General Surgery

Single-stage laparoscopic treatment of a cholecystoduodenal fistula with perforated small bowel ileus and fibrinous purulent peritonitis. A single case study

C. R. D. Demtröder — 2024-03-30

Gallstone ileus is a rare complication of recurrent cholecystitis and one of the rarest causes of mechanical bowel obstruction, with an increasing incidence in the elderly. We present a case of multiple small bowel perforations of the jejunum due to gallstone obstruction and the incidental finding of high‑grade appendiceal mucinous neoplasia of the appendix. To our knowledge, this is the first such case to be described and completely resolved by a laparoscopic approach.

An 83‑year‑old woman presented to our emergency department with severe vomiting, constipation, and deterioration of her general condition. A computed tomography scan revealed thickening of the gallbladder with a continuous aerobe to the duodenum, a mechanical obstruction of the small intestine at the transition to the ileum, and a thickened and calcified appendix. Due to a high suspicion of gallbladder perforation with the formation of a bilio‑duodenal fistula, the patient underwent an emergency exploratory laparoscopy, which revealed a small bowel perforation in three segments with marked local fibrinous, purulent, and stercoral peritonitis of the left hemiabdomen. The gallstone was retrieved through the perforated small bowel, and a partial small bowel resection and a cecal wedge resection were performed laparoscopically. Small bowel continuity was restored with an anisoperistaltic side‑to‑side jejuno‑jejunostomy. The patient was discharged on postoperative day eight.

Despite advances in imaging, gallstone ileus remains a diagnostic challenge. Because the disease occurs predominantly in elderly patients, gallstone ileus remains associated with high morbidity and mortality. It remains unclear from the literature whether the optimal surgical management of bilioenteric fistula is best resolved by a single‑stage or a two‑stage approach.

A clinical case of surgical treatment of appendiceal stump abscess

O. P. Stetsenko — 2024-03-30

In Ukraine, the share of patients with acute appendicitis is 89.1% of the total number of patients with acute surgical pathology. In modern surgical practice, early and late complications occupy the first place in the structure of acute surgical diseases of the abdominal organs, regardless of the age and gender of the patients, and the postoperative mortality is on average 0.15%. In the remote period after an appendectomy, despite the progress of modern surgery, a very rare complication known as inflammation of the stump of the appendix can occur.

The patient, 25 years old, turned to the department of purulent surgery with complaints of a «small wound» at the site of the postoperative scar in the right inguinal area and minor purulent discharge from it. Four months ago, in July, he was operated on for acute phlegmonous appendicitis. On November 1, after physical exertion, the wound reappeared, and on November 3, the patient independently sought a consultation at the reception department of the Clinical City Hospital No3. He was examined by a surgeon and hospitalized. During the revision of the wound, a tumor‑like formation measuring 2.5x3.0x2.5 cm, as well as the parietal peritoneum, was revealed. Appendectomy was performed by the method of pouch ligation with drainage of the abdominal cavity through a separate contraperture with polyvinyl chloride drainage. After the operation, a diagnosis was established: abscess of the stump of the appendix, and external fistula of the anterior abdominal wall. The postoperative wound healed with primary tension, and the sutures were removed.

The diagnosis of appendicitis may be mistakenly excluded from the clinical search due to the presence of a postoperative scar after appendectomy. A clear clinical picture of acute appendicitis or the opening of a fistula at the site of a postoperative scar in the right iliac region indicates the need for a computer tomography of the abdominal organs with contrast to establish an accurate diagnosis and choose the correct treatment tactics. The only treatment for inflammation of the appendiceal stump is a complete appendectomy with appendix removal either by open or laparoscopic surgery, which should be performed urgently to avoid further complications.

Modern endovascular treatment strategies in the management of postpancreatectomy haemorrhage in patients with pancreatic cancer

V. M. Kopchak — 2024-03-30

Objective — to determine the occurrence and management of postpancreatectomy haemorrhage in pancreatic cancer patients, as well as to identify effective treatment strategies to improve patient outcomes.

Materials and methods. From January 2010 to December 2022, 878 patients who underwent radical pancreatic resections for malignant tumours were retrospectively analysed.

Patients were divided into two groups. The main group consisted of 500 patients who were treated in the clinic from 2016 to 2022. In the main group, postpancreatectomy haemorrhage occurred in 31 (6.2%) patients. These patients were treated according to our diagnostic and treatment algorithm, using endovascular techniques as the first step of treatment. The comparison group consisted of 378 patients who were treated in our department from 2010 to 2015. In the comparison group, postpancreatectomy haemorrhage occurred in 20 (5.3%) patients. These patients were treated according to standard approaches. The definition of postpancreatectomy haemorrhage proposed by the International Study Group of Pancreatic Surgery was used in our research.

Results. Out of 31 patients in the main group, 16 (51.6%) had endovascular embolisation. A total of 10 patients underwent endovascular occlusion, whereas 5 patients experienced cessation of bleeding with the use of a stent graft. Angiography did not detect the cause of bleeding in 3 (9.7%) individuals in the main group. They underwent laparotomy with subsequent haemostasis. 11 (35.5%) patients underwent open surgical interventions. In the main group, one (3.2%) patient died due to the emergence of infectious complications after laparotomy and subsequent haemostasis. 2 (10%) patients underwent endovascular haemostasis, while 15 (75%) patients underwent relaparotomy with haemostasis. In the comparison group, 6 (30%) patients died after open relaparotomies.

Conclusions. The initial course of action for managing postpancreatectomy haemorrhage involves the implementation of endovascular techniques, wherein stent grafts are used to address bleeding originating from the main blood vessel. The application of advanced treatment strategies that optimised the use of minimally invasive endovascular techniques resulted in a notable decrease in the mortality rate associated with postpancreatectomy bleeding from 30% to 3.2% (χ²=7.3, p=0.006). Ensuring 24/7 access to endovascular treatment, which can be provided exclusively in high‑volume centres, is imperative for improving the treatment outcomes of patients with pancreatic and periampullary cancer.

A differentiated approach to comprehensive surgical treatment of combined combat thermomechanical injuries

S. O. Korol — 2024-03-30

In recent years, there has been a notable increase in the incidence of thermomechanical injuries, which frequently manifest as a combination of various types of damage. The majority of these injuries require long‑term treatment and result in the development of decompensated (critical) conditions during the early stages, with a substantial death rate ranging from 75% to 80%.

Objective — to improve the results of surgery for combined combat thermomechanical injuries by developing and implementing a differentiated surgical approach that incorporates the assessment of injury severity within the context of medical support.

Materials and methods. A retrospective‑prospective study was carried out to determine the effectiveness of medical care provided for wounded individuals with combined combat thermomechanical injuries sustained during combat operations between 2017 and 2023. The study included a cohort of 97 wounded individuals, who were subsequently divided into two separate clinical groups. The main group (n=56) underwent treatment according to a differentiated surgical approach that included the assessment of the severity of the patient’s condition using the admission trauma scale (AdTS) and the perfusion index (PI). The control group (n=41) received treatment based on established protocols using conventional treatment approaches for combined combat thermomechanical injuries without considering prioritisation.

Results. A differentiated surgical strategy for managing combined combat thermomechanical injuries, which included an objective assessment of injury severity using the AdTS and the perfusion index (PI), allowed for a notable decrease in the occurrence of late purulent‑septic complications as well as a significant reduction in the mortality rate in the main group to 21.4%, compared to 38.8% in the control group (p=0.038). This was related to a decrease in the frequency of fatal outcomes among individuals with serious injuries: 21.2% in the main group, 37.0% in the control group (p=0.013). Furthermore, surgical treatment improved anatomical and functional outcomes in the main group compared to the control group. Group 1 had a higher specific weight of favourable outcomes 52.0±14.2% and a lower specific weight of unsatisfactory outcomes (17.6), [8.7;28.7] %, compared to group 2 20.6±13.4% and 47.3±14.7%. The difference was statistically significant at p=0.001.

Conclusions. The implementation of a differentiated surgical approach with an objective assessment of injury severity resulted in a reduction in mortality from 7.3% to 1.8%, specific weight of amputations from 34.2% to 8.9%, and contractures from 26.8% to 10.5% (p<0.05). Early vacuum therapy in the surgical treatment of combined combat thermomechanical injuries reduced treatment time and allowed for early reconstructive and restorative operations, leading to better functional outcomes. The specific weight of favourable outcomes increased from 20.6% to 52.0%, while the relative number of unsatisfactory outcomes decreased from 47.3% to 17.6% (p<0.05).

Surgical rehabilitation of patients with Crohn’s disease

O. I. Poyda — 2024-03-30

Objective — to enhance the outcomes of surgical rehabilitation for patients with Crohn’s disease through the improvement and implementation of organisational measures as well as general and specialised surgical strategies.

Materials and methods. The study focused on the development of organisational measures as well as general and specialised surgical rehabilitation procedures for Crohn’s disease. The research was conducted to determine the scope of radical surgical interventions for complications resulting from segmental lesions with extensive damage to the intestinal tract. The study also aimed to develop methods of restorative, reconstructive and restorative operations that would reduce the frequency of postoperative complications, disease recurrence, digestive disorders in the intestinal tract, malabsorption, and anal incontinence. Additionally, the study aimed to improve the functional outcomes and quality of life for operated patients.

Results. A total of 53 patients with Crohn’s disease — 28 (52.8%) men and 25 (47.2%) women — were operated on using specially designed surgical rehabilitation techniques. The patients undergoing surgery ranged in age from 19 to 45. 32 (60.4%) patients had segmental resections, while 21 (39.6%) had extensive resections. 8 (15.1%) patients underwent restorative operations, while 40 (75.4%) had reconstructive operations. A lifelong ileostomy was formed in 5 (9.4%) patients. Postoperative complications were observed in 12 (22.6%) patients, and disease relapses in 5 (9.4%) patients. One (1.8%) patient died after surgery. Positive functional outcomes, including improved digestion in the intestinal tract, normal absorption, and preservation of anal retention, were noted following restorative and reconstructive‑restorative operations.

Conclusions. Organisational measures as well as general and specialised surgical rehabilitation strategies for Crohn’s disease allowed for more effective diagnosis and treatment of postoperative complications, better prevention of disease recurrence, improved digestion in the intestinal tract, normalised absorption processes, and preservation of anal retention. Following the implementation of specially designed surgical rehabilitation techniques, 20.7% and 1.8% of patients experienced early and late postoperative complications, respectively. Additionally, there were occurrences of postoperative mortality in 1.8% of patients and relapses in 9.4%. Severe forms of reflux ileitis, postcolectomy syndrome, and secondary anal incontinence syndrome were not observed.

Minimally invasive techniques for surgical treatment of sacrococcygeal pilonidal disease

D. Y. Dubenko — 2024-03-30

Sacrococcygeal pilonidal disease (SPD) is a common disease that affects mainly young men and leads to a decrease in their quality of life and a long‑term loss of working capacity. According to the available statistical data, the disease prevalence in Europe and North America ranges from 26 to 40 cases per 100,000 people.

Objective — to determine the effectiveness of minimally invasive techniques for surgical treatment of chronic and recurrent forms of SPD.

Materials and methods. The study included 23 patients with SPD. It was clinical prospective, with a follow‑up period of 18 months. The evaluation criteria were defined as recurrences, the frequency of postoperative complications, the severity of the pain syndrome, the patient’s self‑assessment of the cosmetic effect, the duration of hospitalisation, and the duration of surgery.

The results. The recurrence rate during the 18 months of observation was 39.1%. The overall frequency of postoperative complications was 21.7%. The median duration of surgery was 20 (CI 95% 15—25) minutes, and the median duration of hospitalisation was 2 (CI 95% 1—3) days. The median score of the pain syndrome according to the modified visual analogue scale was 5 (CI 95% 4—5) points on the 0th postoperative day, 3 (CI 95% 3—4) points on the third postoperative day, and 2 (CI 95% 2—2) points on the fifth postoperative day. The cosmetic effect of surgical intervention was rated as rather dissatisfied (17.4%), rather satisfied (52.2%), and completely satisfied (30.4%).

Conclusions. Minimally invasive techniques are effective for the surgical treatment of chronic and recurrent forms of sacrococcygeal pilonidal disease, reducing both the inpatient period and the surgery duration. Minimally invasive surgical treatment for chronic and recurrent forms of sacrococcygeal pilonidal disease has been observed to cause a moderate pain syndrome in the early postoperative period while contributing to satisfactory cosmetic results in the remote period. The surgical treatment of chronic and recurrent forms of sacrococcygeal pilonidal disease with minimally invasive techniques has been found to result in a relatively high recurrence rate (39.1% over 18 months of follow‑up).

Management of rare complications in obese patients after laparoscopic gastric bypass

V. O. Nevmerzhytskyi — 2024-03-30

The complications resulting from laparoscopic gastric bypass can be categorised into two main groups: early (within 30 days after surgery) and late (after 30 days following surgery). Bleeding, marginal ulcers, and failure of the suture line occur most often. Stenosis of the anastomotic areas, adhesive small bowel obstruction, incarceration of Petersen’s space hernia, gastrogastric fistula, and hemobezoar‑induced small bowel obstruction are less often observed.

Objective — to improve the management of rare complications in obese patients after laparoscopic gastric bypass.

Materials and methods. The study includes a retrospective analysis of patients who underwent laparoscopic gastric bypass in the Department of General Surgery No. 2 at Bogomolets National Medical University from 2011 to 2023. Patients aged 25 to 59 who met the IFSO criteria for obesity participated in the research. The minimum observation period was 12 months. All patients underwent a laparoscopic Roux‑en‑Y Gastric Bypass.

Results. The study included a cohort of 348 patients who underwent laparoscopic gastric bypass. The majority of them were female, including 189 individuals (54.3%). A total of 6 patients (1.72%) were identified with rare problems, consisting of 2 women and 4 men. Two patients were diagnosed with acute small bowel obstruction caused by a hemobezoar, one patient with gastrogastric fistula, one patient with acute adhesive small bowel obstruction, one patient with a marginal ulcer of the «large» stomach complicated by perforation, and one patient with a pinched Petersen’s space hernia. All complications were class IIIb, according to the Clavien‑Dindo classification, and required surgical treatment. In the early period, 3 (50%) cases were diagnosed: acute adhesive small bowel obstruction (2 days postoperatively ) and acute small bowel obstruction caused by a hemobezoar (2—3 days postoperatively).

Conclusions. We found that the incidence of rare complications among obese individuals after laparoscopic gastric bypass was 1.72%. Specifically, 1.14% of patients experienced small bowel obstruction, 0.29% had a marginal ulcer of the «large» stomach complicated by perforation, and 0.29% had a pinched Petersen’s space hernia. Each case of a rare complication requires an individual approach to its management.

Changes in the antibiotic-resistant properties of pathogenic microorganisms in patients with purulent-necrotic wounds against the background of type 2 diabetes when using a probiotic antiseptic

O. Y. Ioffe — 2024-03-30

Antibiotic resistance remains a serious problem, leading to millions of deaths every year. The increasing prevalence of type 2 diabetes mellitus (T2DM) is contributing to the continued spread of this problem. Ukraine, like other countries, feels the consequences of this problem. Over the past ten years, the number of patients with T2DM has doubled, and diabetes is already the cause of disability and death for thousands of people. Complications of T2DM, such as diabetic foot syndrome, often require surgery and antibacterial therapy. New research shows the prospects of using probiotic antiseptics based on lactic acid bacteria of the genus Bacillus in the treatment of wounds, which may open new opportunities to combat this problem and improve treatment outcomes.

Objective — to analyse changes in the antibiotic‑resistant properties of pathogenic microorganisms in patients with purulent‑necrotic wounds in type 2 diabetes mellitus.

Materials and methods. The study, which was conducted at the Department of General Surgery No. 2 of Bogomolets National Medical University in Kyiv City Clinical Hospital No. 3, included 229 patients with purulent‑necrotic wounds and type II diabetes. A total of 229 patients were randomly divided into two groups, with one group receiving probiotic antiseptics and the other traditional chemical antiseptics, with subsequent analysis focusing on changes in antibiotic‑resistant properties against P. aeruginosa and K. pneumoniae. Antibiotic‑resistant properties were evaluated through microbiological examination, revealing significant changes in resistance patterns among patients treated with probiotic antiseptics compared to those using traditional chemical antiseptics, assessed using statistical methods including the Student’s t‑test and Wilcoxon W‑test.

Results. When the first subgroups were compared on the first day, there was no statistically significant difference in the levels of P. aeruginosa wound contamination (p=0.671). On the seventh day, there was a statistically significant difference between contamination levels (p<0.05) and the emergence of sensitivity to reserve antibiotics (p<0.05). On the 14th day, there was a statistically significant difference between contamination levels (p<0.05) and the emergence of sensitivity to reserve antibiotics (p<0.05).

Conclusions. Probiotic antiseptics have a statistically significant advantage over chemical antiseptics in terms of reducing contamination and emergence of antibiotic sensitivity in patients with purulent‑necrotic wounds in type 2 diabetes mellitus.

Choledochoscopy in the laparoscopic treatment of patients with choledocholithiasis: a single-centre study

Y. M. Susak — 2024-03-30

Choledochoscopy is a minimally invasive procedure used for laparoscopic bile duct exploration and the removal of bile duct stones. However, there is insufficient information available about its advantages in diagnosing choledocholithiasis and its role in laparoscopic choledocholithoextraction.

Objective — to compare the diagnostic efficacy of imaging techniques and choledochoscopy in patients with choledocholithiasis and to evaluate the role of choledochoscopy in laparoscopic choledocholithoextraction.

Materials and methods. The study examined the results of 128 patients with calculous cholecystitis and choledocholithiasis who had laparoscopic choledocholithoextraction in combination with choledochoscopy. We assessed the sensitivity and specificity of ultrasound, CT, and MRI in the diagnosis of choledocholithiasis, as well as the efficacy of one‑stage treatment of calculous cholecystitis and choledocholithiasis using choledochoscopy and laparoscopic choledocholithoextraction.

Results. Imaging techniques demonstrated limited sensitivity and specificity in determining the diameter and number of common bile duct stones. A total of 89 (69.5%) patients achieved complete bile duct clearance after blind laparoscopic choledocholithoextraction: 86 (81.1%) had choledochotomy, and 3 (13.6%) underwent transcystic common bile duct exploration. The combination of choledochoscopy and laparoscopic choledocholithoextraction ensured the complete removal of bile duct stones in 97.6% of patients.

Conclusions. The imaging techniques used for determining the number of common bile duct stones in choledocholithiasis had sensitivity and specificity rates of 41.4% and 92.7% for ultrasound, 72.7% and 83.3% for CT, and 86.7% and 60.9% for MRI, respectively. A total of 89 (69.5%) patients achieved complete bile duct clearance after blind laparoscopic choledocholithoextraction: 86 (81.1%) had choledochotomy, and 3 (13.6%)underwent transcystic common bile duct exploration. Choledochoscopy was required for laparoscopic choledocholithoextraction in 18.9% of choledochotomy patients and in 86.4% of those who underwent transcystic common bile duct exploration. Choledochoscopy demonstrated an overall bile duct stone clearance rate of 97.6%.

Hnat Mykhailovych Matyashin: the difficult path of a soldier, surgeon, scientist, and teacher

L. G. Zavernyi — 2024-03-30

The life and professional path of Professor Hnat Mykhailovych Matyashin: a scientist and surgeon, Doctor of Medical Sciences, Honoured Scientist of the Ukrainian SSR, Honoured Doctor of the Ukrainian SSR, Chief Surgeon of the Ministry of Health of the Ukrainian SSR, Head of the Department of Faculty Surgery of the Kyiv Medical Institute.

Nutritional support in patients with acute pancreatitis. Review of published studies

I. V. Kolosovych — 2024-03-30

Acute pancreatitis is a common disease that occurs in 5—10% of patients with urgent pathology of the abdominal cavity. The most prevalent metabolic disorders affecting this group of patients are hypermetabolism and hypercatabolism syndromes, which are accompanied by excessive consumption of carbohydrates, fats, and amino acids, increased oxygen intake, and carbon dioxide production.

Objective — to analyse the current state of the problem of nutritional support for patients with acute pancreatitis.

The degree of nutritional disorders in patients with acute pancreatitis varies depending on the etiological factors and severity of the disease, necessitating a differential approach to their correction. Patients with acute pancreatitis experience disruption of the intestinal microflora due to the antibiotic therapy, nutrient and fiber deficiency, and lack of microbial antagonism. This disruption leads to excessive growth of bacteria, particularly gram‑negative microflora. The effectiveness and safety of enteral tube feeding are determined by a complex of factors: the timing of recovery of peristalsis and the absorption function of the intestinal wall, the type of mixture, and the method of its administration. Restoration of intestinal absorption in patients with severe acute pancreatitis occurs on average 48 hours after the start of complex conservative therapy. The use of antiflatulents as part of a mixture for enteral nutrition allows to improve the laboratory indicators of blood serum and reduce the frequency of intestinal complications on the 7th day by 21.5% (χ²=4.88, 95% CI 2.3—39.5, p=0.03). Nasogastric nutritional support in patients with severe acute pancreatitis is safe and leads to a 25.8% reduction in the incidence of local infectious complications (χ²=4.59, 95% CI 2.43—45.53, p=0.03), length of hospital stay by 16 days (p=0.04), and deaths by 21.4% (χ²=4.13, 95% CI 0.81—39.68, p=0.04) in comparison with parenteral nutrition. Nutritional support should be started with nasogastric administration of a food mixture, and in case of complications (intolerance, aspiration, etc.), nasojejunal administration. Parenteral nutrition should be used if enteral nutrition is impossible or not tolerated.