Vol 16, No 1 (2023)
Original articles
Prediction of the Complicated Wound Process in Overweight Patients Depending on the Composition of the Intestinal Microbiota
Abstract
Introduction. Overweight and imbalance of the intestinal microbiota are risk factors for disruption of reparative processes during the postoperative wound healing. Given the scale of the obesity epidemic in the modern world, the number of overweight patients undergoing surgery for various reasons is also increasing. The potentiation of the risk of a delayed and complicated course of the wound process combined with obesity and violated composition of the intestinal microbiota determines the relevance of this study.
The aim of the study was to investigate the composition of the intestinal microbiota in patients with increased body weight, with long-term non-healing and complicated surgical wounds.
Methods. The composition of the parietal intestinal microbiota was studied by microbial markers in the blood using gas chromatography in 49 overweight women who underwent planned surgical interventions for aesthetic indications in the period from 2019 to 2020, aimed at correcting body contours. After the operation, women were observed for 6 months, with assessment of the timing of wound healing. We carried out a comparative analysis of the composition of the intestinal microbiota in the different course of the wound process, studied the prognostic significance of individual parameters of the intestinal microbiota in relation to the risk of delayed and complicated wound healing.
Results. In the postoperative period, all patients were divided into three groups: group 1 - complicated wound process (n=21), group 2 - delayed wound process 16 (n=16), group 3 - conventional wound process (n=12). Statistically significant differences were found between groups 1 and 2 in terms of "Peptostreptococcus anaerobius (Gr 1) ≥ 562.0" (621.76±962.03 versus 101.75±371.90, respectively, p=0.025) and "Propionibacterium ≥ 3.2" (77.57 ± 48.57 vs. 40.44 ± 38.15, respectively, p=0.014). Differences were found between groups 1 and 3 in terms of “Endotoxin ≥ 0.7” (0.73±0.58 nmol/ml versus 0.86±0.48 nmol/ml, respectively, p=0.051). The most risk of the complicated and delayed postoperative wound healing is observed when the values of the parameters were "Propionibacterium ≥ 32.0", "Peptostreptococcus anaerobius (Gr 1) ≥ 7.0" and "Endotoxin ≥ 0.7". Based on the decision tree analysis, 4 risk classes of delayed and complicated course of the wound process were identified. Patients with a combination of Propionibacterium ≥ 3.2 and Endotoxin ≥ 0.7 had the highest risk.
Conclusion. A number of parameters of the intestinal microbiota have a high prognostic value regarding the risk of developing a complicated and delayed course of the wound process in overweight individuals. The data obtained can be used to predict unfavorable healing of surgical wounds. Further research is needed in this area on a larger sample of patients, including males.
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Prevention of Gastrointestinal Bleeding in Patients Operated on Coronary Arteries for Acute Coronary Syndrome
Abstract
Introduction. Acute coronary syndrome is a collective concept that reflects any form of exacerbation of coronary heart disease from unstable angina to acute myocardial infarction. Modern principles for the diagnosis and treatment of this syndrome are coronary angiography and urgent stenting of the affected coronary artery. These patients, having survived a life-threatening condition and surgical treatment, have a high probability of acute erosive and ulcerative gastroduodenal lesions and dependent gastrointestinal lesions. As a result, conservative treatment of acute ulcers and erosions complicated by bleeding remains unsatisfactory, mortality ranges from 36.4 to 50-80%.
The aim of the study was to evaluate effectiveness of the proposed measures to prevent erosive and ulcerative lesions of the stomach and duodenum and gastrointestinal bleeding in patients with acute coronary syndrome who underwent coronary artery stenting.
Materials and methods. The study included 614 patients who underwent percutaneous coronary intervention and stenting of the arteries of the heart due to the development of acute coronary syndrome. The patients were divided into two groups. The first group included 284 patients treated in 2018. Prevention of acute erosive and ulcerative gastroduodenal lesions was not routinely performed in this group. The second group included 330 patients treated in 2019. All patients in this group underwent prophylaxis and included omeprozole 40 mg per day from the first hours of the patient's stay in the hospital.
Results. During the entire study period, 31 patients died in the early and late postoperative period in the first group, 18 of them during the first hospitalization. In the second group, 35 patients died during the entire study period in the early and late postoperative period, 21 of them during the first hospitalization. With the development of gastrointestinal bleeding, the probability of a full recovery in a patient with acute coronary syndrome is extremely low, and the system of preventive measures avoids this problem.
Conclusion. Prevention of stressful acute erosive and ulcerative gastroduodenal lesions due to use of intravenous proton pump inhibitors in increased dosages (omeprozole 40 mg per day) is indicated to the patients of the studied group; in the presence of additional risk factors, the prophylactic dosage of proton pump inhibitors is doubled (omeprozole 40 mg 2 times a day). Mandatory non-invasive diagnosis of Helicobacter pylori for all patients is also indicated; if the condition is detected, eradication therapy is to be carried out. It is also required to apply proton pump inhibitors for the entire period of dual antiplatelet or anticoagulant therapy.
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Direct Endolymphatic Ozone Therapy in Patients with Diabetic Foot Syndrome: Analysis of the Effectiveness
Abstract
Introduction. Chronic inflammatory process on the foot leads to the depletion of immune defense mechanisms against infection in patients with diabetes mellitus. Application of ozonized solutions, endolymphatic therapy contributes to fight against the infectious process and maintenance of the body homeostasis.
The aim of the study was to evaluate safety and clinical effectiveness of direct endolymphatic ozone therapy in patients with purulent-necrotic complications of diabetic foot syndrome.
Methods. Clinical outcomes of direct endolymphatic ozone therapy, being part of complex therapy, were analyzed in 23 patients with purulent-necrotic complications of diabetic foot syndrome. Inclusion criteria were the degree of damage to the foot according to Wagner 2-4, ankle-brachial index (ABI) less than 0.7. Direct antegrade endolymphatic ozone therapy consisted of introduction of ozonized isotonic sterile sodium chloride solution into the lymphatic collector of the middle third leg for 5 days. The parameters of treatment duration, degree of the pain syndrome, severity of surgical intervention, dynamics of the bacterial contamination, leukocytes and blood lymphocytes, leukocyte indices were assessed.
Results. Under endolymphatic ozone therapy, all patients reported positive changes in subjective perception, the level of peripheral blood lymphocytes increased by 15.3%, which reflected an improvement in the adaptive potential of the body, bacterial contamination decreased by 68.6%, the severity of operations decreased by 39.4%. The duration of treatment did not change statistically significant.
Conclusion. Direct endolymphatic ozone therapy is an effective way to influence the course of the purulent-necrotic process in the complex treatment of diabetic syndrome. The main focus of the technique is correction of the bacterial contamination of inflammation; this option promotes activation of reparative processes in the wound, reduces the risk of infection generalization, and preserves a limb footing ability. The use of leukocyte indices to assess the course of the inflammatory process on the foot in patients with diabetes mellitus is difficult in clinical practice due to the decreased body's reactivity.
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Surgical Correction of Rectocele Via Transvaginal Access: Optimization Option, Immediate and Long-Term Outcomes
Abstract
Introduction. The transvaginal technique with application of patient's proper tissues is considered the most suitable for the surgical correction of the lower and middle rectocele. However, despite the complete anatomical correction, functional results are not satisfactory in 7-20% of patients.
The aim of the study was to improve functional results of surgical treatment of rectocele via transvaginal access.
Materials and methods. The study included 45 female patients who were randomly divided into two groups. In the control group, patients underwent posterior colporrhaphy and anterior levatorplasty using the conventional technique. In patients of the main group the operation was performed with the creation of the connective tissue layer between the levator ani muscles. The results of treatment were clinically assessed immediately after surgery, in one year and in 3 years after surgery by performing defecography and anorectal functional tests.
Results. According to a ten-point scale the pain syndrome was 3.6±0.8 points in the main group and 4.1±0.7 points in the control group (P=0,639). No purulent complications were observed in patients. Defecography evidenced that in patients of both groups, rectocele correction was achieved after a year and corresponded to stage 0-I in 3 years, the results achieved were preserved in most patients. The rate of barium evacuation approached the norm and was 5.3±0.7 g/sec in the main group and 5.2±0.6 g/sec in the control group (P=0,913), in 3 years - 5.4±0.6 g/sec and 5.1±0.5 g/sec (P=0,701), respectively. According to the study terms, there were almost normal parameters of the residual volume of barium after emptying in both groups: 18.5±5.2% and 21.6±5.5% (P=0,683) and 19.1±5.3% and 21.1±4.1% (P=0,766). Evaluation of the reflex function of the rectum demonstrated an improvement in its sensitivity to small volumes of filling and a decrease in the volumes that cause the urge to defecate in the main and control groups, which persisted over the long-term follow-up. 18 patients of the control group noted a feeling of discomfort in the perineum during the first year after surgery and dyspareunia. In 3 years, 10 out of 18 patients noted a feeling of discomfort, dyspareunia persisted in 8 of them. The patients of the main group did not make these complaints.
Conclusions. The proposed method of rectocele correction with the creation of the connective tissue layer between the muscles allowed the authors to avoid negative effects with simultaneous restoration of normal anatomical and defecatory function.
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The Effect of Preoperative Oil Chemoembolization Techniques on the Results of Combined Treatment of Operable Pancreatic Cancer
Abstract
Background: Pancreatogastroduodenal resection is widely used for the treatment of pancreatic cancer but the 5-year survival rate does not exceed 10%. The treatment should be combined, but the question of the expediency of neoadjuvant therapy (NAT) with initially operable cancer has not been resolved.
Aims: Substantiation of the expediency of the use of preoperative intra-arterial interventions in the combined treatment of patients with operable pancreatic cancer and the study of the impact of the technical features of the intervention on the treatment results.
Materials and methods: The study included 92 patients (45 men and 47 women; mean age 63.9±10.1 years, T2N0M0 n=13; T3N0M0 n=32; T2N1M0 n=1; T4N0and1M0 n=46) who received combined treatment for the period 2014-2017.In I group, n=45 patients, the NAT was not performed.In II group, n=47 patients underwent intra-arterial oil chemoembolization of the pancreas with an emulsion of oil contrast and gemcitabine concentrate 400 mg/m2.The technique of distributive embolization of the artery gastroepiploica (GEA) differed: in IIA group, n= 22 patients – with a spiral; in IIB group, n=25 patients – with a temporarily inflated balloon.All 92 patients underwent radical surgery and received adjuvant chemotherapy based on gemcitabine 1000 mg/m2 in 1,8.15 days, 6 cycles. The frequency of specific and general postoperative complications was analyzed. For control, ultrasound, CT with contrast, CA 19-9 antigen level, general and biochemical blood tests were used. For 5 years, the results of each patient were tracked. The primary endpoints were overall (OS) and relapse-free (RFS) survival.
Results: Postembolization syndrome did not affect the timing of the operation. The edematous form of acute pancreatitis was noted in 11 (50%) patients of group IIA and in 5 (20%) patients of group IIB, (p=0.043). Destructive pancreatitis was not marked. The overall 1-year survival rate (OS) in I group (n=31) was 68.9%, in II group (n=40) 85.1%, (p=0.062). The 2-years OS was: in I group (n=19) 42.2%, in II group (n=30) 63.8%, (p=0.042). The 3-year OS was: in I group (n=9) 20%, in II group (n=19) 40.4%, (p=0.021). The 4-years OS was: in I group (n=4) 8.9%, in II group (n=7) 14.8%, (p=0.387). The 5-year OS was: in I group 0, in II group (n=2) 4.3%, (p=0.168). The 1-year RFS was: in I group (n=23) 57.1%, in II group (n=29) 61.7%, (p=0.316). The 2-years RFS was: in I group (n=10) 22.2%, in II group (n=23) 48.9%, (p=0.012). The 3-years RFS was: in I group (n=7) 15.6%, in II group (n=16) 34%, (p=0.047). The 4-years RFS was: in I group (n=3) 6.7%, in II group (n=5) 10.6%, (p=0.568). The 5-years RFS was: in I group 0, in II group (n=1) 4%, (p=0.333).
Conclusions: The results of the study confirm the feasibility of using preoperative intra-arterial interventions in the combined treatment of pancreatic cancer. There was a significant difference in the rates of 2-year and 3-year OS and RFS in patients receiving such therapy. The technique of occlusion of the artery gastroepiploica with a balloon probably provides more preferable results.
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Hemostatic Gauze Surgitamp and Granular Sorbent Molselect G-50 Application in the Treatment of Simulated Bleeding Liver Wounds
Abstract
The aim of the study was to investigate the potential of Surgitamp hemostatic gauze and Molselect G-50 sorbent application in surgical hemostasis of simulated bleeding liver wounds in an in vivo experiment on laboratory animals.
Materials and methods. The study included 30 laboratory animals: Chinchilla rabbits. Laboratory animals underwent median laparotomy under intravenous anesthesia (Zoletil 100 – 0.1 ml /kg, Xylavet – 0.1 ml/kg), the right lobe of the liver was involved into the wound. At a 20 cm distance from the surface of the liver, a metal 92 g load in the form of a triangular prism was attached to the slider with the help of a thread. By operational readiness, the thread was burned, the prism fell vertically and hit the surface of the liver with a pointed end, this resulting in a simulated bleeding liver wound: a wound of the right lobe of the liver, linear in shape 3.0x0.7 cm, 0.6 cm deep, with uneven edges and active bleeding from the defect area. Hemostasis in the experimental group of animals (n=15) was carried out by covering the wound surface with a granular sorbent Molselect G-50, followed by tamponing the wound with a strip of hemostatic gauze Surgitamp. In the control group of animals (n=15) hemostasis was carried out by stitching a bleeding liver wound with a U-shaped suture with a PHA 3.0 thread until the edges of the wound converged. The effectiveness of hemostasis of the liver wounds was evaluated using the following parameters: the time of the final bleeding arrest, the volume of blood loss, the number of episodes of repeated bleeding.
Results. Experimental studies have demonstrated that the surgical hemostasis technique with the hemostatic agent Surgitamp application combined with the granular sorbent Molselect G-50 allows for reliable hemostasis of simulated bleeding liver wounds, reducing the time of bleeding arrest from 461.0(420.0-501.0) sec to 280.0(264.0-308.0) sec (P=0.0001), simultaneously reducing the incidence of recurrent hemorrhages from 46.7% to 6.7% (P=0.035).
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Experience
Comparative Evaluation of the Effectiveness of Atraumatic Dressings for the Treatment of Patients with Burns
Abstract
Rationale. Atraumatic «mesh» bandages are most commonly used bandages for treatment of wounds and burns. To date, considerable experience has been gained in the use of Branolind N bandages in clinical practice in treatment of burn wounds.
Aim. Comparative evaluation of the results of the use of various atraumatic dressings and evaluation of the effectiveness of the Branolind N bandage in treatment of patients with burns.
Materials and Methods. In 222 patients with burns, the comparative clinical and laboratory evaluation of effectiveness of various atraumatic dressings (180 patients) and cotton-gauze dressings with hydrophilic-based ointment Levomekol (42 patients), in various clinical situations, was carried out.
Results. All types of atraumatic dressings had similar clinical effectiveness and were most effective for treatment of superficial and borderline burns of I-II degree, as well as for limited burns of II-III degree after surgical necrectomy at the stage preparation of granulating wounds for skin grafting, starting from the second, and especially in the third stage of wound process. The best results were obtained with the use of Branolind N bandages.
Conclusions. The use of atraumatic "mesh" bandages Branolind N allows to improve the results of medical care for patients with burns. Their use contributes to a favorable course of wound process, provides comfort to patients and convenience for work of medical staff in treatment of patients in hospital, and on outpatient basis.
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Proper Experience of Complex Treatment of a Patient with Complicated Crohn's Disease: Application of Vacuum Duodenal Obturation in Closing High Small Intestinal Fistulas
Abstract
The paper highlights a clinical case of a newly diagnosed Crohn's disease with extended involvement of the small intestine in a 63-year-old patient. The course of the disease was complicated by multiple acute ulcers with perforations and peritonitis; due to this the patient was repeatedly exposed to surgical interventions. As a result of a long-term inflammatory process in the abdominal cavity, the patient developed small intestinal fistulas on the remaining short small intestine. Surgical treatment was combined with a comprehensive conservative treatment of Crohn's disease, parenteral nutrition via an intravenous port, antibiotic therapy, infusion therapy, etc. The authors first applied an intraluminal duodenal endosponge with programmable vacuum aspiration. Complete duodenal obturation was successfully achieved. The use of this design has played a crucial part in the complex treatment of small intestinal fistulas in the presented patient.
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Complicated Course of Meckel's Diverticulum as a Cause of Chronic Iron Deficiency Anemia
Abstract
The paper focuses on a clinical case of a complicated course of Meckel's diverticulum in a 27-year-old patient; the disease was manifested by signs of iron deficiency anemia, without signs of overt or latent bleeding. A brief review of the literature presents major features and potential complications of Meckel's diverticulum. Special attention is paid to specific diagnostic options. The authors discuss the need for surgical removal of uncomplicated Meckel's diverticulum.
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Staged Restoration of Colon Continuity in an Adult Patient with a Segmental Form of Hirschsprung's Disease
Abstract
The article presents a clinical case of the staged treatment of a patient with a functioning colostomy and a segmental form of Hirschsprung's disease. Challenges in diagnosing and determining the tactics of reconstructive and restorative surgery in appropriate cases were demonstrated in absence of adequate medical documentation.
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Review of literature
Hepatolithiasis
Abstract
Hepatolithiasis is a disease characterized by intrahepatic stone formation, being a challenging disorder with frequent recurrences, development of chronic cholangitis and sepsis, as well as liver abscesses. Notably, without prompt and adequate treatment, hepatolithiasis is associated with the development of cirrhosis of the liver and cholangiocellular carcinoma. Recent reports demonstrate an increasing prevalence of hepatolithiasis, likely due to increased immigration and alterations in the Western diet. There is no clear algorithm for treatment of hepatolithiasis; the major treatment options are still removal of stones, correction of strictures associated with them and prevention of recurrence of cholangitis. The method of choice for hepatolithiasis is endoscopic and percutaneous interventions, in case of their failure open operations are performed in different volumes. However, data on the effectiveness of interventions, frequency of complications and relapses vary significantly according to various researchers.
The authors analyse data on the above issue.
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Characteristics of the Endoprostheses Used in the Treatment of Inguinal Hernias by the Method of I.L. Lichtenstein
Abstract
Ventral hernias remain the most common surgical pathology, which occurs in 3-8% of the population or in 510-570 million people. The "gold standard" in the treatment of ventral hernias today remains the use of synthetic materials, and the main method of their treatment is non–tensioning prosthetic hernioplasty according to the method of I.L. Lichtenstein, which is implemented in 70-90% of patients with inguinal hernias. The properties of endoprostheses, which in their physical and mechanical properties should be as close as possible to the tissues of the patient's body, have a great influence on the results of surgical treatment of this contingent of patients. To date, more than 160 names of mesh endoprostheses are used, which differ, including in biological and mechanical characteristics. The paper presents information about the differences between implants used in hernioplasty using the Lichtenstein method in strength, elasticity, cell size, types of weaving and chemical composition of mesh prostheses. The study showed that the properties of endoprostheses, in particular, their structure, type of polymer, structure of filaments, biodegradability, plasticity, inertia of the material and others have a great influence on the results of surgical treatment when performing hernioplasty using the Lichtenstein method. The comparative effectiveness of the application of the developed materials during hernioplasty of inguinal hernias should include, among other things, data on the properties of the implant material and the features of its modeling, the technique of the operation, the results of general clinical, immunological, ultrasound, radiological and histological research methods.
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