Comparative evaluation of the effectiveness of diagnosis and surgical treatment of patients with portal hypertension

The dissertation is devoted to a comparative evaluation of the effectiveness of diagnostic and surgical methods of treatment of patients with portal hypertension syndrome. The work summarizes data on the prevalence of esophagogastric bleeding of portal origin and analyzes existing approaches to the selection of diagnostic criteria and surgical tactics, including vascular portocaval anastomoses and direct interventions on varicose veins of the esophagus and stomach. The author proposes a comprehensive diagnostic and treatment algorithm that involves the use of three-dimensional ultrasound and thermal imaging, together with laboratory monitoring of coagulation and liver function parameters in the pre- and postoperative periods. The findings have made it possible to determine the most informative criteria for assessing the risk of postoperative complications and to establish the optimal ratio between shunting operations and suturing of varicose veins in different variants of portal hypertension, as confirmed by a clinical analysis of short-term and long-term outcomes.

Relevance of the topic. The current level of advanced high medical technologies makes it possible to reconsider a number of conceptual aspects of the traditional surgery of portal hypertension (PH) and to overcome a serious barrier that has developed between the progressive increase in the number of patients dying from bleeding from the veins of the esophagus and stomach (BRVES), on the one hand, and the dominance of a negative attitude toward the surgical treatment of patients with PH, on the other (Eramshchantsev A.K. et al., 1998; Eramshchantsev A.K. et al., 2005; Kitsenko E.A. et al., 2005; Manukyan G.V. et al., 2008; Nazyrov F.G. et al., 2008; Shertsinger A.G. et al., 2008; LaBerge J.M., 1993).

In the Republic of Tatarstan, with a population of 3,779,300 people, the proportion of gastrointestinal bleeding among acute surgical diseases of the abdominal organs is 6.8%, second only to acute appendicitis (42.9%), acute cholecystitis (18.6%), and acute pancreatitis (17.1%). Moreover, 20-25% of patients with gastrointestinal bleeding are patients with esophagogastric bleeding of portal origin (Mrasov N.M., 2005).

Mortality at the height of esophagogastric bleeding under an expectant strategy based on the possibility of spontaneous hemostasis under conservative therapy reaches 65% (Kuznetsov M.V., 2007; Dzidzava I.I. et al., 2008; Eramshchantsev A.K. et al., 2008; Kotiv B.N. et al., 2008). Meanwhile, after operations in the "cold" period, mortality does not exceed 12.3% (Savelyev V.S. et al., 1983; Gauthier S.V., 1999; Lyubivyy E.D., 2004; Lebezev V.M. et al., 2008; Shertsinger A.G. et al., 2008; Wongcharatrawee S. et al., 2000).

Despite the fact that at the turn of the 1980s-1990s the main directions of surgical tactics in the treatment of patients with PH were formed, the questions of when, which operation, and in what combinations is most optimal in a given specific case still remain debatable (Manukyan G.V., 2003; Anisimov A.Yu. et al., 2004; Bedin V.V. et al., 2005; Dzhorobekov A.D. et al., 2005; Collins J.C., 1995; Walser E.M. et al., 2000).

Dissatisfaction with the results of surgical treatment, in our opinion, is also largely associated with the lack of informative diagnostic criteria for objectifying the choice of the method of surgical treatment, the timing of its implementation, and the scope of the intervention (Dzhordzhikiya R.K. and co-authors, 2000).

It is no coincidence that recently we have been witnessing close attention to this problem on the part of researchers and practitioners. This is evidenced by informal discussions on the pages of the journal "Annals of Surgical Hepatology," the proceedings of the III International Congress of the Association of Surgeons named after N.I. Pirogov (Moscow, 2001), the XII Conference of Hepatobiliary Surgeons of Russia and the CIS Countries (Tashkent, 2005), the Moscow International Surgical Congress (Moscow, 2003), and the I International Conference on Thoraco-Abdominal Surgery (Moscow, 2008). In the decisions of these forums, the problem of choosing optimal regimens for the diagnosis and surgical treatment of patients with PH is assigned to issues requiring further study in evidence-based multicenter trials. The solution to this problem constitutes an urgent task of clinical surgery.

Based on the above, the goal and main objectives of the study were defined.

Goal of the study: To improve the results of treatment of patients with various variants of the portal hypertension syndrome by introducing new diagnostic technologies into clinical practice and applying a differentiated approach to the choice of surgical treatment methods.

Objectives of the study:

1. To substantiate the feasibility of surgical treatment, to study the possibilities of 3D ultrasound and thermal imaging methods in diagnosing the severity of portal hypertension.

2. To identify the most informative laboratory criteria for assessing the risk of complications in the postoperative period in patients with portal hypertension.

3. To carry out a clinical analysis of the effectiveness of surgical treatment of patients with portal hypertension in the short-term and long-term periods.

4. Based on a comprehensive examination of patients, to establish the optimal ratio between vascular portocaval anastomoses and direct interventions on varicose veins of the esophagus and stomach in various variants of the portal hypertension syndrome.

Scientific novelty. The combined use of 3D ultrasound and thermal imaging methods allows non-invasive monitoring of the patient's condition before and after surgery, as well as providing objective information on the degree of development of collateral blood flow through the vessels of the anterior abdominal wall.

The most informative laboratory criteria for assessing the risk of complications in the postoperative period in patients with portal hypertension have been identified (APTT, PTI, INR, serum albumin).

The optimal ratio between vascular portocaval anastomoses and direct interventions on varicose veins of the esophagus and stomach has been established for various variants of the portal hypertension syndrome.

Practical significance. The use of the proposed algorithm of a comprehensive treatment-and-diagnostic program, which includes 3D ultrasound and thermal imaging studies and laboratory monitoring in the pre- and postoperative periods, along with the differentiated application of vascular portocaval anastomoses and direct interventions on varicose veins of the esophagus and stomach, has made it possible to exert a positive influence on the dynamics of the pathological process. At the same time, the total number of complications after emergency suturing of varicose veins of the esophagus and stomach was 57.1%, after elective suturing of varicose veins of the esophagus and stomach it was 33.3%, after elective shunting operations it was 27.3%, and mortality was 35.7%, 0%, and 4.5%, respectively.

Implementation of the research results. The results of the study and the main recommendations have been introduced into the practice of the Department of Liver and Portal Hypertension Surgery of the State Institution "Interregional Clinical and Diagnostic Center" of the Ministry of Health of the Republic of Tatarstan, and are also used in the educational process at the Department of Disaster Medicine of the State Educational Institution of Additional Professional Education "Kazan State Medical Academy of the Federal Agency for Health and Social Development."

Approval of the work. The main provisions of the dissertation were reported and discussed at: the XII International Congress of Hepatobiliary Surgeons of Russia and the CIS Countries "Current Problems of Surgical Hepatology," the X Scientific and Practical Conference "Vakhidov Readings-2005" (Tashkent, 2005); a meeting of the Scientific Medical Society of Surgeons of the Republic of Tatarstan (Kazan, 2007); the II International Scientific and Practical Conference of Surgeons and Urologists "High Technologies in Medicine" (Nizhny Novgorod, 2008); the First International Conference on Thoracoabdominal Surgery dedicated to the 100th anniversary of Academician B.V. Petrovsky (Moscow, 2008), the XV International Congress of Hepatobiliary Surgeons of Russia and the CIS Countries (Kazan, 2008); the interdepartmental conference of the departments of disaster medicine and mobilization training of healthcare; surgery with a course in emergency medical care; endoscopy, general and endoscopic surgery; clinical anatomy and outpatient polyclinic surgery of the State Educational Institution of Additional Professional Education "Kazan State Medical Academy of the Federal Agency for Health and Social Development" and the departments of surgical diseases No. 1 with a course in oncology, anesthesiology and resuscitation; general surgery, surgical diseases No. 2 of the State Educational Institution of Higher Professional Education "Kazan State Medical University of the Federal Agency for Health and Social Development" (Kazan, 2008).

Publications. On the topic of the dissertation, 11 printed works have been published.

Structure and scope of the dissertation. The dissertation is set out on 136 pages of typewritten text and consists of a list of abbreviations, an introduction, 4 chapters, a discussion of the results obtained, conclusions, practical recommendations, and a list of references comprising 140 domestic and 71 foreign sources. The dissertation is illustrated with 8 tables and 90 figures.

Propositions submitted for defense:

1. The inclusion of 3D ultrasound and thermal imaging methods in the diagnostic algorithm makes it possible to objectively assess the severity of portal hypertension and thereby substantiate the choice of the method of surgical treatment.

2. Dynamic monitoring of APTT, PTI, INR, AST, and serum albumin levels makes it possible to most informatively assess the risk of postoperative complications in patients with portal hypertension.

3. The differentiated use of vascular portocaval anastomoses and suturing of varicose veins of the esophagus and stomach makes it possible to achieve stable remission of gastroesophageal bleeding as the main symptom of the disease, as well as to reduce the total number of complications and decrease mortality.