Хирургические болезни. Практикум = Surgical diseases. Practice book. Учебное пособие

•suspected malignant transformation of the pancreatic tissues;

•persistent pain syndrome lasting for a long time despite the use of narcotic (opioid) analgesics.

Surgical interventions in ChP are divided into the following groups:

1. Those performed on the autonomic nervous system of the pancreas, aimed at de-innervation of postganglionic fibers for the elimination of persistent pain syndrome.

2. Those aimed at elimination of contributing causes:

•cholelithiasis – by cholecystectomy;

•stenosis of the MDP and long strictures of the common bile duct – by forming biliodigeetic anastomoses, etc.;

3. Those aimed at elimination of hypertension in the duct system of the pancreas which is achieved by:

•organ-saving interventions aimed at: internal drainage of the dilated duct; treatment of fistula or pseudocyst of the pancreas; treatment of virsungolithiasis with extensive proximal duct strictures. The operations of choice in this case include:

wide (not less than 10–12 cm) longitudinal pancreaticotomy with the formation of pancreatic jejunoanastomosis on the isolated (according to Roux) jejunum loop;

pancreatocystojejunstomy – creation of anasomosis between pancreatic and jejunal cysts on a disconnected loop according to Roux (Izbitsky operations are preferred);

•sparing resection of the pancreas which in case of the lesion of the head of the pancreas (pseudotumorous pancreatitis with an increase in the head of more than 4 cm, stenosis of the common bile duct and the duodenum, strictures and dilatations of the main duct of the pancreas) include the following varieties:

partial resection of the head with excision of the front portion of the altered fibrous tissues of “walnut shell” type followed by longitudinal dissection of the pancreatic duct in the head area and the formation of a pancreaticojejunostomy on the disconnected loop of the jejunum according to Roux – operation proposed by F. Frey (1995) – G. Farkas (2001);

subtotal isolated resection of the head of the gland, leaving duodenal ulcer duodenum (operation by G. G. Beger, 2002) – consists in the removal of altered fibrosed tissues during cystic transformation of the pancreatic head, leaving only its narrow strip in the area of pancreatododuinal vessels;

•extensive resection interventions including pancreatoduodenal resection – Whipple operation (1934) which is indicated when it is impossible to exclude malignant transformation of tissues in case of pseudotumorous form of chronic pancreatitis. The operation involves removing the head of the

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Chapter 11

PEPTIC ULCER DISEASE (GASTRIC AND DUODENAL). COMPLICATIONS

11.1. PEPTIC ULCER DISEASE (GASTRIC AND DUODENAL)

Peptic ulcer disease (PUD) (gastric and duodenal) (MCH-10: C 25. Gastric Ulcer, K 26. Duodenal Ulcer) is a group of pluricausal heterogeneous diseases characterized by a chronic, periodically recurrent course with the formation of a morphological substrate – the defect in the mucosal-submucosal layer of the stomach or duodenum due to the prevalence of acid-producing aggressive factors over local protective mechanisms.

It occurs in 0.5–2% of the adult population, 4–10 new cases appear per 100 thousand adults. There are age and sex differences in the structure of the disease: duodenal ulcer is more common in men 20–40 years of age; gastric ulcer is more common in men 40–60 years of age and older. Complications of peptic ulcer are revealed in 12–20% of cases.

Treatment. Indications for surgical treatment of peptic ulcer are divided into:

•absolute – emergency or urgent interventions performed due to lifethreatening complications of peptic ulcer disease:

perforation of ulcers;

profuse gastroduodenal bleeding (AGDB);

decompensated stenosis of the pyloric-duodenal area accompanied by the disturbances of the evacuation function of the stomach;

malignancy confirmed by biopsy (“ulcer-cancer”);

•arbitrary-absolute. These indications include serious complications of ulcers that cannot be treated conservatively:

compensated (or sub-compensated) pyloric-duodenal stenosis accompanied by evacuation disturbances;

callous and penetrating ulcers in the absence of the effect of their adequate conservative 3-month treatment;

recurrent AGDB due to high-risk factors for their recurrence.

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11.2. COMPLICATIONS OF PEPTIC ULCER DISEASE

11.2.1. Perforating ulcer

Perforating ulcer is an acute perforated defect in the wall of the stomach or duodenum accompanied by the output of the contents into the free abdominal cavity and by subsequent peritonitis development.

It occurs in 25% of patients suffering from peptic ulcer. More often it is observed in men 20–40 years of age or 5 times more often in men than in women of the same age group. More often perforation of pyloric-duo- denal ulcers (80–85%) occurs at the age of 20–40 years, while perforations of gastric ulcers develop after 50–60 years.

Classification. Perforated ulcers are divided according to:

•clinical forms:

with perforation into the free abdominal cavity (typical);

with atypical perforation (into peritoneal omental sac, large or small omentum, retroperitoneal tissue, abdominal cavity with abdominal adhesions);

with a combination of the perforation with AGDB, stenosis, penetration;

•clinical periods:

1st – neuro-reflex disorders (or pain shock);

2nd – “imaginary well-being”;

3rd – diffuse peritonitis.

Treatment. When diagnosed perforated ulcers (including covered and atypical) are an absolute indication for urgent surgical intervention, which includes:

•ulcerative defect suturing. It is performed in case of advanced peritonitis in elderly patients with a high operational risk (due to severe concomitant pathology), as well as with juvenile (mild) ulcers without perifocal infiltration. The recurrence of peptic ulcer after these interventions reaches 60–70%; And in case of juvenile ulcers with antiulcer treatment – 10–15%;

•sparing excision of the edges of the ulcerative perforating defect in the form of a rhombus (or with the help of two half-oval incisions) followed by transverse suturing with separate serous-muscular sutures.

Radical operations in perforated gastroduodenal ulcers, aimed at saving the patient’s life and achieving sustainable cure of the disease include:

•suturing in combination with the stem vagotomy (selective proximal or combined (front SPV + posterior stem));

•excision of perforated ulcers followed by pyloroplasty (or duodenoplasty) in combination with the above mentioned types of vagotomy;

•pyloranthromectomy (removal of the antral part of the stomach and pylorus) in combination with stem vagotomy. This intervention is performed in type II ulcers according to Johnson classification: combination of perfo-

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rated ulcer of the duodenum and chronic gastric ulcer, as well as in case of duodenostasis and insufficiency of pyloric pulp;

• different types of distal resections of the stomach.

11.2.2. Acute gastroduodenal bleeding

Acute gastroduodenal bleeding (AGDB) of ulcerative etiology is the most common cause of acute bleeding from the upper gastrointestinal tract, which is up to 45–50% of all other cases. More often ulcer is complicated by the development of AGDB in patients 40–50 years of age (15– 20% of cases). The ratio of bleeding ulcers of the duodenum and stomach is 3 : 1 / 4 : 1.

Total mortality from AGDB reaches 7–15%; in recurrent cases or emergency interventions it increases up to 30–40%.

Treatment. Treatment of AGDB includes a combination of urgent diagnostic and treatment measures (procedures) aimed at:

•arrest of bleeding (I stage);

•correction of changes associated with acute blood loss (II stage);

•elimination of etiopathogenetic ulcer mechanisms (III stage).

The first stage of treatment and diagnostic measures in AGDB begins with emergency FGDS and endoscopic hemostasis (Forrest classification, 1974), the following procedures are used:

•injection techniques for the administration of 70% (less often 96.65% solutions of ethanol, 2% solution of novocaine with the addition of ethanol and vasopressor amines, 1–3% ethoxy sclerol);

•mechanical techniques including:

clipping of the bleeding vessel in the area of the ulcerative defect;

ligation of vessels with the help of special devices;

•thermal techniques including:

the use of monoor bipolar diathermo-coagulation;

laser photocoagulation (with radiation 20–50 W / cm²);

argon-plasma coagulation (APC);

•application methods including the use of film-forming polymers based on cyanocrylates (lifuzol, MK-7 and MK-8 glue), fibrin; thrombin-collagen substance (“tachocomb”); preparations from blood components (collagen sponge, “gelascone K”, double-component fibrin-thrombin glue – caprofer); preparations based on oxidized methylcellulose (sanguinurin, oxycolanim), etc.;

•highly selective celiacography with catheterization of branches of the gastric or gastroduodenal arteries and their subsequent embolization with synthetic emboli or infusion of vaso-constructive drugs (autologous thrombi, absorbable gelatin, oxidized cellulose, polyvinyl alcohol).

Emergency surgical procedures are indicated in case of:

•profuse prolonged hemorrhage with loss of more than 2000 ml of blood within 2–4 hours;

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•hemorrhagic shock with a loss of more than 30% GCB;

•active bleeding (Forrest I) in case of ineffectiveness of conservative and endoscopic treatment.

Indications for urgent intervention are:

•unreliability of conservative and endoscopic hemostasis;

•a high risk of AGDB recurrence (Forrest II-A);

Indications for delayed interventions performed two weeks after AGDB arrest are:

•recurrent bleeding;

•prolonged complicated ulcer history;

•the presence of chronic callous ulcer or scar deformation in patients over 50 years.

Types of surgical interventions in case of AGDB ulcerative genesis are distinguished depending on their location.

In duodenal ulcer complicated by AGDB the following procedures are performed: suturing of the bleeding vessels at the bottom of the ulcer crater (or throughout); excision of ulcerative infiltrate with subsequent primary pyloroplasty (according to the Judd method) or duodenoplasty. In case of penetrated ulcer, extraduodenization followed by pyloroplasty is used (more often in Finney’s modification). Operations limited by simple suturing of bleeding vessels are performed only in patients with a high risk for adverse outcomes and severe comorbidities. In other cases and in the presence of technical conditions preference is given to the operations aimed at eliminating the pathogenesis of peptic duodenal ulcer – stem vagotomy (Taylor’s combination of anterior SPV + posterior stem vagotomy) supplemented by pylori – or duodenoplasty if necessary. Nowadays this intervention is performed with the help of minimally invasive techniques: mini-access or videolaparoscopy.

In gastric ulcer complicated by AGDB, gastrectomy is performed (in a volume of Ѕ to 1 / 3), the volume depends on the localization of ulcer. In gastric ulcer located high along the small curvature, the portion of the stomach is left, which is performed by excision of its body by a broken line (“staircase” or tubular gastrectomy procedure by Porsch method).

11.2.3. Ulcerative pyloroduodenal stenosis

Ulcerative pyloroduodenal stenosis (UPDS) (synonym: scar-ulcerative pyloric stenosis) is a complication of gastric and / or duodenal ulcers accompanied by the narrowing of the organic pyloroduodenal area, evacuation disturbances and severe disorders of water, electrolytes, protein and carbohydrate metabolism.

It occurs in 30–47% of patients with peptic ulcer disease or in 30% of those previously operated for various complications of peptic ulcer.

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Chapter 12

ABDOMINAL HERNIAS

AND HERNIAL COMPLICATIONS

12.1. ABDOMINAL HERNIA

Abdominal hernia (AH) is a protrusion of internal organs through natural holes (openings) in the muscular aponeurotic layer of the abdominal or pelvic wall without breaking the integrity of the internal (parietal peritoneum) and external (skin, transverse fascia) membranes.

Hernias protruding under the skin are called external, while those protruding into the pleural cavity (through the apertures of the diaphragm) or through the pockets and windows of the peritoneum (normally not containing internal organs) are referred to as internal hernias.

Since hernias of the abdominal pockets lack one hernial element, a sac, and are not diagnosed in an uncomplicated condition (until strangulation develops), they are classified not as diseases, but as varieties of internal strangulation.

Abdominal hernia is a common disease that occurs in 2–4% of the adult population or in 10% of patients undergoing treatment in general hospitals. Among all abdominal hernias, about 50% are inguinal hernias; 8–10% are umbilical, 3–5% are femoral, umbilical and midline; 1–2% include hernias of other localization (pelvic, lumbar, etc.).

In women, in comparison with men, the most frequent cases are hernias of the umbilical ring (5 : 1), femoral (4 : 1), pelvic (of perineal and occlusal apertures) (6–7 : 1), as well as hernias of the spigelian line (3 : 1). The majority of patients with AH (about 50–65%) are people of the presenile and senile age.

External abdominal hernias are characterized by the presence of:

•hernial orifice (hernial opening);

•hernial sac;

•hernial contents;

•external hernial membranes.

If at least one of the above elements is absent, this pathological condition is not classified as a hernia. For example, the protrusion of viscera through an acute defect in the muscular aponeurotic layer of the anterior abdominal wall without preserving the integrity of the peritoneum and skin is called “eventration” (eventratio); the protrusion of the viscera covered by the peritoneum through the natural openings (vagina, anus) is called “prolapse” (prolapsus).

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Classification. Hernias are subdivided according to:

•their origin:

congenital (herniae congenita);

acquired (herniae acquisita):

−traumatic (accidental, postoperative);

−dystrophic (hernias due to weakness of AAW – anterior abdominal wall);

•their relationship with the anterior abdominal wall:

external;

internal (omental herniae, herniae recessus duodenalis (or Treitz hernia); recessus subcolica (or Riez herniae); recessus ileocolica or intersygmoidei – hernias of congenital or acquired holes in the intestinal mesentery; diaphragmatic hernias);

•the presence of constituent elements:

true (all the elements are present);

false (the elements are not completely represented);

•their course:

uncomplicated (reducible or free) (herniae reponibilis);

irreducible (herniae ihreponibilis);

complicated;

•the mechanism of formation:

elastic;

fecal;

mixed;

•anatomical and clinical features:

parietal (lateral or Richter herniae);

retrograde (W-shaped or Maydl’s herniae);

strangulation of Meckel’s diverticulum (Littre’s herniae);

false (Brock’s hernia);

antegrade;

•their contents:

simple (containing one organ in a hernial sac);

combined (two or more organs are in the sac), also called eventration hernias;

sliding;

•their localization:

external (abdominal) hernias:

−inguinal (herniae inguinales);

−femoral (h. femorales);

−umbilical and paraumbilical (h.umbilicales);

−midline (h. linea albae);

−lateral (pararectal and spigelian line);

−lumbar (Petit’s triangle or Lesgaft-Grunfeld’s rhombus);

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internal (abdominal) hernias, incl. diaphragmatic, hernias of abdominal pockets, and of mesentery or omentum defects:

−obturator (h. canalis obturatorius);

−pelvic wall and diaphragm (ischiatic and perineal);

−rare localizations (xiphoid hernia or hernia of Larrey’s triangle);

•the diameter of the hernial orifice:

small (up to 10 cm in diameter);

medium (up to 20 cm in diameter);

large (up to 30 cm in diameter);

giant (over 30 cm in diameter).

Etiology. Etiological factors with characteristic differences for their type are distinguished in the development of hernias.

For congenial hernias these are:

•incomplete embryogenesis in the formation of various anatomical regions;

•ontogenetic factors of morphogenesis, including:

perversion of gene information;

teratogenic effects (physical, chemical, biological);

deficiency of maternal and fetal differentiating hormones regulating

the processes of subsequent development of mesenchymal tissues. For acquired hernias all pathomorphological factors of their occurrence

are subdivided into:

•local, including:

closed (accidental) or intentional injuries of a specific anatomical region (including forced and operational);

anatomical disorders, including:

−portions of unfinished prenatal and impaired postnatal development (including patent proximal portion of the vaginal process of the peritoneum or Nuck’s diverticulum, the umbilical ring);

−points of passage of the spermatic cord, separate vessels or nerves through the abdominal wall;

−portions of weak (“predisposed”) development of the musculoaponeurotic layer of the anterior abdominal wall (umbilical ring, spigelian line, midline);

•general causes of AH development are subdivided into two groups of factors:

predisposing ones, including:

−hereditary-constitutional (morpho-functional signs) observed in close relatives in a significant number of generations;

−hypersthenic constitutional type predisposing to the appearance of direct inguinal hernia, the narrow pelvis or asthenic constitutional type predisposing to the development of oblique inguinal hernia;

−male gender for inguinal hernias; female gender for umbilical and femoral hernias;

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