Dissertation for the degree of Doctor of Medical Sciences in the specialty 14.01.03 - Surgery (field of knowledge 22 "Health", specialty 222 "Medicine"). Specialized Academic Council D 64.609.01, The Ministry of Health of Ukraine; Kharkiv, 2021.
The main challenge in bowel surgery, which is still far from being solved, has been the failure of intestinal anastomoses. One of the reasons for that is that all probable complications are not always taken into account and thus the surgeons do not pay due attention to the factors that cause the development of anastomotic failures.
The dissertation is a completed research study which presents experimental and clinical justification of a new direction in solving the current problem of modern surgery - improving the effectiveness of treatment of patients in the need of resection of the small intestine on the background of intra-abdominal infection, based on developing a scientifically sound diagnostic program and prevention of failure of small intestinal anastomoses.
The effectiveness of the method of determining the level of cryoglobulinemia and electrical resistance characteristics of the wall in terms of feasibility and determining the extent of resection of the small intestine and the use of vascular endothelial growth factors in combination with low-intensity electromagnetic influence of the light spectrum are experimentally substantiated and clinically proven.
There was a stable negative correlation between cryoglobulin levels and indicators of plasma and platelet hemostasis (on the first day of observation - with APTT (r = -0.55, p = 0.01) and with platelet aggregation (r = 0.41, p = 0, 06), with increasing negative correlation of cryoglobulinemia on the fifth day of the postoperative period with APTT (r = -0.51; p = 0.007).
It has been shown that in the case of objective assessment of the intestinal wall (influence group) the number of resections of the affected part of the intestine was 33.3%, which is almost twice less than in the study group without objective assessment of intestinal viability, where the rate is 70% ( χ2 = 7.43; p = 0.006); resection was completed by enterostomy in only 5.6% in the exposure group, compared with 32% in the study group (χ2 = 0.07; p = 0.022); postoperative complications developed in the exposure group in 5.6% of cases, compared with 16% in the study group (χ2 = 0.02; p = 0.247).
It was determined that the use of temporary extracorporeal restoration of intestinal passage and delayed anastomosis using the original device allows to perform the primary anastomosis in 91.2% and reduce the recovery time of small bowel continuity to an average of 15 days in the early postoperative period. The use of the proposed methods of treatment along with the original technique of suturing skin wounds after extraperitoneal closure of small intestinal stoma reduced the length of the stay at hospital from 25.2 ± 4.3 to 16.1 ± 3.7 days (p < 0.05).
The introduction of the instrument and technique of delayed anastomoses during surgical interventions in severe patients with the need to form a stoma is clinically justified, which further allows to avoid repeated major surgical interventions, restoring patency of the intestinal tube from local accesses at an early stage. The clinical efficacy of the proposed technique of extracorporeal intestinal prosthetics has been proved.
The clinical effectiveness of the technique of suturing skin wounds after extraperitoneal closure of the small intestinal stoma was proposed and validated.
The use of the proposed methods of diagnosis, prognosis and prevention of failure of small intestinal anastomoses as well as surgical treatment of patients requiring resection of the small intestine, significantly reduced the number of postoperative purulent-inflammatory complications from 52.8% to 22.7% (χ2 (Fisher) = 22.09, p = 0.0001), mortality rate due to surgical complications from 5.6% to 2.1% (χ2 (Fisher) = 0.0163, p = 0.0332) and identified a tendency to reduce overall mortality rate from 7, 7% to 3.5% (χ2 (Fisher) = 0.008, p = 0.10).
Key words: small intestine, resection, anastomotic leak, angiogenesis, cryoglobulinemia, objectified assessment of viability.
