[Complex treatment of patients with pyo-necrotic complications of the neuropathic form of diabetic foot syndrome]. / Kompleksnoe lechenie bol'nykh s gnoino-nekroticheskimi oslozhneniyami pri neiropaticheskoi forme sindroma diabeticheskoi stopy.

OBJECTIVE: Of study is improving the results of treatment of patients with pyo-necrotic complications of diabetic foot syndrome by including the method of negative pressure wound treatment in the complex treatment program in combination with using of the combined antibacterial drug Cifran ST and immunocorrective therapy. MATERIAL AND METHODS: The results of examination and treatment of 184 patients with pyo-necrotic complications of the neuropathic form of diabetic foot syndrome were analyzed. According to choice of treatment methods in the postoperative period all patients were divided into two groups. In 95 patients (group I), iodine-containing ointments based on polyethylene glycol were used for local treatment of purulent foot wounds and standard systemic antibacterial therapy was performed. In 89 patients (group II), negative pressure wound treatment (NPWT) was used to treat wounds in the postoperative period. In addition to standard parenteral antimicrobial therapy, these patients also received an oral combined antibacterial drug Cifran ST and immunocorrective cytokine therapy (Leukinferon). The analysis of the dynamics of the wound process was carried out based on the clinical picture and the results of cytological, bacteriological and immunological studies of the wound exudate. RESULTS: The presented strategy of complex treatment of pyo-necrotic complications of the neuropathic form of diabetic foot syndrome allowed group II patients to significantly reduce the degree of microbial contamination of wounds, to achieve a faster regression of the content of proinflammatory and inflammatory cytokines in the wound exudate, as well as to reduce the time of wound cleansing and the transition of the pyo-necrotic process to the reparative stage in comparison with group I patients. This allowed group II patients to reduce the time of plastic closure of the wound from 24.3±0.5 to 15.6±1.7 days, to avoid generalization of infection, death and high level amputation of the limb. At the same time, 11.6% of patients in group I had high level limb amputation due to generalization of infection. The mortality rate in group I was 5.3%. CONCLUSIONS: Adding of vacuum therapy of wounds, systemic antimicrobial therapy using the combined antibacterial drug Cifran ST and immunocorrective cytokine therapy in the complex treatment program for patients with neuropathic form of diabetic foot syndrome after radical surgical treatment of the pyo-necrotic lesion allows reducing the time of wound cleansing and the transition of the pyo-necrotic process to the reparative stage. On the other hand, this makes it possible for this category of patients to perform plastic closure of the wound at an earlier date, avoid generalization of infection and high level amputation of the limb.

[Evaluation of clinical efficacy of serotonin adipate in treatment and prevention of enteral insufficiency syndrome at generalized peritonitis]. / Otsenka klinicheskoi effektivnosti preparata serotonina adipinat v lechenii i profilaktike sindroma enteral'noi nedostatochnosti pri rasprostranennom peritonite.

AIM: To substantiate pathogenetic expediency and to evaluate the clinical efficacy of the drug use serotonin adipate (dinaton) in a complex correction enteral insufficiency syndrome (EIN) in patients with generalized peritonitis (GP). MATERIAL AND METHODS: The comparative analysis of results of treatment of 182 patients with GP, which in principle approach to EIN correction in the postoperative period were divided into two groups. Group I consisted of 92 patients who received standard intensive therapy using conventional methods of stimulation of intestinal peristalsis. Group II consisted of 90 patients on a background of standard treatment was carried further pharmacological stimulation of intestinal motility drug serotonin adipate (dinaton). The research program included an assessment of clinical parameters intestinal motility recovery, evaluation of the severity of the patients on a scale of APACHE II, determining the blood levels of serotonin and the level of the main biomarkers of systemic inflammatory response (SIR), the study of blood flow in the vessels of splanchnic bed, the measurement of intra-abdominal pressure with the calculation of intraperitoneal perfusion pressure. RESULTS: It is found that the development and progression of abdominal inflammation is accompanied by a sharp decrease in blood serotonin level is in phase III GP decreases 4.7 times compared to the control value. It is shown that using of serotonin adipate (dinaton) in treatment of patients with GP promotes early recovery of intestinal motility and the resolution of EIN, the elimination of intra-abdominal hypertension and disorders of splanchnic blood flow, as well as the rapid regression of the manifestations of the SIR and endotoxemia. Postoperative mortality in group I patients was 28.3% in group II - 20.0%. CONCLUSION: The inclusion of serotonin adipate (dinaton) in the complex corrective therapy standard in the postoperative period in GP patients is pathogenetically justified, as it promotes early restoration of motor activity of the gastrointestinal tract, the elimination of intestinal paresis and resolution of EIN, which leads to an improvement of results of surgical treatment of this patients.

[Choice of surgical treatment in patients with acute destructive pancreatitis].

Medical and diagnostic algorithm in patients with pancreatic necrosis is developed. It takes into consideration features and expansion of necrotic process in retroperitoneal space, objective severity of patients' condition according to SAPS scale and inflammatory process according to serum procalcitonin concentration. Comparative analysis revealed that the use of developed algorithm improves results of treatment.

[Pathogenesis of visceral functions disorder in diffuse peritonitis].

Clinical and laboratory signs of abdominal sepsis and endotoxicosis were noted in 194 examined patients with diffuse peritonitis. It was stated that pathogenesis of visceral functions mainly expressed as a splanchnic blood circulation disturbance, massive translocation of gut organisms in portal bloodstream and the functional liver insufficiency particularly marked as form of macrophage liver insufficiency. The complex program of liver rehabilitation should be included in standards of treatment of the patients with diffuse peritonitis. It should be based on preventive measures of the enteral detoxication and microbial decontamination of small intestine and at the same time the intraportal transsubilical infusion correcting therapy has to be applied.

[Prognosis of outcomes and choice of surgical strategies in general purulent peritonitis]. / Prognozirovanie iskhoda i vybor khirurgicheskoi taktiki pri rasprostranennom gnoinom peritonite.

A comparative analysis of the results of surgical treatment of 233 patients with general peritonitis of different etiology was carried out. It is demonstrated that Manheim's index of peritonitis (MIP) may be used not only for prognosis of outcome, but also as one of main criteria for programmed revisions and sanations of the abdominal cavity, and appliance of laparostomy. Combination of MIP with clinical and laboratory evaluation of endotoxicosis severity permits one to define objectively indications for early preventive methods of enteral and extraorganic detoxication. Differential approach to choice of treatment policy reduced postoperative lethality in general peritonitis from 24.4 to 15.8%.

[Classification and principles of treatment of acute purulent peritonitis]. / Klassifikatsiia i printsipy lecheniia ostrogo gnoinogo peritonita.

State of immune-secretory system of intestinal mucosa, bacterial contamination of the small intestine, peritoneal exudate, portal and systemic venous blood, ultrastructural changes in the liver (electron microscopy) were studied in 167 patients with general acute purulent peritonitis (APP) and clinical-laboratory symptoms of endotoxicosis. It is demonstrated that the main links of APP pathogenesis are disorders of small intestine barrier function, massive bacterial translocation from intestinal lumen to abdominal cavity and portal circulation, damage of reticuloendothelial hepatic barrier manifested as fulminant macrophagal hepatic failure, "bursting" of infectious-toxic agents into systemic circulation with resultant toxico-septic shock and visceral insufficiency. This approach permits to classify three clinical stages of APP and to propose differential surgical policy and detoxication treatment for these patients.

[Systemic hemodynamics, oxygenating lung function and oxygen transport in patients with acute intestinal obstruction and an endotoxicosis syndrome]. / Sistemnaia gemodinamika, oksigeniruiushchaia funktsiia legkikh i transport kisloroda u bol'nykh s ostroi neprokhodimost'iu kishechnika i sindromom éndotoksikoza.

Systemic hemodynamics, oxygenating function of the lungs, and oxygen budgeting were studied in 32 patients with acute bowel obstruction (ABO) with severe endotoxicosis. Profound disturbances of systemic hemodynamics and blood oxygenation in the lungs underlie the hemostasis changes in this category of patients before and early after operation. These hemostasis changes lead to inadequate oxygen delivery and metabolic requirement of oxygen and are associated with development of oxygen deficiency in tissues. As a rule, patients with ABO with severe endotoxicosis develop acute respiratory failure presenting as adult respiratory distress syndrome on days 2-3 postoperation. Significant differences in the pattern of hemostasis changes and compensatory shifts in survivors and patients dying after ABO are detected at this period, which determine the prognosis and outcome of disease.

[Choice of surgical management and methods of detoxication in patients with acute intestinal obstruction]. / Vybor khirurgicheskoi taktiki i metodov dezintoksikatsii pri ostroi neprokhodimosti kishechnika.

A comparative analysis of the results of treatment in 892 patients with various forms of acute bowel obstruction (ABO) of non-tumor genesis has been performed. High informative values of the intraoperative biomicroscopy of bowel wall for evaluation of severity of ischemic damage and viability of the intestine in ABO. The endotoxicosis (ET) in patients with ABO is proposed to be assessed on the basis of integral assessment of clinical and laboratory values of hemostasis. Basic principles of the choice of surgical policy and methods of detoxication in ABO with regard for the grade of ischemic damage of the bowel wall and the ET level are described. The application of the developed methods in patients with ABO allows to avoid mistakes in evaluation of bowel viability, to reduce the rate of development of toxicoseptic shock from 9.8% to 4.7% and to decrease postoperative lethality rate from 12.7% to 6.5%.

[The immuno-microbiological characteristics of the small intestine and the translocation of the enteral microflora in acute intestinal obstruction]. / Immuno-mikrobiologicheskaia kharakteristika tonkoi kishki i translokatsiia énteral'noi mikroflory pri ostroi neprokhodimosti kishechnika.

The complex examination of 72 patients with acute ileus (AI) of nontumor nature with different severity of endotoxicosis was carried out. The study revealed that AI was accompanied by deep suppression of the immunosecretory and motor evacuatory function of the small intestine, as well as by its pronounced bacterial contamination, mainly due to the significant quantitative prevalence of Gram-negative microflora. The combination of these factors played the key role in the increase of the permeability of the enteric barrier for symbiotic microflora and its massive translocation from the intestinal tract to the internal organs of the body (peritoneal exudate, portal bed), which directly correlated with the severity of endotoxicosis in AI patients. The deficiency of the barrier function of the liver was accompanied by the penetration of infective agents into the general blood stream, thus causing the development of endotoxic shock in AI patients. The analysis of the results thus obtained made it possible to determine the main ways for the elimination of intestinogenic intoxication in AI; they should be aimed at the bacterial decontamination of the small intestine, the restoration of its motor evacuatory and protective barrier functions, the liquidation of portal and systemic bacteremia, the correction of the functional deficiency of the liver.

[The prognosis and prevention of the occurrence of acute ulcers and erosions of the stomach and duodenum in surgical patients]. / Prognozirovanie i profilaktika vozniknoveniia ostrykh iazv i érozii zheludka i dvenadtsatiperstnoi kishki u khirurgicheskikh bol'nykh.

Acute ulceration of the gastric and duodenal mucosa was found in 20.3% among 404 patients who died at the surgical department of the hospital. In 89.7% of the patients acute erosive-ulcerous lesions were localized in the gastric mucosa. In 39 patients (9.7%) acute ulcers of the stomach and duodenum complicated by bleedings or perforations were the direct cause of death. Based on results of an analysis of severity of the main and concomitant diseases as well as their complications the authors have determined the factors responsible for the appearance of the ulcers. A complex of prophylactic measures aimed at the main links of the pathogenesis of acute ulcers is proposed.

[Portal and systemic bacteremia as a manifestation of the functional failure of the enteral barrier in acute intestinal obstruction]. / Portal'naia i sistemnaia bakteriemiia kak proiavlenie funktsional'noi nesostoiatel'nosti énteral'nogo bar'era pri ostroi neprokhodimosti kishechnika.

A complex investigation of 72 patients, with acute bowel obstruction (ABO) having clinico-laboratory signs and symptoms of endotoxicosis (ET), was carried out. It was proven that ABO was accompanied by profound decrease of the immuno-secretory function of the small bowel and its extensive bacterial contamination as a result of significant increase in the concentration of gram-negative symbiotic microflora, which leads to increased permeability of bowel barrier. Consequently there is massive translocation of the internal medium of the organism by enteral microflora and most of all in the portal zone and in the presence of inadequate hepatic barrier function--the systemic blood supply which corresponds to the clinical picture of endotoxic shock.