Vol 30, No 5 (2013)

Aim. To improve the results of surgery in patients with focal hepatic diseases using rational surgical tactics, purposeful transfusion therapy and effective hemostatic means. Materials and methods. During the period from 1995 to 2003, 398 patients with focal hepatic diseases were treated. 257 patients (64,6%) underwent hepatic resection including 98 (38,1%) – large hepatic resections (3 segments), 159 (61,9%) – minor hepatic resections. Patients were divided into two groups – the main group ( n =137) and the comparison group ( n =120). In the main group, 54 (39,4%) patients underwent large resections, 83 (60,6%) – minor ones. In the comparison group, 44 (36,7%) had large hepatic resections, 76 (63,3%) – minor ones. In the main group the following means were applied: preoperative autoblood reservation, principle of operation from the vessels, hepatic tissue dissection by means of ultrasonic destructor-aspirator and harmonic Ultracision «Johnson&Johnson» scalpel, Pringle manoeuvre, argonoplasmic coagulation of resected hepatic stump surface, local hemostatic means. In the comparison group, hepatic-duodenal ligament compression, isolation of vasculosecretory elements by resection line using digitoclasy, hepatic stump suturing was used by indications so as to prevent hemorrhage. Results. The volume of intraoperative hemorrhage in the main group reached 1100±20 ml, in the comparison group – 2700±250 ml ( p <0,001). The average number of transfused doses of allogenic blood in the main group was 2,1±0,3, in the comparison group – 12,5±1,3 ( p <0,001). The average volume of previously prepared transfused autoblood in the main group was 0,83±0,1 dose, in the comparison group it was not used. After preoperative autoblood reservation was included into the program, the average volume of transfused allogenic blood decreased from 11,1±1,6 to 1,5±1,1 doses ( p <0,001) in case of large hepatic resections and from 3,6±1,1 doses to 0 – in minor resections ( p <0,001). The postoperative lethality in the main group was 2,2% ( n =3), in the comparison group – 9,2% ( n =11). Conclusion. Introduction of modern equipment into surgical practice for the purpose of performing hepatic parenchyma dissection permits to reduce the volume of hemorrhage and the number of doses of infused donor erythromass. Local hemostatic means applied decrease the risk of developing hemorrhage and biliary excretion from the wound surface of hepatic stump in the postoperative period. The developed system of intraoperative and perioperative safety in hepatic resection surgery allows to reduce the risk of operative intervention, to lower the number of postoperative complications.

Aim. To develop diagnostic and treatment algorithm for patients with postcholecystectomy syndrome (PCES) based on integral assessment of clinical, laboratory and instrumental studies. Materials and methods. While carrying out multifactor analysis of clinical, laboratory and instrumental studies in 164 patients with PCES, the most significant evaluation signs were singled out. Score assessment system to divide patients into 4 groups was worked out. Results. This gradation was found to correspond to Roman consensus for patients with Oddi’s sphincter dysfunction. Patients of group 1 were indicated surgery. Patients of groups 2, 3 and 4 require estimation of bile outflow by means of hepatobiliscintigraphy (HBSG). Some patients had normal bile outflow, but in 68% of patients it was quickened, so there is Oddi’s sphincter failure. To make the reason of clinical manifestations more precise, computer tomography and magnetic resonance cholangiopancreatography was applied. Algorithm of diagnosis and choice of medical tactics was developed on the basis of integral estimation of the results of investigations. Conclusion. The developed algorithm for patients with PCES makes determination of sequences of studies and choice of medical tactics easier. HBSG allows to objectively estimate the state of bile outflow which in most cases is not disturbed and even quickened. After cholecystectomy, it is necessary to exclude other causes of patients’ sufferings and take them into consideration when performing repeated surgeries.

Aim. To determine the occurrence and detection rate of the most significant clinicoinstrumental signs of chronic abdominal ischemia in patients with acute mesenterial insufficiency. Materials and methods. The results of treatment of 165 patients with chronic abdominal ischemia and acute mesenterial insufficiency syndromes were analyzed. For the purpose of revealing the most significant symptoms of chronic abdominal ischemia which widen the opportunity of early diagnosis of acute mesenterial insufficiency, all patients were divided into two groups. The main group included 87 patients with the signs of chronic mesenterial insufficiency and ischemic visceropathies (ischemic gastropathy, hepatopathy, pancreatopathy, colopathy) confirmed by ultrasonic dopplerographic investigation of unpaired aorta branches. The comparison group consisted of 78 patients with different types of acute mesenterial insufficiency. During the study, comparative analysis of clinical and anamnestic data, results of laboratory, endoscopic and ultrasonic methods of investigation of internal organs and visceral vessels was carried out. Results. The most typical clinical, endoscopic and ultrasonic symptoms of chronic abdominal ischemia were detected; occurrence rate of these symptoms in patients with acute disturbance of visceral circulation was analyzed. The most significant clinical symptoms and morphological manifestations of chronic visceral insufficiency were determined that allows in case of acute abdominal pain syndrome to suspect pathology of unpaired abdominal aorta branches and to perform early diagnosis of acute mesenterial insufficiency. Correlation between the lethality, late diagnosis and waiting tactics of treatment was established. Optimal approaches used for early diagnosis of acute and decompensation of chronic mesenterial insufficiency were determined. Conclusion. Early diagnosis as well as laparotomy and revasculizing surgery on the mesenteric artery performed by both abdominal and vascular surgeon essentially improve prognosis of this disease.

Aim. To improve the results of treatment of patients with pyoinflammatory diseases of soft tissues and diabetic foot syndrome by means of differential changes in surgical methods and adequate conservative measures. Materials and methods. The paper presents the results of treatment of 474 patients with diabetic foot syndrome and 40 – with pyoinflammatory diseases of soft tissues. All patients with diabetic foot syndrome were divided into two groups: the main group and the comparison group – 234 and 240 patients, respectively. Complex therapy of patients of the main group additionally included intravenous introduction of thioctic acid drugs (thiogamm) using the modernized infusion system and antihomotoxic means. Local therapy was supplemented with adhesive bandages (Permafoam), expediency of which depending on the stage of wound process was studied in 40 patients (two groups – 20 persons each) including 24 (60%) women and 16 (40%) men with different nosological forms. In the main group, adhesive bandages (Permafoam) were used, in the comparison group – levomicol. Results. The suggested complex of conservative measures used for patients with diabetic foot syndrome significantly reduced the number of amputations, thus in the main group 8,06% of patients underwent high amputations at the femur level, 4,03% – low amputations at the shin and foot level, 12,9% – necrectomy, 6,45% – phlegmonas, but in the comparison group 9,79%; 8,06%; 34,38% and 45,38%, respectively. Among patients of the main group, where efficiency of adhesive bandages was studied, decrease in the length, width and depth of wounds on the days 5 th and 10 th of treatment quickened versus the comparison group by 35% and 30%, respectively. Conclusion. The suggested algorithm of treatment in patients with marked damage of distal parts of magistarl arteries permitted to preserve extremities in 85,91% of patients. Adhesive bandages “Permafoam” applied in local treatment of pyoinflammatory diseases of soft tissues have a positive medical effect, reduce the total time of bandaging and patient’s disability period, lower the costs of treatment.

Aim. To improve the results of surgical treatment of intra-abdominal postoperative complications at the expense of differentiated use of minilaparotomic and endovideosurgical technologies. Materials and methods. Treatment of 617 patients who underwent repeated operative interventions on abdominal organs in connection with different early postoperative intra-abdominal complications were analyzed. Mini-invasive repeated medicodiagnostic operative interventions were performed in 268 (56,4%) cases for acute destructive pancreatitis and its complications, in 65 (13,7%) cases – regarding postoperative biliary complications, in 37 (7,8%) – postoperative appendectomy complications, 31 (6,1%) – postoperative stomach and bowel complications. For the purpose of making prognosis of early postoperative intra-abdominal complications and diagnosis of intra-abdominal hypertensive syndrome, 95 patients underwent indirect measurement of intra-abdominal pressure. Results. Intra-abdominal pressure monitoring with determination of the degree of intra-abdominal hypertension was the basic factor for choosing the tactics of further surgery. The developed algorithm of surgical tactics permitted to decrease the number of relaparotomies to 142 (23%).

Aim. To determine the significance of biophysical methods in dynamics of pathological process of acute pancreatitis so as to change treatment and operative tactics in case of purulo-necrotic complications of pancreonecrosis. Materials and methods. Blood serum liquid crystal status indices were studied in 220 patients with acute pancreatitis using the method of polarization microscopy and blood serum refraction index using the method of refractometry which were compared with clinical, laboratory and apparatus data. Results. Dynamics of biophysical indices when pathological process is getting progressively worse among patients with different forms of acute pancreatitis is of great diagnostic significance as compared to clinicolaboratory indices. Conclusion. Biophysical indices included into complex of clinicolaboratory diagnosis of progressive pathological process in acute pancreatitis promote improvement of the nearest medical results.

Aim. To modernize the system of intraoperative and perioperative safety in endocrine surgery. Materials and methods. Experience of treating 5350 patients with thyroid pathology, 41 – with hyperparathyroidism and 53 – with adrenal diseases using the system of intraoperative and perioperative safety is presented in the paper. Results. Complex method of preoperative preparation of patients, sparing bloodless technique allowed to decrease the number of the postoperative hemorrhages among patients with thyrotoxicosis to 0,4%, hypoparathyrosis – to 1,3%, damaged recurrent nerve – to 0,5%, thyrotoxic reactions – to 1,8%, to reduce the period of hospitalization to 4–5 days, to reach favorable functional and cosmetic results. In patients operated for hyperparathyrosis, no complications were fixed. According to retrospective investigation, calcium metabolism stabilized by the 3 rd week after the operation and was preserved during all the follow-up period. Conclusion. Safety of endocrine surgery is provided by precise determination of indications to the surgery, adequate preoperative examination and preparation to the surgery, rational operative intervention and postoperative follow-up observation. Application of the developed system of intraoperative and perioperative safety permitted to shorten the period of preoperative preparation, to decrease duration of operative intervention and the number of complications. Safety system is effective in the presence of “closed” cycle of treatment including out-patient reception, endocrinological unit, surgical clinic, resuscitation and intensive care unit, postoperative observation by endocrinologist and operating surgeon.

Aim. To determine the capabilities of ultrasonic method of investigation in diagnosis and differentiation of adrenal neoplasms. Materials and methods. Protocols of ultrasonic investigations (US) of 89 patients with verified adrenal tumors treated at Yaroslavl Clinical Hospital over the period from 2002 to 2013 were analyzed. Patients’ age was 25–83 with a mean age of 56,50±11,45 including 62 women (70%) and 27 men (30%). 42 patients underwent aspiration cutting puncture biopsy (ACPB) under the US control. Results. Diagnostic and informative significance of ultrasonic method of investigation was indicated. The role of US as a method of visual control in case of puncture biopsy of adrenal incidentalomas was emphasized. Techniques raising the efficiency of adrenal neoplasm biopsy, taking into account the experience of more than 10 thousand interventions on the other organs under the US control were proposed, Conclusion. US is an operator-dependent method of diagnosis. Ultrasonic picture can be used to assume morphological structure of the revealed hormonally inactive adrenal tumors. The size of adrenal tumor can not be a criterion of its morphological structure. Sonography makes it possible to provide visual control of ACPB.

Aim. To determine the pathogenetic efficiency of antioxidant therapy in correction of hemostasis disorders of traumatic disease. Materials and methods. The work is based on materials of clinicolaboratory investigations of patients with long cortical bone fractures. In the main group, complex therapy was added by antioxidant mexidol. Results. It was shown that in traumatic damages there occurs a marked syndrome of endogenous intoxication which is accompanied by essential disturbance of functional erythrocyte status conditioned by membrane-destabilizing phenomena based on lipid metabolism disorders. Application of antioxidant mexidol in patients with long cortical bone fractures leads to significant reduction of expression of hemostatic disturbances connected with traumatic disease and surgical aggression. Conclusion. Efficiency of this drug is conditioned by its ability to significantly decrease expression of membrane-destabilizing processes at the expense of lowering (by 11,5–27,5%) lipid peroxidation intensity and phospholipase activity (by 14,4–31,8%).

Lipid (fatty) degeneration occurs rare in pheochromocytomas. The paper presents description of two observations of adrenal pheochromocytoma with lipid degeneration. Histological and immunological studies proved accumulation of lipids in tumor cells. In the first observation, the following background diseases were noted: Sanarelli-Schwarzman syndrome, autoimmune thyroiditis, hypothyrosis, degree II-III obesity. In the second observation, taking into account local expression of tenascin-C, we can speak about uncertain potential of tumor malignancy. These observations are of special interest regarding differential diagnosis of pheochromocytoma with fatty degeneration and concurrent tumors (cortical adenoma and pheochromocytoma) and mixed tumors such as adenomas containing cortical substance cells (adenoma-pheochromocytoma)

Aim. To study the status of immunity, thrombocyte component of hemostasis, protein metabolism and iron metabolism for complex assessment of health status in different categories of donors. Materials and methods. Immunological study was carried out using level 1 and 2 tests characterizing the status of cellular and humoral immunity components and nospecific resistance of the body. Functional thrombocyte activity was estimated with turbidimetric method. The total protein content was determined using colorimetric method. Iron metabolism indices were studied with the methods of immunoradiometric and immunochemiluminescent analysis. Results. In donors awarded by the breastplate “Honorary Donor of Russia”, there were observed disorders in immunogram regarding cellular, humoral immunity and nonspecific protection with the frequency of 7,4–18% of the examined patients. Increase in interleukin 1-ß and tumor necrosis factor-α was revealed in 7,5% of donors. However, frequency of the detected deviations of immunological indices in the group of Honorary Donors did not differ from that of primary donors. Reduction of aggregation platelet ability with different inductors was observed in 20–25% of the observed persons. The number of deviations from the standard values of protein metabolism indices per 1 donor was 0,865. Men and women aged 18–23 should be considered the best group of plasma donors for fractionation. Among regular donors of blood and its components, decrease in hemoglobin level caused tension of adaptive mechanisms displayed by elevated production of erythropoietin and strengthening of expression of soluble transferring receptors. Conclusion. A deepened monitoring of active donors’ health is necessity. The obtained data will permit to judge about health status of the population in the region.