On the choice of rational surgical treatment of perforated pyloroduodenal ulcers. (Clinical studies) Chur, Nikolai Nikolaevich. Chur Sergey Nikolaevich
A stone lies in the steppe, the path indicates. A seagull flies over a wave, tells a fairy tale: oh yes, the city of Korcheva on the Two Seas! It is covered with sea salt and steppe dust, blown through by winds.
Ancient city. Under it, underground passages from time immemorial. Who dug them and when is unknown. You will enter into such an entrance to the steppes - you will leave in the city if your heart is pure. And whoever goes with malicious intent, that Chur-stone will not blow. Yes, not everyone knows about that stone.
For a long time the little people of the steppe coveted the riches of the city. So the Korchans filled up the passages-exits with stones, and they decided to block the largest one with an iron door, perhaps, and when it comes in handy. Well, and that door, of course, the blacksmiths Korchevs were instructed to work, who else? Their work is always reliable and lovingly done.
The anvil called out loudly. The hammer-handbrake either jumps on the red-hot iron, where it points to the hammer to hit, then it dances on the anvil with impatience, while it is hot, hurries. The wit shines all over afterwards, and Dubka at least, you know, knocks to himself and grunts, and shakes the silver earring in his ear. But the key to the castle Dubko got along unsuccessfully, but then the wit managed to do it.
Successful door to glory. Such that you can’t take it with a ram and you can’t unlock the lock. On its patterned field, two iron warriors clashed to the death.
The glory of the Korchevs does not give rest to Shushei. The blacksmith Korcha and his sons clamped his soul with good deeds, no one is afraid of the villain now. For a long time, Shusha walked around his fortress, hurried black divination. Surely it was from him that the rumor went that native iron is found in Temirova Balka? And it is for a blacksmith, what land is for a grain grower.
The Korchev brothers were easy-going, they went to that beam without delay. Reluctantly, their mother collected them, saying: you already go there, they say, with an eye, the hour is uneven - wormwood people will jump in.
“You’re still clucking at them,” the father was angry. “Look, the clubs are out. You can’t carry them by the hair, you can’t reach them.
Cautiously, the brothers go down into the beam, through the prickly thorn bushes. But there is no iron anywhere, neither on the scree, nor at the bottom of the streams that have dried up over the summer.
As the thicket began to crush the throat, it seemed to Wit as if a horse whinnied somewhere. He was alarmed and told his brother about it.
- It seemed to you, - Dubko reassured, - this is dry grass rustling.
Stuffy in the beam, sweat covers the eyes, blood hits the temples. But then a breeze blew into the gully from the Surozh Sea. sighed full chest Witty, but suddenly froze and said:
- Did it get hit in the nose by a horse?
“Yes, from yourself forty fathoms, as from a horse it reeks,” Dubko joked. “There is not a single living soul here besides us. Cicadas, you see, you can't even hear them.
And it’s true: no birds anywhere, no lizards. Everyone, as best they could, hid from the heat. The brothers finally decided to look around the turn, and even go back.
Suddenly, out of nowhere, a raven began to circle 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. They sat up, you know, in an ambush little people of the steppe, so with impatience they attacked the brothers.
Yes, not just a Russian person to take in full. What does he need to plow with a plow, what to wave his fist in battle, he does both with zeal. Well, blacksmiths, if they are used to hitting iron, then they have nothing to do on the heads of the filthy and even more so.
The brothers pressed their backs to each other - you will not approach. Ostroum will wave his hand - he will kill enemies from dozens, he will move Dubko with his fist - one and a half will fall dead.
Yes, no matter how strong the brothers were, but weary, they began to break through to the thorn bush. It’s not like a horseman, but a footman can’t poke his head. The brothers were pretty skinned on the thorns, but they hid from the enemies in the bush. They fell to the ground. Intercede, they say, mother earth, defend from enemy arrows.
Yes, the steppe people needed the Korchev brothers alive. They let them fall on the thorn bush. The dry grass caught fire, the smoke eats away the eyes, the heat completely pesters. There is nowhere to go, the brothers came out. In an instant they swaddled their arms and legs with strong lassos, braided from horse hair. Don't breathe, don't move your hand.
The horsemen dragged the captive prince of the steppe to the tent and threw him under his feet. The prince sniffs displeasedly, his narrow eyes closed, as if he held two knives.
“You have beaten and maimed a lot of my people,” he says. Tie you to the tails of wild horses, so that the bones can be pulled apart across the steppe!
The brothers are silent, they do not ask for mercy.
- Steppe people, - he says, - honor the heroes. Steppe people give them life.
He clapped his hands, and removed the fetters from the captives. The prince presented them with the best treat in the steppe - a bowl of mare's milk. The brothers spat, they did not drink.
“Tell me,” they ask, “what you need from us.”
- Yes, nothing at all, - says the prince, - only the door key from the hidden entrance.
“That’s what you wanted,” Dubko was surprised. “And you didn’t sniff it?” - and shoved a shish under the nose of the prince, a sign of the highest contempt among Russians.
What happened here, it is better not to say. To know wormwood-grass is bitter because human blood is watered in the steppe.
Dubka was tied up again, but Ostroum was driven away. They say that if you bring the key, you will save your brother, and if you let it slip, his head will roll down the beam from Temir Mountain.
“Go away, brother, don’t feel sorry for me,” Dubko whispers. At least you stay alive. Bow from me to your father and mother. Say, our name will not be disgraced. Goodbye.
At noon, the owl screams - trouble hurries into the house. Mother on Gorka toils in the morning, waiting for her sons from the steppe. And the swan had two swans, but only one returned to the nest.
Korca was in a hurry, not remembering himself, to his son to the rescue, but the outpost did not let him out of the city. There, they, the enemies, in the steppe, they say that the mosquito in the Tmutarakan floodplains, you won’t fight off everyone. Korcha began to call his friends, to gather a squad.
Witness, meanwhile, 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 into the steppe without a fight, filthy ones. He found among the rubbish of Dubkov the key that had failed then, corrected it and threw it away, coming to his senses. He dreamed of how enemies sneak into the city at night, burn houses, kill the old and the young, steal the young in full. And you can’t outwit the steppe dwellers - they will keep you to the end. Eh, he thinks, forever you and I, brother, apparently said goodbye.
Suddenly, something scratched against the wall of the kitchen. Ostroum looked - there was no one, but a human ear was nailed to the door with an arrow, and a silver earring gleamed in it, brothers. Figured it was a hint. You will, they say, hesitate, and your head will roll after you.
He went crazy here, sensing the torments of the brothers, he rushed to his mother. She pressed him to her heart and said:
- Chur-stone will believe me - we will meet. Farewell for now.
The outpost itself slipped through with the 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 to the city by a secret passage.
Yes, the cunning prince did not believe her to the end. First, he says, you will do the job, and then you will come for your son. Lie down as long as swaddled.
The steppe dwellers gathered in an instant, and with horses in a bridle, a secret course, they set off, they illuminate the road with torches, they look forward to rich booty.
Here Chur-stone lay across the path for them.
“Church me, churn,” said the mother, and walked over him.
Following boldly, the enemies climbed the Chur-stone, and he take it, turn around, and covered them all there to the last.
Dubka's mother returned to free him, but he sheds bitter tears, and does not take them for his own.
“What are you, stupid,” she said. “Look: our city is quietly glowing with lights. There are no enemies there, they did not pass.
Then he picked her up in his arms and, happy, brought her home.
***
The tumbleweed rolled across the steppe, lay down under the Temir Mountain - it turned into a fairy tale.
Reviews
Thank you for the fairy tale, thoroughly saturated with the Russian spirit, for the faith in mighty Russia, for originality, and for everything, everything that makes this fairy tale so cool. And although I am Russian, I have been living in Kazakhstan for a very long time, and my fairy tales are imbued with Kazakh traditions. However, they also have the same human values. Creative success to you with your daughter. Sincerely, Natalia Pavlova.
This dissertation should be submitted to libraries in the near future.
480 rub. | 150 UAH | $7.5 ", MOUSEOFF, FGCOLOR, "#FFFFCC",BGCOLOR, "#393939");" onMouseOut="return nd();"> Thesis, - 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 studies): Abstract of the thesis. ... candidate medical sciences: 14.00.27.- Minsk, 1992.- 22 p.: ill.
Introduction to work
Relevance Volume»» Increased surgical activity in the treatment peptic ulcer stomach and duodenum created" a number of requests that have not been resolved to date.
According to the data of domestic and foreign authors (V.Kh. Vasilok-ko, 1963, Sh.A. GulorDEsha, 1970, S.V. Kuraiov), the incidence of peptic ulcer disease of deladok and duodenal kiyka is from 3.7 to 10.2 per ІГ00 population. The number of operations that are performed on eggs suffering from peptic ulcer ") is steadily increasing*. The most relevant is the treatment of "sore forms of peptic ulcer of the stomach and duodenum: an increase in temporary disability, primary disability, and mortality (I.Y. Ioimprk, 1972, A.I. Gorbashko, 1906, Yu.M. Paninrev 1987, B.A. Veselovsky, 1966, Qing $ Lo I/ 1968). Annually, up to 29 thousand operations are performed for such a formidable complication of peptic ulcer as poryuriyil (M.y.Kuzin, 1968).
At the insistence of time, disagreements are in need of urgent surgical treatment there is no perforated ulcer of the pelvis and duodenum", since the recovery after the operation is 95-98?. There are certain difficulties in choosing the correct surgical aid in terms of long-term results.
There are more than 90 methods of treating perforated ulcers of the stomach and duodenum SA.L.II "Allmov, І9С7). Nevertheless, the variety of surgical interventions developed," but quite satisfy practitioners either because of poor long-term results, or complexity them execution.
Main way opera of the adeno treatment of persons with perforated ulcers "at the present time is the reduction of perforated from--
2--. verotiya, which is produced by 91,3% (B.A. Akhujanov, 1983, V.P. Zinevich, 1983). According to disputable statistics (G.V. Pakhomova, N.S. Uteshev, 1967), the recurrence of an ulcer ranges from 3.2 to 85.2 # after wiping the yazza. At the same time, it should be noted that in the future, look at the widespread introduction of various kinds vagotomy, suturing of the perforated hole, as before; to be performed by a certain part of the freestyle. This group will include persons of the elderly and old age, free with widespread forms of peritonitis, severe comorbidities, as well as faces young age who have no history of ulcers. But the main thing is that the majority of surgeons do not yet have a perfect command of the techniques for performing vagotoiy and especially encounter difficulties in isolating the posterior branch of the wandering pen.
The causes of recurrence of peptic ulcer after suturing are not well understood. A small amount of works devoted to research) secretory function stomach in the long run. Single works are devoted to the study of gastric secretion in the early postoperative period. The role of the primary treatment of the ulcer of the shiloroduodenal zone and the performance of vagotomy in the case of a perforated ulcer have not been studied in the light of immediate and long-term results.
conflicting data on the use of pyloroplasty and vagotomy in the treatment of perforated pyloroduodenal ulcer do not fully satisfy practical surgeons in countryside who need specific recommendations on the applied operations to determine the tactics of treatment "Given that the primary, subet-, rat remains when suturing a perforated ulcer, this, of course, is always a threat, even if vagotomy is performed, the formation of stenosis (cicatricial and inflammatory shaft around the ulcer).
The experience of elective surgery confirms this namesake. So, in the presence of an ulcer in the pnloroduodenal zone, vagotomy accelerates the healing of the ulcer, which can lead to stenosis. Therefore, most surgeons recommend in this situation, despite all types of vagotomy, performing pyloroplasty according to Mniulich or Dzhado. In addition, such issues as the role of anterior vagotomy, a technically simpler operation, have not been sufficiently reflected in the literature. ulcer and its plastics according to Guinea e-Mikulich. The role and place of excision of the ulcer without vagotomy has not been studied in the light of the immediate and long-term results of the operation of the stem bilateral vagotomy, and, therefore, no appropriate recommendations have been given on the appropriateness of their use. Changes in the intestine, especially its distal parts, have not been studied either. The urgency of this problem is also increasing because in recent years the number of young patients has increased significantly. It is precisely these patients who, most of all, have to
In the future, PERFORM THE REPEAT OF THE OPORZTSHI, COMING TO THE INVDL"
dzatsiya or dare profession.
Thus, the problems of treatment of a perioral ulcer of the pyloric-duodenal zone are relevant and in many aspects are not relevant.
Taking into account the above, 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 analysis the results of the treatment of perforated
pyloroduodenal ulcers various methods operational intervention
evidence, in the light of immediate and long-term results
- і» -
focusing on the role of excision of a perforated ulcer and the use of vagotomy.
2. Justify the most specific indications for applications best method correction taking into account the localization of the ulcer, age, severity of the patient's condition, the timing of the disease.
3. To study changes in the iotor-evacuation function of the stomach, duodenum and small intestine in the postoperative period after various modifications of the surgical treatment of perforated pyloroduodenal ulcers.
I ". To determine the function of the gastric secretion glands in the groups of operated patients in the long-term period using the methods of fractional gastric sounding and pH-metry.
I. It is proved that the excision of the ulcer is urgent histological examination its edges allows you to identify the nature of the process and determine the time soon after the operation further tactics treatment of patients.
2. The use of bilateral stem vagotomy for ulcer and pyloroplasty is the most effective and radical method of treatment perforated ulcer pyloroduodenal zone and allows you to get better results than when performing before, it is a stem vagotomy.
3. Studies have shown that anterior stem vagotomy in combination with excision of the ulcer and pyloroplasty gives good long-term results of treatment, is simpler than bilateral, and can be the method of choice in difficult situations in practical surgery.
5 -A. The study of the motor-evacuation function of the small intestine allows us to conclude that the intersection of the vagus nerve in remote period has no significant effect on physiological features organism,
D The most optimal tactics in the treatment of pyloroduodenal ulcer d was determined depending on age, duration of the disease, severity concomitant pathology, localization yaeey.
2. Lana comparative otsta results of treatment of perforated pyloric duodenal ulcer under conditions specialized hospital and pfi ion combatants.
3. It was shown that the use of anterior stem aaroTowif and pyloroplasty on one!) of the techniques that do not significantly lengthen the duration of the operation, technically but complex, lead
"(.Bilateral stem vogotomy is a complex, but the most affective and radical method for the treatment of perforated pyloric duodenal ulcers and allows you to get the best results."
5. In the presence of a pronounced, concomitant pathology on the part of the main systems of the ophthalmia, seppuponny peritonitis, it is quite justified to prescribe ONLY KSSOCHERLYA ulcers with cilorsplitcoP, which is a high guarantee for the prevention of stenosis of the pnlooood of the odonllal zone.
b. The study of the "gogno-otyach" double function small intestine made it possible to establish that ate the intersection of the trunks vagus nerve in the "remote period" significant functional changes do not occur.
the FOLLOWING MAIN GSHSHBShYA are brought to the defense
І.Iabolae a radical method of treating a perforated ulcer of the pyloroduodenal zone is its excision with pylorolysis and bilateral vagotomy. 2. In difficult situations, anterior stem vagotomy 6 can be performed by excision of the ulcer and pyloroplasty. E. The excision of a lateral ulcer with pylorosplasty of the pyloroduodenal zone is a high guarantee of the development of stenosis, but in terms of isolated results, yes. Trunk vagotomy and excision of the ulcer during perforation in the psyuroduodenal zone in the long-term period does not lead to motor-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 (14 Moscow-D991), the Conference of Surgeons of the Linoka Region (Minsk, 1991), at the joint scientific conference of the Department of Surgery of the Belarusian Institute for the Improvement of Higher Education, Minsk, 1992. "), meetings of the surgical society of Minsk (1992 -). The work was carried out according to the plan of research work of the BedSIUV.
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 set out on page 6 of the typewritten text and consists of an introduction, four chapters, closing; conclusions practical advice and list of references. The bibliography includes 265 works, of which 1h9 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 patient who was on inpatient treatment from 1979 to 1987 in the Myanoka Regional Clinical Hospital (GZb patients) and the surgical department No. 1 of the Molodechno Central! city hospital (50 large), V. communications about otitis media, who underwent surgery for perforated niloroduodenal ulcers, "were divided into a number of groups according to the tasks. In each group, the same type of operations were performed" in order to compare the results lechonka.
The first group - ulcer closure (5B patients). ". The second group - excision of the ulcer and pnloroplotnka according to Gaineks-Mikulich (- "th patients).
Third group - excision of the ulcer, pyloroplasty according to Heineke-! (kulich in combination with anterior stem vagotomy (52 patients).
The fourth group "- excision of the ulcer, pyioroplasty according to Gzyneke-Mikukich and bilateral trunk vagotomy (J t0 patients).
Most often, perforation of ulcers was observed at the age of 20 to 59 years, i.e. at their most productive age. There was no definite regularity in the choice of the method of operation depending on the age of the patients. In the sometimes group, ulcers were produced at any age, with any comorbidity, regardless of the timing of admission, neglect of peritonitis. "The second group included patients who had advanced" zo. (5Н,5ії), severe comorbidity, severe symptoms confusing peritonitis. There was no pronounced pattern of age in the choice of the operation method among patients of the third and fourth groups.
Most often, patients of all groups were admitted up to 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 the method of operation depended on the timing of the onset of the disease and admission to the hospital. The severity of the paritoneal phenomena was a contraindication to the half-penny vagotochsh. Duration surgical intervention with perforated gastroduodenal ulcers, it depended on the type of operation, the technique of the operating surgeon, and the intraoperative complication that arose; adhesive process in abdominal cavity and other reasons." Anterior and bilateral trunk vagotomy did not affect the duration of the operation. The duration of the operation, from our point of view, acquired special meaning in severe and debilitated patients, which often adversely affected the course of the postoperative period.
The types of operations that we used in the treatment of perforated gastroduodenal ulcers are well known and studied in detail by various authors. The theoretical prerequisite for performing stomach-draining operations was that when suturing perforated ulcers, there are tubers o-in dazzling substratum of the ulcer margins. When they are sewn together and immersed in serous-muscular willows, conditions are created for the development of stenosis, in addition, the connective tissue formation in the suture does not contribute to the healing of the ulcer in the future, despite the vagotomy. When the ulcer is excised, completely healthy tissues of the edges with good blood supply are sewn together, which contributes to the formation of a tender scar and, of course, is a certain preventive measure. - Due to the rapid adhesion process in the area of the rhoduodenal ulcer, sometimes there were difficulties in mobilizing the duodenal stalk according to Kocher. We have developed AND SUCCESSFULLY APPLIED "METHOD OF EXCISING PERFORATIVE ULCER DV(
duodenum", without the above mobilization. This method is easy to replenish, little tyuvmatic and quite reliable. For vagotomy, a modified Zodorovo clamp was used. The right, or posterior nerve, was found at the right pedicle.
Preoperative preparation was short-term - within I - 2 hours. This period of time was used for conducting gastro-shock measures, correcting cardiac and respiratory disorders, and for conducting general clinical and biochemical analyzes of blood and urine.
AT postoperative period 27% patients were treated with prolonged elimination from ischrx.o?a, prolonged artificial ventilation lungs and on this Background, corrections of the identified abnormalities in homeostasis were carried out. An important bridge was given to early postoperative activity in order to prevent dyskhatelio insufficiency, as well as the regulation of water and normalization of central hemodynamics.
Adequate postoperative decompression played an important role in the treatment bopt:"., especially when performing vagotomy." The technique used by NLMCH proved to be very effective and made it possible to quickly restore the first step: activity and passage through the intestines.
The postoperative period in patients who underwent xsechesto yazzi, pyloroplastis, and vagotomy did not differ significantly from the postoperative period. In patients who underwent suturing of ulcers or excision, it proceeded much easier than after resection of the stomach.
On the eve of the discharge of patients, X-ray 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 the 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: the first - Q.6%, second - 9.0 third - 4,6%, the 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 stationary conditions about hospitalization in surgery department IH5 patients were examined. Treatment results h9 patients were studied by correspondence questioning.
Long-term results were assessed as excellent, good, satisfactory, poor. Long-term results were considered excellent in persons who felt healthy from the first days after the operation and before the time of the examination, did not complain, were able-bodied, and, as a rule, did not adhere to a diet. X-ray after the operation, they revealed slight deformities of the pyloroduodo- dopal zone. Secretory function approached normal.
The long-term results were considered good in those operated patients who had the following complaints: periodic heartburn, belching; heaviness in the opigaotral region, the presence of gastritis with increased or decreased acidity. Working capacity did not change. Subjectively, there was an improvement in the state of health after surgery.
To satisfactory results, we attributed the lack of improvement in the condition after the operation, the presence of a mass of complaints, characterized by
igah.dlya dooparatsionkogo period, diet, and tyakko this-she working capacity and the need to transfer to a lighter / d. Radiologically, they showed differences in the deformity of the stomach and duodenum with significant disorders of the mountain or short-term functions of the colon: a and intestines.
Long-term results were considered poor; in persons who barely had surgery, signs of peptic ulcer with frequent exacerbations persisted, or due to the occurrence of various late complications, external symptoms appeared that required repeated opara-fl. X-ray and endoscopically they revealed pronounced destruction of the form and function of the stomach. In the study of gastric >der *imogo, significant changes in secretory function were determined. For each applicant for clinical examination sick-> a mandatory plan was drawn up, which included: general analyzes of call and night; blood test for glucose, "prothrombin; (D) biochemical analysis blood; ionograima, "fractional zoning gastric juice; ri-metry-stomach; fibrogastroduodeno-sniffle; X-ray of the esophagus and stomach X-ray functional of the stomach and small intestine. The results of the research were processed by the methods of variational statistics using modern computer technology.
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