Millat B, Fingerhut A, Borie F
Hôpital St. Eloi, Rue Bertrand Sans, 34295 Montpellier, France.
World J Surg. 2000 Mar;24(3):299-306. doi: 10.1007/s002689910048.
Indications for surgery of duodenal ulcer (DU) have changed radically because of the efficacy of H(2)-antagonists, endoscopic procedures, and eradication of Helicobacter pylorus. The aim of this study was to analyze the current literature to determine if definitive surgery is still relevant for complicated DU (bleeding, perforation, gastric outlet obstruction). Two studies have compared early to late surgery in terms of bleeding. One recommended early surgery (significant reduction in mortality) in the elderly, but no statistically significant difference was found when analyzed with "intention to treat." In the other, mortality with early surgery was five times higher than with expectant therapy (when it was possible). Two studies comparing different surgical techniques for bleeding favored the radical procedure. Of at least 15 studies comparing endoscopic treatments, however, none has compared endoscopic therapy to surgical intervention for bleeding DU. One trial, comparing nonoperative to surgical treatment for perforation, found similar rates of morbidity, intraabdominal abscess, and mortality; but the hospital stay was longer (p < 0.001). Nonoperative treatment failed more often (p < 0.05) in patients over age 70. In three trials, postoperative morbidity (excepting wound sepsis in one) was not significantly increased by definitive surgery, with less ulcer recurrence (p < 0.05) compared with simple closure. Laparoscopy (versus laparotomy) was shown to take longer (p < 0.001) but required less postoperative analgesics (p < 0.03); there were no statistically significant differences as concerns the duration of nasogastric aspiration, intravenous drips, hospital stay, time to resume normal diet, Visual Analogous Scale pain scores for the first 24 hours after surgery, morbidity, reoperation rate, or mortality. Of 48 laparoscopic patients, 11 (23%) underwent conversion to open surgery. Three surgical techniques [highly selective vagotomy (HSU) + gastrojejunostomy (group 1), HSV + Jaboulay gastroduodenostomy (group 2), or selective vagotomy (group 3) + antrectomy) for gastric outlet obstruction (GOO)] showed that although postoperative results were similar (except wound sepsis in one trial), long-term Visick scores were significantly (p < 0.01) better in group 1 than in group 2, but not in group 3. Further studies are needed to determine the exact prevalence of Helicobacter pylori in complicated DU and to compare (1) definitive to minimal surgery (stop the bleeding or close the perforation) combined with antisecretory drugs and eradication of H. pylori; (2) surgery to endoscopic treatment combined with eradication of H. pylori; and (3) for GOO, surgery to balloon dilatation combined with eradication of H. pylori.
由于H₂拮抗剂、内镜治疗以及幽门螺杆菌根除治疗的有效性，十二指肠溃疡（DU）的手术适应证已发生了根本性变化。本研究的目的是分析当前文献，以确定确定性手术对于复杂性DU（出血、穿孔、胃出口梗阻）是否仍具有重要意义。两项研究比较了出血情况下早期手术与晚期手术的效果。一项研究建议对老年人进行早期手术（可显著降低死亡率），但按“意向性治疗”分析时未发现统计学上的显著差异。另一项研究表明，早期手术的死亡率比保守治疗（如有可能）高出五倍。两项比较不同出血手术技术的研究支持根治性手术。然而，在至少15项比较内镜治疗的研究中，没有一项将内镜治疗与出血性DU的手术干预进行比较。一项比较穿孔非手术治疗与手术治疗的试验发现，两组的发病率、腹腔内脓肿和死亡率相似；但手术组的住院时间更长（p<0.001）。非手术治疗在70岁以上患者中失败的情况更常见（p<0.05）。在三项试验中，确定性手术并未显著增加术后发病率（其中一项试验中伤口感染除外），与单纯缝合相比，溃疡复发率更低（p<0.05）。腹腔镜手术（与开腹手术相比）所需时间更长（p<0.001），但术后所需镇痛药更少（p<0.03）；在鼻胃管抽吸时间、静脉输液时间、住院时间、恢复正常饮食时间、术后24小时视觉模拟评分疼痛得分、发病率、再次手术率或死亡率方面，两者无统计学显著差异。48例腹腔镜手术患者中有11例（23%）转为开腹手术。三项针对胃出口梗阻（GOO）的手术技术[高选择性迷走神经切断术（HSV）+胃空肠吻合术（第1组）、HSV+贾布莱胃十二指肠吻合术（第2组）或选择性迷走神经切断术（第3组）+胃窦切除术]显示，尽管术后结果相似（一项试验中伤口感染除外），但第1组的长期Visick评分显著优于第2组（p<0.01），但与第3组相比无差异。需要进一步研究以确定复杂性DU中幽门螺杆菌的确切患病率，并比较：（1）确定性手术与最小化手术（止血或缝合穿孔）联合抑酸药物及根除幽门螺杆菌；（2）手术治疗与内镜治疗联合根除幽门螺杆菌；以及（3）对于GOO，手术治疗与球囊扩张联合根除幽门螺杆菌。
