Duodenoplastia associada à vagotomia gástrica proximal no tratamento das úlceras duodenais estenosantes

ABSTRACT

Proximal gastric vagotomy has been accepted as the procedure of choice for the elective surgical treatment of chronic duodenal ulcers, being the safest operation when considering morbidity and mortality. Its application has been extended to duodenal to complicated ulcer means of a complementary operation aiming to solve the complication. With the aim of evaluating the proximal gastric vagotomy in the treatment of stenosing duodenal ulcers the clinical results of 80 consecutive patients treated with proximal gastric vagotomy plus vagotomy (VGP + Dp) were compared to those of a series of 106 patients submitted to selective gastric vagotomy plus antrectomy (VGS + A). These patients were evaluated for a period of 2 to 16 years after surgery. The series were homogeneous related in gender and age. Five different types of duodenoplast were performed, according to anatomic characteristics of the stenosed duodenum. In the VGS + A group the reconstruction of alimentary tract was gastroduodenal in 46 patients and gastrojejunal in 60 patients. Post operative endoscopic control showed patency of the duodenal lumen and preserved pyloric sphincter in the patients submitted to duodenoplaty. Ulcer recurrence ocurred in 5% after VGP + Dp and in 1,9% after VGS + A. Late postoperative complications such as diarrhea dumping and bilious vomiting were more frequent and more severe among the patients treated with VGS + A. Bilious vomiting did not occur and dumping and diarrhea were rare, mild and transitory after VGP + Dp. The overall clinical assessment, according to Visick classification, showed excelent results in 73% of the patients with VGP + Dp and in 42% of the patients with VGS + A; excelent and good result were found in 87% of the patients of the first group and in 76% of the second group. The better performance of proximal gastric vagotomy, with less frequent side effects and milder and transitory late complications, turns 5% to 10% ulcer recurrence tolerable and makes it acceptable as the operation of choice for the treatment of uncomplicated chronic duodenal ulcer.

RESUMO

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.