SURGICAL APPROACH FOR TREATMENT OF OBSTRUCTIVE JAUNDICE IN PATIENTS OF DIFFERENT AGE GROUPS.

OBJECTIVE: The aim: Assessment of the effectiveness of using minimally invasive and open methods of bile duct decompression for treatment of obstructive jaundice (OJ) by comparing complications in patients of di!erent age groups. PATIENTS AND METHODS: Materials and methods: We analyzed the results of surgical treatment of 250 patients with OJ. The patients were assigned to two groups: Group I (n = 100) consisting of young and middle-age patients, and Group II (n = 150) consisting of elderly, senile and long-living patients. The average age was 52 ± 6.0 years. RESULTS: Results: 62 (24.8%) Group I patients and 74 (29.6%) Group II patients were submitted to minimally invasive surgical interventions. 38 (15.2%) Group I patients and 76 (30.4%) Group II patients were submitted to open surgical interventions. Complications after minimally invasive surgery (n = 62) in Group I patients were observed in 2 (3.2%) cases, and in 4 (10.5%) cases after open surgeries (n = 38). Complications following minimally invasive interventions (n = 74) in Group II patients were registered in 5 (6.8%) cases, and in 9 (11.8%) cases following open operations (n = 76). 2 (2.6%) Group II patients died for transmural myocardial infarction. CONCLUSION: Conclusions: The use of minimally invasive surgical interventions for treatment of young and middle-aged OJ patients compared to patients of older age groups makes it possible to reduce the frequency of complications by 2.1 times, which is a statistically signi"cant (p <0.05). The frequency of complications after open surgical interventions of bile ducts in patients of di!erent age groups is not statistically signi"cant (p >0.05).

CLINICAL OUTCOMES AND COMPLICATIONS OF ENDOVASCULAR SURGERY IN PATIENTS WITH CHRONIC LIMB-THREATENING ISCHEMIA.

OBJECTIVE: The aim: To review the results of endovascular treatment in patients with chronic threatening ischemia of lower extremities as well as to assess the level of complications developed after the use of modern endovascular technologies. PATIENTS AND METHODS: Materials and methods: 243 patients with occlusive-stenotic lesions of major arteries of infrarenal aorta, operated on by various endovascular techniques, were studied. 51 of them (20.98%) had multi-level lesions. All experimental group patients (83) were thoroughly evaluated preoperatively including assessment of probable development of arterial thrombosis of affected extremity after the surgery. Besides, endovascular treatment algorithm developed and introduced by the authors on the basis of individual anatomical and hemodynamic parameters was used. RESULTS: Results: Thrombosis was the major early postoperative complication in both study groups, being registered in 21 patients (10.6%). The incidence of thrombosis was statistically higher in the control group as compared to experimental group - 11.53% and 7.14%, respectively (p<0.05). 15 patients of both groups underwent amputations - 12 patients (7.5%) in the control group, and 3 patients (3.6%) in experimental group. Early postoperative mortality rate was 2.56% in the control group, while there were no deaths in experimental group in early postoperative period. CONCLUSION: Conclusions: Continuous ultrasound monitoring, avoidance of subintimal positioning of endovascular devices, use of rotary-mechanical thromboaspiration, drug-coated balloons and stents, regional thrombolytic therapy, as well as the concept of angiosome-directed therapy used in the study for restoration of artery patency, made it possible to improve treatment outcomes and decrease complications.

MODERN METHODS OF PREVENTION AND TREATMENT OF COMPLICATIONS OF CERVICAL ESOPHAGO-ORGAN ANASTOMOSIS AT ESOPHAGOPLASTY.

OBJECTIVE: The aim: To improve the results of operative treatment of esophageal strictures by decreasing the rate of failure and stricture of cervical esophago-organ anastomoses. PATIENTS AND METHODS: Materials and methods: There were 45 patients with post-burn corrosive gullet strictures, 17 patients with postoperative corrosive strictures, 10 patients with peptic strictures secondary to reflux-esophagitis, 42 patients with esophageal cancer strictures. The patients were divided into two groups: the comparison group - 55 persons and the main group - 59 persons. Patients of comparison group underwent surgical treatment of esophageal strictures according to classic protocols and standards. In the main group of patients we applied proposed diagnostic algorithm with prediction of complication risk and the designed method of esophago-organ anastomosis formation. RESULTS: Results: The results of operative treatment in patients with esophageal strictures showed the development of early postoperative complications in 59 individuals (51.75 %). In the postoperative period six patients died: four - in the comparison group and two - in the main group. Failure of cervical esophago-organ anastomosis and esophageal strictures occurred in 7 patients (11.86 %) of main group and 20 patients (36.36 %) of the comparison group (p<0.05). CONCLUSION: Conclusions: Application of method predicting the risk of complications of cervical anastomosis, treatment program and instrumental method of formation anastomosis resulted in reduced incidence of failure and strictures of esophago-organ anastomosis from 36.36 % to 11.86 % (p<0.05); decreased time of hospitalization - from 28.2 ± 1.1 to 21.5 ± 0.5 bed-days (p<0.001), postoperative period - from 20.5 ± 1.1 to 16.1 ± 0.7 bed-days (p<0.01); decreased postoperative mortality - from 7.27 % to 3.39 %.

Complex treatment of purulent wounds with the use of high-pressure aerodisperse mixture.

OBJECTIVE: The aim: To investigate the effectiveness of complex treatment of purulent wounds with the use of high pressure aerodispersed mixture of antibacterial drug using sorbents and correction of hydrogen index. PATIENTS AND METHODS: Materials and methods: In total, 54 patients were treated, out of which there were 26 patients with purulent wounds in the main group and 28 patients in the control group. Patients in the main group were treated according to the developed method, patients in the control group were treated with traditional antiseptics and water soluble ointments. RESULTS: Results: Within patients of the main group, there was a decrease in the duration of inflammatory process, decrease in the quantity of microorganisms in the wound; slight changes in the sensitivity of the microorganisms to antibacterial preparations, compared with the control group, which showed a high percentage of development of resistant strains; decreased edema and secretion from wounds, the early appearance of granulation. CONCLUSION: Conclusions: The use of the proposed approach reduces the microbial burden on the wound, accelerates its purification from purulent-necrotic tissues and reduces the duration of the inflammatory process due to the presence of the microbial factor.

Comparative assessment of bile duct decompression methods in patients with obstructive jaundice of non-tumor genesis.

OBJECTIVE: Introduction: Obstructive jaundice is one of the most common diseases of the digestive system observed in 10-15% of the world's population. The question of making a choice among methods of bile duct decompression is still under discussion, since both single-stage and two-stage methods of biliary decompression lead to progression of hepatic insufficiency after restoration of bile passage. The aim: To determine a tempo of biliary decompression after external and internal drainage of bile ducts, endoscopic transpapillary interventions in patients with obstructive jaundice of non-tumor genesis. PATIENTS AND METHODS: Materials and methods: We analyzed the outcomes of surgical treatment of 180 patients with obstructive jaundice of the non-tumor genesis. The patients were divided into three groups: group I (n = 86), where endoscopic methods of biliary decompression were used; group II (n = 48), where biliodigestive anastomoses were formed; and group III (n = 46), where the external drainage of bile ducts was conducted. The average age was 62 ± 6.0 years. The average duration of obstructive jaundice was 20 ± 3.7 days. RESULTS: Results: The patients of the group I demonstrated a gradual decrease of bilirubin and alkaline phosphatase levels, which reached the normal readings on Day 7. The patients of the group II demonstrated normal levels of bilirubin and alkaline phosphatase on Day 14. The patients of the group III demonstrated rapid decrease of bilirubin and alkaline phosphatase levels, which reached the normal readings on Day 28. The transaminase level in each group of patients had reached the norm earlier. CONCLUSION: Conclusions: No significant disturbances of the functional state of the liver after endoscopic transpapillary interventions were observed. Formation of areflux biliodigestive anastomoses was accompanied by a moderate rate of biliary duct decompression. The external drainage of biliary ducts was characterized by a rapid rate of biliary decompression, leading to a post-compression syndrome.

Improving the results of the laparoscopic cholecystectomy in patients with complicated course of the calculous cholecystitis.

OBJECTIVE: Introduction: The laparoscopic cholecystectomy (LCE) has become "gold standard" in treatment of the gallstone disease (GSD). However, introduction of LCE is accompanied by increase in the frequency of the bile duct injuries by 2-5 times, and transfer to the conversion offsets main advantages of the laparoscopic access. The aim:Тo improve the results of treatment of the patients with complicated course of the calculous cholecystitis by developing new methods of the laparoscopic cholecystectomy. PATIENTS AND METHODS: Materials and methods: The results of surgical treatment of 420 patients with complicated course of the calculous cholecystitis were analyzed. The patients were divided intwo groups: group I (n = 210) where the standard four-trocar LCE was used and the group II (n = 210) where the developed methods of LCE were used. The average age made up 62 ± 6.0 years. Duration of disease made up from 1 month to 35 years. RESULTS: Results: The patients in group I LCE with complicated course of the acute cholecystitis was performed in 108 (25.7%) cases, chronic - in 102 (24.3%) cases. The patients in group II surgical intervention with complicated course of the acute cholecystitis was performed in 112 (26.7%) cases, chronic - in 98 (23.3%) cases. The patients of group I intraoperative injuries were observed in 12 (5.7%) cases and patients of group II - in 4 (1.9%) cases. The conversion was applied in 13 (6.2%) and in 4 (1.9%) cases, respectively. 2 (0.9%) patients died. CONCLUSION: Conclusions: Introduction of the developed methods of LCE with complicated course of the calculous cholecystitis allows to reduce the frequency of intraoperative injuries by 3,8% and conversion rate - by 4,3% (p <0,001).

Experience in treatment of patients with esophageal achalasia.

OBJECTIVE: Introduction: Esophageal achalasia is a neuromuscular disease, which is characterized by persistent impaired reflex opening of esophageal sphincter. Disease incidence is 0.6-2.0 per 100 000 population with no tendency to decrease. The aim of the study was to improve the results of treatment in patients with achalasia of cardia by differentiated approach in the choice of therapy method. PATIENTS AND METHODS: Materials and methods:148 patients with esophageal achalasia aged 18 - 67 were studied between 2003 and 2018. The following degrees of the disease were determined (by Petrovskyi's classification): first - in 8, second - in 59, third - in 70, fourth - in 11 patients. Drug therapy was administered in achalasia of first degree, and cardiodilatation courses - in second and third degree of the disease. Indications for surgical treatment were: impossibility to perform cardiodilatation, S-shaped esophageal deformation (stage IV), complications associated with cardiodilatation, achalasia combined with other surgical pathology, recurrence of disease. RESULTS: Review: Cardiodilatation therapy resulted in sustained clinical effect in stages I and II of the disease. In case of unsatisfactory results of cardiodilatation patients underwent elective operations. 18 patients underwent Heller-Dor plastic surgery, 4 - Heller-Petrovskiy operation, 1 - Besley plastic repair, 2 - Nissen fundoplication. In early postoperative period no failure or perforation of the esophagus occurred. The following complications developed: seroma - in 3 patients, postoperative wound infection - in 1 case. In one patient (4%) the recurrence of disease was due to scar deformation of esophagogastric junction after Heller-Petrovskiy operation on the cardia. CONCLUSION: Conclusions: Cardiodilatation is an effective method of conservative therapy in stages I and II of the disease, while in stages III and IV it is warranted as preoperative preparation measure. We think Heller-Dor operation to be the best method of plastic repair in esophageal achalasia.

Selection of biliary decompression method for treatment of obstructive jaundice in patients of older age groups.

OBJECTIVE: Introduction: The development of minimally invasive techniques allowed to expand the indications and possibility of performing surgeries in patients of elderly and old age with obstructive jaundice (OJ). However, the criteria for the selection of minimally invasive and open surgeries in patients with OJ remain undefined. The aim: To study the efficacy of single or multiple-stage methods of biliary decompression for treatment of OJ in patients of older age groups. PATIENTS AND METHODS: Materials and methods: We have analyzed the results of surgical treatment in 140 patients with OJ of benign origin. The patients were divided in two groups: group I (n = 70) where two-stage minimally invasive methods were used and group II (n = 70) where single-stage minimally invasive and open surgeries were used. The average age was 75 ± 6.0 years. The average duration of OJ was 22 ± 3.7 days. RESULTS: Results: The patients in group I were subjected to two-stage minimally invasive surgeries in 70 (50.0%) cases. The patients in group II were subjected to single-stage minimally invasive surgeries in 16 (11.4%) cases and to open surgeries in 54 (38.6%) cases. The average duration of hospital stay in patients of group I made 7.1 ± 1.5 days, and 11.2 ± 1.2 days in patients of group II. The patients of group I experienced complications in 5 (7.1%) cases and patients of group II experienced complications in 10 (14.3%) cases. 1 (1.4%) patient died. CONCLUSION: Conclusions: Stepwise approach to minimally invasive surgeries in patients of elderly and old age with bile duct obstructions allows to reduce the frequency of postoperative complications down to 7.2% (p< 0.05). Single-stage correction is recommended for patients with hyperbilirubinemia of less than 100 mcmol/l and the duration of OJ of less than 14 days, with presence of compensated or subcompensated co-occurring pathology as well as in the absence of purulent cholangitis and biliary pancreatitis.

Operative treatment of corrosive esophageal strictures.

OBJECTIVE: Introduction: Nowadays operative treatment of corrosive esophageal strictures remains one of the difficult and unsolved problems in surgery. The level of postoperative complications such as anastomotic leak (develops in 7-30% of cases), infections, pneumonia, pleural empyema, mediastinitis, peritonitis, postoperative corrosive strictures is still rather high. The aim of our work was to improve the results of surgical treatment of patients with corrosive esophageal strictures by analyzing and refining on conservative therapy options as well as differentiated approach to each operative treatment method. PATIENTS AND METHODS: Materials and methods: 44 patients with corrosive esophageal strictures operatively treated during the period of 1993-2017 were examined. Indications for each of esophagoplasty techniques were established. In colon bypass of the esophagus (26 patients) infusion therapy for prevention of ischemic transplant disorders, roentgenologic and prevascular preparation of future colonic transplant, anti-reflux colonogastric anastomosis were suggested. In gastric esophagoplasty (10 patients), clinically modified transhiatal extirpation of the esophagus with gastric tube plastics, an original method of lengthening of gastric graft, is preferred in clinical practice. Two patients underwent ileocecal segment esophagoplasty because of simultaneous esophageal and gastric lesion or colon diseases. RESULTS: Results: The best method of esophagoplasty associated with a small number of postoperative complications is clinically modified gastric tube esophagoplasty with formation of single extrapleural esophagogastric anastomosis. In cases when the stomach cannot be used and the marginal artery is well marked, isoperistaltic retrosternal colonoplasty with preservation of blood supply due to the left colonic artery is indicated. Suggested method of ileocecal segment esophagoplasty is used in simultaneous esophageal and gastric lesion, providing the formation of relevant reservoir (the cecum instead of the stomach), antireflux mechanism and preventing the development of peptic ulcers and transplant strictures. CONCLUSION: Conclusions: Operative treatment of corrosive esophageal strictures remains a great challenge for surgeons and should be based on individual choice of proper method of esophagoplasty and final intraoperative decision making.

Variant of myocardial infarction course in the patient with left ventricular non-compaction.

Non-compacted left ventricle in adults is a rare occurrence, though it is diagnosed even more rarely. As a rule in patients with non-compacted left ventricle (LVNC) other pathologic condition is diagnosed, notably hypertrophic or dilated cardiomyopathy. The majority of LVNC cases are diagnosed in early infancy but currently there are asymptomatic cases detected by means of echocardiographic examination. Real prevalence of LVNC is unknown. According to many authors LVNC occurs in 9.2-9.5% of children with diagnosed cardiomyopathies. The majority of such children do not survive till adulthood because of progressive severe heart failure, fatal arrhythmias and thromboembolisms. This value ranges from 0.014 to 0.05% in adult population. The article presents a clinical case illustrating the stages in establishing the diagnosis of non-compacted left ventricle in a young patient with myocardial infarction and congestive heart failure. Common characteristics of non-compacted left ventricle and connective tissue dysplasia syndrome in the patient suggested etiopathogenetic relationship between these two pathologic states. The basic common characteristic feature of both non-compacted left ventricle and connective tissue dysplasia syndrome proved to be multiple abnormal chords of the left ventricle. The patient was supposed to have some coronary circulation abnormality inherited together with non-compacted left ventricle and connective tissue dysplasia syndrome. Adverse prognosis and high mortality in non-compacted left ventricle require its early recognition and differentiated approach to treatment depending on the severity of the disease and using all modern methods of treatment both conservative and surgical.

Specific characteristics of intracardiac hemodynamics and vegetative regulation in healthy young individuals with normal heart geometry and concentric remodeling of left ventricle.

OBJECTIVE: Introduction: Heart remodeling is a complex multifactor process determining the prognosis of the patient with any cardio-vascular pathology. There are convincing observations and conclusions in literature about the formation of concentric remodeling of LV prior to the appearance of any changes in AP [4, 5]. But until now there is no common point of view as to the factors involved in remodeling both the myocardium and the vessels, especially in the absence of the major known causative factor - arterial hypertension. From this perspective the study of relationship between cardiac and vascular remodeling as well as the factors involved in their development, especially in young individuals, is urgent. The aim of this work was a comparative study of characteristic features of intracardiac hemodynamics, daily profile of arterial pressure, daily ECG monitoring data and vegetative regulation in young apparently healthy individuals (18-44 years) with normal heart geometry and those with concentric remodeling of left ventricle. PATIENTS AND METHODS: Materials and Methods: Apparently healthy persons aged 18 to 42 years, mean age 25.3±0.6 years, were included in the study. There were 56 males (73.7%) and 20 females (26.36%). All participants of the study were divided into two equal groups consisting of 38 persons according to relative wall thickness (RWT) value of the left ventricle: the patients with RWT > 0.42 (concentric remodeling of left ventricle) and those with RWT ≤ 0.42 (normal geometry of left ventricle). RESULTS: Results and Conclusion: The analysis of obtained findings revealed comparatively larger sizes of left heart cavities, comparatively higher rate of AP morning rise and daily variability of predominantly systolic arterial pressure, decreased activity of parasympathetic nervous system, greater number of supraventricular premature beats mainly at night time as well as the signs of connective tissue dysplasia in the patients with concentric remodeling of left ventricle. More than half of young persons with concentric remodeling of left ventricle showed the signs of connective tissue heart dysplasia, namely prolapse of mitral valve and abnormal left ventricular chords. Those specific characteristics of heart structure, daily profile of arterial pressure and variability of cardiac rhythm can be considered the signs associated with concentric remodeling of left ventricle.