ABDOMINAL HEMORRHAGE IN CASE OF CATATRAUMA.

The results of diagnostic and treatment were analyzed in 111 victims with abdominal multitrauma at the period from 2010 to 2013. Abdominal traumas were diagnosed on the basis of instrumental investigations and laparascopic data. Combined injuries were often observed in 3­5 areas. The abdominal hemorrhages were in 66 patients as a result of injury of the parenchymatous organs. Diagnostic value of clinical symptoms wasn't more than 45,9% in abdominal catatrauma, though in case of plan radiography it was from 41,2% to 66,4% and in case of ultrasound study ­ 91,6%. The laparotomy was performed for 28 patients. The laparoscopy was applied in 66 cases. However, there were revealed the cases of continuing bleeding in 31 patients and because of these complications, the operations were converted to laparotomy in 27 cases. Different variants of laparoscopic coagulation were performed on 4 patients. The rate of lethality consisted of 27%. The authors proposed an algorithm of treatment of the patients with closed abdominal injury on the basis of score assessment of hemoperitoneum (according to USS), which allowed significant rise of treatment efficacy, decrease the rate of postoperative complications and lethality.

[Stages of diagnosis and surgical treatment for combined bladder injuries].

62 case histories of patients with bladder injuries who were admitted in the Department of Urology and Emergency Surgery of the Republican Scientific Center of Emergency Medicine (RRCEM) from 2001 to 2010 were retrospectively analyzed. 15 (24.2%) patients with hematuria or urethremorrhagia were admitted in the emergency room within an hour after the injury onset. Three (4.8%) patients were hospitalized in the period 1-3 h since injury onset, 12 (19.3%) patients since 3-6 hours, 5 (8.1%) - since 6 to 12 h, 16 (25 8%) patients - since 12 to 24 hours, and 11 (17.7%) patients - after 24 hours. Concomitant injury of the bladder with fractures of the pelvic occurred in 21 (33.8%) cases. At the time of admission in the emergency room, I-II degree traumatic shock was diagnosed in 37 (60%) of patients, III-IV degree traumatic shock - in 11 (17,7%). All 62 patients had a complete rupture of the bladder, 37 (59.6%) of patients had intraperitoneal rupture, 23 (37.1%) - extraperitoneal rupture, and only 2 (3.3%) - mixed rupture. Strict adherence to the RRCEM algorithm of diagnosis and treatment of patients with bladder injuries have substantially improved the efficiency of complex of medical and diagnostic measures and improved the outcomes of this group of patients - mortality was 12.9%.

[Functional state of gastrointestinal anastomoses after repeated gastric resection].

Long-term follow-up of 144 patients with different types of gastrointestinal anastomoses after repeated and reconstructive operations was gained. Endoscopic and roentgenological data, as wall as data of electrogastrointestinography were assessed. Hystological samples of gastric stump and efferent intestinal loop were analyzed. The conducted survey proved an end-to-end gastro-duodeno-anastomosis to be the best in functional meaning. When the latter is impossible, an antiperistaltic horizontal short-loop gastroenteroanastomosis should be performed.

[Endoscopic surgery for calculous cholecystitis in combination with non-malignant affection of extra-hepatic bilious ducts].

Treatment results were analyzed in 318 patients with calculous cholecystitis in combination with non-malignant affection of extra-hepatic bilious ducts undergoing stage-by-stage endoscopic and laparoscopic operations. Relying on results of endoscopic retrograde cholangiopancreatography choledocholithiasis was revealed in 163 (53.1%) patients, common bile duct's (CBD) terminal part stenosis--in 32 (10.4%) patients, combination of choledocholithiasis and CBD terminal part stenosis--in 41 (13.4%) patients. Laparoscopic operation was started in 318 patients at the second stage of treatment. It was possible to carry out laparoscopic cholecystectomy in 305 (96%) of these patients including 5 patients who underwent Pikovsky's CBD drainage owing to clinical finding of acute pancreatitis. Conversion was carried out to 13 (4%) patients with marked inflammatory infiltration in the hepatoduodenal ligament area. Among all complications of laparoscopic cholecystectomy damage of extra-hepatic bilious ducts was observed in 2 patients. Lethal outcome was observed in one case (0.3%).

[Laparoscopic procedures at diagnosis and treatment of early postoperative intraabdominal complications in urgent surgery].

Results of diagnosis and treatment of 318 patients with early postoperative intraabdominal complications (EPIAC) after urgent abdominal operations are analyzed. All the patients were divided into two groups depending on method of repeated operation. First group consisted of 212 patients who have undergone traditional relaparotomy, at 106 patients of second group the treatment was started with diagnostic laparoscopy. At 21 (6.5%) patients of 1st group the relaparotomy was diagnostic. At 58 (55%) patients of 2nd group the laparoscopic procedures was the final method of treatment, at 13 (12%) cases the EPIAC were excluded, conversion to open surgery was performed at 35 (33%) cases. Laparoscopy permitted to reduce lethality in 2.5 times and hospital stay in 2 times.

[Surgical treatment of gastric ulcers with correction of ulcerogenic zone and function of the organ].

The results of surgical treatment of 36 patients with gastric ulcers are analyzed. All these patients have undergone resection of 1/2 stomach with excision of the lesser curvature and creation of end-to-end gastroduodenoanastomosis (GDA, n=21), terminolateral GDA (n=2), antiperistaltic horizontal gastroenteroanastomosis (GEA, n=8) and isoperistaltic GEA (n=5). Five-year follow-up demonstrates good results of gastric resection with excision of the lesser curvature in patients with gastric ulcer.

[Operations in injuries and strictures of bile ducts].

Analysis of surgical treatment of 336 patients with cicatricial strictures and iatrogenic external fistulas of extrahepatic bile ducts is presented. The causes of these complications were intrasurgical injuries during cholecystectomy (n=302), resection of the stomach (n=21) and echinococcectomy (n=13). In all the cases correction of water-electrolytic balance, treatment and prophylaxis of hepatic and renal insufficiency, control of anaerobic infection were carried out before and after surgery. Restorative operations were performed in 31 (9.2%) patients, reconstructive surgeries -- in 305 (90.7%). Recurrence of the stricture required surgical intervention in 38 (11,3%) patients. Various postoperative complications were diagnosed in 119 (35.4%) patients, 26 (7.7%) patients died. The main causes of death were insufficiency of anastomotic sutures, intoxication, hepatic and renal insufficiency due to purulent cholangitis and cholangiolytic abscesses of the liver.

[Endoscopic procedures in the treatment of residual and recurrent choledocholithiasis].

Results of endoscopic treatment of 124 patients with residual and recurrent choledocholithiasis after cholecystectomy were analyzed. It is demonstrated that endoscopic papillosphincterotomy with lithoextraction is the method of choice. Lithoextraction after mechanical lithotripsy is indicated in different sizes of the concrement and terminal part of the common bile duct. Conventional nasobiliary drainage (NBD) in incomplete evacuation of the concrements not always predicts repeated impaction of the stone. Original spiral-type catheter procedure for NBD permits one to prevent repeated impaction of the concrement and to perform operation after attenuation of acute purulent cholangitis.

[The role of endoscopy in diagnosis and treatment of gastroduodenal bleedings].

The experience in diagnosis and treatment of 469 patients with gastroduodenal ulcer bleedings is presented. Sensitivity of endoscopy in detection of bleeding source was 98.8%, in detection of ulcer size -- 93.4%, specificity -- 80.6%. It is demonstrated that the most frequently recurrence of bleeding occurs when ulcer size is more than 1 cm. Location of ulcer on posterior, posterior-superior and posterior-inferior walls of the duodenal bulb is an unfavorable prognostic symptom (rebleeding occurs in 17.1, 30.0 and 12.5% cases, respectively). Types Forrest-Ia and Forrest-IIa are especially dangerous for recurrence (21.4 and 15.6%, respectively). In types Forrest-Ib and Forrest-IIb rebleeding occurs less frequently (4 and 6%, respectively). In types Forrest-Ia and Forrest-Ib rebleeding occurs mainly on the first day, rebleeding in types Forrest-IIa occurs more often on the first-second day, however it is possible up to day 7. Rebleeding in types Forrest-IIb occurs also mainly during the first two days. Endoscopic hemostasis (electrocoagulation and injection therapy) was performed in 40 patients. In 6 (15%) cases hemostasis was not achieved. In 8 (20%) cases endoscopic hemostasis led to a temporary effect, i.e. rebleeding was seen within 24-72 hours after endoscopic procedure. Stable hemostasis with endoscopy was achieved in 26 (65%) patients.

[Resection of the stomach with excision of the small curvature and selective vagotomy in primary and reconstructive surgery of gastroduodenal ulcers]. / Rezektsiia zheludka s issecheniem maloi krivizny i selektivnoi vagotomiei v pervichnoi i rekonstruktivnoi khirurgii gastroduodenal'nykh iazv.

Experience in surgical treatment of 261 patients with complicated gastroduodenal ulcer is summarized. A new improved method of resection with subtotal excision of the small curvature and selective gastric vagotomy, creation of a gastric stump in the form of a proximal reservoir and distal tubular canal was used. In 144 cases this method was performed as repeated or reconstructive surgery in post-vagotomic ulcers. The follow-up was 5 years, long-term results were evaluated in 166 patients with the Visik scale. Excellent and good results were seen in 151 (91%) patients, satisfactory -- in 13 (7.8%), and a poor result (recurrence of ulcer) -- in 2 (1.2%) patients.

[Nutrition of patients operated for complicated gastroduodenal ulcers at the early postoperative period].

The investigation is based on an analysis of results of treatment of 102 patients after an emergency resection of the stomach for complicated gastroduodenal ulcers. The probe was inserted into the jejunum intraoperatively. The period of enteral probe nutrition (EPN) was 5-7 days. At the early postoperative period in patients who had undergone the emergency resection of the stomach EPN is an effective method of nutrition maintenance as compared with the infusion-transfusion therapy. The method is simple and open to general use, and is economically advantageous under conditions of any hospital.

[Prevention of post-burn scarring esophageal strictures, strategies of surgical treatment]. / Preduprezhdenie obrazovaniia posleozhogovoi rubtsovoi striktury pishchevoda, taktika khirurgicheskogo lecheniia.

Experience of treatment of 52 patients with oesophageal chemical burn in acute and early postburn period was analyzed, as well as in 649--with oesophageal postburn cicatricial stricture (OPCS). In 18 patients perforation of esophagus had occurred during performance of bougienage. Rational complex of diagnostic and therapeutic measures in such patients was determined. The results of bougienage in patients with OPCS were summarized. Causes of the oesophageal perforation occurrence during bougienage were analyzed. Tactics of surgical treatment of esophageal perforation was determined. Analysis of the treatment results and of the main causes, which conditioned upon the postoperative complications occurrence, was conducted.

[Esophageal injuries: diagnosis and treatment]. / Povrezhdeniia pishchevoda: diagnostika i taktika lecheniia.

The authors describe their experiences with treatment of 63 patients with penetrating damages of the esophagus. Suturing the esophagus wall with drainage of the zone of the injury and mediastinum was performed on 35 patients admitted to the hospital during the first day after injury. The rest of the patients underwent drainage of the injury zone, followed by gastrostomy and application of the nasogastral tube. Lethality was 29.6% and depended on the type of trauma, terms of the beginning of skilled medical treatment and the degree of the developed purulent complications.

[The causes of incompetence of the duodenal stump and gastroenteric anastomosis and the means for its prevention in the surgery of duodenal ulcers]. / Prichiny nesostoiatel'nosti kul'ti dvenadtsatiperstnoi kishki i gastroénteroanastomoza i puti ee preduprezhdeniia v khirurgii duodenal'nykh iazv.

Causes of the incompetence of stump sutures in resection of the stomach observed in 90 out of 3479 patients with chronic duodenal ulcers were analyzed. Most patients were found to have a combination of general and local factors. Among the local factors the leading one was appearance of a large inflammatory infiltration around the "active" ulcers. The endoscopic autohemoapplication to the ulcer included in the complex of preoperative preparation of the patients reduced the frequency of incompetence of sutures from 2.58% to 1.33%.

[Surgical methods in recurrent peptic ulcer after vagotomy]. / Khirurgicheskaia taktika pri retsidivnoi i pepticheskoi postvagotomnoi iazve.

In treatment of recurrent and peptic postvagotomy ulcer, the performance of gastric resection is indicated. Of 53 patients with a recurrent ulcer, 20 had a "difficult" low penetrating ulcer. With the aim ot prevent duodenal suture failure, gastric resection in these patients was performed using the developed by the authors method which permitted to ensure safety of the single-layer suture of a duodenal stump with preservation of food passage through the duodenum. After truncal vagotomy with Jaboulay drainage operation, a defect in the duodenal wall was eliminated by means of creation of anastomosis with a gastric stump.

[Corrective and reconstructive operations in post-vagotomy syndromes]. / Korrigiruiushchie i rekonstruktivnye operatsii pri post-vagotomicheskikh sindromakh.

Among 322 patients with postvagotomy syndromes who were examined by the authors, 133 were subjected to reconstructive and corrective operations. Most of the patients (73.7%) who underwent surgery for the second time suffered from peptic, recurrent, and persisting ulcers due to vagotomy. The authors give preference to resection methods in recurrent ulcer after vagotomy and do not resort to revagotomy in an isolated form. The authors propose a new method for resection of the stomach in peptic ulcers after vagotomy with gastroduodenoanastomosis by the Jaboulay procedure. In the authors' opinion, the choice of method for reconstructive operations should be made with due regard for the pattern of a complication, the type of a primary surgery, and causes of their development.