Comparative Analysis Of The Results Of The Endoscopic Treatment Of Gastroduodenal Ulcerative Bleeding

The study includes 557 patients with ulcer of the stomach and duodenal intestine complicated by bleeding. The control group was 290 patients, of which 48 patients with active bleeding were performed by standard endoscopic hemostasis techniques, and in 242 cases, when verifying stopping bleeding, endoscopy was limited to the diagnostic step with subsequent conservative patient management. The main group includes 267 patients in addition to endoscopic hemostasis with active bleeding (46 patients), the manipulation was supplemented with the implementation of the proposed method of endoscopic treatment of gastroduodenal bleeding of ulcerative genesis. When revealed bleeding (221 patients), endoscopic intervention was also accompanied by the implementation of the proposed method. The application of the composite polymer material over the ulcerative defect contributed to a decrease in the frequency of the nearest recurrences of hemorrhagic syndrome from 9.0% to 1.9%, reduce the need to perform operational treatment from 6.6% to 1.1% and levity indicator from 1.7% up to 0.7%, which generally affected the increase in the share of patients discharged without complications from 90.7% to 97.8% and reducing the timing of the hospital phase of treatment.


INTRODUCTION
Despite the fact that recently the general tendency to reduce the incidence of ulcer of the stomach (SU) and the duodenum (DU) is observed, complications of this pathology in the form of bleeding, perforation and stenosis of the gatekeeper remain the current problem of modern health care. Thus, these complications are the cause of almost 150,000 hospitalizations in the United States annually [1]. In turn, it is precisely bleeding that is the most common complication of ulcerative disease ranges from 19 to 57 cases per 100 000 people. For comparison, the perforation of ulcers is developing from 4 to 14 cases per 100 000 people [2]. According to Lolle I et al. it increases to 15.3%, while there were no differences in the results of the treatment of SU and DU [3]. In another systematic review and metaanalysis devoted to the surgical treatment of complications of gastroduodenal ulcers in Africa Peiffer S. et al. (2020) reported that in the structure of all operations, bleeding as the reason occupied the third place (9%) after perforation (41%) and the sample stenosis (22%), with the postoperative mortality in all analyzed studies on average amounted to 6.6%, according to data published after 2000, the growth of this indicator is noted to 9.7% [4].
The priority value as the first line of diagnosis and treatment of gastroduodenal bleeding is allocated by endoscopic technologies. For the present period, various methods differ in the source of bleeding are used, differing in their physical properties and mechanisms of action: thermal (electrocoagulation, argon-plasma coagulation, laser photocoyaging, etc.); Injection (adrenaline alcohol, sclerosant); Adhesive coatings (cyanaccrylates, thrombin, fibrin glue) and mechanical (clipping, ligation) [5,6]. According to Barkun A.N. et al, conducted metaanalysis showed that endoscopic interventions contributed to a decrease in the risk of re-bleeding compared to pharmacotherapy [7]. In the review Fujishiro M. et al, the effectiveness of various endoscopic hemostasis methods is provided. Thus, in randomy studies, the initial hemostasis indicators on average have become about 90% with a recycling frequency of 2-10%. The exception was the injection of adrenaline, in which the frequency of repeated hemorrhage reached 12-30%. According to the results of the study, the authors recommend the combined application of various techniques, for example, injecting and mechanical [8]. Another embodiment of the endohemostasis is the use of various hemostatic powders and polymer adhesive substances, the use of which is characterized by technical simple and safety [9,10]. However, according to Vitali F. et al.
Their isolated use with ulcer disease provided primary hemostasis only in 80% of cases, while the frequency of bleeding recurrence rate was 34% [11] by the 30 days of observation [11]. Such a large arsenal of various ways to stop bleeding and in some cases, their low performance indicate the need to continue research in terms of increasing effectiveness of endoscopic techniques, including the introduction of new hemostatic materials into clinical practice.
The analysis of literature indicates that the improvement of the results of the endoscopic treatment of gastroduodenal bleeding of ulcerative etiology is currently related to one of the relevant and to the end of the unresolved problems of modern health care. In addition to endoscopic hemostasis, in addition to endoscopic hemostasis, in addition to endoscopic hemostasis, with active bleeding (46 patients), the manipulation was supplemented with the execution of the proposed method of endoscopic treatment of gastroduodenal bleeding of ulcerative genesis (applique of a film-forming polymer made on the basis of the domestic substance "Heprocel" by using a special delivery device introduced In the endoscope channel for the controlled administration and placement of the hemostatic agent over a bleeding erosiveulcerative defect of the mucous). When revealed bleeding (221 patients), endoscopic intervention was also accompanied by the execution of the proposed method (Table 1). To carry out an objective prospective controlled study, compared groups were distributed taking into account comparability in all major indicators: age, gender, source and severity of bleeding. The conservative therapy strategy did not differ in the study groups, all patients received a standardized diagram of anti-sized treatment.

RESULTS AND DISCUSSION
In the control group, early recurrence of bleeding was noted in 3 (8.3%) of 36 patients with endohemostasis with active bleeding from the DU. After verification of the stopping bleeding, the recurrence developed in 18 of 182 (9.9%) cases. As a rule, these relapses arose in the first three days. The addition of endoscopy proposed by the application of the application of the substance "Heprocel" made it possible to reduce the recurrence rate in the main group to 3.1% (in 1 of 32 patients) in a subgroup with active bleeding with endoamostasis and up to 1.9% (in 3 of 188) in a subgroup With stopped bleeding, these values turned out to be significantly better than in the control group (χ2 = 9.996; df = 2; p = 0.007).
Endoscopic treatment of bleeding at Yabg also showed the pre-property of the application of the proposed method. Thus, in the control group, early recurrence of bleeding was noted in 1 (8.3%) of 12 patients with endohemostasis with active bleeding and in 4 (6.7%) out of 60 against the background of stopped bleeding and conservative therapy. In turn, there was no relapse in the main group after the The frequency of recurrence of hemorrhagic syndrome, depending on the initial activity of bleeding, is presented in Table. 3. In general, the recurrence rate with Forrest I in the control group was 17.1% (7 of 41), while in the main group -5.1% (2 of 39), with Forrest II 8.1% (19 235) and 1.4% (3 of 216) (χ2 = 13.753; df = 3; p = 0.004). In this context, the results indicate not only the improvement of the hemostatic effect due to the application of the Heprocel substance to the surface of the ulcer defect, but also that the good adhesive properties of the polymer contributing to the formation of a protective film also reduced the risk of influence of provoking factors, that is, provided Barrier function.
Reducing the risk of recurrence affected the need to perform surgical treatment of ulcerative bleeding. With all the sources of bleeding in the control group, 2 (4.2%) of the patient was operated on after endohemostasis, against the background of conservative tactics 17 more (7.0%), only 19 (6.6%) patients. In the main group, only 3 (1.4%) patients were operated on in a subgroup with the proposed substance that stopped bleeding and the applique of the proposed substance, in just a group, the frequency of operational treatment was 1.1% (χ2 = 10.961; df = 2; p = 0.005). For a full assessment of the treatment tactics taken, the dynamics of the ulcer process was additionally studied. In both groups, on the background of treatment, regardless of the initial size of the defect, its reliable decrease was obtained, which was verified during the control endoscopic inspection by 3-5 days of observation. In the main group, with the initial size of the ulcers, less than 1 cm (39 patients) diameter of the defect (m ± σ) decreased from 0.67 ± 0.14 cm to 0.52 ± 0.16 cm, while the average difference between these values was (Md ± σd) 0.16 ± 0.08 cm (p <0.001). A similar picture was obtained at the initial other sizes. Thus, with an ulcer of 1.0-1.9 cm, the average difference was 0.42 ± 0.12 cm (p <0.001); under ulcers 2.0-2.9 cm This indicator was 0.67 ± 0.15 cm (p <0.001); With ulcers more than 2.9 cm -1.00 ± 0.39 cm (p <0.001) ( Table 4-5). Table 4.

The size of the ulcer defect (m ± σ) in the dynamics in the main group
Size of ulcers (сm) N diameter before treatment diameter for 3-5 days Md±σd t-criterion.

Fig. 1. Distribution of patients on the outcome of the recurrence and cause of mortality
Improving the tactical and technical aspects in bleeding from the DU and the stomach ulcers made it possible to generally affect the duration of the hospital phase of treatment. The regression of the symptom complex characteristic of the ulcerative disease with an absolute effect on the achieved hemostasis has reduced the stage of stationary treatment in a subgroup with an endogemostase from 6.5 ± 1.5 days in the control group up to 4.9 ± 1.4 days in the main group (T = 5.32; p <0.05), in a subgroup with conservative patient management from 5.7 ± 1.3 to 4.1 ± 1.6 days (t = 11.31; p <0.05) and in Overall in groups from 5.8 ± 1.4 to 4.2 ± 1.6 days (t = 12.22; p <0.05). The benefits of the proposed technique make it possible to recommend it for active use in the urgent surgery of the ulcerative disease of the stomach and DU, complicated by bleeding.

CONCLUSION
A prospective study of the effectiveness of the proposed method of endoscopic hemostasis in clinical practice showed that the application of the composite polymer material over the ulcerative defect contributes to a reduction in the frequency of the nearest recurrence of hemorrhagic syndrome from 9.0% to 1.9% (p <0.001), reduce the need to perform operational treatment with 6 , 6% to 1.1% (p = 0.002) and, accordingly, the rate of mortality from 1.7% to 0.7%.
The use of domestic composite material made it possible not only to improve the hemostatic efficacy of endoscopic treatment of gastroduodenal bleeding, ulcerative etiology, but also provided a more pronted reparative effect (p <0.05) due to the prolonged protective properties of the film-forming polymer, which generally affected the increase in the share of discharged no complications Patients with 90.7% to 97.8% (p <0.001) and reducing the timing of the hospital phase of treatment from 5.8 ± 1.4 to 4.2 ± 1.6 days (p <0.001).