[Direct transfistulous ultrasound in minimally invasive surgical treatment of infected pancreatic necrosis]

OBJECTIVE

To develop a method for direct transfistulous ultrasound in minimally invasive treatment of infected pancreatic necrosis.

MATERIAL AND METHODS

There were 148 patients with infected pancreatic necrosis between 2015 and 2019 at the Krasnodar City Clinical Hospital No. 2. Drainage with 28-32 Fr tubes was carried out at the first stage, endoscopic transfistulous sequestrectomy - at the second stage (19 (12.8%) patients). In 84 (56.8%) patients, we applied original diagnostic method (transfistulous ultrasonic assessment of inflammatory focus).

RESULTS

There were 3 accesses to omental bursa in 93 (62.8%) patients and 2 in 43 (29.1%) patients. We also performed 2 access to retroperitoneal space in 63 (42.6%) patients and 1 access in 38 (25.8%) cases. Transfistulous ultrasound was used once in 19 (22.6%) patients, twice in 28 (33.3%) and 3 times in 37 (44.1%) patients. Examination was not performed in 18 (12.2%) patients due to the following reasons: migration of drainage catheters - 5, non-rectilinear fistulous tract - 13. No complications were observed.

CONCLUSION

Transfistulous ultrasound makes it possible to diagnose pathological changes in the pancreas and parapancreatic tissue at various stages of surgical treatment.

[A modified method for percutaneous drainage of acute necrotic collections in patients with infected pancreatic necrosis]

OBJECTIVE

To develop a modified method for percutaneous drainage of acute necrotic collections in patients with infected pancreatic necrosis.

MATERIALS AND METHODS

Minimally invasive surgical technologies were used in 74 patients with infected acute necrotic collections at the Krasnodar Regional Clinical Hospital No. 2 between 2017 and 2019. Of these, 59 (79.7%) people underwent percutaneous drainage as a final treatment. In 11 (14.9%) patients, video sequestrectomy through the fistula was additionally used to increase efficiency of percutaneous drainage.

RESULTS

PCD in our modification implies delivery of double-lumen drains 26-32 Fr in the same plane to zones of necrosis, their programmed replacement for prevention of obstruction and flexible endoscopy for control of pathological process. Local purulent-necrotic parapancreatitis occurred in 31 (41.9%) patients, widespread parapancreatitis - in 43 (58.1%) patients. There were 339 minimally invasive interventions. Laparotomy was required in 4 (5.4%) patients. Incidence of perioperative complications was 10.6%, mortality - 16.2%.

CONCLUSION

A modified percutaneous drainage method may be used as final surgical treatment in 79.7% of patients with infected pancreatic necrosis.

[Technological features of open and minimally invasive surgical treatment of local complications of purulent-necrotic pancreatitis]

There are various options for surgical treatment of purulent-necrotic pancreatitis with significant technological differences. Combining surgical methods other than traditional ones into a group of minimally invasive ones based on the principle of the absence of standard laparotomy is not entirely correct. The review presents modern methods of surgical treatment of acute pancreatitis, comparison of their technology regarding classical stages of surgical intervention and their classification.

The first experience of applying a new pancreatoenteroanastomosis with a «soft» pancreatic stump in pancreatoduodenal resection

The OBJECTIVE was to improve the results of pancreatoduodenal resection by reducing the incidence of pancreatoenteroanastomotic leak and postoperative pancreatitis with a «soft» pancreatic stump.METHODS AND MATERIALS. A new method for the formation of pancreatoenteroanastomosis has been developed and implemented: precision wirsungojejunoanastomosis with additional wide atraumatic peritonization of the pancreatic stump cutoff with the loop of the small intestine. From February 2016 to March 2018, this method was tested in 18 patients.RESULTS. Pancreatoenteroanastomotic leak of class A was noted in 2 (11.1 %) patients, was transient, asymptomatic, did not require additional medical measures and did not extend the duration of the postoperative period. There were no pancreatoenteroanastomotic leak of classes B and C, pancreonecrosis of the stump, lethal outcomes. Objectively worst statistical results were obtained in the comparison group.CONCLUSION. The formation of the small intestine anastomosis with a «soft» pancreatic stump according to the proposed method for pancreatoduodenal resection reduces the incidence of postoperative pancreatitis of the stump and pancreatoenteroanastomotic leak.

[Risk factors of surgical treatment in patients with liver cirrhosis]

OBJECTIVE

To optimize selection of patient for surgical treatment of comorbidities and complications of liver cirrhosis (LC) via analysis of perioperative risk factors.

MATERIAL AND METHODS

There were 610 patients with LC and comorbidities who underwent surgical treatment between 2015 and 2021 at the Regional Clinical Hospital No. 2. Thirty (4.9%) patients died. We analyzed Child-Pugh and MELD scores, Mayo Postoperative Surgical Risk Score and Charlson comorbidity index to predict postoperative mortality.

RESULTS

Perioperative risk in patients with LC depends on the type of surgery, degree of surgical invasiveness, liver function, and severity of LC-associated complications.

CONCLUSION

A thorough preoperative assessment of patients and adequate perioperative management are required to reduce the risk of mortality.

liver cirrhosis, surgical treatment, risk factors.

Transfistulous endoscopic sequestrectomy in the treatment of infected pancreatic necrosis

OBJECTIVE

To develop an effective minimally invasive method for the treatment of infected pancreatic necrosis.

MATERIAL AND METHODS

There were 168 patients with infected pancreatic necrosis who were treated at the Regional Clinical Hospital No. 2 between 2011 and 2018. Eighty-seven (51.8%) patients underwent primary drainage with large-diameter double-lumen drains 28-32 Fr, and original technique of transfistulous endoscopic sequestrectomy was used. Puncture-drainage interventions with transfistulous endoscopic sequestrectomy were used in 23 (26.4%) patients with local and 64 (73.6%) patients with widespread purulent-necrotic parapancreatitis.

RESULTS

Percutaneous channels are accesses to purulent-necrotic cavity and used for transfistulous endoscopic sequestrectomy. This procedure was performed 98 times. Time of primary sanitation in patients with 3 accesses in omental bursa was significantly less compared to 2 accesses (62±4.3 vs. 89±8.2 min, p<0.05). In case of repeated sanitation, time of intervention did not depend on the number of accesses. Incidence of local complications was 9.1%, extra-abdominal complications - 19.4%. Mortality rate was 12.6%.

CONCLUSION

Original technique of transfistulous endoscopic sequestrectomy increases efficiency of sanitation of infected parapancreatitis, improves treatment outcomes and reduces mortality to 12.3%.

[Minimally invasive surgical interventions in the treatment of severe acute pancreatitis]

OBJECTIVE

To improve the outcomes in patients with severe destructive pancreatitis undergoing minimally invasive surgery.

MATERIAL AND METHODS

There were 482 patients with acute destructive pancreatitis for the period from 2007 to 2016. Non-infected acute destructive pancreatitis was diagnosed in 58% (n=280) of patients, infected pancreatic necrosis - in 42% (n=202) of patients. Minimally invasive technologies were used in the treatment of purulent complications of destructive pancreatitis: endoscopic papillotomy, percutaneous puncture of fluid accumulations, ultrasound- and X-ray-assisted drainage of abscesses and retroperitoneal phlegmon.

RESULTS

There were 688 drainage surgeries in 92 patients with infected pancreatic necrosis: US-assisted Seldinger drainage - 599 (87%), single-stage drainage - 89 (13%) cases. Percutaneous transfistular retroperitoneal interventions were made in 72 patients (one intervention - 29 patients, redo procedures - 43 patients). Complications associated with minimally invasive procedures developed in 2.7% (19) of cases. Six patients required laparotomy. Mean length of hospital-stay was 36.5 days. Mean rate of restitution of post-necrotic areas was 37.7 days.

CONCLUSION

Minimally invasive procedures reduce overall mortality up to 6% in patients with acute pancreatitis and up to 14% in those with destructive forms of inflammation.

[Minimally invasive treatment of post-burn esophageal perforation]

Perforation of the esophagus is a serious and dangerous condition due to progressive development of mediastinitis and sepsis. This disease is often fatal. In the last decade, endoscopic stenting of the esophagus became more common in these patients as an alternative to traditional surgery. We report successful minimally invasive endoscopic treatment of esophageal perforation with post-burn necrosis of its wall.

[Endoscopic ligation in treatment and prevention of bleeding from esophageal varices]

AIM

To demonstrate the efficacy of endoscopic ligation in treatment and prevention of bleeding from esophageal varices in patients with liver cirrhosis and portal hypertension.

MATERIAL AND METHODS

We performed a retrospective analysis of 338 patients with liver cirrhosis who underwent ligation for the period 2009 - May 2016. There were 209 (61.8%) men and 129 (38.2%) women. In this group 511 ligations were performed. The total number of ligated nodes was 4086.

RESULTS AND DISCUSSION

Ligation was effective in 502 (98.2%) cases. In 9 (1.8%) cases endoscopic ligation was ineffective and Blackmore tube was required. The main cause of failed procedure was pre- or intraoperative active bleeding from esophageal varices. Complications in this group can be considered 3 cases of bleeding during ligation.

CONCLUSION

Endoscopic ligation is highly effective (from an economic and medical points of view) treatment and prevention of bleeding from esophageal varices in patients with liver cirrhosis.

[Endoscopic transpapillary interventions in diagnostics and treatment of patients with diseases of the pancreatobiliary area]

It was performed analysis of efficiency of endoscopic retrograde transpapillary interventions in diagnostics and treatment of 1513 patients with diseases of the pancreatobiliary area for the period 2008--2012. About half of patients had choledocholithiasis. There were tumors in 9.5% of patients. Associated diseases confirmed or first identified during transpapillary intervention (stricture + choledocholithiasis, cancer + choledocholithiasis, etc.) were revealed in 6.8% of patients. We used almost all types of endoscopic transpapillary techniques which are applies for biliary hypertension including retrograde cholangiopancreatography, endoscopic papillotomy, endoscopic mechanical lithoextraction and lithotripsy, nasobiliary drainage, bougienage, balloon dilatation, stenting and endoscopic contact electrohydraulic lithotripsy of calculus of common bile duct. Efficiency of endoscopic transpapillary interventions was 96.5%. Complications were observed in 4.3% of patients. Mortality rate was 0.06%.

[Indications and surgical results of chronic colostasis treatment]

AIM

To define the surgical indications in patients with chronic colostasis who were operated using original technique and to access obtained results.

MATERIAL AND METHODS

It was analyzed the results of surgical treatment of 81 patients with chronic colostasis in remote postoperative period. We have proved that extended left-sided hemicolectomy with rectosigmoid resection, positive mesentery root rotation and transposition of right large bowel to left part of abdominal cavity, creation of new ligamentary apparatus provide favourable remote results and increase life's quality of operated patients.

RESULTS

Complex analysis of clinical, morphological and functional results before and after medical therapy allowed to define indications and optimal period for surgical treatment in patients with chronic decompensated colostasis.

[Indications for surgical treatment of hard scarring gastric ulcers]

It was done the comparative analysis of the morphofunctional state of the upper gastrointestinal tract between 350 patients with effective conservative treatment and 104 patients with hard scarring gastric ulcers. The analysis identified the predictors of ineffective medical treatment and led to deliver the indications for timely surgical treatment. It was identified the next indications for planned organ-preserving surgical treatment of patients with hard scarring gastric ulcers: penetrating and non-healing ulcers with large or gigantic size in case of the adequate medical therapy, high-grade dysplasia and colonic metaplasia of the gastric epithelium in the borders or fundus of the ulcer,ulcers combination with fixed cardio-fundal or fundo-corporal hiatal hernias; hypotonic-hypokinetic type of the gastric and duodenal activity with the development of gastrostasis and pronounced duodenogastric reflux.

[The method of duodenal bulb plasty in case of complicated chronic ulcer of back wall of the duodenal bulb]

It was proposed the method of organ-preserving surgical treatment of chronic ulcers of back wall of duodenal bulb complicated by decompensated stenosis and penetration in intrapancreatic part of common bile duct (RF patent number 2476164 from 27.02.2013). 12 patients were operated by using of this technique. One patient had post-operative pancreatitis. There were not lethal outcomes.

[Colonoscopy in the diagosis and treatment of the colon polypoid formations]

AIM OF THE STUDY

the estimation of endoscopic methods efficacy in diagnostics and treatment of colon polypoid neoplasm. The study was carried out in versatile city hospital.

METHODS AND MATERIALS

5811 colonoscopies (CS) were executed in endoscopic department of versatile city hospital Nr. 2, Krasnodar during the period of 01.01.2011 -01.01.2012 years. There were 332 endoscopic loop polypectomies, and 12 endoscopic mucosal resections among 5811 CS.

RESULTS

The choice of endoscopic extraction method depended on neoplasm microscopic type and its histological structure according to pre-operated histological investigation. In the most cases the neoplasm Ip and Is types were extracted by loop polypectomy. In cases of III grade or more dysplasia in the neoplasm Ip and Is types had revealed the endoscopic mucosal resection was performed. The neoplasm IIa and IIb were extracted by the endoscopic mucosal resection. The presence of IIc component was assessed as a bad prognostic feature and only the dilatated loop biopsy was carried out. During the endoscopic extraction of 32 villous tumors of the colon (size of 17 ones was more than 3.0 cm, and 3 ones was more 5.0 cm) 2 complications occurred and an urgent surgery was carried out in 1 case. The following periods of endoscopic control were determined according to extracted polypoid neoplasm histological data: 1, 3, 6 and 12 months. The relapse absence was assessed not only visually, but by biopsy from colon mucosal scars.

CONCLUSION

patients with the colon polypoid neoplasm need the dynamic clinic endoscopic supervision because of increased risk of oncotransformation.

[Results of the study of motor and evacuation function of the stomach after gastroplasty]

THE AIM OF THE STUDY

Investigation of motor and evacuated functions of upper parts of digestive tract in patients with hard scarring gastric ulcers (HSGU) after organ-preserving surgery by gastroplasty method.

METHODS AND MATERIALS

Motor and evacuated functions of the operated stomach were studied in 74 patients after gastroplasty (GP) with invaginated corporo-antral anastomosis (CAA) and 30 patients after GP with corporo-antral sphincter (KAS) formation from the ileal loop in different post-operated periods. The roentgenologic barium passage trough the upper parts of digestive tract and inter-digestive motor activity were assessed.

RESULTS

The recovery of functional condition of the operated stomach after GP occurred during a year. It stipulated by adequate motor and evacuated functions of anastomosis performed. The GP technique with KAS formation from the ileal loop has number of advantages before its analogue GP with invaginated KAA: the muscular cuff from the ileal loop obstacles the dilatation of gastric tube; recovers the reservoir function of the fundal gastric part; provides the bolus portioned delivery to antral gastric portion to prevent its overload.

CONCLUSION

The results of the study of motor and evacuated functions of operated stomach have proved that GP with KAS formation from the ileal loop was the optimal method of HSGU surgical treatment.

[The peculiarities of esophageal epithelium of the vertebrates in phylogenesis and Barrett's esophagus]

The esophageal epithelium of vertebrates was studied in phylogenetic aspect and in patients with Barrett's esophagus (BE). The comparative investigation was undertaken to detect phylogenetic recapitulations in the course of BE development. The complex of histochemical methods for selective demonstration of mucins and proteins was used. It was shown that in the phylogenetic series amphibians-reptiles-mammals, the formation of a protective barrier occurred in different ways. In BE, within the areas of metaplasia and dysplasia, partial recapitulation of a histochemical type of protective barrier, peculiar to the esophagus of amphibians and reptiles, seems to take place.

[Azygoportal disconnection at esophageal varicose veins dilatation]

Two original organ-saving surgical technologies are suggested for surgical prophylaxis of bleedings from esophageal and gastric varicose veins dilatation. The azygoportal disconnection surgery has been performed at 42 patients. The rate of bleeding recurrences was 4.8%. This surgical procedure may be regarded as the stage of complex treatment of patients with liver cirrhosis and as the final treatment at the patients with extrahepatic portal hypertension.

[Surgical treatment of bleedings from varicose veins of the esophagus and stomach]

Experience in surgical treatment of bleedings from varicose veins of the esophagus and stomach is analyzed. Two new methods of azygo-portal separation are offered, indications and contraindications, main principles of treatment before and after surgery, short- and long-term results are described.

[Twenty-year experience of retrosternal total coloesophagoplasty with areflux anastomosis]

20-year experience of total two-stage esophagoplasty with a flap made of a left half of the colon in 57 patients with burni strictures, the second stage was anastomosis between the transplant and the esophagus. Original cologastral are flux anastomosis created in the zone of air bubble (then zone of anastomosis was invaginated in fundus of stomach) was used. Long-term results were studied in 15-20 year follow-up. Excellent results were achieved in 68.2% cases, good--in 27.2%. It is demonstrated that are flux cologastral anastomosis provides good protection of the transplant from aggressive gastric contents.