General Surgery

Indocyanine green lymphography as a method for the diagnostics and management of a hylous ascitis. Clinical case

2025-05-14T20:35:30+03:00

Chylous ascites is an uncommon complication following invasive procedures, occurring in fewer than 5% of cases. Most patients with low output lymphorrhea respond favourably to conservative management. However, in cases of persistent lymphatic leakage, surgical intervention may be warranted.

Case presentation. A 42‑year‑old male developed lymphorrhea following ultrasound‑guided percutaneous drainage of a large perisplenic hematoma and hemoperitoneum. Despite repeated drainage of ascitic fluid (performed three times) and conservative therapy, including dietary modifications, the patient exhibited persistent chylous ascites that necessitated surgical intervention. A total of five abdominal computed tomography (CT) scans and two magnetic resonance imaging (MRI) studies failed to identify the site of lymphatic leakage. The patient was admitted to Riga East Clinical University Hospital, where additional CT and MRI imaging of the abdomen was performed. Surgical treatment was scheduled. During laparotomy, intraoperative fluorescence lymphography was employed using near‑infrared imaging with indocyanine green (ICG) injection. Lymphatic leakage was identified in the vicinity of the left diaphragmatic crus. Approximately three minutes after paraaortic administration of ICG, intact lymphatic vessels became visible, and within five minutes, the precise site of leakage was localized via fluorescence‑guided extravasation. The leaking lymphatic vessel was coagulated and sealed using a TachoSil^® hemostatic patch. A surgical drain was placed adjacent to the repair site for postoperative monitoring. No recurrence of chylous ascites was observed during a four‑month follow‑up period. Intraoperative identification of lymphatic leakage remains challenging due to the small calibre of lymphatic vessels and the low‑pressure flow of lymph, which is often imperceptible to the unaided eye. Fluorescence‑guided lymphography using ICG significantly enhances intraoperative visualization of compromised lymphatic structures. In cases of refractory chylous ascites, surgical management incorporating this technique appears to be both safe and effective.

Conclusions. This case highlights the successful surgical management of refractory chylous ascites utilizing intraoperative indocyanine green fluorescence lymphography, which enabled precise identification and closure of the lymphatic leakage site.

A rare case of complicated hernioplasty and reconstruction of the gastroesophageal junction: multistage treatment with a positive outcome

2025-05-12T16:08:36+03:00

This clinical case presents the complex and multistage management of a 48‑year‑old woman with a recurrent hiatal hernia following previous laparoscopic surgical treatment. The initial surgery was complicated by technical errors, leading to early recurrence of the hernia. Subsequent laparoscopic reintervention included mesh‑reinforced hernioplasty and revision fundoplication. However, the postoperative course was complicated by the development of acute gastric fundus ischemia and necrosis, which necessitated urgent atypical wedge resection of the stomach. Despite initial recovery, the patient later developed further complications, including a mesh‑related gastric ulceration and the formation of a chronic inflammatory infiltrate in the upper abdominal cavity. These adverse events required a relaparotomy, complete mesh removal, proximal gastrectomy, and complex gastrointestinal reconstruction using the double‑tract method. The management of this case illustrates several critical challenges: the risk of ischemic complications following fundoplication, the long‑term sequelae of mesh implantation at the gastroesophageal junction, and the technical considerations necessary for successful reconstruction after proximal gastrectomy. Special attention was paid to minimizing postoperative reflux, preserving nutritional function, and ensuring a high quality of life. This clinical case highlights the importance of careful patient selection, meticulous surgical technique, and the necessity for early recognition and management of postoperative complications. Through a stepwise, multidisciplinary surgical approach, a positive long‑term outcome was achieved, with the patient demonstrating good tolerance to a regular diet, no signs of reflux, and satisfactory functional recovery.

The life and work of Borys Horodynskyi: contribution to medical science and education

2025-05-12T16:23:48+03:00

The article focuses on the life and professional accomplishments of Borys Mykhailovych Horodynskyi (1887—1969), an outstanding Ukrainian surgeon, teacher, and scientist. His path from a student at St. Volodymyr University in Kyiv to a leading specialist in general and military field surgery is highlighted. The article explores the main stages of his career, including his work in Kyiv clinics, participation in World War I, management of the surgical departments at the Second Kyiv Medical Institute, and evacuation to Chelyabinsk during World War II. His contributions to the development and implementation of asepsis and antiseptic procedures, abdominal surgery, and treatment of purulent diseases are particularly noteworthy. The educational endeavours of Borys Horodynskyi, his influence on the formation of a new generation of doctors, as well as the circumstances of his dismissal during the 1953 «doctors’ case», are elucidated. We analyse his legacy in Ukrainian medicine, specifically regarding his scientific research, the training of specialists, and the organization of surgical education. The article emphasizes Horodynsky’s significance as a pivotal figure in 20th‑century Ukrainian medicine, with his name engraved in the history of national surgery and medical science.

Evaluation of different methods of endoscopic papillectomy for adenomas of the major duodenal papilla

2025-05-14T10:34:42+03:00

Objective – to assess the outcomes of endoscopic papillectomy (EP) using standard techniques, as well as to develop and implement novel surgical intervention approaches.

Materials and methods. Between 2021 and 2024, the Department of Interventional Endoscopy at the National Cancer Institute performed EP for adenoma of the major duodenal papilla (MDP) on 19 patients, 10 women (52.63%) and 9 men (47.37%), aged 24 to 78 years, with a mean age of 45.6 years. We observed clinical signs of biliary obstruction and cholangitis in the majority of cases (2 (63.15%)).

Results. 10 patients (52.63%) with tumours <1.0 cm underwent the standard procedure of en‑bloc loop resection (Group 1). To prevent intraoperative and postoperative complications, we developed and implemented a two‑stage EP procedure in 6 (31.57%) cases (Group 2). In 3 (15.78%) patients with tumours ranging from 5.0 to 8.0 cm, the piecemeal approach was used to remove all fragments from the area of the neoplasm that reached into the intestinal lumen (Group 3). After a three‑month follow‑up, 2 patients (10.5%) from Group 3 had a recurrence of an adenoma of the MDP. Both cases required loop diathermy excision for recurrent neoplasms and stent removal. Routine tests at 3 and 6 months revealed no evidence of disease progression.

Conclusions. The topographic and anatomical characteristics of the MDP area determine the complexity of surgical interventions for patients with neoplasms. The novel EP approach minimizes the risks associated with both early and late postoperative complications. The outcomes achieved by employing EP in the treatment of patients with MDP adenomas support its recommendation as the primary approach at specialized centers.

Treatment of combat injuries to major arteries with extensive soft tissue defects

2025-05-06T19:34:11+03:00

Objective – to enhance the treatment outcomes of combat injuries to the lower extremities with damage to major arteries and extensive soft tissue defects by preventing complications and implementing an improved surgical algorithm.

Materials and methods. The study was conducted on a cohort of patients with gunshot and explosive wounds in the femoropopliteal segment of the lower extremities, affecting the major arteries. These patients sustained injuries during combat operations and received treatment at the National Military Medical Clinical Center «Main Military Clinical Hospital» between 2014 and 2024. The cohort was divided into two groups. The main group (n=29) included patients who underwent treatment using an improved surgical algorithm that involved selective use of methods for extra‑anatomic revascularization, ligation of the major arteries (in cases of complications in the reconstruction zone), and active application of rotational fasciocutaneous and muscle flaps to close soft tissue defects in the vascular reconstruction zone. The comparison group (n=41) included patients who received treatment using standard methods that involved staged surgical debridement, NPWT, and staged wound closure. All patients were males aged between 23 and 57, with gunshot wounds to the lower extremities that caused damage to major arteries and extensive soft tissue defects.

Results. The improved surgical algorithm focused on patients with extensive soft tissue defects in the area of the reconstructed artery (> 100 cm²), often accompanied by Gustilo‑Anderson grade IIIC gunshot fractures. The treatment strategy included the following key components: 1) Early wound closure using rotational fasciocutaneous and muscle flaps to ensure reliable coverage of the neurovascular bundle. 2) Extra‑anatomic bypass for complications such as erosion, thrombosis, or progression of infection in the reconstructed artery. 3) Ligation of major arteries followed by active monitoring of limb viability and delayed revascularization when feasible in cases of extra‑anatomic vascular restoration failure. The main group (treated using the improved algorithm) had a significantly higher limb preservation rate than the comparison group (treated with conventional methods), with 82.8% limb preservation and 17.2% amputations versus 53.7% limb preservation and 46.3% amputations, respectively. Statistical analysis using the χ²‑test and Fisher’s exact test confirmed the statistical significance of the improved surgical algorithm in amputation reduction rates (χ²‑test 5.16, p=0.023; Fisher’s exact test p=0.02).

Conclusions. The implementation of an improved surgical algorithm for the treatment of gunshot wounds to major arteries in the lower extremities, accompanied by extensive soft tissue defects, significantly reduced the amputation rate in our study, from 46.3% to 17.2% (p=0.02).

Non-contrast MRI and surgical concordance in fistula-in-ano

2025-04-12T13:06:02+03:00

Fistula‑in‑ano is an abnormal connection between the anal canal or rectum and the perianal skin, often resulting from infection in the anal glands. While clinical examination provides some insights, MR fistulogram is essential for detailed assessment and reducing recurrence rates after surgery.

Objective – to compare and correlate the pre‑operative non‑contrast MR fistulogram findings with surgical findings, focusing on concordance rates for fistula type, craniocaudal extent of tracts, number and clock position of internal and external openings, and presence of complicating features like secondary tracts, supralevator extension, presence and location of abscesses.

Materials and methods. We retrospectively analysed 236 patients with fistula‑in‑ano who underwent both MR fistulogram and subsequent surgery within a span of 1 month over one year. MRI scans were reviewed by an experienced radiologist blinded to surgical findings. Parameters assessed included fistula type (Parks, St. James, simple vs. complex), number and clock position of internal and external openings, craniocaudal level of internal openings, puborectalis involvement, secondary tracts, presence of secondary tracts, and location of abscess, if any. Concordance between MRI and surgical findings was evaluated using percentage agreement and weighted kappa coefficients.

Results. Our study cohort had a mean age of 41.7 years, with the majority being men (89%) and cryptoglandular etiology (93.6%). Transsphincteric fistula was the most common type (64%). Complex fistulas were seen in 63.6%. Secondary tracts, abscesses, or multiple tracts were seen in 45%, 30.5%, and 11%, respectively. There was almost perfect agreement between MRI and surgical findings in identifying fistula type, clock position of internal and external openings, secondary tracts, and location of abscesses (k=0.98, 0.93, 0.94, 0.88 and 0.98, respectively), substantial agreement for the craniocaudal level of internal opening (k=0.72), and only moderate agreement for the number of internal and external openings (k=0.56 and 0.51, respectively).

Conclusions. Non‑contrast MR fistulogram, with its excellent soft tissue resolution, accurately depicts the type of fistula‑in‑ano, localises the internal and external openings, and identifies the presence of any complicating features with almost perfect agreement between MRI and surgical findings.

Ultrasound-guided percutaneous surgical techniques as a definitive treatment for acute infected necrotizing pancreatitis

2025-05-14T10:43:19+03:00

Objective – to identify clinical, laboratory, and imaging predictors for open necrosequestrectomy in patients with acute infected necrotizing pancreatitis (AINP).

Materials and methods. A retrospective cohort study involving 188 patients with local AINP complications was conducted in a specialized surgical department from 2018 to 2023. All patients had ultrasound‑guided percutaneous drainage. Patients were divided into two groups based on the effectiveness of ultrasound‑guided minimally invasive surgery (MIS): those receiving ultrasound‑guided MIS as a definitive treatment and those undergoing ultrasound‑guided MIS combined with open necrosequestrectomy. Clinical severity, CT index, comorbidities, laboratory parameters, and bacteriological culture results were analyzed. Statistical significance was assessed using the t‑test, χ² test, and odds ratio (OR).

Results. Ultrasound‑guided MIS was an effective definitive treatment in 127 (67.5%) patients. Open surgery was required for 61 (32.4%) patients. Statistically significant risk factors for resorting to open surgery included a dense tissue component in the drainage area (OR=0.08), hemorrhagic effusion (OR=0.07), hypoalbuminemia (OR=0.09), anemia (OR=0.16), platelet abnormalities (OR=0.13), and early laparotomy (OR=0.09). Mortality in the ultrasound‑guided MIS group was 9.6%, whereas in the open surgery group it was 29.5% (p<0.05).

Conclusions. Ultrasound‑guided minimally invasive drainage procedures are an effective and safe treatment for the majority of patients with infected necrotizing pancreatitis. The identified clinical and laboratory predictors serve as indications for open surgery.

Clinical and anamnestic characteristics of patients with different subtypes of chronic slow transit constipation

2025-05-14T11:40:53+03:00

In recent years, chronic slow transit constipation (СSTC) continued to be an actual clinical challenge due to its high prevalence, multifactorial pathogenesis, and the limited efficacy of current therapeutic strategies. The literature still lacks clear evidence regarding the correlation between the clinical manifestations of CSTC and specific histological alterations within the intestinal wall.

Objective – to identify the clinical course in peculiarities in patients with CSTC depending on the histological subtype of the colonic wall.

Materials and methods. The study included 107 patients diagnosed with chronic slow‑transit constipation (STC group) who underwent evaluation and surgical treatment at the clinical departments of Bogomolets National Medical University between 2011 and 2023. The diagnosis of STC was established according to the Rome IV criteria.

Results. The Cajal subtype was associated with the youngest age of disease onset (8.67±5.08 years), the longest duration of symptoms (25.24±11.18 years), and the highest prevalence of family history (90.5%). This subtype had the lowest average body mass index 20.4±2.3 kg/m². The neuropathic subtype was observed in the oldest patients (52.45±13.61 years) and had a later onset of symptoms compared to other variants. It was characterized by a significantly shorter interval between defecations (8.1±2.5 days). The inflammatory myopathic subtype was accompanied by the most pronounced pain syndrome (4.8±1.4 points on the scale) compared to other subtypes, thereby confirming the role of inflammation in the development of abdominal pain. The dystrophic myopathic subtype was associated with the highest body mass index 25.7±4.3 kg/m² and the longest interval between defecations (12.4±5.5 days), indicating slow transit and muscle layer degeneration. Patients with late onset of symptoms and no need for manual assistance during defecation were more likely to have a histologically intact subtype.

Conclusions. The clinical course in surgically treated patients with CSTC, resistant to conservative therapy, is heterogeneous and significantly varies depending on the histological subtype of the bowel wall, indicating different pathophysiological mechanisms of constipation in different patients. The cajal, neuropathic, myopathic dystrophic, and inflammatory subtypes have clinical differences in the age of disease onset, symptom duration, interval between defecations, pain intensity, and body mass index. Morphological stratification of CSTC based on histological subtypes may provide valuable prognostic and therapeutic information, helping to individualize treatment strategies for patients with severe forms of constipation.

Endoscopic transluminal necrosectomy in patients with acute infected necrotizing pancreatitis. Experience of a specialized center

2025-05-14T11:50:56+03:00

Over the past decades, the treatment of acute infected necrotizing pancreatitis (AINP) has significantly improved due to a better understanding of the disease pathogenesis and the implementation of minimally invasive technologies. Endoscopic transluminal interventions occupy an important place among these techniques and continue to evolve, both technically and tactically.

Objective – to evaluate the results of ETN in the treatment of patients with acute infected necrotizing pancreatitis (AINP) and summarize the experience of our department, including technical and tactical aspects of the procedure.

Materials and methods. The study included 28 patients: 15 (53.6%) men and 13 (46.4%) women with a mean age of 52.6±12.5 years, who underwent ETN between 2021 and 2024 due to a limited peri‑/pancreatic necrotic collection in direct contact with the stomach and/or duodenum. AINP of moderate severity was diagnosed in 19 (67.9%) patients, and a severe course – in 9 (32.1%). The mean size of the walled‑off pancreatic necrosis (WON) was 109.6±32.9 mm. ETN outcomes were assessed as complete, partial, or no clinical success.

Results. The first ETN session was performed on average on day 36.2±16.1 (range: 22 to 86 days) from the onset of the disease. A total of 48 ETN sessions were performed, from 1 to 4 per patient, most often a single session in 14 (50.0%) patients. The intervals between subsequent sessions were mostly 6 – 7 days. Continuous lavage of the WON cavity was performed in 17 (60.7%) patients. The duration of each procedure ranged from 60 to 90 minutes. The rate of intraoperative complications was 3.6% (n=1, profuse bleeding). Complete clinical success was achieved in 18 (64.3%) patients, partial success – in 8 (28.6%), and no clinical success – in 2 (7.1%) patients. Overall, 25 (89.3%) patients recovered, and the mortality rate was 10.7% (3 cases).

Conclusions. In 64.3% of cases, ETN can be the main treatment method in AINP when the indications for the procedure are observed. In 28.6% of patients, it serves as a transitional stage before more invasive surgical procedures. Performing ETN with subsequent continuous lavage of the WON cavity increases the likelihood of achieving complete clinical success by 2.26 times compared to patients without lavage (RR 2.26; 95% CI 1.01 – 5.10; p=0.0485).