Цель исследования-изучить отдаленные результаты модифицированной методики тотального разобщения гастроэзофагеального коллектора у больных с синдромом портальной гипертензии. Материал и методы. К настоящему времени модифицированный вариант операции выполнен 73 больным с синдромом портальной гипертензии (ПГ). У 36 больных причиной ПГ явился цирроз печени (ЦП), у 30 больных диагностирована внепеченочная форма ПГ, еще у 8 больных установлена смешанная форма ПГ. Возраст больных колебался от 13 до 65 лет, средний показатель при этом составил (31,6±1,7) года. По полу больные распределились следующим образом: мужчин-44, женщин-29. В 53 случаях больные госпитализированы в плановом порядке, а 20 пациентов доставлены в экстренном порядке с клиникой гастроэзофагеального кровотечения. Результаты и их обсуждение. Отдаленный период прослежен у 46 больных с первичной методикой и у 66 пациентов с модифицированной техникой тотального разобщения гастроэзофагеального коллектора (ТРГЭК). Рецидив кровотечений отмечен у 15,2% больных, причем в 6,5% на фоне анастомозита. Явления гастростаза выявлены у 3 из 46 пациентов. Явления печеночной недостаточности развились у 23,9% больных. На фоне указанных осложнений умерло 15,2% пациентов. В группе с модифицированной методикой кровотечение отмечено в 6,0% случаев. Кровотечение из эрозий в зоне лигатурной транссекции было остановлено консервативно. Летальность в отдаленные сроки наблюдения составила 7,6% (5 пациентов). Общая летальность за ближайший и отдаленный периоды в группах сравнения составила 22,2% и 16,4% соответственно. Заключение. Прерывание гастроэзофагеального венозного коллектора путем лигатурной транссекции на синтетическом протезе, в отличие от ранее предложенных методов ТРГЭК, позволяет не только облегчить техническое выполнение операции, но и обеспечивает профилактику ранних послеоперационных осложнений, связанных с травматичностью предыдущих методик, а также грубых функциональных нарушений желудка в отдаленном периоде. Ключевые слова: цирроз печени, портальная гипертензия, разобщающие операции, метод лигатурный транссекции, кровотечение из ВРВПЖ.
Objective. To analyze the survival of patients with liver cirrhosis and to assess the effectiveness of endoscopic interventions in the prevention of portal genesis bleedings. Materials and methods. To assess the effectiveness of endoscopic interventions, our study included 449 liver cirrhotic patients with portal hypertension who was admitted with bleeding from varicose veins or the threat of its recurrence for the period from 1996 to 2015. All patients were divided into 2 groups of the study. The main group included 239 patients treated between 2010 and 2015 and the control group consisted of 210 patients in the period from 1996 to 2010. Results. The analysis showed that the percentage of patients without recurrence of bleeding from varicose veins was 27% (33 patients) in the control group and 54.2% (64) in the main group when performing only endoscopic interventions. With the phased tactics of portosystemic shunt performance after endoscopic interventions this figure amounted to 32.4% (45) and 109 (61.6%). In the structure of mortality of patients without cirrhosis in the long-term period (81 patients) with endoscopic interventions recurrence of bleeding were observed in 40.7% (33) cases in the control group and 68.1% (64 of 94) in the main group. In turn, when combined endoscopy and portosystemic shunting in the structure of the patients, without counting deaths from progressive liver cirrhosis, the proportion of absence of recurrence was 45.9% (in 45 of 98 patients) and 71.2% (in 102 out of 153 tracked in the remote period excluding deaths from cirrhosis). In the group of patients that do not carry out any endoscopic intervention and the patients received only conservative therapy only in 3 (10.7%) cases it was possible to avoid recurrence of bleeding, which determines the therapeutic ineffectiveness isolated attempts to reduce the risk of recurrence of hemorrhagic syndrome. Conclusion. Modern possibilities of endoscopic technologies have significantly improved the results of treatment and prevention of varicose bleeding or the threat of its recurrence, and the commitment to the phased tactics, with a combination of minimally invasive and traditional decompressive surgery, allowed to increase the survival rates of patients with 80% to 88% - up to 1 year and from 42% to 64% - to 3 years of follow-up.
Structural issues of primary interventions, development frequency, mortality and treatment tactics of postoperative peritonitis after emergency and selective abdominal operations were analyzed on huge clinical material. The assessment and opportunity of prognostic integral scale application, summery of results, which let to standardize protocols of treatment of patients with postoperative peritonitis, adequately estimate risk and selection of optimal tactics of reoperation.
Purpose. Assess the results of portal systemic shunting (PSSh) in patients with liver cirrhosis (LC) with ascitic syndrome. Materials and methods. Analyse the results of PSSh in 556 patients operated a year from 2000 to 2015. The basis of the analysis taken all the features related to the development and progression of ascitic syndrome. Depending on the shunt type, research conducted with most frequently performed shunts groups. Results. Initial decompensated cirrhosis by edema-ascites syndrome significantly increases the risk of specific complications such as hepatic insufficiency from 6.9% to 13.5%, hepatic encephalopathy from 12.1% to 16.2% and increase in ascites from 7.2% to 16.2%, and the mortality rate from 2.1% to 3.8%. The main cause of early mortality after PSSh is a risk of thrombosis of the anastomosis with recurrent bleeding, whereas other specific complications, conservative measures allow neutralizing the difference in the index of satisfactory results of the operation (96.2% — in the group with ascites before PSSh against; 97.9% — in the group without ascites). Quantitative and qualitative analysis of ascites showed that in the coming period after the shunt (3-5 days) the development of this complication depends on the type of bypass surgery, so when the distal splenorenal shunts (DSRS) production of ascites significantly increased (P <0,01), while total protein component fluid significantly (P <0,02) higher than in patients in ascites with central bypass type. This fact is due to the formation of the selective type of bypass on the background of DSRS, and the growth of ascites does not depend on the presence of complications before surgery, indicating that the impact factor of the severity of portal hypertension and therefore the adequacy of decompression of the portal vein system, against which a decrease in blood albumin fraction and increase it in ascites (R2 = 0,57) may be indicative of a high residual portal pressure. Conclusion. In patients with cirrhosis after PSSh in 70.2% of cases of decompensation of ascites syndrome is caused directly with cirrhotic process and the growth of functional impairment of hepatocytes, the remaining 29.8% of cases, the formation of the complications associated with the progression of PH syndrome on the background of anastomotic thrombosis.
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