[Surgical wound closure in advanced peritonitis]

To date, mortality in widespread peritonitis is still high (15-20%) and increased up to 70-80% in case of septic shock. Surgeons actively discuss wound closure technique in these patients considering intraoperative findings and severity of illness. The authors present scientific data and opinions of national and foreign surgeons regarding the methods of laparotomy closure. There are still no generally accepted criteria for choosing the method of laparotomy closure in secondary widespread peritonitis. Indications and clinical efficacy of each procedure require additional research.

[Choice of surgical approach and option for completing laparotomy in widespread peritonitis]

OBJECTIVE

To create a system for choosing surgical approach and completing laparotomy in advanced secondary peritonitis via combination of clinical, visual intra-abdominal criteria and systems for predicting the outcomes of peritonitis.

MATERIAL AND METHODS

The study included 686 patients with peritonitis between May 2015 and December 2022. Age of patients ranged from 16 to 95 years (mean 53.4±8.7). Male-to-female ratio was 1.2:11 (377:309). Destructive appendicitis was the cause of peritonitis in 274 (39.9%) patients, gastroduodenal ulcer perforation - 160 (23.3%) patients, colonic perforation - 188 (27.4%) patients, other causes - 64 (9.4%) patients. At baseline, 481 (70.1%) patients underwent diagnostic laparoscopy, and laparoscopic surgery was possible in 302 (62.8%) cases. Primary median laparotomy was performed in 205 (29.9%) patients. The closed method of completing laparotomy was used in 345 patients (77 - 22.3% died), staged elective surgeries - 28 (18 - 64.3% died), open abdomen technique was used in 11 patients (5 - 45.5% died). Redo laparotomy on demand was performed in 44 patients. Of these, 21 (47.7%) ones died. Overall mortality was 15.0% (n=103). The main causes of mortality were sepsis/septic shock (67 cases, 65.0%), acute cardiovascular and respiratory failure (15 patients, 14.6%).

RESULTS

The developed index of approach and completion of surgery in secondary peritonitis is valuable to make a decision on access and completion of surgery in patients with widespread peritonitis.

CONCLUSION

Integral systems for assessment of clinical status and choice of treatment strategy are effective in systematizing the results, evaluating treatment outcomes and conducting researches.

[Eritonitis outcome prediction]

The review is devoted to the most common general clinical and specific grading systems for peritonitis outcome prediction. Particular attention is paid to methodological approaches, prediction reliability, simplicity of use in clinical practice and their importance in decision-making. It is shown that none of the modern grading systems is universal and absolutely reliable. Combining several systems is quite difficult and will take additional time that is impossible for intraoperative environment. Despite various systems for peritonitis outcome prediction, none of them can completely satisfy surgeons, primarily in choice of surgical access, intervention type and option for its completion.

[Comparative assessment of prognostic systems for secondary peritonitis outcome]

OBJECTIVE

To compare the most common prognostic systems in patients with peritonitis.

MATERIAL AND METHODS

The study included 352 patients with secondary peritonitis. At admission, sepsis was diagnosed in 15 (4.3%) patients, septic shock - in 4 (1.1%) cases. Mortality was associated with the following main causes: purulent intoxication and/or sepsis - 51 cases (87.9%), cancer-induced intoxication - 4 (6.9%) cases, acute cardiovascular failure - 3 cases (5.2%). We analyzed the efficacy of Manheim Peritoneal Index (MPI), WSES prognostic score, APACHE-II scale, gSOFA score and Peritonitis Prediction System (PPS) developed by the authors.

RESULTS

Age of a patient, malignant tumor, exudate nature, sepsis (septic shock) and organ failure not associated with peritonitis are the most important criteria in predicting fatal outcome. ROC analysis was used to assess prognostic value of various prediction systems. Standard error was less than 0.05 for all scales. Therefore, all prediction systems can be considered accurate for prediction of mortality in patients with peritonitis.

CONCLUSION

PPS (AUC 0.942) has the greatest accuracy in predicting fatal outcome in patients with advanced secondary peritonitis, APACHE II (AUC 0.840) - minimum accuracy. MPI had predictive accuracy > 90% too.

[Differentiated approach to treatment of decompensated lower limb ischaemia with the use of the WIFI classification system]

In the present article, the authors substantiate the necessity of subdividing a heterogeneous cohort of patients presenting with Fontaine-Pokrovsky grade IV critical limb ischaemia into subgroups with the aim of making an appropriate therapeutic decision and predicting the outcome. We also translated into the Russian language the WIfI classification system developed by the Society for Vascular Surgery (2014) in order to predict limb loss and feasibility of performing revascularization. This is followed by comments on the classification, accompanied by examples of own clinical case studies. In order to check-up the ability of the SVS WIfI classification system to predict the one-year risk of major amputation in patients with decompensated ischaemia, we carried out a retrospective multicenter study, enrolling a total of 109 patients with unreconstructable stage IV chronic ischaemia. Our primary endpoint was the frequency of major amputation during the first year of follow up. The patients were divided into 4 subgroups based on a combination of the three WIfI domains, i. e., wound, ischaemia, and foot infection, respectively, as follows: 130 - 27% (n=29), 131 - 23% (n=25), 230 - 20% (n=22), and 231 - 30% (n=33). The frequency of amputation during the first year of follow-up with the natural course of the disease on the background of conventional therapy averagely amounted to 36%. By the WIfI component combinations, we revealed statistically significant differences between the subgroups (p=0.035): 130 - 21% (n=6), 131 - 28% (n=7), 230 - 36% (n=8), 231 - 55% (n=18). The WIfI classification makes it possible to predict the risk of major amputation in patients with limb-threatening ischaemia. The frequency of amputation during the first year of follow up in the natural course of the disease is associated not only with the WIfI clinical stage but also with the WIfI component combinations.

[Transcatheter embolization in prevention of recurrent bleeding from stomach ulcers]

AIM

To evaluate an efficacy of endovascular hemostasis in patients with gastric ulcerative bleeding and high risk of recurrent bleeding and death.

MATERIAL AND METHODS

The work is based on a study of the results in 30 patients with gastric ulcerative bleeding, high risk of recurrent bleeding (rebleeding forecast system (RFS) score over 17) and high risk of death (SAPS II score over 30). We attempted transcatheter embolization of left gastric artery to prevent rebleeding. The control group consisted of 60 patients with gastric ulcerative bleeding and the same RFS and SAPS II values in whom angiography and endovascular hemostasis were not performed.

RESULTS

Technical success of endovascular hemostasis was achieved in 25 (83.3%) cases. In 5 cases embolization was not performed. Complications after transcatheter angiography and embolization were absent. Recurrent bleeding after technically successful embolization was observed in 3 (12.0%) patients. In all cases PVA microemboli were used. Mortality was 11.1% (3 patients).

CONCLUSION

Endovascular hemostasis in patients with severe comorbidities (SAPS II score over 30) and high risk of rebleeding (RFS score over 17) reduced incidence of recurrent bleeding from 36.7% to 11.1%.

[Immediate results of conservative treatment of patients with unreconstructable critical limb ischaemia and trophic changes]

The purpose of the study was to comparatively assess efficacy of using agents belonging to the group of prostaglandin E1 in comprehensive conservative treatment of patients with unreconstructable critical limb ischaemia and trophic changes by the frequency of major amputation, amputation-free survival, and total mortality by combinations of the WIfI classification during a 6-month follow up period. Our retrospective multicentre study enrolled a total of 109 patients, including 60 men and 49 women, with a mean age of 70±7.3 years. The patients were subdivided into 2 groups. Group 1 patients (n=58) received standard conservative therapy without prostaglandin E1 and group 2 patients (n=51) received similar treatment with the use of prostaglandin E1. The statistical analysis (chi-squared test, Fisher criterion, log-rank test) was carried out with regard to stratification of the patients in the groups by the WIfI component combinations. No statistically significant differences between the groups in the frequency of amputation and total mortality were revealed (p=0.094 and p=0.925, respectively). The use of the WIfI classification system made it possible to single out a cohort of patients (with a WIfI combination of 130) for whom the results of administering prostaglandin E1 statistically significantly differed by the frequency of amputation (p=0.042) and by amputation-free survival (p=0.017). No significant differences by these outcomes were obtained for other combinations analysed. A conclusion was drawn that using prostaglandin E1 in comprehensive conservative treatment decreased the frequency of amputation and increased amputation-free survival in patients presenting with unreconstructable critical limb ischaemia and referred to the category with a combination of 130 according to the WIfI classification.

[Inflammatory markers in diagnosis and prognosis of abdominal sepsis]

For today, it is necessary to recognize, that treatment of patients with abdominal sepsis remains the basic problem in urgent surgery due to the invariably high mortality. Early diagnostics and targeted therapy are the key points for improving of sepsis outcome. At present, researchers around the world have proposed a large number of biological markers for diagnosing sepsis and predicting mortality. Ideally, doctors can use biomarkers for risk stratification, diagnosing, monitoring of treatment effectiveness and outcome prediction. The biomarker is a laboratory parameter that can be objectively measured and characterized as an indicator of normal and pathological biological processes. The article presents the modern concept of the sepsis pathogenesis for understanding the role of various biomarkers and inflammatory indicators in its development. We have analyzed literature data and summarized information on the possible use of biological markers and their combinations in the early detection of sepsis, for monitoring sepsis and predicting its outcome.

[Combined forecasting system of peritonitis outcome]

AIM

To create a reliable system for assessing of severity and prediction of the outcome of peritonitis.

MATERIAL AND METHODS

Critical analysis of the systems for peritonitis severity assessment is presented. The study included outcomes of 347 patients who admitted at the Department of Faculty Surgery of Peoples' Friendship University of Russia in 2015-2016. The cause of peritonitis were destructive forms of acute appendicitis, cholecystitis, perforated gastroduodenal ulcer, various perforation of small and large intestines (including tumor).

RESULTS

Combined forecasting system for peritonitis severity assessment is created. The system includes clinical, laboratory data, assessment of systemic inflammatory response (SIRS) and severity of organ failure (qSOFA). The authors focused on easily identifiable parameters which are available in virtually any surgical hospital. Threshold value (lethal outcome probability over 50%) is 8 scores in this system. Sensitivity, specificity and accuracy were 93.3, 99.7 and 98.9%, respectively according to ROC-curve that exceeds those parameters of MPI and APACHE II.

[Repeated endoscopic hemostasis as an alternative to surgical treatment of patients with gastroduodenal ulcerative bleeding]

AIM

To define the role of endoscopic hemostasis in treatment of gastroduodenal ulcers complicated by bleeding.

MATERIAL AND METHODS

The results of endoscopic hemostasis in 770 patients with peptic ulcers were analyzed.

RESULTS

Injection hemostasis had the highest efficacy in case of recurrent bleeding. No other method showed significant advantage in its efficiency. The efficacy of injection method was 52%, argon-plasma coagulation - 83.3%, radiowave technique - 78%, combined endoscopic method  - 96%. In case of recurrent bleeding endoscopic hemostasis is effective alternative to surgery especially in high-risk patients. Repeated endoscopic hemostasis significantly decreases mortality from 45% to 23% in case of recurrent bleeding.

[STENTING VERSUS PALLIATIVE SURGERY IN PATIENTS WITH MALIGNANT GASTROINTESTINAL STENOSIS]

AIM

Retrospective analysis of the results of stenting versus surgical palliation in patients with malignant gastrointestinal stenosis.

MATERIAL AND METHODS

85 patients underwent endoscopic stenting (41) or surgical intervention (44). Level of stenosis: gastric outlet (23/38), multi-level gastric obstruction (2/3), duodenum or jejunum (12/3), gastrojejunoanastomosis (3/0) and gastroduodenoanastomosis (1/0). 49 self-expanding metal stents were implanted in 41 patients. 41 gastroenteroanastomoses and 3 jejunostomas were performed in surgical group.

RESULTS

Stents were successfully inserted in all patients. Early complications were observed in 3 (7.3%) patients after stenting and in 9 (20.5%) after surgical palliation, p = 0.0755. Postoperative lethality was 2,4% (1 patient) after stenting and 31.8% (14 patients) after surgery, p = 0.0003. Mean hospital stay was 15 days in stenting group and 23 days in surgical group, p < 0.001. There was no statistically significant difference in long-term results, neither in late complications (p = 0.3691), nor in survival (p =0.3697).

CONCLUSION

Endoscopic placement of self-expanding stents is an effective method of restoration of oral intake in patients with malignant gastrointestinal obstruction. Stenting is associated with equal rates of early and late complications, lower mortality and decreased in-hospital stay as compared with surgery, and therefore may be recommended as a final palliation in inoperable patients.

[Long-term results of surgical treatment of patients with cancer of biliopancreaticoduodenal area]

500 patients with cancer of biliopancreaticoduodenal area who underwent treatment and survey in the hospital at the period from 1986 to December 2011 years were included in the study. There were 212 (42.4%) males and 288 (57.6%) females. It was analyzed the long-term results of palliative surgical interventions in 72 (40.2%) patients and endoscopic interventions in 107 (65.2%) patients. It was done a comparative analysis of palliative interventions results. It was concluded that both methods have high efficiency for resolution of obstructive jaundice. Average survival rate of patients depends on the biliary decompression method (8 months after surgical interventions and 7 months after endoscopic interventions). It was analyzed the long-term results of radical surgery in 55 (78.5%) patients. It was concluded that the best 5-years survival rate was in patients with major papilla cancer without invasion into mesenterical vessels (54.2%). 5-years survival rate was observed only in 2 patients in case of pancreatic head and terminal bile duct cancer. And lifetime of the majority did not exceed 3 years.

[Gastroduodenal ulcerative bleeding]

It was analyzed the treatment results of 1341 patients with diagnosed ulcerative bleeding. The data shows that at present time mortality rate in case of ulcerative bleeding is determined by bleeding outcomes in patients with severe concomitant diseases including elderly patients. It was not observed significant advantages in any methods of endoscopic hemostasis for stop and prevention of recurrence ulcerative bleeding. All techniques are equivalent alternatives. None prognosis scale of recurrence ulcerative bleeding probability has high specificity and sensitivity.

[Results of the upper digestive tract stenting with self-expanding stents]

The work is based on the analysis of the palliative treatment of 66 patients with malignant upper digestive tract obstruction who underwent implantation of 75 self-expanding metallic stents in the period of 2003-2012 yy. Early postoperative complications developed in 10 (15.2%) cases. Procedure-related complications were observed in 8 (12.1%) patients, non-specific complications occurred in 2 (3.0%) patients. In-hospital lethality was 4.5% (3 patients). 51 patients were followed until death. Symptomatic relapse of obstruction was observed in 4 cases. Median survival was 97 days. Stenting with self-expanding metal stents was concluded to be an effective and safe method of palliation of malignant upper digestive tract stenosis.

[The comparison of prognostic scales of the gastroduodenal bleeding recurrence]

229 patients with ulcerous gastroduodenal bleeding were included in the study. Prognostic scales of the bleeding recurrence by Rockall, Blatchford, Vinokurov and System of Prognosing of Bleeding Recurrence (SPBR) I and II were comparatively analyzed. The SPBR II proved to be statistically relevant and the most accurate in prognosing the bleeding recurrence, then other scales.

[Treatment protocol of gastrointestinal bleedings]

900 patients with gastrointestinal bleedings were included in the study. Basing on the endoscopic findings, prognosis for recurrent bleeding and clinical evaluation of the patients, diagnostic algorithm and treatment protocol were worked out. Use of forecasting system concerning the bleeding risk and clinical evaluation of the patients applying SAPS II for medical tactics choice allowed decreasing lethality from acute hemorrhage from 6.1 to 0.9%, in case of conservative treatment--from 4.5 to 1.0%, postoperative lethality--from 14.5% to 0.

[Prophylaxis and treatment of bleedings from symptomatic gastroduodenal ulcers]

The work deals with problems of prophylactics and treatment of patients with symptomatic gastroduodenal ulcers complicated by bleedings. In somatically critical patients the main disease in 14% of cases is complicated by the appearance of symptomatic gastroduodenal ulcer which in its turn results in bleedings or perforation in 50% of cases. H. pylori is of no leading significance in formation of acute gastroduodenal ulcers. The only indication to surgery in patients with bleedings from acute ulcers is persistent bleeding which can not be arrested by the method of endoscopic hemostasis or a recurrent bleeding in patients with the state of severity not less that 30 scores by the SAPS II scale.

[Prognosis for relapse of gastroduodenal ulcer bleeding]

Treatment results were studied in 542 patients with ulcerous gastroduodenal hemorrhage. Authors offer to use index of bleeding relapse and forecasting system of bleeding relapse for definition of ulcerous bleeding relapse probability. It provides quick and objective appraisal of relapse probability and allows making a proper choice of therapeutic approach reasoning from the patient's status.

[Gastroduodenoscopy at diagnosis and treatment of ulcerous gastroduodenal bleedings]

Results of treatment of 458 patients with ulcerous gastroduodenal bleedings are analyzed. It is demonstrated that argon-plasma coagulation (APC) is the most effective at primary endoscopic hemostasis and amounts to 92.5% compared with 87.5% at radio-wave coagulation and 79.7% at injection method. Treatment and diagnostic algorithm based on patients state severity assessment (by SAPS scale) and risk of bleeding (by Forrest) was developed. Use of this algorithm led to decrease of lethality due to acute blood less from 6.1 to 2.7% (including at conservative treatment from 4.5 to 2.2%) and postoperative lethality from 14.5 to 5.6%.

[Strategy of treatment of patients with ulcerous gastroduodenal bleedings]

The work is based on an analysis of results of treatment of 557 patients with gastro-duodenal bleedings. It was shown that using modem endoscopic methods of bleeding arrest (APC) and antisecretory preparations allowed successful conservative treatment of patients with ulcerous gastroduodenal bleedings, thus minimizing the probability of the development of recurrent bleedings. The proposed medico-diagnostic algorithm allowed total lethality to be decreased from 29.5 to 11.2%, and the number of compulsory operations from 16 to 11.2%.