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THE MORTALITY ANALYSIS OF THE URGENT SURGICAL PATIENTS
Z.Z. Tokhtamurod, K.S. Dolim, M.M. Sattarova, Kh.O. Tursunkulova, Sh.Sh. Komiljonov
Tashkent Pediatric Medical Institute, Uzbekistan
АНАЛИЗ ЛЕТАЛЬНОСТИ УРГЕНТНЫХ ХИРУРГИЧЕСКИХ БОЛЬНЫХ
З.З. Тухтамурод, К.С. Дoлим, М.М. Саттарова, Х.О. Турсункулова, Ш.Ш. Koмилжoнoв Ташкентский педиатрический медицинский институт, Узбекистан
Summary
Objective. To analyze the mortality due to acute abdominal surgical pathology at the emergency surgical department.
Material and methods. The analysis of all mortality cases due to acute abdominal surgical pathology in Tashkent City Clinical Hospital №7 for the 7 year period (between 2011 and 2017) was carried out. The causes of death from acute appendicitis, strangulated hernia, bleedingand perforative ulcer, acute ileus, acute cholecystitisandpancreatitis were analyzed.
Results. 11685 patients were hospitalized in the department with the urgent causes for this period. 262 of patients died reaching overall mortality of 2.2%. 198 of 262 patients had undergone surgery.Surgical activity was 57%. 36% of lethal cases (95 patients) included adults and aged people (over 60). Conclusions. The treatment effectiveness of patients with acute abdominalsurgical diseases depends on many reasons, including the time of admission, age, concomitant diseases.
Key words: emergency surgery, abdominal surgery, mortality.
Резюме
Цель исследования. Провести анализ случаев смертности от острой хирургической патологии органов брюшной полости в отделении экстренной хирургии.
Материал и методы. Изучены случаи летальности больных в отделении экстренной хирургии 7-й городской больницы г. Ташкента за 7-летний период (с 2011 по 2017 год). Проанализированы причины смерти от острого аппендицита, ущемленной грыжи, кровотечений и перфораций гастродуо-денальной язвы, острой кишечной непроходимости, острого холецистита и панкреатита. Результаты. За данный период в отделение экстренной хирургии госпитализировано 11685 пациентов. 262 пациента умерли и общая смертность составила 2,2%. 198 из 262 пациентов были прооперированные пациенты. Хирургическая активность составила 57%. 36% летальных случаев (95 больных) составили взрослые и пожилые люди (старше 60 лет).
Выводы. Эффективность лечения пациентов с острыми хирургическими заболеваниями органов брюшной полости зависит от многих факторов, в том числе от времени поступления больного в экстренное хирургическое отделение, возраста пациентов, а также наличия у них сопутствующих заболеваний.
Ключевые слова: экстренная хирургия, абдоминальная хирургия, летальность.
UDC: 617.55-036.11-036.88-02
Introduction
Acute abdominal surgical diseases occupy a prominent place among all surgical pathologies. Late patient admissionand consequently their delayed delivery to hospital dramatically increase the danger of adverse outcome of urgent abdominal diseases [1-4]. Patients with acute abdominal surgical diseases are the most
difficult and complex group of patients, requiring rapid decision making and management [1]. It is well known that mortality analysis helps to improve the organization of medical and preventive care for patients.Our objective was to analyze the mortalitydue to acute abdominal surgical pathology at the emergency surgical department.
Material and methods
We carried out the mortality analysis of Department of General Surgery of TashPMI which
Results
11685 patients were hospitalized in the department with the urgent causes for the period. 262 of patients diedreachingoverall mortalityof 2,2%. 198 of 262 patients had un-dergonesurgery andit means that surgical activity was 57%.
The significant portion of lethal cases (94 patients, 36%) included adultsand agedpeople (over 60), which corresponds to the literature data [5-9]. One patient who undergoing surgerydied due to ulcerative perforation of stomach was 92 and another one undergoing surgerywith bleeding ulcer was 103 years old.
Unfortunately, the complications after appendectomy were inevitable and depended on many factors, among which delayed call of the patientwas of great importance. Postoperative mortality was 0,04%. The causes of complications after appendectomy were late treatment, and, consequently, delayed surgical interventions, more invasive surgery. These complications were directly depended on degree of destruction of appendix [3, 4].
7244 patients (62%) had surgery for acute appendicitis for this period. Among them 3 patients (0,04%) died, but in all of these cases, the cause of death was exacerbation of concomitant
is situated in Surgical department of Tashkent City Clinical Hospital №7 with acute abdominal surgical diseases for the 7-year period (between 2011 and 2017).
diseases. Thus, one patient (0,01%) had thyro-toxic crisis and his death was caused by cardi-omyopathy with uncontrolled tachycardia and ventricular fibrillation. Two subsequent patients (0,017%) with neglected peritonitis (due to late treatment) after the surgery died from acute myocardial infarction and mesenteric thrombosis. These patients had concomitant cardiac pathology. Death occurred despite taking preventive measures.
Meanwhile, the mortality was several times higher after strangulated hernia repair than elective hernia repair [7]. After strangulated hernia repair 8 patients died (4%). The postoperative mortality was 1,57%. Thus, medical examination and rehabilitation of patients in that category remains the urgent issue. Among elderly patients, where patients with hernias are of significant proportionthe risk of complications rises due to comorbidities, especially in emergency surgery.
15 (6,4%) of 234 patients dieddue to peritonitis after perforated ulcer of stomach and duodenum. We took into account the general condition and age of patients, the presence of concomitant diseases and other theriskfactors. All patients were undergone to suturing of ul-cerperforation and abdominal draining.
Table 1. Number of surgical patients treated for the period of 2011-2017
Years Number ofpatients, n Number of surgeries, n (%) Hospital stay, days Surgical activity, % Postoperative mortality, n (%) Mortality without surgery, n (%)
2011 1938 1304 4.6 67 37 (2.8) -
2012 1884 1138 5.2 60 20 (1.8) 2 (0.76)
2013 1833 1093 4.8 60 29 (2.7) 9 (0.82)
2014 1511 810 5.2 54 39 (4.8) 17 (2)
2015 1668 844 5.1 51 37 (4.4) 12(1.42)
2016 1398 767 5.4 55 19 (2.5) 13(1.7)
2017 1453 754 6.0 52 17 (2.3) 11(1.46)
Total 11685 6710 5.2 57 198 (3) 64 (0.55)
Management of patients with acute pancreatitis was related to the generally accepted maximum conservative, low traumatic principles. Indications for surgery: pancreatoge-nicperitonitis, ineffectiveness of conservative treatment, infected pancreatic necrosis. The diagnosis was made on the basis of the clinical picture and data of laboratory and instrumental examination. Inpancreatic necrosis the draining of omental bursa, marsupilation, injecting into parapancreatictissue 0,5% procainsolution with protease inhibitors, according to the indications were performed, and cholecystectomy with drainage of common bile duct or cholecystos-tomy was done. From 780 patients (6,7%) with acute pancreatitis, 54 (13,8%) were operated, intraoperatively there were varying degrees of pancreatic necrosis, which also progressed after surgery. 41 of them (76%) with died due to severe disease.
Number of patients with ulcerative gastro-duodenal hemorrhages were 1232 (10,5%), 45 from them (3,7%) died, 69 patients (5,6%) had surgery. The time to hospitalization after theble-eding onset mostly was 3-5 hours, butin 4 patients (8,89%) it was from 2 to 10 days (!). All patients were delivered in serious condition, with hemorrhagic shock, 29 of them (64.4%) hadwe-re in terminal state. The patients were between 35 and 103 years, 33 were men and 12were wo-men(73% vs 27%).
The ulcer profuse bleeding was in 28 (2,2%) patients. Six patients as a bleeding source had gastric tumors. One had the acute gastric ulcer and 4 others had progressive deterioration of condition and died on the operating table before surgery has started. All other patients were also operated, and, 7 patients initially being operated for a long time refused surgical treatment, that worsened their condition. In all these patients the endoscopic examination and the Forrest scale assessment showed that all hemorrhages refer to IA or IB degree. The laboratory monitoring of hemoglobin, RBC count and hematocritwere also carried out in follow-up.
The analysis of concomitant diseases showed that one patient had terminal phase of chronic renal failure, 2 patients had liver cirrhosis, 4 patients had coronary heart disease, 2 of them had acute myocardial infarction. 2 patients had-
morbid obesity andone patient suffered from chronicalcoholism.
Thus, all deceased patients with gastroduo-denal hemorrhages were admitted in serious condition and they were hospitalizedlate, often refused to examine (gastroduodenoscopy) and surgical treatment, and they had comorbidities. The dynamics of death for this group of patients showed that the use of active management tactics for surgical interventions increased the lethality, which is confirmed by the literature data [1, 6]. Patients died of acutecardiovascularfailu-reandhemorrhagicshock.
1714 (14,7%) patients admitted to the department with acute cholecystitis, 1148 (67%) of themwere deliveredlaterthan 24 hours after the onset. As a rule, they were elderly people with severe concomitant diseases, suffering from cholelithiasisfor a long time with pronounced morphological and anatomical changes in the affected area. All that created serious technical difficulties during operation, the complexity of postoperative period. The complications in these cases could reach as high as 7-13% and more [2, 5].
All details of preoperative management for patients, the examination, features of the choice for surgical tactics and postoperative care were worked out in sufficient detail. For those 7 years, 321 operations of complicated forms for acute cholecystitis were performed, 5 patients (1,6%) died. The patients often refused fromsurgical treatment, referring to the previous recommendations of internists to perform conservative treatment. Doctors of related specialties must adhere to a single point of view on indications for prompt treatment of this patients.
Liver cirrhosis with esophageal bleeding was in 90 patients (0,8%), 29 of them (32%) died. In 13 (14%) people the cause of death was recurrent bleeding, being accompanied with hepatitis, and 7 (8%) had severe hepatargia. The severe condition of patients did not allow to use surgical treatment. However, almost all patients in the past were treated outpatiently and permanently and none of them had surgery. Close contact of surgeons with internists came to conclusion of more timely examination and treatment of such patients.
The results obtained are shown in the table:
Table 2. Cause of death by nosology
№ nosology operated deceased n (%) causeofdeath non-operated deceased, n (%)
1 acute appendicitis 3(0,04%) 1-thyrotoxic crisis, 1-acute myocardial infarction, 1-later appeal, toxic and hypovolemic shock, mesentericthrombosis.
2 acute cholecystitis 5(1,6%) 5-acute cardiovascular failure. -
3 acute pancreatitis 41(76°%) 33-ongoing peritonitis and toxemia, 5-prolon-ged intravascular coagulation, 3-acute myo-cardial infarction 4-refusal of the patient from the operation
4 strangulated hernia 8(4%) 7-concomitant cardiac pathology, acute cardiovascular failure, 1-hypovolemic and toxic shock, acute multiple organ failure
5 perforated ulcer of stomach and duodenum 15(6,4%) 5-later appeal, toxic and hypovolemic shock, 2-prolongedintravascular coagulation, 8-acute cardiovascular failure.
6 ulcerative gastroduodenal hemorrhages 45(3,7%) All patients were delivered in serious condition, with hemorrhagic shock, 29 of them had were in terminal state, 4-acute cardiovascular failure, 1-terminal phase of chronic renal failure. 5-terminal state, 2-refusal of the patient from the operation, 4-before surgery
7 esophageal bleeding 13(14%) 4-recurrent bleeding, being accompanied with hepatitis, 3-had severe hepatargia, 2-acute cardiovascular failure, 2-terminal state, 2-acu-te multiple organ failure 15(17%)-acute cardiovascular failure 3(3,3%)-late admission, terminal state
8 ileus 5 (1,7%) 1-later appeal, toxic and hypovolemic shock, prolongedintravascular coagulation, 1-acute cardiovascular failure, 1-terminal state, 1-pul-monary edema
9 othernosology 63 31
Total 198 64
It should be emphasized that concomitant diseases play a significant role in the structure of mortality. The overwhelming majority of deceased patients suffered from various, sometimes several concomitant diseases and these diseases were often the cause of death. The received data testified the necessity of continue improving organizational and tactical, medical-diagnostic issues in uncomplicated surgery.
Oonclusions
1. In the mortality structure from acute abdominal surgical diseases, the significant number of patients (36%) are adultsand elderly, which was explained by the presence of concomitant diseases, atypical clinical pictureof disea-
ses in this category of patients and late admission to hospital.
2. The treatment effectiveness of patients with acute abdominal diseases depended on the large extent of ongoing medical and educational work.
3. The mortality rate was: after appendectomy - 0,04%, strangulated hernia - 4%, perforated gastroduodenal ulcer - 6,4%, pancreatic necrosis - 76%, ulcerative gastroduodenal hemorrhages - 3,7%, acute cholecystitis - 1,6%.
4. Effective prophylactic medical examination and planned rehabilitation of those groups of patients were the best measures to prevent and reduce the mortality from strangulated hernias, perforated gastroduodenal ulcers, acute cholecystitis.
Literature
1. Khadjibayev A.M., Rakhimov R.I., Nabiev A.A., Mahamadaminov A.G. Results of surgical treatment of ulcear bleed in patients with ischemic heart disease. «Hospital-replacing technologies: Ambulatory surgery». 2020;1-2:110-116. (In Russ.)
2. Holzheimer R.G., Gathof B. Re-operation for complicated secondary peritonitis - how to indentity patients at risk for persistent sepsis. Eur J. Med. Res 2003; 8:125-134. (In Russ.)
3. Ivatury R., Cheatham M.L. Malbrain M.L., Sur-gae M. Abdominal compartment syndrome. Landes Bioscience 2006:308. (In Russ.)
4. Jerlov G.K., Istomin N.P., Keijan S.V. To the question of surgical treatment of peptic ulcer of the duodenum. Materials of the all-Russian conference of surgeons «Modern problems of emergency and planned surgical treatment of patients with peptic ulcer of the stomach and duodenum». Saratov 2003: 181. (In Russ.)
5. Karimov Sh.l., Khakimov M.Sh., Matkuliev U.I., Ashurov Sh.E., Abdullaev J.S., Jumanazarov A. Choice of Surgical Treatment For Duode-numperforated Ulcer. «Shoshilinchtibbiyo-taxborotnomasi», 2015; 4:5. (In Russ.)
6. Makhovsky V.Z., Aksenenko V.A., Laipanov I.M., Yahya J.M. Emergency combined operations in surgery of the abdominal and pelvic organs. Surgery. Journal of them. N.I. Pirogov. 2012; 9: 48-54.(In Russ.)
7. Makushkin R.Z., Baichorov E.K., Khatsiev B.B., Gadaev Sh.Sh., Petizhev E.B. // Repeated surgical interventions in the prevalent purulent peritonitis. Surgical Journal named after Pirogov N.I. 2009; 11:18-22. (In Russ.)
8. Nishonova E.Kh., Ismailov F.M., Zuparov K.F., Tokhtamurod Z.Z., Abdumadjidov A.Sh. Causes of death in emergency conditions of the abdominal organs. «Young Scientist», 2018;8 (194):44-45. (In Russ.)
9. Tomnyuk N.D., Danilina E.P., Chernykh A.N., Parno A.A., Shurko K.S. Peritonitis, as one of the main causes of death// Modernhightech-nology. - 2010; 10:81-84. (In Russ.)
УРГЕНТ ХИРУРГИК БЕМОРЛАРНИНГ УЛИМ ДАРАЖАСИНИНГ ТАХЛИЛИ
З.З. Тухтамурод, К.С. Долим, М.М. Сатторова, Х.О. Турсункулова, Ш.Ш. Комилжонов
Тошкент педиатрия тиббиёт института, Узбекистан
Резюме
Тадцицот мацсади. Шошилинч жаррохлик булимида цорин бушлиги аъзолари уткир хирургик ка-салликлари туфайли улим курсаткичини тахлил цилиш.
Материал ва усуллар. 7 йиллик даврда (2011-2017 йиллар) Тошкент шахар 7-шифохонаси шошилинч жаррохлик булимида цорин бушлиги аъзолари уткир хирургик касалликлари туфайли юзага келган улим холатлари тахлил цилинди. Уткир аппендицит, чурра цисилиши, ошцозон ва ун икки бармоц ичак ярасининг цонаши ва перфорацияси, уткир ичак тутилиши, уткир холецистит ва панкреатит касалликларида юзага келган улим холатларининг сабаблари урганилди. Натижалар. Ушбу давр мобайнида 11685 бемор шошилинч жаррохлик булимига ётцизилди. 262 бемор вафот этди ва улим курсаткичи 2,2% ни ташкил цилди. 262 беморнинг 198 нафа-рига жаррохлик аралашуви утказилган беморлар булган. Хирургик фаоллик 57% ни ташкил этди. Вафот этган беморларнинг 36% ини (95 бемор) кекса ёшдагилар (60 ёшдан катта) ташкил цилди.
Хулосалар. Корин бушлиги аъзоларининг уткир хирургик касалликларига чалинган беморлар-ни даволаш самарадорлиги куп сабабларга боглиц, шу жумладан беморнинг касалхонагача келиш вацтига, ёши ва хамрох хасталикларга.
Калит сузлар: шошилинч жаррохлик, абдоминал жаррохлик, улим курсаткичи.
Сведения об авторах:
Тохтамурод Зиедулла Зикрилла - кандидат медицинских наук, доцент Ташкентского педиатрического медицинского института. E-mail: ziyodulla1966@gmail.com.
Долим Кенжабек Субутой - кандидат медицинских наук, доцент Ташкентского педиатрического медицинского института.
Саттарова Мадина - студентка Ташкентского педиатрического медицинского института.
Турсункулова Хилола - студентка Ташкентского педиатрического медицинского института.
Комилжонов Шохрух- студент Ташкентского педиатрического медицинского института.
Information about authors:
Tokhtamumd Ziyodulla Zikrilla - Ph.D., docent, Tashkent Pediatric Medical Institute. E-mail: ziyodulla1966@gmail.com.
Dolim KenjabekSubutoy- Ph.D., docent, Tashkent Pediatric Medical Institute.
Sattarova Madina - medical student, Tashkent Pediatric Medical Institute.
Tursunkulova Khilola - medical student, Tashkent Pediatric Medical Institute.
Komiljonov Shokhrukh - medical student, Tashkent Pediatric Medical Institute.
Поступила в редакцию 12.02.2021
Received 12.02.2021
