Modern Ultrasonic Technologies in the Diagnosis and Determination of Treatment Strategy for Patients with Splenic Injury

The dissertation is devoted to the study of modern ultrasonic technologies in the diagnosis of splenic injuries and the determination of treatment strategy for patients with this pathology, as well as in the diagnosis and prevention of postoperative complications after splenectomy. The research includes a comparative assessment of the informativeness of clinical, laboratory, and instrumental diagnostic methods, an analysis of various modes of ultrasonic scanning for the early diagnosis of traumatic splenic injuries. Special attention is given to the echosemiotics of the splenectomy zone, dynamic ultrasonic monitoring of the course of the wound process, and the possibilities of minimally invasive drainage procedures under ultrasonic navigation control. The work has practical significance for surgeons and diagnosticians engaged in the treatment of patients with trauma of the abdominal organs.

Relevance of the Research.

Traumatic splenic rupture is one of the most common injuries of the abdominal organs, occurring in 20–40% of all abdominal injuries [14, 21, 104, 166].

In the diagnosis of combined trauma, clinical assessment of symptoms of splenic injury is sufficiently difficult. This is due to the fact that the general condition of patients is often determined by a combination of sustained injuries, the presence or absence of shock state, coma, or alcohol intoxication. All this significantly complicates the establishment of a correct clinical diagnosis, prolongs the period of provision of qualified medical care, and even leads to medical errors [4, 37, 38, 46, 137].

In the diagnosis and determination of treatment strategy for patients with abdominal trauma, various highly informative instrumental research methods are applied, such as radiography and angiography, computed tomography and nuclear magnetic resonance tomography, as well as video laparoscopy [29, 32, 51, 55, 186].

Nevertheless, at present, the leading role in the complex of early diagnosis of splenic injuries is increasingly attributed to ultrasonic examination. This is due to the fact that the latter can be performed regardless of the severity of the patient's condition and allows, with minimal time loss, to give an assessment of changes in the abdominal organs and retroperitoneal space [2, 30, 41, 190].

Ultrasonic scanning also acquires particular significance in the diagnosis of various postoperative complications after splenectomy. Its application makes it possible to perform early diagnosis of intra-abdominal hemorrhages, inflammatory infiltrates, and abscesses of the abdominal cavity, as well as various inflammatory complications of the pleural cavities [37, 185, 191].

However, the numerous existing aspects of the diagnosis of splenic injury and the identification of complications of the early postoperative period are far from resolved. Questions regarding the comparative assessment of the informativeness of clinical and laboratory symptoms of splenic injury remain only partially studied. The diagnostic significance of various instrumental methods of early diagnosis of its injuries is not fully determined, and the algorithms of their application require improvement. The availability of a new class of ultrasonic diagnostic equipment dictates the necessity of clarifying the informativeness of ultrasonic examination in detecting splenic injuries and diagnosing changes in its angioarchitectonics.

Furthermore, questions regarding the application of ultrasonic scanning in the diagnosis of complications of the early postoperative period after splenectomy remain unresolved, and a unified approach to the performance and evaluation of the effectiveness of minimally invasive punctual manipulations carried out under ultrasonic navigation control in patients with limited fluid collections in the splenectomy zone has not yet been developed.

Thus, the existing questions of early diagnosis of splenic injuries and complications in the splenectomy zone dictate the necessity of their further elaboration and comprehensive analysis. The new information obtained as a result of their resolution will help improve the outcomes of surgical treatment of patients with trauma of the abdominal organs.

In connection with this, the aim of the present study was: to improve the outcomes of surgical treatment of patients with trauma of the abdominal organs by developing a comprehensive program for the early diagnosis of splenic injuries and complications in the splenectomy zone.

To achieve the goal of the research, the following tasks were set:

1. To clarify the informativeness of clinical and laboratory symptoms of splenic injury and to determine the diagnostic significance of various instrumental methods of early diagnosis in patients with trauma of the abdominal organs.

2. To determine the informativeness of various modes of ultrasonic scanning in the early diagnosis of traumatic splenic injuries and to develop algorithms for their application.

3. To study the echosemiotics of the "splenectomy zone" in patients with traumatic splenic injury, to describe variants of ultrasonic visualization of the course of the wound process, and to determine criteria for its positive and negative dynamics.

4. To reveal the role and possibilities of minimally invasive drainage procedures under ultrasonic navigation control in the diagnosis and treatment of patients with complicated course of the wound process in the "splenectomy zone".

Scientific Novelty.

The leading role of ultrasonic examination in the early diagnosis and determination of treatment strategy for patients with splenic injury has been clarified. Its informativeness and diagnostic value in the complex of laboratory and instrumental diagnosis of organ injuries have been studied.

A comparative assessment of the informativeness of various modes of ultrasonic scanning in the early diagnosis of splenic injuries has been performed, indications for their application have been determined, and their diagnostic significance has been established.

The echosemiotics of the splenectomy zone in patients with traumatic splenic injury has been described and systematized.

The role and possibilities of minimally invasive drainage procedures under ultrasonic navigation control in the diagnosis and treatment of patients with complicated course of the wound process in the splenectomy zone have been studied.

Practical Significance.

The algorithm for conducting instrumental examination and evaluating its results in patients with splenic injury has been clarified. Indications for performing emergency ultrasonic examination in the complex of laboratory and instrumental diagnosis of organ injuries have been determined.

The diagnostic significance of echosymptoms of splenic injury has been described, and indications for the application of Doppler mapping modes in clarifying the state of intra-organ vascular architecture have been determined.

An algorithm for performing ultrasonic examination in patients after splenectomy in the early postoperative period has been developed. Ultrasonic variants of visualization of the operative intervention zone have been described, and criteria for complicated course have been determined. The significance of ultrasonic examination in selecting a treatment strategy for patients in the early postoperative period, in determining the effectiveness of the conducted conservative therapy, and in clarifying the volume and type of operative intervention in complicated course has been demonstrated.

Indications for performing minimally invasive punctual manipulations under ultrasonic navigation control in patients with limited fluid collections in the splenectomy zone have been clarified, and a rational scheme for evaluating the effectiveness of their performance has been developed.

Implementation of the Results.

The provisions of the dissertation, methodological and tactical approaches, and 8 recommendations of the dissertation have been implemented in the work of surgical and diagnostic departments of City Clinical Hospital No. 12 and City Clinical Hospital No. 13 of the Department of Healthcare of Moscow.

The materials and results of the dissertation research are used in the pedagogical process in the lecture course and cycle of practical classes for students of the Department of General Surgery of the Faculty of Treatment of the State Educational Institution of Higher Professional Education "Russian State Medical University" (GOOU VPO RGMU Minzdrav Rossii), residents and postgraduate students of the department, surgeons, and physicians of diagnostic departments.

Presentation of the Work.

The main provisions of the work were reported by the author and discussed at the Seventh Scientific and Practical Conference of Polyclinic Surgeons of Moscow and the Moscow Region "Problems of Ambulatory Surgery" (Moscow, 2006), the Fourth International Distance Scientific and Practical Conference "New Technologies in Medicine" (Saint Petersburg, 2007), and a joint meeting of staff of the Department of General Surgery of the Faculty of Treatment of RGMU, the Research Institute of Medical Radiology of RGMU, City Clinical Hospital No. 12, and City Clinical Hospital No. 13.

Publications.

Six scientific works on the topic of the dissertation research have been published in the central press and scientific collections.

Volume and Structure of the Work.

The dissertation is presented in 143 pages of typed text. It consists of the table of contents, introduction, literature review, description of materials and research methods, two chapters of own research, conclusion, findings, practical recommendations, and a reference list. The text of the dissertation research is illustrated with 17 tables and 25 figures. The reference list contains 47 domestic and 173 foreign sources.