Objective. To improve the results of treatment in patients, suffering insufficiency of sutures of intestinal anastomoses, using analysis of rate in the genes polymorphous variants of the matrix ...metalloproteinase Type 2 (C-1306 →T) and the tissue inhibitor of the matrix metalloproteinase Type 2 (G303 →A), as well as the result of elaboration of genetic diagnosis and prognostication of such complication.
Materials and methods. In 32 patients, suffering insufficiency of intestinal sutures, which were treated in Shalimov National Institute of Surgery and Transplantology during 2016 - 2021 yrs, there were conducted the laboratory, genetic, immunohistochemical and statistical investigations.
Results. Genetic and statistical analysis for the genes polymorphism of the matrix metalloproteinase Type 2 (C-1306 →T) and the tissue inhibitor of the matrix metalloproteinase Type 2 (G303 →A) have permitted to determine the genotypes variants, associated with risk for the sutures insufficiency occurrence in the hollow gut organs anastomoses. Basing on the data obtained, the prognostication method was elaborated for the sutures insufficiency occurrence in intestinal anastomoses. Such complications are occurred in 1,36 times more frequently in carriers of homozygous СС genotype in gene of the matrix metalloproteinase Type 2 and in two times lesser (5.9%) in carriers the minor homozygotes ТТ, than in the control - 10% (p>0.05). Among the patients with the sutures insufficiency of intestinal anastomoses a statistically significant in 1,6 times more frequent rate of carriers of the homozygous GG gene variant the tissue inhibitor of the matrix metalloproteinase Type 2 was revealed. Carriers of the minor homozygotes АА among the patients with the sutures insufficiency in intestinal anastomoses were absent, while the same genotype was revealed in the control with the 10% (p<0.05) rate. With objective to study the occurrence risk for the sutures insufficiency in intestinal anastomoses in presence of association in the studied genotypes we have analyzed several clinic-laboratory indices. There was revealed the pathogenetic significance of alleles of the genes polymorphic variants of the matrix metalloproteinase Type 2 and the tissue inhibitor of the matrix metalloproteinase Type 2, which were accompanied by hypoproteinemia, high indices of biochemical markers of collagen biodegradation and lowered expression of monoclonal antibodies for α-гладкоmuscular actin and collagen IV, and, finally. have evolved as the risk factors for development of the sutures insufficiency in intestinal anastomoses.
Conclusion. The method proposed consists of genetic investigation of the genes polymorphism of the matrix metalloproteinase Type 2 (C-1306 →T) and of the tissue inhibitor of the matrix metalloproteinase Type 2 (G303 →A). It permits to prognosticate the probability of the sutures insufficiency development in intestinal anastomoses, and, basing on this, to improve the choice of the patients’ treatment tactic.
Parenchyma–preserving hepatic resection in treatment of metastatic colorectal cancer: analysis of the literature data and of own experience accumulated
The battle trauma of the esophagus Usenko, O. Yu; Sydiuk, A. V.; Sydiuk, O. E. ...
Klinična hìrurgìâ (Kiïv),
12/2022, Letnik:
89, Številka:
7-8
Journal Article
Recenzirano
Odprti dostop
Objective. Estimation of efficacy of diagnosis and methods of treatment in patients, suffering the battle trauma of the esophagus.
Materials and methods. In the Division of Thoraco–Abdominal Surgery ...of the Shalimov National Institute of Surgery and Transplantology the treatment of 7 patients with penetrating esophageal wounds was conducted. In 6 (85.7%) patients the penetrating gun–shot woundings were diagnosed, and in 1 (14.3%) patient – the closed thoracic trauma. Shrapnel woundings prevailed over the bullet woundings, occurring in5 (71.4%) and 2 (28.6%) patients, accordingly. Esophageal trauma as isolated affection, caused by the gun–shot penetraiting wounding was extremely rare – in 1 (14.3%) patient. Efficacy of diagnosis and surgical stationary treatment of esophageal trauma, caused by foreign bodies, was estimated, as well as the terms of the esophagus integrity restoration.
Results. In 2 (2.6%) patients with pleural empyema open toracotomy access with further pleurectomy, pulmonary decortication, and restoration of the esophageal wall integrity was applied. In 4 (57.2%) patients thoracoscopy, pleurectomy, pulmonary decortication, and esophageal suturing were conducted.
Intraoperatively in 6 (85.7%) patients the endoscopic vacuum therapy system was installed locally in the damaged esophagus portion. In 1 (14.3%) patient with local pleural empyema the treatment tactics consisted of the pleural cavity drainage under ultrasonographic control plus endoscopic vacuum therapy. For achievement of its optimal efficacy the pressure value was supported in range from 100 to 120 mm Hg. Endoscopic vacuum system was changed every 4 – 5 days. Average duration of the fistulas healing have constituted 1mo.
Objective. To estimate the impact of formation of gastroenteroanastomosis with Brown’s anastomosis, while performing of pancreatico-duodenectomy, on the gastric evacuation arrest rate in a frame of ...the fast-track surgery program implementation.
Materials and methods. To the investigation 92 patients, ageing 28 -75 yrs old, were included, to whom pancreaticoduodenectomy for benign and malignant pancreatic and peripancreatic zone pathology was performed in Jan. 2015 - Aug. 2020 yrs. Perioperative treatment was conducted in accordance to the fast-track surgery program. The first Group consisted of 60 patients, in whom reconstruction in accordance to Child was done, and the second Group - of 32 patients, in whom gastroenterostomy with anastomosis in accordance to Brown procedure was performed.
Results. In the Group I complications have had occurred in 16 (26.7%) patients, in the Group II - in 7 (21.9%), in Group I there were 22 complications, in the Group II - 10, but trustworthy difference between the Groups in accordance to these indices was absent (p > 0.05). Analysis of parameters for restoration of peroral feeding have shown enhanced susceptibility of the program in patients of Group II. The rate of the gastric evacuation arrest in first Group of patients have exceeded the analogous index in patients of Group II in 2 times - 13.3 and 6.3%, accordingly, but statistically significant difference between the Groups in accordance to this index was absent (p = 0.299).
Conclusion. While formation of gastroenteroanastomosis with anastomosis in accordance to Brown procedure in pancreatico-duodenectomy the implementation level for the fast-track surgery program raises and the rate of gastric evacuation arrest diminishes.
Objective. Studying of morphological characteristics of the duodenal papilla magna malignant tumors on the own material of the Division of Pathological Anatomy and Cytology of the Shalimov National ...Institute of Surgery and Transplantology.
Materials and methods. Into the investigation 82 patients were included, to whom pancreaticoduodenectomy was performed for duodenal papilla magna malignant tumors in 2019 – 2021 yrs with further conduction of morphological analysis of the specimen excised. The average age of the patients have constituted (61.1 ± 8.1) yrs old.
Results. There were revealed 8 histological types of the tumors, most frequent of them – adenocarcinomas of pancreatobiliary and intestinal types. These two variants were compared. They did not differ for the age and gender (р>0,05), but statistically significantly differed for the histological differentiation degree and tumoral spread: р =0.039 and р = 0.003, accordingly. Thus, in the pancreatobiliary type of adenocarcinoma the tumors with low differentiation level (G3) were in 1.9 times more frequent, than in adenocarcinomas of intestinal type: 22.9 and 11.8%, and in 2.8 times more frequently the more spread tumors were revealed (рТ3а–Т3b): 65.7 and 23.5%, accordingly. As well, in the patients with adenocarcinomas of pancreatobiliary type a positive status of regional lymph nodes was revealed more frequently – in 57.1%, than in patients with adenocarcinomas of intestinal type – 44.1%.
Conclusion. Duodenal papilla magna malignant tumors – a heterogeneous group of tumors. Adenocarcinomas of pancreatobiliary and intestinal types are the most prevalent. Pancreatobiliary adenocarcinoma, as a histological type, is more aggressive, than intestinal adenocarcinoma.
Objective. To improve the results of treatment in injured persons with a gun-shot penetrating abdominal woundings with damages of large bowel, using introduction of principle for compliance between ...volumes of the damage and the primary operative intervention through organ-preserving operations.
Materials and methods. There were analyzed 164 gun-shot abdominal woundings of large bowel in 151 injured persons. All the wounded persons were men, aged from 19 to 58 yrs old, (34 ± 5.2) yrs old at average. Penetrating cross-cutting abdominal woundings have occurred in 48 (31.8%) patients, the blunt – in 103 (68.2%). In accordance to character of the large bowel damage there were: deserozation - in 8 (5.3%) injured persons, the blunt wounding – in 57 (37.7%), and a through one – in 86 (57.0%). The bullet woundings have occurred in 31 (20.5%) injured persons, while the comminuted – in 120 (79.5%). The large bowel woundings have had following localizations: coecum – in 37 (24.5%) patients, ascending colon – 19 (12.6%), transverse colon – 32 (21.2%), descending colon – 18 (11.9%), sigmoid colon – 33 (21.9%), and several perts of large bowel – 12 (7.9%). The wounded persons were distributed into two groups, depending on volume of the operative intervention performed: the main – 49 (32.4%) wounded persons, in whom organ-preserving operations were performed, and a control one – 102 (67.6%) wounded persons, in whom resectional methods were applied. The large bowel wall defects suturing with or without formation of unloading colo- or enterostomy were considered as organ-preserving operations.
Results. Definite decision, concerning the operative intervention volume, was made immediately after revision of the abdominal cavity organs, estimation of the damages character (special attention was drawn to dimensions, localization and quantity of intestinal defects, the state of its mesenterial edge and adequacy of a blood flow), presence and remoteness of extended peritonitis, general state of a wounded person (the blood loss volume, the sepsis features presence, hemodynamicac indices and common character of the woundings). Оne or several woundings of large bowel, including big in dimensions, were considered as indications for performance of organ-preserving operations (the intestinal wound suturing, the intestinal wound suturing with colo- or jejunostomy, extraperitonization). In patients of the main group, comparing with those of the control group, the stationary stay and the complications rate were reduced. After rehabilitation and staged closure of unloading stomas all wounded persons of the main group went back to service in Military Forces of Ukraine.
Conclusion. Selecting the surgical treatment method for the gun-shot woundings of large bowel, it is necessary to base on complex analysis of the battle trauma character, the patient’s state and the risk for іntra- and postoperative complications. The first-line application of organ-preserving interventions as more physiological and those, which permit mostly rapid come back to the service duties functioning, is expedient. While choosing the organ-preserving operation volume, the surgeon must adhere to principle of compliance between the damage volume and prevalence, general state of a wounded person and the operative intervention volume.
Objective. To improve the results of treatment in patients with insufficiency of duodenal sutures.
Materials and metods. Retrospective and prospective investigation was accomplished on 17 patients, ...suffering insufficiency of sutures, injuries and fistulas of duodenum, who were admitted for treatment into Shalimov National Institute of Surgery and Transplantology during 2010-2020 yrs. In all the patients a complex examination, including a general clinical one, special laboratory and instrumental methods of investigation, was conducted.
Results. Miniinvasive endoscopic method for the treatment of the duodenal sutures insufficiency was elaborated with a patent obtaining, which consists of endoscopic placement of a covered nitinol self-expanding stent into the defect zone. In presence of the complication, constituting a duodenal fistula, there was proposed to place a covered nitinol self-expanding stent into the defect zone together with vacuum-therapy from the side of the fistula external aperture. Due to application of the treatment method elaborated, it have become possible to reduce the morbidities quantity and to shorten the patients’ stationary stay by 36% - from (38.1 ± 4.16) to (25.4 ± 3.7) bed-days (p < 0.05). General mortality in the investigated group have constituted 9%, what was in two times lower, than the mortality index in a control group - 16%.
Conclusion. The method, investigated by us, have constituted a combined approach with endoscopic placement of a self-expanding stent into the defect zone together with vacuum therapy from the external aperture of fistula, promoting improvement of the treatment results of the duodenal sutures insufficiency, accompanied by shortening of the patients’ stationary stay and reduction of morbidity and mortality.
Objective. To determine the possibility and expediency of application of ferromagnetic instruments for diagnosis and pulling out of the abdominal cavity foreign bodies in the battle gun–shot trauma, ...including application of miniinvasive technologies.
Materials and methods. In the investigation 154 patients took part, including 110 (71.4%) with application of open laparotomy access, аnd 44 (28.6%) – using laparoscopic technologies. While doing open laparotomy interventions magnet surgical instruments were applied.
Results. The magnet instruments were used in 2.5 times more frequently in open laparotomy accesses, than in the laparoscopic.There was established, that the average duration of search and pulling out of foreign bodies without application of special instruments have constituted (21 ± 2.2) min, while with it – (10 ± 1.2) min only, what is in 2 times lesser (p˂0.05). When special instruments were used, 98% of foreign ferromagnetic bodies were pulled out from abdominal cavity, while without it – 34% only, causing necessity to perform the staged interventions for their pulling out.
Conclusion. Practical introduction of the magnet instruments proposed permits to reveal the majority of the ferromagnetic foreign body quantity with lesser time loss for their search, localization and pulling out, what is very important in conditions of military–field surgery. Foreign body of the gun–shot origin in patients, suffering penetrating abdominal wounding, demonstrated visually, palpatory or instrumentally, must be pulled out.
Objective. To estimate immediate results of surgical treatment of peripheral cholangiocarcinoma in elderly and senile patients.
Materials and methods. In 2004-2018 yrs period in the Department of ...Transplantation and Surgery of the Liver of the Shalimov National Institute of Surgery and Transplantology 84 patients, suffering peripheral cholangiocarcinoma, were radically operated: 31 (36.9%) patients older than 60 yrs (the main Group), and 53 (63.1%) patients, younger than 60 yrs (control Group).
Results. Postoperative clinically significant (IIIa-IV degree in accordance to classification of Clavien-Dindo) complications during 90-days of postoperative period were noted in 29.1% patients of the main Group and in 32.1% patients of a control Group (p=0.262), postoperative hepatic insufficiency, in accordance to The International Study Group of Liver Surgery criteria, - in 16.1 and 22.6% accordingly (p=0.473); reoperation was performed in 9.6 and 9.4% patients, accordingly (p=0.973). The causes of postoperative lethality in 2 patients of the main Group were an acute myocardial infarction (1) and an acute pulmonary thromboembolism (1).
Conclusion. Hepatic resection is characterized by satisfactory immediate results of treatment of peripheral cholangiocarcinoma in elderly and senile patients, if performed in highly-specialized multidisciplinary centre and thorough selection of patients.
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