Treatment of subhepatic abscess due to complicated perforation of gastric ulcer

Formation of abdominal abscesses with perforated ulcers of the stomach and duodenum with conservative treatment ranges from 3% to 14%. The main strategy for their treatment is a minimally invasive puncture treatment. A case of a patient’s late treatment of 56 years with a perforated giant gastric ulcer, the formation of a subhepatic abscess and its drainage into the lumen of the stomach is presented. Used methods of drainage of an abscess through a mini-access under the control of gastroscopy. A complex of therapeutic measures has been described, which allowed for the obliteration of an abscess cavity and the healing of a giant stomach ulcer within a month. It is concluded that the need for early use of gastroscopy in the differential diagnosis of perforated ulcers.

Pathomorphological aspects of the diagnosis and treatment of acute cholecystitis

Aim: to find out the possibilities of pathomorphological studies of destructive forms of acute cholecystitis in identifying the characteristics of etiology and pathogenesis factors for the clinical use of the data. Materials and methods. From 2016 to 2018, 266 patients with acute cholecystitis (AC) were operated on in the clinic of the Department of Surgery and Proctology of Shupik National Medical Academy of Postgraduate Education on the basis of Kyiv Regional Clinical Hospital. General clinical methods, ultrasound, X-ray methods, CT, MRI, mini-invasive methods, operative methods — mainly laparoscopic interventions, up to 10% — laparotomy surgeries were used in the diagnosis. The removed gall bladders underwent morphological examination. Results and discussion. Acute calculous cholecystitis was diagnosed in 245 operated patients (92%), stoneless — in 21 (8%). Catarrhal, serous, serous-fibrinous forms were found out in 32 patients (12%), destructive — in 234 (88%). Acute phlegmonous cholecystitis was detected in 147 patients (55%), gangrenous — in 56 (21%), perforated — in 11 (4%), including subhepatic abscess — 8 (3%). According to clinical, biochemical, intraoperative and macromorphological signs, enzymatic forms of AC were diagnosed in 37 patients (11%), emphysema in 4 (2%), vascular in 3 (1.5%) and post-traumatic in 1 (0.5%). In 96 patients with phlegmonous and gangrenous forms of AC, immune-allergic and vascular changes in the gallbladder wall were revealed by special pathomorphological techniques. Conclusion AC is a polyetiological disease with complex pathogenesis and nonspecific histomorphological changes. Phlegmonous (147 (55%) patients), gangrenous — 56 (21%) prevail among destructive forms of AC, perforated forms — 11 (4%), and subhepatic abscess with AC — 8 (3%) are rarely found. Clinical and instrumental intraoperative research methods allow to pre-diagnose special forms of AC, among which the most commonly diagnosed are enzymatic cholecystitis — 37 (11%) patients, the more rare are emphysema — 4 (2%), vascular — 3 (1.5%), and post-traumatic AC — 1 (0.5%). Morphological studies make it possible to verify the degree of inflammation and destruction of the gallbladder wall, to identify immune-allergic and vascular changes in the gallbladder wall. Results of microscopic and pathomorphological studies in patients with AC allow in the postoperative period to adjust antibiotic therapy, prevention of thromboembolic complications, allergic and immunological manifestations to reduce postoperative complications and mortality.

THE POSSIBILITY OF MINIMALLY INVASIVE ROENTGEN-SURGICAL TECHNIQUES IN ABDOMINAL SURGERY

The clinical observations showing the diagnostic and therapeutic capacities of minimally invasive percutaneous roentgen-surgical techniques in the diagnosis and treatment of hepatopancreatoduodenal zone diseases are presented. In these cases, the use of minimally invasive surgical techniques on various stages of diagnosis and treatment have helped to correct diagnosis, and effective treatment, discarding traditional traumatic surgery. In the first clinical observation percutaneous radiosurgical method drainage of an abscess of the liver allowed to reveal chronic form of fascioliasis and conduct specific treatment. In the second - to establish the cause of recurrent subhepatic abscess, in the third-to remove concrements of common bile duct, if unable to perform open surgery or endoscopic papillosfinkterotomiya and remove concrements. Common to all three clinical observations is the fact that up to minimally invasive roentgen-surgical methods of treatment were carried out public activities, which for various reasons proved ineffective. The latest minimally invasive radiosurgical methods allow not only to establish an accurate diagnosis, but may be intermediate or final treatment.This is especially important in severe patients at impossibility of the surgery and if necessary, stabilization of the general status and improving metabolic and functional parameters of the upcoming radical operation. In most cases, a variety of minimally invasive surgical techniques are not competing among themselves, but only complement or substitute one another in every concrete clinical situation.

Diarrhoea caused by Clostridium difficile in patients with postoperative subhepatic abscess

Background. Toxigenic strains of Clostridium difficile in the majority of cases cause disease of the intestinal tract of hospitalized patients. For a long time, Clostridium difficile was considered to produce both types of toxins (A+/B+ strain), however, the investigations conducted in the last ten years point to the existence of clinically significant isolates which produce only toxin B, i.e. toxin A negative / toxin B positive (A-/B+ strain) Clostridium difficile. Case report. We presented the case of a patient admitted to the Surgery Clinic, Clinical Center Nis due to the presence of calculus in the ductus choledochus. Twenty-four hours after the surgical intervention for calculus removal, the first signs of the operative wound infection began to appear. In the course of infection treatment, different antibiotics were administered (cefuroxine, ciprofloxacin, vancomycin, imipenem). After making etiological microbiological diagnosis and application of antibiotics according to antibiogram results, the signs of the operative wound infection began to withdraw, but the patient reported the abdominal pain and liquid stools with traces of blood (up to 17 stools per day). By microbiological examination, Clostridium difficile was cultivated and the presence of toxin B was detected in the stool samples. The patient was sent to the Clinic for Infectious Diseases, where the causal therapy of mitronidazol was administered. Liquid and electrolytes were made up by substitution therapy. After the eight-day-treatment, the patient felt much better, and diarrheas stopped on the 10th day of the therapy application. Conclusion. Our results have shown that toxingen strains Clostridium difficile are present in our country so this bacterium sort have to be considered in differential causal diagnosis of diarrhoea syndrom. Considering that it can cause difficult form of the disease, it is an obligation to establish the presence of some toxins of Clostridium difficile in stool samples of patients and/or production of some toxins in liquid culturate of isolates to provide data for the presence of strains which produce only toxin B.