Substantiation and Improvement of Methods of Ileostomy and Reconstructive Operations for Its Closure

The dissertation is devoted to the substantiation and improvement of methods of ileostomy and the technique of reconstructive operations for its closure in patients with acute abdominal pathology requiring the formation of an intestinal fistula. The work examines the two-stage tactic of surgical treatment of gastrointestinal tract diseases, in which the formation of an ileostomy ensures decompression and eliminates the risk of suture failure of a primary entero-anastomosis.

The study combines anatomical-topographical, clinical, and statistical approaches. The angioarchitectonics of the terminal ileum in normal and pathological conditions, ultrasonographic parameters of the anterior abdominal wall in patients of different constitution, as well as the causes and frequency of complications in various variants of ileostomy were studied. Based on the data obtained, principles of ileostomy formation were developed taking into account the constitutional characteristics of the patient, obesity, and the condition of the abdominal cavity; the choice of timing and methods of reconstructive interventions was substantiated. An original method of ileostomy formation (RF Patent No. 2320278) and an improved technique for creating a fistula that heals spontaneously after removal of the intubation tube were proposed.

Relevance of the study

In certain surgical diseases of the gastrointestinal tract (GIT), the formation of intestinal fistulas for therapeutic purposes is a forced and sometimes the only possible method of eliminating the pathology (Levchik E.Yu., 2004; Klimushev V.N., 2004; Kudzheva F.A., 2004; Vorobyov S.A., 2006; Izmailov E.P., 2007).

Completing the operation by forming a primary entero-anastomosis is extremely dangerous due to the risk of suture failure. The most justified tactic is two-stage treatment, when a fistula is first formed, which is used to decompress the GIT and is closed after the inflammation in the intestine and abdominal cavity subsides (Kochnev O.S., 1984; Sigal M.Z., Ramazanov M.R., 1988; Chernyshev V.N., 2000; Abdulzhalilov M.K., 2003; Pakhomova G.V. et al., 2003; Savelyev V.S. et al., 2004; Belokonev V.I., Izmailov E.P., 2005; Galkin D.V. et al., 2005; Sevostyanov S.I. et al., 2005; Totikov V.Z. et al., 2006; Galkin R.A. et al., 2008).

Ileostomy as a variant of completion of the operation for acute intestinal obstruction and peritonitis is used primarily when the pathology is localized in the distal parts of the small and large intestine. In surgical diseases caused by trauma, diseases of the colon and cecum (ulcerative colitis, Crohn's disease, perforation by a foreign body, complications of appendicitis, etc.), it is especially indicated, since at the stage of restoring the continuity of the GIT it makes it possible to limit oneself to low-volume operations (Totikov V.Z. et al., 2006).

At the same time, complications are possible during the formation of an ileostomy, which worsen the outcome of the patient's treatment (Abdulzhalilov M.K., 2003; Sevostyanov S.I. et al., 2005). At the same time, the results of treatment are influenced by such factors as the patient's sex and age, body weight and the condition of the abdominal cavity, which must be taken into account during the operation. In addition, when forming an ileostomy, it is necessary to create favorable conditions for closure of the fistula at the restorative stage of treatment with minimal trauma to the patient. This dissertation research is devoted to the solution of these issues.

Aim of the work

Improvement of the results of surgical treatment of patients with acute abdominal pathology requiring ileostomy by improving the technique of fistula formation and restorative interventions.

Objectives of the study

1. To establish the causes and frequency of complications in ileostomy formation.

2. To study the features of blood supply to the terminal ileum, as well as the anatomical features of the structure of the anterior abdominal wall in the anticipated zones of ileostomy formation.

3. To develop a method and principles of ileostomy formation in patients, taking into account their constitutional characteristics, the structure of the mesenteric vessels of the ileum, obesity and abdominal pathology.

4. To substantiate the choice of the method of operations and the timing of their performance during ileostomy closure at the restorative stage of treatment.

5. To study the effectiveness of the developed method of ileostomy in comparison with the traditional approach to performing this operation from the standpoint of evidence-based medicine.

Scientific novelty of the study

The frequency and causes of complications arising in the postoperative period with various variants of ileostomy have been studied.

Ultrasonographic data have been obtained on the dimensions of the anterior abdominal wall in its various anatomical regions. The dependence of the change in the thickness of the anterior abdominal wall on the position of the subject's body has been established. Variants of the angioarchitectonics of the mesenteric vessels of the ileum have been clarified.

Principles of ileostomy formation in patients of different constitutional build have been developed.

For the first time, an original method of ileostomy formation has been developed and applied (RF Patent for Invention No. 2320278 dated 27.03.2008).

For the first time, an improved method of ileostomy formation has been applied, which heals on its own after removal of the intubation tube (rationalization proposal No. 628 dated 3.12.2008).

The principles of performing and improving the technique of reconstructive operations aimed at eliminating therapeutic intestinal fistulas have been substantiated (rationalization proposal No. 541 dated 1.03.2007).

Practical significance of the study

Identification of the causes of complications in classical methods of ileostomy formation allows timely prevention of their occurrence.

Planning the site of ileostomy exteriorization on the anterior abdominal wall, taking into account its thickness, as well as the location of the intestine near the excluded distal parts of the intestine, reduces the frequency of early complications.

The developed principles of ileostomy formation contribute to a reduction in the number of complications in the early postoperative period and create optimal conditions for ileostomy closure through access in its projection at the restorative stage of the patient's treatment.

Implementation of the results

The main tactical approaches have been implemented in the work of surgical departments No. 6 and No. 7 of the Municipal Medical Institution "City Clinical Hospital No. 1 named after N.I. Pirogov," Samara; surgical departments of the Municipal Medical Institution "City Hospital No. 8," Samara; surgical departments of the Municipal Medical Institution "City Clinical Hospital No. 2 named after N.A. Semashko," Samara. The materials of the dissertation research are used in the educational process at the Department of Surgical Diseases No. 2 of the State Educational Institution of Higher Professional Education "Samara State Medical University of the Federal Agency for Healthcare and Social Development."

Publications

On the topic of the dissertation, 8 printed works have been published, including 2 in a publication recommended by the Higher Attestation Commission of the Russian Federation. An RF Patent for Invention and 2 certificates for rationalization proposals have been obtained.

Approbation of the work

The main results of the study were reported at the scientific-practical conference dedicated to the memory of Academician A.A. Shalimov "Actual Problems of Practical Surgery" (Kharkiv, 2006); at the VI scientific-practical conference of surgeons of the Orenburg and Samara regions "Errors, Dangers and Complications in Surgery" (Buguruslan, 2006); at the All-Russian scientific-practical conference "Actual Issues of Phlebology. Disseminated Peritonitis" (Barnaul, 2007); at the 854th meeting of the Samara Regional Scientific-Practical Society of Surgeons (2008).

The dissertation was approbated at a joint meeting of the Department of Surgical Diseases No. 2 of SamSMU, the Department of Surgical Diseases No. 1 of SamSMU, the Department of Hospital Surgery of SamSMU, and the Department of Surgery of the Institute of Postgraduate Education of SamSMU on July 1, 2007 (minutes of the department meeting No. 12 dated 01.07.2008).

Volume and structure of the dissertation

The dissertation is presented on 169 pages of typewritten text and consists of an introduction, a review of the literature, 4 chapters of original research, a discussion, conclusions, and practical recommendations. The bibliography contains 219 references, of which 63 are by foreign authors. The text is illustrated with 26 tables and 39 figures.