General Surgery

Evolution of the doctrine of Zollinger-Ellison syndrome. Literature review

Y. A. Dibrova, M. S. Kryvopustov — Tue, 08 Oct 2024 00:00:00 +0300

Zollinger–Ellison syndrome (ZES) is a rare pathology that does not have specific clinical manifestations and is not always diagnosed in time. This is attributed to doctors’ insufficient awareness of this pathology and the limited availability of the necessary examination methods. Foreign literary sources on this problem are analysed. Historical data regarding the discovery of this pathology and the origin of the syndrome’s name are provided. The epidemiology of the disease is highlighted. The most characteristic clinical manifestations and possible complications of ZES are described in detail. The characteristic changes in gastric acid production associated with this pathology and their diagnostic value (sensitivity and specificity) are presented. At the same time, indicators of both basal and maximal stimulated gastric acid production are significantly increased. The most important stage in the examination of patients with suspected ZES is the determination of blood gastrin levels. At the same time, it is shown that it is not always possible to make definitive judgements in support of ZES based on gastrin indicators. An absolute criterion in favor of ZES is fasting gastrin values of 1000 pg/ml or more. When gastrin levels are less than this indicator, tests using secretin or calcium gluconate have significant diagnostic value. In these circumstances, tests with secretin or calcium gluconate are mandatory. The information on the possible localization of gastrin, the incidence of malignant transformation, and the mechanism of metastasis is given. Methods of determining gastrin localization, sensitivity, and specificity are described in detail. Based on the findings, a differentiated treatment strategy for patients with ZES is provided. Indications and contraindications for surgical and medical treatment of patients with ZES are given. The prospects of a new treatment direction ‑ the use of targeted radiotherapy ‑ are shown. These patients require constant monitoring by a gastroenterologist and a surgeon and periodically undergo the necessary examinations.

Difficult choledocholithiasis. Literature review

V. V. Volkovetskii, L. O. Pererva, M. V. Maksymenko, N. V. Puzyr — Tue, 08 Oct 2024 00:00:00 +0300

The incidence of stones in the common bile duct in patients with symptomatic gallstone disease varies significantly and depends on age, ranging from 5% to 33%. In 85—90% of cases, choledocholithiasis is effectively treated with endoscopic papillotomy (EPT) and lithoextraction, which is currently considered the standard method for managing this pathology. However, in 10—15% of cases, choledocholithiasis is technically challenging for endoscopic treatment, requiring alternative methods and specialized equipment. This research examines the epidemiological aspects related to the increasing detection rate of choledocholithiasis, which is attributed to advancements in modern diagnostic techniques. Particular emphasis is placed on etiological factors such as genetics, obesity, and dietary habits that enhance bile lithogenicity. The pathogenesis section elucidates the mechanisms underlying primary and secondary stone formation in the bile ducts and their physiological impacts, including such complications as acute cholangitis, biliary sepsis, cholestatic hepatitis, and biliary cirrhosis of the liver. Distinct focus is placed on the criteria for difficult choledocholithiasis, encompassing stone characteristics, location, altered biliary anatomy, and the patient’s general condition. Diagnostic techniques include laboratory and instrumental investigations, particularly ultrasound, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound. The treatment section emphasizes the importance of timely stone removal to prevent complications. Modern treatment options are discussed, including both conservative and surgical methods such as endoscopic procedures and laparoscopic surgeries. The significance of an interdisciplinary approach to the diagnosis and treatment of choledocholithiasis and its many manifestations is emphasized.

Difficult choledocholithiasis remains a relevant issue in hepatobiliary surgery, and its effective treatment requires an individualized and multidisciplinary approach, involving endoscopic and laparoscopic technologies.

Bifocal endometriomas involving a Pfannenstiel incision. Clinical case

A. E. Mishina, E. V. Gutu, I. V. Mishin, S. E. Gutu — Tue, 08 Oct 2024 00:00:00 +0300

Endometrioma of the anterior abdominal wall (EAAW) is a rather rare variant of extragenital endometriosis, which in most cases occurs after obstetrical and gynecological procedures. EAAW presented predominantly as a single tumour‑like mass, and multiple ectopias were observed in only 1.9—5.6% of cases, exclusively after Pfannenstiel laparotomy.

Here we present a clinical case of a 37‑year‑old patient who complained of the large tumour‑like nodules along the postoperative anterior abdominal wall scar, accompanied by severe cyclic, catamenial pain. Additionally, the patient noted an increase in tumour size during menstruation. Thirty‑three months ago, she underwent an elected cesarean section for obstetric indications. Based on ultrasonography and computed tomography scans, the presence of two EAAW in the corners of the postoperative scar was established: 46 × 32 × 31 mm and 14 × 18 × 13 mm, respectively. Both lesions were excised out without damaging their integrity. The fascial defect was replaced by synthetic polypropylene mesh. The diagnosis of EAAW was finally confirmed based on pathological (presence of endometrial glands and cytogenic stroma) and immunohistochemical (positive membrane expression of CD10 in cytogenic stroma, intense cytoplasmic expression of CK7 in endometrial glands, marked nuclear expression of progesterone (PR) and estrogen (ER‑α) receptors in endometrial glands and cytogenic stroma, proliferative activity index Ki‑67 — 2%) studies. At a follow‑up after 19 months, the patient was asymptomatic; according to physical examination and ultrasound scan, there was no evidence of recurrence.

Abdominal wall endometriosis is a rare condition. Clinicians should be aware of this pathology, especially in women presenting with a painful mass near the scar of a previous obstetrical and gynecological surgery. Surgery is the best treatment modality for endometrioma, whereas its optimal volume is considered to be R0 resection with preservation of endometriomas’ integrity. The final diagnosis of EAAW requires pathological and immunohistochemical confirmation.

Endoscopic transluminal necrosectomy in the complex treatment of a patient with acute infected necrotizing pancreatitis. Clinical case

Tue, 08 Oct 2024 00:00:00 +0300

This study presents a clinical case of acute pancreatitis treatment, which manifested as infected walled‑off necrosis in a 49‑year‑old obese woman. Diagnosis and treatment were provided by a multidisciplinary team comprising surgeons, anesthesiologists, interventional radiologists, and endoscopists. The treatment strategy followed a «step‑up approach,» a modern technique involving gradual progression from less to more invasive methods, thereby reducing the physiological stress on the patient. This approach has demonstrated efficacy in numerous studies.

In Western countries, endoscopic transluminal necrosectomy is gaining popularity, and our clinic has been implementing it successfully since 2021. Despite its effectiveness, clinicians still encounter challenges when opting for endoscopic transluminal interventions over other minimally invasive methods. Key issues include determining the timing and frequency of interventions, choosing debridement techniques and antiseptics for walled‑off necrosis, and establishing criteria for transitioning to more invasive procedures. Today, researchers handle these nuances on a case‑by‑case basis, relying on the expertise and proficiency of a specific specialized department, which necessitates further research.

In this case the patient achieved complete debridement of a localized fluid/necrosis collection through a stepwise approach. Initial management involved ultrasound‑guided percutaneous drainage and lavage, followed by four sessions of endoscopic transluminal necrosectomy as the final minimally invasive intervention. We assess the unfavorable long‑term outcomes, 2.5 years post‑treatment, as negligible.

The golden era of Kyiv surgery

D. Dubenko — Tue, 08 Oct 2024 00:00:00 +0300

The article discusses the academic and university surgery in Kyiv during the 1920s. It is based on data obtained from extensive archival research and available bibliographic sources, and it highlights a specific period of the work of the Faculty Surgical Clinic of Kyiv St. Volodymyr University, which is now known as Bogomolets National Medical University. The article presents information about the lives and professional journeys of the heads and staff of the surgical clinic, including Yevhen Cherniakhivskyi, Yurii Voronyi, Vira Hedroyts, Mykola Volkovych, and Oleksii Lazurenko.

Experience in treating patients with autoimmune pancreatitis

O. I. Dronov, Y. P. Bakunets, F. O. Prytkov — Tue, 08 Oct 2024 00:00:00 +0300

Objective — to establish the main diagnostic signs of autoimmune pancreatitis and aspects of patient treatment.

Materials and methods. The study analyzed the results of examination and treatment of 17 patients with autoimmune pancreatitis (AIP) from 2010 to 2022. Among the total number of patients with AIP, there were 11 men (65%) and 6 women (35%). The average age of the patients was 52.4 years. Among all patients with AIP, focal involvement of the pancreas was found in 3 (18%) patients, with a predominant involvement of the head of the pancreas. Segmental form of AIP was diagnosed in 6 (35%) patients, while diffuse form was found in 8 (47%) patients. Type 1 AIP was identified in 13 (76%) patients, and type 2 AIP in 4 (24%) patients. For all patients suspected of AIP, the HISORt criteria were assessed: instrumental visualization, serological and histological verification, determination of the volume of pancreatic involvement, and response to steroid therapy.

Results. Recurrence of AIP was observed in 8 (47.0%) patients with type 1 AIP and 1 (5.8%) patient with type 2 AIP. AIP recurred in patients with proximal bile duct involvement, diffuse pancreatic involvement, persistently elevated IgG4 levels after steroid induction, delayed radiological remission, and damage to more than two organs. Increased serum levels of IgG, IgG4, apnd eosinophilia indicated a recurrence of IgG4‑RD. A repeat induction of steroids was performed in patients with recurrent AIP, which proved to be very effective, resulting in high remission rates, specifically in 7 (70%) patients with type 1 AIP and in 1 (100%) patient with type 2 AIP. Among all AIP patients that were operated on, 3 (40%) underwent Roux‑en‑Y hepaticojejunostomies, 1 (20%) pancreaticoduodenectomy, and 1 (20%) a Frey procedure.

Conclusions. The low incidence of AIP necessitates the use of a clear diagnostic algorithm, and the peculiarities of the disease’s course require compliance with all the principles of conservative treatment and surgical interventions in case of surgical complications.

Peculiarities of the botulinum toxin type A injection technique and its effectiveness in the surgical treatment of large ventral hernias

O. Y. Ioffe, T. V. Tarasiuk, O. M. Chukanov, M. S. Kryvopustov, O. P. Stetsenko — Tue, 08 Oct 2024 00:00:00 +0300

Ventral hernias (VH) continue to be one of the most common surgical pathologies in planned and emergency surgery. Surgical treatment of large VH (≥10 cm) requires the use of traumatic surgical techniques in order to align the edges of the hernia defect and restore the integrity of the anterior abdominal wall.

Objective — to assess the effectiveness of the botulinum toxin type A (BTA) injections and to study the peculiarities of their administration into the muscles of the anterior abdominal wall in patients with large VH in the preoperative period.

Materials and methods. A prospective cohort study included 66 patients with large VH, primary (PVH), and incisional (IH). From June 2017 to August 2024, all patients underwent treatment and received injections of 100 units of BTA into the anterior abdominal wall muscles in the preoperative period. The patients’ average age was 58.98±9.48. There were 23 men (34.8%) and 43 women (65.2%). Before BTA, the average width of the hernial defect in PVH patients was 12.29±1.93 cm, whereas IH was 13.46±2.06 cm. All patients underwent surgical intervention for their hernias 4—5 weeks after the injection of BTA.

Results. No complications were detected throughout the BTA administration or the 4—5 weeks of observation before the surgical hernia repair. After injection, the length of the anterior abdominal wall muscles increased by an average of 1.7 cm (min 0.1 cm, max 4.01 cm) on each side. Patients with PVH had an average hernial defect width reduction of 4.17±0.68 cm, whereas those with IH had an average reduction of 5.14±0.75 cm (p <0.001). After BTA administration, the volume ratio of the hernia sac to the abdominal cavity decreased from 4.97±3.55% to 3.70±2.77% in patients with PVH (p=0.008) and from 5.59±3.71% to 4.21±2.88% in patients with IH (p=0.008).

Conclusions. The administration of 100 units of botulinum toxin type A in the preoperative period consistenly increases the length of the abdominal wall muscles, reduces the width of the hernial defect, and enhances the possibilities of further surgical treatment of large VH using laparoscopic technologies.

Hemodynamic surgery of varicose veins of the lower extremities with the introduction of modern technologies

I. V. Kolosovych, K. O. Korolova — Tue, 08 Oct 2024 00:00:00 +0300

Minimaly invasive and pathogenetically based methods are currently prevalent in phlebology, as they are in other fields of surgery. CHIVA (Сure conservatrice et hemodynamiу que de l’insuffisance veineuse en ambulatoire) hemodynamic surgery is one of these popular minimally invasive surgical procedures. The execution technique relies on the findings of a duplex ultrasound scan that is used to analyse the hemodynamics of the superficial venous network. The CHIVA strategy aims to preserve the venous material while also restoring normal distal venous pressure and venous function. However, this technique has a number of disadvantages, including the possibility of vein recanalisation and relapses, as well as the fact that the immediate cosmetic outcome is not always satisfactory.

Objective — to compare the outcomes of lower extremity varicose vein treatment based on the employed method: the CHIVA method executed via open surgery versus the CHIVA method combined with other minimally invasive methods (sclerotherapy, endovenous laser coagulation (EVLC)).

Materials and methods. A randomised prospective study was conducted on 52 patients with varicose veins of the lower extremities categorised as C1‑C3 according to the CEAR classification. The patients were divided into 2 groups of 26 patients each, with one group undergoing the CHIVA procedure using the classic open technique, and the other group receiving a combination of CHIVA with EVLC and sclerotherapy. To evaluate the results, we used Hobb’s criteria, measured the diameter of the great saphenous vein via ultrasound, analysed alterations in the Venous Clinical Severity Scoring (VCSS) , studied data from the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ 20), and determined the incidence of relapses.

Results. After CHIVA and CHIVA + EVLC + sclerotherapy, the normalisation of hemodynamics and interruption of the venous shunt led to a substantial reduction in the diameter of the great saphenous vein within 6 months after the operation (p<0.01). Both groups had an improvement in VCSS 6 months after surgery. No statistical difference was observed between the treatment groups. All methods had a positive impact on the quality of life of patients, as shown by the CIVIQ 20 questionnaire. Of the 52 operated patients, there were 4 relapses (7.7%). No relapses were noted in the group receiving CHIVA with EVLC and sclerotherapy (p=0.039). As evaluated by Hobb’s criteria, patients exhibited greater satisfaction with the outcomes of hemodynamic surgery combined with EVLC and sclerotherapy due to its better and faster aesthetic outcomes (р=0.012 and 0.05).

Conclusions. All 52 patients exhibited favourable treatment outcomes, demonstrating a reduction in CVI symptoms during a comprehensive clinical assessment using ultrasound within 6 months and 1 year. The combination of CHIVA with EVLC and sclerotherapy showed distinct advantages in the treatment of varicose veins, yielding the most favourable cosmetic outcomes according to Hobb’s criteria and achieving a reccurence rate of 0%.

Efficacy of the ERAS strategy in patients with type III–IV paraesophageal hernias

O. Y. Ioffe, O. P. Stetsenko, L. Y. Markulan, T. A. Tarasov — Tue, 08 Oct 2024 00:00:00 +0300

ERAS (Enhanced Recovery After Surgery) protocols have demonstrated efficacy across numerous surgical specialties; however, their effectiveness has not been evaluated in patients with paraesophageal hernias (PEH).

Objective — to determine the efficacy of the ERAS strategy in patients with type III—IV PEH undergoing laparoscopic surgery.

Materials and methods. The study was conducted at the Department of General Surgery No 2 of Bogomolets National Medical University from 2017 to 2023, involving 114 patients who underwent laparoscopic hernioplasty for Type III—IV PEH. The ERAS strategy was applied in 96 patients (main group — Group M) and not applied in 18 patients (comparison group — Group C). The efficacy of the ERAS protocol was evaluated by comparing average hospital stay, hunger, thirst, general weakness, and depression levels using a 10‑point visual analogue scale (0=«no concern,» 10=«severe concern»), as well as the frequency of nausea, vomiting, abdominal distention, passage of gas, and bowel movement within the first postoperative day.

Results. Group M showed lower average scores for «general weakness», «hunger», and «thirst» by factors of 1.43, 1.35, and 1.34, respectively, compared to Group C. The application of the ERAS protocol positively influenced bowel function recovery: on the first postoperative day, the proportion of patients with gas passage was higher in Group M than in Group C (78.1% vs. 55.6%), while the incidence of abdominal distention was lower (2.1% vs. 16.7%). Bowel movement was observed in 51.0% of patients in Group M compared to 27.8% in Group C. These positive outcomes associated with the ERAS protocol contributed to a reduced average hospital stay of 1.72±0.76 days compared to 2.33±0.91 days in the control group.

Conclusions. The use of the ERAS protocol in patients undergoing laparoscopic surgery for type III—IV paraesophageal hernia demonstrated significant advantages in the early postoperative period. Patients reported significantly less «general weakness», «feeling of hunger», and «feeling of thirst» compared to the control group. Improved bowel function recovery was recorded, evidenced by a higher proportion of patients with gas passage and bowel movements and a significantly lower proportion of patients with abdominal distension, as well as a reduced average length of hospital stay. The obtained results confirm the feasibility of implementing the ERAS protocol to improve postoperative recovery and reduce postoperative complications in patients with type III—IV paraesophageal hernia.

Severity of pain syndrome, functional activity, and quality of life in male patients with inguinal hernias in the preoperative period

A. V. Trots — Tue, 08 Oct 2024 00:00:00 +0300

According to the European Hernia Society (EHS) and the Hernia Surge Group (HSG), males with inguinal pain syndrome make up the majority of candidates for planned inguinal hernia surgeries. Chronic groin pain in the preoperative stage typically has a negative impact on such patients’ functional activity and quality of life. It is therefore considered a significant indication for planned surgery. According to recent research, appropriate functional outcomes, such as improved physical activity and patient quality of life, are as important as an accurate anatomical restoration of the inguinal region after planned inguinal hernia surgery.

Objective — to assess the severity of preoperative inguinal pain syndrome, functional activity, and quality of life in male patients with inguinal hernias.

Materials and methods. The study focuses on the preoperative clinical examination of 50 patients (males) with primary unilateral inguinal hernias. The patients were treated in the surgical department of the State Scientific Institution «Centre for Innovative Medical Technologies of the National Academy of Sciences of Ukraine» between 2018 and 2024. A questionnaire method was employed to assess the functional activity, quality of life, and severity of pain syndrome in patients before surgery. This method involved the use of the modified Carolinas Comfort Scale (MCCS), the European Questionnaire for the Assessment of Quality of Life (EQ‑5D‑3L), and the Visual Analogue Scale (VAS).

Results. The average pain severity index on the VAS was 2.1±0.9 points. The MCCS was used to assess patients’ functional activity, resulting in an average total score of 33.7±12.1 points, which corresponded to 44.9%, classifying the patients as «not satisfied» in the clinical group. The EQ‑5D‑3L descriptive system was used to assess patients’ quality of life. We found that 30% reported moderate mobility limitations, 18% reported moderate self‑care issues, and 34% reported limitations in their daily activities. 24% of patients exhibited moderate anxiety or depression‑related symptoms. At the same time, all patients noted the presence of pain syndrome, with 76% experiencing moderate pain and 24% suffering severe pain.

Conclusions. The «symptomatic» group of males with inguinal hernias exhibits a high level of local pain syndrome in the area of the hernia protrusion (2.1±0.9 on the VAS, and 24 % of patients reported a significant degree of pain severity before planned surgical intervention (> 3 points) according to the EQ‑5D‑3L system). In the vast majority of cases, it significantly impairs their functional activity and quality of life (66% of patients are not satisfied with their quality of life (32.4±5.6 points on the MCCS)). Effective local pain management is an important objective in the planned surgical treatment of inguinal hernias. This necessitates further investigation into surgical technique selection and procedure adjustments.

Optimisation of bronchoalveolar lavage technique for isolating alveolar macrophages in mice

Tue, 08 Oct 2024 00:00:00 +0300

Bronchoalveolar lavage (BAL) is a widely used technique to collect immune cells from the lungs, with alveolar macrophages (AMs) being the most prevalent cells in BAL fluid. AMs are vital for maintaining lung homeostasis and providing immune defence against airborne pathogens. However, in murine models, BAL procedures usually yield low numbers of AMs, thus limiting experimental design, especially when high cell counts are needed.

Objective — to optimise the BAL technique in mice to maximise the collection of AMs.

Materials and methods. Young and older BALB/c mice were used in the study. Bronchoalveolar lavage was performed following the method of Luckow and Lehmann (2021) with modifications. Statistical analysis was done using the Mann‑Whitney U test, with a significance level set at p<0.05.

Results. Female BALB/c mice of different ages were chosen due to the frequency of their use as models of pulmonary diseases. A simplified method described by Luckow and Lehmann (2021), which avoids tracheotomy by using peroral cannula insertion, was employed. The protocol was modified by securing the cannula with a ligature to prevent BAL fluid leakage in older mice. To reduce mechanical stress on alveoli, a buffer volume of 0.6 mL was used, and the study compared two buffer variants: one at room temperature without EDTA, and another heated to 37°C with EDTA. The pre‑heated buffer with EDTA significantly increased BAL cell yields in all mice groups, confirming the importance of these optimisations for higher cell recovery.

Conclusions. Our modified bronchoalveolar lavage protocol includes securing the trachea with a ligature to prevent BAL fluid leakage, reducing lavage volume to 0.6 mL to minimise lung damage, and using a 37°C solution with EDTA for improved AM recovery rates. Further studies are needed to explore the significance of other buffer components for BAL protocol optimisation, the possible age‑related differences in AM isolation in male BALB/c mice, and the strain‑specific features of the BAL technique.