[Pyoinflammatory complications of the permanent vascular hemodialysis access].

Of 315 patients with permanent vascular hemodialysis access, 23 (7,3%) patients developed pyoinflammatory complications in various terms after the operation. Angiogenic sepsis was registered in 73,9% of them. Lethality among patients with pyoinflammatory complications of the vascular access was 69,6%. Gram-positive polyresistant microorganisms were predominantly defined. Clinical features of the pyoinflammatory process in the category of patients were: typical picture of phlegmon or infiltration in 50%; latent laboratory and clinical signs of the systemic inflammatory response. The above features and immunodeficiency defined late diagnostics and antibioticotherapy and, therefore, high lethality level in that category of patients.

[Radical operative treatment of perforative gastroduodenal ulcer disease].

Data of 363 patients operated on for perforated gastric or duodenal ulcers were analyzed. Immediate and follow-up results were obtained after simple suture plication, Jadd's ulcer excision combined with stem vagotomy and after distal gastric resection. Predictors of the unfavourable outcome were determined. These are: Mannheim peritonitis index >20, surgical risk of IV-V grade, signs of multiple organ failure and symptomatic character of the ulcer. The comparison of long-term results revealed that patients after suture plication experienced the ulcer recurrence in 78,4% and necessity of further operation occurred in 21,5%. Every third patient after stem vagotomy experienced postvagotomic disorders and ulcer recurrence. Primary gastric resection demonstrated the best long-term results concerning ulcer disease. The algorithm of treatment modalities of the perforative ulcer desease was worked. The algorithm is based on stage-by stage determination of indications and contraindications to gastric resection.

[Choice of treatment method at acute gastroduodenal ulcerous bleedings].

Experience of treatment of 1307 patients with acute gastroduodenal ulcerous bleedings is analyzed. Three variants of treatment tactics are compared: expectant, active and differential. Differential tactics based on prediction of bleeding recurrence and assessment of patient's condition severity permit to improve the treatment results. Original clinical-endoscopic system of hemostasis stability assessment was used for prediction of bleeding recurrence, integral scale APACHE III--for assessment of patient's condition severity. Algorithm of treatment at acute gastroduodenal ulcerous bleedings is offered. Principles of differential treatment tactics have permitted to reduce overall lethality at acute gastroduodenal ulcerous bleedings to 3.2%, postoperative lethality--to 6.2%.

[Antisecretory therapy as a component of hemostasis in acute gastroduodenal ulcer bleedings].

Results of antisecretory therapy (pyrenzepin, H(2)-blockers, inhibitors of proton pump, octreotid) in 962 patients with acute gastroduodenal ulcer bleedings (AGDUB) were analyzed over 14-years period. Antisecretory treatment in AGDUB has principally different goals and potential depending on risk of bleeding's recurrence and morphological changes in tissue of gastroduodenal ulcer. Antisecretory therapy is the main treatment in high risk of AGDUB recurrence or before urgent surgery. Intravenous infusion of omeprazol has demonstrated the highest clinical efficacy due to maximal inhibition of gastric secretion and absence of negative influences on oxygen regimen in tissue of ulcer.

[Pathogenesis of recurrences of acute gastroduodenal ulcerous bleedings]. / Patogenez retsidiva ostrykh gastroduodenal'nykh iazvennykh krovotechenii.

Based on analysis of morphologic data, oxygen regime and redox potential it is demonstrated that progressive ischemic necrosis in periulcerous zone is the basis of recurrence of gastroduodenal ulcerous bleedings. Systemic hemostatic therapy, antisecretion drugs, endoscopic methods of hemostasis don't guarantee absence of bleeding recurrence. Prognosis of recurrence of gastroduodenal ulcerous bleedings must be based on evaluation of clinical and endoscopic data. Partial pressure of oxygen and redox potential in ulcer's crater are the objective criteria of threat of bleeding's recurrence.

[Recurrence of acute gastroduodenal ulcer bleedings]. / Retsidiv ostrykh gastroduodenal'nykh iazvennykh krovotechenii.

Multifactor analysis of 818 cases of acute gastroduodenal ulcer bleedings (clinical and laboratory examination, gastroscopy, morphological studies) was carried out, 97 of these patients had recurrence of bleeding. It is demonstrated that recurrence of gastroduodenal ulcer bleeding is cause by progressed ischemic necrosis in periulcerous zone in condition of local hypoperfusion as a result of systemic hemodynamic disorders due to acute blood loss syndrome and chronic ischemia dueto ulcerous process. Systemic hemostatic therapy, antisecretory drugs, methods of endoscopic hemostasis don't guarantee absence of bleeding recurrence. Prognosis of the recurrence must be based on assessment of significant clinical and gastroscopic data. Dynamical determination of pO2 in periulcerous zone is an additional prognostic criterion. Recurrence of gastroduodenal ulcer bleeding increases general and postoperative lethality 2 times as minimum. Active surgical policy based on prognosis of bleeding recurrence probability permitted us to reduce total lethality in acute gastroduodenal ulcer bleedings to 6.2%, postoperative lethality to 8.5%.

[Features of surgical strategy in acute cholecystitis in old patients]. / Osobennosti khirurgicheskoi taktiki pri ostrom kholetsistite u bol'nykh starcheskogo vozrasta.l

Results of treatment of 197 patients at the age of 75-years and older with acute cholecystitis in terms of active (early operations) and active-delaying (delayed and elective operations) policy were analyzed. It was established that changes of gall bladder wall in old patients with acute cholecystitis are of ischemic genesis, of primary-destructive and irreversible nature leading to gangrene and phlegmon of gall bladder wall in 84% cases. In 2/3 cases clinical picture doesn't reflect destructive nature of the disease. Severity of the patients state and its dynamics may be assessed most objectively by APACHE III. Conservative treatment doesn't prevent progress of destructive-inflammatory process and complications development. Cholecystectomy from laparotomy is the operation of choice in this group of patients. Early radical operation for acute cholecystitis in old patients permits to decrease postoperative lethality to 3.3%. The score of APACHE III at hospitalization is the criterion of the scope and terms of surgery. If APACHE III is more than 55 points, it is necessary to carry out complex preoperative correction of somatic disorders. Minimally invasive palliative operations are indicated for 10% patients of this category.