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Section 8. Medical science
References:
1. Abakumov M. M., Lebedev N. V., Makarchuk V. I. Objective assessment of trauma severity in injured patients with combined injuries.//Surg. vestn. - 2001. - 160 (6): 42-45.
2. Bisenkov L. N., Kochegarov О. V. Diagnosing and treatment of heart injury.//Thoracic and cardiovascular surgery. - 1999. -2: 39-43.
3. Borisov A. E., Mitin S. E., Chlopov V B. et al. Endovideosurgery opportunities at treatment of chest trauma.//Endoscopic surgery. - 2001. - 3: 32.
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10. Ismailov D. A., Tashbaev A. M., Kurbanov S. Qualified surgical aid on chest trauma.//Surgery of Uzbekistan. - 2000. -3: 43-44.
11. Porhanov VA., Polyakov V B., Kononenko V B. et al. Videothoracoscopy in treatment of patients with traumatic injuries of chest.//Annals of surgery. - 2001. - 2: 44-50.
12. Florikyan A. K. Surgery of chest trauma (Pathophysiology, clinical features, diagnostics, treatment). - Charkov: Osnova, 1998. - 509 p.
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Khakimov Murod Shavkatovich, MD, Professor, Head of the Surgery Department of Tashkent Medical Academy Adilkhodjaev Askar Anvarovich, PhD, Assistant of the Surgery Department E-mail: askar1981@mail.ru Yunusov Seydamet Shevketovich, Master's Degree Student of the Surgery Department
Integral assessment program for development of specific complications and tolerability of gastropancreatoduodenal resection in patients with periampullar tumors
Abstract:
Purpose: experience of radical surgical treatment of 51 patients with periampullary tumors have been analysed. Based on the original study of fatal cases of 7 patients, the integral assessment program for specific complications in
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Integral assessment program for development of specific complications and tolerability of gastropancreatoduodenal...
patients underwent the gastropancreatoduodenal resection has been developed. Postoperative lethality was 6.8 %, caused by intraoperational complications.
Keywords: periampullary tumors, specific share of factor, confounding factor.
Introduction
As the studies showed, the results of surgical treatment of periampullar tumors (PAT) remain disappointing [1]. Development of many technological methods and their implementation into clinical practice, different management methods for their prevention have not led to a significant reduction of postoperative complications diagnosed after gastropancreatoduodenal resection (GPDR) with in-cidency from 32.5 to 100 %, with a mortality rate of 3.0 to 25.7 % [2; 3].
However, apart from different approaches in the diagnosis and treatment of PAT, a high percentage of postoperative complications and mortality, relatively low life expectancy of the patients about high relevance of the problem [4-11].
The purpose of the report is to improve the results of surgical treatment of periampullary tumors by developing an integral programm of evaluation of specific complications after pancreaticoduodenal resection.
Materials and Methods
Analysis of unsatisfactory outcomes of the control group showed that despite the ability to perform radical surgery, according to laboratory and instrumental methods of treatment, not all the patients might tolerate a radical surgery. Different opinions on criteria of choosing the final treatment method leads to the fact that often exceeds the volume of surgical treatment.
Given the unsatisfactory results of radical surgical treatment, the study phase developed a program to assess the possible development of specific complications after the PDR. During creation of this program we adhered to the following principles:
1. Prediction of the outcome of the disease in its pure form has low value for the clinician, because even with extremely poor prognosis doctor still ought to do everything possible to save the patient’s life.
2. The full range of probability of lethal case from a minimum to a maximum would represent nothing less than the percentage amount of signs leading to the outcomes.
3. Severity index shall be a number variable in accordance with the probability of death from the minimum value to the maximum.
4. The severity of the patient should be determined by the method of calculation before the alleged radical operation.
5. Calculation method of the index must be sufficiently simple, suitable for use in hospitals, providing high-tech surgery.
6. Method should only be based on objective values, and should guarantee the same degree of gravity not only by physicians of a clinic, but any other
hospital specialists with adequate definition of
evaluation criteria.
Based on the foregoing, the factors were identified that affect the likelihood of developing complications or success. To assess the significance of these or other factors on treatment outcome, as well as for assessing the feasibility of surgical treatment and its efficiency indicators were calculated such as risk (R, Р) and odds ratios (OR).
The term “risk” is necessary to understand the probability of any event (in lethal case) under one or another factor. Risk indicators were calculated on the basis of four-base tables. It consists of the following options.
Absolute risk (AR, АР) — probability of dying after surgery when the studied factor or its absence, was calculated according to the formulae:
ARkg = a/a + b,
where: ARkg — absolute risk in the group with lethal outcomes; a — the number of patients who died with the presence of a sign; b — the number of patients without lethal outcome, experiencing the sign.
ARog = c/c + d,
where: ARog — overall risk without lethal outcome; c — the number of patients who have died without this or that sign; d — the number of observations with no deaths in a group of patients without the sign.
The relative factor (RR) characterizes the degree of importance of the factors influencing the target outcome. So, when the RR > 1 — likelihood of the studied outcome is statistically significant. When RR < 1 — the factor had no impact on the outcome and was calculated according to the formula: RR = ARkg / ARog
Absolute risk reduction (ARS) is a value that indicates the degree of how the outcome correlates with effect of the factor, calculated by the formula:
SAR = ARkg - ORog
Relative risk reduction (RRR, СОР) is a value that indicates how many times the probability of target outcome in the absence of studied factors, determined by the formula:
RRR = ARkg - ARog/ARog.
Odds ratio (OR, ОШ) is the ratio of the probability of the studied outcome to his absence, it shows how many times increases or decreases the likelihood of death when exposed to the investigated factor, calculated by the formula:
OR = a*d/b*c.
In this regard, an analysis was made of the results of unsatisfactory results of radical operations observed in control (7 patients) and basic (3 patients) groups. 41 patients in the studied groups convalesce.
Thus, it was determined the specific weight of each sign, the total number of which made it possible to identify the percentage of complications and possible death of the core group.
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Section 8. Medical science
Table 1 - List of aggravating factors in the patients with PAT in planning radical surgery (n = 51)
No. Measurable factors Criteria factors Specific weight of the factor (points) identifying the risk of death % Specific gravity of the factor ( %)
1 2 3 4 5 6
1. Persistent itchy skin after EBI Yes 4.8 4.0 % 3.7 %
No 0.4 0.3 %
2. Persistent weakness after EBI Yes 7.2 5.9 % 5.6 %
No 0.4 0.3 %
3. The presence of lower back pain Yes 4.6 3.7 % 3.6 %
No 0.2 0.2 %
4. Nausea and vomiting Relieved 3.1 3.9 % 2.4 %
Not relieved 1.1 0.9 %
No 0.8 0.6 %
5. Duration of jaundice prior to EBI More than 3 weeks 10.8 9.5 % 8.4 %
Up to 3 weeks 1.44 1.1 %
Up to 2 weeks 0.1 0.1 %
6. Volume of discharged bile after EBI 500-700 ml 0 0.0 % 0.0 %
up to 500 ml 0 0.0 %
7. The persistence of hyperthermia after EBI Yes 3.1 2.9 % 2.4 %
No 0.6 0.5 %
8. Age of patient 70 and older 3.7 5.0 % 2.9 %
59-70 years 1.2 0.9 %
45-59 years 1.1 0.9 %
Up to 45 0.4 0.3 %
9. Sex Male 0.8 1.6 % 0.6 %
Female 1.3 1.0 %
10. Patient build Hyperstenic 3.6 3.9 % 2.8 %
Asthenic 1.2 0.9 %
Normostenic 0.2 0.2 %
11. Previously performed PAT operations Yes 2 2.3 % 1.5 %
No 1 0.8 %
12. Weight loss Expressed 2.3 2.0 % 1.8 %
Moderate 0.3 0.2 %
13. Presence of concomitant pathology Decompensated HD, endocrine and lung diseases 8.6 17.7 % 6.7 %
Decompensated HD, endocrine and lung diseases 7.4 5.7 %
Compensated lung diseases 6.1 4.7 %
No 0.8 0.6 %
14. Tumour markers (CEA, CA 19.9) Dramatically increased 8.2 8.0 % 6.3 %
Moderately elevated 2.2 1.7 %
15. Anaemia II — III degrees 2.2 2.6 % 1.7 %
I degree 1.1 0.9 %
16. Total blood protein Less than 50 g/l 1.2 2.6 % 0.9 %
More than 50 g/l 2.2 1.7 %
17. Blood enzymes (ALaT, ASaT) No downward trend 1 1.4 % 0.8 %
Tends to reduce 0.8 0.6 %
18. Hyperbilirubinemia More than 60 pmol 2-4 2.8 % 1.9 %
Up to 50-60 pmol 1.2 0.9 %
19. MRPChG Block of OVC in middle and upper third 9.2 8.0 % 7.1 %
Block of OVC in lower thirds 1.2 0.9 %
No 0 0.0 %
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Integral assessment program for development of specific complications and tolerability of gastropancreatoduodenal...
1 2 3 4 5 6
20. Fibrinogen indicators More than 2.5 times 1.2 1.6 % 0.9 %
Elevated 1-2 times 0.9 0.7 %
No 0 0.0 %
21. Hyperco agulab ility Expressed 2.1 1.8 % 1.6 %
None 0.2 0.2 %
22. Stage of liver failure Sub and decompensated 2.5 2.8 % 1.9 %
Compensated 1.1 0.9 %
23. The patient’s ability to pay for a radical operation Yes 1.2 4.3 % 0.9 %
No 4.4 3.4 %
24. Previously performed instrumentation data CTI+angiography 1.5 1.6 % 1.2 %
MRPChG + MSCTA 0.6 0.5 %
Вы в о д: | Р еком аиоЕано проведгние р апикальной операции
Fig. 1. “PPGPDR” program interface (DGU 0384 d/d 14.08.2015)
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Section 8. Medical science
The study included anamnestic data, laboratory data, results of MRPChG and MSCTA, which allowed to determine ability to perform radical surgery.
Thus, in proportions equal to 15.7 points or above, and according to instrumental methods of diagnosing the case was resectable, it was the fulfillment of the GPDR.
If the amount is less than 15.7 (12.2 %) points, regardless of the extent of the State, from any interference should refrain with dynamic monitoring of the condition of the patient.
Based on these data, the original computer program « PPGPDR » (Program portability of gastropancreatoduode-nal resection) was developed — DGU 0384 d/d 14.08.2015.
Under this program, individual patient data shall be entered into a form with fixed parameters, each of which had its own specific weight, the sum of which allowed to determine the risk of complications and the tactics of the final treatment (Fig. 1).
So, in the control group of 24 radically operated patients, seven patients have died (29.1 %). Causes of deaths were from 4 patients — pancreatic fistula and three patients (24.5 %) —
underestimation of confounding factors. At the same time, in the main cause of the deaths of all three patients were pancreatic fistula.
The study showed the effectiveness of the proposed method, which has reduced the proportion of deaths from 29.1 % to 9 %.
Therefore, our proposed assessment program of GPDR identified the main factors that lead to unsatisfactory results of surgical treatment that helps you assess the effectiveness of the treatment and diagnostic activities and anticipated final treatments.
Conclusions:
1. Developed integrated program evaluation of the possible developments of complications and tolerance of radical surgical treatment allows to determine the potential risk of developing specific complications, deaths with the definition of accuracy of the method to the 84-86 %.
2. The proposed method of calculation is simple, can be supplemented by other factors and can be recommended for general use.
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Shorustamov Mukhammad Todjalievich, Branch manager clinic of Tashkent Medical Academy, Republic Uzbekistan
E-mail: evovision@bk.ru
Dynamics of mineral density of the calcaneus by ultrasound densitometry at the patient in treatment of acetabular fractures
Abstract: Enhanced core compression-distraction device reduces the time of treatment and rehabilitation of patients with injuries of explosives, it contributes to a more rapid and complete recovery of function of the hip joint.
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