MODERN TACTICS DURING GASTRODUODENAL BLEEDINGS OF ULCER ORIGIN

J.N.HAJIYEV, V.A.ALLAHVERDIYEV, N.J.HAJIYEV

Azerbaijan Medical University, Baku, AZERBAIJAN

Despite successful achievements in the conservative treatment of ulcer disease of stomach and duodenum, occurrence rate of ulcerative bleedings has continuously increased in the recent years. Despite the achievement of initial hemostasis in 90-95% of patients with the help of modern treatment means (endoscopic hemostasis, pharmacotherapy, restoration of lost blood), recurrence of bleeding occurs in 10-40% of cases. Development of the treatment tactics from maximum conservatism to absolute radicalism in the course of the years, shows the great significance of forecasting recurrence of bleeding. But in cases of correct decision-making on the conduct of operation, there is a problem of the nature of such operation.

The aim of the study is to analyze the results of modern treatment tactics during gastroduodenal bleedings of ulcer origin (GDBU). The study includes 67 patients at the age of 24-79 that underwent and surgical operation for GDBU: the reason of bleeding in 19 patients (28,4%) was chronic ulcer of stomach, and in 40 patients (59,7%) of duodenum. In 8 (11,9%) patients there was detected joint ulcer. Resistance of hemostasis was assessed according to J. Forrest (1974) classification: F I – 16 (23,9%), F II – 23 (34,3%) and F III – 28 (41,8%). And the amount of lost blood was determined by A.I.Gorbashko (1982) method: In 24 patients (35,8%) -light, in 23 – moderately severe (34,3%) and 20 patients – highly severe (29,9%) bleeding was observed. In 21 cases (31,3%) thee was carried out urgent surgical intervention because of unproductivity of endoscopic hemostasis. Surgical intervention was carried out urgently in 16 patients (23,9%) because of high recurrence risk of bleeding on the background of endoscopic hemostasis (on the 1-3 day after entrance), and in delayed order in 30 patients (44,8%)after absolute hemostasis (within 1-3 weeks after entrance). Thus, in 52 patients (77,6%) there was carried out resection of stomach, in 8 patients (11,9%) – removal of ulcer jointly with vagotomy and pyloroplasty, and in 7 patients (10,5%) suturing or removal of bleeding ulcer. Various complications occurred in 19 (28,4%) patients in post-operative period. 8 patients (11,9%) of 67 that underwent surgical intervention died in postoperative period.

Thus, endoscopic hemostasis makes it possible to carry out preoperative preparations, to assess the danger of recurrence of bleeding, and select the treatment tactics. Optimal treatment tactics shall be selected by early and objective assessment of danger of recurrence during the GDBU, and the scope of operation shall be determined by consideration of patient’s age and severity degree of his/her condition.

REASONS OF SUTURE FAILURE OF GASTROINTESTINAL TRACT ANASTOMOSES AND THEIR PREVENTION IN URGENT SURGERY

N.A. HOJIMUHAMEDOVA, F.A. HAJIBAYEV

Republican scientific center for emergency medical care, Tashkent, UZBEKISTAN

From 2002 to 2007., in RSCUMA there were performed operations with insertion of different gastrointestinal tract (GIT) anastomoses in 974 of patients operated with acute intestinal obstruction (AIO), with injuries of the anterior abdominal wall, with the anterior abdominal wall hernias, with DUD and GUD. During gastric operations duodenal stump insufficiency was observed in 20 (3.5%) patients, GEA failures - in 8 (1.4%), 13 patients of them (46%) died. During the interventions, EEA insufficiency of colon and small intestine was observed in 18 cases, with the formation of the external enteral fistula in 1 patient, failure of entero-colonic anastomosis - in 14 patients, failure of colo-coloanastomosis - in 13 patients, with the formation of external enteral fistula in 3 cases, nine of them died (20%). Thus, during the operations with the insertion of GAE, interintestinal anastomoses insufficiency of intestinal sutures occurred in 73 (8.3%) patients. Mortality in patients with insufficiency of anastomosis consistuted 30%. It should be noted that all operations were performed in the presence of so-called “risk factors”. Analysis of cases of insufficiency of intestinal anastomosis sutures allowed to distinguish three main groups of reasons, leading to development of insolvency: 1) the state and pathological processes in anastomosed organs, 2) intraoperative factors or factors emerging in the postoperative period, and 3) technical features of the sutures. Experience of our clinic shows that in emergency operations antibiotic treatment shall be started before the obtainment of microbiological data. Based on bac.examinations it can be said that infectious agents may be both grampositive, and gramnegative aerobes and facultative anaerobes. The degree of contamination of the abdominal cavity may widely vary. Moreover, in 20% patients with acute perforations or bowel injuries Candida albicans and other fungi are observed, which serves as an indication for the use of antifungal therapy.

Thus, we formed the following prophylactic measures for the development of failure of anastomoses: 1) anastomosis should fully reconstruct normal anatomo-morphological relations, and b) intestinal suture should provide an accurate comparison of the edges and walls of sutured organs c) morphologically - healing must approach to initial d) blood flow along the suture line should be complete, with the maintainance of reliable hemostasis, and e) method should be simple and easily accessible, with the maintenance of the principles of asepticity.

Date: 2014-12-28; view: 943