Treatment Of Chronic Duodenal Ulcer Research Articles

Professor Anatoly Alekseevich Kurygin (1932–2011) (to the 90th anniversary of the birth)

Anatoly Alekseevich Kurygin was born on September 10, 1932 in the village of Zaborye, Solotchinsky District (now Ryazansky District), Ryazan Region, into a peasant family. In 1950, Anatoly Kurygin graduated from the Solotchinsk complete secondary school with excellent and good marks and applied for admission to the Ryazan Medical Institute. A. Kurygin decided to become a surgeon already at the beginning of his studies at the Institute and persistently went to achieve this goal. After graduating from the 4th year, Anatoly Alekseevich, along with other most successful students, received an offer to continue the study at the Military Medical Faculty at the Kuibyshev Medical Institute named after D. I. Ulyanov, agreed and joined the ranks of the Soviet Army. In July 1956, having received a diploma with honors, lieutenant of the medical service A. A. Kurygin, together with his wife Lyudmila Nikiforovna, departed for the Belarusian Military District. In April 1961, having got the highest grades (five) in the entrance exams, Anatoly Alekseevich was enrolled in the postgraduate course at the Department of Faculty Surgery named after S. P. Fedorov. As a dissertation research, Anatoly Alekseevich was instructed to study the state of lavsan prostheses and a new vascular bed at different times after arterial alloplasty. Soon after defending his dissertation, V. M. Sitenko suggested Anatoly Alekseevich to take up the issue of chronic pancreatitis, which was little studied at that time. During the year, A. A. Kurygin studied the literature on this topic and came to the convincing conclusion that it was impossible as a doctoral dissertation. Anatoly Alekseevich reported his thoughts to the head of the department, substantiated the futility of this topic and expressed a desire to study the physiological and surgical aspects of vagotomy as a new and alternative method of gastric resection for the treatment of chronic duodenal ulcers and its complications. In June 1978, the deputy head of the department, associate professor A. A. Kurygin, successfully defended the first doctoral dissertation in the USSR on the treatment of duodenal ulcers by vagotomy in combination with pyloroplasty. Five years later, in November 1987, professors of the Military Medical Academy V. M. Sitenko, A. A. Kurygin and A. I. Nechay, as part of a group of surgeons from Moscow, Kyiv and Tallinn, were awarded the title of Laureate of the USSR State Prize «For the development and implementation of new methods of treatment of peptic ulcer». In 1985, Professor A. A. Kurygin was appointed head of the Department of Surgery № 2 (for advanced medical training) of the Military Medical Academy. Anatoly Alekseevich was the author and co-author of more than 300 scientific papers, including 39 monographs and manuals, more than 25 teaching aids, 14 inventions, as well as the editor of the Abdominal Surgery section of the Small Medical Encyclopedia. Also, A.A. Kurygin published three collections of poetry. On November 12, 2011, after a severe and prolonged illness, the doctor Anatoly Alekseevich Kurygin was no longer with us. Major-General of the Medical Service A. A. Kurygin was buried on November 15 at the Serafimovsky cemetery in St. Petersburg.

The principles of planned surgical treatment of chronic duodenal ulcer(40-years experience of Clinic named for S.P. Fyodorov)

The experience of planned treatment more than 2 000 patients with chronic duodenal ulcer makes it possible to work out the diagnostic algorithm, based on complex research of acidic stomach secretion. The principles of choosing of interference (organ-retaining, resecting or combining interference) and kind of pyloroplasty were defined. The right choice of operation of complicated duodenal ulcer secures excellent and good results for 85% patients.

Technical feasibility of laparoscopic Finney pyloroplasty examined in a canine model

The efficacy of laparoscopic surgery in the treatment of chronic duodenal ulcer has been demonstrated using minimally invasive approaches. This study aimed to evaluate the technical feasibility of laparoscopic Finney pyloroplasty in six dogs. Under laparoscopic guidance, the anastomosis was created using mechanical devices (n = 3) and combining a linear stapler device and intracorporeal suturing (n = 3). The operative time and complications were recorded. Evaluation of the anastomosis included studies of intraoperative and postoperative endoscopy and ultrasonography as well as the complete gastric emptying time. The animals were killed 4 weeks after surgery. Measurement of luminal diameter, amount of adhesion formation, degree of healing, and inflammation or fibrosis were evaluated in the postmortem studies. The operation was successfully completed for all the animals. No intraoperative or postoperative complications were observed. Gastric emptying was significantly enhanced in the postoperative period, as compared with the preoperative results. After 1 month, there was no evidence of anastomotic leak dehiscence at the gastroduodenal anastomosis. Luminal diameter was increased, and no abnormal findings were encountered during the postmortem abdominal exploration. The technical feasibility of performing a safe laparoscopic pyloroplasty in a dog model was demonstrated in this study.

Ten-year results of vagotomy and gastrojejunostomy in the treatment of chronic duodenal ulcer.

Ten-year results of vagotomy and gastrojejunostomy in the treatment of chronic duodenal ulcer.

Gastro-oesophageal reflux and oesophagitis before and after vagotomy for duodenal ulcer.

Fifty patients undergoing elective vagotomy for the treatment of chronic duodenal ulceration have been investigated pre-operatively and again 3 months postoperatively to determine the extent and severity of associated gastro-oesophageal reflux. Pre-operatively all patients had a normal lower oesophageal sphincter pressure but 50 per cent had symptoms of gastro-oesophageal reflux, 42 per cent had excessive reflux on 24 h pH monitoring and 30 per cent had oesophagitis on endoscopy and/or oesophageal biopsy. Postoperatively, reflux symptoms were present in only 12 per cent of patients but pH studies were still abnormal in 36 per cent and oesophagitis was observed in 32 per cent. Lower oesophageal sphincter pressure was unaffected by vagotomy. Gastro-oesophageal reflux is common in pre-operative duodenal ulcer patients and is not significantly reduced by vagotomy. Careful pre-operative oesophageal assessment is necessary to determine which duodenal ulcer patients require an anti-reflux procedure in addition to vagotomy.

Mortality and morbidity after anterior lesser curve seromyotomy with posterior truncal vagotomy for duodenal ulcer.

A survey has been performed of the mortality and morbidity of anterior lesser curve seromyotomy with posterior truncal vagotomy in the elective treatment of chronic duodenal ulcer. There was one death in a series of 605 patients due to a myocardial infarction, an operative mortality of 0.16 per cent. There was no case of ischaemic necrosis of the lesser curvature or fundus of the stomach. Eleven patients had symptoms of delayed gastric emptying (1.7 per cent) and seven of these underwent a drainage procedure (1.3 per cent). Postoperative dumping did not occur, significant diarrhoea was present in two patients (0.33 per cent). This operation is relatively simple, quick and extremely safe to perform. It is suggested that the more widespread use of this type of elective surgery for duodenal ulcer might reduce the mortality from the condition.

Pylorus-preserving gastrectomy in the treatment of duodenal ulcer.

Abstract Twenty patients with duodenal ulcer have been treated by a pylorus-preserving gastrectomy. A functioning pyloric sphincter was maintained by retaining a 2-cm. cuff of antrum and carrying out a Billroth-I type of resection proximally. Basal acid output was reduced by 52.4 per cent and maximal acid output by 65 per cent. Gastric emptying time was prolonged, without producing stasis. A provocative test for the presence of dumping produced symptoms in only 1 patient following this operation in comparison with a high incidence of symptoms in patients who had had a Polya gastrectomy or vagotomy and drainage. The results suggest that the procedure may be of value in the treatment of chronic duodenal ulcer.

DUODENOPLASTIA ASSOCIADA À VAGOTOMIA GÁSTRICA PROXIMAL NO TRATAMENTO DAS ÚLCERAS DUODENAIS ESTENOSANTES

A vagotomia gástrica proximal firmou-se como o procedimento de escolha no tratamento cirúrgico eletivo das úlceras duodenais crônicas, por ser a operação mais segura quanto à morbidade e mortalidade. Sua aplicação tem sido estendida às complicações da úlcera duodenal, mediante operação complementar que visa solucionar a complicação. Com o objetivo de avaliar a vagotomia gástrica proximal no tratamento das úlceras duodenais estenosantes os resultados clínicos de uma série consecutiva de 80 pacientes submetidos à vagotomia gástrica proximal e duodenoplastia (VGP + Dp) foram comparativos aos de uma série de 106 pacientes submetidos à vagotomia gástrica seletiva e antrectomia (VGS + A); os pacientes foram avaliados 2 a 16 anos após a cirurgia. As séries foram homogêneas quanto ao sexo e à idade. Cinco diferentes tipos de duodenoplastia foram realizados, de acordo com as características anatômicas do duodeno estenosado No grupo da VGS + A a reconstrução do trânsito alimentar foi gastroduodenal em 46 pacientes e gastrojejunal nos 60 pacientes restantes. O índice de mortalidade operatória foi de 1,2% com VGP + Dp e de 1,9% com VGS + A. Controle endoscópico pós-operatório demonstrou patência da luz duodenal e piloro conservado nos pacientes submetidos à duodenoplastia. A recorrência ulcerosa ocorreu em 5% após VGP + Dp e em 1,9% após VGS + A. Conclui-se que: 1. a duodenoplastia resolve a estenose duodenal sem dano do esfíncter pilórico, mantendo as vantagens da vagotomia gástrica proximal sem operação complementar de drenagem do estômago. 2 Na avaliação clínica global os melhores resultados foram obtidos com a vagotomia gástrica proximal. 3. A vagotomia gástrica proximal associada à duodenoplastia é uma boa opção de tratamento da úlcera duodenal estenosante.

Laparoscopic Modified Taylor Procedure in the Treatment of Duodenal Ulcer: Technique and Outcome after 5-Year Follow-Up

Background: Recently, gastric stapling with posterior truncal vagotomy has been performed by laparoscopic surgery, as an alternative to highly selective vagotomy (HSV) and the Taylor procedure for the treatment of chronic duodenal ulcer. Aim: To investigate, after a mean 5-year follow-up, the effect of the stapling-modified laparoscopic Taylor procedure, on gastric secretion, emptying and reflux as well as clinical parameters and recurrence rates in patients treated for duodenal ulcer. Methods: 16 patients, aged 38–66 years, were treated from January 1993 to January 1996 (median 60.5 months), by the laparoscopic stapling-modified Taylor procedure, using the Endo-GIA stapler device. Assessment of the results of gastric acid secretion, solid and liquid gastric emptying, enterogastric reflux, endoscopic findings and clinical parameters, using the Visick grading, was performed. Results: Endoscopy found healing ulcer in 15 patients. One patient showed signs of chronic ulcerative disease without gastritis or pyloric stenosis indicative of progressive ulcerative diathesis and was classified as Visick III. 14 patients were classified as Visick I and 1 as II. The enterogastric reflux index ranged from 0 to 26%, basal and peak acid output were 1.4 ± 0.6 and 11.7 ± 6.1 mmol H⁺/h, respectively. The half-emptying times of the solid and liquid meal were 82 ± 7 and 16 ± 6 min, respectively. These results are likely to be similar to those obtained from series of patients who underwent HSV or Taylor procedure and are closed to those from healthy controls. Conclusions: The laparoscopic modified Taylor procedure, using the Endo-GIA stapler device allows a more rapid, technically easier and radical performance of the operation with excellent long- term results and should be included in the armamentarium of the treatment of chronic duodenal ulcer.

Anterior lesser curve seromyotomy using a stapling device and posterior truncal vagotomy for the treatment of chronic duodenal ulcer: longterm results

Background: Recently, gastric stapling with posterior truncal vagotomy has been performed, either by conventional or laparoscopic surgery, as an alternative to highly selective vagotomy and the Taylor procedure for the treatment of chronic duodenal ulcer. Our aim was to investigate the longterm effects after a stapling-modified Taylor procedure, conventional and laparoscopic, on gastric secretion and emptying and on clinical indices and recurrence rates in patients treated for duodenal ulcer before 1994. Study Design: Thirty-one patients, aged 40 to 76 years (mean 53 years), were treated between 1986 and 1993, 21 by conventional and 10 by a laparoscopic stapling-modified Taylor procedure. Outcomes were studied for gastric acid secretion, solid and liquid gastric emptying, euterogastric reflux, endoscopic findings, and clinical indices using the Visick grading. Results: Endoscopy revealed a healing ulcer in 29 patients. Two patients showed signs of chronic ulcerative disease with mild symptoms, without gastritis or pyloric stenosis indicative of progressive ulcerative diathesis, and were classified as Visick III. Twenty-four patients were classified as Visick I and 5 as Visick II. The enterogastric reflux index ranged from 0% to 27%, and basal and peak acid output were 1.5 ± 0.6 mmol H +/h and 12.2 ± 6.4 mmol H +/h, respectively. The half-emptying time of solid and liquid meals was 78 ± 9 minutes and 18 ± 6 minutes, respectively. These results are likely to be similar to those obtained from the series of patients who underwent highly selective vagotomy or Taylor procedure and are close to those achieved in healthy controls. Conclusions: This modification of the original Taylor operation (conventional and laparoscopic) allows a more rapid, technically easier, and radical performance of the operation with excellent longterm results and should be considered an effective alternative for the treatment of duodenal ulcer.

Laparoscopic vagotomy for chronic duodenal ulcer disease.

Two laparoscopic procedures for treatment of chronic duodenal ulcer are described: bilateral truncal vagotomy with balloon pyloric dilatation and posterior truncal vagotomy with anterior lesser curve seromyotomy. The first procedure is simple to perform and easily reproducible, but the latter is preferred because it respects the physiology of the stomach. Thirty-six patients were operated on over a period of 18 months with good results comparable to those with open surgery. The indications for surgery were intractable chronic duodenal ulcers resistant to optimal medical therapy. There was no perioperative morbidity or mortality, and recurrent ulcers have not been demonstrated during early postoperative follow-up. The proper role of laparoscopic surgery in the arsenal of treatment of duodenal ulcers is unclear. The method of laparoscopic vagotomy requires rigorous experimental evaluation in specialized centers before widespread clinical application. Future multicentric prospective studies with long-term follow-up are necessary to assess the results of this innovative therapy of acid-peptic disease.

A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy

We performed truncal posterior right vagotomy with lesser curve anterior gastric myotomy by videocoelioscopy on 10 patients (5 men and 5 women, ranging in age from 19 and 54 years, with a mean age of 32 years). All had a long history of chronic duodenal ulcer with a mean duration of symptoms of 3.8 years. The mean length of the operation was 60 minutes (range: 55 to 110 minutes). There was no morbidity, and all patients were discharged after 5 days. The acid secretion tests under basal conditions and under insulin stimulation preoperatively and 1 month postoperatively showed a mean decrease in the basal output of 79.3% and a mean decrease of 83.04% in the maximal output. The fibroscopic control at the second postoperative month showed a complete healing of the ulcer in nine patients and a residual ulcer scar in one. No patients had any abdominal complaints. Right truncal vagotomy and anterior lesser curve seromyotomy by videocoelioscopy is an efficient and elegant method of treating chronic duodenal ulcer, but it needs thorough experimental practice.

Technique of laser lesser-curve seromyotomy

A new technique for performing a lesser-curve superficial myotomy of the stomach for the treatment of chronic duodenal ulceration has been proposed, using Nd-YAG laser energy delivered to the target via sapphire tips. A total of 12 patients have been operated on with only one haemorrhagic complication.

Principles of surgical indications: aids in decision making

Several types of clinical studies provide important decision aids for surgical indications. They include quantitative data on outcomes and utility analysis, graphic illustration of the various possibilities for decisions by decision trees, controlled clinical trials with data used in decision trees and--if these trials fail for several reasons--carefully conducted and documented prospective and retrospective trials. Items for defining the term "surgical indication" were illustrated by constructing a decision tree for treatment of chronic duodenal ulcer.

Cimetidine vs Ranitidine in the Treatment of Chronic Duodenal Ulcers

Cimetidine vs Ranitidine in the Treatment of Chronic Duodenal Ulcers

Treatment of chronic duodenal ulceration: Effectiveness of colloidal bismuth subcitrate tablets compared with cimetidine

Fifty-eight patients with chronic duodenal ulceration proven at endoscopy consented to enter a trial comparing the effect of colloidal bismuth subcitrate (CBS)tablets with that of cimetidine. Fifty-four patients completed the six-week trial. An endoscopic assessment of healing was made at four weeks. If healing had not occurred, the trial was continued for another two weeks and the endoscopy was repeated. At four weeks, healing at endoscopy was demonstrated in 82% of patients receiving CBS and in 58% of those receiving cimetidine. At six weeks, the healing rates were 93% and 81%, respectively. No side effects were noted in either group. Continued smoking was not found to have an adverse effect on the healing rate of ulcers in either treatment group.

Lesser Gastric Curvature and Fundus Myotomy

To eliminate successfully the undesirable side effects of the highly selective vagotomy, we developed a new, simpler type of vagotomy. As it was thoroughly demonstrated in dogs, myotomy of the lesser gastric curvature and fundus of the stomach denervates the parietal cell mass. Preoperative and postoperative acid studies were carried out with histamine phosphate (0.4 mg/kg given intramuscularly) and insulin injection (0.2 units/kg given intravenously). After myotomy, the curve was shifted to the right in response to histamine; insulin response was completely abolished. These results provided the basis for the treatment of duodenal ulcer in a human patient and confirmed that the operation is capable of producing satisfactory secretory inhibition. Our early experimental and clinical results have been encouraging. Therefore, we support further investigation regarding clinical application of this method in the treatment of chronic duodenal ulcers.

Proximal gastric vagotomy after five years.

A follow-up of 93 patients with chronic duodenal ulceration treated by proximal gastric vagotomy without drainage five to nine years previously shows a high incidence of confirmed recurrent ulceration of 16.1%. In addition, there have been patients with transient recurrent ulceration, and a small group with persistent dyspeptic symptoms but in whom no ulcer has been demonstrated. The operation is commendable for its lack of side-effects, but the high incidence of recurrent or persistent symptoms may lead to some reservations about its general application in the treatment of chronic duodenal ulceration.

EFFECT OF CIMETIDINE ON SURGERY FOR DUODENAL ULCER

Information from six centres engaged in the surgical treatment of chronic duodenal ulceration was compared on the basis of the number of operations performed for 5 years before and 4 years after the introduction of cimetidine. This showed a mean reduction of 39% in the number of operations since the drug was introduced.

Cimetidine and the gastric surgeon

AbstractA study of the effects of cimetidine has been made in patients referred to a surgical clinic. Cimetidine is undoubtedly useful in aiding the healing of acute duodenal ulcers, but once treatment is stopped, the majority recur. After healing, maintenance treatment is useful in preventing ulcer recurrence, but once the drug is stopped, recurrence soon follows. At present the evidence suggests that treatment with cimetidine may have to be life‐long. Most surgeons would not accept this as an alternative to surgery in the treatment of chronic duodenal ulcer. However, in the treatment of recurrent ulceration after surgery, and where symptoms are relieved by cimetidine, the patient may prefer drugs to further operation.