Let us dwell in more detail on the complications that are observed in our patients. After resection of the esophagus using the Savin method, they differ significantly from those observed after the Dobromyslov-Torek operation. Therefore, we will consider them separately.

Complications after resection of the esophagus using the Savin method. These complications were observed in 23 of 66 patients.

1 out of 5 patients had a second complication - the onset of intestinal necrosis (artificial esophagus).

2 patients had a second complication - a small fistula in the area of ​​the esophageal-intestinal anastomosis in the neck.

As can be seen from table. 10, there were 26 complications for 23 patients. The most severe complication that occurred during the operation was bilateral pneumothorax. Three out of 5 patients who had bilateral pneumothorax died within 1-2 days after surgery. In two of them, the serious condition was aggravated by the beginning necrosis of the jejunum, located in the posterior mediastinum. Three who died from this complication were operated on in the years when esophageal surgery was just beginning to be used in the clinic. The injury to their second mediastinal pleura occurred spontaneously and was not noticed; 2 patients were operated on later. The surgeon saw damage to the pleura, so the operation was completed only by resection of the esophagus without simultaneous plastic surgery, and in one case it was done under intubation anesthesia. After the operation, air was aspirated from both pleural cavities. The postoperative period proceeded smoothly in these patients.

A serious postoperative complication that led to death in all 4 patients was necrosis of the jejunum-posterior mediastinal artificial esophagus. The patients died on the 2nd, 9th, 20th and 32nd days after surgery. In patients who died on the 9th and 32nd days, 3 days after surgery, the necrotic intestine was removed from the mediastinum and resected, but purulent mediastinitis developed. The patient, who died on the 20th day after surgery, had necrosis not of the entire mobilized jejunum, but of its upper section measuring 10-12 cm. A week later, purulent mediastinitis and right-sided purulent pleurisy developed. The patient, who died a day after the operation, had extensive necrosis of not only the entire mobilized loop small intestine, but also a significant area distal to the selected one.

The next complication, which led to death, was the divergence of the inter-intestinal anastomosis, which occurred on the 9th day after surgery. A repeat operation was immediately undertaken, but severe shock, peritonitis, and intoxication developed. The patient died on the same day.

Here is an extract from his medical history.

Patient Yu., 59 years old, was admitted to the clinic on 22/111 1952. Clinical diagnosis: cancer of the lower thoracic esophagus, stage II.

21/1U, resection of the esophagus was performed using the Savinykh method with simultaneous small bowel plasty of the esophagus. Initially, the postoperative period proceeded without complications. On the 4th day the patient was allowed to swallow water and fruit juice, and on the 8th day he was allowed to eat semi-liquid food. At the same time, the patient began to walk; 30/1U, on the 9th day after surgery, in the morning the sutures in the neck and anterior abdominal wall were removed - healing by primary intention. During the day, the patient suddenly developed sharp abdominal pain and a state of shock. An hour later, an operation was performed: relaparotomy, during which a divergence of the interintestinal anastomosis was discovered. The anastomosis was restored. Tampons were inserted into the abdominal cavity. By the evening of 30/1U the patient died.

Acute dilatation of the stomach developed on oh day after surgery in one patient. Therefore, a week after the main operation, she had a gastric fistula. Subsequently, diffuse fibrinous peritonitis developed, and the patient died on the 87th day after surgery.

Here is an extract from the medical history.

Patient B., 51 years old, was admitted to the clinic on 28/1U 1954. Clinical diagnosis: cancer of the lower thoracic esophagus, stage II.

14/U, resection of the esophagus was performed using the Savinykh method with simultaneous small bowel plasty of the esophagus. No gastrostomy was performed.

During the first 4 days after surgery, the condition was satisfactory. On the 4th day the patient is allowed to swallow liquids; The patency of the artificial esophagus is good. On the 5th day, the patient began to experience increasing bloating, especially in the upper sections. The cleansing enemas used did little to improve the condition; 20/The patient’s condition has deteriorated significantly: the abdomen is swollen, especially in the left half, and pain is noted on palpation. 21/Your condition is even worse: severe pain in the abdomen appears, the left half is especially swollen and tense. Tongue dry, thirsty. On the night of 21/22/U, the patient was urgently operated on. During relaparotomy it was discovered sharply bloated stomach overflowing with liquid. After opening the stomach, about 3 liters of cloudy, bile-tainted contents with a fetid odor were removed from it. A gastrostomy tube was placed.

After repeated surgery, the patient's condition improved somewhat. However, normal gastric emptying could not be achieved. Food taken through the artificial esophagus partially entered the stomach and stagnated there. There was suppuration and partial dehiscence of the wound around the gastrostomy tube. The patient's condition periodically became better; she sat and tried to walk around the ward; At times she felt worse, lost her appetite, and became increasingly weak.

9/U1N the patient died on the 87th day after resection of the esophagus.

From the pathoanatomical epicrisis it follows that in the postoperative period a complication arose - gastric atony and acute dilatation. A repeat laparotomy and gastrostomy were performed, but after the second operation, partial melting of the anterior wall of the stomach occurred. Its contents entered the abdominal cavity, and diffuse fibrinous peritonitis developed, which was the immediate cause of the patient’s death.

From that time on, the clinic began to apply a gastric fistula to every patient after resection of the esophagus.

A similar complication - gastric atony after resection of the esophagus - was described in 1954 by Pxscher. His patient died on the 5th day after surgery. He also concluded that after resection of the esophagus with closure of the cardia, a gastric fistula should be applied.

Later, the works of E.V. Loskutova appeared, who studied the secretory and evacuation functions of the stomach after resection of the esophagus. She found that “after intrathoracic resections of the esophagus according to Dobromyslov-Torek, accompanied by resection vagus nerves, a significant disturbance occurs in the secretory and evacuation functions of the stomach.”

As a result of a postoperative complication, designated by pathologists as postoperative asphyxia, one patient died, who had a tumor of the upper thoracic esophagus. The operation went quite satisfactorily. On the 2nd and 3rd days after the operation, the patient periodically began to experience attacks of suffocation, consisting of difficult, tense short inhalation and noisy long exhalation. Cyanosis appeared. All possible means of combating suffocation were used, including tracheostomy and artificial respiration, but on the 4th day after the operation the patient died during an attack.

Here is an extract from the medical history.

Patient M., 58 years old, was admitted to the clinic on 15/CN 1955. Clinical diagnosis: cancer of the upper thoracic esophagus, stage II -III.

27/KhP, resection of the esophagus was performed using the Savinykh method with simultaneous plasty of the esophagus. The tumor has adhered to the right mediastinal pleura. A section of the pleural layer was excised and remained on the tumor. Right-sided pneumothorax occurred. However, the operation proceeded quite satisfactorily and was completed safely.

The next day after the operation, the patient's condition was satisfactory. The temperature is normal, pulse 96 per minute, respiratory rate 24 per minute, breathing freely. Blood pressure 110/72 mm Hg. Art. The voice is hoarse (the left recurrent nerve is somewhat injured).

29/CP the patient's condition worsened. Morning temperature 37.7°, pulse 100 per minute. In the afternoon after cupping, the patient began to choke, and fear of suffocation appeared. Pulse is about 150 per minute. Some cyanosis of the skin of the face and fingers. The patient was given oxygen. Gradually the breathing evened out. The night passed peacefully.

30/CP in the morning, temperature 36.9°, pulse 100 per minute, breathing freer than the day before. The face is purple-red. The voice is whispery. The patient said that he felt well. At 13:30 an attack of difficulty breathing, cyanosis. Oxygen given. 20 ml of 40% glucose solution, 1 ml (20 units) of convasid and 0.8 ml of 0.1% atropine were injected intravenously under the skin. After about half an hour, my breathing evened out. At 14:30 there was another attack of suffocation: a short, difficult inhalation and a long, noisy exhalation. Gradually the breathing stopped. There was no consciousness. Skin cyanosis increased. The pulse remained good. At 15:05 a tracheostomy was performed. A small amount of mucous-bloody contents was aspirated from the tracheal lumen. They continued artificial respiration and gave oxygen. After 15-20 minutes the patient began to breathe on his own. At 16:00 consciousness returned. Pulse 96 per minute, blood pressure 115/70 mm Hg. Art. The night went well.

31/HP at 7:35 a.m. an attack of suffocation occurred again: noisy and difficult breathing. Pulse 90-94 per minute. Oxygen was given for inhalation, a 40% glucose solution and 10% calcium chloride. The difficulty in breathing increased. Artificial respiration was performed. Tachycardia appeared. The patient began to behave restlessly. At 9:30 a.m., death occurred due to symptoms of asphyxia.

The results of the pathological autopsy: the condition after the operation of resection of the esophagus and plastic surgery using the Savinsky method. Bilateral (small!) pneumothorax, hemorrhages in the area of ​​the neurovascular bundles of the neck. Reflex asphyxia. Emphysema of the anterior mediastinum. Cause of death: postoperative asphyxia.

We were inclined to explain this breathing disorder by injury and irritation of the vagus nerves during the operation of isolating a high-lying tumor.

In the remaining patients, the complications were not fatal. In 8 people, fistulas developed in the area of ​​the esophageal-intestinal anastomosis in the neck, which closed on their own at various times within up to 3 weeks. Dehiscence of the sutures of the anterior abdominal wall on the 10th and 13th days after surgery was observed in 2 patients. Both had small hematomas in the subcutaneous tissue of the suture area; In addition, there was a slight cough. The skin sutures and the aponeurosis sutures separated. Secondary sutures were placed on the same day. On the 16th day after surgery, a 65-year-old patient developed limited thrombophlebitis of the left leg, into the vein of which blood was drip-fed during the operation. Appropriate treatment was undertaken and after a week all the phenomena subsided.

Finally, the last complication that we had to encounter was paresis of the area mobilized and left in abdominal cavity jejunum. In a patient after resection of the esophagus using the Savin method and mobilization of the initial sections of the jejunum for plastic surgery of the esophagus, at the end of the operation it was discovered that a section of the prepared loop 8-10 cm long had a bluish color. It was decided to leave her in the abdominal

cavities. On the 4-5th day after surgery, abdominal bloating and pain were noted. I had to do a laparotomy. The 10-12 cm end of the intestine was slightly cyanotic and edematous, and the rest of the mobilized intestine was distended with gases and did not peristalt. The contents of the intestinal loop were released through the puncture of the wall, peristalsis appeared, but cyanosis at the end was not detected. Considering that such a somewhat inflamed loop would produce many adhesions in the abdominal cavity, we placed it subcutaneously on the anterior chest wall. Subsequently, the patient underwent retrosternal prefascial plasty of the esophagus using this intestine.

Of the 23 patients who experienced complications, 10 died in the postoperative period. The most common, severe and fatal complications were necrosis of the intestine - artificial esophagus - and bilateral pneumothorax. Since 1955, when the Savinykh operation for esophageal cancer began to be used according to developed indications, bilateral pneumothorax occurred only 2 times in 41 operations. This means that if resection of the esophagus using the Savin method is used strictly according to indications, a serious complication in the form of bilateral pneumothorax can be avoided.

Complications in the form of necrosis of the jejunum - the artificial esophagus - can also be eliminated. After mobilizing the intestinal loop, passing it through the posterior mediastinum, do not allow the loops to be tucked under the mesentery or even the slightest tension. When removing the end of an intestinal loop into a cervical wound, you should not rush to apply an anastomosis, but wait 10-15 minutes, observing the color of the end of the graft. If there is the slightest suspicion of inadequate blood supply to the intestinal loop (cyanosis!), it should be returned to the abdominal cavity and left there. After 11/2-2 months, this intestine can be freely, without the danger of necrosis, removed through the retrosternal-prefascial tract to the neck and anastomosed there with the esophagus (in the area of ​​the fistula).

It seems to us that surgeons who successfully use the colon, which has better blood supply than the thin one, after resection of the esophagus using the Savin’s method, they can carry out the large intestine in the posterior mediastinum and not be afraid of necrosis. This means that the second fatal complication can be overcome. The remaining Complications that led to the sad outcome were isolated.

The discrepancy of the inter-intestinal anastomosis should be alarming regarding compliance with the diet of cancer patients 7-10 days after surgery.

After we began to complete the operation by applying a gastrostomy, and in the postoperative period to monitor the condition of the stomach, acute dilatation of the stomach was never observed, although congestion did occur.

Death as a result of postoperative asphyxia once again emphasizes that the localization of the tumor in the upper thoracic esophagus is the most difficult for surgical treatment. We will not dwell on the remaining, non-fatal, complications. Let us only point out that they, too, can often be prevented.

As can be seen from table. 11, the only complication that led to death was bleeding

One of these patients also had pulmonary edema.

In one patient, sections of both mediastinal pleura were resected during surgery and there was bilateral pneumothorax.

In one patient, sections of both mediastinal pleura were resected and bilateral pneumothorax occurred.

In one patient, the tumor was located in the upper and middle thoracic parts of the esophagus. Sectional diagnosis: postoperative bleeding into the posterior mediastinum and the cavity of the right pleura. Partial atelectasis of the right lung. Edema of the left lung. There was no separate, large enough bleeding vessel found on the section. It can be assumed that the isolation of a high-lying esophageal tumor adjacent to the aortic arch was quite traumatic, which later, in addition to bleeding from the esophageal arteries, reflexively led to pulmonary edema.

The second patient, who died of bleeding, had an extensive tumor of the middle and lower thoracic parts of the esophagus, 10 cm long. The tumor was excised from the mediastinum with great difficulty. Sectional diagnosis: massive acute bleeding into the posterior mediastinum from arterial vessel, cancer metastases to the retroperitoneum lymph nodes. In this patient, either one of the esophageal arteries was not ligated, or the ligature came off it.

Complications in the remaining patients (21) were not fatal.

Serous pleurisy on the right, observed in 6 patients, was eliminated 10-14 days after appropriate therapy.

Pneumonia (right-sided in 3 patients and left-sided in 2 patients) quickly resolved under the influence of treatment and did not have a significant effect on the condition of the patients.

Cardiac weakness was observed in 2 patients. It occurred on the second postoperative night and was manifested by a frequent small pulse, general weakness, pallor, and cold sweat. The medical personnel on duty used cardiovascular drugs: strophanthin with glucose, camphor oil, caffeine. Oxygen was given for inhalation. By morning all the phenomena had passed.

Upper mediastinitis diagnosed with X-ray examination in the form of a shadow extended to the right, accompanied by elevated body temperature, was present in 2 patients. Antibiotics were administered for 10 days, and gradually all the phenomena subsided.

Chylothorax was observed in 2 patients in whom the thoracic duct was injured during esophageal resection during tumor isolation. Despite the fact that both ends of the duct were trimmed and ligated, fever subsequently developed. In one patient, chylous fluid was separated through the drainage tube in a small amount, and after a month the fistula in the right pleural cavity closed. In the second case, chylous fluid did not flow through the drainage tube; the tube had to be removed. Only 2 weeks later, for the first time, chylous fluid was obtained by puncture of the right pleural cavity. From this time on, punctures removed 1-1.5 liters of infected fluid every 2-3 days. Blood transfusions were repeated and anti-inflammatory and restorative treatment was used. 1'/2 months after the operation, the right pleural cavity was drained. The patient was discharged 4 months after resection of the esophagus with a functioning pleural fistula. At home, the pleural fistula closed, and the patient was admitted to the clinic again for esophagoplasty.

Furunculosis developed in one patient in general good condition. The administration of penicillin and blood transfusion contributed to the rapid cessation of the infection.

One patient had impaired gastric emptying, expressed in complaints of nausea, heaviness in the epigastric region and bloating. Over the course of a week, he had to open the gastric fistula several times every day, release the contents and wash out the stomach. warm water. Gradually, gastric emptying was restored.

At the end of the operation, one patient was found to have paresis of the left facial nerve, and the next day - left-sided hemiparesis. A consultant neurologist diagnosed a vascular crisis in the area of ​​the right middle cerebral artery as a thrombosis. Appropriate treatment was given. 24 days after the operation the patient was allowed to sit down, and 34 days later - to walk. The symptoms of paresis have passed almost completely. One month after the operation, the patient was discharged from the clinic in satisfactory condition.

We classified paresis of the right arm in one patient as a complication. Neurologist's conclusion: multiple metastases to the brain. The patient recovered after the operation, but the paresis of his right arm did not go away. We believe that due to the difficulties in diagnosing brain metastases, which did not manifest themselves before surgery, we made a mistake in classifying this patient as operable.

Complications after other operations on the esophagus. Of the 9 patients who underwent other operations for esophageal cancer, complications were observed in two. In one patient who suffered from cancer of the lower thoracic esophagus, after diaphragmatic crurotomy, extrapleural resection of the lower esophagus was performed with the imposition of an esophageal-gastric anastomosis 7-8 cm above the level of the diaphragm. On the 9th day the patient died due to anastomotic failure.

The second patient with a stage III tumor of the mid-thoracic esophagus and the second with a tumor in the subcardial stomach using a combined approach (right thoracotomy, laparotomy and diaphragmotomy) underwent resection of the thoracic esophagus and the upper half of the stomach with the imposition of esophageal and gastric fistulas. In the postoperative period, the patient's condition was severe, and on the 7th night after surgery, acute cardiovascular failure occurred. Strophanthin with glucose was administered 2 times a day, aminophylline with glucose, camphor oil, and oxygen was given. Only on the 18th day was the patient allowed to sit in bed, and on the 25th day to walk. He was discharged from the clinic on the 36th day after surgery.

The remaining 7 patients had no complications in the postoperative period.

In total, out of 130 patients after esophageal resection, complications were observed in 48 (37%). There were 52 complications in total, as 4 people had two postoperative complications. In 13 patients complications led to death.

Yu, E. Berezov (1956) of 27 operated patients observed complications in 20; There were 38 complications in total.

S.V. Geynats and V.P. Kleschevnikova (1957) lost half of their patients as a result of complications in the postoperative period. N. A. Amosov (1958) observed complications in 25 of 32 operated patients; 14 of them died.

If we compare the nature of postoperative complications observed by us and the complications described by other surgeons, a significant difference is visible. In our patients, the most frequent and severe complications leading to death were necrosis of the intestine - artificial esophagus, bilateral pneumothorax and bleeding into the mediastinum. Severe, often fatal, complications described by other surgeons were cardiovascular and pulmonary disorders, as well as failure of the esophagogastric anastomosis.

Some surgeons (E.L. Berezov, A.A. Pisarevsky) saw the main reasons leading to severe postoperative complications in the opening of the second pleural cavity, the occurrence of pleuropulmonary shock and pulmonary edema, which often led to the death of patients.

Other authors (Yu. E. Berezov, N. M. Amosov, N. M. Stepanov, N. I. Volodko, with co-authors, etc.) consider disruption of the cardiovascular system and respiratory organs to be the most severe complications leading to death .

Most surgeons consider cardiovascular failure, respiratory failure and anastomotic failure to be the most dangerous complications, often leading to the death of patients.

Sometimes disorders of the cardiovascular system and insufficiency of respiratory function in the postoperative period are combined into one concept of cardiopulmonary failure. This name for these disorders can be considered correct, since a disorder of cardiovascular activity always causes respiratory failure and, conversely, a disorder of respiratory function leads to profound changes in the activity of the heart. Only in some cases the leading, most pronounced, is respiratory failure, in others it is cardiovascular. Therefore, in the literature they are often separated.

Currently, all surgeons know that the more traumatic and longer the operation in the pleural cavity, especially when the second mediastinal pleura is injured, the more pronounced cardiopulmonary failure in the postoperative period.

To combat cardiovascular failure that occurs in the first days after surgery, the entire arsenal of cardiac and vascular drugs is currently used. It is often possible to cope with this serious complication.

The fight against respiratory failure, which depends on the accumulation of mucus in the trachea and bronchi, consists of suctioning the contents of the respiratory tract. To do this, use a catheter passed through the nose into the trachea, or perform this manipulation using bronchoscopy. The improvement is short-term. Therefore, in recent years, to combat respiratory failure, a tracheostomy has been applied, through which it is convenient to remove mucus from the trachea and give oxygen to patients. If necessary, artificial respiration can be applied using a special tracheotomy cannula and spiropulsator. Surgeons who have used tracheostomy for respiratory failure consider this operation to be life-saving (I.K. Ivanov, M.S. Grigoriev and A.L. Izbinsky, V.I. Kazansky, P.A. Kupriyanov and co-authors, B.N. Aksenov , Soshz, etc.).

Other causes leading to respiratory failure are atelectasis and pulmonary edema, as well as pneumonia. They try to prevent atelectasis by straightening the lung at the end of the operation before suturing chest wall and careful removal of air from the pleural cavity immediately after surgery and in the immediate postoperative days. Measures to prevent and combat pulmonary edema are not effective enough. This complication is almost always fatal.

Inflammatory phenomena in the lungs are prevented from the first days by turning patients in bed, breathing exercises, and administering antibiotics and camphor oil. Inflammation of the lungs that occurs in the postoperative period is treated like regular pneumonia.

Let us dwell on the next common, often fatal, complication - anastomotic failure. There are enough works devoted to regeneration in the area of ​​the esophageal-gastric or esophageal-intestinal anastomosis, the study of the causes of insufficiency, the diagnosis and treatment of fistulas in the anastomosis area, and the study of the best methods for applying anastomosis.

L.N. Guseva conducted a morphological study of the esophageal-gastric and esophageal-intestinal anastomoses after resection of cancer of the esophagus and cardia. She found that in preparations “with anastomosis failure, in all cases, marginal necrosis of the anastomosed organs is determined with circulatory disorder in this area and subsequent cutting of the sutures... Careless adaptation of the mucous membranes of the anastomotic area leads to the penetration of infection into deep-lying tissues, which can contribute to massive growth connective tissue, leading to a narrowing of the latter." Research by this author has shown that within 4 days after surgery, swelling is observed in the area of ​​the anastomosis, narrowing the lumen of the anastomosis. Therefore, L.N. Guseva believes that eating before the 6th day after surgery “is contraindicated and may contribute to the divergence of the anastomotic edges.” Her research is interesting and valuable. They should be remembered when performing operations on the esophagus, A. G. Savinykh attached great value correct comparison of layers of sutured organs, especially mucous membranes, operation without tension of organs and without the use of splints. He wrote: “...physiological operating techniques reduce trauma, reduce inflammation, and prevent the formation of pathological reflexes. All this brings closer to normal tissue regeneration in the entire surgical field, which invariably leads to clinical success.”

The work of A. A. Olshansky and I. D. Kirpatovsky is devoted to the issue of tissue regeneration in the area of ​​anastomosis. T. N. Mikhailova, using a large clinical material, showed that the insufficiency of the sutures of the anastomosis is not an absolutely fatal complication. She developed measures to prevent anastomotic failure, which consist of maintaining “the blood supply to the esophagus, preventing tension on the sutured organs, and crossing the esophagus at a sufficient distance from the tumor boundaries.”

B. E. Peterson carried out extensive experimental work on the application of esophageal-gastric and esophageal-intestinal anastomoses using a variety of methods and with different approaches. He supported the results of his experimental studies with clinical observations and came to the conclusion that the simpler the anastomosis, the less often its failure is observed. It is better to perform the anastomosis with “double-row interrupted sutures”, “in conditions of good access”, “with a blood circulation-sparing technique for isolating the esophagus”.

These works were devoted mainly to the study of anastomoses performed after resection of cardia cancer. When performing operations for cancer of the thoracic esophagus, the principle of anastomosis with careful comparison of the mucous membranes, without tension on the anastomosis line and while maintaining the vascularization of the sutured organs remains. However, there is a danger of necrosis of the stomach that is widely mobilized and raised high into the chest cavity. To prevent necrosis of the stomach during its mobilization, S.V. Geynats proposed preserving the left gastric artery, and A.A. Rusanov developed a technique for mobilizing the stomach along with the spleen.

For better suturing of the esophagus and stomach in order to prevent insufficiency of the anastomosis, A. M. Biryukov developed his own method of applying an esophageal-gastric anastomosis with an open stump of the stomach. In 22 such operations, he did not observe anastomotic failure.

To strengthen the anastomosis line, S.V. Geynats sutured the mediastinal pleura, Yu.E. Berezov covered the entire anastomosis line with “the gastric or intestinal wall, sometimes with additional coverage with the omentum, pleura or peritoneum.” When mobilizing the stomach, a piece of the omentum or gastrosplenic ligament is left on the greater curvature and the anastomosis is strengthened with them.

B.V. Petrovsky suggested covering the anastomosis with a flap from the diaphragm. M.I. Sokolov applied this method in the clinic, and A.G. Chernykh experimentally proved good engraftment of the diaphragm flap in the area of ​​the anastomosis.

Experimental work has been carried out on the use of pericardial transplants with a thrombofibrinogen clot during operations on the esophagus and on the use of the pleura and pericardium for plastic surgery of the esophagus.

The great attention of surgeons and experimenters to the esophagogastric junction suggests that this anastomosis is surgically imperfect, since insufficiency of the sutures often occurs.

Thus, according to I.P. Takella, of the 14 who died after resection of the esophagus, 7 had anastomotic insufficiency; according to G.K. Tkachenko, of the 24 who died, the cause of death in 8 was divergence of the anastomosis. The same data was presented by B. A. Korolev. Of the 24 patients, 9 died from anastomotic leakage. He reported that in almost 50% of his patients death occurred as a result of insufficiency of the anastomosis sutures.

V.I. Kazansky and co-authors wrote: “Improving immediate results in cancer of the esophagus and cardia with a transition to the esophagus should follow the path of eliminating the main postoperative complication - insufficiency of the esophageal-gastric or esophageal-intestinal anastomosis. Apparently, at this stage in the development of esophageal surgery, this complication is the main cause of postoperative failures.”

In 1957, B.V. Petrovsky reported that, according to his data, the mortality rate from anastomotic discrepancy decreased from 65% to 25%. This is a good achievement, but still the cause of death of every fourth patient is the indicated complication. Yu. E. Berezov and M. S. Grigoriev, having studied the postoperative mortality given in the literature and their own data, note that almost *D deaths die from insufficiency of anastomotic sutures. According to data collected from 11 centers, out of 259 fatal complications after esophageal resection, 76 cases of anastomosis insufficiency (29.3%) were noted.

Regarding surgery for cardia cancer, he wrote that the real reason for the anastomotic discrepancy should be sought not in mechanical and technical factors, but in functional disorders ah, general disorders in the body of a cancer patient and local functional changes in the stomach and esophagus.

We can agree that general disturbances in the body of a cancer patient significantly affect the healing of the anastomosis. This has been observed many times by surgeons in their practice. Sometimes a technically inferior esophageal-intestinal or esophageal-gastric anastomosis in a patient with a benign esophageal stricture healed without the formation of a fistula, while a technically impeccable anastomosis in a cancerous patient of the same age was complicated by failure.

As for local functional disorders of the esophagus and stomach, one thing is certain. Wide mobilization of the stomach over a large area with additional intersection of nerves and vessels is more dangerous due to the possibility of divergence of the anastomosis with the esophagus in the chest cavity than in cases of preservation of the main vascular trunks. Not in vain, who owns the most large number observations on resection of the esophagus for cancer, carries out the stomach subcutaneously, anastomoses with the esophagus on the neck, where failure of the anastomosis is not a fatal complication. It is no coincidence that our

domestic specialists in esophageal surgery (B.V. Petrovsky, V.I. Kazansky, V.I. Popov and V.I. Filin, A.A. Rusanov, A.A. Vishnevsky, Yu.E. Berezov, etc. ), having tested various methods of operations, in recent years, for cancer of the thoracic esophagus, they began to use the Dobromyslov-Torek operation, abandoning high simultaneous anastomoses in the chest cavity.

Quite common complications include expansion of the stomach located in the chest cavity. It occurs due to its paresis after the intersection of the vagus nerves. An enlarged stomach has a negative effect on cardiac and respiratory activity. In addition, it contributes to the tension of the anastomosis, which can lead to insufficiency of the anastomosis sutures.

In order to reduce the expansion of the stomach in the chest cavity, S. V. Geynats (cited by M. S. Grigoriev and B. E. Aksenov) proposed corrugating its walls using sutures. Another method of improving evacuation from the “thoracic stomach” is pyloromyotomy (S. V. Geynats and V. P. Kleschevnikova, Be Vakeu, Co1eu, G)ip1or, etc.).

During the operation, a so-called Lewin tube is inserted into the stomach through the nose, through which the stomach contents are aspirated for several days. In recent years, a double polyvinyl chloride probe has been used, with the help of one tube the contents of the stomach are removed, and through the second tube located in the intestine, nutritional fluids begin to be administered from the 2nd day. The use of these measures made it possible to successfully combat the violation of the evacuation of the “thoracic stomach”.

We described the complications that are most common in the postoperative period. There are many other, rarer complications that are sometimes difficult to predict and therefore prevent.

Rare complications include myocardial infarction, cerebral embolism, profuse bleeding from the gastric stump, bleeding through a fistula between the aorta and the gastroesophageal anastomosis, diaphragmatic hernia, acute necrosis of the pancreas, adrenal insufficiency and many others. Most of them lead to an unfavorable outcome.

It should be noted that a previously rare complication - pulmonary embolism - has become more common in the last 5-3 years. Thus, one of the 13 patients who died after surgery in V.I. Kazansky and co-authors died from this complication; in M. S. Grigoriev it was the cause of death in 10 out of 106 deaths (9.4%).

The first criterion for the usefulness of the surgical intervention undertaken is the number of patients surviving immediately after the operation.

Not all statistics published in the literature are presented, since some authors reported unfavorable outcomes together after resection for cancer of the gastric cardia and esophageal cancer, or together with deaths after trial and palliative operations.

Our aim was to present, to the extent possible, data regarding postoperative outcomes after esophageal resection for thoracic cancer.

As can be seen from table. 12 and 13, according to domestic and foreign surgeons, the mortality rate for a large number of operations averages 35-31.1%, i.e. every third patient dies after surgery.

However, there are noticeable shifts towards a decrease in postoperative mortality. If in 1953, Autumn presented collected data on 700 operations with 41.4% of unfavorable outcomes, and in 1957, Kehapo reported 714 operations with 44.5% mortality, then over the past few years, with an increase in the number of operations and the number operating surgeons (which especially needs to be taken into account), mortality decreased by 8-10%. Data from V.I. Popov and Yakawat show that the number of adverse outcomes can be significantly reduced. Studying the work of these surgeons, one can understand that they owe their success to the surgical methods they use for resection of the esophagus.

V.I. Popov and V.I. Filin mainly use two-stage operations: first they perform resection of the esophagus according to Dobromyslov-Torek, then esophagoplasty.

Yakawata himself admits that success depends on the method of operation he uses with an antethoracic stomach and anastomosis in the neck. This technique gave him the lowest mortality rate: 8.5% for 271 operated patients.

The highest mortality rate (S.V. Geynats and V.P. Kleshchevnikova, N.M. Amosov, M.S. Grigoriev and B.N. Aksenov, B.A. Korolev) was obtained after single-stage operations of the Garlock type and combined Lewis type.

We in no way want to diminish the importance of early diagnosis of tumor localization in the esophagus, preoperative preparation, method of pain relief, qualifications and experience of the surgeon during the postoperative period and the outcome of the operation. However, the data presented clearly show that the result of the operation largely depends on its technique. In our opinion, the relatively low mortality rate (10%) after esophageal resection in our clinic largely depends on the surgical methods used.

Let us consider the outcomes of our operations (resection of the esophagus) depending on the location of the tumor (Table 14). For tumors located in the upper thoracic esophagus, the greatest number of complications occurred and almost 73 of those operated on did not undergo surgery. These results fully confirm the literature data on the rarity of esophageal resection for highly localized cancer, on the large number of postoperative complications and unfavorable outcomes.

When the tumor was localized in the mid-thoracic region, we obtained quite satisfactory immediate outcomes after resection of the esophagus: out of 76 operated patients, three died (4%).

However, with resection for a tumor of the lower thoracic esophagus, the mortality rate reaches 17.8%.

How can we explain such a significant discrepancy with the established pattern in esophageal surgery?

In table 15 shows the number of esophageal resections and the outcome for various surgical methods. When the tumor was localized in the lower third of the esophagus, out of 8 patients who died after surgery, 7 were operated on using the Savinykh method. However, these figures cannot at all discredit the method. It should be noted that 6 people out of this number died before 1955 (in the first period), when the operation was being developed and it was performed on any patient with esophageal cancer without appropriate indications. Of the 6 patients, three died as a result of bilateral pneumothorax.

If we exclude from the number of 45 patients with a tumor localized in the lower third of the esophagus 10 operated on in the first period with 7 unfavorable outcomes, then for 35 patients with the specified localization, operated on since 1955 with various methods strictly according to established indications, we lost one after the operation (2 ,9%). Thus, our site-specific postoperative outcomes are in complete agreement with those reported by most surgeons.

Deaths after surgery for colon cancer may be due to peritonitis. in 18-20% complications from the lungs. 75% of patients operated on for rectal cancer, and 25% operated on for cancer of other parts of the colon, experience complications from urinary tract- difficulty emptying bladder with possible subsequent septic urinary tract infection. In 1/3 of patients operated on according to Mikulicz, intestinal fistulas form.

Treatment of patients with inoperable forms of colon cancer is limited to dietary and symptomatic therapy in the absence of intestinal obstruction.

In case of loss of appetite, nausea and vomiting due to autointoxication - subcutaneous administration of saline or 5% glucose solution with vitamins, drip transfusion of same-group blood.

Diet therapy for these patients is aimed at preventing rapidly progressing emaciation, combating anorexia and dyspeptic complaints, eating food that mechanically spares the intestines and prevents the development of acute obstruction.

The laxative effect is achieved by taking honey, fruit jams, prunes, yogurt or one-day kefir, olive oil with lemon juice.

Deep radiation therapy can provide temporary remission in lymphosarcoma and organ lymphogranulomatosis of the intestine; in other cases, its therapeutic effect is very problematic.

Patients with an artificial anus require special care and the provision of a portable colostomy bag; care for the skin around the anus and measures to deodorize the fecal odor, which, if not properly cared for, bothers patients and those around them, are especially important.

Information from the site www. vip-doctors. ru should not be used for self-diagnosis and treatment of diseases.

Complications after surgery. Pain in the intestines.

Mila | Age: 28 | City: Kaliningrad

Good evening. I had a laparoscopy on my ovary, there was a cyst. The operation took place in November. Now I have pain in my lower abdomen. It really hurts to go to the toilet. when I strain and push. The pain is cutting and stabbing. The stool is normal, every day. More pain during intercourse. I'm afraid that the intestines were damaged during the operation. Tell me what this could be?

Konstantin Skripnichenko ON CLINIC

Hello Mila! If there had been direct injury to the intestinal wall, the complaints would have been somewhat different. The following is more likely: inflammation of the wall due to an infection or an adhesive process that has tightened a loop of intestine somewhere. The first and simplest thing I would recommend you do is ultrasound of the abdominal cavity and irrigography, and based on the results, decide the issue further. Be healthy!

Complications after appendectomy

Due to the fact that the risk of unnecessary surgery is much less than the risk of missing a perforation of the appendicitis, surgeons, even in cases of doubt about its inflammation, resort to removing the appendix.

The patient may be prescribed bed rest for further observation, but if his condition does not improve, doctors perform an excision of the appendix, that is, the appendix is ​​removed.

Removing the appendix is ​​a simple operation performed under general anesthesia, which takes no more than half an hour. The use of modern medications and antibiotics has significantly reduced the likelihood of possible complications, but they can still occur.

Consequences of appendectomy

After successful removal of the appendix, the patient is ready to be discharged from the hospital within a few days. And after a week, the postoperative sutures are removed.

After surgery to remove the appendix, during the healing period, the person operated on may feel periodic pain, which stops after one to two months.

A common consequence of surgical intervention in the abdominal cavity is the accumulation of gases in the intestines, in addition, it ceases to function for some time.

Temporary bloating indicates that the digestive system is gradually returning to its normal functioning and this means that the recovery stage has begun.

Possible complications after appendectomy

If the removal operation acute appendicitis was carried out incorrectly or malfunctions occurred on the part of the body during the healing period, a number of postoperative complications are possible:

• On the fifth to seventh day, compaction may appear in the area of ​​the sutures, body temperature rises to 37-38 degrees and higher. This may indicate the presence of purulent inflammation.
• Increased adhesion formation, which in turn can cause an even more serious complication - adhesive intestinal obstruction, which is manifested by nausea, vomiting, bloating, lack of gas and stool, and cramping abdominal pain.
• The presence of an abdominal abscess is indicated by symptoms such as: an increase in temperature on the eighth - twelfth day to thirty-eight - forty degrees, the occurrence of abdominal pain, changes in blood tests, chills.
• The discharge of intestinal contents from the wound indicates such a formidable complication as intestinal fistula.
• One of the most severe complications after removal of acute appendicitis is purulent thrombophlebitis of the portal vein - pylephlebitis. It usually appears in early dates, two to three days and up to two to three weeks after the operation. The development of the complication occurs rapidly: the patient’s condition becomes serious due to pain in the right hypochondrium, tremendous chills, weakness, increased body temperature to thirty-nine to forty degrees, and severe sweating. There is yellowness of the skin and sclera, enlargement of the liver and spleen.

Unlike appendicitis, there is a disease that is very difficult to diagnose - severe pneumatosis intestinalis.

Sources: vip-doctors. ru, www. eurolab. ua, pichevarenie. ru

Carrying out bowel resection

Removing a specific area of ​​intestine that is damaged by disease is called resection digestive organ. Bowel resection is a dangerous and traumatic operation. The procedure is different from many others using anastomosis. After excision of part of the digestive organ, its ends are connected to each other. Therefore, a person should be aware of the indications for performing the procedure and what complications may arise.

Classification of operations

Resection is a surgical procedure to remove the inflamed part of the digestive organ. This is a rather complex operation and can be classified according to several factors: by type and section of the intestine, by anastomosis. Below is a classification of the surgical techniques used depending on the nature and characteristics of the organ damage.

Removal (resection)

Occurs on the following types of digestive organ:

Excision by department

Classification according to the affected part of the intestine is proposed:

• small intestinal removal: ileum, jejunum or duodenum;
• colonic resections: blind section, colon or rectal area.

Classification by anastomosis

According to the definition, the following types of techniques are meant:

• "End to end." It is characterized by the connection of the two ends of the intestine after removal of the affected area. Adjacent departments can be connected. This type of tissue connection is physiological, but the risk of complications in the form of scars is high.
• "Side to side." This type of operation allows you to firmly fasten the lateral tissues of the intestine and avoid the development of complications in the form of obstruction of the digestive organ.
• "Side to end." An anastomosis is made between the efferent and afferent intestinal zones.

Indications for surgery

There are several main indications for prescribing resection for a person:

• intestinal volvulus (strangulation obstruction);
• intussusception - layering of two sections of the intestine on top of each other;
• formation of nodes in the intestines;
• cancerous formation on the digestive organ;
• death of the intestine (necrosis);
• abdominal pain.

Preparing for bowel resection

To determine the affected areas of the intestine, a full examination is required before surgery.

A person turns to a specialist, complaining of pain in the abdominal cavity. Before the operation, it is necessary to undergo a full examination to determine the affected areas of the intestine and their location. The organs of the digestive system are examined and assessed. After diagnosing the affected areas, a series of laboratory tests are performed. Based on the data obtained, the specialist clarifies the health status and performance of the liver and kidneys. If concomitant diseases are detected, the person additionally consults specialized specialists. This will make it possible to assess the risks of surgery. Consultation with an anesthesiologist is required. The doctor should check with the patient for any allergic reactions to medications.

Resection of any digestive organ takes place in 2 stages: removal of the affected area and formation of an anastomosis. The operation is performed using a laparoscope through a small incision or using the open method. On at the moment Laparoscopy is a common method. Thanks to the new technology, traumatic effects are minimized, and this is important for rapid further recovery.

The operation and methods of its implementation

The open resection method is divided into several stages:

1. The surgeon makes an incision in the affected area of ​​the intestine. To reach the damaged area, it is necessary to cut the skin and muscles.
2. The specialist applies clamps on both sides of the affected area of ​​the intestine and removes the diseased area.
3. An anastomosis is used to connect the edges of the intestine.
4. According to indications, the patient may have a tube installed to excess liquid or pus leaked from the abdominal cavity.

After surgery, your doctor may prescribe a colostomy to collect stool.

For patients in serious condition after surgery, the doctor may prescribe a colostomy. This is necessary to remove feces from the affected area. A colostomy is placed slightly above the removed area and facilitates the removal of bowel movements. Feces, leaving the intestines, are collected in a bag specially attached to the abdominal cavity. After the operated area has healed, the surgeon prescribes an additional operation to remove the colostomy.

The hole in the abdominal cavity is sutured and the pouch is removed to collect stool. If the main part of the thick or small intestine, the patient will adjust to life with a colostomy. Sometimes, based on indications, a specialist decides to remove most of the digestive organ, and even some neighboring organs. After resection, the patient is under the supervision of medical personnel in order to avoid complications after removal of the affected area of ​​the intestine and pain.

Postoperative prognosis

The quality of life after surgery depends on several factors:

• stages of the disease;
• complexity of the resection;
• following the doctor's recommendations during the recovery period.

Complications and pain after resection

After resection, the patient may experience pain and complications, namely:

• addition of infection;
• scarring in the intestines after surgery, which leads to stool obstruction;
• the occurrence of bleeding;
• development of a hernia at the site of resection.

Nutritional Features

The dietary menu is prescribed by a specialist depending on the area of ​​the intestine where the resection was performed. The basis of proper nutrition is to eat foods that are easy to digest. The main thing is that nutrition does not cause irritation of the mucous membrane of the operated organ and does not provoke pain.

There are different approaches to diet after excision of the small and large intestines due to the different digestive process in these parts of the intestine. Therefore, it is necessary to choose the right foods and diet to avoid unpleasant consequences. After excision of the affected area of ​​the small intestine, the ability to digest a bolus of food that moves along the digestive tract is reduced. The ability to absorb beneficial and nutrients from food is reduced. A person does not receive enough fats, proteins and carbohydrates. Metabolism is disrupted and the patient's health suffers.

Principles of nutrition after small bowel resection

The specialist prescribes a diet to avoid unpleasant consequences after resection.

To correct the situation, the specialist prescribes a diet that is most suitable for resection of the small intestine:

• To compensate for the lack of protein in the body, the diet must contain exactly low-fat varieties fish and meat. Preference can be given to rabbit and turkey meat.
• To compensate for the lack of fat, it is recommended to use unrefined vegetable oil or butter.

The doctor makes a list of foods that you need to avoid or reduce your consumption. Negatively affect the digestion process:

• products with high content fiber (example: radishes and cabbage);
• coffee and sweet drinks (carbonated);
• beets and beet juice;
• prunes, which stimulate the functioning of the digestive organs, which contributes to pain, and this is undesirable after surgery.

Principles of nutrition after colon surgery

For resection of the large intestine, dietary nutrition is required. It is similar to the previous diet, but there are differences. By removing a section of the colon, the body’s receipt of fluids and vitamins is disrupted. Therefore, it is necessary to adjust the diet so that these losses are replenished. Most people are wary of undergoing resection. All because they do not know the consequences of surgical intervention and nutritional rules. The doctor must provide the patient with a full consultation before the operation in order to reassure and explain all the nuances. The specialist draws up a daily menu and daily routine to reduce the consequences of the operation and speed up the recovery process.

Other recovery methods

Often a person experiences reduced motor skills after resection, so the specialist will refer you for a light massage to get the digestive organ working. Bed rest is mandatory and correct menu. Tolerate pain syndrome and you cannot self-medicate. This only leads to a worsening of the condition and aggravation of the disease. Treatment should only be prescribed by a competent and experienced specialist.

What are the types of intestinal surgeries and their consequences?

The intestine is an important part of the digestive system, which, like other organs, is susceptible to many diseases. It consists of 2 main functional sections - the small and large intestine, and they are also divided according to anatomical principles. The small intestine begins with the shortest section - the duodenum, followed by the jejunum and ileum. The colon begins with the cecum, then the colon, sigmoid and rectum.

The general function of all sections is the promotion of food and the evacuation of its undigested residues; the thin section is involved in the breakdown and absorption of nutrients; the thick section absorbs water and microelements into the blood. The load on this organ is quite large; it is constantly exposed to food and toxins, which is why diseases are quite common. Many of them are treated surgically.

When are bowel interventions indicated?

Diseases that cannot be treated conservatively fall within the competence of surgeons:

• congenital malformations;
• open and closed damage;
• benign tumors;
• carcinomas (cancer);
• obstruction;
• severe forms of adhesive disease;
• nonspecific ulcerative colitis with bleeding;
• Crohn's disease (autoimmune inflammation) with obstruction;
• bleeding and perforated ulcer;
• thrombosis of the vessels of the mesentery (folds of the peritoneum, in the thickness of which arteries and veins pass);
• purulent processes (paraproctitis, abscess, phlegmon);
• external and internal fistulas.

In any case, indications for interventions are determined by specialists after conducting a comprehensive examination and establishing an accurate diagnosis.

Advice. even the most harmless disorders digestive tract may be the initial symptoms of serious diseases requiring surgical intervention. Do not neglect them; it is better to consult a doctor for examination.

Research methods

A comprehensive examination will help avoid mistakes when making a diagnosis.

X-ray, ultrasound and instrumental methods are used to examine the intestines.

X-ray examination includes a survey of the abdominal organs, a contrast study with the introduction of a barium sulfate suspension, and a computerized tomographic scan - virtual colonoscopy.

Modern ultrasound examination is carried out in 3D format, Doppler ultrasound is also performed, which provides information about the structure of the organ, its vessels, and blood circulation.

To the most common instrumental methods include rectoscopy (examination of the rectum), colonoscopy of the intestine. when, after special preparation (cleaning), an endoscope equipped with a miniature camera, a system of magnifying lenses and lighting is inserted. In this way, the rectum, sigmoid, and colon sections are examined to the ileocecal angle - the place where the ileum enters the cecum.

The thin section is difficult to access due to its anatomical features - tortuosity, many loops. Capsule endoscopy is used for this purpose. The patient swallows a small capsule (PillCam) containing a video camera-scanner, and it, moving gradually from the stomach along the entire digestive tract, scans and transmits the image to the computer screen.

Types of interventions

All operations are divided into 3 groups:

• laparotomy (open, with a wide dissection of the abdominal skin);
• laparoscopic (performed by introducing an optical device and instruments through several small incisions);
• endoscopic, without opening the abdominal cavity, by inserting an endoscope into the lumen of the organ through natural openings.

Endoscopic removal of polyp in the intestine

Classical laparotomy is used mainly to remove part of an organ - thin, rectal, sigmoid, colon for cancer, vascular thrombosis with necrosis, congenital anomalies. The laparoscopic method is used in the case of benign tumors, to cut adhesions; modern operating robots use this technology. The surgeon controls the robot's "arms" using a remote control under the control of the image on the screen.

Endoscopic technology is used to perform surgery to remove rectal polyps. sigmoid and colon, for extraction foreign bodies, performing a biopsy. This is usually done during a diagnostic colonoscopy.

In terms of scope, operations can be radical, with the removal of part of an organ, palliative, aimed at restoring patency, as well as organ-preserving. Alternative methods such as laser and ultrasound surgery are widely used in modern surgery.

Possible consequences of the operation

After any surgical intervention, even after appendectomy, disturbances occur to varying degrees. In the first days, intestinal atony, weakened peristalsis, bloating, and difficulty passing gases often develop. It is no coincidence that surgeons jokingly call the normalization of this process in an operated patient “the best music for a doctor.”

The development of many other consequences is also possible: abscess, peritonitis, bleeding, wound suppuration, obstruction, suture failure, post-anesthesia complications from internal organs. All this occurs in the early period, when the patient is under observation in a hospital, where specialists will provide professional assistance in a timely manner.

Features of the postoperative period

Adhesions in the intestines

Among all the consequences, intestinal adhesions develop most often after surgery. More precisely, they always develop to one degree or another, depending on the complexity of the operation and the characteristics of the patient’s body, and this process can be expressed in varying degrees. Already 2-3 weeks after discharge, pulling pain in the abdomen may appear, followed by bloating, stool retention, nausea, and periodic vomiting.

Advice: when specified symptoms You should not self-medicate, take painkillers and laxatives. This can provoke the development of acute adhesive obstruction, so it is better to immediately contact a specialist.

Warning adhesive process Promotes sufficient physical activity - walking, special exercises, but without heavy loads and tension. We must not forget about therapeutic nutrition, avoid rough and spicy foods, foods that cause bloating. The restoration of the intestinal mucosa has a positive effect fermented milk products, which contain beneficial lactobacilli. It is also necessary to increase the number of meals to 5-7 times a day in small portions.

Particularly careful adherence to the diet is needed by patients undergoing chemotherapy for intestinal cancer after surgery to remove part of it (rectum, sigmoid, colon or small intestine), so-called adjuvant polychemotherapy. These drugs slow down the recovery process, and the course of treatment can last 3-6 months.

To avoid many of the consequences of surgical operations, as well as repeated interventions, and ultimately to live a normal life full life, you need to carefully follow a therapeutic diet, strictly adhere to a physical activity regimen in accordance with the individual recommendations of a specialist.

Attention! The information on the site is presented by specialists, but is for informational purposes only and cannot be used for independent treatment. Be sure to consult your doctor!

Intestinal resection, surgery to remove the intestine: indications, course, rehabilitation

Intestinal resection is classified as a traumatic intervention with a high risk of complications, which is not carried out without good reason. It would seem that a person’s intestines are very long, and removing a fragment should not have a significant impact on well-being, but this is far from the case.

Having lost even a small section of the intestine, the patient subsequently faces various problems, primarily due to changes in digestion. This circumstance requires long-term rehabilitation, changes in diet and lifestyle.

Patients requiring intestinal resection are predominantly elderly people, in whom both atherosclerosis of intestinal vessels and tumors are much more common than in young people. The situation is complicated by concomitant diseases of the heart, lungs, and kidneys, in which the risk of complications becomes higher.

The most common causes of intestinal interventions are tumors and mesenteric thrombosis. In the first case, the operation is rarely performed urgently; usually, when cancer is detected, the necessary preparation for the upcoming operation is carried out, which may include chemotherapy and radiation, so some time passes from the moment the pathology is detected to the intervention.

Mesenteric thrombosis requires emergency surgical treatment, since rapidly increasing ischemia and necrosis of the intestinal wall cause severe intoxication and threaten peritonitis and death of the patient. There is practically no time for preparation, or even for a thorough diagnosis, and this also affects the final result.

Intussusception, when one section of the intestine invades another, leading to intestinal obstruction, nodulation, and congenital malformations are the area of ​​interest of pediatric abdominal surgeons, since it is in children that this pathology occurs most often.

Thus, indications for intestinal resection may include:

• Benign and malignant tumors;
• Gangrene (necrosis) of the intestine;
• Intestinal obstruction;
• Severe adhesive disease;
• Congenital anomalies of intestinal development;
• Diverticulitis;
• Nodulation (“volvulus”), intussusception.

In addition to the indications, there are conditions that prevent the operation:

1. The patient’s serious condition, suggesting a very high operational risk (for pathologies of the respiratory system, heart, kidneys);
2. Terminal conditions, when surgery is no longer practical;
3. Coma and serious disturbances of consciousness;
4. Advanced forms of cancer, with the presence of metastases, carcinoma germination neighboring organs, which makes the tumor inoperable.

Preparing for surgery

To achieve the best possible recovery after bowel resection, it is important to prepare the organ as best as possible for surgery. In case of emergency surgery, preparation is limited to a minimum of examinations; in all other cases, it is carried out to the maximum extent.

In addition to consultations with various specialists, blood tests, urine tests, ECG, the patient will have to cleanse the intestines in order to prevent infectious complications. For this purpose, the day before the operation, the patient takes laxatives, undergoes a cleansing enema, eats liquid, excluding legumes, fresh vegetables and fruits due to the abundance of fiber, baked goods, and alcohol.

Can be used for bowel preparation special solutions(fortrans), which the patient drinks in a volume of several liters on the eve of the intervention. The last meal is possible no later than 12 hours before the operation, water should be abandoned from midnight.

Before intestinal resection, antibacterial drugs are prescribed to prevent infectious complications. The attending physician must be informed of all medications taken. Nonsteroidal anti-inflammatory drugs, anticoagulants, and aspirin can provoke bleeding, so they are canceled before surgery.

Bowel resection technique

Bowel resection surgery can be performed through laparotomy or laparoscopy. In the first case, the surgeon makes a longitudinal incision in the abdominal wall; the operation is performed in an open manner. Advantages of laparotomy – good review during all manipulations, as well as the absence of the need for expensive equipment and trained personnel.

With laparoscopy, only a few puncture holes are needed to insert laparoscopic instruments.Laparoscopy has many advantages. but it is not always technically feasible, and in some diseases it is safer to resort to laparotomy access. The undoubted advantage of laparoscopy is not only the absence of a wide incision, but also a shorter rehabilitation period and speedy recovery patient after the intervention.

After processing the surgical field, the surgeon makes a longitudinal incision in the anterior abdominal wall, examines the abdominal cavity from the inside and looks for the altered section of the intestine. Clamps are applied to isolate the portion of intestine that will be removed, and then the affected area is cut off. Immediately after dissection of the intestinal wall, it is necessary to remove part of its mesentery. Vessels feeding the intestine pass through the mesentery, so the surgeon carefully ties them up, and excises the mesentery itself in the shape of a wedge, with its apex facing the root of the mesentery.

Removal of the intestine is carried out within the healthy tissue, as carefully as possible, in order to prevent damage to the ends of the organ by instruments and not provoke their necrosis. This is important for further healing postoperative suture on the intestines. When the entire small or large intestine is removed, it is called a total resection.subtotal resection involves excision of part of one of the sections.

subtotal resection of the large intestine

To reduce the risk of infection with intestinal contents during surgery, tissues are isolated with napkins and tampons, and surgeons practice changing instruments when moving from a more “dirty” stage to subsequent ones.

After removing the affected area, the doctor faces the difficult task of creating an anastomosis (connection) between the ends of the intestine. Although the intestine is long, it cannot always be stretched to the required length; the diameter of the opposite ends may differ, so technical difficulties in restoring the integrity of the intestine are inevitable. In some cases, this cannot be done; then the patient has an outlet hole placed on the abdominal wall.

Types of intestinal connections after resection:

If it is technically impossible to restore the movement of intestinal contents as physiologically as possible, or the distal end needs to be given time to recover, surgeons resort to placing an outlet on the anterior wall of the abdomen. It can be permanent, when large sections of the intestine are removed, or temporary, to speed up and facilitate the regeneration of the remaining intestine.

Colostomy is a proximal (near) segment of the intestine, removed and fixed to the abdominal wall, through which feces are evacuated. The distal fragment is sutured tightly. With a temporary colostomy, a second operation is performed after a few months, in which the integrity of the organ is restored using one of the methods described above.

Resection of the small intestine is most often performed due to necrosis. The main type of blood supply, when blood flows to the organ through one large vessel, then branches into smaller branches, explains the significant extent of gangrene. This happens with atherosclerosis of the superior mesenteric artery, and the surgeon in this case is forced to excise a large fragment of the intestine.

If it is impossible to connect the ends of the small intestine immediately after resection, a ileostomy to remove feces, which either remains forever or is removed after several months with the restoration of a continuous bowel movement.

Resection of the small intestine can also be performed laparoscopically, when instruments are inserted into the abdomen through punctures, carbon dioxide is injected for better visibility, then the intestine is clamped above and below the site of injury, the mesenteric vessels are sutured and the intestine is excised.

Colon resection has some features, and it is most often indicated for neoplasms. In such patients, all, part of the colon, or half of it is removed (hemicolectomy). The operation lasts several hours and requires general anesthesia.

With an open approach, the surgeon makes an incision of about 25 cm, examines the colon, finds the affected area and removes it after ligating the mesenteric vessels. After excision of the large intestine, one of the types of end joining is performed or a colostomy is performed. Removal of the cecum is called a cecectomy, the ascending colon and half transverse or the descending colon and half transverse is hemicolectomy. Resection sigmoid colon– sigmectomy.

The operation for resection of the colon is completed by washing the abdominal cavity, layer-by-layer suturing of the abdominal tissue and installing drainage tubes into its cavity for the outflow of discharge.

Laparoscopic resection for colon lesions is possible and has a number of advantages, but is not always feasible due to severe damage to the organ. Often there is a need to switch from laparoscopy to open access right during surgery.

Operations on the rectum differ from those on other parts, which is associated not only with the peculiarities of the structure and location of the organ (strong fixation in the pelvis, proximity of the organs of the genitourinary system), but also with the nature of the function performed (accumulation of feces), which is unlikely to be performed by another part of the large intestine.

Resections of the rectum are technically complex and result in much more complications and unfavorable outcomes than those performed on the thin or thick sections. The main reason for interventions is cancer.

Resection of the rectum when the disease is located in the upper two-thirds of the organ makes it possible to preserve the anal sphincter. During the operation, the surgeon excises part of the intestine, ties the vessels of the mesentery and cuts it off, and then forms a connection as close as possible to the anatomical course of the terminal intestine - anterior resectionrectum .

Tumors of the lower segment of the rectum require the removal of components of the anal canal, including the sphincter, therefore such resections are accompanied by all kinds of plastics in order to somehow ensure the exit of feces to the outside in the most naturally. The most radical and traumatic abdominoperineal extirpation is performed less and less often and is indicated for those patients whose intestine, sphincter, and tissues are affected pelvic floor. After removal of these formations, the only option for fecal drainage is a permanent colostomy.

Sphincter-sparing resections are feasible in the absence of growth of cancerous tissue into the anal sphincter and allow maintaining the physiological act of defecation. Interventions on the rectum are performed under general anesthesia, in an open manner, and are completed by installing drains in the pelvis.

Even with impeccable surgical technique and compliance with all preventive measures, avoiding complications during intestinal operations is problematic. The contents of this organ contain a lot of microorganisms that can become a source of infection. Among the most common negative consequences after intestinal resection are:

1. Suppuration in the area of ​​postoperative sutures;
2. Bleeding;
3. Peritonitis due to suture failure;
4. Stenosis (narrowing) of the intestinal section in the anastomosis area;
5. Dyspeptic disorders.

Postoperative period

Recovery after surgery depends on the extent of the intervention, the general condition of the patient, and his compliance with the doctor’s recommendations. In addition to generally accepted measures for a speedy recovery, including proper hygiene postoperative wound, early activation, the patient’s nutrition becomes of paramount importance, because the operated intestines will immediately “meet” food.

The nature of nutrition differs in the early stages after the intervention and in the future, the diet gradually expands from more gentle foods to those familiar to the patient. Of course, once and for all you will have to give up marinades, smoking, spicy and heavily seasoned dishes, and carbonated drinks. It is better to exclude coffee, alcohol, fiber.

In the early postoperative period, meals are provided up to eight times a day, in small volumes, food should be warm (not hot or cold), liquid in the first two days; from the third day, special mixtures containing protein, vitamins, and minerals are included in the diet. By the end of the first week, the patient switches to diet No. 1, that is, pureed food.

With a total or subtotal resection of the small intestine, the patient is deprived of a significant part of the digestive system, which digests food, so the rehabilitation period can take 2-3 months. For the first week, the patient is prescribed parenteral nutrition, then for two weeks, nutrition is provided using special mixtures, the volume of which is increased to 2 liters.

After about a month, the diet includes meat broth, jelly and compotes, porridge, soufflé made from lean meat or fish. If the food is well tolerated, steamed dishes are gradually added to the menu - meat and fish cutlets, meatballs. Vegetables include potato dishes, carrots, and zucchini; legumes, cabbage, and fresh vegetables should be avoided.

The menu and the list of products allowed for consumption are gradually expanding; they are moving from pureed food to finely chopped food. Rehabilitation after intestinal surgery lasts 1-2 years, this period varies from person to person. It is clear that many delicacies and dishes will have to be abandoned completely, and the diet will no longer be the same as that of most healthy people, but by following all the doctor’s recommendations, the patient will be able to achieve good health and compliance of the diet with the needs of the body.

Bowel resection is usually performed free of charge, in regular surgical hospitals. Tumors are treated by oncologists, and the cost of the operation is covered compulsory medical insurance policy. In emergency cases (with intestinal gangrene, acute intestinal obstruction), we are not talking about payment, but about saving lives, so such operations are also free.

On the other hand, there are patients who want to pay for medical care and entrust their health to a specific doctor in a specific clinic. Having paid for treatment, the patient can count on higher quality consumables and equipment, which may simply not be available in a regular public hospital.

The cost of intestinal resection on average starts from 25 thousand rubles, reaching 45-50 thousand or more, depending on the complexity of the procedure and the materials used. Laparoscopic operations cost about 80 thousand rubles, closing a colostomy costs 25-30 thousand. In Moscow, you can undergo a paid resection for 100-200 thousand rubles. The choice is up to the patient, whose ability to pay will determine the final price.

Reviews from patients who have undergone intestinal resection are very different. When a small section of the intestine is removed, health quickly returns to normal, and problems with nutrition usually do not arise. Other patients who were forced to live for many months with a colostomy and significant dietary restrictions report significant psychological discomfort during the rehabilitation period. In general, if you follow all the doctor’s recommendations after a high-quality operation, the result of the treatment does not cause negative reviews, because it eliminated a serious, sometimes life-threatening pathology.

Postoperative period and its complications - Surgical diseases

Page 5 of 25

Postoperative complication is a new pathological condition, out of character for the normal course of the postoperative period and not resulting from progression of the underlying disease. It is important to distinguish complications from operational reactions, which are natural reaction the patient's body to disease and surgical aggression. Postoperative complications, in contrast to postoperative reactions, sharply reduce the quality of treatment, delay recovery, and endanger the patient's life. There are early (from 6-10% and up to 30% during long and extensive operations) and late complications.
Each of six components is important in the occurrence of postoperative complications: the patient, the disease, the operator, the method, the environment, and chance.
Complications may be.
— development of disorders caused by the underlying disease;
— dysfunctions of vital systems (respiratory, cardiovascular, liver, kidneys) caused by concomitant diseases;
- consequences of defects in the execution of the operation or the use of faulty techniques.
What matters are the characteristics of a hospital infection and the system of patient care in a given hospital, schemes for the prevention of certain conditions, dietary policy, and the selection of medical and nursing personnel.
We cannot discount the elements of chance, and perhaps fate. Every surgeon who has been practicing for a long time cannot forget the completely absurd and incredible complications that do not leave individual patients alone, layer on each other and often end in death in the postoperative period.
However, features pathological process, disturbances of homeostasis, infection, tactical, technical and organizational errors of doctors, the level of technical support - this is a typical set of reasons that require competent prevention and adequate treatment in the early stages in any clinic and hospital.
Postoperative complications are prone to progression and recurrence and often lead to other complications. There are no minor postoperative complications. In most cases, repeated interventions are required.
The frequency of postoperative complications is about 10% (V.I. Struchkov, 1981), while the proportion of infectious ones is 80%. (hospital strains (!), immunodeficiency). The risk increases during emergency as well as long-term operations. The duration of the operation is one of the leading factors in the development of purulent complications - a marker of trauma and technical problems.
Technical errors: inadequate access, unreliable hemostasis, traumatic performance, accidental (undetected) damage to other organs, inability to delimit the field when opening a hollow organ, leaving foreign bodies, inadequate interventions, “tricks” in performing operations, suture defects, inadequate drainage, defects postoperative management.

CLINIC OF THE NORMAL POSTOPERATIVE PERIOD AFTER ABDOMINAL OPERATIONS includes surgical aggression superimposed on the patient’s initial state. A surgical operation is a non-physiological effect, and therefore the entire body, its individual systems and organs are overloaded. The body copes with surgical aggression with open classical access within 3-4 days. In this case, the pain subsides and is felt only with movement and palpation. Feeling better. The temperature decreases from low-grade or febrile levels. Expanding motor activity. Tongue is wet. The abdomen becomes soft, intestinal motility is restored by 3-4 days. On the 3rd day, before the passage of intestinal gases and feces, moderate bloating and soreness with some deterioration in well-being may be noted. Slight pain remains only in the area of ​​the operated organ upon deep palpation.
Laboratory indicators: in proportion to the surgical blood loss, a decrease in hemoglobin (up to 110 g/l) and erythrocytes (4·1012 l), an increase in leukocytes (9-12·109 l) with a shift to 8-10% of band leukocytes is recorded. Biochemical indicators either within normal limits, or in case of their initial violations with a tendency to normalization. Recovery slows down in patients undergoing emergency surgery for underlying purulent-inflammatory diseases or massive bleeding. They have more pronounced symptoms of intoxication or anemia. Due to the unpreparedness of the intestines on day 2, bloating can be a problem.

PREVENTION OF POSTOPERATIVE COMPLICATIONS.
There are no strict criteria for the tolerability of the operation in borderline states. The goal of prevention is to reduce the risk as much as possible.
General principles:
1) systemic fight against hospital infection;
2) reducing the duration of preoperative (if up to 1 day - 1.2% of suppurations, up to 1 week - 2%, 2 weeks and more - 3.5% - Kruse, Foord, 1980) and postoperative stay;
3) preparation in terms of strengthening specific and nonspecific resistance, nutritional status;
4) identifying foci of infection in the body, including dormant ones in old postoperative scars (test provocation with dry heat, UHF helps);
5) prophylactic use of antibiotics before and during operations;
6) high-quality suture material;
7) professional education of surgeons;
early diagnosis and the most complete examination - every patient with abdominal pain should be examined by a surgeon;
9) timely detection and surgical sanitation, adequate therapeutic treatment - good state social policy;
10) participation in the postoperative treatment of the operating surgeon;
11) timely relief of postoperative reactions (for example, intestinal paresis);
12) uniform schemes of surgical actions and postoperative management in the clinic (dressings, diet, activation);
13) reasonable implementation of the concept of “active management of the postoperative period” (early getting up, exercise therapy and earlier nutrition).

GENERAL CLINIC FOR POSTOPERATIVE COMPLICATIONS. There are no asymptomatic complications. In each case there are specific signs. However, there are also common ones. They are associated mainly with ongoing intoxication, and are manifested by changes in appearance and deterioration of health. The look is anxious, the eyes are sunken, the facial features are sharpened. Characterized by dry tongue, tachycardia, and lack of peristalsis. Signs of ongoing intoxication syndrome: fever, sweating, chills, decreased urine output. Acutely intensifying abdominal pain, and against the background of dulled perception of it, is a sign of an abdominal postoperative catastrophe. Symptoms of peritoneal irritation.
Nausea, vomiting and hiccups are not typical for the normal postoperative period.
With the gradual development of complications, the most constant sign is progressive intestinal paresis.
The sign of collapse is extremely alarming - it may be a sign of internal bleeding, suture failure, acute dilatation of the stomach, as well as myocardial infarction, anaphylactic shock, pulmonary embolism.
Action Methodology if a postoperative complication is suspected:
- assessment of the level of intoxication syndrome (pulse, dry mouth, laboratory parameters) in dynamics (taking into account the ongoing detoxification);
- extended dressing of the surgical wound with probing (in conditions of sufficient pain relief);
— directed and exploratory instrumental research (ultrasound, X-ray diagnostics, NMR).

WOUND COMPLICATIONS. Any wound heals by biological laws. In the first hours, the wound channel is filled with a loose blood clot. The inflammatory exudate contains a large amount of protein. On the second day, fibrin begins to undergo organization - the wound sticks together. During the same period, the phenomenon of wound contraction develops, which consists of a uniform concentric contraction of the edges of the wound. On days 3-4, the edges of the wound are connected by a delicate layer of connective tissue made of fibrocytes and delicate collagen fibers. From 7-9 days we can talk about the beginning of scar formation, which lasts 2-3 months. Clinically, uncomplicated wound healing is characterized by the rapid disappearance of pain and hyperemia, and the absence of a temperature reaction.
Alternative exudative processes are aggravated by rough manipulations in the wound, drying out (dry lining), significant charring of tissues by electrocoagulation, infection with the contents of the intestine, abscess, etc.). Generally biologically, microflora is necessary because it promotes rapid wound cleansing. The critical level of bacterial contamination is 105 microbial bodies per 1 g of wound tissue. Rapid proliferation of microorganisms occurs 6-8 hours after the operation. In a wound hermetically sealed with sutures for 3-4 days, the exudative process spreads inward along the interstitial pressure gradient. In conditions of infection, the wound heals through granulation tissue, transforming into scar. The growth of granulations slows down with anemia and hypoproteinemia, diabetes mellitus, shock, tuberculosis, vitamin deficiency, and malignant tumors.
Patients with pronounced tissue and increased trauma are prone to wound complications.
There is a strict sequence of complications.
Bleeding external and internal 1-2 days.
Hematoma— 2-4 days.
Inflammatory infiltrate(8 - 14%) - 3-6 days. The tissues are saturated with serous or serous-fibrinous transudate (prolonged hydration phase). The boundaries of the infiltrate are 5-10 cm from the edges of the wound. Clinic: pain and feeling of heaviness in the wound, low-grade fever with elevations up to 38°. Moderate leukocytosis. Locally: swelling of the edges and hyperemia, local hyperthermia. Palpable compaction.
Treatment is probing the wound, evacuating exudate, removing some of the sutures to reduce tissue pressure. Alcohol compresses, warmth, rest, physiotherapy, x-ray therapy (rarely).
Wound suppuration(2-4%) - 6-7 days. As a rule, due to a visible hematoma and then infiltration. It is less common for a patient to be unresponsive to a particularly virulent infection, but then it occurs very quickly.
Clinic: hectic fever, drenching sweat, chills, headache. The wound area is bulging, hyperemic, and painful. If the abscess is subgaleal in location due to irritation of the peritoneum, there may be dynamic obstruction and then differential diagnosis with postoperative peritonitis is relevant.
With an anaerobic or other virulent infection, the purulent process can proceed rapidly, appearing 2-3 days after surgery. Severe intoxication and local reaction. Emphysema of the perivulnar region.
Treatment. Removing stitches. Pockets and leaks open in the cavity of the abscess. The wound is cleaned of non-viable tissue (washing) and drained. If an anaerobic process is suspected (the tissues have a lifeless appearance with a purulent-necrotic coating of a dirty gray color, the muscle tissue is dull, gas is released), a mandatory wide excision of all affected tissues is required. If widespread, additional incisions are required.
Yellow or white odorless pus - staphylococcus, E. coli; green - viridans streptococcus; dirty gray with a fetid odor - putrefactive flora; blue-green - Pseudomonas aeruginosa; raspberry with a putrid odor - anaerobic infection. During treatment, the flora changes to hospital flora.
With a putrefactive wound infection, there is abundant hemorrhagic exudate and foul-smelling gas, gray tissue with necrosis.
As granulation and cupping develop exudative phase or applying secondary sutures (tightening the edges with a plaster), or switching to ointment dressings (in cases of extensive wounds).

POSTOPERATIVE PERITONITIS. Occurs after any operations on the abdominal organs and retroperitoneal space. This new a qualitatively different form of the disease. It is fundamentally important to distinguish postoperative peritonitis from progressive, ongoing or sluggish peritonitis, in which the first operation does not solve (sometimes cannot solve) all the problems.
Etiopathogenesis. Three groups of reasons:
— medical errors of a technical and tactical nature (50-80%);
— deep metabolic disorders leading to insufficiency of immunobiological mechanisms and defective regeneration;
- rare, casuistic reasons.
In practice, the following are common: insufficient delimitation of the abdominal cavity from enteral infection, unsystematic revision, careless hemostasis (modern technique: “tweezers-scissors-coagulation”), lack of sanitation of the abdominal cavity at the end of the operation (dry and wet sanitation, toilet of the pockets and sinuses of the abdominal cavity) . The problem of failure of gastrointestinal anastomoses is urgent, including due to technical defects (prevention by maintaining sufficient blood supply, wide contact of the peritoneum without entrapping the mucosa, infrequent sutures).
Classification postoperative peritonitis.
By genesis (V.V. Zhebrovsky, K.D. Toskin, 1990):

• primary - infection of the abdominal cavity during surgery or in the near future after it (perforation of acute ulcers, necrosis of the wall of the abdominal organ due to incorrect assessment of viability, undetected intraoperative damage);
• secondary peritonitis - as a consequence of other postoperative complications (suture failure, abscess rupture, with intractable paralytic obstruction, eventration).

According to the clinical course (V.S. Savelyev et al. 1986): fulminant, acute, sluggish.
By prevalence: local, general
By type of microflora: mixed, colibacillary, anaerobic, diplococcal, pseudomonas.
By type of exudate: serous-fibrinous, serous-hemorrhagic, fibrinous-purulent, purulent, bile, fecal.
Clinic. There is no universal clinical picture of postoperative peritonitis. The problem is that the patient is already in serious condition, has a surgical illness, has suffered surgical aggression, and is being intensively treated with medications, including antibiotics, hormones, and drugs. In all cases, it is impossible to focus on pain and tension in the muscles of the anterior abdominal wall. Therefore, diagnosis should be carried out at the level of microsymptoms.
Clinically there are two options:
1) acute deterioration against the background of a relatively favorable course ( soft belly, good physical activity, but fever is possible). The later peritonitis occurs, the better it is to diagnose it;
2) progressive severe course against the background of ongoing intoxication.
Signs of peritonitis.
- direct (defense), - are not always detected against the background of intoxication, hypoergy and intensive treatment;
- indirect (!) - disturbance of homeostasis (tachycardia, hypotension), impaired motility of the stomach and intestines (not decreasing intestinal reflux), persistence or worsening of the intoxication syndrome, despite intensive treatment.
As a rule, the leading clinic is recurrent intestinal paresis and the progressive development of systemic syndrome inflammatory reaction accompanied by multiple organ failure.
There are no asymptomatic postoperative peritonitis. Diagnostic principles:

• dominant clinical thinking of the surgeon;
• comparison of the predicted normal course of the postoperative period in a given patient and the existing one;
• progression or persistence of intoxication syndrome during intensive detoxification.

The basis of diagnosis is: persistent intestinal paresis, non-decreasing endogenous intoxication (fever, dry tongue), tendency to hypotension, tachycardia, decreased diuresis, development and progression of renal, liver failure.
An obligatory stage is an extended inspection of the wound with its probing.
The next stage of diagnosis is the exclusion of other sources of intoxication: bronchopulmonary process, gluteal abscesses, etc. X-ray (free gas in the abdominal cavity, be careful!), ultrasound of the abdominal cavity (presence of fluid in the abdominal cavity), and endoscopy.
Treatment. Conservative treatment has a 100% mortality rate. The key is relaparotomy followed by intensive detoxification and, in some cases, repeated sanitation.
The operation should be as radical as possible, but correspond to the vital capabilities of the patient - individual surgery.
General principles: suction of exudate, elimination of the source, postoperative lavage, intestinal drainage. Sometimes, if circumstances permit, you can limit yourself to the minimum. The latter is possible with early diagnosis and accurate determination of the extent of damage.
For example, in case of peritonitis caused by the failure of the gastrointestinal anastomosis during distal gastrectomy, N.I. Kanshin (1999) recommends, in the absence of a pronounced purulent process in the anastomosis area, reinforcing sutures (cover with Tachocomb) and transverse through perforated drainage along the anastomosis (constant aspiration with air leakage and periodic rinsing), and insert a probe for decompression and enteral nutrition into the outlet loop through the anastomosis. If there is a significant defect in the anastomosis and severe peritonitis, a double-lumen tube is inserted into the afferent loop with fixation to the edge of the defect, covered with an omentum, and a jejunostomy is applied at a distance of 50 cm.
Peritoneal detoxification is important - up to 10-15 liters of heated solution, as well as intestinal decompression: transnasal for up to 4-6 days or through an intestinal fistula.
A variant of suspended compression enterostomy for peritonitis according to N.I. Kanshin: a Petzer catheter with an excised bottom of its bell is inserted through the minimal enterotomy opening and crimped with a purse-string suture. The catheter is brought out through a puncture of the abdominal wall, pressing the intestine to the peritoneum, and is fixed in a given position with a tightly dressed rubber bar until compression.
If peritonitis occurs after endovideoscopic interventions, then re-intervention can also be performed endovideoscopically or from a mini-access (the professionalism of the operator is very important, which, however, is essential in classical repeated operations).

POSTOPERATIVE INTRA-ABDOMINAL ABSCESSES. There may be intraperitoneal, retroperitoneal and abscesses of the abdominal organs. They are localized in the bags, pockets, canals and sinuses of the abdominal cavity, the cellular spaces of the retroperitoneal tissue, as well as in the liver, spleen, and pancreas. Predisposing factors are neglect of acute surgical diseases, insufficient sanitation, sluggish peritonitis, irrational and ineffective drainage of the abdominal cavity.
Clinic. On days 3-10, deterioration in general condition, pain, fever, tachycardia. Phenomena of intestinal motor insufficiency appear: bloating, inadequacy of the effect of intestinal stimulation, pronounced reflux of the gastric tube. Dominant of active search and clinical diagnosis. The key is to palpate to look for even minimal pain and infiltration, starting from the postoperative wound, along the anterior, lateral and posterior walls, ending along the intercostal spaces. The hope for universal help from ultrasound, CT, and NMR cannot be absolute.
Subphrenic abscesses. Persistent vomiting is an important presentation. The key is Grekov's symptom - pain when pressing with fingers in the lower intercostal spaces above the abscess. Also important are Kryukov’s symptom—pain when pressing on the costal arches—and Yaure’s symptom—balloting of the liver.
X-ray examination in a vertical position is informative (gas bubble above the liquid level, immobility of the diaphragm dome, concomitant pleurisy).
Treatment. In case of right-sided localization, high subphrenic abscesses are opened with resection of the 10th rib according to A.V. Melnikov (1921), the posterior ones - with resection of the 12th rib according to Ochsner, the anterior ones - according to Clermont.
Interintestinal abscesses occur with a combination of clinical septic process and intestinal obstruction (dynamic and mechanical). Diagnosis is predominantly clinical. The beginning of treatment is conservative (at the stage of infiltration). An old trick: X-ray therapy. When the septic condition increases, the autopsy is often performed through a median relaparotomy. The use of puncture and catheterization under ultrasound guidance is promising.

POSTOPERATIVE INTESTINAL OBSTRUCTION. There are early (before discharge) and late (after discharge).
We should talk about early adhesive obstruction only after a period of restoration of normal function of the gastrointestinal tract and at least one normal bowel movement.
Causes of early mechanical obstruction.

• adhesions when the integrity of the serous covering is violated (mechanical, chemical, thermal injuries, purulent-destructive process in the peritoneal cavity, talc, gauze);
• obstruction due to anastomositis, compression of the loop by infiltrate (like a “double-barreled gun”);
• obstruction due to poor placement of tampons and drains (external compression, volvulus);
• obstruction due to technical defects in the execution of the operation (defects in anastomosis, being caught in a ligature when suturing a laparotomy wound of the intestinal wall).

Clinic. Impaired passage of intestinal contents with retention of gases and defecation for more than 4 days after surgery, persistent bloating, increased amount of discharge through the gastric tube.
Diagnostics. It is important to differentiate early intestinal obstruction due to actual adhesions, for example, stimulated by tampons, from involvement of the intestine in the inflammatory infiltrate, as well as from intestinal paresis due to a septic process in the abdomen. It is difficult to notice the transition from dynamic to mechanical. The critical period for making a surgical decision is 4 days.
Great help in the X-ray method.
Separately, there is high obstruction during interventions on the stomach and duodenum (acute anastomositis after gastric resections, impaired patency of the duodenum after suturing perforated ulcers, compression in the area of ​​the head of the pancreas), manifested by persistent significant discharge through the gastric tube. The modern solution is to perform gastroscopy with bougienage of the narrowed area and insertion of a nutritional probe below the narrowing site, the usefulness and safety of which was proven back in the 80s by V. L. Poluektov.
Surgery should be complemented by nasoenteric intubation, colon decompression with an anorectal tube, and anal sphincter divulsion.
Adequate intensive care.

POSTOPERATIVE PANCREATITIS develops after operations on the bile ducts and pancreas, stomach, after splenectomy, papillotomy, removal of the large intestine, when direct or functional contact with the pancreas occurs.
Occurs 2-5 days after surgery. It manifests itself as dull pain in the epigastric region, bloating, and gas retention. Amylasemia and amylasuria explain the reason for the deterioration of the condition. Old doctors attributed the appearance of psychotic disorders primarily to postoperative pancreatitis.
The key is active drug prophylaxis with antienzyme drugs and sandostatin in patients with the above interventions, in which the pancreas reaction can be predicted.
The treatment is the same as for other forms of pancreatitis with priority to intensive care and antibiotic therapy.

POSTOPERATIVE MYOCARDIAL INFARCTION. The occurrence of peri- and postoperative infarction is realistic with the following risk factors (Weitz and Goldman, 1987): heart failure; myocardial infarction within the previous 6 months; unstable angina; ventricular extrasystole with a frequency of more than 5 per minute; frequent atrial extrasystole or more complex rhythm disturbances; age over 70 years; emergency nature of the operation; hemodynamically significant aortic stenosis; general serious condition. The combination of any three of the first six indicates a 50% probability of perioperative myocardial infarction, pulmonary edema, ventricular tachycardia, or death of the patient. Each of the last three factors individually increases the risk of these complications by 1%, and any combination of two of the last three increases the risk to 5-15%.
A heart attack usually develops in the first six days after surgery. It is important to record an ECG on days 1, 3 and 6 after surgery.

POSTOPERATIVE DEEP VEIN THROMBOSIS OF THE LEG. About 80% of cases of deep vein thrombosis after surgery are asymptomatic (Planes et al. 1996). The most dangerous thrombosis of the muscle veins of the leg is due to: 1) turning off the central mechanism of blood outflow from the legs in bed patients - the muscular-venous pump of the leg; 2) high frequency of silent ectasia of the tibial and muscular veins of the leg; 3) subclinical manifestations; 4) absence of swelling of the leg due to preserved outflow of blood from the limb.
Important: prevention in broad and narrow terms; identification of risk groups; daily palpation of the calf muscles as a standard for postoperative monitoring.

POSTOPERATIVE PNEUMONIA — the most severe bronchopulmonary complication . Causes: aspiration, microembolism, congestion, toxicoseptic condition, heart attack, prolonged standing of gastric and intestinal tubes, prolonged mechanical ventilation. It is predominantly small-focal in nature and is localized in lower sections.
Clinic: worsening fever not associated with wound findings, chest pain when breathing; cough, flushed face. It begins as tracheobronchitis. Appears within 2-3 days.
Three variants of the course (N.P. Putov, G.B. Fedoseev, 1984): 1) a clear picture of acute pneumonia; 2) with the prevalence of bronchitis; 3) erased picture.
Indicators of severe prognosis for hospital-acquired pneumonia (S.V. Yakovlev, M.P. Suvorova, 1998): age over 65 years; mechanical ventilation for more than 2 days; severity of the underlying disease (head injury, coma, stroke); severe concomitant diseases (diabetes mellitus, chronic obstructive pulmonary diseases, alcoholism and cirrhosis of the liver, malignant tumors); bacteremia; polymicrobial or problematic (P. Aeruginosa, Acinnetobacter spp. fungi) infection; previous ineffective antibacterial therapy.
In the treatment complex, antibacterial treatment is important, taking into account the characteristics of nosocomial infection of the medical institution and operational control for bronchial patency (bronchoscopy).

POSTOPERATIVE MUMPS — acute inflammation of the parotid salivary gland. More often in elderly and old age, with diabetes mellitus. Contributes to carious teeth, decreased function salivary glands due to dehydration, in the absence of chewing, prolonged standing of probes, leading to the proliferation of microbial flora in the oral cavity.
Clinic. On days 4–8, pain, swelling, and hyperemia occur in the parotid areas with the development or worsening of a septic condition. In addition, dry mouth, difficulty opening the mouth.
Prevention. sanitation of the oral cavity, rinsing the mouth, removing plaque from the tongue, chewing sour things.
Treatment. local (compresses, dry heat, rinsing) and general (antibacterial therapy, detoxification). If suppuration appears, open with two incisions parallel to the vertical part of the lower jaw and along the zygomatic arch (work digitally on the gland).

– Early – as a rule, develops in the first 7 days after surgery;

– Late – develops at various times after discharge from the hospital

From the side of the wound:

1. Bleeding from a wound

2. Wound suppuration

3. Eventration

4. Postoperative hernias

5. Ligature fistulas

From the side of the operated organ (anatomical area):

– Failure of anastomotic sutures (stomach, intestines, bronchus, etc.).

- Bleeding.

– Formation of strictures, cysts, fistulas (internal or external).

– Paresis and paralysis.

– Purulent complications (abscesses, phlegmon, peritonitis, pleural empyema, etc.).

From other organs and systems:

– From the cardiovascular system – acute coronary insufficiency, myocardial infarction, thrombosis and thrombophlebtitis, pulmonary embolism;

– From the side of the central nervous system – acute disorder cerebral circulation (stroke), paresis and paralysis;

– Acute renal, liver failure.

- Pneumonia.

Postoperative complications can be presented in the form of a diagram

Care begins immediately after the surgery is completed. If the operation was performed under anesthesia, permission for transportation is given by the anesthesiologist. With local anesthesia, the patient is moved onto a gurney after surgery either independently or with the help of staff, after which he is transported to the recovery room or to a ward in the surgical department.

Sick bed should be prepared for the moment of his arrival from the operating room: covered with fresh linen, heated with heating pads, there should be no folds on the sheets. The nurse must know what position the patient should be in after surgery. Patients usually lie on their back. Sometimes after surgery on the abdominal and thoracic cavities, patients lie in the Fowler's position (a semi-sitting position on the back with the limbs bent at the knee joints).

Patients operated on under anesthesia are transported to the intensive care unit on a bed in the same department. Shifting with operating table transfer to a functional bed is carried out under the supervision of an anesthesiologist. The unconscious patient is carefully lifted from the operating table and placed on the bed, while sharp flexion of the spine (possible dislocation of the vertebrae) and hanging limbs (possible dislocation) should be avoided. It is also necessary to ensure that the bandage from the postoperative wound is not torn off and the drainage tubes are not removed. At the time of transferring the patient to the bed and transporting, signs of respiratory and cardiac disturbances may occur, therefore the support of an anesthesiologist and nurse anesthetist Necessarily . Until the patient regains consciousness, he is laid horizontally, his head is turned to the side (prevention of aspiration of gastric contents into the bronchi - the nurse should be able to use an electric suction to help the patient with vomiting). Cover with a warm blanket.

To better provide the body with oxygen, humidified oxygen is supplied through a special device. To reduce bleeding of the operated tissues, an ice pack or a load (usually a sealed oilcloth bag with sand) is placed on the wound area for 2 hours. Drainage tubes are attached to the system to collect the contents of a wound or cavity.

In the first 2 hours, the patient is in a horizontal position on his back or with the head end down, since in this position the blood supply to the brain is better ensured.

During operations under spinal anesthesia, the horizontal position is maintained for 4-6 hours due to the risk of developing orthostatic hypotension.

After the patient regains consciousness, a pillow is placed under his head, and his hips and knees are raised to reduce blood stagnation in the calf muscles (prevention of thrombosis).

The optimal position in bed after surgery may vary, depending on the nature and area of ​​surgery. For example, patients who have undergone surgery on the abdominal organs, after they have regained consciousness, are placed in bed with their heads slightly raised and knees slightly bent and hip joints feet.

A long stay of the patient in bed is not advisable, due to the high risk of complications caused by physical inactivity. Therefore, all factors that deprive him of mobility (drains, long-term intravenous infusions) must be taken into account in time. This is especially true for elderly and senile patients.

There are no clear criteria defining the timing of a patient getting out of bed. Most patients are allowed to get up 2-3 days after surgery, but the introduction modern technologies V medical practice changes a lot. After laparoscopic cholecystectomy, you are allowed to get up in the evening, and many patients are discharged to outpatient treatment the very next day. Getting up early increases confidence in a favorable outcome of the operation, reduces the frequency and severity of postoperative complications, especially respiratory and deep vein thrombosis.

Even before surgery, it is necessary to teach the patient the rules of getting out of bed. In the evening or the next morning, the patient should sit on the edge of the bed, clear his throat, move his legs, and in bed he should change his body position as often as possible and make active movements with his legs. At the beginning, the patient is turned on his side, on the side of the wound, with his hips and knees bent, with his knees on the edge of the bed; the doctor or nurse helps the patient sit down. Then, after taking several deep breaths and exhalations, the patient clears his throat, stands on the floor, takes 10-12 steps around the bed, and goes back to bed. If the patient’s condition does not worsen, then the patient should become more active in accordance with his own feelings and the doctor’s instructions.

Sitting in bed or a chair is not recommended due to the risk of slowing venous blood flow and causing thrombosis in the deep veins lower limbs, which in turn can cause sudden death due to blood clot rupture and pulmonary embolism.

To timely identify this complication, it is necessary to measure the circumference of the limb daily and palpate the calf muscles in the projection of the neurovascular bundle. The appearance of signs of deep vein thrombosis (swelling, bluishness of the skin, increased volume of the limb) is an indication for special diagnostic methods (ultrasound Dopplerography, venography). Deep vein thrombosis occurs especially often after traumatological and orthopedic operations, as well as in patients with obesity, cancer, and diabetes. Reducing the risk of thrombosis in the postoperative period is facilitated by the restoration of impaired water-electrolyte metabolism, the prophylactic use of direct-acting anticoagulants (heparin and its derivatives), early activation of the patient, and bandaging the lower extremities with elastic bandages before surgery and in the first 10-12 days after it.

4.9. INTOXICATION

We will not consider intoxication, which depends on the nature of the pathological process itself and already exists at the time of the operation, often aimed at eliminating it. Let us dwell on intoxication that occurs as a result of surgery, and on the tasks of the assistant in preventing it. At the same time, we will understand here by the very general term “intoxication” only a complex of various unfavorable consequences of the penetration of bacteria and their toxins into the blood and lymphatic channels, as well as products of tissue decay that arise precisely as a result of surgical manipulations. Let's not consider them either pathogenetic mechanisms, often fundamentally different. We will also not touch upon such types of intoxication that are inevitably associated with the characteristics of this surgical intervention (for example, after the application of a direct portocaval shunt) or with the nature of the anesthesia.

Having thus defined intoxication, let us dwell on its immediate causes. These reasons can be divided into 2 groups - those associated with the presence of a localized source of intoxication and those associated with the formation of a new source of intoxication.

Intoxication in the presence of a localized source occurs when protective barriers are destroyed and conditions are created for the generalization of the process. These conditions are:

Open gaping lumens of blood vessels, especially venous plexuses, large and intraorgan veins;

Restoration of blood flow in intact vessels as a result of separation of blood clots or elimination of their mechanical compression (destruction of the protective barrier of localized abscesses; elimination of intestinal volvulus with compression of the mesenteric vessels);

Ingress of toxic contents onto a large absorptive surface - the villous mesothelial cover of the visceral and diaphragmatic peritoneum.

Purely mechanical factors contributing to the implementation of the first two conditions are an increase in pressure in a localized focus of intoxication and the occurrence of a “pump effect.”

Intoxication in the presence of a localized source is generalized under the listed conditions, most often in the following situations:

When opening intraperitoneal and extraperitoneal abscesses, infected hematomas, accumulations of tissue decay (parapancreatitis), having a pronounced infiltrative or granulation barrier;

In case of ingestion of pus, tissue decay products, contents of hollow organs (especially infected or in case of intestinal obstruction), cysts, etc. into the free abdominal cavity;

With detorsion of intestinal or node volvulus.

The task of the assistant in preventing intoxication in these cases is similar to his task in preventing surgical infection when there is a threat of developing diffuse peritonitis, bacterial shock, etc. The question of the advisability of volvulus detortion or intestinal resection is decided by the surgeon. Usually, before this, a puncture is performed and toxic contents are evacuated from the intestine.

The assistant should in every possible way avoid such manipulations with napkins inside the abscess, which can increase the pressure there and cause a “pump effect”.

Intoxication associated with the formation of a new source as a result of surgery, has various causes. The most common of them are the following:

Getting toxic disinfectants into the abdominal cavity and into the wound (when using any liquids for washing the abdominal cavity, the assistant must personally verify their name and concentration by reading the label on the bottle; the same applies to the use of novocaine or alcohol for all kinds of intraoperative blockades and anesthesia) ;

Carrying out autoinfusion (reinfusion) of infected blood spilled into the abdominal cavity (to prevent this danger, the assistant evaluates, together with the surgeon, the possibility of reinfusion and provides the surgeon with the conditions for a thorough inspection of the abdominal organs in order to promptly identify organ damage that could serve as a source of infection of the spilled blood );

Tight tamponade of areas of tissue decay or bleeding areas of organs and tissues, creating conditions for the retention of toxic discharge behind the tampons with insufficient outflow (when performing tamponade in the indicated cases, the assistant positions the organs surrounding the site of the tampon so that the tampons can be removed into the wound in the shortest way and so that this channel is, if possible, funnel-shaped with the base facing the skin wound; when suturing a wound of the abdominal wall, it must provide conditions that prevent compression of the tampons, which leads to disruption of their drainage function and retention of discharge flowing past the tampons; be spread over the entire width, should not be twisted in the form of a tourniquet, and a finger should fit freely between the edge of the tampon and the suture of the abdominal wall);

The use of excessively narrow drainage tubes that do not provide proper outflow of tissue discharge or contents of hollow organs and their excretory ducts (the assistant must check the patency of the drainage tubes using a syringe with a solution of novocaine. After installing and fixing the drainages in the lumen of the hollow organ, he must make sure that there is an outflow of contents and in the absence of obstructions to the outflow - blockage with clots of mucus, “sand”, kinks in the tube, suction of the side windows in the tube to the wall of the organ, etc.; only by ensuring proper decompression of the hollow organ can the development of intoxication in the postoperative period be prevented);

Wound intoxication due to the disintegration of tissues cut and crushed during surgery (even with small incisions, careful hemostasis and reliable closure of the wound with sutures, minor wound intoxication in the postoperative period is inevitable; the larger the incision, the larger the area of ​​surgical damage to tissues, especially muscles, the more areas of hemorrhage , unremoved hematomas, crushed with clamps, tied with ligatures and deprived of blood supply, doomed to tissue necrosis, the more pronounced wound intoxication in the postoperative period; it intensifies if the surgical wound is left unsutured for some reason or is poorly drained; a large-scale operation, and wound intoxication will be barely pronounced; poor surgical technique, rough handling of tissues, blunt cutting instruments, poor hemostasis, entrapment of excessively large areas of tissue in ligatures, crushing of muscles with clamps, crushing and blunt separation of tissues instead of cutting them. lead to severe wound intoxication even after small operations; the source of intoxication, as a rule, is histamine-like tissue breakdown products; To prevent wound intoxication, every possible reduction in the volume of surgical trauma and careful, delicate surgical technique are necessary, which largely depends on the quality of assistance).

A special and independent cause of intoxication is postoperative pneumonia. The causes of pneumonia after operations on the abdominal organs and abdominal wall are different. These include defects in preoperative preparation and management of the postoperative period, errors in anesthesia, especially artificial ventilation, the nature of the initial surgical procedure and concomitant diseases, but the surgical intervention itself plays an important role in the development of pneumonia. Let's consider the main reasons that contribute to the occurrence of pneumonia and are directly related to the surgical technique.

Duration of the operation. The longer the abdominal cavity is open, the greater the likelihood of pneumonia. One of the reasons for its occurrence is cooling, so the assistant’s task is to warm the ventrated organs and cover the wide surgical wound.

Area of ​​surgical intervention. The closer this area is to the diaphragm, the greater the likelihood of developing pneumonia. Limiting the respiratory excursions of the diaphragm by placing napkins and towels under it, pressing it with mirrors impairs lung ventilation and contributes to the development of pneumonia.

Hypoventilation due to compression chest. It was stated above that the assistant should not lean on the patient’s chest and should not place surgical instruments on it.

Reflex effects from the abdominal organs, especially its upper floor. Rough pulling on the stomach, gall bladder, trauma to the pancreas, etc. lead to the development of subsegmental lobular (disc-shaped) atelectasis (collapses) in the lower lobes of the lungs and contribute to the occurrence of pneumonia.

Blood loss and traumatic (surgical) shock. Measures to prevent these complications are described above.

When deciding to undergo surgery, every person hopes for a successful outcome. Of course, a lot depends on modern technologies and the skill of the surgeon. “But the results of even the most successful operation can be nullified if it is not accompanied by competent and timely rehabilitation,” says anesthesiologist and resuscitator Sergei Vladimirovich DANILCHENKO. Among the problems that await surgical patients after elective surgery(especially regarding cancer and operations on the lungs and heart), doctors highlight the following.

Any surgical intervention (especially one associated with large blood loss) causes a physiological protective reaction: the body seeks to increase blood clotting in order to reduce blood loss. But at a certain point, this defensive reaction can become pathological. In addition, due to prolonged bed rest, the speed of blood flow in the veins decreases. As a result, blood clots form in large vessels (in the veins of the leg, iliac, femoral, popliteal), which, breaking away from the walls of the vessels, can enter the pulmonary artery with the blood flow and lead to acute respiratory and heart failure, and ultimately to death.

HOW TO WARN.

If you are at risk due to the development of thromboembolism (there was a large blood loss during the operation, you have thick blood, or have a history of vascular problems), the doctor, after examining clinical picture, may recommend taking anticoagulants. These drugs reduce blood clotting, which means they prevent the formation of blood clots. They must be taken in strictly defined doses and for as long as the doctor says - this is important for restoring health. Also, to prevent such a serious complication, all patients are advised to wear compression hosiery- within a month after surgery. This wardrobe item should be present every day! You can remove tights at night ( elastic bandages less preferable, since it is difficult to achieve the desired degree of compression when bandaging the legs with them). The third rule that will help avoid stagnation in blood vessels is physical activity. If possible, with the doctor's permission, it is advisable to “get back on your feet” as soon as possible. The load must be controlled (with the help of the attending physician and exercise therapy doctor) so as not to overdo it and not to strain the body weakened after the operation. Compliance with all rules will help minimize the occurrence of thromboembolism.

Prolonged stay in a horizontal position leads to the appearance of zones in the lungs that are poorly supplied with oxygen. As a result, favorable conditions are created for the development of the inflammatory process, which can lead to hypostatic (congestive) pneumonia. Postoperative pneumonia is especially dangerous for older people - it is often severe and can lead to dire consequences.

HOW TO WARN.

As soon as the person comes to his senses, you need to start breathing exercises(even if he is in intensive care). This is done by exercise therapy instructors who are part of a specialized rehabilitation team. The patient must do it himself, to the best of his ability. breathing exercises that will be assigned to him. Under their influence, the respiratory muscles are strengthened and the mobility of the chest increases. Breathing becomes less frequent and deeper, vital capacity and maximum ventilation of the lungs are restored - all this is the best prevention of inflammatory diseases of the bronchi and lungs. When the patient is transferred to the ward, with the doctor’s permission, it is necessary to do a light vibration massage for 10-15 minutes a day, preferably in the morning (stroking, rubbing, tapping with the edge of the palm, patting with palms folded into a boat shape). Such exercises help cleanse the lungs, improve blood supply, and contact with a loved one has an overall beneficial effect, calms the patient and distracts him from the worries associated with the operation.

This problem is possible after abdominal surgery, when surgical intervention can lead to subsequent divergence of muscle tissue at the site of the recent incision and exit of the gastrointestinal tract (usually the intestines) beyond the peritoneum.

HOW TO WARN.

If you have had surgery on the anterior abdominal wall, wear a special elastic bandage for two months. Do not lift more than two kilograms. Avoid sharp bends and turns of the body to the side. Treat colds in a timely manner, especially if you are prone to bronchopulmonary diseases with a severe cough. Stop smoking - this is the main provocateur of coughing attacks. Eat vegetables, greens, fruits. The fiber they contain will prevent constipation (severe straining for 2-3 months is dangerous due to the appearance of a hernia), in addition, the predominance of plant foods in the diet guarantees a stable weight, and this contributes to a healthier life. fast healing fabrics. As soon as the doctor allows you to increase physical activity, start strengthening your muscle corset. For the prevention of cicatricial hernia, exercises “” are useful - trains the muscles of the back, oblique and rectus abdominis muscles, “Corner” (you hang on the horizontal bar and hold your legs at a right angle), “Legs in weight” (lie on the mat, hands behind your head, and keep your legs at a 45 degree angle). And also the famous “Bicycle”. Be consistent. Avoid sudden physical activity that is not commensurate with your strength.

With prolonged immobilization (often happens after abdominal heart surgery, oncological operations) it develops muscle weakness, the supply of organs and tissues with nerves is disrupted, which ensures their connection with the central nervous system(muscle innervation). Because of this, the patient cannot lift his arms or legs, or even breathe fully.

HOW TO WARN.

Rehabilitation of such patients begins in the intensive care unit, as soon as the condition stabilizes. Specialists from the rehabilitation team, which includes a neurologist, physical therapy instructors, and a speech therapist, begin their work. However, rehabilitation measures should be performed if the patient is in a state of medicated sleep and on artificial ventilation. First of all, this is passive gymnastics (flexion-extension, massage of arms and legs). As strength is restored, with the permission of the doctor, the patient should begin to be seated in a bedside chair; this helps to increase the tone of the trunk muscles, as well as improve pulmonary ventilation. Next begins the stage of restoring walking skills using walkers and canes. Then follow the elements of active gymnastics. The level and volume of load is determined by the head of the rehabilitation group and the exercise therapy instructor, taking into account the individual capabilities and condition of the patient. A lot depends on the moral and physical support of relatives, who should try to inspire the patient and show their maximum interest in restoring his health. It is important to remember that only if the recommended loads are observed, muscle atrophy gradually disappears.

These complications develop in almost all patients who remain on mechanical ventilation for a long time, which is carried out either through a tracheostomy or through an endotracheal tube. As a result, not only speech may be impaired, but also the act of swallowing, due to which some of the food will enter the respiratory tract, and this can lead to aspiration of the lungs.

HOW TO WARN.

In most cases, the swallowing function, as one of the most important biological functions, as a rule, is restored. However, in the first 2-3 weeks after surgery, the following rules should be strictly followed:

eating only in an upright position with the head slightly tilted forward.

food should be chopped, not dry and without large fragments.

It is better to give the liquid to drink from a straw. By the way, a liquid with a pleasant taste restores swallowing skills faster and is swallowed better than ordinary water.

It is necessary to feed a person only in a state of full wakefulness (not sleepy, not lethargic).

there is no need to force you to eat everything cooked; appetite is restored gradually; forceful eating can lead to a person choking.

Also, a speech therapist must work with the patient. By using special exercises The speech therapist not only restores the patient’s speech, but also the normal act of swallowing. The sooner rehabilitation measures begin, the faster the restoration of lost skills occurs and the better the treatment results will be.

These are connective tissue lumps that appear after surgery. This is how the body tries to “fence off” the damaged area (inflammatory process), “gluing” the tissues together and preventing the infection from spreading to other organs. Most often, operations on the pelvic organs lead to the formation of adhesions, be it abortion, curettage after a miscarriage or polyps, cesarean section or installation of an intrauterine device. Abdominal surgery in this regard, it is the most dangerous, since it has the greatest traumatic effect.

HOW TO WARN.

After the operation, you will be prescribed a course of antibiotics, which you must complete! Infectious agents must not be allowed to remain in the uterus or tubes, adapt to the internal environment and begin to multiply! Often, it is negligence towards antibacterial therapy that causes the formation of adhesions. After the intervention, as soon as the doctor allows, you need to get out of bed and take short walks. Movement improves blood circulation and prevents the appearance of adhesions. For prevention, drugs based on hyaluronidase are also used; they have a resolving effect. Hirudotherapy has proven itself well. Leech saliva normalizes blood supply to tissues and organs.

And special enzymes thin the blood well and have a destructive effect on fibrin, which is the basis of adhesions. After 2-3 weeks, the doctor may recommend physical therapy. Among the most common methods are: ozokerite and paraffin applications to the abdominal area. Thanks to their warming effect, they promote the resorption of adhesions. Electrophoresis with calcium, magnesium and zinc also helps.

Doctors consider the ability to care for oneself (eat, shower, go to the toilet) to be a criterion for successful rehabilitation after surgery.

These skills should return within the first week (the information is general, since much depends on the complexity of the operation and the age of the patient). The next stage of rehabilitation (ideally) should be a transfer to either a sanatorium or a rehabilitation center. If spa treatment is indicated for you, do not refuse. This is a good way to relax after surgery and fully regain your strength.