Vol 17, No 3 (2024)
Original articles
Specific Complications after Pancreatoduodenal Resection Depending on the Pancreatic Transection Plane and the Dorsal Pancreatic Artery Origin
Abstract
Pancreaticoduodenectomy (the Whipple procedure) is one of the most complex surgical interventions in abdominal surgery and is associated with a high risk of severe postoperative complications. Studying all aspects of the operation can reduce the incidence of adverse outcomes. One of the ways to reduce the incidence of postoperative complications after pancreaticoduodenectomy is to shift the pancreatic transection line to the left in order to remove the poorly blood-supplied zone between the cephalocervical and corporocaudal segments.
The aim of the study was to evaluate the effect of different pancreatic transection planes on the incidence of pancreatic fistula in various anatomical origins of the dorsal pancreatic artery.
Material and Methods. The study included 103 patients with the determined origin of the dorsal pancreatic artery. All patients were divided into two groups: with a standard origin of the dorsal pancreatic artery (69 patients) and with a variant origin of the dorsal pancreatic artery (34 patients). In each group, two subgroups were identified depending on the transection plane of the pancreas (at the midpoint of the portal vein and 10-15 mm to the left of its left edge). The short-tern treatment outcomes in subgroups were compared based on the arterial anatomy and transection plane.
Results. In cases of a standard origin of the dorsal pancreatic artery, relocation of the transection plane to the left led to a statistically significant reduction in the frequency of specific complications (p=0.04), clinically significant pancreatic fistula (p=0.037), and gastrostasis type B (ISGPS) (p=0.038). In cases of a variant origin of the dorsal pancreatic artery, no statistically significant difference in subgroups with different transection planes was found.
Conclusion. In case of a standard origin of the dorsal pancreatic artery, it is advisable to shift the transection line to the left. The algorithm for transecting the pancreas in other variants of the dorsal pancreatic artery origin requires further study.
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C-reactive Protein of Blood Plasma as a Precursor of Early Surgical Complications in Prosthetic Repair of the Anterior Abdominal Wall
Abstract
Despite the achievements in the treatment of abdominal hernias, the incidence of postoperative complications is still high, which entails an increased probability of hernia recurrence, repeated surgical interventions, and an increased mortality rate. Detection of the precursors of the above complications will allow for their timely diagnosis and treatment; this will improve the prognosis of the course of the disease.
The aims of the study was to determine blood plasma C-reactive protein concentrations correlated with the presence and severity of early surgical complications according to the Clavien-Dindo classification (1992) in cases of prosthetic repair of the anterior abdominal wall.
Materials and methods. This was a clinical prospective multicenter study conducted in 2018-2022. Patients with a non-strangulated hernia of the anterior abdominal wall (n=89) underwent a hernia defect repair with a "conventional" polypropylene mesh implant. The patients were divided into two groups depending on the presence of early surgical complications according to the Clavien-Dindo classification (1992). In the postoperative period, the patients underwent enzyme immunoassay of blood plasma for C-reactive protein, ultrasound scanning of the anterior abdominal wall tissues, and monitoring of local changes in the wound area. In 5 days after surgery, the groups were compared based on the criterion of blood plasma C-reactive protein concentration (within the reference values or exceeding them for more than > 5 mg/l).
Results. The excessive reference level of C-reactive protein in blood plasma (more than 5 mg/l) on the 5th day after prosthetic plastic surgery of the anterior abdominal wall correlated with a 30.3% (p<0.001, Fisher's exact test) higher rate of early surgical complications; of these, 73.1% of cases (p=0.014, Fisher's exact test) required invasive interventions (grade II complications according to the Clavien-Dindo classification). The presence of early surgical complications according to the the Clavien-Dindo classification correlated with an 8-fold (p<0.001, Mann-Whitney U test) higher concentration of C-reactive protein in blood plasma on the 5th day after prosthetic plastic surgery of the anterior abdominal wall (13.31 [6.12; 26.67] versus 1.68 [0.89; 3.99] in their absence).
Conclusions. C-reactive protein of blood plasma level exceeding > 5 mg/l on the 5th day after prosthetic repair of the anterior abdominal wall is a precursor of early surgical complications.
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Effectiveness of Magnetic Resonance Imaging and Ultrasound Examination in Visualizing Anal Fistulas
Abstract
Chronic paraproctitis is one of the most common proctological diseases with prevalence equal 8 - 23 cases per 100,000 population. Ultrasound examination (US) and magnetic resonance imaging (MRI) allow studying in detail the fistula topography, presence or absence of purulent leaks and cavities in the perirectal space and fistula relations to the closure apparatus of the rectum. The relevance of choosing an effective option to diagnose rectal fistulas is associated with the potential preoperative determination of the optimal surgical treatment option.
The aim of the study was to evaluate the effectiveness of magnetic resonance imaging and ultrasound in the visualization of anal fistulas of cryptoglandular origin.
Materials and methods. The study included 88 (100%) patients with anal fistulas of cryptoglandular origin treated in the proctology department of the Surgut District Clinical Hospital in 2023. The authors analysed results of patients’ examinations. Both general clinical and instrumental investigations were involved: collection of complaints and anamnesis of the disease, inspection and palpation of the perianal area, digital anorectal examination, probing of the fistula tract, dye test, anoscopy, rectoscopy or videocolonoscopy, ultrasound examination of the pelvis and magnetic resonance imaging of the perineum. All patients in the analysed group were found to have complex anal fistulas: cases of transsphincteric fistulas involving more than 30% of the sphincter and cases of extrasphincteric fistulas. Magnetic resonance imaging of the perineum and ultrasound examination of the pelvis were performed to visualise the fistulas. All patients were divided into two groups; the first group included 76 (86.4%) patients who underwent MRI of the perineum, the second group included 12 (13.6%) patients who underwent ultrasound examination of the pelvis. The data obtained during ultrasound and MRI examinations were compared with the intraoperative findings. Statistical analysis was performed using the StatTech v. 3.1.8 program (developer OOO Stattech, Russia) based on the created database in Microsoft Excel software with the determined sensitivity and accuracy of each diagnostic option.
Results. The topography of the fistula passage, indicating localization of the internal fistula opening, was determined in 76 (86.4%) patients during MRI and in 12 (13.6%) patients during pelvic ultrasound examination. During surgical intervention, the discrepancy between the MRI data and the topography of the fistula was revealed in 2 (2.3%) cases, according to ultrasound data - in 3 (3.4%).
Conclusions. The analysis demonstrated 100% sensitivity of magnetic resonance imaging and ultrasound examination in diagnosing anal fistulas, with an MRI accuracy equal 97.4%, ultrasound accuracy equal 75.1%, respectively.
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Local Treatment of Ischemic Skin Wounds Using a Unique Drug Mixture in Combination with Magnetic Therapy
Abstract
The main cause of ischemic wounds is peripheral arterial disease (PAD). The overall prevalence of PAD varies within 3-10%, increasing to 15-20% among patients over 70 years of age. The PAD prevalence is slightly higher in men than in women. This problem is crucial for healthcare, since such wounds can lead to the need to amputate the lower extremities in case of ulcerative-necrotic processes and gangrene, being one of the common causes of increased disability and mortality in the population.
The aim of the study was to investigate features of the wound process when healing ischemic skin wounds with local application of a unique mixture of benzalkonium chloride, dexpanthenol and pentoxifylline in combination with magnetotherapy.
Materials and methods. Ischemic skin wounds were simulated on the hind limbs of 90 male Wistar rats (RU Patent for Invention No. 2807383). The animals were divided into three groups based on the features of the treatment performed. In animals of the 1st group, a unique mixture of benzalkonium chloride, dexpanthenol and pentoxifylline was applied to the skin defect; in animals of the 2nd group, magnetotherapy was used; in animals of the 3rd group, the unique medicinal mixture and magnetotherapy were used simultaneously. The analysis of the results included an assessment of the wound area, microcirculation, pH of the wound surface and the local temperature. The results were recorded on the 1st, 3rd, 5th, 8th and 10th days of the study. Microsoft Excel 2014 and Statistica 13.0 programs with the Kruskal-Wallis test were used to process data statistically. Significant differences were considered at p<0.05.
Results. A combination of benzalkonium chloride, dexpanthenol and pentoxifylline with the simultaneous use of magnetic therapy is effective in the treatment of ischemic wounds. The third group showed the greatest effectiveness, where the area of wounds significantly decreased on the 10th day by 1.9 times compared to group 1 and 9.4 times compared to group 2, respectively. The healing rate was also significantly higher in group 3 compared to group 1 (1.3 times) and group 2 (1.7 times), respectively. The third group also showed the best result during the assessment of microhemocirculation and a shift in pH to the slightly acidic side already on the 3rd day; only on the 8th day there were significant differences of 1.1 times between the 1st and 3rd groups.
Conclusions. The use of the specifically developed unique medicinal combination of drugs applied together with magnetic therapy has confirmed its effectiveness if compared with the control treatment groups. This treatment option has a beneficial effect on the healing process of ischemic skin wounds and allows recommending it for further preclinical studies.
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New in surgery
Modern Approaches to the Classification of Adhesions and Adhesive Disease of the Abdominal Cavity
Abstract
Classifications of abdominal adhesive disease developed to date are not universal, which is associated with polyetiology, the versatility of local and systemic manifestations of the disease, high requirements for prognostic value and objectification of the pathological process. Classifications with a large number of variables do not often become popular due to their complicatedness, and too simple assessment systems cannot reflect all the features of the disease. This paper presents an attempt to distribute all known classifications by specific features, with their subsequent analysis, and proposes the authors’ version to classify adhesions and adhesive disease of the abdominal cavity. The presence of a unified system to assess the adhesive process, working both in experimental and clinical conditions, will allow achieving reproducible, standardized results required to implement principles of evidence-based medicine.
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Review of literature
Promising Directions in Radiation Diagnostics of Oncopathology – Potentials of Radiomics in Digital Analysis of Features of Hepatocellular Carcinoma
Abstract
In the structure of all malignant liver tumors, hepatocellular carcinoma accounts for 75-90% of cases and is a crucial issue for health care providers due to low survival rates. In most cases, this is due to late diagnosis, when the possibility of radical surgical treatment is excluded. In this context, a critical issue is not only the primary verification of the tumor, but also differential diagnostics, which allows optimizing tactical options for the treatment of hepatocellular carcinoma. One of the promising areas in modern radiation diagnostics is the technique of high-performance quantitative image analysis, which is called "Radiomics". The literature review highlights current trends in the use of artificial intelligence in diagnostics, dynamic monitoring and prognosis for hepatocellular carcinoma. Despite achievements in this field, the problem of using artificial intelligence in digital visualization of liver tumors is still far from being solved. To maximize the usefulness of this non-invasive diagnostic analysis, further research is required.
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Pathogenetic Aspects of the Choice of Drug Therapy in the Treatment of Acute Pancreatitis
Abstract
Difficulties in determining effective treatment tactics for acute pancreatitis are associated with a complex multifactorial pathophysiological mechanism of the disease development. The central part in the pathogenesis of acute pancreatitis is taken by disorders of pancreatic microcirculation. Regardless of the etiology, increasing changes in microcirculation enhance the degree of pancreatic ischemia, thus intensifying the systemic inflammatory response syndrome and resulting in multisystem organ failure. Initial treatment of patients with moderate-to-severe and severe acute pancreatitis combined with transient or persistent organ failure should be carried out in intensive care units. Currently, there are no drugs effective for the treatment of acute pancreatitis in clinical practice. Initial treatment of various forms of acute pancreatitis is essentially supportive and aimed at relieving pain, nausea and vomiting, infusion therapy and early enteral nutrition. Indications for the use of antibacterial therapy in necrotizing acute pancreatitis are cases of infected pancreatic necrosis confirmed by CT or fine-needle aspiration biopsy, or clinical suspicion of infecting necrotic accumulations. To assess the severity and treat patients with severe acute pancreatitis, coordinated work of a multidisciplinary team of specialists is necessary. In the early stage of severe acute pancreatitis, responsibility for coordinating such multidisciplinary work should be borne by specialists of the intensive care units, at a late stage (in 2 weeks), such a role should be played by surgeons, determining the tactics of treating complications of necrotizing forms of acute pancreatitis and the use of various options for invasive interventions.
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