Simultaneous Operations via Minimally Invasive Accesses in the Treatment of Cholelithiasis and Multifocal Atherosclerosis

The research is devoted to the development and justification of a surgical treatment strategy for patients suffering from cholelithiasis in combination with multifocal atherosclerosis of the aorta and its branches. The relevance of the work is determined by the high frequency of combined surgical diseases and the insufficient study of the application of simultaneous minimally invasive operations in this combination of pathologies. In the work, an optimal preoperative examination algorithm has been developed, indications for staged and simultaneous surgical tactics have been justified, criteria for predicting technical difficulties when using minimally invasive accesses have been proposed, and the impact of simultaneous operations on patients' quality of life has been evaluated.

The dissertation contains an analysis of clinical observations, research materials and methods, characteristics of functional indicators of major organ systems, indications and contraindications for simultaneous operations, clinical results of minimally invasive technologies, and characteristics of complications with preventive measures. The results of the work have been implemented in clinical practice and incorporated into the educational process.

Relevance of the Topic.

Despite the fact that the frequency of combined surgical diseases reaches 20–30% [64,102-105,121,122], simultaneous surgical interventions are performed, on average, in only 3% of surgical patients [98]. At the same time, performing combined operations has many advantages and, in some cases, is preferable to dividing surgical treatment into several stages, as it relieves the patient of two or more nosologies simultaneously, of the need for repeated surgical intervention and the associated risks of anesthesia, postoperative complications, emotional stress, as well as of the danger of exacerbation of an unregulated concomitant disease in the early postoperative period and of the high risk of emergency surgery [2.37,162,164].

In connection with this, in recent years increasing importance has been attached to developments concerning surgical tactics in various combined diseases: from ventral hernias in combination with pathology of the thyroid gland, mammary glands, veins of the venous system, diseases of the gastrointestinal tract, and pelvic organs [3,98.111]; diseases of the pancreas in combination with coronary artery atherosclerosis, allergic pathology, pulmonological diseases in combination with chronic persistent viral infection, atherosclerosis in combination with combined surgical pathology of abdominal organs [1,5,14, 48,64.104,120,157]. Special attention is devoted to simultaneous surgical interventions in combined surgical pathology of the abdominal organs as the most complex and frequently encountered situations in emergency and planned surgery. At the same time, one of the least studied directions, despite the significance of the problem, is the operative treatment of diseases of the gallbladder, specifically cholelithiasis, combined with vascular pathology (atherosclerosis of the aorta and its branches). The prevalence of such combinations and the insufficient study of the problem determine the relevance of its consideration. In recent years, the drive toward minimally invasive methods has led to the introduction of minimally invasive operations both for performing cholecystectomies [21,22,27,88,127,169,190,284] and for vascular operations [149,155,182,183,227.228,268,281,287]. However, the justification for their use in the combination of nosologies (cholelithiasis and atherosclerosis) remained an insufficiently studied problem, as did the question of the advisability of performing combined operations themselves in patients with cholelithiasis and atherosclerosis of the aorta and its branches. Until now, a unified algorithm of preoperative examination has not been developed to determine the choice of surgical treatment tactics. The optimal volume and indications for the application of staged or single-stage surgical treatment tactics have not been justified. The algorithm for choosing the method of surgical intervention (minimally invasive or via traditional laparotomy access) has not been optimized. The criteria for improving quality of life in the postoperative period after simultaneous operations for cholelithiasis and atherosclerosis of the aorta and its branches have not been studied. The solution of these questions determines the goal and objectives of the present research.

The aim of the work is to optimize the diagnosis and surgical treatment of cholelithiasis combined with atherosclerosis of the aorta and its branches.

Research Objectives:

1. to conduct an analysis of the results of operations for cholelithiasis and various manifestations of multifocal atherosclerosis;

5. to evaluate the influence of simultaneous operations in the combination of cholelithiasis and multifocal atherosclerosis on the quality of life of patients.

NOVELTY OF THE RESEARCH

An optimal algorithm of preoperative examination for patients with combined cholelithiasis and multifocal atherosclerosis has been justified. Indications for staged and simultaneous surgical treatment tactics for combined cholelithiasis and multifocal atherosclerosis have been justified based on the analysis of functional reserves of the organism, operative risk, coronary reserve, and rehabilitative potential. It has been demonstrated that the performance of single-stage operations for multifocal atherosclerosis via minimally invasive access and minimally invasive cholecystectomies does not worsen the quality of life of patients compared with patients who have undergone only cholecystectomy or only operations for multifocal atherosclerosis, as well as compared with patients who have undergone combined cholecystectomy with operations on the aorta and its branches via a single traditional laparotomy access. The choice of tactics for simultaneous surgical interventions via minimally invasive accesses in the surgical treatment of cholelithiasis and atherosclerosis has been scientifically justified. Criteria for predicting technical difficulties when using minimally invasive accesses have been proposed. The most frequently encountered complications of the early postoperative period after cholecystectomies (ChE) and vascular operations via minimally invasive accesses (including performed simultaneously) for cholelithiasis and atherosclerosis of the aorta and its branches have been refined and analyzed. A positive influence of simultaneous operations via minimally invasive accesses in combined cholelithiasis and atherosclerosis on the quality of life of patients has been demonstrated.

3. After simultaneous operations via minimally invasive accesses, the number of complications is substantially lower compared with traditional technologies.

IMPLEMENTATION OF THE RESULTS OF THE WORK INTO PRACTICE. The results of the dissertation work have been implemented in the practice of the departments of general and cardiovascular surgery of City Clinical Hospital No. 81, in the educational process of the Department of Surgical Diseases and Clinical Angiology of Moscow State Medical-Dental University, and have been included in the lecture course of the postgraduate education system of the Sklifosovsky Research Institute of Emergency Surgery.

PUBLIC PRESENTATION OF THE WORK. The main provisions of the work were presented at a meeting of the Moscow Surgical Society (May 2005), at the Russian Gastroenterological Week (October 2005), at an interdepartmental conference of the Department of Surgical Diseases and Clinical Angiology of MGSMU, the Department of General Surgery of MGSMU, the Department of Angiology and Vascular Surgery of RMAPO, and the departments of general and cardiovascular surgery of City Clinical Hospital No. 81.

PUBLICATIONS ON THE DISSERTATION TOPIC: 9 scientific works have been published on the materials presented for the dissertation defense, 6 of which are in leading medical journals.

VOLUME AND STRUCTURE OF THE DISSERTATION. The dissertation consists of an introduction, five chapters, a conclusion, conclusions, practical recommendations, and a list of references comprising 169 domestic and 128 foreign works. The dissertation text is presented across 155 typed pages, illustrated with 26 tables and 19 figures.