Kvasnevskyi Y. Surgical approach in large bowel battle trauma (clinical and experimental research)

The thesis is devoted to the problem of surgical treatment of battle trauma of the abdomen with damage to the large bowel at the stages of medical evacuation of the troops medical support system. Based on a comprehensive clinical and experimental study and analysis of the results of treatment of 83 wounded who were delivered from the area of anti-terrorist operation (ATO)/joint forces operation (JFO) at the period 2014-2018 at the stage of medical evacuation of II-IV levels of medical care, a number of directions of wound severity assessment, diagnosis and surgical approach in patients with the thick bowel damage. Two clinical groups were developed: the comparison group and the main group. The comparison group included 42 wounded patients (2014 April - 2015 February), who were used surgery based on the principles of traditional coloproctology. The main group included 41 patients (March 2015-2018), whose treatment was based on a selective approach to the choice of surgical management at the II level of medical care as follows: determining the sequence and extent of surgery on different parts of the body according to FAST protocol; assessment of the severity of the wounded patients according to the perfusion index (PI); application of damage control surgery (DCS) technology in the wounded patients with extremely severe trauma. At the III-IV levels of medical care, a differential approach was used to perform the operations of the third phase of damage control surgery, "second look" and treatment of postoperative complications. New developments have also been introduced into the practice of surgical treatment: "Intestinal clip", "Unloading rectal tube", "Laparoport for dynamic laparoscopy for battle injuries of the abdomen". The wounded patients with the battle trauma of the thick bowel by type of injury had missile wounds as a rule - 49 (59.1 %). There were 30 (36.1 %) patients with bullet wounds, and 4 (4.8 %) with closed injuries. Most of the injuries were combined - 58 (69.9 %), and with only abdominal injuries - 25 (30.1 %), mostly multiple - 21 (25.3 %). The great majority of the thick bowel injuries belonged to sigmoid - 32 (38.6 %) and transverse colon - 21 (25.3 %), which is explained by relatively large size of these parts of the intestine. The results of experimental study of the pathomorphology of gunshot wounds of the thick bowel during simulation of gunshot wound on the "Thoracoabdominal Ballistic Simulator" were taken into account during the choice of surgical approach and the extent of surgical interventions. The experiment evaluated the macro- and microscopic consequences of damage when using firearms of different kinetic energy. Modification of diagnostic management resulted in significant decrease (on average by 50 %) of the total preoperative term in the main group in relation to the comparison group. Surgical approach in relation to abdominal injuries in the main group was developed with taking into account the severity of the condition by PI, the nature and severity of abdominal injuries, the ballistic characteristics of the wounding projectile. In the comparison group, the severity of the condition was assessed by clinical signs and blood pressure without taking into account ballistic characteristics of the projectile. As a result of the clinical and organizational measures, the number of patients with postoperative abdominal complications in the main group - 19 (48.7 %) decreased as compared to the comparison group - 28 (75.7 %) - (p = 0.0156), which we associated with repeated exploration, additional surgical manipulations aimed at improving the surgical outcome during the second operation with DCS and second look management. Lethality rate in the study group was 11 (26.2 %) cases in the comparison group and 4 (9.8 %) in the main group (p < 0.049; Fisher's exact test). The main causes of death of the wounded patients with large bowel injuries were traumatic shock and blood loss (1st-2nd day): 5 (11.9 %) in the comparison group and 3 (7.3 %) in the main group; septic complications: 6 (14.3 %) in the comparison group; pulmonary embolism - 1 (2.4 %) in the main group. A significant difference in the causes of death in the study groups was found in the category of septic complications (p = 0.012).