Ways to improve replantation of large segments of the upper extremity

The research is dedicated to improving the surgical treatment of patients with traumatic amputations of large segments of the upper extremity. The study analyzes the factors affecting the clinical course of injuries in the early postoperative period and develops methods for diagnosing and preventing early postoperative complications. Special attention is given to evaluating the state of microcirculation in the replanted segment using modern methods such as chemiluminescence of blood plasma and laser Doppler flowmetry. The research demonstrates the advantages of a nodal microvascular anastomosis and substantiates a complex approach to the prevention and treatment of complications aimed at preserving the replanted limb and improving functional outcomes.

Relevance of the problem.

The relevance of the problem of replantation of segments of the upper extremity is due to a significant frequency of unsatisfactory results (Bogomolov M.S., Sedov V.M., 2003; Krylov V.S., 2005; Fayzullin A.A., 2005).

In turn, unfavorable functional outcomes of replantations largely depend on the possibilities of diagnosis, prevention, and treatment of complications of the early postoperative period (Datnashailn R.O., 1991; Belousov 1998). Despite a large number of publications dedicated to this section of microsurgery, significant successes in diagnosis, prevention, and treatment of early postoperative complications have not yet been achieved (Gainullin R.M., 1994; Khasbulatov S.S., 2004).

The possibilities of modern anticoagulant and antithrombotic therapy have not been fully determined, and there is no consensus on the technique of restorative operations (Krasnovsky I.D. 1968; Shibaev E.Yu. and co-authors, 2004; Kaplan I. et al. 1995; Oh S.J. et al. 1995).

The complexity of the replantation problem is explained by the lack of informative criteria and standards for diagnosing early postoperative complications. Monitoring the state of microcirculation in the replanted segment, in most clinics, is limited to routine clinical methods. Hemorheological indicators often signify a critical degree of segment ischemia. Under these conditions, there is an urgent need to improve them, develop new diagnostic methods and tools using the latest scientific and technical achievements, including the use of chemiluminescence of blood plasma and laser Doppler flowmetry (Kharhudinov R.P., 1945; Dautov S.B., 2000).

The solution of these and other problems is devoted to this research.

RESEARCH OBJECTIVE: to improve the results of surgical treatment of patients with traumatic amputations of large segments of the upper extremity.

To achieve the set goal, the following TASKS have been defined:

1. To determine the factors affecting the clinical course of traumatic injuries of large segments of the upper extremity in the early postoperative period.

2. To conduct a comparative evaluation of nodal and continuous microvascular anastomosis based on laser Doppler flowmetry data.

3. To optimize the complex surgical tactics in replantations of large segments of the upper extremity and determine the optimal combinations of drugs in the postoperative period.

4. To evaluate the early and late results of complex treatment of early postoperative complications.

SCIENTIFIC NOVELTY.

The significance of the activation of lipid peroxidation in the development of early postoperative complications after replantation of large segments of the upper extremities has been shown.

The state of microcirculation in the replanted segment of the upper extremity has been evaluated using chemiluminescence of blood plasma and laser Doppler flowmetry. It has been established that when thrombosis of the microvascular anastomosis occurs, the amplitude of the fast flash increases according to chemiluminescence of blood plasma data. When using a nodal suture in the early periods after replantation, the frequency of oscillations of all types of waves of laser Doppler flowmetry increases. According to ultrasonography data, in the early postoperative period, the advantages of a nodal microvascular suture in replantation of large segments of the upper extremity are shown, characterized by an increase in systolic blood flow velocity.

The analysis of the causes of unsatisfactory treatment results of traumatic amputations of large segments of the upper extremity, obtained during the study of complex diagnostic data, allowed the development of principles of a standardized approach to choosing surgical tactics.

PRACTICAL SIGNIFICANCE.

It has been established that including chemiluminescence of blood plasma in the complex diagnosis of early postoperative complications allows predicting the development of complications.

The developed complex method of prevention and treatment, including an optimal combination of low-molecular-weight heparins, antiplatelet agents, peripheral vasodilators in combination with the use of antioxidants, allows reducing the frequency of complications in the early postoperative period. It has been shown that timely repeated surgical intervention when monitoring the state of microcirculation in the replanted segment using ultrasonography, chemiluminescence of blood plasma, and laser Doppler flowmetry in cases of developed acute circulatory failure is one of the mandatory conditions for preserving the replanted limb.

The late results of treatment have been studied. It has been proven that the introduction into the practice of medical institutions of developed methods and operative techniques for diagnosis and treatment of injuries of large segments allows improving the treatment results of patients by reducing the frequency of postoperative complications, shortening the treatment and recovery time of the damaged limb.

Propositions to be defended.

1. Monitoring the state of microcirculation in the replanted segment in the early postoperative period using ultrasonography, chemiluminescence of blood plasma, and laser Doppler flowmetry allows detecting complications in the early periods.

2. The use of low-molecular-weight dextrans, angioprotectors in the complex prevention and treatment of early postoperative complications is justified and allows optimizing the management of patients after replantation of large segments of the upper extremity.

Dissertation testing.

The main provisions of the dissertation were presented at the 7th International Congress of Young Scientists "Human Sciences" (Tomsk, 2006), the 71st Republican Scientific Conference of Students and Young Scientists of the RB (Ufa, 2006), the 5th Republican Conference of Young Scientists of the RB "Medical Science", at the meeting of the Association of Surgeons of the RB (Ufa, 2006) and at the problem commission "Main Surgical Diseases" (Ufa, 2006).

Publications.

8 works have been published on the topic of the dissertation.

Structure and volume of the dissertation.

The dissertation consists of an introduction, four chapters of own research, conclusion, conclusions and practical recommendations, and is presented on 104 pages of typed manuscript. The work contains 1 table and 16 figures. The bibliography includes 182 sources (115 domestic and 67 foreign).