New in Bronchial Asthma Surgery from The Perspective of Valvular Gastroenterology

Clinics of Surgery
Review Article ISSN 2638-1451 Volume 5
New in Bronchial Asthma Surgery from The Perspective of Valvular Gastroenterology
Martynov Vladimir Leonidovich*
Doctor of Medical Sciences, Associate Professor, National Research Nizhny Novgorod State University named after N.I. Lobachevsky
(UNN), Russia
*Corresponding author:
Martynov Vladimir Leonidovich,
Associate Professor, National Research Nizhny
Novgorod State University, city of
Nizhny Novgorod, st. Zaprudnaya, building 3,
apartment 176, Russia,
Tel: 89049188600,
E-mail: hirurgia12@mail.ru
Received: 24 Feb 2021
Accepted: 11 Mar 2021
Published: 15 Mar 2021
Copyright:
©2021 Martynov Vladimir Leonidovich, et al. This is
an open access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and build upon your work
non-commercially.
Citation:
Martynov Vladimir Leonidovich, New in Bronchial Asth-
ma Surgery from The Perspective of Valvular Gastroenter-
ology. Clin Surg. 2021; 5(3): 1-5
Keywords:
Bronchial asthma; Failure of the Bauhinia flap;
Chronic impairment of duodenal patency
1. Summary
Based on the analysis of literature data, the authors distinguish the
following links in the etiopathogenesis of bronchial asthma (BA),
which depend on the state of the gastrointestinal tract (GIT): micro
aspiration into the bronchopulmonary system of the contents of
the stomach and duodenum: failure of the esophageal sphincters;
pathological reflexes emanating from the gastrointestinal tract;
dysbiosis; irrational diet; hernia of the esophageal opening of the
diaphragm; hyperacid state of the stomach. The indicated reasons
for asthma are explained by the pathological state of the valve sys-
tem of the digestive tract. 52 patients with asthma underwent baug-
inoplasty and correction of chronic duodenal obstruction (CHD).
The operation was successful for most patients. Disadvantages in
the implementation of the volume of the surgical aid are indicat-
ed: inadequate correction in a number of cases of HNDP, failure
to perform vagotomy with gastric hyperacidity and subsequent
fundoplication. The necessity of using computed tomography and
ultrasound in the diagnosis of arteriomesenteric compression of
the lower horizontal part of the duodenum (as one of the forms of
CPAP) has been expressed.
Bronchial asthma (BA) affects 3% of humanity. In the United
States, about 4% of the population suffers from actively recurrent
asthma, and another 3% have a history of it. In Russia, as in most
European countries, asthma is common among 5% of the adult
population and 7% of children, i.e. in the country there are about
7 million BA patients [11]. This indicates the urgency of the prob-
lem.
One of the reasons for various forms of bronchial obstruction is
a pathological change in the gastrointestinal tract (GIT). Back in
1934 J. Bray [cit. 6] pointed out the connection between the pa-
thology of the gastrointestinal tract and BA, noting the stretching
of the stomach after eating with the emergence of vagal reflexes. In
1946 S. Mendelson [cit. 6] observed aspiration of gastric contents,
which caused an asthma-like syndrome. A number of works of a
later period have shown a clear connection between gastroesopha-
geal reflux (GER) and AD [3, 10, 14-18]. In the last decade, it has
been increasingly indicated that gallbladder often gives various
bronchopulmonary complications, which are based on inconspic-
uous micro aspiration of gastric contents into the bronchi. Particu-
larly dangerous is the ingestion of hydrochloric acid, pepsin, fats,
bile and pancreatic enzymes into the respiratory tract, which can
cause deep damage to the bronchial wall, thinning of the alveolar
septa, impaired surfactant production and a significant decrease
in the diffuse capacity of the lungs. Clinical manifestations of
the pathology of the bronchopulmonary system in patients with
gastrointestinal tract infection largely depend on the frequency of
aspiration, the quantity and quality of the aspiration material. Ini-
tially asymptomatic GERD eventually necessarily leads to compli-
cations [cit. by 6]. So, L.Ch. Geller et al. [3], observing 63 patients
with the initially detected gastrointestinal tract for 5-8 years, in 9
cases the development of BA and in 3 cases of chronic bronchitis
with an asthmatic component was established. According to M.
Puchala [17], 10% of patients have respiratory lesions. According
to various authors, in patients with BA, gallbladder is detected in
clinicsofsurgery.com 1

40-82% of cases [3, 10, 13, 17].
The effect of the contents of the stomach and duodenum (12 sc) on
the spastic reaction of the bronchi was also studied experimentally
[13]. Thus, patients with (a) esophagitis, (b) AD, (c) esophagitis
and AD were injected with a 0.1N HC1 solution through a catheter
into the esophagus. Only in patients of the third group (a combina-
tion of esophagitis and asthma) there was a significant decrease in
the peak expiratory flow rate and a significant increase in bronchial
resistance; functional impairments in other groups were minimal.
After the introduction of saline into the esophagus, reactions were
not observed in any group. No changes in the parameters of lung
function were observed after the infusion of HCl in patients of the
third group after a three-day course of atropine administration. It
has been suggested that moderate bronchial obstruction in patients
with asthma combined with severe inflammation of the esopha-
gus is due to the presence of HC1 in the esophageal cavity, and
the positive effect of atropine in bronchoconstriction indicates the
involvement of the parasympathetic nervous system. In dogs with
esophagitis, esophageal HCl perfusion caused bronchospasm [13].
After vagotomy, acid had no effect.
The presence of micro aspiration is most convincing when detect-
ing gastric contents by methods for determining lipids in alveolar
macrophages. This method is sensitive (83%) and specific (94%).
All aspiration complications of the gastrointestinal tract more often
develop at night when the patient is asleep in a horizontal position,
especially after taking sleeping pills, alcohol, drugs [7]. Therefore,
patients with asthma who do not have clinical manifestations of
reflux esophagitis, but with nocturnal attacks of bronchospasm, are
recommended to have a compulsory examination for gastrointes-
tinal fluid. The very same treatment of the bronchospastic reac-
tion with drugs that relieve the tone of smooth muscles, causes a
decrease in the tone of the esophageal sphincter, which increases
the possibility of manifestation of gastrointestinal tract infection
and its severity, which, in turn, aggravates the course of AD [12].
Treatment of dysfunctions of the esophagus in the presence of
gallbladder not only significantly reduces complaints associated
with gallbladder, but also reduces the severity of BA manifesta-
tions at the same time, in 75% of patients, the intake of anti-asthma
drugs is reduced by more than half. Without targeted treatment of
gallbladder, the number of anti-asthma drugs taken decreased only
in 42% of patients [14]. Many consider antacid therapy mandatory
[13].
ZhPD is the most frequent and characteristic symptom of cardia
insufficiency due to hernia of the esophageal opening of the dia-
phragm. According to a number of authors, reflux esophagitis is
observed in 14-90% of all patients with hernia of the esophageal
opening of the diaphragm. Such patients have a very high risk of
developing AD [8, 9].
In almost 90% of cases, dysbacteriosis is detected in BA patients
[11]. In this regard, enterosorption can have a positive effect [2],
the main mechanisms of which are detoxification of cellular con-
tents, release from toxic or potentially dangerous substances of exo
and endogenous nature due to their binding and neutralization in
the gastrointestinal tract, sorption of food allergens, histamine and
other biologically active substances, bacterial antigens, normaliza-
tion of intestinal microflora, immunocorrective effect (sorption of
circulating immune complexes, effect on intestinal lymphoid tis-
sue, blocking immunoglobulin E) [1].
Improvement of the condition of BA patients can be achieved with
the help of unloading dietary therapy (EAD), the mechanisms of
action of which, through positive changes in the immunocompe-
tent system, are apparently associated with the suppression of al-
lergic inflammation, the exclusion of food allergic products with
the subsequent passage of macromolecular food residues through
the liver and the lymphatic system of the gastrointestinal tract into
the general bloodstream [4]. Elimination of products of infectious
sensitization originating from the gastrointestinal tract, by hemo-
sorption, plasmapheresis, is accompanied by stimulation of the ad-
renal cortex with the release of glucocorticoids into the blood, as
well as inhibition of the immune-pathological component of AD
pathogenesis [11].
Summarizing the above, during BA the following pathological
links can be distinguished, depending on the state of the gastroin-
testinal tract: • micro aspiration into the bronchopulmonary system
of stomach contents and 12 p.c.; • incompetence of the esophageal
sphincters, leading to gallbladder and micro aspiration; • patholog-
ical reflexes emanating from the gastrointestinal tract, going along
the afferent nerve pathways to the central nervous system, and
from there along the centrifugal pathways to the bronchopulmo-
nary system, followed by bronchospasm; • dysbiosis of the gastro-
intestinal tract, leading to autointoxication and microbial allergies,
immunological shifts; • food allergy; • irrational diet; • hernia of
the esophageal opening of the diaphragm; • hyperacid state of the
stomach as an organ of production and finding of a pathological
agent (hydrochloric acid) in the pathogenesis of AD.
Considering that at this stage in the development of medicine, AD
is incurable, any new data on the etiopathogenesis and treatment of
AD should be given close attention. Nevertheless, the overwhelm-
ing majority of specialists continue to be skeptical about such im-
portant pathogen etic mechanisms of AD. Meanwhile, its final rec-
ognition could allow a new look at the etiology and pathogenesis
of respiratory pathology, and the impact on these links would be
an impetus for the development of new methods of treating AD.
In our opinion, the indicated causes of AD, caused by the gastroin-
testinal tract pathology, can be explained by the pathological state
of the valve system of the digestive tract [5]. If the valve system
breaks down, the principle of "one-way road" of chyme movement
along the gastrointestinal tract is violated.
Volume 5 Issue 3-2021 Review Article

We will trace the pathophysiological and path anatomical changes
in case of disturbances in the functioning of the valve system in
the gastrointestinal tract. According to L.G. Peretz (1955), in 1 ml
of the small intestine contents there are up to 5 thousand microbes,
and in 1 ml of the contents of the large intestine there are about
30-40 billion of them. The differentiation of the functions of the
small and large parts of the intestine is due to the formation in
the ileocecal region of this obturator, which ensures the isolation
of the small intestine from reflux of colonic contents. Isolation of
the gut by the race is necessary due to the sharp difference in the
chemical composition, physiological state and bacterial spectrum
of its contents and the large intestine.
The importance of the ileocecal region in the motor activity of the
intestine has also been determined, its high sensitivity to the chem-
istry of the chyme and the reflex effect of the ileocecal apparatus
on the motility of the gastrointestinal tract in general. The specified
section of the intestine performs the function of an "internal ana-
lyzer" coordinating such an important function of the intestine as a
portioned rhythmic conduction of chyme from the small intestine
to the large intestine, which is necessary for the completeness of
bacterial processes in the right half of the large intestine. In case
of insufficiency of the ileocecal locking apparatus, constant reflux
of the colon contents into the small intestine disrupts not only its
function, but also its structure. As a result of insufficiency of the
ileocecal obturator, billions of microbes are thrown from the large
intestine into the small intestine, colonization of the small intes-
tine with allochthonous (foreign) microorganisms occurs, which
leads to the appearance of putrefactive and fermentative process-
es in the small intestine. Waste products - indole, phenol, cresol,
skatole, pyrocatechol, carbolic acid, hydrogen sulfide, mercaptan,
methane, ethane, etc. - infect the mucous membrane of the small
intestine and, being absorbed into the blood, cause the phenomena
of autointoxication. These metabolites cannot be sufficiently de-
toxified by the body, especially in liver disease.
Invasive, toxic, and often necrotic factors of microorganisms con-
tribute to dystrophic and necrotic changes in the mucous mem-
brane, which further leads to the destruction of the intestinal wall.
In this case, the barrier role of the intestinal wall is violated. The
intestine becomes an entrance gate for infection, as evidenced by
nonspecific bacteremia in patients with intestinal dysbiosis and the
formation of foci of endogenous infection. Chronic enteritis de-
velops, called reflux enteritis. As a result of the chronicity of the
process, local and regional lymphoid tissue suffers, as a result of
which a deficiency of immunoglobulins A and M develops. The
body becomes less protected against microbial aggression. With
microbial colonization of the small intestine in the proximal gas-
trointestinal tract, premature deconjugation of bile acids occurs.
The resulting free bile acids have a damaging effect on the mu-
cous membrane, enhancing morphological changes in the small
intestine. In this case, the absorption of bile acids in the ileum is
impaired. Normally, up to 90% of all bile acids are absorbed in the
indicated section of the intestine, and the rest pass into the large
intestine, from where they are excreted with feces. In conditions
of reflux enteritis, a significant part of them is not absorbed in the
small intestine, which is the cause of the development of colitis
and a risk factor for the development of a tumor. In the presence of
dysbacteriosis of the small and large intestine, enzymes are not in-
activated, and the remains of food protein molecules formed in the
more proximally located parts of the gastrointestinal tract (stom-
ach, liver, pancreas, tic intestine), causing inflammation of the mu-
cous membrane of the underlying parts as well. So, on the basis of
insufficiency of the Bauhinia valve (NBZ), enterocolitis develops.
In addition to the toxic effect on the intestine, the waste products
of bacteria have a similar effect on the liver, gallbladder, stomach,
and pancreas. As a result of inflammation of the wall of the small
intestine, lymphatic vessels and lymph nodes located in the ret-
roperitoneal space and about 12 p.c., a spastic process develops
around the last and initial parts of the small intestine. These parts
of the intestine are located mesoperitoneally and do not have a
mesentery, therefore, they are inactive and often undergo an ad-
hesive process. Fibrous tissues formed as a result of the adhesion
process and enlarged lymph nodes squeeze from the outside the
end section of 12 sc, which makes it difficult for its contents to exit
the intestine, increasing the cavity pressure. Hypertension at 12
sc. makes it difficult for the secretions of the organs flowing into
it (gallbladder, pancreas, stomach, liver) to escape, which leads to
their infection and the occurrence of chronic inflammation.
In addition to these processes, the output of content from 12 bp.
often complicated by compression of its lower-horizontal part by
the upper mesenteric vessels. This is how a chronic violation of
duodenal patency is formed with relaxation of the pyloric and car-
diac esophageal sphomas, which, in turn, can cause duodeno-gas-
tro-esophagial-lingual reflux with subsequent microaspiration of
the contents. This is the path of development of the pathology of
the organs of the digestive system on the basis of dysfunction of
the valves of the gastrointestinal tract, which is a huge zone for the
occurrence of pathological reflexes that go to the central nervous
system and from there to the smooth muscles of the bronchi with
subsequent bronchospasm.
Attention should be paid to the already proven fact that bile reflux
from 12 p.c. into the stomach causes hypersecretion of hydrochlo-
ric acid, if deep atrophy of the gastric mucosa has not yet occurred
(chronic duodenal obstruction (CHNDP) is the reason for this).
The indicated etiopathogenetic influence of dysfunction of the
valve system allows supporting the opinion of some authors that
AD is a complication of gastrointestinal tract pathology.
We have experience in the treatment of 700 patients in whom NBZ
was proved during irrigoscopy. All these patients underwent baug-

inoplasty, in 165 cases it was supplemented with correction of the
CPAP. Among these patients, there were 52 patients suffering from
BA from 5 to 35 years old, at the age from 13 to 57 years. ChNDP
was found in 46 of them. Analyzed were complaints of gastroen-
terocolitic nature in 202 patients suffering from asthma (including
those operated on). They complained of pain (63%) and heaviness
in the abdomen (61%), nausea (49%), belching with air (61%),
regurgitation of food (45%), heartburn and bitterness in the mouth
(74%), diarrhea and loose stools (43%), intolerance to milk and
other food (41%), bad breath (52%), bloating and rumbling in the
abdomen (62%). 48% of patients underwent various operations on
the abdominal organs.
In the group operated on, the leading form of AD was aller-
gic (71%), non-allergic form was noted in 5%, mixed - in 24%
of patients. Moderate BA was noted in 63.1%, mild - in 21.1%,
severe - in 15.8% of patients. The association of asthma attacks
with food allergens was noted by 52.6%, with house dust - 47.4%,
plant pollen - 26.3%, drugs - 21.1% of patients. The provoca-
tion of physical activity was noted by 52.6% of patients, cold air
- 50%, psychoemotional overstrain - 31.6%. In 84.2% of cases,
nocturnal attacks of suffocation predominated. Extrapulmonary
allergic manifestations were also observed in the group of oper-
ated patients: urticaria or angioedema was noted in the anamnesis
in 78.9%, allergic rhinitis - in 47.7%, seasonal conjunctivitis - in
21.1%, atopic dermatitis - in 15.8 %.
When studying the function of external respiration, a predominant
violation of the patency of the bronchi of large and medium cali-
ber was recorded: the average indicators of MOC25 and MOC50
were, respectively, 44.8 ± 6.2 and 46.2 ± 7.6% of the required val-
ue, while MOS75, which characterizes the patency of small armor
¬khov, - 61.2 ± 9.6%. Esophagogastroduodenoscopy noted signs
of gastritis, duodenitis, esophagitis in all patients, and the signs of
CPD were: duodeno-gastric reflux (69%), dehiscence of the car-
dia (59%) and pylorus (73%). Step-by-step manometry using the
open catheter method revealed isolated duodenal hypertension in
28.9%, duodenal hypertension with "discharge" into the stomach
- in 44.7%, duodenal hypertension with "discharge" into the stom-
ach and into the esophagus - in 10.5%, hypertension in stomach
with normotension - in 12 p.c. in 7.9%, the norm of 12 p.c. and
the stomach - in 7.9% of cases. Average pressure in the lumen 12
p.c. amounted to 192.4 ± 31.2 mm of water. Art. (norm - 80-130
mm of water column), in the lumen of the stomach - 110.6 ± 22.7
mm of water. Art. (norm - 60-80 mm of water column). The data
obtained indicate the presence of HNDP. To concretize the causes
of CNDP, probe fluoroscopy 12 sc was carried out. without hy-
potension: antiperistalsis in the horseshoe 12 sc. noted in 60.5%
of studies, duodenogastric reflux - in 55.3%, antiperistalsis in the
jejunum - in 47.4%, ejunoduodenal reflux - in 39%, expansion of
12 sc. - in 28.9%, slowing down of emptying 12 p.c. - in 21.1%,
high duodeno-jejunal transition in 87%, contrast stop in the middle
third of the lower-horizontal part of 12 bp. (place of arteriomesen-
teric compression 12 PC) - in 65% of cases.
Violation of the microbial landscape of the small intestine was
detected in 33 patients (80.8% of the examined): I degree - in 3
people, II degree - in 19, III degree - in 9, IV degree - 2 people.
The most pronounced changes related to anaerobic microflora:
complete absence or deficiency of bifidumbacteria - in 26 patients,
lactobacilli - in 17, excessive growth of E. coli - in 16, other oppor-
tunistic flora (Proteus, Klebsiella, Candida) - in 12 patients.
The reaction of urine to indican was positive in 63% of patients.
The level of average blood serum molecules was increased in 76%
of patients, on average it turned out to be 46% higher than normal
values and amounted to 0.35 ± 0.01 at a norm of 0.24. An increase
in lipid peroxidation in intensity was detected in 50%, in terms
of the light sum of radiation - in 70%. Total cholesterol did not
exceed the norm in all cases. Triglycerides were increased in 28%
of cases, and the atherogenic coefficient - in 52%. These data indi-
cate the presence of a syndrome of endogenous intoxication in the
examined patients with BA and NBD, and it is more pronounced in
them than in patients with NBD who do not suffer from BA.
All 52 patients with asthma underwent plasty of the ileocecal ob-
turator according to the methods developed in the clinic: 46 - with
simultaneous correction of CNDP (34 - dissection of the Treitz
ligament (PCT), 12 - duodeno-jejunostomy). The operation was
successful in most patients. Thus, asthma attacks did not recur af-
ter surgery in 12 patients, in 40 patients the clinical picture became
less pronounced; 18 patients stopped taking hormones, and anoth-
er 20 began to reduce their intake.
A retrospective analysis of the volume of surgical aid for BA pa-
tients revealed the most significant drawback - inadequate correc-
tion of CPAP in some cases.
Currently, we attach great importance to computed tomography
(CT) and ultrasound in the diagnosis of arteriomesenteric com-
pression of 12 sc. as one of the forms of KhNDP. We found that
the distance between the aorta and the superior mesenteric artery
at the level of the lower horizontal part is 12 bp. less than 2.0 cm
requires duodenojejunostomy, and not PCT, which is proven by
stopping the contrast at the indicated place (compression!) when
performing duodenoscopy with a probe without hypotension.
In the overwhelming majority of cases, the development of AD de-
pends on the state of the gastrointestinal tract. The most important
links in the pathology of the gastrointestinal tract, contributing to
the development of AD, are HNDP and NBZ. Adequate surgical
correction of CNDP and NBZ makes it possible to improve the
condition of patients with BA, which is a promising direction in
the treatment of this category of patients.

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