delivered by N. N. Petrov, V. A. Oppel, E. R. Hesse, S. S. Girgolav, I. I. Grekov, Ya. O. Galpern, and others. I. I. Grekov compared the intensity of the debate over the procedure of choice at this surgical congress to the dispute between "Old Believers and the Orthodox". Although the number of supporters of resection and gastroenterostomy was approximately equal (both in numbers and scientific authority), there is no reason to consider the 19th Congress as a "turning point in favor of resection as the method of choice".

In 1928, S. I. Spasokukotsky reported at a meeting of the surgical society on 7 patients operated on for ulcer bleeding who underwent gastric resection. Finsterer reported on 93 operated patients with a mortality rate of 20.4%, but mortality was significantly lower when patients were operated on within the first 24–48 hours from the onset of bleeding, and much higher after prolonged, unsuccessful conservative therapy. An active approach was advocated by S. S. Yudin and B. A. Petrov; they reported that after a watchful waiting strategy, mortality was 23.3%, whereas after surgery, it was 14.8%.

A huge step forward in the treatment of acute gastrointestinal bleeding was the ESTABLISHMENT OF THE first Institute of Hematology and Blood Transfusion in Ukraine in 1930 by government decree, with Professor V. M. Shamov as its organizer and first director. The feasibility of blood transfusions was demonstrated, both for the purpose of hemostasis and blood replacement.

In 1938, the 24th All-Union Congress of Surgeons took place in Kharkiv, becoming an authoritative forum where gastric resection was officially recognized as the method of choice. A particularly important role in this regard was played by S. S. Yudin's reports and the speeches of P. A. Herzen, A. A. Ogloblin, E. L. Berezov, and other surgeons. In the same year, Finsterer expressed the view that the golden age of gastric surgery would arrive when all cases of ulcer bleeding were operated on within the first 48 hours from the onset of hemorrhage.

During the first three decades of the 20th century, clinicians accumulated experience from many thousands of gastroenterostomies, and based on a large, statistically reliable body of data, its negative immediate and long-term consequences were identified. Even such a well-known proponent of gastroenterostomy as Ya. O. Galpern believed that it did not cure the ulcer itself. Furthermore, by the late 1920s, the postoperative mortality rate for resection and gastroenterostomy had equalized, standing at approximately 5%–7%.

The most severe complication after gastroenterostomy proved to be marginal (peptic) ulcer of the anastomosis. Since the gastric or duodenal ulcer is not removed during this operation, the risks of malignancy, perforation, penetration into adjacent Organs, and bleeding remain. The transition of resection into the method of choice was facilitated by improvements in surgical techniques and the general progress of medicine—the development of anesthesia and pain management, blood transfusion, and later, the introduction of Antibiotics into practice.

In the post-war years, the main organizational issue was resolved, and patients with acute gastrointestinal bleeding were henceforth admitted exclusively to surgical departments, where they underwent Diagnostics to identify the source of bleeding, Assessment of the severity of blood loss, conservative therapy, and, if necessary, surgical treatment. Thanks to early hospitalization and emergency surgery for profuse bleeding, mortality rates were significantly reduced (S.S. Yudin, 1955; B.S. Rozanov, 1960; A.I. Gorbashko, 1962).

S.S. Yudin emphasized: "if there is sufficient Evidence indicating the ulcerative Nature of the active bleeding, in patients who are neither too young nor excessively old, it is better to operate than to wait. And if we are to operate, it is best to do so immediately, that is, within the first 24 hours. No amount of blood transfusion can compensate for the Damage caused by lost time."

E.L. Berezov (1956) recommended a watchful waiting approach, starting the treatment of bleeding with conservative therapy and performing surgical intervention only if it proved ineffective. Patients with arrested bleeding were to be operated on after 2–3 weeks. This strategy led to a significant reduction in postoperative mortality.

The establishment of gastric resection as the method of choice was closely linked to the understanding of The Role of different gastric regions in gastric juice secretion, primarily Hydrochloric acid. As is well known, I.P. Pavlov identified two Main phases of gastric secretory activity: the first (psychic) and the second (chemical). In 1906, Edkins proposed that the antrum of the stomach produces the hormone gastrin, which stimulates hydrochloric acid secretion by parietal Cells. The functioning of the second, chemical phase of gastric secretion began to be viewed as a relatively independent link in the overall REGULATION OF GASTRIC activity. In the 1940s, methods emerged that allowed for determining the predominance of one of the Two phases of gastric secretion. Consequently, surgeons focused their efforts specifically on suppressing the second phase of gastric secretion. Given this understanding of peptic ulcer pathogenesis, only gastric resection could claim the role of the method of choice, a role it successfully fulfilled from the 1930s to the 1960s.

The dominance of gastric resection in the surgical practice of that era is illustrated by the following facts. In 1913, only 297 gastric resections for peptic ulcers were performed in Russia. In 1928, there were 942 resections; in 1937, 951; in 1950, 25,821; and by the 1960s, approximately 60,000 resections were performed annually for peptic ulcer disease.

Against the Background of the widespread use of resection, its negative consequences began to emerge (suture line leakage, duodenal stump leakage). Mortality rates in leading clinics ranged from 2% to 3%, while nationwide they remained at 7–10%. Following resection, patients required prolonged hospitalization (15–18 days). Temporary postoperative disability lasted about 5–6 months. Disability rates were high, reaching up to 30% according to some reports, and the quality of life of operated patients was low. Specific sequelae of the surgery, known as post-resection syndromes, were identified—including dumping syndrome, afferent loop syndrome, hypoglycemic syndrome, diarrhea, and several others—which often made the patients' quality of life worse than before the operation.

Vagotomy emerged as an alternative to resection in the 1920s. Beginning in the mid-1940s, vagotomy combined with organ-preserving surgeries developed rapidly, and by the late 1960s, it had achieved the status of the method of choice in the surgical treatment of peptic ulcer disease.

The theoretical, ethical, and deontological foundation for the development of vagotomy in ulcer treatment was laid by the classic works of I.P. Pavlov on experimental vagotomy in dogs. Thanks to the research of Pavlov's school, the fundamental principles of Digestive System functioning were uncovered, and a vast body of experimental data was accumulated. During this period, the MAIN TYPES OF gastric surgical interventions were developed and pathophysiologically substantiated.

The first clinical vagotomies began to be performed in Europe in the 1920s. Exner, Bircher, Latarjet, and other surgeons were at the origins of this method. The first 18 vagotomy procedures in the USSR were performed in 1924 in the city of Kharkiv.

Podkaminsky, Exner, and Bircher performed truncal vagotomy, while Latarjet introduced selective vagotomy into clinical practice. Podkaminsky performed all 18 operations using Latarjet's technique combined with gastroenterostomy, achieving good results. However, from the mid-1920s to the mid-1940s, both Western and Soviet surgeons abandoned The Use of vagotomy. In 1943, the American surgeon L. Dragstedt began performing vagotomies. In the 1940s, some Soviet surgeons also used vagotomy in the treatment of peptic ulcer disease, but they employed this method only under very limited indications (A.I. Bakulev, A.N. Filatov, M.I. Bryakin, etc.) or as an auxiliary procedure to prevent peptic ulcers (S.S. Yudin). From the late 1940s to the mid-1960s, vagotomy was not used by Soviet surgeons as a surgical treatment for peptic ulcer disease. During this period, surgeons in the USA and Western Europe developed the main variants of vagotomy used by modern surgeons. Vagotomy became the method of choice for treating peptic ulcer disease in Soviet surgery by the late 1960s and early 1970s, when several leading surgeons (M.I. Kuzin, V.S. Mayat, Yu.M. Pantsyrev, A.A. Shalimov, A.A. Kurygin, etc.) began to widely introduce it into clinical practice.

Farris and Smith (1958) proposed performing vagotomy with pyloroplasty and ligation of the bleeding vessel for the treatment of bleeding duodenal ulcers. In 1967, they reported the outcomes of surgeries in 100 patients, achieving favorable short-term and long-term results. However, the main drawback of such operations was recurrent bleeding, which was observed in 7–15% of patients, particularly when the ulcer was located on the posterior wall of the duodenum.

Vagotomy received official recognition at the XXIX All-Union Congress of Surgeons, held in Kyiv in 1974. The congress adopted a resolution calling for the broader use of vagotomy in combination with organ-preserving surgeries. A unique Summary of the use of vagotomy in the USSR was presented at an all-union conference held in Moscow in 1978. Along with the establishment of vagotomy as the method of choice, the concept of an individualized approach to the treatment of peptic ulcer disease gained ground. Gastric resection, as is well known, was performed according to certain standards involving the removal of 2/3 or 3/4 of the stomach. The introduction of vagotomy combined with various types of organ-preserving surgeries made it possible to implement the principle of "a tailored surgery for every patient."

A fundamentally new era in the Diagnosis and treatment of acute gastrointestinal bleeding began in 1962, when Hirschowitz first utilized fibrogastroduodenoscopy. He demonstrated the necessity and high diagnostic yield of urgent endoscopic examination in patients with gastrointestinal bleeding. In 1974, J.A.H. Forrest et al. first described the endoscopic stigmata (signs) of peptic ulcer bleeding. With the DEVELOPMENT OF NEW technologies, it became possible to act directly on the source of bleeding through the endoscope channel to achieve hemostasis and prevent recurrent bleeding. This development led to a revision of tactical approaches to the treatment of gastrointestinal bleeding in the 1980s. In cases of active bleeding, an increasing number of surgeons consider the failure of endoscopic hemostasis methods as an indication for emergency surgery. In patients with arrested bleeding, delayed surgeries are recommended within 24–48 hours of admission, depending on the risk of recurrent bleeding (Borman et al., 1985; Deutsch et al., 1985; V.D. Bratus et al., 1986; V.T. Zaytsev et al., 1987; V.A. Kharaberyush et al., 1988; Yu.A. Nesterenko et al., 1988).

The widespread use of organ-preserving surgeries with vagotomy for bleeding ulcers was promoted by the works of such prominent scientists as O.O. Shalimov, M.I. Kuzin, V.F. Saenko, Yu.M. Pantsyrev, V.S. Saveliev, A.A. Kurygin, and several others.

A crucial role in improving the treatment outcomes of patients with gastrointestinal bleeding of ulcer etiology was played by the clinical Introduction of new drugs—antacids, selective M-anticholinergics, H2-receptor antagonists, and proton pump inhibitors.

In the late 1980s and 1990s, specialized centers for patients with gastrointestinal bleeding were established in Ukrainian cities, including Kyiv, Kharkiv, Lviv, Donetsk, Odesa, and Vinnytsia. The establishment of these centers allowed for the analysis and accumulation of experience in treating such patients. Thanks to these centers, new tactical approaches to the management of bleeding ulcers were developed, as well as new methods of surgical intervention (ulcer excision, ulcer extraperitonealization, circular pyloroduodenoplasty, etc.). The issues of bleeding ulcers were addressed in many clinics, facilitated by the developments of our country's leading scientists (L.Ya. Kovalchuk, 1984; M.M. Veligotsky, 1985; V.D. Bratus, 1986; V.V. Grubnik, 1988; V.T. Zaytsev, 1989; V.A. Kharaberyush, 1989; P.G. Kondratenko, 1990; M.P. Pavlovsky, 1995; I.Ya. Dziubanovsky, 2000; I.I. Mitiuk, 2001; V.V. Boyko, 2004; P.D. Fomin, 2005; Ye.M. Shepetko, 2008).

The development of surgery in the 1980s and 2000s confirms the validity of the thesis regarding The Importance of an individualized choice of surgical method. Debates aimed at refining the indications for various types of surgical interventions continue to be actively discussed in specialized publications to this day. Different surgeons consider both radical resections and organ-preserving operations to be pathophysiologically justified. A comprehensive Analysis of the cause-and-effect patterns of the disease's development, representing the joint work of surgeons, internists, morphologists, and physiologists, appears highly appropriate. One can express hope that the experience of the thorny path traveled by physicians in the 20th century in search of the optimal approach to treating peptic ulcer disease and its complications (bleeding) will remain valuable to surgeons and physicians of other specialties in the 21st century.