Surgical treatment of ulcer disease

Operative intervention when ulcers can be planned and emergency. Indication for planned surgical interventions on the stomach and duodenum ulcers is unsuccessful long-term conservative treatment and the presence of complications: cicatricial stenosis of the outlet of the stomach cancer rebirth ulcers, penetration (penetration) sores in the adjacent body of re-bleeding.
Emergency surgery for ulcers necessary in perforating ulcer, as well as in profuse gastric-intestinal bleeding that you cannot stop a conservative measures.
Elective surgery for ulcers are resection of the stomach - see the Stomach, gastric surgery.
When a ruptured stomach ulcer or duodenal ulcer in the first 4-b hour. after perforation usually also produce resection of the stomach, at a later date - closure ulcers.
Cm. also the Postoperative period, the Preoperative period.

Indications for the surgical treatment of ulcer disease, carried out in a planned manner: the futility of long stationary conservative treatment, the occurrence of chronic current complications of ulcers (ulcers penetration in the adjacent body, stenoses privratnika or duodenal ulcer, cicatricial deformity of the stomach, repeated bleeding), suspected malignant degeneration ulcers. Emergency surgical intervention is indicated for acute complications arise that threaten the rapid destruction of the patient,perforation, ulcers and profuse bleeding from her.
Planned surgery for ulcer is, as a rule, in gastrectomy (see Stomach surgery), usually performed by one of the modifications of the method Billroth II, most often on Finsterer.
Sometimes localization ulcers and its features allow you to apply resection type Billroth I. Gastroenterostomy, the former once the main type of surgery for peptic ulcer disease, is not efficient enough, is often the cause of serious late complications and when gastric ulcer is completely abandoned.
Even with duodenal ulcer, located low and is not available to remove prefer the so-called palliative resection of the stomach by type Billroth II, leaving ulcers off in the duodenum. However, created the conditions for peace are often insufficient for healing big kallusnoi ulcers, especially if it pinetreeroad in the pancreatic tissue. In such cases, the ulcer is left in place, but isolated from the bowel lumen and free from the abdominal cavity. When such operations a specific challenge is the closure of the duodenal stump; to ensure the highest reliability has developed a number of special techniques. The way Jacobovici (Fig. 6): after crossing the duodenum the gatekeeper its front wall cut through longitudinal incision for 6-7 cm and remove the mucous membrane of the dissected area, probably closer to the edges of the ulcer. Both sides gemokonservant the gut wall on each side of the longitudinal incision rolled towards one another in two rolls, touching his serous cover, sew their interrupted sutures on the line of contact and the free ends so that they form a tube, closing and stump duodenal ulcers, ulcerative niche.

Fig. 6. Resection of the stomach in Jacobovici (1-4 - the closing stages of the stump vendramini intestine).
Fig. 7. The way snail S. S. Yudina (1-6 - the closing stages of the stump of the duodenum).
Fig. 8. How Century I. Kolesova (1-5 - the closing stages of the stump of the duodenum).

The way snail S. S. Yudina (Fig. 7): the duodenum cross obliquely, trying to keep possibly longer azkabani flap front wall. Possibly remove the back wall around plague, the plague is treated with iodine tincture. From the top of the flap, stitch the side walls of the colon so that protection stump it takes the form of a cone-shaped trunk. This trunk roll "snail", immersed in a niche ulcers and fix stitches to the capsule of the pancreas.
How Century I. Kolesova (Fig. 8) similar to the method Jacobovici, but the longitudinal splitting of the ulcer is produced in two places parallel slits. After diaconale front of the formed flaps of the intestinal wall rolled into a roll serous cover outward, cover them niche ulcers, and the rear flap impose and hem the top. These methods of closing the stump of the duodenum, like others, do not give a full guarantee of success.
Penetration ulcers in the colon forces to resect the latter, in gallbladder - to cholecystectomy, in the hepatic parenchyma - to-plane liver resection. When cicatricial stenoses of the duodenum operation of choice is surgical removal of the stomach by type Billroth II, and in the pyloric stenosis - sometimes by Bilrot I. Only occasionally in patients extremely emaciated and dehydrated, have limited gastroenterostomy. If the plague, causing stenosis, healed, rational back pozavcherashny gastroenterostomy short loop (see Stomach, operations), because in these cases the imposition of anastomosis can be a comprehensive intervention and further surgical treatment is not required. When unhealed ulcer with stenosis of gastroenterostomy should be considered as preliminary event, which is on the recuperation of the patient will be followed by resection. This especially applies to stenoses privratnika, caused large kaluznij ulcers, threatening malignant degeneration. In such cases it is more profitable to impose gastrojejunostomy so that he made the least difficulty for the upcoming gastrectomy - front veridicitatii, long loop. However, with the improvement of methods of preoperative preparation, pain management, operational equipment cases stenosis, not allowing immediate gastrectomy, are becoming rarer.
In recent years, along with resection of the stomach, all with great success produce vagotomy with simultaneous piloroplasty or economic gastrectomy. Vagotomy - subphrenic, and sometimes transpleural (supradiaphragmatic) aims sharp decrease the acidity of the digestive power of juice. However vagotomy leads to the pyloric spasm rings, which should eliminate Pilorama, economical resection or gastrojejunostomy.