[Accelerated postoperative rehabilitation: multidisciplinary issue (Part 1)].

AIM: To discuss the main aspects of multimodal method of accelerated postoperative rehabilitation (fast track surgery). MATERIAL AND METHODS: The program of accelerated rehabilitation consists of minimization of surgical treatment's stressful influence on patient's organism in perioperative period. The method implies use of efficient preoperative management, minimally invasive operations, regional anesthesia and short-acting anesthetics, early postoperative rehabilitation. RESULTS: The program improves the results of surgical treatment, reduces number of complications and cost of treatment, improves the "quality" of hospital stay.

[Accelerated postoperative rehabilitation: multidisciplinary issue. Part 2]. / Uskorennoe vosstanovlenie posle khirurgicheskikh operatsii: mul'tidistsiplinarnaya problema. Chast' 2.

AIM: To discuss the main aspects of multimodal method of accelerated postoperative rehabilitation (fast track surgery). MATERIAL AND METHODS: The program of accelerated rehabilitation consists of minimization of surgical treatment's stressful influence on patient's organism in all stages of perioperative period. The method implies use of efficient preoperative management, minimally invasive operations, regional anesthesia and short-acting anesthetics, early postoperative rehabilitation. RESULTS: The program improves the results of surgical treatment, reduces number of complications and cost of treatment, improves the "quality" of hospital stay and satisfaction of meeting with doctors.

[Clinico-morphological aspects of diagnostics and treatment of the surgical sepsis].

Treatment results of 63 patients with surgical sepsis (aged 17-92 years) were analyzed. The necessity of intravenous immunoglobulin infusion in the complex treatment of sepsis was proved by the comparative morphological study of immunocompetent tissues of 30 patients, died of sepsis and nonseptic reasons. The rational use of intravenous immunoglobulin should be based on the condition of the patient and defined by the APACHE II and SOFA scores.

[Deep veins thrombosis prophylaxis in patients with fractures of long bones of the lower limbs].

Analysis of the complex deep veins thrombosis prophylaxis, considering also pulmonary thromboembolism prevention, in 1180 patients (694 male and 486 female) with closed long bones fractures of the lower limbs. Thrombosis prophylaxis aimed venous blood flow acceleration, liquidation of blood congestion and fibrinolysis stimulation performed with the use of physical factors (nonspecific prophylaxis) and hemostasis normalization (specific prophylaxis). The study revealed that prophylactic measures in patients at low thrombotic risk can be limited to nonspecific prophylaxis. Whereas patients at high and medium thrombotic risk need anticoagulant and disaggregant therapy. The use of standard heparin should be justified only in the absence of other drugs because of the high rate of hemorrhagic complications (42,9%). Any low-molecular heparin is effective for the deep veins thrombosis prophylaxis, though Clexane showed to be the most effective (no complications in 87,5%, deep veins thrombosis in 7,9%, hemorrhagic complications in 5,0%, no registered cases of pulmonary thromboembolism).

[Immunotherapy in complex treatment of surgical sepsis].

The results of treatment of 73 patients with confirmed diagnosis of sepsis are analyzed. The most frequent immune disorders in septic patients are: decrease in lymphocyte count, both T (60%) and B (45.7%) populations, decrease of T-helpers and T-suppressors (52.6%) count, increase of C3-complement activator titre (50%) and phagocytic coefficient (52.4%). The more expressed immune depression observed in patients with gram-negative sepsis in comparison with the gram-positive. Standard immunoglobulins were used in the treatment of 38 patients: "Endobulin" (ImmunoAG, Austria)--in 9 cases; "Intraglobin" (Biotest, Germany)--in 14 and "Pentaglobin" (Biotest, Germany)--in 15 cases. Analyze of the control immunogramms showed the reliable improvement of immune indices and normalization of T-cell counts. Lethality among septic patients treated with immunoglobulins was 14.5%.

[Mini-invasive ways of cholecystectomy for acute cholecystitis in aged patients].

Analysis of radical surgical treatment results by means of laparoscopic cholecystectomy and cholecystectomy from modified mini-access in 203 patients from senior age group with acute cholecystitis is presented. Using experimental studies optimal localization of mini-access on the anterior abdominal cavity was proved. Taking into account the dynamics of stress hormones (prolactin and cortisol) level at mini-invasive radical operations it is proved that pneumoperitoneum is one of the most significant intraoperative aggressive factors. Priority indications for cholecystectomy from mini-access in case of acute cholecystitis are defined. Technical facilities of this treatment mode are shown.

[Diagnosis and treatment of sterile pancreonecrosis].

The experience in the treatment of 77 patients with sterile pancreonecrosis is analyzed. The importance of USE as an effective method of screening-diagnosis is emphasized. Computed tomography provides a more accurate diagnosis of pancreonecrosis and complications of it. Lethality in pancreonecrosis correlates with necrosis severity. More than 50% necrosis-affected parenchyma in combination with three and more systemic complications is an unfavorable prognostic factor. Hemofiltration and early management with carbapenem antibiotics arrest progression of multiorgan failure and pyoseptic complications in 75% of cases. Laparoscopic sanation of the abdominal cavity is necessary only for patients with peritonitis. This procedure may be supplemented with laparoscopic cholecystectomy and endoscopic papillosphincterotomy with lithoextraction directly during sanation.

[Diagnosis and differential treatment of acute pancreatitis of biliary etiology].

The experience in examination and treatment of 208 patients with acute pancreatitis of biliary etiology was analyzed. Complex endoscopic treatment was carried out in 88% patients. If there are indications, it is reasonable to perform retrograde pancreatocholangiography (RPCG) and endoscopic papillosphincterotomy (EPST) during surgery in patients with concomitant enzymatic ascites-peritonitis. In the others patients RPCG and EPST must be regarded as the first stage of treatment. Surgical procedure of choice at the second stage of treatment is laparoscopic cholecystectomy.

[Differential treatment of acute pancreatitis].

Results of examination and treatment of 194 patients with acute pancreatitis were analyzed. It is revealed that the diagnosis of an etiopathogenetic form of acute pancreatitis is a key moment in the choice of the treatment. Patients with acute biliary pancreatitis and alimentary pancreonecrosis with pancreatogenic peritonitis require urgent surgical treatment at early stages of the disease. Laparoscopic cholecystectomy and Haulstad's drainage of the common bile duct are the procedures of choice in acute biliary pancreatitis. Alimentary pancreonecrosis with pancreatogenic peritonitis is the indication for videolaparoscopic drainage procedure and peritoneal dialysis as soon as possible after the disease beginning. This approach decreased lethality, number of complication and hospital stay.

[Ultrasonic technologies in diagnosis and surgery planning in patients with nodular pathologies of the thyroid gland].

Twenty patients of the control group without pathology of the thyroid gland were examined for development of the method of 3D-ultrasonic reconstruction and 3D-angiography. The study group consisted of 74 patients with nodular pathologies of the thyroid gland, 53 of them underwent surgery. Ultrasonic data was compared with results of clinical and laboratory studies, puncture biopsy and intraoperative data. Three-dimensional ultrasonic pictures permitted to detect spatial orientation of the nodes relative to lobes and segments of the thyroid gland, vascular structures, to evaluate character of nodes vascularization, to analyze nature and invasiveness of the tumor. Based on these data optimal variant of surgery was chosen. In 12 cases virtual modeling of surgeries with 3D-echography and ultrasonic angiography was performed. These methods permit to choose optimal variant of surgery and make possible prediction and prevention of complications.

[Extracorporeal detoxication in combined treatment of surgical sepsis]. / Ekstrakorporal'naia detoksikatsiia v kompleksnom lechenii khirurgicheskogo sepsisa.

The methods of extracorporeal detoxication acquire special importance in combined treatment of sepsis. The sessions of plasmapheresis, hemodialysis and isolated ultrafiltration were performed in 61 of 83 patients with sepsis. Indications to these methods are determined, their efficacy is evaluated. It is established that administration of antibiotics and immunoglobulins after sessions of plasmapheresis and hemodialysis to achieves therapeutic drug concentration in blood. It is difficult to select the dose of antibiotics and immunodrugs in permanent round-the-clock ultrafiltration since the part of them are eliminated through the filters. Overall lethality was 20.4% (17 of 83 patients died), in the group of patients with severe polyorganic insufficiency and septic shock who needed extracorporeal detoxication--27%.

[Treatment of acute destructive alimentary pancreatitis]. / Lechenie ostrogo destruktivnogo alimentarnogo pankreatita.

The paper reports treatment of 52 patients with acute destructive pancreatitis for the period from 1993 to 1999. Up to 1997 conservative policy for management of such patients was used, operative treatment was carried on only in pyoseptic complications (43 patients, group 1). Later on early video-endoscopic procedures (9 patients) aimed at removal of toxic exudate from the abdominal cavity, its sanation and drainage with the use of not less than 5 drainage tubes were employed. From 43 patients of group 1 10 died. There were no lethal outcomes in group 2. The authors believe that early evacuation of the toxic purulent exudate with lavage and drainage of the abdominal cavity promotes more effective elimination of multiorganic insufficiency and decreases the risk for development of pyoseptic complications.

[Debatable questions of surgical sepsis treatment and diagnosis]. / Diskussionnye voprosy diagnostiki i lecheniia khirurgicheskogo sepsisa.

On the basis of critical analysis of the results of combined treatment of 73 patients, the authors suggested that sepsis could be diagnosed only in the presence of systemic inflammatory response, multiorganic insufficiency and obligatory isolation of hemoculture. The microorganisms' specimen from the infected area and the blood are not identical both in primary and repeated inoculation. Impossibility to verify the pathogenic microorganism in the blood prevents from carrying out adequate and purposeful treatment. The absence of correlation between the severity of clinical course of sepsis, microflora species and laboratory immunography data, confirms the opinion that the organism responds to the inflammatory process by complex general physiologic reaction of defence, which includes, besides immunologic system, fermentative, endocrine, vegetative and other systems of homeostasis.

[The clinical picture and treatment of destructive pancreatitis]. / Klinika i lechenie destruktivnogo pankreatita.

The results of treatment of 319 patients with acute pancreatitis are analyzed, 48 from them (15.1%)--with pancreanecrosis. Etiologic factors in destructive pancreatitis were alcohol addiction (41.67%), cholelithiasis (37.5%), hyperlipidemia (10.41%), hypercalcemia (4.17%), postoperative (4.17%). Location of the necrosis in parapancreatic fat cellular tissue was detected in 6 patients, in pancreatic head--in 8 and both in pancreatic head and corpus--in 11, in corpus and in tail--in 10; total pancreo-necrosis was observed in 5 patients. Therapeutic measures were conservative and only in cholelithiasis cholecystectomy was performed as well as drainage of the choledochus and abdominal cavity. Intensive care was aimed at blocking pancreatic and gastric secretion, inhibition of pancreatic enzymes ferments and suppressing mediators of inflammation, immunocorrection, prophylaxis of infection in the necrotic tissues. Desintoxication was carried out by combination of infusion therapy with forced diuresis, usage of extracorporeal methods and laparoscopic sanation of the abdominal cavity with subsequent lavage. Surgical interventions were carried out in far-off period only for complications of pancreanecrosis. Mortality rate in pancreanecrosis made up 20.85% and in total number of patients with acute pancreatitis--3.13%.

[Antiseptics on the base of Octenidine Hydrochloride]. / Antisepticheskie preparaty na osnove Oktenidingidrokhlorida.

Comparative evaluation of laboratory and clinical investigation of antiseptic preparations on the base of octenidin-hydrochloride and bigluconate chlorhexidine in 537 patients was carried out. Statistically valid decrease in dissemination through the operation field and surgical wound after application of octenidin containing solutions was determined. It was established as well that these preparations were more effective fools of protection of the operation wound from its microbial contamination in comparison with antiseptic solutions widely spread to date in surgical practice.

[Immunotherapy of surgical sepsis]. / Immunoterapiia khirurgicheskogo sepsisa.

The results of treatment of 73 patients with surgical sepsis are analysed. 57% of the patients were older than 60 years. In 35.6% of the cases sepsis was caused by soft tissue infection, in 35.6%-pyo-inflammation of the blood vessels. In 81% of the cases infective agents were verified; in 45.2% they were found in associations. In 35.1% of the cases there were gram-positive microorganisms, in 40.5%-gram-negative and in 17.0%-asporogenic anaerobes. The count of T- and B-lymphocytes was low (60.0% and 45.7%), the count CD4 was decreased in 40.2% of the patients, CD8-in 31.6%, the content of M-and G-immunoglobulins was also decreased on a background of a slightly increased CD3-activator. Polyorganic insufficiency has been detected in all the patients, predominantly-kidney and liver insufficiency. Septic metastases were detected in 26% of the cases, septic shock-10%. Early treatment of abscesses, adequate antibacterial and detoxication therapy are major tasks in the treatment of sepsis. Intravenous injections of immunoglobulins (Endobulin., Intraglobin and Pentaglobin), extracorporeal detoxcication and polyorganic disorders correction have led to positive results in most cases. The mortality rate in this group was 14.5% compared with 38.5% in the control group.

[Clinical course of asymptomatic cholecystolithiasis]. / Klinicheskoe techenie bessimptomnogo kholetsistolitiaza.

Gallbladder concrements were found in 6.7% of 30,000 persons over 40 years of age during dispensary screening. In 720 (2.4%) of them the clinical and laboratory findings corresponded to those in chronic calculous cholecystitis, whereas in 1,290 persons gallbladder concrements were asymptomatic. Detailed study of 84 records of patients with asymptomatic cholecystolithiasis made in possible to recognize in most of them also chronic inflammatory diseases and dyskinesia of the gastrointestinal tract which could be conducive to the formation of concrements. During a 4-year follow-up period, signs of chronic calculous cholecystitis appeared in only 6% of these patients. The authors conclude that most patients with asymptomatic cholecystolithiasis must be subjected to regular medical examination and only with the development of a clinical picture of chronic calculous cholecystitis only some of them should be treated by surgery.

[Clinical aspects and therapy of cholelithiasis in elderly patients]. / Klinika i lechenie zhelchnokamennoi bolezni u bolnykh pozhilogo i starcheskogo vozrasta.

The article analyses the results of surgical treatment of 110 patients aged over 70 with acute cholecystitis. All of them underwent cholecystectomy with intraoperative cholangiography: choledocholithiasis was found in 26.4% and stricture of the distal choledochus in 10.0% of cases. Postoperative complications developed in 19% of patients, the mortality rate was 5.45%. Simultaneously, 72 elderly and old-aged patients were operated on for chronic calculous cholecystitis after thorough examination and preoperative management. Postoperative complications occurred in 13.9% of cases, none of the patients died. The authors conclude that in adequate preoperative management, careful choice of the method of anesthesia, and substantiated postoperative management, cholecystectomy is the operation of choice in acute calculous cholecystitis in patients over 70 years of age. Planned operations are very advisable in chronic calculous cholecystitis in patients of this age group for the prevention of severe complications, if adequate treatment of concomitant diseases is applied.

[Diagnosis and treatment of septicemia]. / Diagnostika i lechenie sepsisa.

There were 52 patients with sepsis, 61.6% were over 60 years of age (63.3% of patients had septicemia, 36.7% had septicopyemia). The disease was caused by ++pyo-inflammatory diseases of the vessels in 34.6% and the urinary system in 17.3% of cases. Microbial causative agents were isolated from the blood in 83.3% of patients (monoculture in 46.6%, associations of microorganisms in 36.6%; staphylococcus in 59.7%, gram-negative microflora in 46.7%). The most frequently encountered disorders of the immunological status were reduction of the number of lymphocytes and their T- (85%) and B-population (62.9%), increase of the level of immunoglobulins M (81.5%) and A (55.6%), decrease of the number of accessory T-cells (73.6%) and the ratio of accessory and suppressant T-cells (52.6%). Along with the application of antibacterial therapy, which relieved the microcirculatory blockage, and detoxication measures in the treatment of the purulent foci, much attention was paid to immunologic correction for the removal of primary and secondary insufficiency (endobulin, ++T-activin, isoprinosin). Blocking of the immunological reaction was relieved in 65.5% of patients by discrete plasmapheresis with compensation for the deficiency with endobulin, quick-frozen plasma, and rheopreparations. In the group of 52 patients 12 died (mortality 23.1%).