The choice of the method of surgical intervention in the treatment of stomach ulcers. Bleeding stomach ulcers
If there are indications for surgical treatment of gastric ulcers, gastric resection is the operation of choice. For ulcers localized in the distal part of the stomach, hemigastrectomy is indicated. For ulcers located in the proximal sections, the stomach is resected 3 cm above the edge of the ulcer. Restoring the continuity of the digestive tract can be done according to Billroth I or Billroth II. Each of the two methods can be used with equal success. But due to the high frequency of relapses, the same good results cannot be achieved using Billroth I for duodenal ulcers. If gastric resection is supplemented with stem vagotomy, then the likelihood of recurrence with Billroth I resection will be as low as with Billroth P resection. Some surgeons with pyloric ulcer and prepyloric ulcer with gastric hypersecretion supplement hemigastrectomy with stem vagotomy. Patients with simultaneous gastric and duodenal ulcers (type II according to Johnson) are also shown gastric resection. If a hemigastrectomy is performed with a duodenal ulcer, it is necessary to supplement it with a stem vagotomy. In the case when it is envisaged to remove 2/3 of the stomach or more with a duodenal ulcer, there is no need to supplement the resection with a stem vagotomy. Patients with highly positioned lesser curvature ulcers or cardiac ulcers should undergo a Pauchet extended resection with ulcer excision, which will be described later. There are surgeons who, instead of the Pauchet operation, resect a high-lying ulcer and close the defect of the stomach wall with a double-row suture, complementing this operation with a stem vagotomy with pyloroplasty. Some surgeons remain in favor of the Kelling-Madlener operation, which involves resection of cardiac and subcardial ulcers. The Pauchet operation is undoubtedly the most adequate and safe for high gastric ulcers, especially those accompanied by bleeding. All of the above operations can only be performed on benign ulcers. If the cardiac or subcardial ulcer is malignant. during the operation, it is necessary to observe the principles of performing oncological operations used for the treatment of ulcerated cancer (ulcer-cancer) of the proximal stomach. Bleeding stomach ulcers Stomach resection is the safest and most adequate operation for stomach ulcers complicated by bleeding, which does not respond to drug therapy. If the ulcer is localized high along the lesser curvature in the area of the cardia, it is necessary to operate according to Pauchet. Some surgeons, however, hemostasize the bleeding ulcer by suturing the ulcerated bleeding area. Others excise the ulcer without performing a gastric resection and close the defect with a two-row suture. They usually complement local ulcer resection with stem vagotomy with pyloroplasty. Suturing of a bleeding ulcer, as well as local resection of an ulcer, does not guarantee that the bleeding will stop, and bleeding often recurs. Supplementation with pyloroplasty and stem vagotomy does not improve results. Operations that do not include gastric resection simultaneously with ulcer resection should be performed only in patients in very serious condition, unable to undergo gastric resection, or in the case when the surgeon has no experience in performing gastric resection, especially according to Pauchet. Some patients are very difficult to keep stable when there is a lot of blood loss. They need to stop the bleeding as soon as the abdominal cavity is opened to stabilize the condition, and then proceed to resection of the stomach, including the ulcer area. The order of operation is as follows. First, an ulcer is found and a gastrotomy is performed. Since the dissected walls usually bleed, several large atraumatic Duval forceps are placed on the edges of the incision, both to stop the bleeding and to traction the walls to better view the stomach. The surgeon uses both hands to remove the blood clot from the stomach. Aspiration to remove clots is usually ineffective, as it damages the mucous membrane, which increases bleeding. If an ulcer and a source of bleeding are found, sutures are applied to achieve temporary hemostasis. When this goal is achieved, the gastrotomy opening is closed with a continuous suture and resection of the stomach, including the ulcer zone, is performed. It should be remembered that about 15% of bleeding stomach ulcers are malignant. For some patients with bleeding stomach ulcers, temporary endoscopic arrest or reduction of bleeding may be done with electrocautery, thermocauterization, or laser irradiation before surgery.