General Surgery

Pathophysiology of the gastrointestinal tract in burn disease

O. V. Kravets, V. V. Yekhalov, V. V. Gorbuntsov — Sun, 30 Jun 2024 00:00:00 +0300

The review of foreign publications resulted in a generalisation of medical reports on the pathological changes of the gastrointestinal tract in burn disease. Burn disease produces an immediate reaction in all organs and systems, which are not always able to maintain homeostasis and frequently suffer pathophysiological and morphological damage. One of those target systems is the gastrointestinal tract. Only in very rare cases do severe (mainly electrical) burns cause direct injury to the abdominal cavity organs, thus resulting in a very severe clinical course and high mortality. Patients of all ages who have experienced a burn injury have an increased overall risk of developing gastrointestinal diseases, which include pathology of the esophagus, stomach, and intestines, as well as lesions of the gallbladder, biliary tract, and pancreas. With a burn area of 40—95%, 5.7% of the victims were diagnosed with pathology of the abdominal organs. Among them, 26.0% had an abdominal catastrophe (infarction or perforation), 37.0% had bleeding from the upper parts of the gastrointestinal tract, 32.0% had paralytic intestinal obstruction, and 5.0% developed pancreatitis and acute necrotizing cholecystitis. Large burns are usually associated with a significant decrease in splanchnic perfusion. After severe burns, intestinal ischemia and hypoxia disrupt the intestinal epithelial barrier and enteric bacterial translocation, leading to serious complications such as systemic inflammatory response syndrome, sepsis, and multiple organ failure. Peritonitis or gastrointestinal bleeding accounted for 88.2% of deaths among patients with gastrointestinal dysfunction. In general, gastrointestinal dysfunction was more common in patients with inhalation injuries, burn shock, large burn areas, and high analgesic requirements.

Yurii Voronyi – a surgeon who was ahead of his time

D. Dubenko — Sun, 30 Jun 2024 00:00:00 +0300

The article outlines the historical milestones in the biography of the outstanding Ukrainian surgeon, Professor Yurii Voronyi, who was a disciple of Professor Yevhen Cherniakhivskyi. The study includes a compilation of historical records, archival sources, and other materials illustrating the life of Professor Voronyi. It highlights the professional and public achievements of Yurii Voronyi, particularly his participation in the struggle for Ukrainian independence between 1917 and 1921.

Lemniscate intestinal loop through an internal hernia after Roux-en-Y gastric bypass cause of coecum mobile. A case report

Sun, 30 Jun 2024 00:00:00 +0300

The internal hernia is a typical complication after laparoscopic Roux‑en‑Y gastric bypass surgery. In most cases, there are chronic symptoms that only lead to a diagnostic laparoscopy during the diagnostic exclusion procedure. Less common is acute internal hernia with devastating pain, ileus symptoms and even the development of intestinal gangrene. Although this case describes a typical constellation, it posed a particular challenge because it resulted in mesenteric lemniscate‑like torsion through the Petersen pouch.

Case presentation. A 29‑year‑old patient presented to our emergency department with abdominal pain, complained of sudden epigastric pain that lasted overnight, and radiated into the back with a permanent belching every 10 seconds. Four weeks ago, the patient received an abdominoplasty, complaining of postprandial nausea, meterorism and constipation afterwards. 19 months ago, a Roux‑en‑Y gastric bypass with a weight of 109 kg and a body mass index of 42.6 kg/m² was done. The current body weight was 60 kg and the body mass index was 23.4 kg/m². After focused assessment with sonography for trauma and the detection of dilated intestinal loops, an abdominal computer tomography (CT) was performed. Radiologically, the suspicion of mesenteric malrotation was confirmed. The SWELL (CT‑graphic swirl sign, excess weight loss >95%, liquid in abdomen CT scan) score was positive with a CT‑graphic swirl sign and an excess weight loss of 108.9% (> 95%), no chylus or ascites. We discussed an immediate, necessary diagnostic laparoscopy. Based on the ileocoecalpol, it was not possible to establish a proper assignment of the detached gastrointestinal tract. The exploration of the sigmoid colon as the only fixed point revealed that this was a complete fixed twisting of the right intestinal part with a twist of the caecum into the right upper abdomen through the Petersen space. This necessitated a laparotomy to manually cancel Bernoulli’s lemniscate‑like loop and perform a mesenteric defect suture of the mesenteric space of Brolin and the Petersen space with a non‑absorbable suture. The intestinal loops and patient recovered quickly. The dismission was on the 4th post‑operative day.

Conclusions. The internal hernia after gastric bypass remains a diagnostic challenge despite advances in imaging. Due to the increasing number of patients undergoing bariatric surgery, this differential diagnosis must always be considered in the case of abdominal complaints. In addition to the excess weight loss of >95%, this case shows that a recent abdominoplasty can also provoke an internal hernia.

A clinical case of secondary breast augmentation after previous implants removal

O. Panchuk, I. Donets, K. Galperin — Sun, 30 Jun 2024 00:00:00 +0300

The patient underwent primary breast augmentation at a different clinic. Two years later, the implants were replaced with larger breast implants (500 ml each). Three months after the procedure, inflammation of the right and left mammary glands occurred, which led to the removal of both implants. The patient was 24 years old when the surgery took place. She underwent a preoperative examination in accordance with the standards set by the Ministry of Health of Ukraine. The patient came to us for breast augmentation, correction of mammary gland contour imperfections, and management of postoperative scars. Round‑shaped and moderate‑profile implants were selected. Implant parameters: width 13 cm, projection 4.4 cm, implant texture — microtexture, volume 400 ml. We placed the implants in the retropectoral space, and used the dual‑plane method for cavity formation. The surgical procedure lasted for a total of 140 minutes. The duration of the patient’s hospitalisation was one day. No drains were used. The scars on the abdomen were also corrected and fixed in the projection of the inframammary fold. No complications occurred in the postoperative period. The patient received antibiotic therapy and took nonsteroidal anti‑inflammatory drugs. Postoperative wound management was carried out. We prescribed compression underwear for the patient to wear for two months after surgery.

Mammoplasty is a commonly performed procedure in plastic surgery. It aims to produce predictable and agreed‑upon aesthetic outcomes for the patient while maintaining a low rate of complications by adhering to modern surgical standards. The patient experienced complications that led to a significant scarring process. The pectoralis major muscle had a significant deformity, and the tissue showed scarring. The lack of muscle elasticity complicated the implant placement, leading to specific challenges throughout the operation. The occurence of complications following mammoplasty invariably has a lasting impact on the capsule’s formation and increases the risk of developing both early and late postoperative issues.

Postoperative complications and hernia recurrence after the use of various ventral hernia repair techniques

O. Y. Ioffe, T. V. Tarasiuk, M. S. Kryvopustov, O. P. Stetsenko — Sun, 30 Jun 2024 00:00:00 +0300

Prosthetic hernioplasty (HP) for ventral hernias (VH) has a complication rate of up to 27% and a hernia recurrence rate up of to 37%, depending on the chosen technique. The use of laparoscopic HP techniques allows for a shorter hospital stay and a lower risk of wound infection. There is a wide range of data on the superiority of laparoscopy over the open technique in terms of recurrence rates and various types of complications. The results of comparing HP with and without suturing of the hernia defect are controversial.

Objective — to study the structure and incidence of postoperative complications, as well as the frequency of hernia recurrences after the use of open and laparoscopic HP for VH.

Materials and methods. A multicenter prospective study, which included 482 patients diagnosed with VH, was conducted at the clinical base of the Department of General Surgery No. 2 at Bogomolets National Medical University. A total of 279 (57.9%) patients had primary VH, while 203 (42.1%) had incisional VH. The patients were divided into two groups, comparable in terms of age, sex, and hernia size distribution. Group 1 included 250 (51.9%) patients who underwent open HP with suturing of the hernia defect: subgroup 1a — open sublay (n=243; 50.4%), and subgroup 1b — open intraperitoneal onlay mesh technique (IPOM) (n=7; 1.5%). Group 2 included 232 (48.1%) patients who underwent laparoscopic HP using the IPOM technique: subgroup 2a — IPOM without suturing of the aponeurosis defect (n=81; 16.8%), subgroup 2b — IPOM with suturing of the aponeurosis defect (n=108; 22.4%), and subgroup 2c — IPOM+ with open aponeurosis defect suturing (n=43; 8.9%). Follow‑up evaluations were carried out at intervals of 2 weeks, 1 month, 6 months, and 1 year to assess the presence of complications, recurrence, and satisfaction with the cosmetic effect of the operation.

Results. The overall frequency of complications after HP was 15.6%, while after open sublay it was 21.2%, and after laparoscopic IPOM it was 9.9%. All cases of complications belonged to Grades I—IIIb according to the Clavien‑Dindo classification. In both groups, there were no fatalities. In group 1, the frequency of seroma was 11.6% and hematoma was 5.6%, and in group 2, it was 7.3% and 0.9%, respectively. A statistically significant increase in the frequency of hematoma development was observed after open HP techniques compared to laparoscopic ones (p=0.004), while the frequency of seroma detection was comparable (p=0.148). Non‑suturing of the aponeurosis defect after laparoscopic IPOM in patients with VH did not result in an increase in the total number of complications or the percentage of recurrence (p >0.05). Laparoscopic IPOM with hernia suturing demonstrated significantly higher patient satisfaction with the appearance of the anterior abdominal wall compared to other HP techniques (р <0.05).

Conclusions. The open sublay and laparoscopic IPOM HP procedures have a comparable recurrence rate of VH (p >0.05). The incidence of infectious complications and hematomas is significantly higher after open operations compared to laparoscopic ones (p=0.041 and p=0.004, respectively).

Quality of life in patients with chronic slow-transit constipation according to the PAC-QOL questionnaire and the effectiveness of conservative therapy

I. M. Leshchyshyn, L. Y. Markulan, O. I. Okhotska, P. L. Byk — Sun, 30 Jun 2024 00:00:00 +0300

Objective — to assess the quality of life (QOL) of patients with chronic slow‑transit constipation (CTC) according to the PAC‑QOL (Patient Assessment of Constipation Quality of Life) questionnaire, as well as the effectiveness of conservative therapy.

Materials and methods. The study included 246 patients with chronic (more than 5 years) slow‑transit constipation (CSTC group) and 70 patients without CSTC (reference group). These individuals were examined and treated in the clinics of Bogomolets National Medical University from 2014 to 2023. The onset of chronic slow‑transit constipation often occurred at an average age of 22.2±0.8 years (from 1 year to 67 years) and lasted 20.2±0.7 years (from 5 to 53 years). The average duration of the delayed passage of stool was 9.4±0.3 days (from 3 to 22 days). All patients received an adjusted course of conservative treatment according to the Rome guidelines. The nosospecific PAC‑QOL questionnaire was used to evaluate the patients’ quality of life on their initial visit and 6—8 months after conservative therapy.

Results. During the initial assessment, the CSTC group had a mean score of 3.03±0.56 on the «Physical Discomfort» subscale, while the reference group had a mean score of 1.19±0.29. On the «Psychosocial Discomfort» subscale, the CSTC group had a mean score of 2.21±0.52 compared to 0.84±0.18 in the reference group. The mean score for the «Worries and Concerns» subscale was 2.49±0.41 in the CSTC group and 0.77±0.24 in the reference group. The mean score for the «Satisfaction» subscale was 3.31±0.43 in the CSTC group and 0.86±0.28 in the reference group. The PAC‑QOL questionnaire total score was 2.63±0.26 in the CSTC group and 0.87±0.12 in the reference group (p <0.001 for all). After conservative treatment, the PAC‑QOL scores improved by an average of 40.4±20.0% (to 0.68—2.71 points). The cluster analysis revealed that after the course of conservative therapy, the PAC‑QOL questionnaire scores formed three distinct clusters: Cluster I — 0.68—1.39 points (49.2% of patients), Cluster II — 1.40—1.99 points (17.5% of patients), and Cluster III—2.0—2.8 points (33.3% of patients). These clusters represent good, satisfactory, and unsatisfactory results.

Conclusions. The PAC‑QOL questionnaire revealed a statistically significant decline in QOL in patients with CSTC (2.63±0.26 points compared to 0.87±0.12 points in the reference group). Modern conservative treatment improved quality of life in 49.2% of cases. 17.5% of cases showed a satisfactory result, while the remaining ones exhibited insignificant or no improvement. Other treatment options, including surgery, should be considered for patients who do not respond to conservative therapy.

The significance of clinical and morphological characteristics of spinal cord astrocytomas in the choice of surgical tactics

O. I. Troyan, A. V. Muravskiy, M. O. Marushchenko, M. V. Khyzhnyak — Sun, 30 Jun 2024 00:00:00 +0300

Objective — to determine the factors affecting the dynamics of the neurological status in the postoperative period in patients with intramedullary spinal cord astrocytomas (SCA) in order to improve the results of their surgical treatment.

Materials and methods. Between 2010 and 2019, we conducted a retrospective study on the surgical treatment outcomes of 39 SCA patients operated on at the SI “Romodanov Neurosurgery Institute of the National Academy of Medical Sciences of Ukraine”. The age of the patients ranged from 19 to 67 years, with an average age of 41.4 years. Out of the total, 25 patients (64%) were men and 14 patients (36%) were women. We observed cervical localization in 11 (28%) clinical cases, thoracic localization in 25 (64%), and conus medullaris in 3 (8%). All patients underwent a comprehensive clinical and instrumental examination using magnetic resonance imaging with intravenous enhancement, computed tomography, and spondylography. The dynamics of neurological symptoms were evaluated using the modified McCormick before surgery, at the time of the patient’s hospital discharge, and during follow‑up examinations.

Results. Total removal of SCA was performed in 7 (18%) patients, subtotal in 25 (64%), and partial in 7 (18%). Pilocytic astrocytoma (PA) (World Health Organisation (WHO) grade I) was detected in 19 (49%) patients, diffuse astrocytoma (DA) (WHO grade II) in 17 (43%), and anaplastic astrocytoma (AA) (WHO grade III) in 3 (7%). Partial regression of neurological symptoms was noted in 29 (74%) patients, the neurological status remained at the preoperative level in 6 (15%) patients, and a slight increase in the neurological deficit was noted in 4 (10%) patients. Age <60 years is significantly more frequently associated with the growth of PA, while age >60 years is significantly more frequently associated with the growth of AA. The duration of anamnesis (< 1 year and >1 year) and the degree of radicality of the operation were identified as significant factors that can influence the neurological status in the late postoperative period, mainly in patients with PA and DA. However, such factors as tumour location and the degree of infiltration of nearby structures are not statistically significant. AA is associated with an unfavourable prognosis across all important criteria.

Conclusions. The most important determinants of SCA prognosis are preoperative and postoperative neurological condition, resection extent, and histological grade. Patients with minor neurological damage at the time of surgery, those under the age of 60, and those with highly differentiated SCA had the greatest surgical treatment outcomes. Assessment of the preoperative neurological status and determination of the histological type of the tumour are important factors in choosing the optimal surgical tactics, which сan improve treatment outcomes and the quality of life in SCA patients.

Differentiated approach to hernioplasty of paraesophageal hernias

O. Y. Ioffe, T. A. Tarasov, L. Y. Markulan, M. M. Bagirov — Sun, 30 Jun 2024 00:00:00 +0300

The results of surgical treatment of paraesophageal hernias indicate a high recurrence rate, from 15% to 66%, with an average follow‑up period of 12 to 40 months. The main options for repairing the defect of the esophageal hiatus in the presence of paraesophageal hernia are crurorraphy and mesh‑reinforced crurorraphy. Both methods have their own advantages and disadvantages. The criteria for choosing a method have not been specified.

Objective — to develop a differentiated approach to the surgical treatment of paraesophageal hernias, taking into account the size of the esophageal hiatus, and to determine its effectiveness.

Materials and methods. The study included 157 patients who were operated on for paraesophageal hernias. They were divided into two groups. The patients in both groups did not exhibit any statistically significant differences in terms of mean age, body mass index, sex ratio, type, frequency of complaints, or results of the endoscopic and radiological examination.

In Group I, hiatoplasty was performed using crurorraphy (61 (38.9%) patients). In this group, the threshold values of the esophageal hiatus dimensions were calculated using the developed device and methodology, which allowed predicting hernia recurrence during the follow‑up period of up to 18 months. In Group II (96 (61.1%) patients), the hernioplasty technique (crurorraphy or mesh‑reinforced crurorraphy) was chosen on the basis of the obtained threshold values.

Results. In Group I, the mean hiatal surface area was 86.8±18.2 mm² (53 to 161 mm²) and the width of the esophageal hiatus was 29.3±3.3 mm (24 to 38 mm). In Group II, they were 95.6±23.2 mm² (51 to 212 mm²) and 31.1±3.7 mm (24 to 43 mm), respectively. The threshold hiatal surface area, at which the probability of recurrence after crurorraphy was >50%, was 90 mm² (AUC — 0.926 (95% confidence interval — 0.827—1.000), with a sensitivity and specificity of 87.5% and 97.8%, respectively. The width of the esophageal hiatus was measured at a cut‑off point of 32 mm (AUC — 0.864 (95% confidence interval — 0.733—0.995), with a sensitivity and specificity of 75.0% and 78.0%. In Group II, posterior crurorraphy was performed in the case of a hiatal surface area <90 mm² and a distance between the crura diaphragmatis <32 mm. In other cases, mesh‑reinforced crurorraphy was conducted. The recurrence rate in Groups I and II was 26.2% and 7.3% (p=0.001).

Conclusions. The device and methodology that have been developed are capable of measuring the dimensions (length, width, and area) of the esophageal hiatus intraoperatively. These measurements can be taken for the entire area within the esophageal hiatus contour, independent of its shape, even when using laparoscopic methods. The study found that there was a probability of recurrence after crurorraphy >50% when the threshold hiatal surface area was 90 mm², and the width of the esophageal hiatus was 32 mm. A differentiated approach to hiatoplasty involves using crurorraphy for hiatal surface areas <90 mm² or distances between the crura diaphragmatis <32 mm. For larger hiatal surface areas or widths, mesh‑reinforced crurorraphy is indicated. This approach has resulted in a significant reduction in the recurrence rate from 26.2% to 7.3% (p=0.001) and has prevented complications associated with the use of implants for up to 18 months after surgery.

Sarcopenic obesity and severity of chronic venous disease in postmenopausal women

G. O. Kostromin, O. V. Balaban, R. V. Honza — Sun, 30 Jun 2024 00:00:00 +0300

Sarcopenic obesity (SO) is a functional and clinical condition that is characterised by the simultaneous existence of sarcopenia and excess adipose tissue. This condition may be one of the pathogenetic factors for chronic venous disease (CVD) of the lower extremities and chronic venous insufficiency (CVI), due to impaired muscle venous pump function. Furthermore, obesity is considered a risk factor for these conditions.

Objective — to investigate the association of sarcopenia and sarcopenic obesity with the severity of chronic venous disease in postmenopausal women.

Materials and methods. The study included 117 postmenopausal women who were divided into two groups: Group I — 87 (74.4%) women with CVD, and Group II—30 (25.6%) women without any signs of CVD. Within Group I, two subgroups were distinguished based on the class of CVD as defined by the CEAP classification system. Subgroup IA consisted of 45 women (51.7%) with CVD classes 1 and 2, which correspond to compensated chronic venous insufficiency (CVI). Subgroup IB included 42 women (48.3%) with CVD classes 3, 4, and 5, indicating subcompensated or decompensated CVI. The measurement of fat and lean mass was conducted using dual‑energy X‑ray absorptiometry with the Hologic device (Discovery WI, USA, 2015). The presence of sarcopenia was determined by the skeletal muscle assessment index ASM/height2, where ASM is the total appendicular skeletal muscle mass of the legs and arms. Sarcopenia was diagnosed when the value of ASM/height2 was <6.0 kg/m². The diagnosis of SO was made in patients with sarcopenia and a body mass index >25 kg/m².

Results. The mean age of women was 67.32±9.12 years (46—86 years), the mean body mass index was 29.1±6.0 kg/m² (18.4—50.1 kg/m²), and BMI/height2 was 6.72±0.864 kg/m². Women in Group I had lower values of BMI/height2 (6.63±0.72 kg/m²) than women in Group II (6.97±1.0 kg/m², p=0.056). Sarcopenia was detected in 27 (23.1%) women, and SO in 17 (14.5%). There was no statistically significant difference between the groups in the frequency of sarcopenia: in Group I, 5 (16.7%) women had sarcopenia, in Group II — 22 (25.3%), (p=0.334). The proportion of patients with SO in Group I was statistically significantly larger compared to Group II — 18.4 and 3.3% (p=0.044). There was an increase in the proportion of women with sarcopenia and SO with increasing severity of CVI: 8 (17.8%) patients in subgroup IA and 14 (33.3%) in subgroup IB had sarcopenia (p=0.095), and 4 (8.94%) and 12 (28.6%) had SO, respectively (p=0.018).

Conclusions. Postmenopausal women with CVD were more likely to have SO (18.4%) compared to patients without CVD (3.3%, p=0.044). Postmenopausal women with subcompensated and decompensated CVI were more likely to have SO (12 (28.6%)) than women with compensated CVI (4 (8.94%, p=0.018, odds ratio 6.54, 95% confidence interval 0.83—51.58). Menopausal women with CVD were more likely to have sarcopenia and had a higher incidence of subcompensated and decompensated CVI compared to women without sarcopenia, but the difference was not statistically significant.

Preclinical evaluation of the individualized approach for chronic non-healing wounds management

Sun, 30 Jun 2024 00:00:00 +0300

Chronic non‑healing wounds (CNHW) are very common and often incorrectly treated, the morbidity and associated costs of chronic wounds management highlight the need to implement wound prevention and treatment concepts.

Objective — to evaluate the possibility of different metal nanooxide polymer nanofilms use for CNHW’ local treatment.

Materials and methods. The study design is based on evaluation of various types of dressing materials considering their option for use in CNHW local treatment. Samples of biodegradable polymer films (with an optimal composition of gelatin, polyvinyl alcohol, lactic acid, glycerin and distilled water) saturated with nanoparticles of several oxides with expected antibacterial and pro‑regenerative feature — nZnO, nMgO in concentrations of 1%, 5%, and 10% were used in the study of antimicrobial action and substance release profiling. Quarterly ammonium antiseptic decamethoxin 0.02% was used for control.

Results. Obtained data shows that polymer based biodegradable films incorporating optimal component composition (gelatin, polyvinyl alcohol, lactic acid and glycerin) enriched with 5% and 10% zinc nanooxide have potent antimicrobial activity against both gram‑positive and gram‑negative microorganisms, the most common causative agents of CNHW’s. The ion release capacity analysis showed that the Zinc impregnated wound‑healing biodegradable polymer film gradually releases the active substance in a time dependent manner, and the nano‑sized particles of nanoZinc oxide are released from the polymer composition faster than ordinary zinc oxide.

Conclusions. Complex natural biodegradable polymer based nanofilms are composite materials impregnated with metal nanooxides showing high potential in local treatment of chronic non‑healing wounds. Polymer film with 5% nanoZnO showed up to the 58% higher antimicrobial activity, comparable or exceeding the one of quarterly ammonium compound decamethoxin. Furthermore, nanoZnO impregnated polymer films compared to standard ZnO impregnated polymer films showed up to 63.2% faster substance release profile with rapid and more unified curve.