TACTICS AND STRATEGY IN THE TREATMENT OF PATIENTS WITH ULCER GASTRODUODENAL BLEEDINGS

V.N.CHERNOV, V.V.SKORLYAKOV, S.S.KESHYAN

Rostov State Medical University, Rostov-on-Don, RUSSIA

Purpose: improvement of the results of treatment in patients with acute ulcerative gastroduodenal bleeding (AUGDB).

Materials and methods: 560 patients with AUGDB, 2-level computer pH-metry, and variation computer pulsometry, the daily monitoring of gastric pH.

Results: The treatment algorithm of patients with AUGDBconsists of 2 stages. Stage I: 1.Identification of degree of blood loss and hospitalization of patients with severe bleeding in DARwith hemostatic and substitution therapy. 2.Urgent EFGDS on admission or under the DAR conditionswith the identification of the threat of recurrence of bleeding (RB) by Forrest and conduct of endoscopic hemostasis given the localization of ulcers by Jonson. 3.DynamicEFGDS performed on the first day from the moment of admission in patients with FI a, and b, c and FII a, b, as well as patients with RB with an attempt to repeated endohemostasis. 4.Adequate antisecretory therapy by parenteral drugs under the control of gastric pH in the “on-line”mode.

Introduction of this algorithm allowed to reduce the number of RB to 6%. Active endoscopic tactics in AUGDB led to a reduction of operational activity to 3%. The overall mortality rate of patients with AUGDBconstituted 10%.

The 2^nd stage of treatment is a comprehensive examination of a patient after stabilization of condition, to identify the group of patients at high risk of development of recurrent fatal complications of ulcer disease (UD). Based on the functional studies in 85% of patients that had AUGDB, high efficiency of drug therapy and longrecurrentless period is forecasted. 15% of patients withforecasted high risk of recurrence of UD and complicationsradical gastric surgeries are performed without the development of fatal complications. The operational method is determined according to the data of functional methods of investigation. Selective proximal vagotomy was performed in 6% of patients, gastric resection by Billroth -I type- in 22-24% of patients, Billroth-II type in 65-70%. The number of good and excellent results constituted respectively 100%, 84% and 73%.

Conclusions:

1. The use of endoclipping given the localization of ulcers by Jonson and implementation of antisecretory therapy under the control of pH allows to reduce the number of RB to 6%.

2. In patients with AUGDB, minimal surgical intervention aimed at saving the life of a patient is an operation of choice.

3. Patients with AUGDBare subject to two-stage treatment. Stage 1 - endoscopic arrest of bleeding, if not possible - the minimum operation. Stage 2 - a comprehensive examination with the forecasting of the risk of recurrence of UD and identification of optimal treatment strategy.

Date: 2014-12-28; view: 922