[Surgical Site Infections after Open Appendectomy and Effectiveness of Complex Approach to Their Prevention].

AIM: To assess an incidence rate of surgical site infections (SSI) after open appendectomy and effectiveness of combined preventive measures (CPM). MATERIAL AND METHODS: This study was performed at three surgical departments of Smolensk hospitals. A total of 150 consecutive patients (50 at each department) hospitalized since January 2012 were included into the retrospective observation (period I). In order to perform prospective evaluation of CPM, a total of 66 consecutive patients (randomized 1:1) hospitalized since December 2012 (period II) were followed up at each of the departments. Antibiotic prophylaxis (AP) with IV amoxicillin/clavulanate (1.2 g) was planned for all patients from period II. The study group (group 1) included patients with surgical wound closure with triclosan-coated polyglactin 910 and additionally with a skin 2-octylcyanoacrylate-based adhesive. The control group (group 2) included patients with surgical wound closure with non-triclosan-coated polyglactin 910. Each patient from the period II was assigned to an "Individual SSI Prevention Package" (IPP), which included an antibiotic, sutures, skin adhesive (only in a package for CPM) and label "AP" for patients' medical records. Patients' medical records were reviewed by one expert. Exclusion criteria were: age <14 years; transition to midline laparotomy; drainage of the abdominal cavity through the surgical wound; simultaneous interventions; secondary appendicitis; refusal to use of sutures from the IPP. In order to determine signs of SSI presence/absence within 30 days after surgery, attempts to contact with patients by phone were made. The data obtained was recorded into case report forms and then entered into the study database. RESULTS: A total of 322 patients were included into the final analysis (mean age: 34.8±17.1 years). The mean length of hospital stay was 8.2±2.5 days. The mean duration of hospital stay with or without SSI was 7.9±1.8 and 14.2±4.0 days, respectively (p<0.001). The AP during the periods I and II was performed in 56.1% (83/148) and 97.7% (170/174) of patients, respectively (p<0.00001). Cephalosporins I-IV were the most frequently used antibiotics during the period I (85.6%). During the period II, amoxicillin/clavulanate from IPP was used in 98.2% of patients. Percentage of IV antibiotic administration in different time periods was 57.3% and 98.2%, respectively (p<0.0001); frequency of the first administration before skin incision was 53.6% and 97.1%, respectively (p<0.0001). The telephone contact with patient was successful in 74.8% (both periods), 56.8% (period I) and 90.2% (period II) of cases, respectively. SSI was recorded only once per patient with the following priority: SSI was documented in the patient's medical record; patient developed SSI that was not documented (in the expert's opinion) in the patient's medical record; SSI signs were determined during the telephone contact or reported by the patient. The incidence of SSI in both study periods, period I and period II was 14.9%, 15.5% and 14.4%, respectively (p>0.05 for all comparisons). In the patient subgroup with successful telephone contact, the incidence of SSI in both study periods, period I and period II was 17.4%, 21.4% and 15.3%, respectively; the incidence of SSI in group 1 and group 2 of the period II was 12.0% and 18.9%, respectively (p>0.05 for all comparisons). CONCLUSION: SSI after an open appendectomy remains an important problem. In order to determine a true incidence of SSI, it is necessary to improve the national nosocomial infection surveillance system. The CMP used in the study have showed a trend to significant SSI risk reduction and may be recommended to maximize patient protection. Further large studies are needed to confirm effectiveness of the proposed CMP.

[Nonstrain plasty of incarcerated hernias].

The article presents an experience with treatment of 129 patients with incarcerated hernias of the abdomen. Immediate results of the operative treatment with using plasty with polypropylene transplant were analyzed. The data obtained are compared with the results of plasty with local tissues.

[Choice and specificities of formation of pancreaticodigestive anastomosis in proximal resections of the pancreas].

The authors describe the direct results of 116 proximal resections of the pancreas made for tumor and benign diseases of the pancreas head and periampular zone. Advantages of gastroanastomosis are shown compared with pancretojejunoanastomosis at the reconstructive stage of the pancreatoduodenal resection. Incompetence of the pancreatogastgroanastomosis was noted in 1 (1.9%) case and lethality was 1.9%. Incompetence of the pancreatoduodenal anastomosis was 14 (22.2%) cases, lethality 12.7%.

[Pancreatic stump preparation by pancreatoduodenal resection].

Short-term results of 124 pancreatoduodenal resections (PDR) are analyzed. 65,3% of patients had pancreatic cancer, 12,1% - cancer of the papilla Vateri, 3,2% - cancer of the terminal part of the common bile duct, 2,4% - cancer of the duodenum, 2,4% carcinoid of the pancreas, 14,5% - chronic pancreatitis with the affection og the head. Standard Whipple procedure performed in 91 patients, pyloro-saving PDR - in 32 cases and total pancreatoduodenectomy in one patient. 3 types of pancreatic stump preparation were used. Pancreatojejunal anastomosis (PEA) (n=63) considered to be the first, pancreatogastroanastomosis (PGA) (n=46 ) - the second and external pancreaticostomy (n=15) - the third. Overall anastomosis failure rate was 12,1% (n=15). By PEA, failure rate was 27,5% and was noticed predominately in cases of connecting all area of pancreatic slice with the gut (43,5%). PGA failure rate was 2,1% (n=1). Therefore, PDA should be considered to be a reliable pancreatodigestive anastomosis, allowing a decrease of postoperative complication rate to 26,1% and lethality rate to 2,1%.

[Clinico-morphological factors of prognosis in cancer of the major duodenum papilla].

Long-term results of radical operative treatment of 19 patients with cancer of the major duodenal papilla were analyzed. One year, three years and five years survival was found to make 89.4%, 57.8% and 36.8% respectively. The median of life span was 44 months. The data of a univariant analysis show that favorable factors of survival are the early stage of the tumor disease, the absence of metastatic lesion of the regional lymph nodes, tumor invasion into the pancreas and a microscopic picture of pancreatitis in the stage of exacerbation. But the multivariant analysis showed that the stage of the disease is an independent factor of prognosis.

[The long term results and survival prognostic factors of surgical treatment ampulla Vateri cancer].

Results of radical operative treatment of 21 patients with ampulla Vateri cancer are presented. Within the first 30 days after pancreaticoduodenal resection 2 (9.5%) patients have died. The long-term results were studied at 19 (90.4%) patients. The one-year, the three-year and five-year survival percentage was 89.4, 57.8 and 36.8% accordingly. The median of life expectancy is equal to 44 months. Factors having prognostic value for survival rate are the stage of disease, metastatic regional spread, tumor invasion in a head of a pancreas, microscopic picture of a pancreatitis in a phase of acute condition. However, the only independent factor of the prognosis for a disease is the stage of neoplastic process.

[Pancreatoduodenal resection in treatment of cancer of pancreatic head and periampullar zone]. / Pankreatoduodenal'naia rezektsiia v lecheniia raka golovki podzheludochnoi zhelezy i periampuliarnoi zony.

Results of 120 pancreatoduodenal resections are analyzed. Early postoperative period complications were seen in 51 (42.5%) patients. Overall lethality during 30 days after surgery was 13.3%. Over the last decade lethality reduced to 5%. Life time was studied in 91 patients with cancer of the pancreas (PS) and periampullar zone (PAZ) with Kaplan-Meyer method. Median of life of patients with cancer of PS was 14 months, Vater's papilla (VP)--37 months, terminal part of common bile duct (TPCBD)--30 months, duodenum--30 months. One-, 3-, 5-year survival in cancer of PS was 53, 11 and 3%, in cancer of VP--80, 50 and 31%, in cancer of TPCBD--80, 20% and 0, in duodenal cancer--80, 50 and 33%, respectively. Prognosis factors correlating with the survival were following: 1) primary location of tumor; 2) size of tumor; 3) radicality of surgery; 4) regional lymphatic metastases; 5) invasion of vessels by tumor; 6) index of oncomarker CA 19-9. Early diagnosis of cancer of PS and PAZ, optimization of surgical policy and techniques, using other methods in complex improve results of pancreatoduodenal resections.

[Diagnosis of chronic duodenal obstruction]. / Diagnostika khronicheskoi duodenal'noi neprokhodimosti.

The results of examination of 111 patients with chronic duodenal obstruction (CDO) were analyzed. CDO makes up 3.8% in the whole structure of the diseases of the organs of gastro-intestinal tract, and in the structure of the diseases of pancreato-duodenal area--6.1%. Mechanical form of CDO was revealed in 43.6% of patients, functional--in 51.4%; the disease in compensated stage was detected in 38.7% of patients, in subcompensated stage--in 52.3% and in decompensated stage--in 9.0%. Clinical manifestations of the disease are characterized by diversity of symptoms, which necessitates the use of the complex of instrumental examinations. For establishment of the causes of CDO, besides the routine methods USE and computed tomography were used. In simultaneous contrast of the duodenum, the aorta and superior mesenteric artery computed tomography in comparison with other methods makes it possible to make more precise diagnosis of mechanical CDO caused by arteriomesenterial compression.

[Pancreatoduodenal resection in cancer of the head of the pancreas]. / Pankreatoduodenal'naia rezektsiia pri rake golovki podzheludochnoi zhelezy.

The nearest results of surgical treatment of 375 patients with carcinoma of the pancreatic head and of 104 patients with cancer of other organs of the pancreatoduodenal area are described. Radical operations were made on 62 of them. Resectability was 16.5%, lethality--9.7%, postoperative complications were noted in 35.5% of the patients.

[The surgical treatment of chronic duodenal obstruction in combination with chronic pancreatitis and tumors of the pancreaticoduodenal area]. / Khirurgicheskoe lechenie khronicheskoi duodenal'noi neprokhodimosti pri sochetanii s khronicheskim pankreatitom i opukholiami pankreatoduodenal'noi zony.

Results of 102 surgical interventions were analyzed. In 39 patients chronic duodenal obstruction was associated with benign diseases, 63 patients had malignant tumours. The chronic duodenal obstruction resulted from diseases in the pancreatoduodenal area in 80 patients, in 22 patients it proved to be the cause of chronic pancreatitis. The adequate surgical correction of the duodenal obstruction is believed to be sufficient for normalizing the pancreas functions in patients with primary chronic duodenal obstruction. Direct surgical interventions are preferable for secondary chronic duodenal obstruction. Prophylactic formation of gastroenterostomy during the biliodigestive surgery can relieve the symptoms of the developing duodenal obstruction and allows to avoid another operation at the advanced stage of chronic duodenal obstruction.

[Results of the surgical treatment of patients with chronic duodenal obstruction]. / Rezu'ltaty operativnogo lecheniia bo'lnykh s khronicheskoi neprokhodimos'tiu dvenadtsatiperstnoi kishki.

For chronic duodenal obstruction, duodenojejunostomy was performed in 12 patients, the Roux gastric resection--in 18, the Robinson operation--in 12. The Roux gastric resection has proved to be effective in patients with subcompensated and decompensated forms, the Robinson operations--in patients with compensated form of the disease. The different variants of duodenojejunostomy didn't contribute to recovery of the patients.