SURGICAL TACTICS, TECHNICAL CHARACTERISTICS AND RESULTS OF TREATMENT OF COMPLICATED POSTBULBAR AND JUXTAPAPILLARY ULCERS

E.N. SHEPETKO, A.E. SHEPETKO, V.V. YEFREMOV

National Medical University named after A.A.Bogomolts; Kiev, UKRAINE

Purpose. To develop surgical tactics, methods of operations with reimplantation of a large duodenal papilla (LDP), to reduce postoperative lethality and the number of postoperative complications in the surgical treatment of complicated postbulbar (PMU) and juxtapapillary (JPU) ulcers.

Materials and methods. To analyze the results of treatment and early postoperative complications (EPC) in 270 patients operated for complicated postbulbar (PBU) (220 patients, group 1) and juxtapapillary ulcers (JPU) (50 patients, group 2). Postbulbar ulcer is an ulcer located at a distance of not less than 3 cm from the pyloric sphincter. Juxtapapillary ulcer (JPU) – is an ulcer, located close to the LDP or involving it into the ulcerative process.

A modified classification of complicated JPU is offered. I. Suprapapillary ulcer - an ulcer, located proximal to (above) LDP, so that between it and the LDP remain a mucous bridge not less than 0.5 cm and not more than 1 cm. II. Parapapillary ulcer - an ulcer located at the level of LDP on right or left at a distance of not less than 0.5 cm III. Papillary ulcer - located in the area of ​​LDP with its partial involvement. IV. Giant papillary ulcer with significant destruction of LDP, so that orifice of the bile duct and pancreatic duct are visualized separately. V. Infrapapillary ulcer - located distally (below) to LDP not less than 0.5 sm. VI. Kontrpapillary ulcer - located opposite the LDP on the opposite duodenal wall.

If the bleeding from PBU can be stopped endoscopically, then in the absence of the threat of early reccurrence of bleeding (FIIВ, FIIС, FIII by Forrest) the patients shall be prepares for surgery after a comprehensive examination and blood replacement. Only in cases when the bleeding continues (F1A, FIB) and methods of conservative therapy, including endoscopic hemostasis are ineffective, and the patient has recurrent bleeding – there emerges a need for urgent surgery at the height of bleeding. Such tactic is an active-individualized and based on the consideration of the severity of bleeding, individual characteristics of a patients and data about the location and sizes of ulcer substrate, nature and degree of manifestation of concomitant pathology. In acute bleeding JPU active-expectant tactics with the use of active conservative therapy, which includes infusion, hemostatic, anti-ulcer and H. pylori therapy is more reasonable. In cases when conservative therapy was effective, the ulcer did not give rebleeding and in repeated endoscopic examinations we see a positive dynamics conservative treatment shall be continued according to the above methods. The shown tactics has active-expectant and rational character, as allows to clarify the localization of the ulcer, to prepare for the technically complex surgery, to reduce the risk of intra-and postoperative complications. The methods of reimplantation of LDP in different classes of duodenal jejunum JPU with transduodenal and transjejunal transpapillary external drainage of choledoch and main pancreatic duct (TPDC).

Results. It is established that of 19 reimplantations of LDP in complicated JPU 2 patients died in the I period, and 3 of 17(17,6%) patients in the II period. With the development of new methods of reimplantation LDP it became possible to reduce postoperative mortality 5.7 times. Total EPC occurred in 26 of 220 patients operated (11.8%) for the complicated PBU, 13% (15 of 115 patients) in the I period of observation (1992-1983.) and 10.5% (11 of 105 patients) - in II period (1993-2008). In complicated JPU EPC emerged for the entire period of observation in 21 of 50 patients (42%), and in 66.6% patients with JPU EPC occurred in the I period, in 16 of 41 operated patients (39%) - in the II period. The incidence of EPC in complicated JPUs is 3.6 times (or 30.2%) higher than after surgery for complicated PBU (c²=23,803, p<0,0001). Acute postoperative pancreatitis (APP) occurred 14 times more after surgery for JPU (11 of 50, or 22%), as compared to PBU (3 of 220, or 1,6%) (c²=30,394, p<0,0001). The relative frequency of occurrence of APP in JPU decreased 2 times in the period II as compared to the I period of observations. By analyzing the postoperative mortality rates in complicated PBU according to periods it should be noted that in the I period, mortality was 10.4%, while in II - 7,6%. After the introduction of the developed techniques of surgical interventions for complicated JPU, as well as through appropriate methods of biliary drainage, postoperative mortality was reduced from 33,3% in period I to 14.6% in the II period, i.e 2.3 times. For the whole period of observations postoperative mortality in complicated PBU was 9.1%, in JPU - 18%.

Conclusions. 1. Surgical tactics in acute bleeding PBU is an active-individualized and based on the consideration of the severity of bleeding, individual characteristics of a patients and data about the location and sizes of ulcer substrate, nature and degree of manifestation of concomitant pathology, while in acute bleeding JPU - active-expectant and efficient, allowing to specify the localization of ulcers, to prepare for technically complex surgery, to reduce the risk of intra-and postoperative complications. 2. Application of the rational surgical treatment with the use of new methods of surgical intervention with reimplantation LDP and TPDC allowed to reduce postoperative mortality 2.3 times, and the incidence of EPC in complicated JPU - 1.7 times.

Date: 2014-12-28; view: 980