Diagnostic and management algorithm of acute pancreatitis

The analysis of diagnostics and treatment of 602 patients with destructive pancreatitis has shown that definition of etiological and pathogenetic forms of pancreatitis defines strategy of treatment. In this way, patients with biliary pancreatitis require emergency operative treatment with use of endoscopic interventions without dependence from a stage of disease. To patients with alcoholic or alimentary pancreatitis in the stage of enzymatic toxemia conservative treatment should be spent only, until shock and/or delirium won't be reduced. Endoscopic retrograde cholangiopancreatography + endoscopic papillosphincterotomy with concrement removal from common bile duct--is the operation of choice in case of acute biliary pancreatitis at the first stage. Laparoscopic cholecystectomy is the operation of choice at the second stage of disease. At destructive pancreatitis of other origin in a stage of the infection or necrotic suppurative inflammation use of open and closed small invasive methods of intervention is most proved. Given tactics of treatment has allowed to lower severity of clinical course, frequency of complications and lethality.     

Surgical strategy in liver hemangiomas

The authors made an analysis of results of surgical treatment of 129 patients with hepatic hemangiomas and of the 9-year follow-up of these patients. The dynamic care of these patients is recommended in cases of 5 cm diameter hemangiomas and the absence of clinical symptoms. The surgical treatment was necessary but in 10% of such patients. In the majority of such patients embolisation of the hepatic artery is expedient if surgical treatment is necessary. Indications for resection of the liver are restricted.     

Ultrasonic diagnosis of focal damages in thoracoscopic operations

5-year experience of developed in PAMS A.V. Vishnevsky Institute of Surgery RAMS ultrasonic examination (USE) of the lung in thoracoscopic operations for focal lung lesions (FLL) is presented. Pilot experience of ultrasonic topical and differential diagnosis of FII opens a new page in diagnosis of respiratory diseases. Over 5 years 74 USE of FLL were performed. FLL were found in 91% cases. Detailed topical diagnosis of allows to design the lung resection with the best functional result. In postoperative X-ray examination neither atelectases nor zones of stable hypoventilation were detected. Normal echographic picture of lung tissue and echosemiotics of different focal lesions are descubed. The experience of diagnosis by echographic signs of FLL shows teasibility of differentiation of hamartomas from tuberculomas and focal metastatic lesions. The payential of differential diagnosis is illustrated. Differential diagnosis supported enucleation in superficial hamartomas and resection in suspected malignant tumor or tuberculosis. Use of intraoperative USE in the majority of cases of focal lesions located both in depth of lung tissue and subpleurally warrants the success of operation in thoracoscopic variant.     

Surgical aspects of the treatment of generalized peritonitis

Advantages and disadvantages of different methods of surgery termination at generalized peritonitis are discussed. Drainage of abdominal cavity can not guarantee adequate sanation. Disadvantages of peritoneal lavage exceed the clinical value of this method. Active influence on infectious process during postoperative period can be realized with laparostomy, programmed revisions and sanations of abdominal cavity. These methods lead to recovery of more 80% patients with generalized peritonitis. Laparoscopic sanation is effective when bacterial contamination of peritoneal exudation doesn't exceed 10(5) mb/g.     

Diagnosis, treatment and prophylaxis of acute ulcero-erosive gastroduodenal bleedings at cardiosurgical patients

Results of treatment of 495 patients who has undergone various cardiac operations with artificial circulation are analyzed. The complex program "Blood-free surgery" was used at 388 (78.4%) of them. Among the patients treated traditionally the acute gastroduodenal erosions and ulcers were diagnosed at 25.7% patients, the rate of gastroduodenal bleedings was 3.0%. Complex of prophylactic measures permits to reduce the rate of acute erosions and ulcers in 1.5 times (18.4%) and the rate of postoperative gastroduodenal bleedings--to 0.7%. Control of risk factors, timely diagnosis, complex prophylaxis and treatment of acute gastroduodenal erosions and ulcers are effective way to improvement of operations results at cardiosurgical patients. "Blood-free" program doesn't lead to increase of acute postoperative gastroduodenal erosions and ulcers rate. Endoscopic (including repeated) hemostasis at acute ulcero-erosive gastroduodenal bleedings is available method and permits to achieve the stable hemostasis.     

Treatment tactics of patients with choledocholithiasis complicated with acute cholangitis

The results of observation and treatment of 137 patients with choledocholithiasis complicated acute cholangitis are presented. The estimated scale APACHE II is adopted for the state severity of patients with choledocholithiasis and cholangitis sigh determination are examined. With multivariant correlative-regression analysis the most informative factors are determined, its grade estimation are carrying out. Optimal treatment tactics depended from state severity is definited. It permits to improve the treatment results owing to decrease of postoperative complications frequency, duration of patients therapy in hospital.     

Some aspects of treatment of dissecting aneurysm of the aorta

The problem of dissecting aneurysms of the aorta (DAA) is discussed on the basis of an analysis of treatment of 63 patients, a comparison of 19 clinico-morphological findings included. It was found that in elderly and senile patients DAA often developed in its abdominal portion against the background of atheromatous-ulcerous lesions responsible for the "scrappy" dissection and formation of "pockets" in the aorta wall. The formation of distal fenestration with a "double-barrel" was observed much more rarely. For the early diagnosis of the aorta aneurysm dopplerography of the abdominal part of the aorta is recommended in elderly and senile patients with arterial hypertension and symptoms of occlusion in the aorta-femoral segment. The operative treatment of DAA and its long-term results are analyzed. A case of clinical management of dissecting aneurysm of the ascending portion of the aorta developed against the background of congenitial dysplasia of the connective tissue successfully operated in a woman with rheumatism is described.     

Surgical treatment of Meckel diverticulum complicated by an acute hemorrhage

Mekkel's diverticulum (MD)--is the inborn anomaly, caused by incomplete yolk duct development, it is present in near 2% of population and in 95% of observations lacks clinical manifestations. Symptoms of the disease manifest while complications occurrence only--in presence of peptic ulcer with possible hemorrhage and perforation occurrence, while ileus, diverticulitis, hernia, umbilicus fistula and tumor development. Eight patients, suffering MD, complicated by gastrointestinal hemorrhage, were treated during 1983-2006 yrs in Kyiv's city center for giving the aid to patients suffering gastrointestinal hemorrhage (GIH). These had constituted 6.6% of general quantity of adult patients, suffering rare causes of GIH occurrence, and 0.03% of all the patients, suffering GIH. For the diagnosis establishing in all the patients colonoscopy, barium enema and abdominal ultrasonography were applied. Definitive diagnosis was established only postoperatively. MD was extirpated in 5 patients, the wedge ileum resection with MD was accomplished in 1 patient and ileum resection with MD--in 2 patients. All the patients are alive.     

The possibility and prognostic value of secondary lymphatic cancer spread in intrapulmonic metastases of solid tumors

In the period from 1996 to 2007 operations were fulfilled in 120 patients with isolated pulmonary metastases of solid tumors (68 men and 52 women aged from 22 through 77 years): 46 patients with metastases of colorectal cancer, 28 - with cancer of the kidney, 23 - with non-small cell carcinoma of lung, 7 - with breast cancer, 9 - with endometrium cancer, 7 - with melanoma. Altogether there were 128 operations. The operations have revealed lesion of intrathoracic lymph nodes in 29 patients (24%). In most cases (21 patients) they were lesions of lymph nodes of the lung root and intrapulmonary lymph nodes. In 93% of cases (27 patients) localization of the lesion coincided with anatomical pathways of lymph outflow from the affected part of the lung. The survival rate median of the operated patients who had alterations in the lymph nodes was 21 months, in cases with intact lymphatic system it was 37 months. A conclusion is made of possible secondary lymphatic cancer spread from intrapulmonary metastases of solid tumors and its negative influence on results of treatment that allows recommendation of revision of the lymphatic system of the lungs and mediastinum in all cases of surgical treatment of intrapulmonary metastases, and in a number of cases recommendation of anatomical resections of the lung tissue as operation of choice.