Stavropol State Medical Academy, Stavropol, RUSSIA
Treatment of patients suffering from post-burn corrosive stricture of esophagus is a difficult and actual problem. All authors prefer bougienage in its different variants. We are also the supporters of conservative treatment of corrosive strictures of esophagus held under strict compliance to the main principles of bougienage – restoration of passability of esophagus in combination with caution and reasonable persistence, as well as of supporting bougienage courses.
The aim of the investigation is the analysis of complications and lethality after bougienage in post-burn corrosive strictures of esophagus in the territorial clinic center of the specialized medical aid in Stavripol city.
The results of treatment of 319 patients suffering from corrosive strictures of esophagus after chemical burn happened in 1995-2010 were submitted to the present work. We treat the patients suffering from chemical burn over 1.5 month and more as the patients suffering from corrosive strictures. Bougienage of esophagus was implemented by 289 patients, and hollow bougie on the metallic string-conductor under the control by x-ray television at 94 out of them, under endotracheal narcosis using hard esophagoscope at 190 out of them and bougienage “without end” on threads through gastrostomy at 5 out of them. Averagely 3 sessions of bougienage were implemented with the interval of 2-3 days.
A steady clinic effect was achieved at 246 (85,1%) patients. Bougienage of esophagus was ineffective because of extent of the stricture at 43 patients, different types of plastic surgery of esophagus were implemented by it. Nourishing gastrostomy was put in at 28 patients according to A.F.Chernousov for the purpose of preparation to the plastic surgery of esophagus and a nourishing jejunostomy at one patient in connection with combined burn of esophagus and stomach at the first stage. Perforation of esophagus after bougienage occurred at 4 patients, but bougienage was implemented under supervision by hard esophagoscope at all patients. The primary plastic surgery of esophagus was implemented against the background of mediastinitis (1 - in the course of the first 6 hours and 2 16-18 hours after bougienage) at three patients according to the extreme indications. Mediastinotomy, mediastinum drainage was implemented at one patient according to Sabinus method. Lethal termination was marked at a patient after the initial plastic surgery of esophagus operated 18 hours after the moment of perforation of esophagus in the result of acute cardiovascular disorder progressed in the early postoperative period.
Thus, an adequate selection of bougienage method depending on abundance and character of lesion, as well as its regular conduction allowed to reach a steady clinic effect at 85.1 patients. Extirpation of esophagus with primary plastic surgery is absolutely indicated in injury (perforation) of esophagus in the first 10-12 hours from the injury moment.
ANALYSIS OF RESULTS OF SURGICAL TREATMENT OF PATIENTS WITH BLEEDING GASTRIC ULCER
Branch of the Republican Scientific Center for Emergency Medical Care,
Purpose - to compare the results and effectiveness of different methods of surgical interventions in patients with bleeding gastric ulcers (BGU) at the stages of urgent medical aid (UMA).
The total number of patients included in the analysis constituted 565 patients: 1st period (1990-2000.) covers the period till the appearance of UMA centers in the Republic - 144 (25.5%) patients; 2nd period (2001-2009.) covers the period after appearance of UMA centers in the Republic and its 12 regional branches, capable of providing 24-hour staged specialized UMA in accordance with accepted standards. Prospectively total of 421 (74.5%) patients were studied within the period. Comparatively, there were studied the results of different methods of surgical interventions performed in 176 (31.2%) patients with BGU. In the 1st period, there were operated 93 (64.6%) patients who were not performed preliminary endohemostasis. In the 2nd period 83 (19,7%) (Pχ2 = <0,001) patients were operated, 52 (62,7%) of them were operated without preliminary endohemostasis, and 31 (37.3%) with preliminary endohemostasis.
The revealed significant difference between the operational activity of 1st and 2nd periods shows differentiated approach to the selection of operation method for in bleeding gastric ulcer in connection with the use of endohemostatic aids. 30 patients with high operative risk in BGU were performed less traumatic palliative surgical interventions (suturing and excision of a bleeding ulcer), of which in the 1st period there were 8 (26.7%), and in the 2nd - 22 (73.3%). However, suturing of a bleeding ulcer had a risk of recurrence of a bleeding ulcer in the postoperative period, mainly encountered in patients with chronic BGU in the 1st period (3, 60.0% of 5 patients). In connection with this, the intervention should be considered inadequate from the point of view of reaching a definitive hemostasis in BGU. The share of resection methods with fatal outcome of 6.8% constituted significant majority - 83.0% (146 of all 176 operations) (Pχ2 = <0,001): 85 - in the 1st, and 61 - in the 2nd period. That is, in the 1st period there were carried out more (85, 58.2%) resections than in the second (61, 41.8%), due to application of active-differentiated tactics and endohemostatic aids in the 2nd period.