Институт общей и неотложной хирургии им. В.Т. Зайцева НАМН Украины 1 , Харьковский национальный медицинский университет 2 , г. Харьков, Украина Цель. Оптимизация хирургической тактики при висцеральных псевдоаневризмах путем использования индивидуализированной тактики лечения, а также применения комбинированных методов их оперативного лечения. Материал и методы. В исследование включены 35 пациентов с висцеральными псевдоаневризмами. Локализация в селезеночной артерии выявлена у 20 человек (57,2%), в общей печеночной артерии-у 8 пациентов (22,8%), в верхней или нижней панкреатодуоденальной артерий-в 5 наблюдениях (14,3%), в верхней брыжеечной артерии-в 2 случаях (5,7%). Асимптомное течение отмечено у 17 пациентов (48,6%), в то время как у остальных 18 человек (51,4%) отмечено симптомное течение заболевания. Для диагностики локализации псевдоаневризм использованы традиционные методы медицинской визуализации, а также ангиография, которая использована в качестве лечебно-диагностической процедуры. Результаты. Полный технический успех эндоваскулярных вмешательств был достигнут у 20 пациентов (57,1%), частичный-в 15 наблюдениях (42,9%), что потребовало применения комбинированных вмешательств. Отсутствие технического успеха рентгенхирургических операций было связано с невозможностью внутрисосудистого доступа к поврежденной артерии либо артериям, питающим псевдоаневризму, к ее шейке, сомнением в кровоснабжении органов, которые питает поврежденная артерия, после ее эндоваскулярной окклюзии, а также большими размерами псевдоаневризмы. Частичным успехом в этом случае считали уменьшение интенсивности кровотечения либо временный гемостаз, которые позволяли выполнить вмешательство из традиционного доступа. Осложнения отмечены у 12 пациентов (34,3%) указанной группы. При этом тяжелые осложнения выявлены у 6 человек (17,1%). Летальность составила 11,4%. Заключение. Эндоваскулярные вмешательства должны рассматриваться в качестве опции первой линии хирургического лечения пациентов с висцеральными псевдоаневризмами. При техническом неуспехе или частичном техническом успехе комбинированное оперативное пособие с применением рентгенэндохирургической техники и традиционного оперативного вмешательства позволяет добиться приемлемых результатов лечения данной категории пациентов. Ключевые слова: висцеральные псевдоаневризмы, кровотечение, интервенционная радиология, ангиография, рентгенэндоваскулярное лечение, комбинированные операции Objective. Optimization of surgical treatment of visceral pseudoaneurysms (PA) by means of using individualized treatment tactics and combined methods for their surgical treatment. Methods. The treatment results of patients (n=35) with visceral PA are presented in the article. Localization of PA in the splenic artery was detected in 20 patients (57.2%), in the common hepatic artery-in 8 patients (22.8%), in the superior or inferior pancreatoduodenal artery-in 5 cases (14.3%), in the superior mesenteric arteryin 2 cases (5.7%). The asymptomatic course of PA was observed in 17 patients (48.6%), while the remaini...
Objective. To determine the possible triggering mechanism for the development and manifestation of acute suppurative cholangitis based on the study of the rheological, physical and chemical properties of bile. Methods. The bile of choledoch was studied inpatients (n=41) with calculous obstruction of the biliary tract, 25 of them had clinical picture of cholangitis. For comparison, 32 patients with asymptomatic choledocholithiasis were examined. Bile sampling was performed in each patient twice: the first bile intake was obtained during duodenoscopy and cannulation of the major papilla of the duodenum and endoscopic papillosphincterotomy and the second portion - during a follow-up examination three days after the endoscopic papillotomy. The biliary pH, viscosity, the amount of solids in it, the concentration of primary bile acids, microbial contamination and the intraductal pressure were studied. Results. For the first time, it has been hypothesized that a reduced concentration of bile acids in the bile causes a subsequent chain of triggering and manifestation of acute cholangitis. In the first bile intake the concentration of bile acids is three fold decreased in patients with acute cholangitis in comparison with the patients of control group, and in the second case it reliable increased but was lower than in the control group. It was a small amount of bile acids caused sedimentation of a colloidal bile solution, increased its viscosity and amount of dry sediment, caused precipitation and sludge. This chain process caused the instantaneous inclusion of concretion in sludge and acute obstruction of the choledoch. As a result of bacterial contamination, the microbial dissemination of bile increases by 10<sup>3</sup>-10<sup>4</sup> times, the choledoch becomes like an abscess. Endoscopic papillosphincterotomy breaks this chain and surgical management is the definitive mode of treatment for decompression and biliary track sanitation. Conclusion. A decrease of bile acids in the content of the bile causes a chain process of sedimentation, the formation of sludge and a complete block of the choledoch, which is the primary trigger for cholangitis. What this paper adds Scientific and theoretical principles which in their essencedetermine the possible mechanism of the development of cholangitis due to choledocholithiasis have been developed. The physicochemical properties of bile play a decisive role in the triggering mechanism of cholangitis. Reduction of the synthesis of bile acids in the liver or their resorption in the intestine starts an avalanche-like process of sedimentation in the micellar solution of bile in the choledoch, sludge with the stones appears, the pH decreases, intraductal pressure rises, as a result of bacterial infection microbial contamination the microbal dissemination increases by 10<sup>3</sup>-10<sup>4</sup> fold.
Objective. Complex estimation of state of the immune system tumoral chain in patients, suffering purulent cholangitis was done to determine diagnostic and prognostic immunological markers in different course of the disease. Materials and methods. Depending on pathological changes in biliary system of the investigated patients, they were distributed into three groups: I –cholangitis, caused by choledocholithiasis, ІІ – cholangitis in environment of cicatricial strictures, ІІІ – cholangitis in environment of performed reconstruction of ductal system. The levels of immunoglobulins A, M, G, and cytotoxical tumoral factors were investigated. Results. In acute course of inflammation the changes in immunoreactivity were determined, showing high levels of immunoglobulins of early immune response. In chronic cholangitis the enhanced raising of the blood serum cytotoxicity was noted, and its level connection with the disease clinical severity. Statistically significant high level of the middle molecular mass polypeptides have constituted the result of accumulation of secondary endogenic toxins with their insufficient elimination. Conclusion. The summarized amplitude in the immunoreactivity changes was maximally pronounced in patients with an acute course of cholangitis, demonstrating high levels of the early immune response immunoglobulins. In chronic course the signs of the immune response exhaustion dominated.
The aim — to determine the role and effectiveness of various surgical treatment methods for liver echinococcosis, depending on the type of echinococcal cyst, its location and size.Materials and methods. A treatment results analysis of 56 patients with liver echinococcosis who were treated in the clinic from 2008 to 2018 was performed. There were 42.9 % of men and 57.1 % of women. The mean age of the patients was 48 ± 2.3 years. The standard examination algorithm included mandatory contrast enhanced CT and the detection of antibodies to echinococcus in blood serum in addition to routine laboratory and instrumental tests. CL type of cysts were detected in 3 patients (5.4 %), type CE1 in 27 patients (48.2 %), type CE2 in 10 cases (17.9 %), type CE3 in 12 cases (21.4 %), type CE4 — 5 — in 4 patients (7.2 %). Patients underwent various surgical interventions, depending on the type of echinococcal cyst. PAIR was used in 3 patients (5.4 %), PAIRD was used in 7 patients (12.5 %). Echinococcectomy was performed in 17 patients (30.4 %) The open approach was performed in 8 patients (14.3 %), and laparoscopic approach — in 9 cases (16.1 %). Pericystectomy was performed in 19 patients (33.8 %)/The open approach was used in 16 cases (28.4 %), and laparoscopic approach — in 3 cases (5.4 %). In another 10 cases (17.9 %), liver resections varying from segmentectomy to hemihepatectomy were performed.Results and discussion.Bile leakage via the drainages of the abdominal cavity was observed in 7 cases (12.5 %). Allergic reactions of varying severity were observed in 3 cases (5.6 %). The recurrence of decease was noted in 2 patients (4 %). There was no lethality in this group of patients.Conclusions. The absence of a unified surgical tactics for liver echinococcosis requires the use of an individualized approach. The choice of treatment method depends on the location and size of the cyst, the stage of parasite development. Postoperative therapy with albendazole (mebendazole) in the presence of a live parasite is required. In the presence of a non‑living parasite (cysts of type CE4 — CE5) it is advisable to use observant tactics.
The aim — to analyze the causes of biliary tract pathology after the stomach and duodenal surgery, and possibility for its correction.Materials and methods. The treatment results analysis of 46 patients with gallstone disease after operations on the stomach and duodenum was performed. Most of them have been operated for a complicated peptic ulcer. The complicated course of the early postoperative period was observed in 18 patients. The hepatopancreatic system disorders developed in the period from 14 days to 15 years after primary operation.Results and discussion. The extension of repeated surgical interventions depended on the revealed hepatopancreatotobiliary system pathology. Complications after repeated interventions were detected in 7 patients: bile leakage — 2, the postoperative wound suppuration — 1, pleurisy — 4 patients. 2 patients died after the operation.Conclusions. The main factors of the hepatobiliary system pathology after the stomach and duodenal surgery were: biliary tract iatrogenic damage, suture failure in pyloroplasty area or gastrointestinal anastomosis, sphincter of Oddi disorders and vagotomy. During repeated interventions on the biliary system, surgical tactics were chosen individually, depending on the signs detected at the preoperative and intraoperative stage. In case of necessary reconstructive interventions, the most justifiable was the RouxenY choledocho/hepaticojejunoanastomosis.
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