Objective.
The aim of the study was to develop the safest technique for surgical disconnection of high, unformed jejunal fistulas, so as to avoid problems with detection the intestine leading to the ...fistula and to avoid complications of viscerolysis.
Material and methods.
The authors present their experience in surgical management of 35 patients with high delimited unformed debilitating jejunal fistulas. Of these, 22 patients were included in the comparison group; their fistulas were closed or disconnected with the known methods. Findings obtained from other 172 patients with adhesive intestinal obstruction after infectious complications of laparotomic wounds and topography of visceroparietal planar adhesions of the peritoneum were analyzed. After studying the nature and location of visceroparietal adhesions, the authors could develop a technique for proximal disconnection of high delimited unformed debilitating jejunal fistulas using posterolateral access which was applied in 13 patients from the studied group.
Research results.
The proposed technique of unilateral disconnection of high unformed jejunal fistulas reduces duration, damage and risk of prolonged bowel deserosing. As a result, a significant decrease in postoperative mortality from 59.1 ± 9.2% to 23.1 ± 11.2% (t=2.5; p<0.05) was registered. Due to the preoperative endoscopic marking showing direction to the fistula of intestinal loop and duodenojejunal junction, intraoperative orientation was more accurate and took much less time than in the comparison group. The posterolateral surgical approach to the fistula in the jejunal loop reduced the risk of its damage, since there was no need for extensive enterolysis anymore. Therefore, postoperative period in patients of the studied group was better and with fewer complications than in the comparison group.
Conclusion.
The posterolateral access prevented extended viscerolysis and allowed to put a reliable and atraumatic interintestinal anastomosis so as to disconnect the fistula. The unilateral disconnection of the jejunal fistula at postoperative intestinal paresis unloaded the interintestinal anastomosis, similar to Meidl’s definitive jejunostomy. The abovementioned positive aspects of the proposed surgical intervention allowed to significantly decrease postoperative complications and mortality rate, if to compare with outcomes after known surgical interventions with a similar purpose.
Despite the success in treatment, currently 30.0% of patients with diabetic foot syndrome (DFS) still undergo high amputations with a mortality rate of up to 54.0–68.0 %. The causes of high low limb ...amputations in 28.0 % of patients are infection, and in 46.0 % – arterial insufficiency in the stage of critical limb ischemia.
Objective:
to improve the results of patients treatment by reducing the number of high amputations of the lower extremities, reducing the occurrence of complications and deaths of the disease.Materials and methods. To study the results of treatment of patients with DFS, they were divided into two comparison groups and two main groups. From 1982 to 2019, the frequency of amputations, mainly at the hip level, was 71.0 % (177 amputations in 248 patients). These patients formed the first comparison group of observations. The second comparison group (1988–1994) included 58.3 % of patients in whom amputations were performed according to more stringent indications (157 amputations in 269 patients). The first main group of observations (1995–2013) included 9.9 % of patients with DFS who were amputated only for wet gangrene, incurable critical limb ischemia, and infection with a systemic inflammatory response (130 amputations out of 1312 patients). In ischemia with preserved blood flow through the deep artery of the thigh, amputation of the lower leg was performed in a sequential-two-flap method with removal of the soleus muscle. Amputations were completed with the imposition of drainage removable muscle-fascial sutures. The second main group (2014) consisted of 11.4 % of patients who underwent amputations only for sepsis or wet gangrene (124 amputations in 1083 patients). The difference between the second main group and the first was the division of the high amputation intervention into 2 stages.
Results.
Comparison of the treatment results in the main groups and in the comparison groups revealed a 6-fold decrease in the number of high amputations (from 64.6 to 10.69 %) and a significant improvement in the main quality indicators. This concerns a 6-fold decrease in mortality, which was a consequence of the introduction of a two-stage tactic for high amputation treatment of the most severe patients and the limitation of indications for amputation of the hip. Using of removable drainage muscle-fascial sutures decreased postoperative wound complications from 51.9 to 13.0 %, and the number of re-amputations decreased in 17th times.
Conclusion.
Amputation of the lower extremities for irreversible critical limb ischemia can be performed with a decrease in TcP02 of the stitched stump tissues to no more than 30 mm Hg. Preserving the knee joint improves the possibilities of prosthetics, which allows older diabetics to lead an active life. Methods of performing parallel- or sequential-two-flap high amputation improve the conditions for cutting out racquet-shaped wound flaps, which provides free displacement of the soft tissues of the stump connected by removable drainage sutures.
Nephrotic syndrome secondary to minimal change disease (MCNS) usually is considered to have a good renal prognosis, but frequency of relapses and steroid dependency are therapeutic challenges to ...physicians. Treatment of patients with multiple relapses remains controversial because few control studies are available. We report the case of a 23-year-old woman of Malian origin who experienced more than 30 relapses of MCNS. Long-term remission was observed only with rituximab (anti-CD20 antibody) treatment after step-by-step use of all currently available medications for MCNS were unsuccessful. Our observation is the first report of efficacy of rituximab during multirelapsing MCNS in an adult patient with a significant follow-up and no adjuvant therapy. This case suggests a role of B cells in MCNS, possibly by regulating T-cell function.
Context: Anterior cruciate ligament (ACL) injuries are common and costly in the athletic population and prevention strategies are needed. Augmented feedback has been used to successfully modify ...possible risk factors, such as ground reaction forces, but has not been studied as a method to alter frontal plane kinematic and EMG data. Objective: To investigate the effects of augmented feedback on knee valgus angles and hip muscle activity during a jump landing task.
Treatment results of 368 patients with infected pancreonecrosis were analyzed. Overall lethality was 29.6 ± 3.4%. Maximal lethality was among patients with phlegmona - 43.6 ± 5%, minimal (12.9 ± ...3.8%) among patients with abscess. Spread phlegmonas, when closed sequestrectomy was impossible, were treated by transversal omentobursopancreatostomy. When the closed drainage of infected pancreonecrosis areas was not effective after 10-13 days, conversion to the omentobursopancreatostomy was performed. Lethality among patients with non-alternative closed drainage was 50.0 ± 4.5%. Lethality after omentobursopancreatostomy was 19.0 ± 4.2%.
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