[Treatment of undeveloped external intestinal fistulas]. / Lechenie nesformirovannykh haryzhnykh svishcheí.

135 patients with undeveloped intestinal fistulas (116-85.9%-males, and 19-14.1%-females) were followed up by the authors. The patients underwent surgery for acute appendicitis-17 (12.6%), traumatic injuries of abdominal organs-78 (57.8%), acute intestinal obstruction-33 (24.4%), inflammatory processes of the uterus and adnexites-7 (5.2%). Small bowel fistulas were observed in 88 (65.2%) of patients, large bowel fistulas-in 47 (34.8%). The optimal mode of treatment for the fistula seems the obturation of fistula duct by means of catheter of Petzer of Foley. It is guite necessary to perform a simultaneous broad exploration of abscesses of anterior abdominal wall and their sanatation by the method of flowing-aspiration therapy by N.N. Kanshin. For elimination of endotoxicosis the ultraviolet irradiation of autologous blood was used as well as intravenous laser irradiation of blood, hemosorption, plasmapheresis, infusions of plasma and plasma substitutional solutions. The patients were given 2-3 antibiotics of a broad spectrum of action, one of which being obligatory introduced intravenously. From 135 patients 104 (77.0%) underwent surgery. The method of choice in small bowel fistulas the authors suggest intraabdominal resection of the bowel, and in large bowel fistulas-resection of 3/4 by the method of A.V. Melnikov. 17 patients (17.3%) died after the surgery.

[Treatment of diffuse peritonitis]. / Lechenie diffuznogo peritonita.

From study of the values of central and peripheral hemodynamics in 369 patients with peritonitis of the diffuse form, it may be concluded that they reflect objectively the degree of intoxication. A hypodynamic reaction of the blood-vascular system is a poor prognostic sign indicative of progressing peritonitis. Much significance is attached to morphological and microbiological study of the biopsy material of the parietal peritoneum, which allows judgement of the stage of peritonitis. Along with the traditional infusion and antibacterial therapy in peritonitis, UVI of autoblood and intravenous laser irradiation of the blood in stages IIA and IIB are applied. This should be followed by hemosorption which contributes to the active excretion of toxins from the organism. The authors recommend the method of programmed relaparotomy in stage IIB when there is a large amount of exudate with a collibacillary odour and a tendency to the formation of unterintestinal abscesses. Intraaortal infusion of medicinal agents is recommended in this clinical group marked by a tendency towards hypotension. In the group of 369 patients who underwent operation 112 (29.5%) died.

[Treatment of generalized peritonitis with fenestration of the abdominal cavity]. / Lechenie rasprostranennogo peritonita metodom fenestratsii briushnoi polosti.

The authors suggest a new method for the treatment of generalized peritonitis. It is based on the use of a device of the authors' construction which allows the condition of the abdominal cavity to be visualized continuously and the cavity to be cleansed regularly with the aid of laparoscope. The method is called fenestration of the abdominal cavity. The authors had 395 patients with purulent peritonitis, 171 (43.3%) of them were treated by the semiopen method, 41 of these patients (10.4%) were subjected to fenestration of the abdominal cavity. The authors consider fenestration indicated in generalized peritonitis with signs of polyorganic insufficiency in the presence of a large amount of exudate and concurrent interintestinal, subdiaphragmatic, and pelvic abscesses or when there is a tendency towards their development. With the use of the device for fenestration the number of cleansing relaparotomies was reduced to minimum. Relaparotomy was conducted once in 35, twice in 4, and three times in 2 patients. In all patients the abdominal cavity was examined daily with a laparoscope, the exudate was aspired, and antibiotics were introduced. Phlegmon of the anterior abdominal wall was in early postoperative complication in 2 patients. Five (12.2%) patients died.

[Injury to the bile ducts during surgery]. / Povredenie zhelchnykh protokov vo vremia operatsii.

The authors had 51 patients with iatrogenic injuries to the bile ducts. This complication occurred most frequently in cholecystectomy (45 patients). The injury was localized in the distal segment of the supraduodenal part of the hepaticocholedochus in 11, at the junction of the cystic and hepatic ducts in 15, and in the region of the opening of the hepatic ducts in 23 patients; the lobar hepatic ducts were injured in 2 patients. Injury to the bile ducts was recognized during the first operative intervention in 13 patients, in 8 of them restorative operations could be performed. After the first operation peritonitis developed in 2, obstructive jaundice in 16, a complete external biliary fistula in 14, and obstructive jaundice and an incomplete external biliary fistula in 6 patients. The biliary tract was reconstructed in all of them by forming a bilio-digestive anastomosis with an isolated jejunal loop after Roux. The authors prefer using a changeable transhepatic drain. Six patients died in the early postoperative period.

[Blunt and penetrating injuries of gallbladder and extrahepatic bile ducts]. / Zakrytoe i otkrytoe povrezhdenie zhelchnogo puzyria i vnepechënochnykh zhëlchnykh protokov.

The authors observed 23 sufferers with closed and open injuries to the gallbladder and extrahepatic bile ducts. Trauma to the gallbladder was revealed in 20, that to the common bile duct--in 3, associated injuries--in 18 sufferers. In injury to the gallbladder, cholecystectomy was performed. The organ-preserving operation is justified only in presence of a small cut wound without disturbance of blood circulation of the organ. In trauma to the common bile duct, the end-to-end biliobiliary anastomosis was created over a removable transhepatic drain (RTHD), and when it's creation was unfeasible, hepaticojejunostomy over RTHD was performed.

[Liver resection in closed injuries]. / Rezektsiia pecheni pri ee zakrytykh povrezhdeniiakh.

The authors have observed 129 patients with closed injuries of the liver. Resection is thought by the authors to be indicated to patients with vast wounds when there are areas with disturbed blood circulation, in patients with abruptions and crush of portions of the liver. Operations on most patients were performed as atypical resections with transparenchymatous ligation of the vessels and bile ducts. Lethality did not depend on the resection volume but was in direct correlation with the character of associated injuries. After resection of the liver 13 patients of 31 died. Of 98 patients who had ruptures of the liver and were subjected to other operations 47 patients died.

[The surgical treatment of acute cholecystitis in patients with a high operative risk]. / Khirurgicheskoe lechenie ostrogo kholetsistita u patsientov s vysokim operatsionnym riskom.

An analysis of 406 observations of acute cholecystitis was made. It was found that 70.9% of the patients were older than 60. All of them had severe coexistent diseases. Emergent operations are considered to be indicated with the presence of localized or diffuse peritonitis. Hemosorption on the day of admittance and a radical operation within 1-2 days are recommended to patients with bile stasis of up to 7 days duration, longer time of bile stasis requires endoscopic papillotomy at the moment of admittance to the hospital and nasobiliary drainage followed by 2-3 sessions of hemosorption and radical operation within 7-9 days. Not effective conservative therapy should be changed by laparoscopic microcholecystostomy. The radical operation should be performed at the cold period.

[Clinical characteristics of acute cholecystitis in males]. / Klinicheskie osobennosti ostrogo kholetsistita u muzhchin.

The analysis of 682 case histories of males suffering from acute cholecystitis suggested a conclusion on occasional deviations in clinical manifestations of the disease in males. Various combinations of complications are not a rare finding making the diagnosis problematic. Acute destructive process in the gall bladder occurs in the presence of chronic inflammatory and infiltrative alterations in the hepatopancreatoduodenal area. Clinically, general symptoms of endotoxicosis dominate, local signs presenting indistinctly. Late diagnosis results in late surgical treatment: 9.2% of the admitted patients only are operated on within 24 hours since hospitalization. The authors hold that choledochotomy is indicated to 50.7% of the patients. Lethal postoperative outcome was registered in 2.2% of those operated on. The deaths were attributed to cardiovascular and hepatic failure.

[Acute cholecystitis in the early postoperative period]. / Ostryi kholetsistit v rannem posleoperatsionnom periode.

The authors observed 6 patients, who developed acute cholecystitis at day 2--5 after the operation. In 3 patients, an operation on the abdominal organs was performed, in 3--the urologic intervention. The leading symptoms of postoperative cholecystitis are the following: epigastric pain, stable intestinal paresis, high body temperature. The authors recommend a wide use of the ultrasound investigation of the abdominal cavity, and in its negative results, or in absence of the apparatus--laparoscopy. All the patients were reoperated. One patient died.

[Repeat surgery in focal lesions of the liver]. / Povtornye operatsii pri ochagovykh porazheniiakh pecheni.

The authors had 302 patients with focal lesions of the liver, 232 of them were operated on. Radical operations were carried out on 96 and palliative operations on 136 patients. Operations were performed for a second time in 35 patients, radically in 24 of them. A previously conducted exploratory laparotomy is still no evidence of inoperability of the process. In alveococcosis of the liver with no clinical signs of biliary stasis, it is advisable to consider resection of the liver after a previously conducted bile-draining operation. Patients who had been subjected to cavernotomy may also be operated on radically. The appearance of jaundice in the late-term periods after resection-fragmentation of the liver indicates growth of the remaining area of the parasitic nodus and dictates the indications for a bile-draining operation. Obstructive jaundice is considered the main indication for undertaking a palliative operation for the second time. Five patients died after surgery.

[Diagnosis and surgical treatment of cancer of the gallbladder and extrahepatic bile ducts]. / Diagnostika i operativnoe lechenie raka zhelchnogo puzyria i vnepechenochnykh zhelchnykh protokov.

Data on 148 cases of cancer of the gallbladder and extrahepatic bile ducts were studied. Jaundice proved the cardinal symptom. No clear-cut clinical picture of the disease was identified. Diagnostic procedure should start with ultrasonography. Cholangiectasia and the enlarged pancreatic head make the case for fiber bronchoscopy and hypotonic duodenography. Cancer-negative patients should further undergo transcutaneous transhepatic cholangiography and, if proving still negative, retrograde cholangiopancreatography. Resection of bile ducts with simultaneous lymphadenectomy is considered radical. The authors suggest a surgical procedure for cancer of the gallbladder which includes resection of the liver, hepatico-choledoctomy and cholecystectomy with formation of cholangio-jejuno-anastomosis using disposable transhepatic drains. Recanalization of bile ducts by transhepatic drain is considered optimal for palliation. Survival depends upon extent of surgery and level of bile duct obstruction.

[Questions of tactics and choice of surgery in gastroduodenal hemorrhage]. / Voprosy taktiki i vybora operatsii pri gastroduodenal'nykh krovotecheniiakh.

The authors analysed 368 clinical cases with gastroduodenal hemorrhages. The changes in blood microcirculation and nonspecific immunity were studied in 62 patients. They proposed a method of complex nonoperative treatment of gastrointestinal hemorrhages, including ganglionic block, which made it possible not only to reduce the operative activity but also to achieve epithelialization of ulcers in patients with peptic ulcer. As the result of the study, a unique classification of the severity of blood loss is suggested which is based on the degree of deviation off the tests studied from the normal values. If gastroduodenal hemorrhage continues, an operation is recommended, the character of which is determined by the patient's age, the severity of blood loss, and the source of bleeding and its localization.

[Errors in the diagnosis and treatment of pancreatic cysts]. / Oshibki v raspoznavanii i lechenii kist podzheludochnoi zhelezy.

Errors in the diagnosis and treatment of pancreatic cysts have been studied at various stages of rendering medical aid. In a polyclinic the diagnostic errors are due to inadequate skill of physicians, insufficient study of medical records, inadequate examination and ungrounded refusal to consult a surgeon. The most informative methods of examination are X-ray of the stomach, duodenography in the state of hypotonia, pneumoperitoneography in combination with retropneumoperitoneography and ultrasound examination. It is emphasized that the most common complication of cysts of the pancreas are suppuration of its contents and malignant transformation of its walls. The operation of choice in this condition is pancreatico-jejunostomy with an isolated jejunum according to the Roux-en-Y technique. External drainage of the cyst is indicated only in suppuration. Pancreatogastrostomy is considered an emergency operation.

[Paracholecystic and intrahepatic abscesses as a complication of acute cholecystitis]. / Parapuzyrnye i vnutripechenochnye abstsessy kak oslozhnenie ostrogo kholetsistita.

The authors have studied 776 operations performed for acute cholecystitis. In 15 patients (1.9%) paravesicular and intrahepatic abscesses were found. Clinical symptoms are described which were observed in patients with such complications. The authors consider that these complications can be diagnozed in the preoperative period. The operation of choice is cholecystectomy (sometimes like the Pribram mucoclasias). In the paravesicular abscess it is necessary to resect the omentum involved in the inflammatory process. Great significance is attached to drainage of subdiaphragmatic and subhepatic space after Redon and to transumbilical infusion in the early postoperative period.