The most common causes of massive bleedings from the hemorrhagic erosive gastritis and similar lesions of duodenum and thin intestine, which well react on the operational treatment, are ulcerations induced with stress, or with ingestion of aspirins and alcohols. Stress, aspirin and alcohol, disrupt the “gel-function” of gastric mucus, so-called the mucosal barrier for the backscattering H-Jons, which is it’s the most important defensive factor.
The increased backscattering of H-Jons, enable ulterior damage, liberating vessel-active substances, and leads to degranulation of mastocits of gastric mucous membrane, and liberation of heparin, and consecutive bleeding.
The conservative methods of treatment can be successful only then, when the speed of the blood leaking enables its compensation, preventing so a hypovolemic shock. In stressful conditions every delay of the surgical intervention leads deepening of the lesions and brings in the risk later operational procedure, when we must to implement a subtotal or total Palmer’ gastrectomy.
Discovery that vagotomy is opening A-V connections in the mucosa and submukosa, introduced a double-sided subdiaphragmatic trunkal vagotomy with pyloroplastic in routine procedure for the treatment of such bleedings. But this method had many disadvantages; it did not preserve the hepatic and pyloric branch what led to the biliary complications, postprandial Dumping, and the biliary reflux.
Cholinergic enervation reduces motility of the stomach and the intestine, the gastric secretion and the tone of the gall bladder and the gall canals, increasing tonus of the lower oesophageal sphincter and the sphincters Oddi. In order to avoid negative effects implemented so-called proximal selective vagotomy (PSV). At the proximal selective vagotomy is performing selective enervation of the parietal cells of the stomach with that we reduce the gastric secretion, but not as much as at the bilateral sub-diaphragmatic vagotomy with pyloroplastic.
Disadvantages these operations are in incompleteness, every one is burdened with complications, which we can avoid with modification of the selective vagotomy that is also selective for gastrointestinal bleeding. With sub-diaphragmatic section of the trunk of the back vagus, and with enervation of the parietal part of the stomach with section branches of frontal vagus and protection of the hepatic branch and n. Latarjet, we attain the full effect: we avoid atony of gall-bladder and its canals, and the Dumping syndrome. Peristaltic of the antrum is so preserved. In the doctoral thesis I presented the effect of such vagotomy on the profusion of the mucosa of duodena and jejunums with blood, with that I irrefutable proved this selection also for the bleeding of the duodenum and intestine.
Selective vagotomy for the gastrointestinal bleeding, in the master’s theses called: “Modified selective vagotomy”, is advantage comparing it with before used double-sided sub-diaphragmal and the proximal selective vagotomy for the operational treatment of the massive bleeding from the stomach too. It reduces incidences of postoperative bleedings, giving smaller percent disability. After subtotal gastrectomy are not rare repeated bleedings, which demand the most radical intervention: Palmer’s total gastrectomy. After modified selective vagotomy (selective for gastrointestinal bleeding) smaller is a probability for appearances of the postprandial dumping, the biliary reflux and an antral’s gastritis with the hyperplasia of parietal cells and consecutive hyper-secretion, which later leads to bleeding.
The modified selective vagotomy needs to use at all superficial erosions of any aetiology, if are erosions less than 3 mm in diameter and do not reach the muscular mucosa, having the dotted appearance. In all others cases, where exists a doubt that lesions reach the muscular mucosa, needs to apply the subtotal gastrectomy wit a use of conservative methods.
The modified selective vagotomy successfully stops the bleeding from erosions of mucous membranes of stomach, duodenum and thin intestine in for this indicated case. Preservation of the adrenergic innervations enables full effect, and preservation of hepatic and pyloric branches makes pyloroplastic redundant. Latarjet’s nerve and branches of the hepatic’s vagus, which arrive pylori-antrum’s region via art. gastricae dx., as also the ramus pyloricus, guard antrum’s peristalsis postoperative.
The method can be applied quickly and simply. Vagotomy is rarely when complete incomplete - a complete autonomic enervation is not possible. More briefly said, the modified selective vagotomy (selective for gastrointestinal bleedeng) reduces, or completely eliminate the consequences of bilateral vagotomy: holinergic enervations that decrease motility of stomach, duodenum and intestine, and the tone of gall-bladder, increases, in the same time tone of sphincters Oddi and the lower oesophageal sphincter. In the doctor’ dissertation I presented the effect of such vagotomy on the bleeding from duodenum and jejunum, with which I irrefutable proved its useful for treatment of the bleeding from the duodenum and jejunum.
SYMPATHETIC STIMULATION AND MICROCIRCULATIONS OF THE MUCOUS MEMBRANE OF JEJUNUM
Stimulation of the noradrenergic fibres of the villus lowers the lymph flow, the coefficient of the capillary filtration, and the capillary pressure. Also reduces the pressure of the interstitial circulation. This means that during the stimulation of the n. sympaticus there is no the “self-regulation” none of these elements (l6, 21,). Stimulations of the sympathetic fibres of jejunum promptly reduce the blood flow, which after gradually returns in normal values. Arterioles and veins are actively and balanced contracting. Because of this biphasic answers comes to the relative weak fall of the capillary pressure. The intestinal flow promptly falls on 48,3 with oscillations about 7,0 %. (Later it increases on 73,7 with the oscillation about 4,2 %.) The coefficient of the capillary filtration reduces for 75 %. The adrenergic stimulation increases the total intestinal resistance for 47 %. Increase is caused with increasing of pre-capillary resistance. Increasing of the post-capillary resistance is insignificant. During the sympathetic stimulation also increases the lymphatic osmotic pressure, which indicates to the intestinal dehydration (l7).
The sympathetic nerve system plays an important role in reflexive control of the blood volume. The reflex activation of n. sympathicus in the answer on the bleeding causes vasoconstriction and increasing pre- and post-capillary resistance. As the result of segmental changes of the vascular resistance the capillary pressure falls, and the interstitial liquid absorbs in the vascular system in purpose of restoration of the blood volume (the "auto-transfusion”) (18). Maintenance approximately the constant capillary pressure during stimulation of the n. sympathicus is important for the protection of the delicate function of the alimentary canal in the preventing of intestinal dehydration (19, 20,). The tone of the pre-capillary sphincters seems that plays resolute role in the reduction of the capillary flow (l8). The reduced transportable capacity of the intestinal microcirculation depreciates filtration. Lundgren and co-workers noticed increase absorption of liquid and electrolytes during stimulation of the n. sympathicus (18, 20, 22,). Other authors (Shepherd AP and co-workers) also confirmed that the sympathetic stimulation closes pre-capillary sphincters. Decrease of the capillary flow reduces the amount of the oxygen supply to tissue on the level of diffusion (23, 24,). Some work (Gidda JS and co-workers) show that vagotomy does not have any effect on the electric activity of the thin intestine. Conclusion: n. vagus leads excitatory and inhibitory fibrils. The inhibitory influences are dominant in the intact intestine (25).
Hepatic branch of n. vagus goes through the small omentum towards the hepatic plexus in the porta of hepatis innerving the biliary tract, proximal duodenum and the pylorus. Celiac vagus lowers within gastro-pancreatic peritoneum toward the celiac and the upper mesenteric autonomous plexus, innerving intestines up to the spleen flexure of the colon. The front and the last wall of stomach innerve the anterior and posterior n. vagus. However, the stomach receives motor and secretor innervation from the hepatic the celiac vagus, whereunto usual nobody thinks. Ramus pyloricus of the hepatal branch of n. vagus anterior supplies the pylorus and the most distal antrum. This piloric-antral area innerves also the fibres, which leaves the hepatic plexus in the porta hepatis, and associated to the right gastric artery reach up to the piloric-antral area. Bilateral trunk subdiaphragmal vagotomy is the total vagotomy. It cuts all gastric, hepatic and celiac threads, which leads to the complete gastric, hepatic and celiac vagotomy. Anatomical variations, in not so few numbers of cases, lead to the incomplete vagotomy. Selective vagotomy, on the other hand, consists of cutting all gastric threads with the preservation of hepatic and celiac vagus, including the protection those hepatic threads which goes to the pylorus and the most distal antrum. Selective vagotomy makes unnecessary drainage’s pyloroplastic. By execution this vagotomy needs to keep in mind that in particular cases hepatal branch starts completely low on the cardia and some its threads can be cut which results with incompleteness.
In the literature are described also other types of vagotomy, like the front selective and the back trunkal (preserve only the hepatal branch) and front total and back selective (preserve only the celiac branch of the n. vagus). The intestine and vagotomy
Statistics of published cases about the level of the post-vagotomy diarrhoeas are different and contradictory. Therefore, it has little meaning. Rarely appearing of the post-vagotomy diarrhoeas and the paresis of intestine is not completely explained so far. Two factors could play the certain role: possibility that in the majority of patients the intestine is innerved with parasimpatic threads of the n. splanchnicus, and the second, with possibility of the numerous anatomical variations of celiac vagus. Incomplete celiac vagotomy is therefore more frequent than the incomplete gastric or hepatic. Therefore are incidences of the post-vagotomy complications after celiac vagotomy are statistically insignificant (255).
Celiac vagus supports the muscular tone of the intestine. Loss of this tone would result with difficult pareses. However, to this does not come because practically there is no any possibility for the total enervation of the intestine with vagotomy. Significant is preponderances of tones of sympaticus after cutting the back vagus. The intensified sympaticotonus opens A-V communications in the mucosis and submucosis of the intestine, producing ischemia of mucosa, stopping so bleeding caused with superficial erosions.
Cutting of celiac branch of posterior n. vagus for a partial liberations of sympathetic innervations (total autonomic enervation of any organ is not possible) is technically to majority surgeons, and me also in that time, unfeasible. Besides that numerous variations could prevent efficacy of this vagotomy.
Therefore I approached to a detailed study of the gastric innervations, and anatomies of n. vagus and sympathicus, gastric microcirculations, aetiology and pathogenesis of the erosive gastritis, and concluded that the anterior selective vagotomy with preservation of the pyloric branch and Latarjet’s nerves, and the back trunk, can achieve ultimate performances in the treatment of the massive bleeding of duodenum and intestine in for this indicated cases. Wit performing the front selective vagotomy with preservation hepatic and pyloric branches, and the Latarjet’s nerve, is not need a pyloroplasty.
With preserving the hepatic branch we avoid biliary complications, not reducing depressive effect of hepatic vagus on the gastric motility. We so reduce, how we earlier have seen the incidence of Dumping syndrome and practically prevents the biliary reflux with all its consequences: antral gastritis with hyperplasia of parietal cells, hyper-secretion and an inclination to appearing of hemorrhagic lesions of whole gastric mucous membrane with predominant antral predilection.
Preserved Latarjet’s nerve brings motor threads of n. vagi into the myenteric plexus of the antrum, enabling the strong antral peristaltic. This activity on supports treads of n. vagus which arrives in this plexus via box pyloric branch of the hepatic vagus, as well as fibres which leaves the hepatic plexus in the porta hepatis, there associates to the right gastric artery and with it reaches this area.
The back trunk vagotomy is performing total enervation of the celiac solar plexus, excluding the celiac vagus. The adrenergic innervations of the stomach, which approaches via gastric and gastroepiploic blood vessels, loses so its antagonist and opens A-V anastomosis in the muscular layer of mucosa and submucosa, producing an ischemia of mucosa and stopping bleeding in certain cases. Depressions of gastric secretion made with liberation of adrenergic influences earlier braked vagus, reduces the acidity of gastric contents in the postoperative flow, and thus contributes to decrease possibility of later recidivism of bleeding, and repetition of the illness. Besides it the duodenum and intestine up to spleen flexure receive the parasympathetic innervations via n. splanchnicus, so that complications which this back trunkal vagotomy can produce become insignificant and they are not worth mentioning.
By the execution of operation the small and the large curve of the stomach need leave intact avoiding coarse manipulations, preventing so “stripping” adrenergic fibres, which via blood vessels approach to the stomach. In this way we prevent theirs pareses which can endanger succeed of the operational intervention. Therefore for the exploration of the place of bleeding, I carried out the high front transversal gastrotomy, realizing soon that it supplements the selectivity of the front vagotomy, and enables the inspection of ezophagogastric estuary on the esophageal varices.
On the other hand, every manipulation with the stomach in narcosis, and in the area of the ezophagogastric estuary and neighbouring parts, can produce a paresis of gentle branches of n. vagus for the front and back wall of stomach and help to achieving wanted effect. The identification of n. vagus posterior needs to carry out after mobilization of oesophagus and withdrawing it in the operational field. The back trunk we can easily and simply identify and cuts.
Front selective vagotomy I carried out so that I cut the periezofageal wrapping from the place of cutting the back vagus, obliquely downwards and median. Intervention I supplemented by subserose cutting vagus threads linearly towards the corner which closes pars densa with pars flaccida omenti minoris, or, better said, pars the hepatogastrica omenti minoris with omentum. In this way hepatic vagus threads remains completely preserve, Latarjet’s nerve is preserved, and the small and the large curve saved of ours manipulations.
Here needs emphasize that the gastrotomy need to close only when we convinced that bleeding is detain, and the status of the patient is good, for what is sufficiently ten minutes. Gastric tubes is obligatory, it serves how much for aspiration of contents in the postoperative flow, so much also for control of bleeding, and eventually conservative treatment of complication.
DESCRIPTION of OPERATIONAL METHOD
A left paramedial transrectal laparatomy. Inspection of the abdominal burrow, stomach and duodenum. The front high gastrotomy and exploration of the source of bleeding. Setting up the indication for the operational intervention. Mobilization of the left lobus of livers, mobilization of esophagus’s, separating the periezophageal connective tissue from the muscular layer of esophagus, and identification of the n. vagus posterior. Cutting the back trunk 2 to 3 cm proximal of the ezophagogastric estuary. Cutting all threads of the front vagus together with periezopaageal connective tissue from the place of cutting the back n. vaguse towards the corner that closes pars hepatogastrica omenti minoris with pars flaccida. In this way we cut all threads of the plexus esophagus anterior which goes to the stomach. In this way the part of the plexus esophagus anterior that goes from the ezophagogastric estuary through the pars hepatogastrica omenti minoris, as well as Latarjetov nerve, remain preserve.
When we ensured us in succeed of the operation, we introduce a gastric tube and close the gastrotomy. Follows a closing the operation’s wound without drainage.
Selective vagotomy for gastrointestinal sangvination, in for it indicated cases, stops the bleeding of the mucosa membrane of the gastrointestinal tract.