Харьковская медицинская академия последипломного образования, г. Харьков, Украина Постхолецистэктомический синдром с позиции хирурга и гастроэнтеролога Резюме. Представлены результаты лечения 173 больных с постхолецистэктомическим синдромом (ПХЭС) с органическими изменениями сфинктера Одди и 140 больных с функциональными изменениями сфинктера Одди. Основным направлением лечебной тактики при органических причинах ПХЭС было максимальное использование эндоскопических методов лечения и эндохирургии в сочетании с современными терапевтическими средствами. При выявлении функциональных изменений сфинктера Одди применялась медикаментозная терапия с дифференцированным подходом к выбору препаратов в зависимости от преобладания гипертонуса или недостаточности сфинктера Одди (мебеверина гидрохлорид (дуспаталин), итоприд, тримебутина малеат (тримспа)). Для нормализации физико-химических свойств желчи и профилактики повторного холедохолитиаза использовались производные урсодезоксихолевой кислоты (Урсофальк).
Summary. Goal — optimization of treatment of patients with trophic ulcers Materials and methods: data on the treatment of trophic ulcers of the lower extremities in 66 patients by vacuum extraction (VE) are presented. Results and discussion: the effectiveness of the method for the treatment of complications of varicose disease, reducing the healing time of wounds compared to traditional methods of treatment is shown. The advantages and features of the method are described Conclusions: The main goals of VE in CVI are to stop or reduce the clinical manifestations of CVI, to heal a trophic ulcer, and to prepare for surgery. In some patients, radical surgery cannot be performed. Therefore, periodic courses of VE is the main method of treatment for them. The combination of VE and traditional methods can improve the quality of life and reduce the time of preparing the patient for surgery.
Summary. Objective. Development of an algorithm for choosing the method of pancreatojejunoanastomosis in pancreatoduodenal resection, taking into account the degree of change in the pancreatic parenchyma. Materials and methods. Pancreatoduodenal resection was performed on 291 patients with obstructive diseases of the pancreatoduodenal zone. Three options were used for pancreatojejunoanastomos: invagination ductopancreatojejunal — in 210 (72.4 %), invagination pancreatojejunal — in 68 (23.4 %), pancreatojejunal with bandage repair of the crescent ligament of the liver — in 13 (4.4 %) patients. Results. The pancreatic parenchyma was assessed by the following factors: puffiness, infiltration, obesity, degree of pancreatic parenchyma fibrosis, location and diameter of the Wirsung duct. High and low risk factors for the development of pancreatic fistula were identified. Diagnosis of pancreatic fistula was carried out according to the classification of ISGPF (2016). A differentiated approach was applied to the choice of pancreatojejunoanastomosis depending on the degree of changes in the pancreatic parenchyma, the diameter and location of the Wirsung duct. Conclusion. Evaluation of the degree of pancreatic parenchyma changes, the diameter and location of the Wirsung duct allows you to choose the optimal technique for pancreatojejunoanastomosis in pancreatoduodenal resection. The use of a differentiated approach to the choice of pancreatojejunoanastomosis technique for pancreatoduodenal resection, taking into account the degree of change in the pancreatic parenchyma, can reduce the incidence of PF (type B, C).
The aim of the research. To develop an algorithm for the two-stage treatment of patients with tumors pancreatoduodenal zone complicated by obstructive jaundice using biliary decompression techniques at the first stage and conducting pancreatoduodenal resection at the second stage of treatment. Materials and methods. Preliminary biliary decompression was conducted in 51 patients with prolonged obstructive jaundice and high bilirubin numbers (above 250 μmol/l). The following minimally invasive options were used for biliary decompression: percutaneous transhepatic cholangio-drainage in 21 (41.2 %), endoscopic stenting in 18 (35.3 %), various cholecystostomy (percutaneous transhepatic, contact, video laparoscopic) in 12 (25, 8 %) patients. A two-stage method has been developed for the treatment of pancreatic tumors complicated by obstructive jaundice. Results. Percutaneous transhepatic cholangio-drainage was performed under ultrasound-X-ray navigation — in 11 (52.4 %), under angiographic control — in 10 (47.6 %) patients. Endoscopic stenting was performed in 18 (35.3 %) patients; plastic stents were used. Three options were used for pancreatojejunoanastomos: invagination ductopancreatojejunal — in 31 (60.8 %), invagination pancreatojejunal — in 16 (31.4 %), pancreatojejunal with bandage plasty of the crescent ligament of the liver — in 4 (7.8 %) patients. Diagnosis of pancreatic fistula was carried out according to the classification of ISGPF (2016). Biochemical leak was observed in 3 (5.9 %), pancreatic fistula (type B) in 2 (3.9 %) patients. Post-operative gastrostasis was detected in 3 (5.9 %) patients. Conclusions. Percutaneous transhepatic cholangio-drainage and endoscopic stenting are the most effective methods of biliary decompression. The use of biliary decompression in patients with pancreatic tumors complicated by the development of obstructive jaundice allows patients to prepare for the execution of PDR with reduced perioperative risk.
The aim. Improving the algorithm for diagnosing patients with postcholecystectomy syndrome (PCS), taking into account functional and organic changes in the major duodenal papilla (MDP). Materials and methods. 208 patients with PCS were examined. Laparoscopic cholecystectomy (CE) was performed in 172 patients in history, open CE was performed in 36 patients. 47 patients had obstructive jaundice, 84 had signs of biliary hypertension without an increase in bilirubin, 77 had no signs of biliary hypertension and an increase in bilirubin. The following instrumental research methods were used: abdominal organs ultrasound examination (AO USE), duodenoscopy, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT). In the main group, to study the morphofunctional changes in MDP, duodenoscopy with parietal impedancemetry, ultrasound of the hepatobiliary zone with a choleretic load were used. Results. In the main group, 34 patients underwent ultrasound of the hepatobiliary zone and Vater's nipple area with a choleretic breakfast according to Boyden according to the method of Grigoriev P.Ya. in our modification, 21 patients had an expansion of the choledochus by 2 mm. At the same time, taking meverin led to a decrease in the diameter of the choledochus, which indicated functional changes in the MDP. In 13 patients, the expansion of the choledochus, observed when taking a choleretic breakfast, persisted with the use of antispasmodics, which indicated the presence of an organic pathology of MDP. Duodenoscopy with impedancemetry was performed in 41 patients: 20 patients had 760–820 Ohm, which indicated the presence of functional changes, 12 patients had inflammatory changes in the MDP and 703–760 Ohm were detected, 9 patients with cicatricial fibrous changes had indicators impedance measurement 640–703 Ohm. The use of ultrasound with a choleretic breakfast and duodenoscopy with parietal impedancemetry in patients of the main group made it possible to identify functional and organic (inflammatory, fibrous) changes in the MDP, which made it possible to develop a therapeutic algorithm using both conservative therapy and the use of various options for transpapillary endoscopic interventions. Conclusions. Conducting an in-depth diagnosis of morpho-functional changes in MDP using parietal impedancemetry of MDP and ultrasound of the hepatobiliary zone with choleretic load allows us to identify both functional and morphological changes in MDP, which makes it possible to develop a therapeutic algorithm using drug therapy and transpapillary endoscopic techniques.
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