Optimization of Surgical Treatment Tactics for Patients with Acute Cholecystitis in the Setting of a Central District Hospital

The dissertation is devoted to the improvement of surgical treatment tactics for patients with acute cholecystitis in the setting of a central district hospital. The work is based on clinical material from the Republic of Sakha (Yakutia), a Far North region characterized by difficult climatic and geographic conditions and the remoteness of populated areas, which affects the organization of emergency surgical care. The study compares the results of treatment of patients with acute cholecystitis in two periods of observation (1998–2002 and 2003–2007) and describes the introduction of minimally invasive methods of surgical interventions on the biliary tract.

The dissertation improves the scoring scale for assessing operative risk factors and the severity of the physiological state of patients, distinguishes four categories of severity, and for each of them determines the possible outcome of the operation and the frequency of postoperative complications. On the basis of the developed scale, a differentiated treatment-and-diagnostic tactic is proposed, oriented toward general surgical hospitals of district and urban hospitals of the northern regions, which provides for the use of cholecystectomy from a minilaparotomy access taking into account the predicted outcome of the operation.

The number of patients with complicated forms of acute cholecystitis continues to grow and in our country amounts to 15–20% of the total number of urgent surgical patients (Dadvani S.A. et al., 2000; Ermakov E.A. et al., 2003). A characteristic feature is the increase in the proportion of patients of older age groups with severe concomitant pathology and a high percentage of complications of acute cholecystitis (Krylov Yu.M., 1995; Strizheletsky V.V. et al., 2000; Galperin E.I. et al., 2001; Ermolov M.I., 2004; Chernyshev I.R. et al., 2004; Scoper N.J. et al., 2004; Mercado M.A. et al., 2005; Kimura T. et al., 2005). Surgery remains the only radical method of treatment for acute cholecystitis; however, there is a contradiction between its scope and the traumatism of the surgical access, the prolonged rehabilitation periods, and the considerable number of complications. The choice of the method of surgical intervention continues to be debatable and remains the subject of scientific discussions and conferences (Vinokurov M.M., 2002; Kuznetsov N.A. et al., 2003; Maistrenko N.A. et al., 2005; Kaman L. et al., 2005). At present, methods of surgical interventions using small accesses are becoming widely disseminated, making it possible to avoid the serious complications inherent in laparoscopic cholecystectomy while combining its positive aspects (Prudkov M.I. et al., 1996; Ermolov A.S. et al., 2004; Khadzhibaev A.M. et al., 2005; Assalia A. et al., 1997; Diamantis T. et al., 2005; Wang Y.-C. et al., 2006).

Despite the achievements in the surgical treatment of acute calculous cholecystitis, the results of treatment remain not entirely satisfactory owing to the considerable number of postoperative complications and lethal outcomes. It should be acknowledged that the presence of extensive inflammatory infiltrative changes and the high risk of damage to the elements of the hepatoduodenal ligament to a certain extent hinder the widespread, ubiquitous use of minimally invasive methods of cholecystectomy in acute cholecystitis (Shulutko A.M. et al., 1995; Kuzin N.M. et al., 2000; Vishnevsky V.A. et al., 2003; Galperin E.I. et al., 2003; Savar A. et al., 2004; Kaman L. et al., 2005). These methods continue to be used to this day as optimal variants of surgical treatment for chronic calculous cholecystitis, which accounts for 79.4–92.5% of all cases of MCE and LCE (Sashko A.A., 2002; Vinokurov M.M., 2002; Rusanov V.P., 2003; Ivanov A.I. et al., 2003; Giger U. et al., 2005). At the same time, an analysis of recent publications indicates a rather high rate of conversion in complicated forms of acute calculous cholecystitis — 11.27%, which corresponds to 5.5% per 150.1 thousand operations (Koreshkin I.A. et al., 1998; Ivanov A.I., 2003; Saveliev V.S. et al., 2006; Syracos T. et al., 2004; Junghans T. et al., 2006).

In the Republic of Sakha (Yakutia), more than 2 thousand cholecystectomies are performed annually. The Republic of Sakha (Yakutia) is a typical example of a natural extreme zone of the Far North of the Russian Federation. The difficult climatic and geographic conditions, the remoteness of populated areas over long distances, and the complex transportation schemes for the delivery of emergency patients play a significant role in the provision of emergency medical care to patients with acute pathology, which includes acute cholecystitis.

The new economic conditions require accurate diagnosis and rapid treatment of the patient with the shortest possible hospital stay. Therefore, in the treatment of patients with acute cholecystitis, the use of low-cost and effective technologies is an urgent requirement of practical public health. In this regard, the development of issues concerning the organization of emergency surgical care for patients with acute cholecystitis in the setting of district urban hospitals using various methods of diagnosis and surgical treatment (traditional, laparoscopic, and minilaparotomic cholecystectomy) acquires extremely high relevance and significance. Undoubtedly, such an approach will make it possible to develop the most optimal diagnostic and treatment-and-tactical guidelines that take into account the real conditions of the climatic and geographic location of a Far North district.

Objective of the study: Improvement of the treatment tactics for patients with acute cholecystitis on the basis of prediction of the outcomes of the operation with the use of minimally invasive methods.

Tasks of the study:

1) To analyze the results of surgical treatment of patients with acute cholecystitis in 1998–2002 in order to identify the positive and negative aspects of the treatment tactics applied.

2) To improve the method of scoring assessment of the physiological state of patients with acute cholecystitis for application in the setting of central district hospitals.

3) To optimize the treatment-and-diagnostic tactics of treating patients with acute cholecystitis, basing them on the developed method of predicting the outcomes of the operation.

4) To introduce minimally invasive methods of operations on the biliary tract, taking into account the prediction of the outcome of the operation, in a district surgical hospital.

5) To study the immediate results of the application of the improved treatment-and-diagnostic tactics in acute cholecystitis using cholecystectomy from a minilaparotomy access.

Scientific novelty

For the first time, with the help of the recommended treatment-and-diagnostic tactics, based on a scoring assessment of the severity of the physiological state of the patients, the necessity of a differentiated approach to the treatment of patients with acute cholecystitis in the setting of a central district hospital has been substantiated.

The scoring scale of operative risk factors has been improved, and the category of severity of the physiological state of a patient with acute cholecystitis has been determined taking into account the sum of scores. Four categories of severity of the physiological state have been distinguished, for each of which the possible outcome of the operation and the frequency of possible postoperative complications have been predicted.

A rational tactic for the application of minimally invasive methods in acute cholecystitis has been developed, taking into account the prediction of the outcomes of operations, oriented toward general surgical hospitals of urban and district hospitals of the northern regions.

The result of the application of the improved surgical treatment tactics in acute cholecystitis was the improvement of the results of surgical treatment of patients with acute cholecystitis in the setting of central district and urban hospitals of the Republic of Sakha (Yakutia).

Practical significance of the work

The new approaches to the treatment-and-diagnostic tactics for patients with acute cholecystitis developed in the dissertation make it possible to differentiate the choice of the method of surgical intervention, which ultimately allows achieving high-quality results of surgical treatment.

The scoring assessment of the severity of the physiological state of patients with acute cholecystitis makes it possible to objectively evaluate the severity of the physiological state of the patient and to take a selective approach to constructing the program of surgical treatment, and is also convenient for practical application in any surgical hospital.

The improved treatment-and-diagnostic tactics of treating patients with acute cholecystitis on the basis of prediction of the outcomes of the operation make it possible, already in the first hours of the patient's stay in the hospital, to determine the timing of the patient's preparation for the operation and to choose the optimal type of surgical intervention, and shorten the duration of the patient's stay in the hospital.

Main propositions submitted for defense

For the choice of the method of surgical treatment of acute cholecystitis and its complications, the examination of patients must be comprehensive and accessible in the setting of general surgical hospitals of urban and district hospitals of the northern regions.

The use of the improved scoring scale for assessing the severity of the state of patients with acute cholecystitis makes it possible to predict and choose the safest method of the operative technique and to take a selective approach to constructing the program of surgical treatment.

The performance of cholecystectomy from a minilaparotomy access on the basis of prediction of the outcome of the operation reduces possible complications, accelerates the postoperative hospital-stay day, and is preferable to traditional cholecystectomy.

The technique of minilaparotomy operations on the biliary tract, after appropriate mastery of the surgical technique and with the availability of instruments, can be accessible in any general surgical hospital of the northern regions.

The optimized treatment tactics in acute cholecystitis on the basis of prediction of the outcome of the operation makes it possible to take a differentiated and objective approach to the choice of preoperative preparation, the type of operation, and to improve the immediate results of treatment.

Implementation into practice

The results of the dissertation work have been implemented in the practical work of the surgical departments of the city of Vilyuysk and the Republican Hospital No. 2 of the Republican Center for Emergency Medical Care in Yakutsk, Republic of Sakha (Yakutia). The materials of the dissertation research are used in lecture materials and in conducting classes with students at the Department of Faculty Surgery of the Medical Institute of the State Educational Institution of Higher Professional Education "M.K. Ammosov Yakutsk State University".

Approval of the work

The main propositions of the dissertation were discussed at the annual scientific and practical conference of the Medical Institute of the State Educational Institution of Higher Professional Education "M.K. Ammosov Yakutsk State University" (2006, 2007); at the interregional scientific and practical conference of surgeons "The Current State of the Surgical Service of the Republic of Sakha (Yakutia)" (Yakutsk, December 2006); at the regional seminar of young scientists and public health specialists of the uluses of the Vilyuy zone "Scientific Youth and Public Health" (Verkhnevilyuysk, March 2006); at the II Interregional Scientific and Practical Conference of Surgeons of the Far Eastern Federal District (Yakutsk, October 2007); at the joint scientific and practical conference of the Departments of Faculty, Hospital, and General Surgery of the Medical Institute of YSU, the Academic Council of the Yakutsk Scientific Center of the Russian Academy of Medical Sciences (Yakutsk, 19 April 2008).

The dissertation was approved at:

- the joint scientific and practical conference of the Departments of Faculty, Hospital, and General Surgery of the Medical Institute of Yakutsk State University, the Academic Council of the Yakutsk Scientific Center of the Russian Academy of Medical Sciences and the Government of the Republic of Sakha (Yakutia), and physicians of the surgical and intensive care departments of the Republican Center for Emergency Medical Care (Republican Hospital No. 2 — TsEMP) and the National Center of Medicine (Yakutsk, 5 June 2008).

Publications

On the main propositions of the dissertation, 8 works were published, including 2 works in journals recommended by the Higher Attestation Commission of the Russian Federation.

Scope and structure of the dissertation

The dissertation is set out on 169 pages of typewritten text and consists of an introduction, 5 chapters, a conclusion, conclusions, practical recommendations, an appendix, and a list of references. The work contains 44 tables and 10 figures. Bibliography: 245 sources (135 domestic and 110 foreign authors).