[Microflora of the small intestine in patients with perforating duodenal ulcers].

The toxic phase of peritonitis in patients with perforating duodenal ulcers is accompanied with the development of syndrome of redundant bacterial colonization of the small intestine. However, it is less pronounced than in other forms of intra-abdominal infection. The greatest quantitative growth in all the patients is observed among the species of the family of enterobacteria and aerobic Gram-positive bacilli, the bacterial species dominating in the upper part of the intestine in health being the leading etiological agents of intra-abdominal infection in patients with perforating duodenal ulcers. Unlike peritonitis of other etiology strict anaerobic bacteria are found in the small intestine much rarer.

[Causes of recurrences of gastrointestinal ulcer bleeding, their prophylaxis and treatment].

The authors have analyzed main causes of recurrences of gastro-intestinal ulcer bleeding which are thought to be the continuing ulcer alteration, lysis of the protective thrombus with gastric juice or the fibrinolysis system. The data obtained allowed determination of laboratory signs of the development of DIC-syndrome and its significance in the appearance of recurrent bleeding and greater lethality. The role of antirecidivation antisecretory therapy and therapeutic endoscopy was studied for prevention of recurrent bleeding depending on the degree of blood loss. The indications were formulated for emergency, postponed and planned surgery for gastro-intestinal ulcer bleedings as well as the content of conservative antirecidivation therapy.

[Associated complications of peptic ulcer and their surgical treatment].

Based on an experience with treatment of 269 patients with complicated peptic ulcer the authors came to a conclusion that the most sparing and radical operation was subdiaphragmatic truncal vagotomy with Finney pyloroplasty with lethality of 6.8%. Resection of the stomach and forced palliative interventions such as suturing of perforated and bleeding ulcers resulted in lethal outcomes in more than 50% of them.

[Correction of a reperfusion dysfunction in acute intestinal obstruction].

An analysis of experimental investigations carried out in 32 dogs and 30 rabbits and laboratory data of 242 patients has shown that the application of antioxidant and antihypoxic medicines decrease reperfusion lesions and endotoxicosis in operative treatment of acute intestinal obstruction.

[Experience in surgery of diastatic ruptures of the colon].

An experience with treatment of 58 patients operated upon for carcinoma of the colon complicated by acute intestinal obstruction and diastatic perforation has been analyzed, 13 patients had incomplete diastatic ruptures (tears) of the colon. In 23 patients the IV stage of the tumor process (remote metastases) were found and the other 35 patients had the III stage. In early terms after operation 37 (63.8%) patients out of 58 patients died. Lethality after incomplete diastatic ruptures of the colon made up 53.8%, and after diastatic perforation - 67.7%. The main cause of lethal outcomes was polyorganic insufficiency against the background of intoxication of mixed genesis (cancerous + endogenous). Ablation of colonic tumor is justified in cases of local peritonitis. Hemicolectomy with ablation of the diastatic rupture is indicated for the right-side localization of the tumor Obstructive resection is expedient for left-side localization of the tumor and rupture, the diastatic ruptures should be sutured or extraperitonized with application of cecostoma. Subtotal colectomy is possible for left-side localization of the tumor and diastatic ruptures of the right half of the colon. Symptomatic operations are indicated for canceromatosis of the peritoneum, terminal phase of peritonitis or infectious-toxic shock.

[Use of the protocols of organization of the medico-diagnostic care for ulcerous gastroduodenal bleedings in clinical practice].

Results of realization of the protocols of organization of the medico-diagnostic care to patients with bleedings from chronic gastric and duodenal ulcers since 2002 have been analyzed. A simplified scale of the assessment of severity of ulcerous bleedings (UB) at admission including 8 criteria is proposed. Protocols of medical strategy for "severe UB" under conditions of the resuscitation unit are discussed. The principles of rendering the medico-diagnostic care for UB allowed stabilization of total lethality among these patients at the level of 3.4-3.7% at operative activity 27%. The possibility to improve results of the treatment of this pathology in future is associated by the authors with the available and high quality elements of conservative treatment.

[Vagotomy in surgical gastroenterology: legends and reality].

The work has shown high effectiveness of vagotomy in a number of diseases. In 2565 patients with perforated duodenal ulcer operation of suturing finished with lethal outcome in 9.2% of cases and recurrent disease in 54% of patients. After vagotomy the results were 1.5% and 14% respectively. In 277 patients with massive bleeding due to erosive gastritis lethality after different operations was 39-46%, after vagotomy--10.0%. After 403 vagotomies for decompensated stenosis of the duodenum atony of the stomach developed in 1.2% of patients, recurrent ulcer appeared in 6%, lethality was 1%. Vagotomy proved to be effective for peptic ulcers of the jejunum (106 patients) in 86% of cases, for chronic indurative pancreatitis (86 patients) in 97% of cases, lethality was 1.2%.

[Surgical treatment without recurrences ventral hernias as a social problem].

The authors have analyzed social aspects of surgical treatment of postoperative ventral hernias and described results of the surgical treatment of 149 patients. Specific measures used in preoperative preparation and in operative treatment of elderly and senile patients are considered. Long-term results of surgical treatment of 76 patients have been studied who had undergone plasty of the anterior abdominal wall with the application of a reticulate polypropelene explant. This method was shown to be pathogenetic and highly reliable for surgical treatment of postoperative ventral hernias.

[Acute pancreatitis (protocols of diagnosis and treatment)].

Protocols of diagnosis and treatment of acute pancreatitis are presented. Definition based on pathogenesis of the disease is given. Phases of acute pancreatitis, features of diagnosis and treatment in each phase are analyzed. Terms of surgical treatment, main principles of postoperative treatment are discussed.

[Choice of a method of plasty of the anterior abdominal wall in patients with postoperative ventral hernias].

The individual characteristics of the structure of the anterior abdominal wall were studied for revealing the anatomical preconditions for the formation of postoperative ventral hernias in order to substantiate efficient methods of surgical treatment. It was established that patients with brachiomorphous build had anatomical features facilitating the formation of ventral hernias. The greatest strength of the fascio-aponeurotic complex of the anterior abdominal wall is characteristic of patients with a dolichomorphous constitution, while the least strength of the fascio-aponeurotic complex of the anterior abdominal wall is characteristic of patients with brachiomorphous constitution. Patients with the dolicho- and mesomorphous constitution having postoperative ventral hernias can undergo plasty of the hernial gates with the local tissues. Patients with brachiomorphous constitution after elimination of the postoperative ventral hernias need the strengthening of the anterior abdominal wall with cellular explants.

[Local and individual features of angioarchitectonics of the stomach and their significance in manifestation of bleedings]. / Lokal'nye i individual'nye osobennosti angioarkhitektoniki zheludka i ikh znachenie v proiavlenii krovotechenii.

The investigation has shown that on the lesser curvature in the area of the body and cardial part of the stomach there is a 2.3+/-0.3 cm section where there are no large branches of the left gastric artery and tributaries of the coronary vein. In the antral portion of the stomach such a section is not determined. Here there are terminal branches of the posterior descending and right gastric arteries. However, the diameter of these arteries when introduced into the gastric wall is rarely more than 1 mm. In addition, the arterial loops of the first and second order are formed on the anterior and posterior walls of the antral portion by the arteries of less diameter than in other parts of the stomach. In cases of the bleeding complicating the gastric ulcer it can be observed from any part of blood circulation, but the severity of bleeding is mainly dependent on the erosion of the arterial vessels. Hence, the site of the ulcer in the zone of the invasion of large arterial vessels into the gastric wall and their presence in the crater in the endoscopy picture should incline the surgeon to operative intervention.

[Surgical treatment of perforative gastroduodenal ulcers in elderly and senile patients]. / Khirurgicheskoe lechenie probodnykh gastroduodenal'nykh iazv v pozhilom i starcheskom vozraste.

The work is based on experiences with surgical treatment of 206 elderly and senile patients with perforating gastroduodenal ulcers. In 67.5% of cases the perforations took place in duodenal ulcers, in 16%--in the pyloric canal. The gastric body and antral portion ulcers were perforative more rarely--9.8% and 4.8% respectively. Perforations of the cardial and retrobulbar ulcers were found in 1.9% and 1% respectively. At early terms after operation 67 patients (33.5%) died. After suturing the perforative opening 38 out of 98 patients died (38.8%), after dissection and suturing the ulcers died 7 out of 19 patients, after Oppel-Polikarpov operation died 7 out of 11, after resection of the stomach died 4 out of 6, after truncal vagotomy with pyloroplasty died 11 out of 72 patients (15.3%). The main cause of lethal outcomes is thought to be complications of the coexistent diseases, totally responsible for 46.2% of deaths. Truncal vagotomy with a dissection of the ulcer and pyloroplasty performed in 60-70 year old patients gave the least indices of lethality and early postoperative complications, so the indications to radical organ-saving operations in patients of this age must be wider. This method of treatment for perforative ulcers in patients of 71-80 years of age should be used with restrictions due to not bad long-term results of suturing the ulcers (good and excellent results took place in 53.8% of cases). In patients older than 80 radical operations are not indicated. In such cases the ulcer should be better dissected and sutured, the posterior wall of the organ being examined for a "mirror" ulcer.

[Ulcerous gastrointestinal bleedings]. / Iazvennye zheludochno-kishechnye krovotecheniia.

On the basis of the study of 2388 patients with chronic gastric and duodenal ulcers complicated by acute bleeding, the most disputable organizational and tactical issues of ulcer bleeding (UB) treatment are discussed. It is reasonable to divide surgery for UB into urgent, delayed and elective. Indications for different surgeries in UB and basic surgical principles are discussed. Severe blood loss is the main factor of general lethality. Combined conservative therapy must provide correction of posthemorrhagic tissue hypoxia, functional disorders, hemostatic disturbances and immunosuppression. Artificial transmitters of oxygen and infusion of antihypoxants are promising in management of UB. Antisecretory drugs are a necessary component of conservative treatment in UB. Therapeutic endoscopy is important in the treatment of acute UB, but it is not alternative to surgical hemostasis. It may be regarded as a method of temporary hemostasis before delayed for more than 2 hours operation or as a method of final hemostasis in combined conservative treatment, first of all in patients of "surgical risk" group.

[Lengthy epidural blockade and intestinal motor function in the early postoperative period]. / Dlitel'naia épidural'naia blokada i motornaia funktsiia kishechnika v rannem posleoperatsionnom periode.

The telemetry method of registration of the intraintestinal pressure was used for the investigation of the motor function of the intestine under condition of continuous epidural blockade (CEB) with Trimekain at early terms after operations on the stomach for ulcer disease. It was found that the motor cycle structure of the small and sigmoid bowels within the first three days after resection of the stomach and truncal vagotomy was not substantially changed under the influence of CEB. A pronounced stimulating effect of the epidural blockade manifested itself as an improvement of the main quantitative parameters of intestinal motility. The character of these changes in the small and sigmoid bowels was the same and did not depend on intactness of vagus nerves. The combined mechanism of the influence of CEB on intestinal motility includes analgesia, improved respiratory function, greater volume of mesenterial circulation and the influence on the intramural nervous system and muscle apparatus of the intestine.

[Vagotomy in the treatment of acute ulcerations of the stomach complicated by severe hemorrhage]. / Vagotomiia v lechenii ostrykh iz"iazvlenií zheludka, oslozhnennykh tiazhelym krovotecheniem.

It has been found that the intramural nerve apparatus of the stomach is involved in the mechanism of formation of acute gastroduodenal ulcers. Under stress there occurs simultaneous activation of the sympathetic and parasympathetic parts of the vegetative nervous system. The released acetylcholine and noradrenaline influence the corresponding receptors of the target cells which results in hyperproduction of the hydrochloric acid under conditions of hypoxia of the gastric wall and promotes acute ulceration. Conservative hemostatic therapy allows complete hemostasis to be obtained in 95% of patients with acute gastroduodenal ulcers complicated by bleedings. If it fails, the operation of choice is thought to be suturing the source of bleeding supplemented with truncal vagotomy and pyloroplasty.

[Bacteriological features of peritonitis in perforative gastroduodenal ulcer]. / Bakteriologicheskie osobennosti peritonita pri perforativnykh gastroduodenal'nykh iazvakh.

Bacteriological investigation of 137 probes of the exudate from the abdominal cavity has revealed positive results in 60.6%. The detection of microbial flora was the more frequent the greater was the spread and degree of peritonitis. The monoculture was revealed in 92.8%, the colibacillus being the most frequent. The isolated microbial flora was sensitive to antibiotics of the cephalosporin group.

[The ways of improvement of surgeons' training at the Department of Managerial Medical Staff of the Military Medicine Academy]. / Puti sovershenstvovaniia podgotovki khirurgov na fakul'tete rukovodiashchego meditsinskogo sostava Voenno-mediitsinskoi akademii.

The urgent need to discuss with military surgeons the problem of improvement of educational process in the faculty of managerial medical staff of the Military-and-Medical Academy under the new social-and-economic conditions against the background of the RF Armed Forces reformation has prompted the authors to write this article. The first report deals with the problems of general organization of educational process taking into account the needs for surgeons with higher military education and creation of certified specialized surgical care in the Troops. The authors suggest that all people with interests at stake should express their opinion concerning this problem.

[The late results of surgical treatment in patients with perforated gastroduodenal ulcers]. / Otdalennye rezul'tatay khirurgicheskogo lecheniia bol'nykh s perforativnymi gastroduodenal'nymi iazvami.

It was shown that suturing perforative ulcers of the stomach and duodenum gives bad outcomes in more than 52% of the patients. More than half of such patients continue suffering from the ulcer and its complications, every fifth patient needs future radical reoperation. The most frequent indication for reoperation is a recurrent ulcer and stenosis of the pyloric area of the stomach. Somewhat better results of simple suturing the ulcer are observed in patients aged 15-20 years. The maximum amount of unfavourable results (60%) are noted in young patients aged 21-30 years. Perforation of "dumb" gastroduodenal ulcers was followed by a considerable amount (43.5%) of unsatisfactory results of treatment which often required reoperations. Truncal vagotomy with the dissection of the ulcer and pyloroplasty cures the disease and its complications in 85.2% of patients with perforative gastroduodenal ulcers. Somewhat worse results of this operation are noted in patients aged 21-30, considerably better outcomes in patients older than 50. In them the amount of excellent and good results is 67% and 94.2% correspondingly.

[Debatable problems in the surgical treatment of perforated gastroduodenal ulcers]. / Spornye voprosy khirurgicheskogo lecheniia perforativnykh gastroduodenal'nykh iazv.

The experience in surgical treatment of 1027 patients with perforated gastroduodenal ulcer was assessed. Particular attention was paid to the most arguable problems of surgical treatment of this disease. The records evidence that at present there are no reliable objective criteria which enable to differentiate acute perforated ulcers from chronic ones before or during the operation. It has been convincingly proved, that in spite of all known risk factors (age of patients above 60 years, accompanying diseases, preoperative shock and duration of the perforation over 24 hours, disseminated peritonitis, etc.), truncal vagotomy with excision of the ulcer and pyloroplasty provides lower lethality rate in comparison with any other surgical operation. The operation is recommended not only for saving of patients life, but for receiving in great majority of cases favourable long-term results in patients of young as well as old age irrespective of the presence of ulcer in the anamnesis.