[Mirizzi syndrome management (in Russian only)]

AIM

To assess an effectiveness of complex preoperative diagnosis, conservative treatment, minimally invasive biliary decompression for Mirizzi syndrome and to analyze surgical outcomes depending on the effectiveness of minimally invasive biliary decompression.

MATERIAL AND METHODS

There were 67 patients with Mirizzi syndrome aged 27-96 years (mean age -64.8 years). The diagnosis was established on the basis of complaints, objective data, laboratory survey, abdominal X-ray, ultrasound (US), endoscopic gastroduodenoscopy (EGDS), computed tomography (CT) and magnetic resonance imaging (MRI). Extrahepatic bile duct visualization in case of suspected biliodigestive fistula was achieved by using of percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, cholecystocholangiography, intraoperative cholangiography.

RESULTS

The analysis of the diagnosis and treatment of patients with Mirizzi syndrome and mechanical jaundice with and without symptoms of cholangitis was carried out. It should be noted that percutaneous transhepatic cholangiography and cholecystocholangiography with antegrade contrasting were able to confirm Mirizzi syndrome type 1 without complications. Retrograde cholangiopancreatography in patients with Mirizzi syndrome type 2 reduced the diagnostic value of contrast-enhancement with complications in every fifth patient. Percutaneous drainage for Mirizzi syndrome type 1 was effective in all patients. There was low effectiveness of medication for Mirizzi syndrome. Medication combined with antegrade biliary decompression was 7 times more effective than retrograde decompression. All patients underwent surgery. Mortality depended on surgical emergency and effectiveness of biliary decompression. So, emergency interventions were followed by mortality rate near 60% while there were no deaths after elective procedures. Overall mortality was 11.9%.

[Influence of biliary decompression technique on the outcomes of reconstructive surgery]

AIM

To evaluate bile ducts injuries and effect of biliary decompression technique on the outcomes of reconstructive surgery.

MATERIAL AND METHODS

There were 21 patients with biliary injury during cholecystectomy, 20 patients with cholelithiasis, and 1 patient after surgery for perforated duodenal ulcer. Their age was 22-81 years (mean 54.3 years). Primary surgery through median laparotomy was followed by biliary injury in 12 patients, laparoscopic cholecystectomy - in 6 patients, open laparoscopy - in 3 patients. Patients were divided into 2 groups. In group 1 (n=11) biliary injury was diagnosed intraoperatively, in group 2 (n=10) - in 2-11 days after primary procedure. According to European Association for Endoscopic Surgery (EAES) 2013 classification biliary injury type 1 was found in 5 patients, type 2 - in 9 cases, high damage involving confluence (type 3) - in 1 patient, type 4 - in 1 patient, and type 6 - in 5 patients. Endoscopic retrograde cholangiopancreatography in 3 patients revealed that biliary drainage output after laparoscopic cholecystectomy was caused by cystic duct clipping failure, endoscopic papillosphincterotomy was successfully used for biliary drainage output (type 6). In 3 patients operated through median laparotomy biliary excretion cessation was observed after 2-3 days that indicated damage of aberrant bile ducts.

RESULTS

Bile outflow into gastrointestinal tract was restored in 11 out of 16 patients with iatrogenic biliary injury types 1-4, external biliary drainage was used in 4 patients due to their severe condition and abdominal inflammatory changes. Biliary fistulae occurred in 5 out of 8 patients in both groups after primary reconstructive surgery. Biliary stricture was observed in 3 cases due to external biliary drainage failure followed by peritonitis. 7 patients underwent reconstructive surgery with positive result. Mortality was absent. In 1 patient with biliary fistula outcome is unknown.

CONCLUSION

Transumbilical biliary drainage is optimal during reconstructive surgery.

[Intussusception followed by intestinal obstruction in adults]

AIM

To evaluate the effectiveness of complex preoperative diagnostics and medication of intussusception followed by intestinal obstruction in adults with the choice of surgical repair and analysis of the outcomes depending on the causes of intussusception.

MATERIAL AND METHODS

15 intussusception patients aged 19 - 86 years were enrolled. Mean age was 52.7 years. Patients were hospitalized within 12 hours - 1-2 weeks after onset of the disease. Diagnosis was established on the basis of complaints, anamnesis, objective and additional survey. All patients underwent abdominal X-ray and ultrasound. Intestinal obstruction at admission was diagnosed in all patients, and only 1 (6.7%) of them had intussusception.

RESULTS

Medication and additional survey contributed to detection of intussusception followed by intestinal obstruction in 13 (86.7%) out of 15 patients prior to surgery. All patients underwent urgent or delayed surgery. Small intestine resection was performed in 9 patients, 2 patients underwent resection of small intestine with submucosal tumor (1) and Meckel's diverticulum (1) after intussusception repair. Right-sided hemicolectomy was performed in 3 patients, sigmoid colon resection with lymph nodes dissection - in 1 patient. The cause of intussusception followed by intestinal obstruction were epithelial and stromal tumors (9), less often metastasis of melanoma (2), Meckel's diverticulum (1) and functional bowel disorders (1). Postoperative complications arose in high risk patients hospitalized after 24 hours from onset of the disease and present concomitant diseases and malignancies. 1 (6,7%) patient died.

[Effect of different nutritional support on pancreatic secretion in acute pancreatitis]

AIM

To develop and justify optimal nutritional support in early phase of acute pancreatitis (AP).

MATERIAL AND METHODS

140 AP patients were enrolled. They were divided into groups depending on nutritional support: group I (n=70) - early enteral tube feeding (ETF) with balanced mixtures, group II (n=30) - early ETF with oligopeptide mixture, group III (n=40) - total parenteral nutrition (TPN). The subgroups were also isolated depending on medication: A - Octreotide, B - Quamatel, C - Octreotide + Quamatel. Pancreatic secretion was evaluated by using of course of disease, instrumental methods, APUD-system hormone levels (secretin, cholecystokinin, somatostatin, vasointestinal peptide).

RESULTS

ETF was followed by pancreas enlargement despite ongoing therapy, while TPN led to gradual reduction of pancreatic size up to normal values. α-amylase level progressively decreased in all groups, however in patients who underwent ETF (I and II) mean values of the enzyme were significantly higher compared with TPN (group III). Secretin, cholecystokinin and vasointestinal peptide were increasing in most cases, while the level of somatostatin was below normal in all groups.

CONCLUSION

Enteral tube feeding (balanced and oligopeptide mixtures) contributes to pancreatic secretion compared with TPN, but this negative impact is eliminated by antisecretory therapy. Dual medication (Octreotide + Quamatel) is more preferable than monotherapy (Octreotide or Quamatel).

[MORPHOLOGICAL CHANGES IN THE SMALL INTESTINE ASSOCIATED WITH STRANGULATION OF MECHANICALLY OBSTRUCTED BOWEL]

AIM

To estimate the degree and prevalence of pathomorphological changes in the small intestine at different distances from the visible necrosis boundary depending on acute mechanical obstruction for the choice of the optimal extent of resection.

MATERIALS AND METHODS

Small intestine fragments for morphological study were obtained from 52 patients aged 17-83 (mean 47 ± 17) years after emergency resection of mechanically obstructed necrotic bowel. Strangulation caused by obstructive adhesion was diagnosed in 48%, constricted hernia in 38.5%, torsion in 13.5% of the cases. Tissue morphology was studied by histological staining and light microscopy at 5 cm intervals between the sections.

RESULTS

The degree and prevalence of pathomorphological changes in the small intestine depended on the severity of obstruction and increased with its decompensation.

CONCLUSION

The extent of resection in proximal and distal directions from the visible boundary of necrosis must be chosen on an individual basis depending on the degree of compensation of mechanical intestinal obstruction. The absence of extensive resection especially in the proximal direction allows to reduce the frequency of short bowel syndrome with malabsorption in the late postoperative period.

[Diagnostics and surgical treatment of the tumor obturative intestinal obstruction]

The study summarize the results of diagnostics and treatment of 536 patients aged 37-97 years with colon cancer stage II-IV, complicated by bowel obstruction. Patients with subcompensated and decompensated bowel obstruction prevailed. The dependence of the clinical picture from the tumor localization and the severity of the obstruction were identified. The authors pose that the decision about the median laparotomy needs the preoperative diagnosis of the obturative obstruction without verification of its causes. Decision about the delayed radical operation and minimizing the treatment to colon decompression should be based on additional diagnostic data (X-ray, irrigoscopy and colonoscopy). Surgical interventions with the median laparotomy showed the mortality rate of 30.7% and morbidity of 57.5%. The miniinvasive decompression of the colon reduces these rates to 1.8 and 7.1%, respectively.

[Enteral nutrition in the complex treatment of patients with mechanical jaundice in gallstone disease]

The article summarizes the results of the examination and treatment of 99 patients with mechanical jaundice (MJ) related to gallstone disease (GSD). The patients were distributed into three groups according to three degrees of the dysfunction of the greater duodenal papilla (GDP) sphincter. Group 1 consisted of 52 patients with transitory MJ (degree I), Group 2 consisted of 32 patients with stable MJ remaining after coping with the pain attack (degree II), and Group 3 consisted of 15 patients with MJ and cholangitis (degree III). Trophic status disturbances and the effects of balanced clinical nutrition on the results of surgical treatment were assessed in all the patients. The severity and duration of jaundice were found to influence the severity of trophic changes. Clinical nutrition (sipping and enteral tube feeding) favored survival after papilla-sparing surgery in patients with MJ related to gallstone disease.

[Classification of acute inflammation of pancreas]

The common classifications of acute pancreatitis are analyzed. The original classification based on experience of the treatment more 3000 patients is suggested. This classification reflects ethiology, pathogenesis, severity, clinical manifestation and complications of pancreatitis and permits to optimize the treatment of patients.

[Extended, combined, and concurrent surgery in patients with neoplastic obturation large bowel obstruction]

The study included 552 patients (mean age 68.9 +/- 1.0 years) with neoplastic obturation large bowel obstruction (NOLBO). They were allocated to 3 groups depending on the character of surgical intervention. Group 1 comprised 172 patients (31.2%) operated under endotracheal anesthesia (ETA) through a medial approach for the resection of the segmented intestine and its tumours with colostomy or ileostomy (n = 154) and primary interintestinal anastomoses (n = 18). Group 2 of 56 patients (10.1%) with neglected NOLBO in very severe condition underwent medial laparotomy under ETA with internal or external colonic decompression without tumour resection. Minimally invasive decompressive ileotsomy or colostomy depending on localization of the tumor was performed under local anesthesia after premedication in 324 (58.7%) patients of group 3. The grave clinical condition of the patients was due to polyorgan insufficiency (POI). Postoperative lethality in groups 1, 2, and 3 following surgery in the acute phase of NOLBO was 26.9, 39.3, and 1.8% respectively. The condition of patients of group 1 and 2 with indications for urgent extended, combined or concurrent surgery was too serious to allow for an adequate intervention; it was possible only in 7 (14.6%) of the 48 patients. Diminution of POI manifestations by restoration of segmented intestine patency by low-invasive intervention in patients of group 3 and their preoperative preparation by balanced diet during 3-4 weeks made possible extended combined surgery in all 50 patients of this group without a fatal outcome.

[Treatment tactics of patients with pyloroduodenal stenoses]

Overall 172 patients aged 29 to 87 years with stenosis of stomach pyloric part and duodenum were studied. The complications of gastric or duodenal ulcer (119), cancer of stomach (49) and pancreas (4) were the cause of stenosis. All the patients were divided into 3 groups: 1st group consisted of 43 patients who has undergone urgent surgery due to stenosis with bleedings and perforations without additional protein-energetic treatment before operation; 2nd group - 65 patients who were prepared preoperatively with complete parenteral nutrition; 3rd group - enteral tube feeding with balanced mixtures before surgery (64 patients). The best results were achieved in the patients with preoperative enteral tube feeding; it allowed to reduce lethality from 25.5 and 16.3% at 1st and 2nd group to 0% ant 3rd group.

[Puncture method for the treatment of postnecrotic pancreatic cysts]

Results of treatment of 39 patients with false pancreatic cysts with fine needle aspiration punctures are analyzed. Diagnostic and treatment value of method is discussed; technical aspects of puncture treatment are described. Aspiration puncture method was effective at 59% cases that permitted to reduce the number of external and internal drainage operations at the patients with false pancreatic cysts.

[Conservative treatment of complete distal pancreatic fistula]

36 patients with external pancreatic fistulas have been analysed. Complete distal fistulas have been demonstrated in 23 patients. Pancreatic fistulas were caused by trauma of the pancreas (8), acute pancreatitis (10), surgical treatment of the pancreatic cancer (5). The study of endocrine and exocrine functions has demonstrated that in 2-3 months a gradual decrease of exocrine function of the distal segment of the pancreas takes place. This segment is drained through the fistula. The processes of fibrosis and atrophia are major factors of such a decrease. The method of "biological" filling based on the results of the study of fistulas' pathogenesis, usage of a rational therapy and capillary drain appeared to be the most effective in treatment of this complication. It provided a gradual formation of a narrow fistula and its closure with granulations.

[The pharmacokinetics of Kefzol in patients with acute pancreatitis when administered intravenously and endolymphatically]

Pharmacokinetics was studied of kefsole administered by intravenous and endolymphatic routes to patients (n = 23) with acute pancreatitis. The studies made showed that intravenous route for the drug administration makes for a quicker entering of the antibiotic into the peritoneal exudate. Apart from these reasons, endolymphatic antibacterial therapy does not appear to avert the development of complications involving pus-formation/discharging in acute pancreatitis and does not seem to be essential in the complex of therapeutic measures to be applied for treating the above patients.

[Surgical treatment of purulent complications of acute pancreatitis]

The results of the treatment of 34 patients with purulent lesions of the pancreas and parapancreatic fat are presented. The surgical policy is proposed, depending on the location of purulent cavities. The policy includes evaluation of the rate of the purulent process dissemination, dissection of the necrotic and nonviable tissues and adequate drainage of the parapancreatic fat with subsequent aspiration (in 48-72 hours) and irrigation of the cavities starting from the 5-7th day. The blood vessels, located in purulent zone should be ligated. 26 of 34 patients have been successfully discharged. Postoperative enteric fistulas have developed in 3 patients.

[The interrelationship of the results of microbiological blood and lymph studies with the severity of the course of acute pancreatitis]

With the purpose of studying the routes for infecting the necroses of pancreas in the time course of development of acute pancreatitis, microbiological investigation were carried out on blood (n = 49) and lymph (n = 11). Comparative evaluation of the microflora composition in different milieus of the organism showed that it is only under aerobiosis that bacteria are recovered from blood and lymph, which fact makes it possible to distinguish the above microflora from the pus of retroperitoneal and pancreatic abscesses. No regularities were found in the patterns of bacterial strains recoverable from blood of those patients with acute pancreatitis relative to phases of disease course.

[The use of enteral tube feeding in patients with gastric and duodenal peptic ulcer]

The authors used enteral tube feeding with a multicomponent balanced mixture "Ovolakt" in complex treatment of gastric and duodenal ulcer in 69 patients among which 42 had complicated forms (stenosis, penetration, bleeding) and 27 had no complications. In establishing the diagnosis laboratory tests and radiological and endoscopic examination were conducted. The gastric secretory function was studied by intragastric pH-metry and pH-chromoscopy conducted during enteral feeding and in dynamics after it was ended. In most cases of cicatrization of the gastric and duodenal defects, hypo- and hyperchlorhydria respectively, persisted. Among 42 patients with complicated course of peptic disease, 21 were treated by operation and 19 received nonoperative treatment. The postulcer cicatrix formed 2-3 weeks after enteral feeding was ended in 27 cases of uncomplicated peptic ulcer and in 19 patients with complicated ulcers who were given nonoperative treatment. Complications after operative treatment were not encountered. Patients not treated by operation spent 20-30 days in the hospital.

[Prospects of intraoperative dynamic cholangio-manometry by tensor detectors with graphic recording of pressure function]

Intraoperative cholangio-manometry with a miniature tensor sensor and graphic recording of the results were conducted to study the function of the major duodenal papilla in 53 patients. A periodical activity of the ampulla of the papilla was revealed, which was characterized by certain values of the peak and basal pressure, and duration of contraction and relaxation periods. The numerical values and the pattern of the pressure curve differed in patients with obstructive cholecystitis, biliary pancreatitis, and a concrement incarcerated in the ampulla of the papilla. The informativeness of the study increases with the use of the glucagon test.

[Transumbilical cholangiostomy]

The authors suggest a method for decompression of the biliary system in obstructive jaundice with bile drainage blocked at a high level. The method consists in catheterization of the bile ducts through the lumen of the umbilical vein dilated by bougienage. The efficacy and safety of the method were proved in 15 cases. No complications were encountered.

[Prevention and treatment of complications of acute pancreatitis]

Results of treatment of 156 patients with acute pancreatitis (with the first attack of the disease) were analyzed. These patients had 284 early and 76 late complications of the disease. Causes of the complications observed are discussed. The authors describe their methods of conservative and operative treatment and give practical recommendations for prevention of complications of acute pancreatitis. The complex treatment of acute pancreatitis with special attention to prophylactics and improved methods of treatment of the complications is shown to give better results.

[Endoscopic placement of a jejunal tube and a method of conducting enteral feeding with special mixtures]

The endoscopic placement of a nasoenteral probe for jejunal nutrition can be brought about by four main technical modes: conducting the probe through the biopsy canal of the endoscope, placement along the string, parallel introduction with the endoscope and combination of the above methods. An emulsion product containing 1 kkal/ml, macro-, microelements, vitamins was used for the enteral nutrition. Three main methods of enteral probe nutrition were used depending on specificity of the main disease, character of functional disorders of the intestine and the presence of inflammation in digestive organs.