Mini-Laparotomy in the Surgical Treatment of Gallstone Disease in Patients of Elderly and Senile Age

The dissertation addresses the problem of surgical treatment of gallstone disease in patients of elderly and senile age. The work examines features of pathophysiology and pathomorphology of the disease, the impact of concomitant diseases on surgical outcomes, and the high mortality associated with traditional open operations in this age group. Special attention is given to mini-laparotomy and other minimally invasive surgical methods that can reduce the trauma of operations.

The author developed a cybernetic model and a computer program for predicting the optimal method of surgical treatment at the primary stage of hospitalization. Rational elements for performing mini-laparotomy and a method for stopping intraoperative bleeding using a modified aspiration electrode-ball have been proposed. The research includes an analysis of risk factors, reliability of prediction, and evaluation of surgical treatment outcomes depending on the chosen approach.

Relevance of the problem. The outcomes of surgical treatment of gallstone disease in patients of elderly and senile age are influenced not only by features of pathophysiology and pathomorphology, but also by concomitant diseases. Among persons suffering from calculus cholecystitis, patients of Group I of elderly and senile age constitute 49–65% (Fedorov V.V., 2002; Semenov D.Yu., 2004). The high risk of decompensation of the cardiovascular and respiratory systems in patients of elderly and senile age is determined, primarily, by the degree of surgical aggression.

Particular complexity is represented by acute calculus cholecystitis, the surgical treatment of which in these patients in the middle of the last century ended in a fatal outcome in 37.2%. Surgeons tried by every means to avoid surgery in patients of elderly and senile age with an attack of acute calculus cholecystitis. Until the mid-1980s of the 20th century, the generally accepted primary method of surgical treatment of calculus cholecystitis was traditional (laparotomy) cholecystectomy. For a long time, mortality in open operations remained at the level of 6–10%, while in patients of elderly and senile age it reached 10–45%. In patients over 80 years of age, with destructive forms of acute cholecystitis, it amounts to 94.1% (Borisov A.E. et al., 2000, 2003). Therefore, surgical intervention was limited to cholecystostomy.

The drive to perform maximally conservative interventions led to the formation of new directions in modern surgery, known as "minimally invasive," in particular laparoscopy and mini-access interventions (Topuzov E.G., 1996, 2000; Fedorov V.D., 2004; Prudkov M.I., 2000). Having initially gained wide development as cosmetically advantageous interventions, minimally invasive operations constantly expand their sphere of application. With their help, combined and complex interventions are increasingly performed. However, not the entire volume of manipulations on the gallbladder and ducts has entered widespread practice. It has become the preserve of only a small number of surgeons. Due to emerging difficulties, it is often necessary during surgery to switch to a traditional access (laparotomy) — to perform a conversion. All this creates new, more difficult conditions for performing operations on patients of elderly and senile age, increases the duration of surgery, and raises the risk of technical problems and intraoperative complications. This, in turn, requires the development of new approaches to the treatment of this group of patients. (Sedov V.M., 2002; Beburishvili A.G., 2002; Dadvani S.A., 2000;

Until the present time, objective criteria for predicting the course of calculus cholecystitis in patients of elderly and senile age are under development. It is also advisable to develop a clinical-laboratory model of "calculus cholecystitis in a patient of elderly and senile age," on the basis of which it will be possible to predict the outcome of the disease with sufficient reliability, determine indications for surgery and the method of its performance (Maystrenko N.A., 2002; Shugaev A.I., 2003).

The choice of the method of surgical treatment of calculus cholecystitis in this category of patients necessarily includes an assessment of the degree of surgical risk (Vetsev P.S., Shulutko A.M., Prudkov M.I., 2005). At the current stage of surgical development, an intuitive approach to risk assessment is unacceptable. Therefore, it is necessary to assess the degree of surgical risk taking into account objective and subjective factors.

Goal and objectives of the research. The goal of the work is to develop methods and technology for the optimal selection of the method of minimally invasive interventions in patients of elderly and senile age suffering from gallstone disease.

To this end, the following tasks were set:

1) to study the features of approaches in the surgical treatment of gallstone disease in patients of elderly and senile age;

2) to develop a computer program for selecting the optimal method of surgical treatment of calculus cholecystitis in patients of elderly and senile age;

3) to evaluate the results and outcomes of surgical treatment of gallstone disease in patients of elderly and senile age, depending on the chosen access;

4) to optimize the technique of mini-laparotomy in gallstone disease in patients of elderly and senile age.

Scientific novelty of the research. For the first time, a cybernetic model has been created that allows predicting the choice of surgical treatment tactics for gallstone disease in patients of elderly and senile age at the primary stage of hospitalization. An automated system for selecting the method of surgical treatment of gallstone disease in patients of elderly and senile age has been created based on a personal computer (Certificate of official registration of computer programs No. 2007613367 dated 10.08.2007).

Reliable risk factors have been identified that influence the outcome of the disease after surgical treatment in patients of elderly and senile age, depending on the access.

Rational elements for performing mini-laparotomy in patients of elderly and senile age have been proposed. A method for stopping intraoperative bleeding using a modified aspiration electrode-ball in mini-access operations has been developed and implemented (Certificate of rationalization proposal No. 1549 dated 14.05.2003).

Theoretical and practical significance. An algorithm of surgeon action has been created for a surgeon constantly encountering surgical treatment of gallstone disease in their practical activities. The creation of an electronic database containing information obtained during observation and treatment of patients of elderly and senile age suffering from gallstone disease with a known outcome will allow the algorithms based on it to work effectively.

The creation of a cybernetic model can reflect the need to make a decision on the choice of access. The developed provisions have made it possible to refine indications and contraindications for various methods of surgical treatment of gallstone disease in patients of elderly and senile age.

The optimal choice of surgical access for interventions on the gallbladder and ducts makes it possible to improve short-term and long-term outcomes of surgical treatment of calculus cholecystitis in patients of elderly and senile age.

Implementation in practice. The results of the dissertation have been implemented in the practical work of surgical departments of clinics of SPbGMA named after I.I. Mechnikov, surgical departments of the Alexandrovskaya Hospital of Saint Petersburg, surgical departments of the Road Clinical Hospital of the October Railway of Saint Petersburg, and in the educational process of the department of surgical diseases with a course of pediatric surgery (Head of the Department, Professor Topuzov E.G.) State Educational Institution of Higher Professional Education "SPbGMA named after I.I. Mechnikov of Roszdrav."

Presentation of the work. The main provisions of the dissertation were reported at conferences of young scientists of SPbGMA (2004, 2005, 2006, 2007); the VI All-Russian Scientific and Practical Conference "Current Issues of Clinical Diagnosis and Treatment in a Multidisciplinary Medical Institution," BMA (2003); the II International Slavic-Baltic Forum "Saint Petersburg — Gastro-2004"; the All-Russian Conference "Current Issues of Modern Surgery" dedicated to the 85th anniversary of the Astrakhan Regional Scientific Medical Society of Surgeons (Astrakhan, 2006); the Jubilee Conference "Modern Technologies in Surgery" dedicated to the 120th anniversary of the Department of Surgery named after N.D. Monastyrsky of SPb MAPO and the 10th anniversary of the Emergency Endovideochirurgy Center of the Alexandrovskaya Hospital, Saint Petersburg (2006).

Author's contribution. The author personally treated patients in the studied groups and is proficient in all studied methods of surgical treatment. The author developed the principles of mini-laparotomy in patients of elderly and senile age and developed and implemented a device for stopping bleeding in mini-access operations. The author conducted the selection and analysis of literature data. A computer database of patients, their clinical features, and factors in the choice of surgical treatment method has been compiled and presented. The author created an original computer program for selecting the method of surgical treatment of gallstone disease in patients of elderly and senile age. The program received a certificate of official registration of computer programs (No. 2007613367).

Provisions for defense.

1. The use of minimally invasive surgical methods is indicated for the majority of patients of elderly and senile age suffering from gallstone disease. Features of morphological changes in the gallbladder and ducts should not limit the use of minimally invasive interventions.

2. The use of the developed computer program makes it possible to predict the safest method of surgical treatment in patients of elderly and senile age suffering from gallstone disease.

3. The performance of minimally invasive operations in patients of elderly and senile age reduces the number of complications, postoperative bed-days, duration of intensive care, activation period, postoperative pain syndrome, and the frequency of narcotic analgesic use compared to traditional laparotomy.

4. The use of a modified aspiration electrode-ball makes it possible to improve the results of mini-access operations in patients of elderly and senile age.

Publications. Nine printed works have been published on the topic of the dissertation.

Structure and scope of the dissertation. The dissertation is presented on 150 pages of computer typesetting. It consists of an introduction, a literature review, a description of materials and methods, a chapter analyzing the results, conclusions, practical recommendations, and an appendix. The reference list includes 75 Russian and 103 foreign authors. The dissertation contains 20 tables and 17 figures.