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PREVENTION OF POSTOPERATIVE COMPLICATIONS

A postoperative complication is a new pathological condition that is not typical for the normal course of the postoperative period and is not a consequence of the progression of the underlying disease. It is important to distinguish complications from surgical reactions, which are a natural reaction of the patient’s body to illness 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;

Violations of the functions of vital systems (respiratory, cardiovascular, liver, kidneys) caused by concomitant diseases;

Consequences of defects in the execution of an 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, the features of the pathological process, homeostasis disorders, 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, postoperative defects management

The clinic of the normal postoperative period after abdominal operations includes surgical aggression superimposed on the patient’s initial state.

Surgery- this is a non-physiological effect, due to which the entire body, its individual systems and organs experience overload. 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. Motor activity is expanding. 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 There may be moderate bloating and tenderness with some deterioration in well-being. Slight pain remains only in the area of the operated organ upon deep palpation.

Laboratory indicators: in proportion to the operational blood loss, a decrease in hemoglobin (up to 110 g/l) and red blood cells (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 original violations with a tendency towards 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.

There are no strict criteria for the tolerability of surgery in borderline conditions. 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 over - 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 those dormant in old postoperative scars (test provocation with dry heat, UHF helps);

5) prophylactic use antibiotics before and during operations;

6) high-quality suture material;

7) professional education of surgeons;

8) 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 for 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 in 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.

A sign of collapse is extremely alarming - this could be a sign internal bleeding, failure of seams, acute dilatation stomach, as well as myocardial infarction, anaphylactic shock, embolism pulmonary artery.

Methodology of action in case of suspected postoperative complication:

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 according to biological laws. In the first hours, the wound channel is filled with a loose blood clot. The inflammatory exudate contains large number squirrel. On the second day, fibrin begins to undergo organization - the wound sticks together. During the same period, the phenomenon of wound contraction develops, consisting in 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, as it contributes to quick cleansing wounds. 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 closed with sutures for 3-4 days, exudative process spreads deeper along the interstitial pressure gradient. In conditions of infection, the wound heals through granulation tissue, which turns into scar tissue. 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.

External and internal bleeding for 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, heat, 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.

Pus is yellow or white, odorless - staphylococcus, E. coli; green - viridans streptococcus; dirty gray with a fetid odor - putrefactive flora; blue-green - Pseudomonas aeruginosa; raspberry with putrid smell- 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 granulations develop and the exudative phase is stopped, either secondary sutures are applied (tightening the edges with a bandage), or switching to ointment dressings (in cases of extensive wounds).

POSTOPERATIVE PERITONITIS

Occurs after any operation on the abdominal organs and retroperitoneal space. This is a new, 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 of 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 abdominal organ with an 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).

By clinical course(V.S. Savelyev et al., 1986): lightning-fast, 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. Universal clinical picture There is no 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. It is impossible in all cases to rely on pain syndrome and on muscle tension in 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 abdomen, good motor 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 clinical picture is recurrent intestinal paresis and the progressive development of systemic inflammatory response syndrome, 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-reducing endogenous intoxication (fever, dry tongue), tendency to hypotension, tachycardia, decreased diuresis, development and progression of renal and liver failure.

An obligatory stage is an extended inspection of the wound with its probing.

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 when early diagnosis and accurately determining the extent of damage.

For example, with peritonitis caused by 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 leaks and periodic washings), and insert a probe into the outlet loop through the anastomosis for decompression and enteral nutrition . 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.

If peritonitis occurs after endovideoscopic interventions, then repeated intervention can also be performed endovideoscopically or from a mini-access (the professionalism of the operator is very important, which, however, is also essential in classical repeated operations).

POSTOPERATIVE INTRA-ABDOMINAL ABSCESSES

Postoperative intra-abdominal abscesses can 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 manifestation. 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.

Informative X-ray examination in a vertical position (gas bubble above the liquid level, immobility of the diaphragm dome, concomitant pleurisy).

Treatment. With right-sided localization, high subphrenic abscesses are opened with resection of the 10th rib according to A.V. Melnikov (1921), posterior - with resection of the 12th ribs according to Ochsner, anterior - according to Clermont.

Interintestinal abscesses occur with a combination of clinical septic process and intestinal obstruction (diamic 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 in case of violation of the integrity of the serous cover (mechanical, chemical, thermal injury, purulent-destructive process in the peritoneal cavity, talc, gauze);

obstruction due to anastomositis, compression of the loop by infiltration (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, obstruction 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

Postoperative pancreatitis develops after operations on bile ducts and pancreas, stomach, after splenectomy, papillotomy, removal of the large intestine, when there is direct or functional contact with the pancreas.

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 examination calf muscles as a standard for postoperative monitoring.

POSTOPERATIVE PNEUMONIA

Postoperative pneumonia is the most severe bronchopulmonary complication. Causes: aspiration, microembolism, congestion, toxicoseptic condition, heart attack, prolonged stay of gastric and intestinal tubes, prolonged mechanical ventilation. It is predominantly small-focal in nature and localized in the 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 medical institution and operational monitoring of bronchial patency (bronchoscopy).

POSTOPERATIVE MUMPS

Postoperative parotitis is an acute inflammation of the parotid salivary gland. More often in elderly and senile patients, 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 foods.

Treatment: local (compresses, dry heat, rinsing) and general (antibacterial therapy, detoxification). When 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).

PATHOLOGY AFTER OPERATIONS ON THE STOMACH AND DUODEN - SURGICAL DISEASES

Early complications. Gastric bleeding occurs from sutures on the lesser curvature, gastrointestinal anastomosis, as well as from remaining or newly formed ulcers, erosions on the mucous membrane of the gastric stump. Fortunately, most often it is moderate.

A thin gastric tube placed during surgery makes it possible to recognize this condition and assess the dynamics of bleeding. Minor (up to 50 ml) loss of fresh blood requires conservative actions (locally cold saline, aminocaproic acid) while monitoring hemodynamics and blood tests. Gastroduodenoscopy, performed urgently regardless of the timing of the operation (V.L. Poluektov, 1980) for the purpose of diagnosis and endoscopic hemostasis, facilitates patient management.

Inspection of the stomach during emergency relaparotomy is performed through a longitudinal gastrotomy opening 4-5 cm above the anastomosis with suturing of bleeding areas under visual control.

Bleeding into the abdominal cavity. The most severe cause is intraoperative trauma to the spleen, liver, pancreas, and coagulopathy. Control drainage after surgery is important. The separation of more than 200-250 ml of fresh blood requires vigorous measures.

Failure of the duodenum stump is the most common and serious complication after operations using the Billroth-2 method (more common with ulcers).

Decisive factors: poor blood supply due to ulcerative sclerotic changes in the area of stump formation and intraoperative mobilization of the duodenum, hypertension in the stump, necrosis of the head of the pancreas (surgical trauma or duodenostasis). In addition, common causes are important: hypoproteinemia and anemia, cancer intoxication, septic disorders - everything for which surgery is performed.

When diagnosing incompetence, surgery is necessary. It is possible to refrain from emergency surgery if there is good outflow through the catching drainage and a calm abdomen and the patient’s condition is satisfactory.

Objectives of relaparotomy: sanitation of peritonitis and formation of an isolated fistula. Fundamental positions: in the absence of diffuse peritonitis, actions should be local in the upper floor of the abdominal cavity - bringing a drainage to the hole for active long-term aspiration. In case of defect large size We use a Welch-type method: insertion of tubular drainage (preferably a cut Petzer catheter) with a pouch and wrapping with an omentum, also for active aspiration.

It is useful to pass a nasogastric tube through the anastomosis into the adductor colon.

Anastomositis occurs as a result of roughly applied sutures with low-quality suture material (we have a negative attitude towards a suture wrapped around all layers with catgut), crushing and rough manipulation, a short length of the gastrointestinal anastomosis, the presence inflammatory process in the wall of the stomach and duodenum (exacerbation of ulcers, post-burn gastritis). It appears on the 4th-5th day with copious discharge through the tube, the inability to drink and eat. Treatment includes anti-inflammatory measures, correction of metabolic disorders and restoration of enteral nutrition. The key is to endoscopically pass the feeding tube past the anastomosis.

Late complications. Mucosal ulcerations indicate residual hypersecretion (Zollinger-Ellison syndrome, incomplete resection or vagotomy), as well as the persistence of Helicobacter pylory (persisted in 39.7% of those who underwent gastric resection).

Treatment - antiulcer treatment, taking H 2 receptor antagonists, repeat surgery.

Peptic ulcer of the anastomosis. The reason is the remaining high level of gastric secretion. The pain is constant and intense. Possible complications: bleeding, perforation, penetration.

Conservative therapy is ineffective. Possible surgical options: truncal vagotomy (supradiaphragmatic), reresection.

Adductor loop syndrome is characterized by complaints of bloating and vomiting 30-60 minutes after eating. The condition is complicated by the growth of bacteria.

Causes: long adductor loop, absence of a spur to the lesser curvature, previous duodenostasis, obstructions in the outflow of contents from the adductor loop to the efferent loop (scars, adhesions, infiltrates, sharp spur, tense adductor loop).

X-ray diagnosis: long-term retention of barium in the afferent loop with its overstretching.

Treatment in some cases is surgical (interintestinal anastomosis between the afferent and efferent loops, better reconstruction of the gastroenteroanastomosis according to Roux).

Alkaline reflux gastritis can cause nausea, vomiting, weight loss and epigastric pain. Consequence of reflux of duodenal contents. Manifested by pain after eating, nausea, vomiting.

Requires conservative treatment.

Early dumping syndrome occurs 30 minutes after eating with the development of dizziness, flushing of the face, sweating, and palpitations. In severe cases, fainting and loss of consciousness. Hyperglycemia is observed. Associated with release large quantities intestinal hormones during immediate evacuation of gastric contents.

Treatment: eating while lying down, limiting carbohydrates and liquids during meals. Somatostatin.

Late dumping syndrome develops several hours after eating. Manifested by dizziness, weakness, drowsiness. Reactive hypoglycemia is characteristic. Treatment is conservative (avoid carbohydrate foods and fluid intake during meals, frequent small meals, lie down after meals). Surgical treatment is aimed at reduodenization (for example, reconstruction of Roux-en-Y gastrojejunostomy).

Anemia in 25% of patients. Reasons: 1) gastritis of the gastric stump and microbleeding, 2) deficiency hydrochloric acid, converting iron into an absorbable form (Fe 3+), 3) deficiency of intrinsic factor of Castle and deficiency of vitamin B 12. Treatment is conservative.

SURGICAL AND ABDOMINAL SEPSIS - SURGICAL DISEASES

Systemic inflammatory response syndrome, surgical and abdominal sepsis. By “surgical infection” we mean: 1) an infectious process in which surgical treatment is crucial and 2) a process in the form of complications of the postoperative period and injuries.

Purulent-septic infections are true infectious diseases. In a hospital setting they are highly contagious. Targets are patients with immunodeficiency - a consequence of the underlying disease or intensive specific, including surgical therapy. A sign of epidemiological distress is the duration of persistence of this strain in the hospital as a result of infection of newly admitted patients.

The most severe type of surgical infection is surgical sepsis. Mortality 35-70%. The mortality rate of patients with gram-negative sepsis is two times higher than the mortality rate with gram-positive sepsis.

Requires very expensive treatment. Costs for a patient with sepsis for 3 weeks are 70-90 thousand dollars.

The diagnosis of sepsis was used by Hippocrates 2500 years ago, speaking of a disease of the whole organism. Formally defining it is sometimes as difficult as defining the state of “health”. And the shorter the time from the onset of the disease, the more difficult it is. “Direct confirmation of sepsis... is usually delayed, and the outcome is determined by rapid treatment and early onset. Therefore, the diagnosis should be made on the basis of indirect signs of sepsis - clinical and laboratory” (A.P. Kolesov).

“Surgical sepsis” should be understood as a severe general disease that occurs against the background of a local focus of infection, changes in the body’s reactivity and requiring surgical and intensive treatment. The reasons are varied. Leading infection. Sepsis is based on a reduced ability to suppress pathogen vegetation outside the infectious focus. Transient bacteremia can occur in a healthy person and does not require treatment (with the insertion of catheters or surgery).

There are a number of definitions of a septic condition: “sepsis”, “septic shock”, “systemic inflammatory syndrome”, “multiple organ dysfunction”, “septic-pyemic disease”, “purulent-resorptive fever”. All of them imply: 1) generalized vasodilation, 2) reduced peripheral resistance, 3) impaired microcirculation, 4) generalized inflammation (redness, fever, swelling, organ dysfunction), 5) impaired oxygen diffusion and oxygen utilization by tissues.

Participants in the systemic inflammatory response: inflammatory and anti-inflammatory cytokines, fibrinolysis, activation of the coagulation cascade, complement, prostaglandids, peroxidation, kinins. Very quickly all this turns into biochemical chaos.

The current level of medicine does not allow creating a scientifically based universal classification sepsis. The constructive solution was to identify a specific type of reaction of the body in general, which, having an inflammatory reaction as its basis, takes on a generalized character. In 1991, at the Chicago Consensus Conference, it was recommended to introduce the concept of “systemic inflammatory response syndrome” (SIRS) as a specific reaction of the body when the inflammatory reaction takes on a generalized, pathological character. Defined following criteria Diagnosis of SIRS - general symptoms of an inflammatory reaction:

temperature above 38 or below 36 degrees,

heart rate more than 90 beats,

breathing rate over 20 times per minute,

the number of leukocytes is more than 12 thousand or below 4 thousand, with an excess of immature forms of more than 10%.

SIRS is diagnosed if all four are present (S.A. Shlyapnikov, 1997), in the USA - two of the four listed (extensive interpretation of sepsis). But these same symptoms can occur with polytrauma (different history).

Signs of organ failure

Lungs - need for mechanical ventilation or oxygen insufflation to maintain PO2 above 60 mmHg. Art.

Liver - bilirubin level over 34 µmol or AST and ALT levels more than double.

Kidneys - an increase in creatinine over 0.18 mmol or oliguria less than 30 ml/hour for at least 30 minutes.

Cardiovascular system - decrease blood pressure below 90 mm. rt. Art, requiring the use of sympathomimetics.

Hemocoagulation system - a decrease in platelets below 100·109 or an increase in fibrinolysis over 18%.

Gastrointestinal tract - dynamic intestinal obstruction, refractory to drug therapy for more than 8 hours.

CNS - a somnolent or soporous state of consciousness, in the absence of traumatic brain injury or cerebrovascular accident.

In the early 90s, the so-called consensus classification of septic conditions was created (according to R. Bone):

1) bacteremia (positive blood culture);

2) systemic inflammatory response syndrome;

3) sepsis (SIRS + positive blood culture);

4) severe sepsis (sepsis + organ dysfunction);

5) septic shock (severe sepsis + arterial hypotension).

Surgical sepsis is considered diagnosed if there is SIRS syndrome and a documented infection in the blood. In practice, diagnosis surgical sepsis placed when: 1) there is a surgical lesion (purulent disease, previous surgery, trauma); 2) the presence of at least three of the symptoms of SIRS; 3) the presence of at least one organ disorder.

Sepsis is a generalized form of surgical infection that develops against the background of a systemic inflammatory response syndrome with proven circulation of the pathogen in the bloodstream.

How to treat “sepsis without a pathogen”? The adopted approach makes it possible to treat the patient early (by identifying SIRS) and in full, without waiting for confirmation of bacteremia, and this is its rationality.

Fundamentally important feature Abdominal sepsis is an endogenous infection of foci of aseptic inflammation of the abdominal cavity from the gastrointestinal tract. Translocation of flora from the intestine was first described by Durvandiering in 1881. It is one of the pathological effects of intestinal failure syndrome. "Motor" of multiple organ failure in abdominal sepsis. Damage to enterocytes, hyperperfusion. It can be treated with great difficulty. And it supports sepsis, metabolic distress syndrome, causing an energy crisis, destruction of its own amino acids, and the development of protein and amino acid balance disorders.

Microbiological diagnostics. Bacteremia is the basis for the diagnosis of sepsis. A feature of bacteremia earlier (V.F. Voino-Yasenetsky, 1934) and at the present stage is a high beat. weight of polymicrobial bacteremia (20%). Observed in diseases of the gastrointestinal tract, urogenital infections, massive lesions skin, in neurological patients with catheters and with reduced immunity. Mortality 60-70% (the process caused by monoinfection is much easier).

The role of coagulase-negative staphylococci (previously considered saprophytes) is increasing. The frequency of streptococcal bacteremia is decreasing, but enterococcal bacteremia is increasing. Gram-negatives remain a problem - E. coli is the leading one (22% in community-acquired infections). The second place of community-acquired infection is pneumococcus, then staphylococcus (16%). For nosocomial infections, CES group: Klebsiella, Enterobacter, Seratia and Proteus group. Candida sepsis is increasing.

Polymicrobial sepsis is often an association of gram-negative bacteria. Gram-negative anaerobes (bacteroides) are significant.

Currently, gram-negative bacteria are being replaced by coagulase-negative staphylococci, Staphylococcus aureus, but also enterococci and candida. Most often gram-positive cocci and gram-negative rods.

The problem of nosocomial infection has become more acute. Sources: purulent wounds (necessity of closed drainage), invasive diagnostic and medical procedures(ventilation, intubation, all kinds of catheters), intensive use antibiotics. The survival rate of staphylococci on linen and towels is up to 35-50 days, on walls - tens of days.

Infection rates are high in intensive care units. The risk of infectious complications in patients there is 5-10 times higher than in general surgical departments (S.Ya. Yakovlev, 1998). The most common and dangerous of them are pneumonia and intra-abdominal infections. According to a multicenter study conducted in 1417 intensive care units in 17 European countries (1992), various staphylococci (Staphylococcus aureus - 30%, Staphylococcus spp. - 19%) and Pseudomonas aeruginos (29%), as well as Escherichia coli are in first place (13%), Acinetobacter spp. (9%), Klebsiella spp. (8%), Enterobacter spp. (7%), Proteus spp. (6%). Of the gram-positive - Enterococcus spp. (12%) and Streptococcus spp. (7%).

Some dependences of bacteremia on the localization of the lesion were traced. It is known that with various heart valve defects we are often talking about streptococci, enterococci and staphylococci. The latter are also observed with foreign bodies in the body (therapeutic catheters, prostheses). Bones and soft tissues - staphylococci.

Purulent foci of the abdominal cavity often have mixed flora: gram-positive and gram-negative. With peritonitis - anaerobes, enterobacteria. Postoperative infection is often staphylococcus or mixed infection. During immunosuppression, Enterobacteriaceae and Pseudomonas are cultured.

Modern microbiological approaches to the diagnosis of sepsis: blood culture testing 4-8 times during the first 24-48 hours. The study is effective 2-3 hours before the peak of fever.

A more gentle approach is to test blood 2-3 times at intervals of 15-20 minutes. If samples are taken simultaneously into aerobic and anaerobic vials, the efficiency increases by 20%. It is better to collect blood from a central catheter, if available, especially if infection is suspected. It is necessary to culture the material from the wound. There is not always a parallel between the microflora from the wound and from the blood during sepsis. 50% compliance.

Main part bacteriological results can be received in 48-72 hours.

Microbiological monitoring 2 times a week, as the flora changes during treatment. Be aware of afibrile septicopyemia in the elderly.

Serological tests - determination of antigens (depending on reagents) - as a variant of microbiological diagnostics, are not more sensitive, but faster.

The newest method is molecular biological (DNA and RNA).

Clinic of septic shock: fever, tachycardia, at the beginning hyperventilation with respiratory alkalosis, rather high stroke volume of the heart with a decrease in peripheral vascular resistance. First of all, the lungs, kidneys, liver, and heart suffer. All these are objects of our therapy.

An early sign in diabetics is an increase in sugar. Leukocytosis (or leukopenia). Thrombocytopenia.

Treatment strategy for abdominal sepsis.

Elimination of the source of infection. If there is no timely sanitation of the abdominal abscess, multiple organ failure occurs.

Rational antibacterial therapy (antibiotics do not treat) implies identification of microflora and knowledge of sensitivity to antibiotics. Before the identification stage - empirical therapy.

The importance of adequate antimicrobial therapy. The modern rational way is to have empirical therapy schemes within one hospital, based on the results of microbiological monitoring of a given medical unit.

Taking blood and other fluids after starting antibiotic therapy is a grave mistake. Focus on polyflora with the participation of aerobes and anaerobes.

Routine set: third generation cephalosporins (ceftriaxone, cefotaxime, ceftazidime) with aminoglycosides (gentamicin, amikacin).

With gram-positive flora good effect from vancomycin and rifampicin.

The situation with third-generation cephalosporins is tense and they are losing ground. Dynamic monitoring of the level of resistance is important. The fourth generation of cephalosporins is better and the carbopinems are better, respectively. But they are not 100% empiricists. It is not advisable to use them without laboratory diagnostics.

Sensitivity to gentamicin is no more than 50%. There is a parallel identical reaction with tobramycin. It's a little better with amikacin. The combination of betalactams and aminoglycosides does not provide reliable benefits.

The appearance 10 years ago of carbopenems with extreme breadth was revolutionary. antimicrobial spectrum and low toxicity - a renaissance of the idea of monotherapy. Meronem, unlike tienam, does not have neuro- and nephrotoxic properties and is a first-line drug in special clinical situations and as a reserve drug in a multi-stage antimicrobial situation (B.R. Gelfand, 1999).

Questions before prescribing empirical antibiotic therapy:

1. Are there liver and kidney dysfunctions? If there is, the dose is chosen less.

2. Are there invasive catheters (a risk factor for infection)? In particular, the presence of Swanz-Ganz catheters significantly increases mortality. In this case, the dose must be increased.

3. Where did the patient get the infection and what is the source (on the street or in the hospital)?

4. Is the patient immunosuppressed?

5. Is there hypersensitivity?

6. If there is a central nervous system infection, should antibiotics be dissolved in the cerebrospinal fluid?

7. Where is the localization of the process (a prerequisite is sanitation of the outbreak)?

8. What is a hospital infection and what is its sensitivity in the clinic?

Conditions: rational choice of synergistic antibiotics, high dosage during the first 2 weeks, microbiological monitoring, the suspected pathogen must be taken into account depending on the location, strive for complete identification of the microbe.

Prescription of an antibiotic in a timely manner already at the time of abdominal surgery or before it as part of premedication. Especially when implantation of a foreign body is expected.

A complication of antibiotic therapy is the Jarisch-Herxheimer reaction. It manifests itself as symptoms of hectic fever against the background of a normalizing course of the disease due to the development of a new wave of endotoxicosis, up to shock. The reason is antibiotic-dependent mediatosis, an explosion of competitive opportunistic blood. Diagnosis by stopping antibiotics for 2-3 days.

Maintaining adequate oxygen transport (more than in a healthy person - 600 ml of oxygen per 1 square meter) is a key position.

Treatment of intestinal failure syndrome to interrupt the translocation of bacteria and their toxins: intraintestinal lavage, enterosorption (chitosan), selective decontamination of the gastrointestinal tract, restoration of motility. The use of pectin is promising.

Relief of organ failure, including immunotherapeutic drugs.

The use of antitoxins and antibodies (did not go beyond the scope of a clinical experiment).

Blockade of cytokinogenesis is still being developed and is very expensive. Introduction of antidotes for tumor-necrotic factor, platelet necrotizing factor, etc. Mediators are necessary protective factors (they are also released during heavy physical activity, in athletes, but do not exceed a certain limit and quickly return to normal). With peritonitis, a massive and uncontrolled release of mediators - mediatosis - leads to organ failure. Today, more than 200 different mediators are known that take part in the septic process, and it is not yet possible to neutralize them all.

Intensive treatment is based on monitoring the main processes (direct blood pressure, central venous pressure, urine during a catheter, Swan-Ganz catheter, electrolytes, blood gases). Elimination of anemia to a hemoglobin level of more than 10 grams. Elimination of acidosis and equalization of electrolyte status. Tendency to refuse the use of corticosteroids (their effectiveness has not been proven, but may be harmful). Intensive care is a very narrow path. Excessive fluid infusion leads to swelling. Vasopressors lead to organ ischemia. It is important to predict the course of further development of the disease.

ALGORITHMS AND OPTIMIZATION OF TREATMENT IN SURGERY

30 years ago I was lucky enough to take part in pioneering research on the use of mathematical technologies and computer technology in clinical medicine, conducted under the auspices of the then legendary Nikolai Mikhailovich Amosov. A powerful impetus for subsequent research was provided. Their results were dissertations in various sections of surgery, a large number of scientific publications, including priority monographs (“Clinical prognosis” (co-authored with O.P. Mintser), Kyiv, “Naukova Dumka”, 1983; “Fundamentals of decision optimization in surgery", Omsk, 1994). Many years of work in this area have allowed us to build a certain system. A powerful and efficient technology, aimed at maximum individualization of treatment for specific patients, and it seems appropriate to present it in a modern form.

Nowadays, the significance of this direction not only does not raise objections, but it is already considered integral to clinical medicine. No matter how perfect the diagnostic equipment base of medicine is, even with the prospect of further development, treatment and tactical decisions in this, perhaps, the most complex area of human knowledge can only be made at the level of intelligence. That is why efforts to organize it and increase efficiency in replicating it for mass medicine are very useful. Today, it is modern to focus scientific research, including dissertation research, on optimizing the tactics of choosing treatment for certain diseases and creating algorithms for making treatment and diagnostic decisions adapted to a specific pathology and socio-territorial environment.

The term "optimization" is drawn from the field of mathematics. It, like others (individualization, rational treatment), assumes the best choice of methods from the standpoint of certain criteria therapeutic effects for patients. The result of optimization should be the individuality of the application of certain strategies for a particular patient - a goal that runs like a red thread throughout the history of medicine.

The basis of the methodology under discussion is the use of: 1) mathematical assessments of factors, symptoms, symptom complexes, which ultimately determine the individuality of the patient and the disease as a specific set; 2) a list of tactical decisions that are, in principle, possible in relation to the disease in question and 3) one or more criteria against which treatment tactics are optimized. There aren't many of the latter. Most often this is the mortality rate, but there may also be a level of specific complications. The key to surgery, of course, is to preserve life. The criterion characterizing the quality of life is important. In recent years, the criterion of necessary costs has been increasingly used. It is important to determine all these parameters as much as possible at the preliminary stage of compiling the algorithm.

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INTRODUCTION

1. Postoperative complications. Their types

2. Clinic for normal postoperative period after abdominal surgery

3. Prevention of postoperative complications

4. General clinic of postoperative complications

5. Wound complications

6. Postoperative peritonitis

7. Postoperative intra-abdominal abscesses

8. Postoperative intestinal obstruction

9. Postoperative pancreatitis

10. Postoperative myocardial infarction

11. Postoperative deep vein thrombosis of the legs

12. Postoperative pneumonia

13. Postoperative mumps

CONCLUSION

LIST OF REFERENCES USED

INTRODUCTION

The problem of surgical treatment of early postoperative complications, such as peritonitis, early intestinal obstruction, intra-abdominal abscesses, acute pancreatitis, bleeding into the abdominal cavity and the lumen of the gastrointestinal tract, eventeration, complications from the laparotomy wound, is one of the central ones in abdominal surgery.

Identification of postoperative complications is ensured by careful clinical observation and examination of patients. The reports of doctors and nurses on duty at morning conferences are of great importance, at which the characteristics of the behavior and condition of patients during their duty are revealed. Careful observation of those on duty helps the attending physician to suspect certain violations and, during the subsequent examination of the patient, confirm or refute the suspicion.

The morning rounds of operated patients should begin with a detailed questioning of the staff on duty and a conversation with the patient about his well-being. When talking with a patient, it is necessary to familiarize yourself with the readings of his temperature, observe the depth and frequency of breathing, examine the frequency, filling and tension of the pulse, the condition of the tongue, the color of the mucous membranes, etc.

You should find out the presence and nature of pain, check the condition of the bandage, whether it is wet (with blood, bile, pus, etc.), the presence or absence of swelling, edema, redness in the areas surrounding the surgical suture, etc. After this, proceed to the examination the patient's organs, while maintaining strict consistency and thoroughness. When examining the gastrointestinal tract, in addition to previously obtained data on the condition of the tongue and stool, attention is paid to the condition of the abdomen (bloated, retracted, tense, soft, painful), what is the localization and intensity of the changes noticed. It is necessary to feel the liver and kidneys. When examining the lungs, percussion and auscultation are required not only from the front, from the sides, but also from the back, since when the patient is positioned on his back, this is where postoperative pneumonia begins. For such an examination, the patient must be seated in bed. In cases where the study does not provide an accurate answer about the presence of complications in the lungs, it is necessary to resort to chest X-ray. The cardiovascular system is examined not only to determine the function of the heart, pulse rate and filling, but also to identify the possible formation of thrombophlebitis in the peripheral veins.

If necessary, the examination must be supplemented with X-ray, cardiological, laboratory and special types of research, some of which are done for all patients (for example, general analysis blood, urine), some usually for special indications (examination of urine for diastase, feces for stercobilin, blood for prothrombin, etc.).

The data obtained enable the doctor to clarify the diagnosis of a particular postoperative complication and begin its treatment in a timely manner.

1. POSTOPERATIVE COMPLICATIONS. THEIR TYPES

Postoperative complications are a new pathological condition that is not typical for the normal course of the postoperative period and is not a consequence of the progression of the underlying disease. It is important to distinguish complications from surgical reactions, which are a natural reaction of the patient’s body to illness 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.

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.

Complications from the nervous system.

The main complications after surgery from the nervous system are pain, shock, sleep and mental disorders.

Pain of varying intensity is observed in all patients after surgery. The strength and duration of pain directly depends on the extent, traumatic nature of the operation and the excitability of the patient’s nervous system.

Mental trauma and pain can lead to metabolic disorders and tissue regeneration processes. Painful sensations reflexively lead to disruption of the cardiovascular system, breathing, intestinal paresis, urinary retention, etc. I.P. Razenkov proved the presence of disorders of blood chemistry as a result of pain.

To carry out prevention and control of pain, it is important to know that the reaction to painful stimuli of the same strength in the same patient can be different depending on the degree of fatigue, excitability of the nervous system, exhaustion, mental preparedness to endure pain, the attention of others, etc.

Prevention of postoperative pain is primarily determined by good contact between the surgeon and the patient in the preoperative period, a decrease in the excitability of the patient’s nervous system, as well as compliance with the rules of surgical deontology.

Usually used for medicinal purposes subcutaneous injections 1 ml of 1% morphine solution or 2% pantopon solution 2-3 times on the first day after surgery. In case of significant pain, on the 2nd day, inject drugs 1-2 times, on the 3rd day - only at night. The administration of drugs can be continued for several more days if the patient continues to have severe pain, but one should always keep in mind the possibility of addiction to them and the development of morphinism - serious illness, which is difficult to fight. In addition, morphine, which inhibits the activity respiratory center, can lead to congestion in the lungs, it lowers metabolism and reduces diuresis. Fluoroscopy performed in these patients on the 12-14th day after surgery with liquid barium indicates a complete or almost complete absence of evacuation from the stomach. During the 3rd week after surgery, rapid exhaustion of the patient and scarring in the area of the inflammatory infiltrate of the anastomosis continues.

Sleep disturbance is severe complication postoperative period, which may be associated with pain, intoxication, excessive stimulation of the neuropsychic sphere, and worries. The struggle for good sleep in an operated patient is an important task for the surgeon, since insomnia leads to disruption of the wound healing and recovery process.

Postoperative mental disorders to a pronounced degree are rarely observed, however, surgical patients always have a reaction from the psyche, reactions, the degree and nature of which are different.

An operation, as a trauma to the nervous system, the patient’s psyche, depending on his general condition, the extent of the intervention and compensatory capabilities, reserves of the central nervous system, can lead to easily compensated changes or turn out to be a very strong irritant and cause severe violations psyche.

Postoperative psychoses often develop in weakened, exhausted, and intoxicated patients. This group usually includes all types of mental disorders that occur after surgery: exacerbation of previously former mental illnesses, reactive states, reactive intoxication psychoses, etc.

Postoperative psychoses not only disrupt the normal course of the postoperative period, but also create a direct threat to the patient’s life and disrupt the healing process. They are often accompanied by refusal to eat, sudden agitation with physical stress, which creates a number of additional dangers in the postoperative period.

Prevention of postoperative psychoses consists of normal preoperative preparation, which reduces intoxication and exhaustion of the patient and improves the function of all organs and systems, including the patient’s nervous system.

A significant factor influencing the psyche of the patient undergoing surgery is the external environment of the surgical department. You should give up the “fear” of hanging pictures, curtains, upholstered furniture, etc., which creates convenience and coziness (P. I. Dyakonov, V. R. Khesin). Treatment of postoperative psychoses is carried out by psychiatrists, who sometimes keep these patients in special conditions and observe them together with the surgeon. In view of this, where possible, it is necessary to strive to make wider use of Pantopon, Medial, Veronal, Pyramidon, bromine preparations, etc., to combat pain.

Anastomotic obstruction often develops in patients with severe perivisceritis after traumatic mobilization of the stomach and duodenum with penetrating ulcers. With stomach cancer, this complication is much less common.

Treatment of this complication in the first days of its development, when the nature of the anastomotic obstruction is not yet clear, should be carried out in two directions, namely in the direction of restoring gastric tone and fighting infection.

To restore the tone of the gastric wall, it is necessary to ensure periodic or constant suction of its contents with a probe, active behavior of the patient, and subcutaneous administration of strychnine. Important role The correct diet plays a role in restoring gastric tone, which should be individual for each patient and depend on the nature of the operation performed, the degree of obstruction of the anastomosis and the time that has passed since the operation. It is of great importance to raise the tone of the whole organism by maintaining saline solution, 5% glucose, blood transfusion, etc.

To fight the infection, the patient is prescribed antibiotics (penicillin, streptomycin, biomycin, etc.), which help resolve the inflammatory infiltrate.

In some of these patients, conservative treatment is unsuccessful and it is necessary to resort to relaparotomy. Repeated intervention should be carried out as soon as possible, as soon as it becomes clear organic nature obstruction. Considering the exhaustion and weakness of the patients, they must be prepared for it with glucose infusions, blood transfusions, administration of cardiac drugs, etc. It is safer to perform the operation under local anesthesia. Typically, the operation consists of applying an additional anterior gastrointestinal anastomosis with the interintestinal anastomosis, since the presence of infiltrate and perivisceritis of the anastomosis area in a severely weakened patient does not allow for more radical intervention.

Gastric atony or efferent loop spasm small intestine also lead to the clinical picture of anastomotic obstruction, but usually its phenomena are not so constant, the patient does not become dehydrated and exhausted so quickly, and improvement is noted from subcutaneous administration of atropine and strychnine. The fight against this complication consists of constant or periodic emptying and lavage of the stomach through a tube, by subcutaneous administration of atropine, strychnine, blood transfusions, etc.

Belching indicates fermentation of the stomach contents, overfilling or compression of the stomach by surrounding organs. Sometimes belching is observed during an inflammatory process in the upper abdomen, with paresis and distension of the stomach.

Hiccups - convulsive, periodically repeated contractions of the diaphragm - are very debilitating for the patient. Hiccups are caused by irritation of the phrenic or vagus nerve.

The location of the source of irritation may vary. Thus, hiccups are often observed with tumors of the mediastinum or lung.

postoperative complication clinic treatment

2. CLINIC OF THE NORMAL POSTOPERATIVE PERIOD AFTER ABDOMINAL OPERATIONS

Includes operational 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. Motor activity is expanding. 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 operational 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 parameters are either within normal limits, or in the case of their initial violations with a tendency to normalize. 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.

3. PREVENTION OF POSTOPERATIVE COMPLICATIONS

There are no strict criteria for the tolerability of surgery in borderline conditions. 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 over - 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 those dormant 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;

8) 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 for 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).

4. GENERAL CLINIC FOR POSTOPERATIVE COMPLICATIONS

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.

A sign of collapse is extremely alarming - it can be a sign of internal bleeding, incompetent sutures, acute dilatation of the stomach, as well as myocardial infarction, anaphylactic shock, pulmonary embolism.

Methodology of action in case of suspected postoperative complication:

· assessment of the level of intoxication syndrome (pulse, dry mouth, laboratory parameters) over time (taking into account the ongoing detoxification);

· extended dressing of the surgical wound with probing (in conditions of sufficient anesthesia);

· directed and exploratory instrumental research (ultrasound, X-ray diagnostics, NMR).

5. WOUND COMPLICATIONS

Any wound heals according to 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, consisting in 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, which turns into scar tissue. 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.

External and internal bleeding for 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, heat, rest, physiotherapy, x-ray therapy (rarely).

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.

Pus is yellow or white, odorless - 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.

6. POSTOPERATIVE PERITONITIS

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.

By genesis (V.V. Zhebrovsky, K.D. Toskin, 1990):

1. 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 with an incorrect assessment of viability, undetected intraoperative damage);

2. 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):

1. Lightning fast

3. Sluggish

By prevalence:

1. Local

By type of microflora:

1. Mixed

2. Colibacillary

3. Anaerobic

4. Diplococcal

5. Pseudomonas aeruginosa

By type of exudate:

1. Serous-fibrinous

2. Serous-hemorrhagic

3. Fibrinous-purulent

4. Purulent

5. Gall

6. Feces

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 abdomen, good motor 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 clinical picture is recurrent intestinal paresis and the progressive development of systemic inflammatory response syndrome, 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 this patient and the existing one;

· progression or persistence of intoxication syndrome during intensive detoxification.

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 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 repeated intervention can also be performed endovideoscopically or from a mini-access (the professionalism of the operator is very important, which, however, is also essential in classical repeated operations).

7. 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.

X-ray examination in a vertical position is informative (gas bubble above the liquid level, immobility of the diaphragm dome, concomitant pleurisy).

Treatment. With right-sided localization, high subdiaphragmatic 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.

8. 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 in case of violation of the integrity of the serous cover (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 drainages (compression from the outside, 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 p/o 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.

9. POSTOPERATIVE PANCREATITIS

Develops after operations on the bile ducts and pancreas, stomach, after splenectomy, papillotomy, removal of the large intestine, when there is direct or functional contact with the pancreas.

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.

10. POSTOPERATIVE MYOCARDIAL INFARCTION

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.

11. POSTOPERATIVE DEEP VEIN THROMBOSIS OF THE LEG

Important: prevention in broad and narrow terms; identification of risk groups; daily palpation of the calf muscles as a standard for postoperative monitoring.

12. POSTOPERATIVE PNEUMONIA

The most severe of bronchopulmonary complications.

Causes: aspiration, microembolism, congestion, toxicoseptic condition, heart attack, prolonged stay of gastric and intestinal tubes, prolonged mechanical ventilation. It is predominantly small-focal in nature and localized in the 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 flow options (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):

1. age over 65 years;

2. Mechanical ventilation for more than 2 days;

3. severity of the underlying disease (head injury, coma, stroke);

4. severe concomitant diseases (diabetes mellitus, chronic obstructive pulmonary diseases, alcoholism and cirrhosis of the liver, malignant tumors);

5. bacteremia;

6. polymicrobial or problematic (P. Aeruginosa, Acinnetobacter spp., fungi) infection;

7. previous ineffective antibacterial therapy.

In the complex of treatment, antibacterial treatment is important, taking into account the characteristics of nosocomial infection of the medical institution and operational monitoring of bronchial patency (bronchoscopy).

13. POSTOPERATIVE MUMPS

Acute inflammation of the parotid salivary gland. More often in elderly and senile patients, with diabetes mellitus. Contributes to carious teeth, decreased function of the salivary glands due to dehydration, lack of chewing, and 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 foods.

Treatment: Local (compresses, dry heat, rinsing) and general (antibacterial therapy, detoxification). When 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).

CONCLUSION

Monographs, congresses, conferences, and plenums are devoted to issues of etiology, pathogenesis, diagnosis, clinical picture, prevention and treatment of postoperative infectious complications. The development in recent years of clinical microbiology, clinical immunology, biochemistry and other fundamental disciplines makes it possible to evaluate the etiopathogenetic aspects of the occurrence, development and course of infection from a new perspective.

Development and implementation modern methods antimicrobial, detoxification therapy, immunotherapy, enzyme therapy, physiotherapy, creation of new medicines and antiseptics, improving treatment technologies and prevention regimens will significantly reduce the incidence and reduce adverse consequences postoperative infectious complications.

List of used literature

1. Zhebrovsky V.V., Toskin K.D. The problem of postoperative complications in abdominal surgery // Postoperative complications and dangers in abdominal surgery. M.: Medicine, 1990; 5-181.

2. Savchuk T.D. Purulent peritonitis. M.: Medicine, 1979; 188 p.

3. Milonov O.T., Toskin K.D., Zhebrovsky V.V. Postoperative complications and dangers in abdominal surgery. M.: Medicine, 1990; 560.

4. Toskin K.D., Zhebrovsky V.V., Bereznitsky F.G. Postoperative intraperitoneal and extraperitoneal abscesses // Postoperative complications and dangers in abdominal surgery. M.: Medicine, 1990; 84-133.

5. Vilenskaya I.F., Sheprinsky P.E., Osipova A.N. and others. Features of postoperative complications in a surgical hospital // Proc. report II Russian. scientific-practical conf. with intl. participation. M., 1999; 51-2

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Complications during the resuscitation period and early postoperative period

Cardiac arrest, ventricular fibrillation
Acute respiratory failure (asphyxia, atelectasis, pneumothorax)
Bleeding (from a wound, into a cavity, into the lumen of an organ)

Late complications:

Wound suppuration, sepsis function
Disruption of anastomoses
Adhesive obstruction
Chronic renal-liver failure
Chronic heart failure
Lung abscess, pleural epiema
Fistulas of hollow organs
Thrombosis and vascular embolism
Pneumonia
Intestinal paresis
Heart failure, arrhythmias
Failure of sutures, wound suppuration, eventeration
Acute renal failure

Hemodynamic disorders

After severe traumatic operations, acute cardiovascular failure, hypertensive crisis. The state of the cardiovascular system can be judged by pulse rate and blood pressure level.

Acute cardiovascular failure

Acute cardiovascular failure develops after severe long-term interventions, when by the end of the operation blood loss has not been compensated or hypoxia has not been eliminated. Such patients experience tachycardia, low arterial and venous pressure, pale and cold skin, slow awakening from anesthesia, lethargy or agitation. In case of hypovolemia, blood loss is compensated by transfusion of hemodynamic drugs, blood, and administration of prednisolone and strophanthin.

Pulmonary edema

Acute heart failure is manifested by anxiety and shortness of breath. Cyanosis of the mucous membranes and extremities increases rapidly. Moist rales are heard in the lungs, tachycardia is noted, blood pressure may remain normal. Sometimes pulmonary edema with right ventricular failure occurs at lightning speed. More often, pulmonary edema develops gradually.

Treatment. Tourniquets are applied to the upper and lower extremities to reduce blood flow to the heart. Inhalation is performed with alcohol mixed with oxygen. To do this, alcohol is poured into the evaporator and oxygen is passed through it, which the patient breathes through a mask. Strophanthin and furosemide are administered intravenously. The pressure in the pulmonary artery is reduced with arfonade or pentamine - from 0.4 to 2 ml of a 5% solution is administered carefully under the control of blood pressure levels. In severe cases, tracheostomy, sputum suction and mechanical ventilation are necessary.

Hypertensive crisis, myocardial infarction

In persons with hypertension in the postoperative period, a crisis with a sharp rise in blood pressure may develop. In such cases, the amount of transfused fluid and saline solutions is limited, and drugs that lower blood pressure are administered.

Patients suffering from angina pectoris are prescribed nitroglycerin - 2-3 drops of a 1% solution under the tongue, Zelenin drops, mustard plasters on the heart area, nitrous oxide with oxygen (1:1) and for persistent pain, 1 ml of a 2% solution of promedol.

Myocardial infarction after major operations can occur atypically, without a pain component, but with motor agitation, hallucinations, and tachycardia. The diagnosis is confirmed by ECG data. Treatment measures for myocardial infarction include: