Evaluation of the Results of Simultaneous Abdominal Operations

The dissertation is devoted to the evaluation of the results of simultaneous abdominal operations in patients with combined surgical pathology of the abdominal organs. The work aims to develop objective criteria for the selection of patients for one-stage surgical treatment using the P-POSSUM functional status scale. The study covers issues of terminology and classification of simultaneous interventions, analysis of the clinical material, as well as the results of simultaneous operations in large postoperative ventral hernias, gallstone disease and malignant tumours of the colon and rectum. On the basis of the data obtained, threshold values of the P-POSSUM scale have been defined, at which the performance of simultaneous operations is accompanied by minimal or significant risk.

Scientific and technological progress has brought surgery to a qualitatively new level. In leading surgical centres, the operative treatment of many diseases, including certain severe conditions, is approaching the "gold standard," that is, zero mortality (Adam U. et al., 2004). Nevertheless, according to WHO data, in recent years approximately 20–30% of patients present with combined surgical pathology (Makhovskii V.Z., 2003). Within the morbidity structure of the population, pathology of the gastrointestinal tract is no less frequent than diseases of the cardiovascular system. Alongside coronary heart disease, cholelithiasis (gallstone disease, GSD) has become an "epidemic" of the twentieth century and ranks second in prevalence after atherosclerosis (Everhart J.E., 2001). According to the data of the VI World Congress of Gastroenterologists, 10% of the world's population suffers from GSD. Gastroesophageal reflux disease, often caused by hiatal hernia, has come to be regarded as the pathology of the twenty-first century (Sheptulin A.A., 2003; Samsonov A.A. et al., 2004; Darwin V.V. et al., 2008). Gastric and duodenal ulcer disease affects about 10% of the adult population (Kuzin M.I., 2004). Abdominal hernias are diagnosed in 5% of men and 2% of women (Shevchenko Yu.L., 2000). A special group is constituted by patients with large postoperative ventral hernias (Moshkova T.A., 2008; Sedov V.M. et al., 2008). Postoperative ventral hernias occur in 5–14% of patients who have undergone laparotomy.

Therefore, the combination of various surgical diseases of the abdominal organs is no longer considered a curiosity at present. This is mainly determined by an increase in life expectancy and by improvements in the quality of diagnosis. In such situations, staged surgical correction of one organ, separated by a defined interval, may be followed in the early postoperative period by severe complications from another, non-operated organ. It has been established that, particularly when pathologically affected organs lie in anatomical proximity, each disease may, under certain circumstances, complicate the course of the other (Malinovskii N.N. et al., 1983; Makhovskii V.Z., 2002; Shumakov V.I. et al., 2007). The simultaneous relief of an operated patient from two or more diseases has become an objective reality. Simultaneous operations have become a new programme-directed direction in surgery (Perelman M.I., 1989; 2000; Fedorov V.D., 2001; Shumakov V.I. et al., 2007).

Simultaneous operative interventions on the stomach, biliary ducts, liver, pancreas, intestines, as well as in abdominal wall hernias, have become the prerogative of a number of surgical centres (Petrov V.P., 2003; Dadvani S.A. et al., 1999; Kozlov I.A. et al., 2003; Fedorov V.D. et al., 2005). The advantages of simultaneous operations are indisputable: two or three surgical conditions are cured at the same time; progression or severe complications of a disease whose operative treatment would otherwise be postponed are prevented; the risk of a repeat operation, repeat anaesthesia and its complications is eliminated; repeated stress reactions in patients are avoided; the need for repeated examination and preoperative preparation is removed; the total length of hospital stay and subsequent treatment is shortened; and the economic efficiency of treatment is increased (Malinovskii N.N. et al., 1983; Gantsev Sh.Kh., 1991; Griffin M.R., 1998).

However, the possible negative consequences of simultaneous interventions must also be taken into account: increased duration of anaesthesia; possible increase in blood loss; higher probability of intraoperative and postoperative complications. The performance of simultaneous operations in cases of diverse surgical pathology combined with malignant neoplasms of other organs is largely predetermined by the fatal prognosis if timely operative intervention is refused. Nevertheless, patients requiring operative treatment frequently present with concomitant non-oncological abdominal surgical pathology. In such situations, questions remain unresolved to this day (Shumakov V.I. et al., 2007). Certain difficulties are caused by the lack of integration between representatives of individual surgical specialties. Therefore, the adequate provision of simultaneous operations is still the prerogative of highly qualified multidisciplinary institutions. The experience with such interventions remains relatively limited, which accounts for the continuing, as a rule fruitless, debates in favour of simultaneous or staged operations (Makarov P.A. et al., 1998; 2002; Zhidkov S.A., 2003; Mason E.E. et al., 1992). This is also explained by the absence of reliable objective methods for predicting the outcomes of such interventions, which constitute the principal factor in the effectiveness and optimisation of treatment.

As M.I. Kuzin noted as early as 1984, despite numerous schemes for determining the degree of operative risk, the surgeon unfortunately lacks reliable criteria for assessing the patient's tolerance of a complex operative intervention. Moreover, a favourable prognosis does not always correspond to a favourable outcome. Following detailed examination during preparation for elective surgery and the diagnosis of an additional surgical disease, the opportunity arises to determine the tactics: simultaneous or staged operation. An objective assessment of the severity of the patient's condition in these situations makes it possible to evaluate the risk factors. If combined pathology is diagnosed after laparotomy, the resolution of the problem may prove difficult. Without sufficient examination and consideration of risk factors, the patient may be exposed to danger.

Recent decades have been marked by the emergence of various methods for determining operative risk (Lebedev N.V. et al., 2007). Nevertheless, assessing the severity of the condition of a patient with combined diseases for the selection of treatment tactics remains relevant. Among the risk factors for simultaneous operations, concomitant pathology and the patient's age are of primary importance. The severity of operative trauma and the duration of the surgical intervention may also adversely affect the patient's condition.

We have become convinced of the necessity and feasibility of performing simultaneous operations in patients with various diseases of the gastrointestinal tract. In this way, not only the radical nature of the intervention, with its cosmetic advantages and economic benefit, is ensured, but also a lesser psychological trauma. Psychological difficulties in a person who has undergone one severe operation often restrain him or her from another operative intervention. Nevertheless, the problem of determining the indications, the type and the scope of surgical interventions in combined abdominal surgical pathology remains unsolved to the present day. The management of these patients remains a matter of debate.

The development of objective criteria for the tolerability of simultaneous operations will make it possible to define indications and contraindications for such interventions and to improve the results of treatment in this complex group of patients. This determined the aim and objectives of the present study.

Aim and objectives of the study

To improve the results of simultaneous operations in patients with combined abdominal surgical pathology through comprehensive preoperative examination, taking into account the prognostic capabilities of the P-POSSUM functional status scale.

Research objectives

1. To study the capabilities of the P-POSSUM functional status scale in assessing operative risk criteria for simultaneous operations in combined abdominal surgical pathology.

2. To substantiate the necessity of simultaneous abdominoplasty during tension-free hernioplasty in recurrent large and giant postoperative ventral hernias.

3. To analyse the results of simultaneous operative interventions in patients with gallstone disease and to develop indications and contraindications for their application, taking into account the P-POSSUM functional status scale.

4. To evaluate the effectiveness of simultaneous operative interventions in malignant tumours of the colon and rectum combined with non-oncological surgical abdominal pathology. To define indications and contraindications for their application, taking into account the indicators of the P-POSSUM functional status scale.

Scientific novelty

For the first time, the capabilities have been studied and an assessment has been made of the severity of the condition of patients with combined surgical abdominal pathology in the preoperative period by means of the functional status indicators and the prediction of the probability of lethal outcome and the frequency of non-lethal complications according to the P-POSSUM scale. In studying the indicators of the P-POSSUM functional status scale, a reliable relationship was revealed between the severity of the patients' condition on admission, the conduct of preoperative preparation and the immediate results of the performed simultaneous operations. Assessment of the operative risk of simultaneous operations by the P-POSSUM scale after preoperative preparation objectifies the determination of indications and contraindications for their application.

It has been established that, with TF values below 20 points and TO below 17 points on the P-POSSUM scale, the probability of a lethal outcome after simultaneous operative intervention approaches zero. It has been proven that, with TF values above 21 points and TO above 23 points on the P-POSSUM scale, the performance of simultaneous operations is accompanied by a significant risk. In such patients, staged operations are indicated. At the first stage, it is necessary to perform the principal intervention that directly threatens the patient's life.

Practical significance

The point-based assessment of the severity of the functional status according to the P-POSSUM scale before surgery makes it possible to objectively determine the indications and contraindications for simultaneous operations in combined surgical abdominal pathology. Assessment of the operative risk of simultaneous operations by the P-POSSUM scale makes it possible to identify patients for whom a simultaneous intervention is feasible after additional preoperative preparation. The results of the study allow simultaneous interventions to be recommended in gallstone disease and other surgical diseases of the abdominal organs.

Statements for defence

1. The performance of simultaneous operations in patients with gallstone disease is indicated when TF values are below 20 points and TO below 17 points on the P-POSSUM scale. In such cases, the performance of simultaneous operations is not accompanied by an increase in the number of postoperative complications caused directly by cholecystectomy. This tactic prevents the development of postcholecystectomy syndrome.

2. Simultaneous abdomino- and hernioplasty operations using polypropylene mesh endoprostheses in giant and large postoperative ventral hernias restore the anatomical and physiological parameters of the anterior abdominal wall and achieve good functional and aesthetic results.

3. Being one of the most frequent oncological diseases, cancer of the colon and rectum is often combined with other non-oncological surgical diseases of the abdominal organs. To improve the results of treatment of these patients, the performance of simultaneous operations is relevant, taking into account the prognostic capabilities of the P-POSSUM functional status scale. With TF values below 20 points and TO below 17 points on the P-POSSUM scale, a simultaneous operation is indicated. With TF values above 23 points and TO above 22 points, the performance of simultaneous operations is accompanied by a significant risk.

Implementation of the study results

The proposed assessment of the severity of the functional status of patients by the P-POSSUM scale for the performance of simultaneous operations in combined abdominal surgical pathology is used in the routine activity of the surgical departments of the Ivanovo Regional Clinical Hospital, as well as in the surgical departments of the 1st and 2nd Clinical Hospitals of the city of Ivanovo, and has been introduced into the teaching process at the Department of Faculty and Hospital Surgery named after V.V. Kulemin of the State Educational Institution of Higher Professional Education IvGMA of the Federal Agency for Health Care and Social Development.

Approval of the dissertation

The obtained results of the study were reported and discussed at the International Congress of Surgeons-Hepatologists of the CIS Countries "Current Issues of Surgical Hepathology," 19–21 September 2007, Saint Petersburg; at the Scientific and Practical Conference of Surgeons of the Central Federal District of the Russian Federation "Current Issues of Clinical Surgery," Yaroslavl, 2008; at the Scientific and Practical Conference of Students and Young Scientists of IvGMA "Week of Science — 2009," Ivanovo, 2009; and at the inter-departmental meeting of the surgical departments of the Ivanovo State Medical Academy, May 2009. Six scientific works have been published based on the research materials.

Publications

Six printed works have been published on the topic of the dissertation, of which three are in journals and publications defined by the Higher Attestation Commission.