General Surgery

Peculiarities of a differentiated approach to surgical treatment of patients with combined combat thermomechanical injuries and long-bone gunshot fractures by the levels of patient care

S. O. Korol, I. P. Palii, O. I. Zhovtonozhko, V. S. Honcharuk — Mon, 30 Dec 2024 00:00:00 +0200

Objective — to improve treatment outcomes for wounded individuals with long‑bone fractures and combined combat thermomechanical injuries (CCTMI) by developing and implementing a differentiated approach to surgical treatment at different levels of patient care.

Materials and methods. The surgical outcomes of 178 wounded individuals with long‑bone fractures and CCTMI were investigated. The study employed general clinical, surgical, laboratory, biochemical, morphological, and statistical methods. The wounded individuals were divided into two clinical comparison groups: the main group and the control group. The main group included 91 wounded individuals with long‑bone gunshot fractures who underwent surgical treatment according to a differentiated surgical approach that involved assessing the severity of CCTMI. The control group included 87 wounded individuals with long‑bone gunshot fractures and CCTMI who received standard surgical treatment for burn and gunshot wounds. The comparative analysis was carried out based on age, the specific gravity of long‑bone gunshot fractures, body surface area of the burn, type of wound tract, number of wounds, type of injury, time of admission, the effectiveness of organizational and medical interventions (p >0.05).

Results. The analysis of treatment interventions revealed that the incidence of fasciotomies in the main group was 27.47% compared to only 9.20% in the control group. Additionally, the application of vacuum therapy reached 40.91% versus 23.17% in the control group (p <0.05). In CCTMI with significant bone defects, the main group used more modern fragment‑fixing procedures, including the Ilizarov apparatus and the two‑stage Masquelet technique (84.09% vs. 50.00%, p <0.01). The use of the admission trauma scale (AdTS‑CCTMI) and the perfusion index in all cases of the main group facilitated the timely assessment of the patient’s condition, improving treatment quality and preventing complications. In terms of early complications, the main group had considerably lower rates of anemia (62.64% vs. 78.16%, p <0.05), resulting in fewer metabolic changes in the myocardium (23.08% vs. 36.78%) and acute renal failure (9.89% vs. 14.94%). The control group experienced nearly twice as many thromboembolic problems (12.64% vs. 7.69%, p <0.05), highlighting the need for improved preventive measures. Among the late complications, postoperative wound suppuration and osteomyelitis remained significant challenges. However, these complications were less common in patients in the main group (9.89% and 6.59%, respectively) than in the control group (21.84% and 16.09%). 4.40% of patients in the main group underwent limb re‑amputations for gangrene or osteomyelitis compared to 10.34% in the control group (p <0.05).

Conclusions. The functional treatment outcomes, as measured by the Mattis‑Lyuboshyts‑Schwarzberg scale, demonstrated an increase in the proportion of good results from 39.08±5.23% to 56.98±2.85%, with a decrease in the relative number of unsatisfactory results from 18.39±4.15% to 6.24±0.31%, at p <0.05. A differentiated surgical strategy with an objective assessment of injury severity at different levels of patient care resulted in a decrease in mortality from 10.34% in the control group to 5.49% in the main group, reflecting a reduction of 4.85%.

Minimally invasive and standard operative techniques in the surgical treatment of acute complicated pancreatitis

V. P. Andriushchenko, D. V. Andriushchenko, Y. S. Lysiuk, M. V. Prikupenko — Mon, 30 Dec 2024 00:00:00 +0200

The surgical treatment of acute pancreatitis, particularly the choice of operative technique, is becoming increasingly relevant.

Objective — to develop a surgical approach for treating patients with acute complicated pancreatitis by determining the effectiveness of minimally invasive and traditional operative techniques, both independently and in combination.

Materials and methods. Surgical treatment was performed on 170 patients with acute complicated pancreatitis. In the main group (Group M) — 109 patients were predominantly treated with minimally invasive techniques (MITs), while in the comparative group (Group C) — 61 patients underwent standard operations. The age of hospitalized patients ranged from 22 to 74 years, including 36 women (33%) and 73 men (67%).

Results. MITs were performed as «final» in 62 cases (69%), «staged» in 16 cases (18%), and «stabilizing» in 12 cases (13%). The number of combined interventions was higher in Group M — 26% versus 12% in Group C (p=0.04), while standard operations dominated in Group C — 67% compared to 17% in Group M (p <0.0001). Primary laparotomy was performed in 41 patients (67%) in Group C and 19 patients (17%) in Group M (p <0.0001). The volume of standard operations in Group M mainly consisted of necrosectomy and the Beger procedure, including closed drainage — 26 cases (55%) and 15 cases (31%), respectively. Necrosectomy with subsequent staged debridement for general purulent‑necrotic lesions did not differ statistically between the groups — 11 cases (23%) and 13 cases (26%) (p >0.05).

Conclusions. The developed approach to the surgical treatment of acute complicated pancreatitis with the independent and combined use of MITs and standard operations demonstrated a tendency to reduce the frequency of postoperative complications and postoperative mortality rates — from 13.1% to 8.3% and from 14.8% to 9.2%, respectively.

Management of ventral hernias: treatment results based on the developed algorithm

O. Y. Ioffe, T. V. Tarasiuk, M. S. Kryvopustov, O. P. Stetsenko — Mon, 30 Dec 2024 00:00:00 +0200

The surgical treatment of anterior abdominal wall hernias is one of the most common procedures in elective surgery. However, the rate of laparoscopic hernioplasty is lower when compared to open methods. Experience in treating large ventral hernias (і 10 cm) using minimally invasive techniques is limited due to the inability to compare the edges of the hernial defect without component separation.

Objective — to develop an algorithm for choosing a surgical treatment method for patients with ventral hernias and to evaluate the results of treatment.

Materials and methods. A prospective multicenter study was conducted, which included 534 patients with ventral hernias of various sizes. All patients were treated from September 2011 to November 2024. Preoperatively, patients with hernias ≥10 cm were injected with 100 Units of botulinum toxin type A (BTA) into the muscles of the anterior abdominal wall. The mean age of the patients was 56.49±14.59 years, with 307 (57.5%) women and 227 (42.5%) men. All patients underwent hernia surgery using laparoscopic and open hernioplasty methods according to the developed algorithm.

Results. The algorithm classified patients into three groups based on their hernia size: group 1 — patients with hernias <4 cm wide (n=269; 50.4%), group 2 — with a size of 4—10 cm (n=173; 32.4%), and group 3 — with a size of ≥10 cm (n=92; 17.2%). The mesh was placed intraperitoneally during laparoscopic hernia repair. In all three groups, laparoscopic hernioplasty demonstrated a significantly lower rate of complications and length of hospital stay compared to open procedures (p <0.01). Seromas were among the most common complications in all three groups in our study (n=19; 7.1% vs n=26; 15.0% vs n=14; 50%), and their frequency increased with hernia defect size. In group 3, among patients with large hernias, BTA administration allowed for the reduction of the aponeurosis defect to ≤10 cm in size in 89.4% of cases and the performance of laparoscopic surgery in patients who agreed to it. The recurrence rate after laparoscopic surgery was 0.8%, while after open surgery, it was 1.1%.

Conclusions. The use of the algorithm for selecting the hernioplasty method allows implementing a personalized approach to the surgical treatment of patients with ventral hernias. Laparoscopic hernioplasty with intraperitoneal mesh placement demonstrates significantly better results compared to open methods of hernia repair in terms of length of hospital stay and complication rate (p <0.01). The use of BTA for hernias ≥10 cm in the preoperative period makes it possible to perform hernioplasty using laparoscopic techniques and minimize surgical trauma in case the patient refuses laparoscopy.

Treatment outcomes for grades I-II chronic hemorrhoids using the bipolar vaporization method

L. S. Bilianskyi, I. V. Voloshyn, L. Y. Markulan — Mon, 30 Dec 2024 00:00:00 +0200

Minimally invasive methods for the treatment of chronic hemorrhoids are a crucial component of modern proctology. However, they do not always provide optimal outcomes due to recurrences, complications, and the need for repeat procedures. Some methods have limited accessibility due to high requirements for physician expertise and expensive equipment, highlighting the need for improved approaches.

Objective — to evaluate the efficacy and safety of bipolar vaporization for treating grades I—II chronic hemorrhoids.

Materials and methods. The study included 32 patients (19 men and 13 women) aged from 19 to 70 years with chronic hemorrhoids of grades I—II that were resistant to conservative treatment. The duration of chronic hemorrhoids ranged from 1 to 20 years, with an average of 6.8±4.5 years. The bipolar vaporization procedure was performed using the Ukrainian‑made bio‑welding generator EK‑300M «Sarmed.» The primary endpoints included assessment of hemorrhoid symptoms, complications, patient satisfaction with treatment outcomes, and recurrence rates.

Results. Persistent bleeding and/or node thrombosis were the primary indications for surgery in 100% of patients, affecting 14 patients (43.8%). Intraoperative blood loss did not exceed 20 ml, with an average of 8.3±3.7 ml. The mean duration of the procedure was 44.3±7.1 minutes. The average number of ketorolac doses on the first postoperative day was 1.4±0.9 doses (ranging from 1 to 4 doses), and on the second day, 1.8±0.8 doses (ranging from 1 to 3 doses). The mean hospital stay was 2.3±0.5 days (2 to 3 days), and the average period of incapacity for work was 5.8±0.7 days (5 to 7 days). On the 7th postoperative day, 65.6% of patients reported pain, but its intensity was low (1.62±0.7 points, p=0.003). At 6 weeks and 1 year postoperatively, none of the patients reported pain. After one year, 96.9% of patients were free of prolapse, itching, or soiling, and bleeding was absent in all cases. Patient satisfaction after one year averaged 8.31±0.74 points. Recurrence occurred in 3.1% of patients.

Conclusions. Bipolar vaporization is an effective and safe method for treating chronic hemorrhoids of grades I—II, providing significant symptom relief, minimal blood loss, and a short recovery period. The method demonstrates a high level of patient satisfaction and a low recurrence rate. The study results confirm the high efficacy and safety of this method, making it a promising approach for the treatment of chronic hemorrhoids.

Endoscopic stent placement in the management of esophagojejunal anastomosis leakage

Mon, 30 Dec 2024 00:00:00 +0200

Objective — to evaluate the effectiveness of endoscopic stent placement compared to surgical methods for the management of esophagojejunal anastomosis leakage (AL) after gastrectomy at the National Cancer Institute (NCI) from November 2017 to November 2019.

Materials and methods. The study included patients receiving treatment at the Upper Gastrointestinal Oncology Department of the National Cancer Institute between November 2017 and November 2019. Throughout this period, 186 total gastrectomies were performed. 13 (6.9%) patients developed an anastomotic leak in the postoperative period. All patients had Roux‑en‑Y esophagojejunostomy. 6 patients (46.1%) underwent endoscopic stent placement in the AL area, along with perianastomotic drainage positioning and enteral feeding via a naso‑intestinal tube. Of the remaining patients, 7 (53.9%) underwent surgical treatment, including esophagostomy or esophageal stump formation with a nutritional jejunostomy. This manuscript employed methods of descriptive statistics.

Results. Endoscopic stent placement was successful for 5 patients. Complete defect closure following stent placement was confirmed in 5 patients (83.3%) using endoscopic and radiological methods. The mean hospital stay in the stent group was 15.4 days (range: 9—22 days). The mean time for endoscopic stent removal during rehospitalization was 49.5 (33—62 days) days after initial placement. Complications associated with AL, specifically sepsis resulting from infection in the AL area, led to the death of 1 (16.7%) patient in the stent group. Surgical treatment was successful in 5 patients (71.4%). 2 patients (28.6%) died due to infectious complications and multiple organ failure syndrome. The average hospital stay for surgical patients was 32.8 (19—40) days. Mortality rates were 16.7% and 28.6% for the stent placement and surgical groups, respectively.

Conclusions. Endoscopic endoluminal stent placement in the area of AL using self‑expandable metallic stents combined with local drainage and enteral nutrition is a promising method for treating esophagojejunal anastomotic leakage after total gastrectomy. This study demonstrates that endoscopic stent placement reduces hospital stay and mortality rates compared to surgical methods. Endoscopic stent placement provides effective defect closure with fewer complications. However, surgical treatment remains indispensable in cases of severe sepsis or failure of conservative methods, despite the high mortality risk. Further studies are needed to develop standardized approaches for selecting treatment methods based on leak size and the patient’s overall condition.

The role of clinical and genealogical study in the examination of patients with chronic venous insufficiency

I. V. Kolosovych, K. O. Korolova, Z. V. Korolova — Mon, 30 Dec 2024 00:00:00 +0200

Objective — to demonstrate the role of heredity in the development of varicose veins using a clinical‑genealogical study, analyze family cases of varicose veins of the lower extremities, determine the type of disease inheritance in the examined patients, and assess the possible outcomes of genetic inheritance for their descendants.

Materials and methods. The study involved 64 patients, mostly women — 52 (81.3%), with different clinical classes of varicose veins. The clinical‑genealogical method of pedigree analysis was used to establish the type of inheritance. We determined the nature of the disease trait (hereditary or non‑hereditary) and the type of inheritance (autosomal dominant, autosomal recessive, or gender‑linked).

Results. Among the 64 examined patients, 28 (43.8%) had familial cases of varicose veins. In our clinical‑genealogical study of the pedigrees of patients with chronic venous insufficiency, we found an autosomal dominant inheritance of this pathology, not linked to gender. Direct inheritance across generations was observed.

Conclusions. The analysis of the pedigrees of patients with varicose veins of the lower extremities and other manifestations of chronic venous insufficiency revealed the familial nature of disease inheritance, characterized by an autosomal dominant inheritance type and a high degree of gene expression. In these families, children are more likely to show signs of the disease. A hereditary predisposition to certain forms of varicose veins has also been noted. Consequently, in individuals with reticular varicose veins, the main veins of the lower extremities exhibited no alterations with age, whereas reticular varicose veins simply increased in prevalence.

Postoperative quality of life in patients with chronic slow-transit constipation according to the PAC-QOL scale

I. M. Leshchyshyn, L. Y. Markulan, O. I. Okhotska, P. L. Byk — Mon, 30 Dec 2024 00:00:00 +0200

Chronic constipation is a common heterogeneous condition affecting all population groups, with its prevalence increasing with age. The prevalence of chronic constipation varies from 3% to 27% in the general population. Worldwide, the average prevalence of constipation is 16%, with a prevalence of 33.5% in adults aged 60—110 years. Information about the quality of life in patients with chronic slow transit constipation (CSTC) in Ukraine is very limited.

Objective — to assess the quality of life in patients with chronic slow transit constipation using the Patient Assessment of Constipation Quality of Life Questionnaire (PAC‑QOL) scale after surgical treatment.

Materials and methods. 107 patients with CSTC were examined and treated at the surgical department of the Saint Michael Clinical Hospital in the period 2011—2023.

Results. Significant improvements in all PAC‑QOL scale indicators were observed one year after surgery. The physical component score decreased from 2.78±0.52 to 1.01±0.32; p <0.01; the psychological component score decreased from 1.90±0.48 to 0.83±0.41; p <0.01; the anxiety component score decreased from 1.99±0.31 to 0.72±0.34; p <0.01; and the satisfaction component score decreased from 2.35±0.60 to 0.84±0.47. The total PAC‑QOL score decreased from 2.14±0.23 to 0.82±0.35; p <0.01. A reduction in the PAC‑QOL score was observed one year after surgery, with an average improvement of 61.5±14.9% (ranging from 6.2% to 77.2%). The highest percentage of improvement was registered in the «Satisfaction» component, with an increase of 81.2±15.0% (ranging from 33.3% to 88.2%), while the lowest improvement was in the psychological component, 56.7±16.1% (ranging from 0.0% to 78.6%). For the physical component, the percentage of improvement was 63.14±11.23% (ranging from 30.0% to 81.82%), and for the worries component, it was 64.0±15.75% (ranging from 0.0% to 77.2%).

Conclusions. According to the PAC‑QOL scale, surgical treatment involving colectomy improves quality of life significantly in the long‑term postoperative period in patients with CSTC who are resistant to conservative therapy. Overall PAC‑QOL scores improved by 61.51%, as did all components: physical (63.14%), psychological (56.73%), anxiety (64.0%), and satisfaction (81.2%).

A life dedicated to surgery: Serhii Tymofieiev’s contribution to medicine and education

Y. P. Tsiura, M. S. Kryvopustov — Mon, 30 Dec 2024 00:00:00 +0200

Serhii Lukianovych Tymofieiev (1875—1943) was a renowned physician, surgeon, scientist, and teacher in the history of Ukrainian medicine. Continuous education and practice shaped his professional career, which began in the Kherson province. Tymofieiev became a Doctor of Medical Sciences after defending his dissertation on the pathogenesis of renal edema. His contribution covers several medical fields, including orthopedics, traumatology, urology, and military surgery. Serhii Lukianovych founded the Department of Traumatology and Orthopedics at the Kyiv Medical Institute, which became the basis for the development of modern Ukrainian orthopedics. He developed innovative approaches to the treatment of injuries, reconstructive surgery, and the training of future doctors. During World War I, Tymofieiev headed the surgical department of the Kyiv Military Hospital, where he treated gunshot wounds. His pedagogical activity was focused on improving the teaching of military field surgery, a topic that is particularly relevant during times of military conflicts. Tymofieiev not only worked tirelessly but also educated a generation of doctors who continued his legacy. Having written more than 90 scientific works, he became one of the founders of Ukrainian surgery and medical education. His life path is an example of high professionalism, extensive scientific knowledge, and commitment to the medical profession. Tymofieiev made a significant contribution to the history of medicine, and his legacy continues to inspire modern doctors.

26-Year perspective on stapled hemorrhoidopexy – insights into managing severe complications. Two case reports and literature review

Mon, 30 Dec 2024 00:00:00 +0200

Stapled Hemorrhoidopexy, first introduced by Longo in 1998, has become a widely adopted surgical method for treating hemorrhoidal disease. This innovative procedure gained popularity due to reduced postoperative pain, shorter hospital stays, and faster recovery. However, it is not without risk and is associated with rare but severe complications that can significantly affect patient outcomes. This study describes two illustrative clinical cases of such complications. The first case involves a 41‑year‑old male patient who developed a perirectal hematoma accompanied by acute abdominal bleeding caused by mesenteric vessel rupture at the rectosigmoid junction. Urgent surgical intervention and intensive postoperative care were required. The second case concerns a 49‑year‑old female patient who experienced anal stenosis and subsequent fecal incontinence, necessitating both surgical correction and prolonged rehabilitative therapy to restore bowel function and improve quality of life. These cases emphasize the critical importance of early recognition and effective management of complications associated with stapled hemorrhoidopexy. They also highlight the necessity of a multidisciplinary approach involving colorectal surgeons, general surgeons, and gastroenterologists to optimize patient care.
A comprehensive literature review identifies key risk factors for complications, including patient comorbidities, technical nuances of the procedure, and the careful selection of candidates. Best practices for preventing and managing complications are also discussed, focusing on surgical technique refinement, thorough preoperative evaluation, and enhanced staff training. These insights aim to equip clinicians with essential knowledge to minimize risks, enhance patient safety, and maintain the advantages of this innovative method.

A case of metachronous ascending colon cancer and synchronous primary rectal and duodenal cancer in a patient with Lynch syndrome

Y. M. Susak, I. M. Leshchyshyn, О. М. Lobanova — Mon, 30 Dec 2024 00:00:00 +0200

Multiple primary malignant tumours (MPMTs) are defined as the simultaneous or sequential occurrence of two or more primary malignant tumours in a single patient, which may originate from the same organ, paired organs, different parts of the same system, or different organs. Synchronous MPMTs develop within 6 months of the primary tumour, while metachronous ones occur more than 6 months later. The available sources have no information on metachronous or synchronous colorectal and duodenal cancer.

Objective — to present treatment outcomes of a rare case of metachronous ascending colon cancer and synchronous primary rectal and duodenal cancer in a patient with Lynch syndrome.

A male patient, born in 1963, underwent a right‑sided hemicolectomy for ascending colon mucinous adenocarcinoma — stage III (рT_4рN₁M₀) — in 2002. In the summer of 2022, he complained of pain in the right hypochondrium, nausea, general weakness, and blood in the stool. The examination revealed the presence of synchronous primary cancer in the rectosigmoid section and duodenal cancer. The decision to proceed with a two‑stage surgical intervention was based on the partial colonic obstruction. The first stage (September 08, 2022) included the anterior resection of the rectum with sigmo‑recto anastomosis (рТ_4сN_2bM₀, stage III, R‑0). The second stage (December 08, 2022) included the resection of a portion of the descending and lower horizontal parts of the duodenum with duodeno‑duodenoanastomosis, followed by Roux‑en‑Y gastrojejunostomy. The procedure entailed stitching the stomach in the prepyloric section, performing a cholecystectomy, and draining the abdominal cavity (duodenal adenocarcinoma with free margins: R‑0). The patient was diagnosed with Lynch syndrome based on immunohistochemistry screening results and genetic studies. After the first and second stages, the patient categorically refused to undergo a course of traditional adjuvant therapy. At the control CT scan 1.9 months after the last operation, there were no signs of prolongatio morbi. A rare case of synchronous rectal and duodenal cancer, demonstrating favourable treatment outcomes after two‑stage surgery without standard adjuvant therapy, is described. Patient follow‑up is ongoing; therefore, the results may change in the future.