Improvement of Diagnosis and Optimization of Surgical Tactics in Patients with Postoperative Intra-abdominal Complications

The research is dedicated to the improvement of diagnosis and the optimization of surgical tactics in the treatment of postoperative intra-abdominal complications. The study analyzes the effectiveness of traditional and modern instrumental methods, such as laparoscopy, ultrasonography, and gas analysis of the abdominal cavity. Special attention is given to the early diagnosis of suture insufficiency of digestive anastomoses and the development of criteria for indications for laparoscopic sanitation. The aim is to reduce the frequency of unfavorable outcomes and mortality by integrating minimally invasive technologies into the comprehensive program of patient management.

Relevance of the Problem. Despite the improvement in methods of surgical treatment of diseases of the abdominal organs, the issues of diagnosis and treatment of early postoperative intra-abdominal complications have not lost their relevance. According to domestic and foreign authors, the frequency of relaparotomy ranges from 0.5% to 13.6% (Abduljalilov M.K., Nazhmudinov Z.Z., Abdulaev U.M., 2005, Beburishvili A.G., Akinchits A.N., Elistratova E.E., 2005, Budnevsky V.I. et al., 2005, Glabay V.P., Sharov A.I., Arkharov A.V., 2005). From the overall structure of these complications, postoperative peritonitis accounts for 7.3% to 86% (Zhebrovsky V.V., Toskin K.D., 1990; Petukhov I.A., 1980; Shalimov A.A., Shaposhnikov V.I., Pinchuk M.N., 1981, Shugaev A.I., Shehu M.D., 1996; Farrakhov A.Z., Krasilnikov D.M., Zainullin I.V., Galeeva O.P., 2005). The progress that has emerged in recent years in the diagnosis and treatment of postoperative complications requiring relaparotomy has, unfortunately, barely reflected in the final outcomes. Moreover, in some types of complications, there has been a steady trend toward stabilization and even a slight increase in the level of unfavorable outcomes (Guzhkov O.N. 1997; Rychkovsky G.F., Tretyakov A.A., Streltsov Yu.P. et al., 2005). The causes of the situation cannot be explained solely by changing socio-economic conditions of life, the aging of the population, and the untimely appeal of patients for medical help. Intensive therapy carried out in the postoperative period is capable of radically changing the clinical picture of the arising complication, reducing the degree of expression of the symptoms of the arising complication. The literature provides undeniable evidence of the complexity of diagnosing postoperative intra-abdominal complications and establishing indications for relaparotomy (Milonov O.B., Toskin N.F., Zhebrovsky V.V. et al., 1990; Krasilnikov D.M., Skobelkin O.K., Fedorov V.V. et al., 1994; Shugaev A.I., Shehu M.D., 1996; Kovalev A.I., 2005). The atypical clinical picture of postoperative complications leads to untimely performance of repeated laparotomy in 17-48% of patients and is the main cause of their unfavorable outcome (Budnevsky V.I., Demidov G.I., Allentov M.I., 2005). Mortality in this case amounts to 20.9%-37.2% (Glabay V.P., Sharov A.I., Arkharov A.V., 2005; Golik A.D., Sitnikov V.N., Turbin M.V. et al., 2005; Rychkovsky G.F., Tretyakov A.A., Streltsov Yu.P. et al., 2005). Along with this, none of the currently used diagnostic methods possesses absolute reliability.

The widespread introduction of minimally invasive technologies into clinical practice currently predetermines the correction of the existing algorithm for diagnosing and treating postoperative intra-abdominal complications, the central element of which was relaparotomy. However, the role of these methods in the complex of postoperative therapeutic and diagnostic measures has been insufficiently assessed.

The goal of the study is to improve the outcomes of treatment of patients with postoperative intra-abdominal complications by improving the methods of instrumental diagnosis and minimally invasive surgery.

To achieve the stated goal, it was necessary to solve the following tasks:

1. To study the effectiveness of traditional methods of diagnosis and treatment of early postoperative intra-abdominal complications.

2. To justify, using data from experimental and clinical studies, the feasibility of studying the gas composition of the abdominal cavity in the early diagnosis of suture insufficiency of digestive anastomoses.

3. To establish the main criteria determining the indications for laparoscopic sanitation of the abdominal cavity in postoperative peritonitis and to evaluate its effectiveness.

4. To conduct a comparative analysis of the effectiveness of treatment of postoperative intra-abdominal complications using the traditional approach and using modern instrumental technologies.

Scientific Novelty. For the first time, a complex diagnosis of postoperative intra-abdominal complications has been optimized, based on the early detection of suture insufficiency of digestive anastomoses.

The ways to increase the effectiveness of early diagnosis of suture insufficiency of digestive anastomoses using the method of gas analysis of the abdominal cavity in the postoperative period have been determined and scientifically substantiated.

The main criteria for the necessity of laparoscopic sanitation of the abdominal cavity have been determined, which are: unresolved peritonitis, bile leakage, retention of lavage fluid in the abdominal cavity after sessions of peritoneal lavage, intra-abdominal hematomas.

A working classification of the syndrome of unfavorable postoperative course has been proposed, reflecting the main variants of its clinical manifestation.

Practical Significance. A new device for studying the gas composition of the abdominal cavity in intra-abdominal postoperative complications has been introduced into surgical practice.

The inclusion of instrumental methods, such as ultrasound diagnosis, study of the gas composition of the abdominal cavity in the early postoperative period when signs of the syndrome of unfavorable course appear, laparoscopic sanitation of the abdominal cavity, in the complex program of diagnosis and treatment of patients with postoperative intra-abdominal complications contributes to the reduction of the duration of dynamic observation, the establishment of indications for repeated surgical interventions, the frequency of purulent-inflammatory complications from 44.4% to 22.4%, mortality from 23.2% to 8.9%, inpatient treatment for patients with a favorable outcome from 23.2+4.8 to 19.3+4.5 days.

Implementation of the Research Results. The main results of the study have been implemented in the practical activities of the departments of planned and emergency surgery of the City Clinical Hospital No. 7 of Kazan, as well as in the educational process of the Department of Surgery with a course of emergency medical care of the State Educational Institution of Higher Professional Education "Kazan State Medical Academy FA NO and SR".

Presentation of the Work. The main provisions of the dissertation were reported and discussed at: the Interregional Scientific Conference dedicated to the 70th anniversary of Professor O.S. Kochnev "Actual Problems of Abdominal Surgery" (Kazan, 2002), the IV All-Army International Conference "Intensive Care and Prevention of Surgical Infections" (Moscow, 2004), the 9th, 10th International Congresses of Endoscopic Surgery (Moscow, 2005, 2006), the Congress of the Russian Association of Endoscopic Surgery (Moscow, 2006), the meeting of the Republican Scientific Society of Surgeons (Kazan, 2007).

Publications. 11 printed works on the topic of the dissertation have been published, including a textbook, and 4 Russian Federation patents for utility models have been obtained.

Propositions to be Defended:

1. Existing traditional methods of diagnosis in patients with postoperative intra-abdominal complications in most cases lead to delayed relaparotomies, which are accompanied by an increase in the frequency of unfavorable outcomes.

2. The inclusion of instrumental methods in the complex program of diagnosis and treatment of patients with postoperative intra-abdominal complications reduces the number of wound purulent-inflammatory complications, reduces mortality and the duration of inpatient treatment for patients with favorable outcomes.