Indications for surgical treatment. Main contraindications to anesthesia Medical contraindications to planned surgical treatment

MILITARY-MEDICAL ACADEMY

Department of Military Traumatology and Orthopedics

"APPROVE"

Head of Department

Military traumatology and orthopedics

Professor Major General of the Medical Service

V. SHAPOVALOV

"___" ____________ 2003

Senior Lecturer, Department of Military Traumatology and Orthopedics
Candidate of Medical Sciences
colonel of medical service N. LESKOV

LECTURE #

in military traumatology and orthopedics

On the topic: "Plasty of bone cavities and tissue defects

With osteomyelitis"

for clinical residents, students of I and VI faculties

Discussed and approved at the meeting of the department

"_____" ____________ 2003

Protocol No._____

LITERATURE

a) Used in preparing the text of the lecture:

1. Akzhigitov G.N., Galeev M.A. etc. Osteomyelitis. M, 1986.

2. Ariev T.Ya., Nikitin G.D. Muscular plasty of bone cavities. M, 1955.

3. Bryusov P.G., Shapovalov V.M., Artemiev A.A., Dulaev A.K., Gololobov V.G. Combat injuries to limbs. M, 1996, p. 89-100.

4. Vovchenko V.I. Treatment of the wounded with gunshot fractures of the femur and tibia, complicated by defects. Dis. cand. honey. Sciences, St.Petersburg, 1995, 246 p.

5. Gaidukov V.M. Modern methods of treatment of false joints. Abstract doc. dis. L, 1988, 30 p.

6. Grinev M.V. Osteomyelitis. L., 1977, 152 p.

7. Diagnosis and treatment of wounds. Ed. SOUTH. Shaposhnikova, M., 1984.

8. Kaplan A.V., Makhson N.E., Melnikova V.M. Purulent traumatology of bones and joints, M., 1985.

9. Kurbangaleev S.M. Purulent infection in surgery. M.: Medicine. M., 1985.

10. Treatment of open bone fractures and their consequences. Mater. conf. dedicated to the 100th birthday of N.N. Pirogov. M., 1985.

11. Melnikova V.M. Chemotherapy of wound infection in traumatology and orthopedics. M., 1975.

12. Moussa M. Plasty of osteomyelitic cavities with some biological and synthetic materials. Dis. cand. honey. Sciences. L, 1977.

13. Nikitin G.D. Chronic osteomyelitis. L., 1982.

14. Nikitin G.D., Rak A.V., Linnik S.A. and other Surgical treatment of osteomyelitis. St. Petersburg, 2000.

15. Nikitin G.D., Rak A.V., Linnik S.A. Bone and muscle-bone plastics in the treatment of chronic osteomyelitis and purulent false joints. St. Petersburg, 2002.

16. Popkirov S. Purulent-septic surgery. Sofia, 1977.

17. Experience of Soviet medicine in the Great Patriotic War 1941-1954. M., 1951, vol. 2, pp. 276-488.

18. Wounds and wound infection. Ed. M.I. Kuzina and B.M. Kostyuchenko. M.. 1990.

19. Struchkov V.I., Gostishchev V.K., Struchkov Yu.V. Guide to purulent surgery. M.: Medicine, 1984.

20. Tkachenko S.S. Military traumatology and orthopedics. Textbook. M., 1977.

21. Tkachenko S.S. Transosseous osteosynthesis. Uch. allowance. Leningrad: VmedA im. S.M. Kirova, 1983.

22. Chronic osteomyelitis. Sat. scientific works of Len. sanitary and hygienic honey. institute. Ed. prof. G.D. Nikitina. L., 1982, v. 143.

2, 3, 4, 6, 13, 14, 15, 20.

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Introduction

The problem of osteomyelitis at the present time cannot be considered finally solved. The reasons for this are largely determined by the special properties of bone tissue - its rigidity, a tendency to necrosis when exposed, circulatory disorders and infection (formation of bone sequesters), cellular structure (formation of closed purulent foci, which in themselves are a source of infection), a state of unstable balance in the "macroorganism-microbes" system, changes in the body's immunoreactivity.

The long course (for years and tens of years) of all forms of chronic osteomyelitis, the occurrence of exacerbations after periods of calm, severe complications (amyloidosis, nephrolithiasis, allergization of the body, deformities, contractures and ankylosis of the joints in the vicious position of the limb) - all this gave rise to a near In the past, osteomyelitis was considered an incurable disease. The development of the pathology and treatment system for acute and chronic osteomyelitis by domestic authors made it possible to refute this statement. The successful use of antibiotics in the post-war period, the introduction of radical plastic surgery into practice made it possible to obtain a stable recovery in 80-90% of operated patients.

At present, due to the evolution of purulent infection and the change in the resistance of the human body to it, there is an increase in the number of unsuccessful outcomes of osteomyelitis treatment, an increase in the number of late relapses of the disease, and a manifestation of infection generalization. Osteomyelitis, like other purulent diseases and complications, is becoming a social and sanitary problem.

Open fractures and their adverse consequences over the past decades have attracted increasing attention of surgeons, traumatologists, immunologists, microbiologists and doctors of other specialties. This is primarily due to the aggravation of the nature of injuries due to an increase in the number of multiple and combined injuries, as well as a high percentage of suppurative processes in patients with open bone fractures. Despite the significant progress in medicine, the frequency of suppuration in open fractures reaches 45%, and osteomyelitis - from 12 to 33% (Goryachev A.N., 1985).

A significant increase in operational activity in the treatment of injuries, their consequences and orthopedic diseases, the expansion of indications for internal osteosynthesis, an increase in the proportion of elderly patients among those operated on, the presence of immunodeficiency of various genesis in patients, lead to an increase in the number of suppurations and osteomyelitis.

This lecture will discuss the issues of surgical treatment of osteomyelitis, depending on the phase of the wound process and the size of the secondary bone defect formed as a result of surgical treatment: direct and cross muscle, free and non-free bone grafting.

Many domestic and foreign scientists dealt with the issues of diagnosis and treatment of purulent osteomyelitis. Of particular importance were the works of the Finnish surgeon M. Schulten, who in 1897 was the first to use muscle plasty for the treatment of bone cavities in chronic purulent osteomyelitis, and the Bulgarian surgeon S. Popkirov, who in 1958 showed the effectiveness of surgical treatment of bone cavities in osteomyelitis using bone autoplasty.

The principles of osteomyelitis treatment were developed as early as 1925 by T.P. Krasnobaev. They include: impact on the body in order to reduce intoxication, normalize homeostasis; drug effect on pathogens; surgical treatment of the focus of the disease.

Surgical treatment of osteomyelitis is of decisive importance, all methods of general and local effects on the body aimed at optimizing the wound process are only of additional importance, all of them are not effective enough without rational surgical tactics.

With an exacerbation of the osteomyelitic process, opening and drainage of the purulent focus is shown, necr - sequestrectomy. Reconstructive and plastic surgeries are performed after the subsidence of acute inflammation. During surgery, a radical sequestrectomy is performed, resulting in the formation of a secondary bone cavity or bone defect throughout.

Elimination of the defect and stabilization of the bone are necessary conditions for the treatment of osteomyelitis.

Operative methods of treatment for a bone defect in chronic osteomyelitis can be divided into two main groups: conservative and radical in relation to the formed secondary cavity.

Conservative methods include isolated local antibiotic treatment for all forms of osteomyelitis, the use of trepanation and bone treatment (flattening of foci, the use of fillings, most of which have only historical significance).

With a small cavity (up to 3 cm), it can be treated under a blood clot (Schede method), large cavities require replacement. For this, in some cases, seals are used.

Fillings in medicine mean organic and inorganic substances introduced into cavities with solid walls to cure caries and chronic osteomyelitis. A distinctive feature of all types of fillings is the absence of its biological connections with the body, primarily vascular and nervous. That is why it is wrong to call plastic surgery for chronic osteomyelitis "biological filling".

There are three types of seals: designed for rejection or removal in the future; designed for resorption and biopolymer materials.

There are over 50 types of fillings. The most serious studies on the use of fillings were conducted by M. Moussa (1977), who used biopolymer compositions containing antibiotics in the treatment of chronic osteomyelitis. Currently, the drug "Kollapan" is used to replace bone cavities.

Regardless of the material, all fillings, all compositions are allogeneic biological tissues, which, when introduced into the bone cavity, become foreign bodies. This violates the basic principles of surgical treatment of wounds - the removal, and not the introduction of foreign bodies into it (Grinev M.V., 1977). Therefore, the percentage of positive treatment results in general for various authors who used fillings does not exceed 70-75%.

Modern research indicates the fundamental unacceptability of most types of fillings when used in surgical practice.

The most acceptable at present is the replacement of the cavity with a blood-supplying muscle or bone tissue.

An initially existing bone defect, which is widened by necrosequestrectomy and radical cleaning, remains a major treatment problem. It cannot be performed on its own, it exists for many months and years, turning into a bed of a chronic purulent process that supports fistulas and additionally damages and destroys bone tissue. Such a wound is not capable of self-healing (Ivanov V.A., 1963). The task becomes even more difficult when a bone defect causes instability or when its continuity is broken.

Indications and contraindications for surgical treatment

The existence of a fistula supported by the bone cavity is overwhelmingly an absolute indication for surgical treatment. Surgery is also required for non-fistulous forms of osteomyelitis, including Brodie's abscess, which is usually almost asymptomatic, and more superficial soft tissue and bone defects called osteomyelitis ulcers. In most cases, it is very difficult to establish what is the main reason preventing the healing of an ulcer or fistula - sequesters, granulations, scars, foreign bodies or a cavity, therefore, the most correct and mandatory is the removal of all pathological tissues that form a purulent focus in the form of a cavity or surface defect fabrics. Patients who underwent repeated surgical interventions did not receive treatment only because the final stage of the operation was not carried out - the elimination of the resulting secondary cavity or bone defect. In 46.7% of cases, the cavity itself is the main cause of a non-healing fistula or ulcer, in 2% of cases, on its own or after surgery on the focus of osteomyelitis, the fistula is supported by rejected bone sequesters (Nikitin G.D. et al., 2000).

Thus, the indications for surgical treatment of osteomyelitis are:

1. The presence of non-healing fistulas or ulcers that correspond to the x-ray picture of osteomyelitis;

2. A form of osteomyelitis occurring with periodic exacerbations;

3. Fistulous forms of osteomyelitis, confirmed by X-ray;

4. Rare forms of chronic osteomyelitis, complicating tuberculosis, syphilis, tumors of the skeletal system.

Contraindications to surgical treatment are identical to those before any other operation. The most serious obstacle to plastic surgery is acute inflammation in or near the focus of osteomyelitis. In these cases, opening and drainage of the abscess, expansion of the fistulous tract, sometimes trepanation of the bone, removal of sequesters and antibiotic therapy should be applied beforehand. Temporary contraindications may occur with extensive bone lesions in relatively recent cases of hematogenous osteomyelitis, where topical diagnosis of osteomyelitis is difficult, since the boundaries of the lesion have not been determined, or a pathological fracture is possible due to weakening of the bone. In these cases, it is advisable to postpone the operation for 2-3 months, so that during this period the acute inflammatory process subsides, the bone becomes stronger and the focus is delimited.

Contraindications to surgery may also arise in cases where there are technical difficulties for its implementation: a significant size of the bone cavity with a corresponding lack of soft tissues in the affected area and the inability to obtain them on the other limb. This makes it necessary to resort to transplantation of free musculocutaneous flaps using microvascular technology.

Assess the state of the main organs and systems of the patient's body (identify concomitant diseases).

Psychologically prepare the patient.

Carry out general physical training.

Perform specific training as directed.

Directly prepare the patient for surgery.

The first two tasks are solved during the diagnostic stage. The third, fourth and fifth tasks are the components of the preparatory stage. Such a division is conditional, since preparatory measures are often carried out against the background of performing diagnostic techniques.

Direct preparation is carried out before the operation itself.

The tasks of the diagnostic stage are to establish an accurate diagnosis of the underlying disease and assess the condition of the main organs and systems of the patient's body.

Making an accurate surgical diagnosis is the key to a successful outcome of surgical treatment. It is precisely an accurate diagnosis with an indication of the stage, prevalence of the process and its features that makes it possible to choose the optimal type and volume of surgical intervention. There can be no trifles here, every feature of the course of the disease must be taken into account. In surgery of the 21st century, almost all diagnostic issues must be resolved before the start of the operation, and during the intervention, only previously known facts are confirmed. Thus, even before the start of the operation, the surgeon knows what difficulties he may encounter during the intervention, clearly imagines the type and features of the upcoming operation. Stetsyuk V.G. A manual on surgical manipulations.-- M .: Medicine, 1996

Many examples can be cited to demonstrate the importance of a thorough preoperative examination. Here is just one of them.

Example. The patient was diagnosed with peptic ulcer, ulcer of the duodenal bulb. Conservative therapy for a long time does not give a positive effect, surgical treatment is indicated. But such a diagnosis is not enough for the operation. There are two main types of surgical interventions in the treatment of peptic ulcer: gastric resection and vagotomy. In addition, there are several varieties of gastric resection (according to Billroth-I, according to Billroth-II, in the modification of the Hofmeister-Finsterer, Roux, etc.) and vagotomy (stem, selective, proximal selective, with various types of draining the stomach operations and without them). What intervention to choose for this patient? It depends on many additional factors, they must be identified during the examination. You should know the nature of gastric secretion (basal and stimulated, nocturnal secretion), the exact localization of the ulcer (anterior or posterior wall), the presence or absence of deformation and narrowing of the gastric outlet, the functional state of the stomach and duodenum (are there any signs of duodenostasis), etc. If not to take into account these factors and unreasonably perform a certain intervention, the effectiveness of treatment will significantly decrease. So, the patient may develop a recurrence of an ulcer, dumping syndrome, afferent loop syndrome, gastric atony and other complications, sometimes leading the patient to disability and subsequently requiring complex reconstructive surgical interventions. Only by weighing all the identified features of the disease, you can choose the right method of surgical treatment.

First of all, accurate diagnosis is necessary in order to resolve the issue of the urgency of the operation and the degree of need for the surgical method of treatment (indications for surgery).

After the diagnosis is made, the surgeon must decide whether an emergency operation is indicated for the patient. If such indications are identified, you should immediately proceed to the preparatory stage, which, in case of emergency operations, takes from several minutes to 1-2 hours.

The main indications for emergency surgery are asphyxia, bleeding of any etiology, and acute inflammatory diseases.

The doctor must remember that the delay of the operation every minute worsens its result. With continued bleeding, for example, the sooner intervention is started and blood loss stopped, the greater the chance of saving the patient's life.

At the same time, in some cases, short-term preoperative preparation is necessary. Its nature is aimed at stabilizing the functions of the main body systems, especially the cardiovascular system, such training is carried out individually. For example, in the presence of a purulent process complicated by sepsis with severe intoxication and arterial hypotension, it is advisable to carry out infusion and special therapy for 1-2 hours, and only then perform the operation.

In cases where, in accordance with the nature of the disease, there is no need for an emergency operation, an appropriate entry is made in the medical history. Then the indications for planned surgical treatment should be determined.

Indications for surgery are divided into absolute and relative.

Absolute indications for surgery are diseases and conditions that pose a threat to the life of the patient, which can only be eliminated surgically.

Absolute indications for performing emergency operations are otherwise called "vital". This group of indications includes asphyxia, bleeding of any etiology, acute diseases of the abdominal organs (acute appendicitis, acute cholecystitis, acute pancreatitis, perforated gastric and duodenal ulcer, acute intestinal obstruction, strangulated hernia), acute purulent surgical diseases (abscess, phlegmon , osteomyelitis, mastitis, etc.).

In elective surgery, indications for surgery can also be absolute. In this case, urgent operations are usually performed, not postponing them for more than 1-2 weeks.

The following diseases are considered absolute indications for a planned operation:

* malignant neoplasms (cancer of the lung, stomach, breast, thyroid, colon, etc.);

* stenosis of the esophagus, the output of the stomach;

* obstructive jaundice, etc.

Relative indications for surgery include two groups of diseases:

Diseases that can be cured only by surgery, but do not directly threaten the life of the patient (varicose saphenous veins of the lower extremities, uninjured hernia of the abdomen, benign tumors, cholelithiasis, etc.).

Diseases that are quite serious, the treatment of which can in principle be carried out both surgically and conservatively (ischemic heart disease, obliterating diseases of the vessels of the lower extremities, peptic ulcer of the stomach and duodenum, etc.). In this case, the choice is made on the basis of additional data, taking into account the possible effectiveness of a surgical or conservative method in a particular patient. According to relative indications, operations are performed in a planned manner under optimal conditions.

Treating the patient, not the disease, is one of the most important principles of medicine. It was most accurately stated by M.Ya. Mudrov: “One should not treat a disease by its name alone, but should treat the patient himself: his composition, his body, his strength.” Therefore, before the operation, it is in no way possible to limit oneself to the study of only a damaged system or a diseased organ. It is important to know the state of the main vital systems. In this case, the actions of the doctor can be divided into four stages:

Preliminary estimate;

Standard minimum examination;

Additional examination;

Definition of contraindications to surgery.

Preliminary estimate

A preliminary assessment is carried out by the attending physician and an anesthesiologist based on complaints, a survey of organs and systems, and data from a physical examination of the patient. At the same time, in addition to the classical methods of examination (inspection, palpation, percussion, auscultation, determination of the boundaries of organs), you can use the simplest tests for the compensatory capabilities of the body, for example, the Stange and Genche tests (the duration of the maximum breath holding on inhalation and exhalation). When compensating the functions of the cardiovascular and respiratory systems, this duration should be at least 35 and 20 s, respectively.

After a preliminary assessment before any operation, regardless of concomitant diseases (even if they are absent), it is necessary to conduct a minimum set of preoperative examinations:

Clinical blood test;

Biochemical blood test (total protein, bilirubin, transaminase activity, creatinine, sugar concentration);

Blood clotting time;

Blood type and Rh factor;

General urine analysis;

Fluorography of the chest (no more than 1 year old);

Conclusion of the dentist on the sanitation of the oral cavity;

Therapist's examination;

For women - examination by a gynecologist.

Upon receipt of results that fit within the limits of the norm, the operation is possible. If any deviations are detected, it is necessary to find out their cause and then decide on the possibility of performing the intervention and the degree of its danger to the patient.

An additional examination is carried out if a patient has comorbidities or if the results of laboratory tests deviate from the norm. An additional examination is carried out to establish a complete diagnosis of concomitant diseases, as well as to control the effect of the ongoing preoperative preparation. In this case, methods of varying degrees of complexity can be used.

As a result of the conducted studies, comorbidities can be identified that can, to one degree or another, become contraindications to the operation.

There is a classic division of contraindications into absolute and relative.

Absolute contraindications include a state of shock (except for hemorrhagic shock with continued bleeding), as well as an acute stage of myocardial infarction or cerebrovascular accident (stroke). It should be noted that at present, if there are vital indications, it is possible to perform operations against the background of myocardial infarction or stroke, as well as in case of shock after stabilization of hemodynamics. Therefore, the allocation of absolute contraindications is currently not fundamentally decisive. Nurse's Handbook for Nursing / ed. N.R. Paleeva, - M., Alliance - V, 1999

Relative contraindications include any concomitant disease. However, their impact on the tolerability of the operation is different. The greatest danger is the presence of the following diseases and conditions:

Cardiovascular system: hypertension, coronary heart disease, heart failure, arrhythmias, varicose veins, thrombosis.

Respiratory system: smoking, bronchial asthma, chronic bronchitis, pulmonary emphysema, respiratory failure.

Kidneys: chronic pyelonephritis and glomerulonephritis, chronic renal failure, especially with a pronounced decrease in glomerular filtration.

Liver: acute and chronic hepatitis, cirrhosis of the liver, liver failure.

Blood system: anemia, leukemia, changes in the coagulation system.

Obesity.

Diabetes.

The presence of contraindications to surgery does not mean that the surgical method cannot be used. It all depends on the ratio of indications and contraindications. When identifying vital and absolute indications, the operation should be performed almost always, with certain precautions. In those situations where there are relative indications and relative contraindications, the issue is resolved on an individual basis. Recently, the development of surgery, anesthesiology and resuscitation has led to the fact that the surgical method is used more and more often, including in the presence of a whole "bouquet" of concomitant diseases.

There are three main types of preoperative preparation:

Psychological;

General somatic;

Special.

The operation is the most important event in the life of the patient. It is not easy to take such a step. Any person is afraid of surgery, as they are more or less aware of the possibility of adverse outcomes. In this regard, the psychological mood of the patient before the operation plays an important role. The attending physician should clearly explain to the patient the need for surgical intervention. It should, without delving into technical details, talk about what is planned to be done, and how the patient will live and feel after the operation, outline its possible consequences. At the same time, in everything, of course, emphasis should be placed on confidence in a favorable outcome of treatment. The doctor must "infect" the patient with a certain optimism, make the patient his colleague in the fight against the disease and the difficulties of the postoperative period. A huge role in psychological preparation is played by the moral and psychological climate in the department.

For psychological preparation, pharmacological agents can be used. This is especially true for emotionally labile patients. Often used sedatives, tranquilizers, antidepressants.

The consent of the patient for the operation must be obtained. Doctors can do all operations only with the consent of the patient. At the same time, the fact of consent is recorded by the attending physician in the medical history - in the preoperative epicrisis. In addition, it is now necessary for the patient to give written consent to the operation. The corresponding form, drawn up in accordance with all legal norms, is usually pasted into the medical history.

It is possible to perform an operation without the consent of the patient if he is unconscious or incapacitated, which should be the conclusion of a psychiatrist. In such cases, they mean the operation according to absolute indications. If the patient refuses the operation when it is vital (for example, with continued bleeding), and dies as a result of this refusal, then legally the doctors are not guilty of this (with the appropriate registration of the refusal in the medical history). However, there is an unofficial rule in surgery: if the patient refused the operation, which was necessary for health reasons, then the attending physician is to blame. Why? Yes, because all people want to live, and the refusal of the operation is due to the fact that the doctor could not find the right approach to the patient, find the right words in order to convince the patient of the need for surgical intervention.

In psychological preparation for surgery, an important point is the conversation of the operating surgeon with the patient before the operation. The patient must know who is operating on him, to whom he trusts his life, to make sure that the surgeon is in good physical and emotional condition.

The relationship between the surgeon and the patient's relatives is of great importance. They should be of a confidential nature, because it is close people who can influence the mood of the patient and, in addition, provide him with purely practical assistance.

At the same time, we must not forget that in accordance with the law, it is possible to inform relatives of information about the patient's illness only with the consent of the patient himself.

According to vital and absolute indications, operations should be performed in all cases, with the exception of the preagonal and agonal state of the patient, who is in the terminal stage of a long-term current disease, leading inevitably to death (for example, oncopathology, liver cirrhosis, etc.). Such patients, according to the decision of the council, undergo conservative syndromic therapy.

With relative indications, the risk of surgery and the planned effect of it should be individually weighed against the background of concomitant pathology and the age of the patient. If the risk of surgery exceeds the desired result, it is necessary to refrain from surgery (for example, removal of a benign formation that does not compress vital organs in a patient with severe allergy.

126. Preparation of organs and systems of patients at the stage of preoperative preparation.

There are two types of preoperative preparation: general somatic and special .

General somatic training is carried out for patients with common surgical diseases that have little effect on the state of the body.

Skin should be examined in every patient. Rash, purulent-inflammatory rash exclude the possibility of performing a planned operation. Plays an important role sanitation of the oral cavity . Carious teeth can cause diseases that are severely reflected in the postoperative patient. Sanitation of the oral cavity, regular brushing of teeth are very useful for preventing postoperative parotitis, gingivitis, glossitis.

Body temperature before a planned operation should be normal. Its increase finds its explanation in the very nature of the disease (purulent disease, cancer in the stage of decay, etc.). In all patients hospitalized in a planned manner, the cause of the temperature increase should be found. Until it is detected and measures are taken to normalize it, the planned operation should be postponed.

The cardiovascular system should be studied especially carefully. If blood circulation is compensated, then there is no need to improve it. The average level of arterial pressure is 120/80 mm. rt. Art., may vary between 130-140 / 90-100 mm. rt. Art., which does not necessitate special treatment. Hypotension, if it represents the norm for this subject, also does not require treatment. If there is a suspicion of an organic disease (arterial hypertension, circulatory failure and cardiac arrhythmias and conduction disturbances), the patient should be consulted with a cardiologist and the issue of surgery is decided after special studies.

For prevention thrombosis and embolism determine the protombin index and, if necessary, prescribe anticoagulants (heparin, phenylin, clexane, fraxiparin). In patients with varicose veins, thrombophlebitis, elastic bandaging of the legs is performed before surgery.

Training gastrointestinal tract patients before surgery on other areas of the body is uncomplicated. Eating should be limited only on the evening before the operation and in the morning before the operation. Prolonged fasting, the use of laxatives and repeated washing of the gastrointestinal tract should be performed according to strict indications, as they cause acidosis, reduce intestinal tone and contribute to stagnation of blood in the vessels of the mesentery.

Before scheduled operations, it is necessary to determine the status respiratory system , according to indications, eliminate inflammation of the accessory cavities of the nose, acute and chronic bronchitis, pneumonia. Pain and the forced state of the patient after surgery contribute to a decrease in respiratory volume. Therefore, the patient must learn the elements of breathing exercises included in complex of physiotherapy exercises of the preoperative period.

Special preoperative preparationat planned patients can be long and voluminous, in emergency cases short-term and quickly effective.

In patients with hypovolemia, impaired water and electrolyte balance, acid-base state, infusion therapy is immediately started, including the transfusion of polyglucin, albumin, protein, sodium bicarbonate solution for acidosis. To reduce metabolic acidosis, a concentrated solution of glucose with insulin is administered. At the same time, cardiovascular agents are used.

In acute blood loss and stopped bleeding, blood, polyglucin, albumin, and plasma are transfused. With continued bleeding, transfusion is started into several veins and the patient is immediately taken to the operating room, where an operation is performed to stop the bleeding under the cover of infusion therapy, which is continued after the operation.

The preparation of organs and systems of homeostasis should be comprehensive and include the following activities:

14. improvement of vascular activity, correction of micro
circulation with the help of cardiovascular agents, drugs, improve
microcirculation (reopoliglyukin);

15. fight against respiratory failure (oxygen therapy, normal
circulation, in extreme cases - controlled ventilation of the lungs);

16. detoxification therapy - fluid administration, blood replacement
solutions of detoxification action, forced diuresis, with
change of special methods of detoxification - plasmophoresis, oxygen therapy;

17. correction of disorders in the hemostasis system.

In emergency cases, the duration of preoperative preparation should not exceed 2 hours.

Psychological preparation.

The upcoming surgical operation causes more or less significant mental trauma in mentally healthy people. Patients often at this stage have a feeling of fear and uncertainty in connection with the expected operation, negative experiences arise, numerous questions arise. All this reduces the reactivity of the body, contributes to sleep disturbance, appetite.

Significant role in psychological preparation of patients, hospitalized in a planned manner, is given medical and protective regime, the main elements of which are:

14. impeccable sanitary and hygienic conditions of the premises where
the patient walks;

15. clear, reasonable and strictly enforced rules internally
th schedule;

16. discipline, subordination in the relationship of medical translation
sonala and in the relationship of the patient to the staff;

17. cultural, caring attitude of the staff to the patient;

18. full provision of patients with medicines, apparatus
swarm and household items.

The issue of surgical treatment of clinical manifestations that are caused by a herniated disc requires a qualified decision (after a thorough examination) with the participation of a neurologist, neurosurgeon, therapist (and in some cases with the participation of an orthopedist and / or rheumatologist).

Unfortunately, surgery is often performed in the absence of proper indications (which will be discussed in this article), which is fraught with the formation of chronic post-discectomy pain syndrome or failed back surgery syndrome (FBSS - Failed Back Surgery Syndrome "), which is caused by many factors, for example , violation of the biomechanics of movement in the operated segment of the spine, adhesions, chronic epiduritis, etc.

Consider the indications for surgical treatment of clinical manifestations caused by a herniated disc, which are published by leading experts in the field of neurology, veterinary neurology and manual therapy.

In the article of the professor, d.m.s. O.S. Levina (Department of Neurology of the Russian Medical Academy of Postgraduate Education, Moscow) "Diagnosis and treatment of vertebrogenic lumbosacral radiculopathy" in relation to the problem we are considering, the following is indicated:

Recent large-scale studies have shown that although early surgical treatment undoubtedly leads to faster pain relief, after six months, a year and two, it does not have advantages in the main indicators of pain syndrome and the degree of disability over conservative therapy and does not reduce the risk of chronic pain.

It turned out that the timing of the surgical intervention in general does not affect its effectiveness. In this regard, in uncomplicated cases of vertebrogenic radiculopathy, the decision on surgical treatment can be delayed for 6-8 weeks, during which adequate (!) conservative therapy should be carried out. Preservation of intense radicular pain syndrome, severe limitation of mobility, resistance to conservative measures during these periods may be indications for surgical intervention.

Absolute indications for surgical treatment are compression of the roots of the cauda equina with foot paresis, anesthesia of the anogenital region, dysfunction of the pelvic organs. An indication for surgery may also be an increase in neurological symptoms, such as muscle weakness. As for other cases, questions about the appropriateness, optimal time and method of surgical treatment remain the subject of discussion.

In recent years, along with traditional discectomy, more sparing methods of surgical intervention have been used; microdiscectomy, laser decompression (vaporization) of the intervertebral disc, high-frequency disc ablation, etc. For example, laser vaporization is potentially effective in radiculopathy associated with a herniated disc while maintaining the integrity of the fibrous ring, its bulging by no more than 1/3 of the sagittal size of the spinal canal (about 6 mm) and in the absence of movement disorders or symptoms of root compression in the patient horse tail. Minimally invasive intervention expands the range of indications for it. Nevertheless, the principle remains unchanged: the surgical intervention should be preceded by optimal conservative therapy for at least 6 weeks.

Regarding the use of sparing methods for the treatment of a herniated disc, there is also the following recommendation (which can be found in more detail in the article: “Neuropathic pain syndrome in back pain” by A.N. Barinov, First Moscow State Medical University named after I.M. Sechenov):

If there is a non-sequestered lateral (foraminal) disc herniation, less than 7 mm, and the short-term effectiveness of foraminal blockades and / or poor tolerance of glucocorticoids, a minimally invasive procedure of laser vaporization (or its modification - foraminoplasty), cold plasma ablation or intradiscal electrothermal annuloplasty is performed, which is effective in 50-65% of patients. If this minimally invasive procedure does not lead to pain regression, then a microdiscectomy is performed.

According to the recommendations of L.S. Manvelova, V.M. Tyurnikova, Scientific Center of Neurology of the Russian Academy of Medical Sciences, Moscow (published in the article "Lumbar pain: etiology, clinic, diagnosis and treatment") indications for surgical treatment of clinical manifestations caused by a herniated disc are divided into relative and absolute:

The absolute indication for surgical treatment is the development of caudal syndrome, the presence of a sequestered herniated intervertebral disc, a pronounced radicular pain syndrome that does not decrease despite the treatment.

The development of radiculomyeloishemia also requires emergency surgical intervention, however, after the first 12-24 hours, the indications for surgery in such cases become relative, firstly, due to the formation of irreversible changes in the roots, and secondly, because in most cases in in the course of treatment and rehabilitation measures, the process regresses within approximately 6 months. The same terms of regression are observed in delayed operations.

Relative indications include the ineffectiveness of conservative treatment, recurrent sciatica. Conservative therapy in duration should not exceed 3 months and last at least 6 weeks.

It is assumed that the surgical approach in case of acute radicular syndrome and the failure of conservative treatment is justified during the first 3 months after the onset of pain to prevent chronic pathological changes in the root. Relative indications are cases of extremely pronounced pain syndrome, when there is a change in the pain component with an increase in neurological deficit.

As a conclusion, so to speak, summing up the above, one should list the indications for surgical treatment of a herniated disc, adapted for their correct perception by patients and doctors who are not related to neurology and neurosurgery, and published in the article F.P. Stupina(doctor of the highest category, candidate of medical sciences, associate professor of the course of restorative medicine at the Department of Physical Rehabilitation and Sports Medicine of the Russian Medical Academy of Postgraduate Education) “Intervertebral hernia. Is an operation necessary? (read full article ->):

“According to the results of many years of observations and the results of surgical and conservative methods of treatment, we noted that the indications for surgery are:
. paresis and paralysis of the sphincters of the rectum and bladder;
. the severity and persistence of radicular pain, and the absence of a tendency to their disappearance within 2 weeks, especially when the size of the hernial protrusion is over 7 mm, especially with sequestration.

These are urgent indications when you need to agree to an operation out of captivity, otherwise it will be worse.

But in the following cases, you need to go for an operation only of your own free will, carefully weighing your decision:
. ineffectiveness of conservative treatment for 3 months or more;
. paralysis of limbs and segments;
. signs of muscle atrophy against the background of the absence of functional activity of the root.

These are relative readings, i.e. about a person's ability to endure pain, the need to go to work, and the ability to self-care."

The established diagnosis of esophageal cancer is an absolute indication for surgery - everyone recognizes this.

A study of the literature shows that the operability of patients with esophageal cancer is rather low and, according to various surgeons, varies widely - from 19.5% (BV Petrovsky) to 84.4% (Adatz et al.). The average figures for operability in the domestic literature are 47.3%. Consequently, approximately half of the patients are scheduled for surgery, and the second is not subject to surgical treatment. What are the reasons for such a large number of patients with esophageal cancer to refuse surgery?

First of all, this is the refusal of the patients themselves from the proposed surgical treatment. It was reported above that the percentage of patients who refused surgery in various surgeons reaches 30 or more.

The second reason is the presence of contraindications to surgical intervention, depending on the state of the already elderly organism itself. The operation of resection of the esophagus for cancer is contraindicated in patients with organic and functional heart diseases, complicated by circulatory disorders (severe myocardial dystrophy, hypertension, arteriosclerosis) and lung diseases (severe pulmonary emphysema, bilateral tuberculosis), unilateral pulmonary tuberculosis is not a contraindication, also as well as pleural adhesions (A. A. Polyantsev, Yu. E. Berezov), although they, no doubt, burden and complicate the operation. Diseases of the kidneys and liver - nephrosonephritis with persistent hematuria, albuminuria or oliguria, Botkin's disease, cirrhosis - are also considered a contraindication to surgical treatment of esophageal cancer.

The operation of resection of the esophagus is contraindicated and debilitated patients who have difficulty walking, severely emaciated, until they are taken out of this condition.

The presence of at least one of the listed diseases or conditions in a patient with cancer of the esophagus will inevitably lead to his death either during the operation of resection of the esophagus, or in the postoperative period. Therefore, with them, radical operations are contraindicated.

Concerning age of the patients appointed for operation, there are different opinions. G. A. Gomzyakov demonstrated a 68-year-old patient operated on for cancer of the lower thoracic esophagus. She underwent transpleural resection of the esophagus with a one-stage anastomosis in the chest cavity. After the demonstration by F. G. Uglov, S. V. Geynats, V. N. Sheinis and I. M. Talman, it was suggested that advanced age in itself is not a contraindication to surgery. The same opinion is shared by S. Grigoriev, B. N. Aksenov, A. B. Raiz and others.

A number of authors (N. M. Amosov, V. I. Kazansky, etc.) believe that the age over 65-70 years is a contraindication to resection of the esophagus, especially by the transpleural route. We believe that elderly patients with esophageal cancer should be carefully scheduled for surgery. It is necessary to take into account all changes in the age character and the general condition of the patient, take into account the scale of the proposed operation, depending on the localization of the tumor, its prevalence and the method of the surgical approach. Without a doubt, resection of the esophagus for a small carcinoma of the lower esophagus using the Savinykh method can be successfully performed in a 65-year-old patient with moderately severe cardiosclerosis and emphysema, while resection of the esophagus with a transpleural approach in the same patient may end unfavorably.

The third group of contraindications is due to the esophageal tumor itself. All surgeons recognize that distant metastases to the brain, lungs, liver, spine, etc. are an absolute contraindication to radical resection of the esophagus. Patients with esophageal cancer with distant metastases can only undergo palliative surgery. According to Yu. E. Berezov, Virchow's metastasis cannot serve as a contraindication to surgery. We agree that palliative but not radical surgery can be performed in this case.

The presence of an esophageal-tracheal, esophageal-bronchial fistula, perforation of a tumor of the esophagus into the mediastinum, lung are a contraindication to resection of the esophagus, as well as a change in voice (aphonia), indicating the spread of the tumor beyond the wall of the esophagus when it is localized in the upper thoracic or, less often, in the mid-thoracic region. Operation is contraindicated, according to some surgeons (Yu. E. Berezov, V. S. Rogacheva), in patients with significantly pronounced infiltration of the mediastinum by a tumor, determined by x-ray examination.

This group of contraindications, depending on the extent of the tumor of the esophagus, is determined by the technical impossibility of resection of the esophagus due to the germination of carcinoma in neighboring non-resectable organs or the futility of the operation due to extensive metastasis.

All other patients who have no contraindications undergo surgery with the hope of resection of the esophagus. However, as can be seen from Table. 7 (see the last column), resection of the esophagus can be performed not by all operated, but by 30-76.6%, according to various authors. Such a big difference in the given figures depends, in our opinion, not so much on the activity and personal attitudes of the surgeon, as Yu. E. Berezov believes, but on the quality of preoperative diagnostics. If you carefully study the patient's complaints, the history of the development of his disease, the data of clinical and radiographic studies, taking into account the localization of the tumor, its extent along the esophagus and mediastinal infiltration, then in most patients it is possible to correctly determine the stage of esophageal cancer before surgery. Errors are possible mainly r, but due to unrecognized metastases before the operation or underestimation of the stage of the process, which lead to trial operations.

When the stage of esophageal cancer is determined, then the indications are clear. All patients with esophageal carcinoma in stages I and II are subject to resection of the esophagus. As for patients with stage III cancer of the esophagus, we solve the issue of resection of the esophagus in the following way. If there are no multiple metastases in the mediastinum, in the lesser omentum and along the left gastric artery, then resection of the esophagus should be performed in all those cases where it is technically possible to perform it, i.e. the tumor has not sprouted into the trachea, bronchi, aorta, vessels of the lung root.

Almost all surgeons adhere to this tactic, and yet resectability, i.e., the number of patients who manage to perform resection of the esophagus, ranges from 8.3 to 42.8% (see Table 7) in relation to all those admitted to the hospital. On average, operability is 47.3%, resectability - 25.7%. The figures obtained are close to the average data of Yu. E. Berezov and M. S. Grigoriev. Therefore, at present, about one in 4 patients with esophageal cancer who seek surgical help can undergo resection of the esophagus.

In the hospital surgical clinic named after A. G. Savinykh of the Tomsk Medical Institute, since 1955, various operations have been used for resection of the esophagus in cancer, depending on the indications. Indications for the use of a particular method are based on the localization of the tumor and the stage of its spread.

1. Patients with cancer of the esophagus stage I and II, with the localization of the tumor in the thoracic region, resect the esophagus according to the Savinykh method.

2. In case of cancer of the upper and middle thoracic sections of the esophagus, stage III, as well as when the tumor is located on the border of the middle and lower sections, resection of the esophagus is performed according to the Dobromyslov-Torek method through the right-sided access. In the future, after 1-4 months, retrosternal-prefascial small-bowel esophagoplasty is performed.

3. In stage III esophageal cancer with tumor localization in the lower thoracic region, we consider partial resection of the esophagus with a combined abdomino-thoracic approach with a one-stage esophageal-gastric or esophago-intestinal anastomosis in the chest cavity, or resection of the esophagus according to the Savinykh method.