Olefir O. Preoperative Diagnosis and Prognosis of Complications of Urgent Pathology of the Small Intestine

Українська версія

Thesis for the degree of Doctor of Philosophy (PhD)

State registration number

0825U001360

Thesis Registration Form

0825U001360.pdf

Applicant for

Specialization

  • 222 - Медицина

Specialized Academic Board

PhD 8430

Kharkiv National Medical University

Essay

As shown by the conducted studies, in patients with small bowel necrosis before surgery, a significant decrease in blood parameters such as platelets (on average by 21.1%), INR (on average by 73.3%), antithrombin (on average by 23.9%) was observed against the background of a decrease in blood pressure by an average of 37.9% and abdominal perfusion pressure by 7.4% (p < 0.01). At the same time, significant values were obtained for the parameters that were increased in small bowel necrosis before surgery: D-dimer (on average by 14.9%), fibrinogen (on average by 13.7%) and APTT (on average by 12.7%) (p < 0.01). D-dimer demonstrated good diagnostic performance (AUC  0,880) in thromboembolic occlusion of the superior mesenteric artery, but its sensitivity and specificity varied in different ranges in different pathologies. In the group of patients examined by us, wide fluctuations in the I-FABP index were registered - from 199.8 to 2189.6 pg/ml. The analysis of the odds ratio and probability of predicting early mortality in patients before surgery showed that only one of the studied indicators was at the level of 80% and above, namely the SOFA scale (89.1%). When conducting regression analysis, we confirmed a good dependence of mortality in these patients on the development of multisystem disorders in the postoperative period: AUC = 0.814, 0.95% CI 0.728–0.896, with a sensitivity of 81.2% and a specificity of 74.6%. It was determined that the groups of patients who survived and did not survive had similar values for four main indicators when patients were admitted to the hospital: blood lactate level (81.3%), I-FABP (83.6%), abdominal perfusion level (82.0%), and the presence of criteria for abdominal sepsis (81.9%). The statistical significance of the obtained discriminant function for these indicators was assessed based on Wilks' Λ-statistic and was Λ = 0.626 at χ2 = 20.31 (p = 0.000). The algorithm for choosing the completion of the operation after resection of the small intestine with its necrosis according to the modified Paul-Mikulich method, which consists of the following prerequisites: the presence of unstable hemodynamics upon admission of patients to the hospital and the presence of abdominal sepsis are considered reliable risk factors that often lead to adverse outcomes. When emergency surgery with stable hemodynamics is associated with extended resections of the small intestine in weak patients with a very poor general condition, or during surgery for generalized peritonitis, restorative procedures may also be contraindicated during the first surgical intervention. To choose other tactical approaches, we relied on the following criteria: 1) in the absence of risk factors for failure and mortality before and during surgery for necrosis of the small intestine, resection of a segment of the small intestine with anastomosis of the “side-to-side” type was performed; 2) in case of unstable hemodynamics without peritonitis – resection of a segment of the small intestine without anastomosis+laparotomy and “second look” strategy after 48-72 hours; 3) in case of unstable hemodynamics with peritonitis – resection of a segment of the small intestine without anastomosis, NPWT with negative pressure and “second look” strategy after 48-72 hours. The developed diagnostic and treatment approach allowed to reduce the total proportion of patients with registered life-threatening complications of varying severity according to Clavien-Dindo in the form of single-organ or multisystem disorders (IVa and IVb stages) from 8.9% to 5.7% and from 6.5% to 2.9%, respectively, and the 30-day mortality from 17.1% to 9.5% (213,330, p0,010).

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Research papers

1. Kryvoruchko IA and Olefir OS. The Assessment of the Severity of Patients with Generalized Intra-abdominal Infection: An Emphasis on the Predictive Value of Reducing Abdominal Perfusion Pressure in the Complex Treatment of Patients. Acta Scientific Medical Sciences. 2021; 5.11: 17-26. (90). - С. 44-46.

2. Kryvoruchko I, Olefir A. Adhesive obstruction of the small intestine: features of diagnosis and treatment in the context of minimally invasive technologies (review). Inter Collegas. 2021; 4: 238-246. https://doi.org/10.35339/ic.8.4.238-246.

3. Kryvoruchko IA, Boyko VV, Sartelli M, Coccolini F, Catena F, Olefir OS. Surgical Treatment Of Acute Small Bowel Obstruction: Clinical And Laboratory Parameters Associated With Strangulation And Early Mortality After Surgery. Wiad Lek. 2022;75(12):2891-2900. doi: 10.36740/WLek202212101. PMID: 36723300

4. Kryvoruchko IA, Olefir AS, Antonova MS. Association of screening markers of coagulation with the short-term outcome in the small bowel obstruction in adults: a retrospective study. Wiad Lek. 2022;75(9pt2):2244-2251. doi: 10.36740/WLek202209212. PMID: 36378703.

5. Igor A. Kryvoruchko, Tetiana O. Briukhanova, Oksana A. Nakonechna, Olexander S. Olefir. Biomarker assessment in urgent surgical pathology of the small bowel: case-control analysis of a retrospective database. 4open 2022; 5(12): 12 p. https://doi.org/10.1051/fopen/2022014.

6. Криворучко ІА, Бойко ВВ, Олефір ОС, Антонова МС. Хірургічне лікування гострої непрохідності тонкої кишки: показники, що пов’язані зі странгуляцією та ранньою летальністю після операції. Попередні дані ретроспективного дослідження. Харківська хірургічна школа. 2022; 1(112): 11-18. https://doi.org/10.37699/2308-7005.1.2022.02.

7. Олефір ОС. Особливості вибору оперативної тактики за гострої кишкової непрохідності й розповсюдженого перитоніту. Харківська хірургічна школа. 2023; № 1-2:104-109. DOI: https://doi.org/10.37699/2308-7005.1-2.2023.22

8. Igor A. Kryvoruchko, Alexander S. Olefir, Nikolai A. Sykal. Predicting of postoperative mortality in cases of abdominal sepsis for two surgical strategies using a new mathematical model: two centers review of a 10 years’ experience with the same diagnostic and tactical approaches to the treatment. The International Surgical Week ISW 2022 in Vienna, Austria in August 2022. Abstract book. 61.01.

9. Igor A. Kryvoruchko, Alexander S. Olefir. Assessment of the severity of patients with generalized intra-abdominal infection: an emphasis on the predictive value of reducing abdominal perfusion pressure in the complex treatment of patients. The International Surgical Week ISW 2022 in Vienna, Austria in August 2022. Abstract book. 61.04.

10. Igor A. Kryvoruchko, Valeriy V. Boyko, Olexander S. Olefir. Surgical treatment of acute small bowel obstruction: clinical, laboratory and instrumental parameters associated with strangulation and short-term in-hospital mortality after surgery. The International Surgical Week ISW 2022 in Vienna, Austria in August 2022. Abstract book. PE075.

11. Криворучко ІА, Олефір ОС, та ін. Алгоритм прийняття тактичних рішень при гострій непрохідності тонкої кишки непухлинного ґенезу. Авторське свідоцтво. Літературний письмовий твір No. 111610 від 03 лютого 2022 р.

12. Криворучко ІА, Олефір ОС, та ін. Гостра непрохідність тонкої кишки: лабораторні та інструментальні показники, пов'язані з странгуляцією. Авторське свідоцтво. Літературний письмовий твір No.111609 від 03 лютого 2022 р.

13. Криворучко ІА, Олефір ОС, та ін. Диференціальна діагностика обтураційної та странгуляційної гострої непрохідності кишечника. Авторське свідоцтво. Літературний письмовий твір №120499 від 13.07.2023.

14. Криворучко ІА, Олефір ОС, та ін. Прогнозування результатів лікування хворих на гостру кишкову непрохідність. Авторське свідоцтво. Літературний письмовий твір №120500 від 13.07.2023.

15. Криворучко ІА, Олефір ОС, та ін. Алгоритм вибору завершення після резекції тонкої кишки при її некрозі. Авторське свідоцтво. Літературний письмовий твір № 123763 від 13 лютого 2024 р.

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