On the choice of rational surgical treatment of perforated pyloroduodenal ulcers. (Clinical research) Chur, Nikolai Nikolaevich
A stone lies in the steppe, indicating the path. A seagull flies over the wave, telling a fairy tale: oh yes, the city of Korchev on the Two Seas! It is covered with sea salt and steppe dust, and is blown through by the winds.
An ancient city. Beneath it there have been underground passages since time immemorial. It is unknown who dug them and when. If you enter such an entrance into the steppes, you will come out in the city if your heart is pure. And whoever goes with evil intent will not blow the Chur-stone. Not everyone knows about that stone.
For a long time now, the people of the steppe have coveted the riches of the city. So the Korchan people blocked the passages and exits with stones, and decided to block the largest one with an iron door, perhaps when it came in handy. Well, it’s clear that the Korchev blacksmiths were tasked with working that door, who else? Their work is always done reliably and with love.
The anvil began to chime. The handbrake hammer either jumps onto the hot iron, indicating where to hit the hammer, or dances on the anvil out of impatience, while it’s hot, hurrying. His wit is already sparkling, but at least Dubku is knocking and grunting, yes silver earring shaking in the ear. But the key to the Dubko castle did not work well, but his wit later managed.
The door was a great success. It’s such that you can’t take it with a ram and you can’t open the lock. On a patterned field, her two iron warriors clashed to the death in battle.
The fame of the Korchevs does not give Shusha any peace. The blacksmith Korcha and his sons squeezed his soul with good deeds, no one is afraid of the villain now. For a long time Shusha walked around his fortress, hastening black divination. Was it really from him that the rumor came that there was native iron in Temirovaya Gully? And it is for the blacksmith what the earth is for the farmer.
The Korchev brothers were easy-going, they went to that beam without hesitation. Reluctantly, the mother collected them, saying: you go there, they say, with an eye, the hour is uneven - the wormwood people will run into you.
“You keep cackling at them,” the father got angry. - Look - the clubs are waving. You won’t be able to pull them by the hair, you won’t be able to reach them.
Carefully, the brothers descend into the ravine and make their way through the thorny bushes. But there is no iron anywhere, neither on the scree, nor at the bottom of streams that dried up over the summer.
As the thickets of the throat began to crush, it seemed to Wit that a horse neighed somewhere. He became alarmed and told his brother about it.
“It seemed to you,” Dubko reassured, “it was dry grass rustling.”
It’s stuffy in the beam, sweat covers your eyes, blood hits your temples. But then a breeze blew into the ravine from the Sea of Surozh. Sighed full breasts Witty, but suddenly froze and said:
- Didn’t the horse hit you in the nose later?
“Yes, you yourself smell forty fathoms, like a horse,” Dubko joked. - There is not a single living soul here except us. Cicadas, you see, you can’t even hear them.
And it’s true: not a bird anywhere, not a lizard. Everyone hid as best they could from the heat. The brothers finally decided to look around the bend and go back.
Suddenly, out of nowhere, a raven began circling overhead. The brothers stopped, sensing something was wrong, but it was too late. The ground trembled under the hooves, the beam resounded with wild cries. The steppe people sat in ambush, so they impatiently attacked the brothers.
Yes, it’s not just a Russian person to take into account. Whether he plows a plow or swings his fist in battle, he does both with zeal. Well, as far as blacksmiths are accustomed to hitting iron, they have nothing to do on the heads of the filthy ones.
The brothers pressed their backs to each other - you couldn’t get close to them. If Wit waves his hand, he’ll knock out dozens of enemies, he’ll hit Dubko with his fist, and one and a half will drop dead.
Yes, no matter how strong the brothers were, they were tired and began to make their way to the thorn bush. Not only can one on horseback, but also one on foot, not fit into it. The brothers were badly torn on thorns, but they hid from their enemies in the bushes. They fell to the ground. Intercede, they say, Mother Earth, protect from the enemy’s arrow.
Yes, the steppe people needed the Korchev brothers alive. They let fall among the thorns. The dry grass started to burn, the smoke eats away your eyes, the heat completely bothers you. With nowhere to go, the brothers came out. They immediately swaddled their arms and legs with strong lassos made of woven horsehair. Don't breathe or move your hand.
The horsemen dragged the captives to the tent of the prince of the steppe and threw them at his feet. The prince sniffles displeasedly, closing his narrow eyes as if he were holding two knives.
“You have beaten and maimed many of my people,” he says. Tie you to the tails of wild horses, so that you can scatter the bones across the steppe!
The brothers are silent and do not ask for mercy.
“The steppe people,” he says, “honor the heroes.” The steppe people give them life.
He clapped his hands, and the chains were removed from the captives. The prince presented them with the best treat in the steppe - a cup of mare's milk. The brothers spat and did not drink.
“Tell me,” they ask, “what you need from us.”
“Nothing at all,” says the prince, “just the door key to the secret entrance.”
“That’s what you wanted,” Dubko was surprised. -Have you smelled this? - and shoved a shish under the prince’s nose, a sign of the highest contempt among Russians.
It’s better not to say what happened here. To know, wormwood is a grass that is bitter because it is watered with human blood in the steppe.
They tied up Dubka again, and began to drive Wit away. They say if you bring the key, you will save your brother, but if you let it slip, his head will roll down the ravine from Temir Mountain.
“Go away, brother, don’t feel sorry for me,” Dubko whispers. - At least you will remain alive. Bow down from me to your father and mother. Tell me, our name will not be disgraced. Goodbye.
At noon, the owl screams - trouble is rushing into the house. The mother on Gorka has been toiling since the morning, waiting for her sons from the steppe. The swan had two babies, but only one returned to the nest.
Korcha, without remembering himself, hurried to his son’s rescue, but the outpost did not let him out of the city. There are them, the enemies, in the steppe, they say that there are mosquitoes in the floodplains of Tmutarakan, you can’t fight them off from them all. Korcha began to call his friends and gather his squad.
Meanwhile, Wit is walking around the forge, not knowing what to do. After all, they will cut off Dubka’s head as soon as they see the squad, and they will gallop off to the steppe without a fight, the filthy ones. He found the key among the rubbish of Dubkov, which had failed then, corrected it, and threw it away, coming to his senses. He dreamed of enemies sneaking into the city at night in secret, burning houses, killing old and young, and driving away young people. And if you don’t outwit the steppe people, they will keep you with you until the end. Eh, he thinks, you and I have said goodbye forever, brother.
Suddenly something scratched against the kitchen wall. Wit looked - there was no one, but a man’s ear was pinned to the door with an arrow, and the silver earring in it was shining, brother. I guessed that this was a hint. If you hesitate, they say, your head will roll.
He was stunned here, sensing his brother’s torment, and rushed to his mother. She pressed it to her heart and said:
“If Chur-Kamen believes me, we’ll meet.” Goodbye for now.
The outpost itself slipped through the outpost with a mouse. She stood before the prince of the steppe, thirsty for wealth, and said to him:
- Let your son go unharmed. I’ll lead you into the city through a secret passage myself.
Yes, the cunning prince did not completely believe her. First, he says, you will do the job, and then you will come for your son. It will lie there until it is swaddled.
The steppe people immediately gathered, with their horses in the lead, along a secret path, and set off, lighting the road with torches, anticipating rich booty.
Then the Chur-stone lay across their path.
“Keep away from me,” said the mother and walked along it.
Next, the enemies boldly climbed onto the Chur-stone, and he took it, turned around, and covered them all there, every single one.
Dubka’s mother returned to free him, but he sheds bitter tears and does not accept him as his own.
“What are you, stupid,” she said. - Look: our city is calmly glowing with lights. There are no enemies there, we haven’t passed through.
He then picked her up in his arms and, happy, brought her home.
***
The tumbleweed rolled across the steppe, lay under Temir Mountain - it turned into a fairy tale.
Reviews
Thank you for the fairy tale, thoroughly saturated with the Russian spirit, for your faith in mighty Rus', for originality, and for everything, everything that makes this fairy tale so cool. And although I am Russian, I have lived in Kazakhstan for a very long time, and my fairy tales are imbued with Kazakh traditions. However, they also contain the same human values. I wish you creative success with your daughter. Sincerely, Natalya Pavlova.
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This dissertation work should be available in libraries in the near future.
480 rub. | 150 UAH | $7.5 ", MOUSEOFF, FGCOLOR, "#FFFFCC",BGCOLOR, "#393939");" onMouseOut="return nd();"> Dissertation, - 480 rubles, delivery 1-3 hours, from 10-19 (Moscow time), except Sunday
Chur, Nikolai Nikolaevich. On the choice of rational surgical treatment of perforated pyloroduodenal ulcers. (Clinical research): abstract of thesis. ...candidate medical sciences: 14.00.27.- Minsk, 1992.- 22 p.: ill.
Introduction to the work
Relevance volume"" Increased surgical activity in treatment peptic ulcer stomach and duodenum created a number of issues that have not been resolved to date.
According to domestic and foreign authors (V.H. Vasilok-ko, 1963, Sh.A. GulorDEsha, 1970, S.V. Kuraiov), the incidence of peptic ulcer of the duodenum and duodenum ranges from 3.7 to 10.2 per IG00 population. The number of operations performed on eggs suffering from peptic ulcer disease is steadily increasing. The most relevant ulcer is the treatment of the most severe forms of peptic ulcer of the stomach and duodenum: an increase in temporary disability, primary disability, as well as mortality (I.I.Ioimprk, 1972, A.I.Gorbashko, 1906, Yu.M.Paninrev 1987, B.A.Veselovsky, 1966, Price $ Lo I/ 1968). Up to 29 thousand operations are performed for such a serious complication of peptic ulcer disease as peptic ulcer (M.Y.Kuzin, 1968).
Time is in suspense, disagreement is in urgent need surgical treatment there is no perforated ulcer of the celestium and duodenum, so how long is recovery after surgery is 95-98?
There are more than 90 methods of treating perforation of the stomach and duodenum S.L.II "Allmov, І9С7). However, the variety of surgical interventions developed," but are quite satisfactory to practitioners, either due to poor long-term results, "or complexity their execution.
Main way Opera adeno treatment of persons with perforated ulcers is currently the treatment of perforated ulcers -
2--. verotia, which is produced by 91,3% (B.A. Akhudzhanov, 1983, V.P. Zinevich, 1983). According to controversial statistics (G.V. Pakhomova, N.S. Uteshev, 1967), the recurrence of ulcers ranges from 3.2 to 85.2# after the ulcer has healed. At the same time, it should be noted that in the future, look at the widespread introduction into practice various types vagotomy, suturing of the perforation, as before; will be carried out by a certain part of the free people. This group will include elderly and old age, free with common forms of peritonitis, severe concomitant diseases, as well as faces young who do not have a history of ulcers. But the main thing is that most surgeons do not yet have a perfect grasp of the methods of performing vagotomies and especially encounter difficulties in isolating the posterior outlet of the vagus feather.
The reasons for the recurrence of peptic ulcer after suturing have not been studied enough. A small number of works are devoted to the study of the secretory function of the stomach in the long term. A few works are devoted to the study of gastric secretion in early postoperative period. The role of primary excision of an ulcer in the sciloroduodenal zone and the performance of vagotomy for a perforated ulcer in the light of immediate and long-term results have not been studied.
Conflicting data on the use of pyloroplasty and vagotomy in the treatment of perforated pyloroduodenal ulcers do not fully satisfy practical surgeons in rural areas who need specific recommendations on the operations used to determine treatment tactics" Considering that the primary, subet-, rat remains when suturing a perforated ulcer, this, naturally, is always a threat, even if vagotomy is performed, the formation of stenosis (scar and inflammatory shaft around the ulcer).
The experience of Planned Surgery confirms this name.” Thus, in the presence of an ulcer in the pnoroduodenal zone, vagotomy accelerates the healing of the ulcer, which can lead to stenosis. Therefore, most surgeons recommend in this situation, despite performing all types of vagotomy, to perform pyloroplasty according to Mniulich or Jado. In addition, issues such as the role of anterior vagotomy - a technically simpler operation - in excision of the visual tract are not sufficiently reflected in the literature. ulcer and its plastic surgery according to Guinea e-Mikulich. The role and location of excision of the ulcer without vagotomy have not been studied in the light of the immediate and long-term results of the operation of bilateral trunk and vagotomy, and, therefore, appropriate recommendations have not been given on the advisability of their use. Changes in the intestine, especially its distal parts, have also not been studied. The relevance of this problem is also increasing because over the years the number of young patients has increased significantly. It is precisely because of this that patients, most of all, have to
IN THE SUBSEQUENT, REPEAT THE OPORPZTSHI, COMING TO INVDLI"
knowledge or daring profession.
Thus, the problems of treating perioral ulcers of the pyloroduodenal zone are relevant in many aspects but not inappropriate.
Taking into account what we have learned, we set goals to improve the results of treatment of perforated pyloroduodenal ulcers.
To achieve the goal, it was necessary to solve the problem
chi:
I. To study in a comparative manner the results of treatment of perforated
pyloroduodenal ulcers various methods operational interventions
tions, in the light of immediate and long-term results
- і» -
focusing on the role of excision of perforated ulcers and the use of vagotomy.
2. Justify the most specific indications for applications optimal method corrections taking into account the location of the ulcer, age, severity of the patient’s condition, and timing of the disease.
3.Study changes in the iotonic-evacuation function of the stomach, duodenum and small intestine in the postoperative period after various modifications of surgical treatment of perforated pyloroduodenal ulcers.
I". To determine in the long-term period the function of the gastric secretion glands in groups of operated patients using the methods of fractional intubation of the stomach and pH-metry.
I. It has been proven that excision of an ulcer is urgent histological examination its edges makes it possible to identify the nature of the process and determine further tactics for treating patients in the immediate aftermath of the operation.
2. The use of bilateral truncal vagotomy for excision of the ulcer and pyloroplasty is the most effective and radical method of treatment perforated ulcer pyloroduodenal zone and allows one to obtain better results than when performing truncal vagotomy in front of it.
3. Research has proven that the front truncal vagotomy in combination with excision of the ulcer and pyloroplasty gives good long-term result s treatment, is simpler than double-sided, and can be the method of choice in difficult situations in practical surgery.
5 -A. The study of the motor-evocative Function of the small intestine allows us to conclude that the intersection of the sexes of the vagus nerve in long term does not have a significant impact on physiological characteristics body,
D The most optimal tactics in the treatment of pyloroduodenal ulcers have been determined, depending on age, duration of the disease, severity concomitant pathology, localization yaeeee.
2. Lana comparative ottta results of treatment of perforated pilo-roduodenodal ulcer in a specialized hospital and surgical treatment.
3. It was revealed that the use of anterior stem aaroTowif and pyloroplasty By one!) of the techniques, which do not significantly lengthen the duration of the operation, are technically but complex, lead
"(.Bilateral trunk vogotomy is a complex, but most effective and radical method of treating perforated pilonidal ulcers and allows one to obtain the best results."
5. In the presence of pronounced, concomitant pathology on the part of the main systems of the organ, ulcerative peritonitis, it is quite justified to use it ONLY in conjunction with ulcers with cervical ulcers, which is a high guarantee of the prevention of stenosis of the pnloodinal zone.
b.Study of the gonorrheal function small intestine made it possible to establish that the intersections of the trunks were eaten vagus nerve in the "remote period" significant functional changes doesn't come.
The FOLLOWING MAIN GSHBSHIS are introduced for defense
I.Iaibolae radical method Treatment of a perforated ulcer of the pyloroduodenal zone is its excision with pylorus and bilateral vagotomy. 2. In difficult situations, anterior truncal vagotomy 6 can be performed by excision of the ulcer and pyloroplasty. E. Excision of a pelvic ulcer with pyloroplasty of the pyloroduodenal zone is a high guarantee of the development of stenosis, but in terms of isolated results, yes. Truncal vagotomy and excision of an ulcer with perforation in the pyroduodenal zone in the long-term period does not lead to motor and ejaculatory disorders of the stomach and small intestine.
Approbation slave oty. The main provisions of the dissertation work were presented and discussed at the X Congress of Surgeons of the Republic of Belarus (14MSKD991), the conference of surgeons of the Linok region (Minsk, 1991), at the joint scientific conference Department of Surgery, Belarusian Institute of Advanced Medical Studies, Minsk, 1992," meetings of the Minsk Surgical Society (1992 -). The work was carried out according to the research plan of BedGIUV.
0і55НШ1^2_О1^_І5Е!І!і_^ї^vnia. On the topic of the dissertation
2 6 .^JL^"bt!LT15?.-S*L^S.Eii l iM" The dissertation work is presented on the 1st page of typewritten text and consists of an introduction, four chapters, a conclusion; conclusions, practical recommendations and a list of references. The bibliography includes 265 works, of which 1–9 are domestic and 116 foreign authors. The work is illustrated % tables.
_7-; Material and research methods,
The work was based on our own clinical observations treatment of 1 patients who were on inpatient treatment from 1979 to 1987 in the Myanoka regional clinical hospital (GZ patients) and the surgical department No. 1 of the Molodechno central! city hospital (50 large), V. connection about the patient who underwent surgery for perforated niloroduodenal ulcers, "were divided into a number of groups according to the assigned tasks. In each group, the same type of operations were performed" in order to compare the results lechonkya.
The first group is suturing the ulcer (5B patients). ". The second group is excision of the ulcer and pneumonectomy according to Gainex-Mikulich (-"th patients).
Third group - excision of the ulcer, pyloroplasty according to Heineke-! (kulic in combination with anterior truncal vagotomy (52 patients).
The fourth group" - excision of the ulcer, pyoroplasty according to Gzyneke-Mikukic and bilateral truncal vagotomy (J t0 patients).
Most often, perforation of ulcers was observed at ages from 20 to 59 years, i.e. at the most working age. There was no specific pattern in the choice of surgical method depending on the age of the patients. In some groups, ulcers occurred at any age, with any concomitant pathology, regardless of the timing of admission or the severity of peritonitis. The second group included patients who had advanced age. (5Н,5ії), severe concomitant pathologies”, pronounced symptoms of confused peritonitis. There was no pronounced pattern depending on age in the choice of surgical method among patients in the third and fourth groups.
Most often, patients of all groups were admitted before 12 hours from the onset
8 diseases, which had a significant impact on the timing of surgical treatment and the outcome of the disease. The percentage of late hospitalization is insignificant and amounted to 3.^5. The choice of surgical method depended on the timing of the onset of the disease and admission to the hospital. The severity of paritoneal phenomena was a contraindication to vagotosh. Duration surgical intervention in case of perforated gastroduodenal ulcers, it depended on the type of operation, the technique of the operating surgeon, and any intraoperative complications that arose; adhesive process V abdominal cavity and other reasons." Anterior and bilateral truncal vagotomy did not influence the duration of the operation. The duration of the operation; from our point of view, acquired special meaning in severe and weakened patients, which often had an unfavorable effect on the course of the postoperative period.
The types of operations that we used in the treatment of perforated gastroduodenal ulcers are well known and have been studied in detail by various authors. The theoretical prerequisite for performing gastric drainage operations was that when suturing perforated ulcers there is a dazzling island substrate of the edges of the ulcer. When they are stitched and immersed with serous-muscular willows, conditions are created for the development of stenosis; in addition, the connective tissue formation in the suture does not subsequently contribute to the healing of the ulcer, despite the vagotomy performed. When excision of an ulcer, completely healthy tissue of the edges with good blood supply is sutured, which contributes to the formation of a gentle scar and, naturally, is a certain preventive measure. - Due to the intense adhesive process in the area of the duodenal ulcer, sometimes difficulties arose in mobilizing the duodenum according to Kocher. We have developed and successfully applied a “METHOD FOR EXCISING A PERFORATIVE ULCER OF THE DV (
duodenum", without the above-mentioned mobilization. This method is easy to replenish, has little trauma and is quite reliable. For vagotomy, a modified Zodorovo clamp was used. In this case, the nerve was taken on clamps at a distance of 2.5 - E cm from each other and ligated, about the nerve between they were excised. The right, or posterior nerve, was found at the right pharyngeal pedicle. In this case, we used the method of P.M. Postolov, A.A. Pollntsev.
Preoperative preparation was short-term - within 1 - 2 hours.” This period of time was used to carry out shock measures, correct cardiac and respiratory disorders, and conduct general clinical and biochemical tests of blood and urine.
IN postoperative period 27% patients were treated with prolonged elimination from ishrx.o?a, prolonged artificial ventilation lungs and against this background, corrections of the identified environmental homeostasis were carried out. Important importance was given to early postoperative activity with the aim of preventing mental insufficiency, as well as regulating fluid flow and normalizing central hemodynamics.
Adequate postoperative decompression played an important role in treatment bopt:"., especially when performing vagotomy." The used nlmch technique proved to be very effective and made it possible to quickly restore activity 1: activity and passage through the intestines.
The postoperative period in patients who underwent ulcer surgery, pyloroplastis and vagotomy did not differ significantly from the postoperative period in patients who underwent ulcer suturing or excision, and was much easier than after gastric resection.
On the eve of the patients' discharge, X-ray examination was allowed
10 - examination of the stomach. top scores were obtained in patients of the third group, somewhat worse - in the fourth.
The lowest duration of treatment was observed among patients of the first and third groups, the highest - in the second and fourth groups.
Significant prevalence postoperative complications was not in any of the groups: first - Q.6%, second - 9.0 third - 4,6%, fourth - $7.5.
The study of long-term results was carried out on the basis of an analysis of 19"+ case histories of patients in 1967-1989. Of the above number in inpatient conditions about hospitalization in surgery department IH5 patients were examined. Treatment results h9 patients were studied by correspondence questionnaire.
Long-term results were assessed as excellent, good, satisfactory, poor. Long-term results were considered excellent in persons who felt healthy in the first days after surgery and before the examination, did not have any complaints, were able to work, and, as a rule, did not adhere to a diet. X-rays after surgery revealed slight deformities of the pyloroduodopal zone. Secretory function was approaching normal.
Long-term results were classified as good in those operated patients who had the following complaints: periodic heartburn," belching; heaviness in the opigotral region, the presence of gastritis with increased or decreased fluid density. Performance did not change. Subjectively, there was an improvement in health after the operation.
We considered satisfactory results the absence of improvement in condition after surgery, the presence of a mass of complaints,
igah.for the pre-surgery period, adherence to a diet, and this is how work capacity is and the need to transfer to an easier one /d. X-rays revealed differences in the deformation of the ventricle and duodenum with significant disorders of the gastrointestinal tract and bowel functions.
Long-term results were considered poor; in persons who had barely undergone surgery, signs of peptic ulcer disease with frequent exacerbations remained, or due to the occurrence of various late symptoms of peptic ulcer disease, external symptoms appeared that required repeated opara-fl. X-ray and endoscopic examination revealed significant disruption of the form and function of the stomach. When examining gastric secretions, significant changes in secretory function were determined. For each person received for clinical examination painful -> a mandatory plan was drawn up, which included: general tests, call and night; blood test for glucose content, prothrombin; (D) biochemical analysis blood; ionograima," fractional calling gastric juice; rI-metry-of-the-stomach; fibrogastroduodeno-snot; X-ray examination of the esophagus and stomach; X-ray functional characteristics of the esophagus and small intestine. The research results were processed by methods of variation statistics using modern computer technology.
