HBO IN COMPLEX SURGICAL TREATING OF ULCER GASTRODUODENAL BLEEDINGS.

Tutory for students and interns.

Introduction.

The gastric and intestinal ulceris among the most broadcasted diseases in the world. From 10 to 15% of sicks suffer from bleedings (Pantsyrev Yu., Greenberg A., 1979, Zakharova and co-authors, 1980). These bleedings compose 82-86 % if all bleedings of duodenum (Rozanov B., Bratuth V., 1972; Struchkov V, 1977, Chuhrienko D., 1983; Szoor J., Shadi O., 1981).

Gastroduodenal bleedings (GB) are up today often finished lethally (33,3%) after the resection of stomach on the top of bleeding (Komakhidze M., 1979; Toskin K., 1980; Natalini G. et al., 1980; Tracanelli V.et al., 1980).

The main reason for the lethality in GB is the hemorrhage shock and complications of operations on the top of bleeding (Belichenko I., 1984).

These unsatisfactory values cause the investigation of the new methods of treating with minimization of lethality. The HBO, as an important particular method for such kind of diseases, can be one of them.

1. Therapeutic influence of HBO on ulcer GB.

Treating with oxygen is applicable because of the obvious reason ­oxygen is the source of existence of proteinal bodies. Oxygen is an important bioagent, it can significantly improve the status of sick organs.

In oxygenotherapy the tension or concentration of oxygen in aerial mix for respiration is improved; that causes the stabilization of its concentration in blood and tissue.

The last time a new method of therapy is successfully developing; that is HBO, the oxygenotherapy with an improved tension of oxygen. This is a complicated method; it requires a developed equipment and stuff. Nevertheless, already 400 divisions of HBO-therapy exist in 170 cities.

The advantages of HBO are:

1. lessening of the ishemia of tissue by means of dissolving of oxygen in blood, and permits the supply of the body with a saturating amount of oxygen, while the blood stream is weak. That normalizes the exchanging process in sick zone (Chernousov et al., 1983);

2. reduction of the inflation, improvement of the micro circulation; 3. treating of hemic hypoxia (Ginzburg et al., 1975).

In experiments (Boerema .,1962) on animals the blood was mixed with reomacrodex, saturated with hemoglobin to 0,4%. After that the animals continued the successfully existence in barochamber under 3,5AT pressure, independently on the severe reduction of erythrocytes. These experiments permitted HBO in bleeding therapy ­after HBO 75% of animals survived with noone survived without HBO (Belokurov Yu. et al., 1981).

HBO stimulates reparations in cerebrum; kidney; liver; the eritropoez is stimulated (Sidorov T., 1970; Tumanovsky Yu., 1977; Barkova E., Petrov A.,1979).

Even after sharp bleeding the changes in the cerebrum can be reversible if HBO is applied  (Petrov A.,1981).

 

A.Leonov (1981) stresses, that in accompany of hypoxia HBO stimulates the metabolic desintoxication of many organs: cerebrum, heart, liver and kidney when their blood circulation is damaged.

The seaming of ulcer accelerates twice in case the application of HBO (Zamotaev et al., 1981); its structure also changes; the mucusal isn't damaged.

HBO in GB improves the reduction of the local hypoxia and damaging of the mucosal of stomach and duodenum (V.Vasilenko,1970; G.Dorofeev,1983; T.Gati,P.Guth,1970).

The positive effect also deals with the normalization of function of nervous system (F.Komarov,1983).

N.Uteshev,1983; V.Krivko,1979 correlate the reverse of damages with the ability of blood to transport the oxygen to tissue in time. HBO also reduces the amount of donor's blood in operation: the sick is stimulated for the proliferation after HBO.

Yu.Isakov et al.,1981 marks that HBO lessens the loading of cardiosystem.

Many specialists include HBO in therapy of GB of ulcer of stomach and duodenum ( V. Vasilenko, Yu.Isakov, N.Uteshev, A.Chernousov, V.Bulynin, B.Komarov, N.Matrenizkaya).

2. Indications of HBO in complex surgeon treating of GB.

E.Bykov (1981) proclaims that HBO lessens the damages and helps the regeneration of suffered from hypoxia tissue.

That was the reason for the application of HBO in treating of GB ulcer.

The first task was to interrupt the bleeding (this can be controlled by symptomatology together with fibrogastroduodenoscopy). It would be stressed, that the course never was  interrupted because of repeating bleeding.

3. Complications of HBO and their prevention.

The complications can be of medical or technical origin.

All the equipment of the barochamber, conditioner and patient - all of them would be compulsory electrically neutralizes.

The dress wouldn't be made from synthetic to avoid the fire.

The functional electrodes would be inactive during the procedure of HBO.

The maintenance of the chamber isn't dangerous as usual; but the people with acute negative reaction on oxygen or tension shiftscan be among the patients. The principle symptom for interruption of HBO procedure is the improvement of pulse index. Fast decompression also can cause the lung wounds.

All these complications can be caused by the rejection of some general rules and recommendations on the application of barochambers for HBO; on contrary, following of the recommendations gives an effective treating of disease.

4. Equipment for HBO and control.

The single-place barochambers are applied: "Oka-MT", "Irtysh-MT", "Enisey-3", BL-3.

Imported chambers "Vickers" and "Degger" are also applied.

For the control were applied:

1. Cardiosignalisator KS-02, controller of pulse with various types of indication.

2. Multichannel electrocardiograph 3NEK - for complex control of cardiosystem.

3. Polarograph PPT-1 measures the tension if oxygen in tissue using the chronamperograms.

4. Electrogastograph EGS-4m - estimates bioelectricity of stomach. 5. AZIV-2, microanalyser, estimates pH of body.

6. Flame photometer - examines the electrolytes of body.

5. The application of HBO in complex surgical treating of GB.

An investigation would be held in advance the HBO therapy:

5.1. Anamnez: determination of epilepsy, otorhinolaryngologic diseases, lung pathologies; claustrophobia.

5.2. Investigation: pulse, cardiac system, respiration.

5.3. Certain attention would be paid to pathology of ears of patient. 5.4. Roentgen of lung.

5.5. Instruction on behavior during the procedure.

5.6. Instruction on the way of respiration during the decompression. 5.7. Just before the procedure patient would take off all metallic accessories and dress himself in cotton.

5.8. If ulcer has a bleeding, diet  of Meilengrakht would support the HBO therapy.

5.9. The procedure would be held in 20-30 minutes after the food reception.

5.10. Just before every procedure investigations on pulse; cardiography; tension of oxygen; resistance of erythrocytes; pH of blood plasma (by Ziggart-Adersen); vascular pressure of blood would be held.

5.11. The first procedure of HBO wouldn't last more than 30 minutes; during it the sensitivity of patient to oxygen is in study.

5.12. Any procedure consists of three parts:

compression - improvement of pressure with 9,81 kPa per minute, according to directions RTM-42-2-1-84. The speed of compression can be less or even be made step by step if the patient feels himself not well.

isopression - the principle part of procedure when the pressure is saturated at 2AT - lasts for 40 minutes. These values were selected after investigations of patients with polarography and electrogastography. If any of: pulse; respiration; cardiogram; electrogasrtogram; subjective feelings is out of order, the procedure would be immediately interrupted.

decompression - returning of pressure to normal with 9,81 kPa per minute, sometimes probable twice more.

5.13. After the procedure the same investigations would be held as before it.

5.14. Criteria of efficiency of HBO is reduction of pulse and general bettering.

5.15. Reducing the pulse in extreme way corresponds the best regime of treating.

5.16. The procedures would be held every day.

5.17. The post hemorrhage anemia requires 3-10 procedures (G.Ratner,1979)

The HBO-therapy if accompanies GB, can be held in three variants:

1. The pre-operational therapy just after the bleeding is interrupted - the treating of hypoxia requires 4-6 procedures of HBO. The procedures are also supported usually with the lessening of size of ulcer, improvement of mucosal. The operation is done after them.

2. The application of HBO after the operation on the top of bleeding

- the course would be begun in a day or two after the operation and include 4-8 procedures. HBO can be finished after the complete reduction of anemia; normalization of motoral activity of stomach; regeneration of normal oxygenation of tissue. That variant allows to avoid various complications after operation.

3. The application of HBO before operation for preparation and after operation for prevention of complications - that is a combination of the first two variants of application.

The optimal parameters for course can be selected from the Table 1.

6. The principles of use of HBO in complex surgeon treating of GB.

Eighty patients were investigated about the efficiency of HBO-therapy: 59 mail; 21 female; the age - from 20 up to 66. 25% suffered from a stomach bleeding; 75% - from a duodenum one. 16 patients didn't have stomach diseases before; 80% had an ulcer-gastric anamnez; 27,5 % had already GB.

The principles of the application of HBO in complex surgical treating of GB.

properties of bleeding
OCK-deficit, ml	bleeding	variants of use
less 500	interrupted	replacing therapy + HBO + operation after OCK-compensation
	not-interrupted	replacing and hemostatic therapy + HBO + operation after OCK- compensation
500-	interrupted	replacing therapy + HBO + operation after OCK-compensation + 1000 HBO after the operation
	not-interrupted	replacing therapy+immediate operation +HBO  after operation.
More 1000	not-interrupted	replacing therapy+immediate operation + HBO after operation.

 

Character and percent of after operational complications with GHafter HBO and without it. 

23,7% of patients had a slight bleeding (DKC 500 ml);

30% - medium (500-1000 ml);

46,2% - strong bleeding (DKC 1000 ml).

 

Besides the main group an additional group of 79 men - 67 mail; 12 female, owing GB also existed. HBO didn't support the operation for that control group.

Character and difficulcy of operation on GB with HBO and without it.

	with HBO	without	sum
character of operation	80	79	159
Resection of 1/2,2/3,3/4 of stomach asB-1	8	15	23
Resection of 2/3,3/4 of stomach asB-2	3	22	25
Antrumectomy + SI	32	12	44
Angular resection of stomach	7	9	16
Cutting of ulcer + SV	13	9	22
Gastroduodenotomy, sewing of bleeding vascular, pyroloplastics + SV.	17	12	29
In general	80	79	159

 

73% of patients from the control group had a duodenum bleeding; 27% -

ulcer of stomach. 37,9% of patients had a slight bleeding (DKC 500 ml); 36,7% - medium (500-1000 ml); 25,4% - strong bleeding (DKC 1000 ml). 56,9% of patients had already ulcer; 81% got GB for the first time; 19 % had it already before.

Operations were done to all 159.

Character and percent of after operational complications with GH after HBO and without it.

	number of complications
character of complications	with HBO	without	sum
purulence of wound	2(2,5%)	7(8,7%)	9(5,7%)
seams wrong sewing	1(1,2%)	4(5,1%)	5(3,1%)
pneumonia	1(1,2%)	3(3,7%)	4(2,5%)
infiltrates; abscesses of stomach	2(2,5%)	2(2,5%)	4(2,5%)
repetitive bleedings	------	4(5,1%)	4(2,5%)
acute cardiac shortage	------	3(3,8%)	3(1,9%)
anastomosit	1(1,2%)	1(1,3%)	2(1,2%)
eventration	------	2(2,5%)	2(1,2%)
on the whole	7(8,7%)	26(32,9%)	33(20,6%)
dead	1(1,2%)	16(20%)	17(10,7%)

 

These figures obviously present the efficiency of HBO in addition to operations: HBO-therapy 4 times reduced the complications. B.Komarov et al.,1985, managed to reduce it by 2,6 times; serious complications (purulence of wounds, wrong seals, eventrations) reduced by 5 times. The lethalitty reduced by 20 times (1,2%), that correlates with the values of V.Bulynin et al.,1985.

The represented results show a high efficiency of HBO in treating of GB; but further developing of this method in practice is required.