Myronenko O. Optimization of surgical strategy of small bowel obstruction.

The thesis is devoted to the optimization of surgical strategy's choise of adhesive small bowel obstruction (SBO). At the first stage of the work the basic tendencies of clinical current of adhesive SBO and signs of gut stasis by traditional radiography methods in 384 patients were determined. These patients have made control group. The received results have allowed to plan ways of optimization of tactics of treatment, to develop new ways of diagnostics of an intestinal stasis and surgical strategy's choise which were applied in 144 patients at the second stage. Patients at the second stage have made basic group. The patients both groups were divided into 3 subgroups. The criterion to divide the patients into subgroups was radiography visualization of gut stasis. The 1 subgroup included patients who had the absolute indications to a choice of operative tactic. The 2 and 3 subgroups consisted of patients with operative and conservative tactics of treatment, which choice was determined only after additio nal research of an intestinal stasis. The both groups at the first and second stages were representative on age, sex, clinical characteristics and terms of hospitalization. At the first stage the 1 subgroup included 241 patients. The 2 and 3 subgroups consisted of 81 and 62 patients respectively. It has been established that routine radiography methods of diagnosis in control group are not aJlways informative to make a decision in managment. Especial category (the 2 and 3 subgroups) consists the patients who had previous abdominal operations or were operated on for mechanical intestinal obstruction. Term of choice of operative treatment made 85% in patients of 2 subgroup from 6 to 12 hours. High bacterial contamination (34,6% against 27,8%), primary majority on complexity of operative measures (performance of resection and an intubation of a small bowel) (32,1% against 2,9%) and high frequency of occurrence of postoperative complications (30,8% against 25%) and postoperative mortality (13,6% against 11,6%) in patients of 2. subgroup in comparison with the patients of 1 subgroup was established. At the second stage the 1 subgroup included 92 patients. The 2 and 3 subgroups consisted of 36 and 16 patients respectively. The new diagnostic complex based on study of a functional condition of an intestinal wall and degree of vegetative frustration. The following kind of investigation have been used: the gut pressure was investigated by of an intraluminary manometry; activity of enzymes of the digestive tube and separate of biochemical parameters and their translocation in abdominal cavity. The conditions of the gut barrier and resorbtion function are evaluated by the investigations of methylene blue translocation and absorbtion from the gut to the blood plasma and to the abdominal cavity (patent of Ukraine № 36531 A). The analyses of peritoneal liquid and blood plasma were taken 1, 2, 3 h later. Selection of peritoneal liquid for investigation performed with the help of a puncture under the ultrasonic control. As a resu lt of our study in basic group we have concluded that: term of choice of operative treatment in patients of 2 subgroup consisted 3 hours; bacterial contamination in patients of 2 subgroup decreased to 22,2%; postoperative complications reduced from 30,8% to 25% and postoperative mortality decreased from 13,6% to 11,1%. The application of this method in patients with adhesive SBO allows to avoid mistakes in evaluation of bowel ishemic damage and endogenous intoxication, to reduce the postoperative complications rate on 5,8 and to decrease postoperative mortality on 2,5 per cents.