PECULIARITIES OF THE REHABILITATION PROGRAM IN ELDERLY PATIENTS IN THE POST-OPERATIVE PERIOD WITH ACUTE CALCULOUS CHOLECYSTITIS

Currently, the elderly and senile account for 10 to 25% of all hospitalized for acute calculous cholecystitis. High operative-anesthetic risk, concomitant diseases and low resistance to surgical trauma are the cause of high frequency of postoperative complications and fatalities in this category of patients. In recent years, a reduction in postoperative mortality in acute cholecystitis, which is currently 0.28-2.9%, with gangrenous cholecystitis, it is higher to 17.8%. The aim of the study is to analyze and develop a rehabilitation program in the postoperative period in elderly and senile patients after surgery with acute calculous cholecystitis. Materials and methods We conducted an analysis of surgical treatment of 53 elderly and senile patients with acute calculous cholecystitis. In all patients, this diagnosis was confirmed intraoperatively and histologically. The age of all patients ranged from 61 to 89 years (mean 72.4 ± 8.7 years). Among the examined sick men there were 12 (22.6%), women - 41 (77.4%). The main criteria for assessing and creating a rehabilitation program in patients after surgery with acute calculous cholecystitis were the following processes: improving the general condition of patients, restoring intestinal motility, restoring or improving all impaired cardiovascular and respiratory functions, prevention of general complications (cardiovascular, respiratory, urinary, digestive and other systems), local (from the wound), normalization of blood parameters, One of the important components of successful surgical treatment of patients in the postoperative period is the timely restoration of respiratory, cardiovascular, digestive system after surgery. a guarantee of prevention of probable postoperative complications which are formed in the first 3-5 days after surgery. Objectives of the rehabilitation program in the early postoperative period in elderly and senile patients with acute calculous cholecystitis: to reduce the impact of drugs and accelerate the excretion of toxic substances from the body; restore adequate respiration and oxygen saturation; improve external respiration function, bronchial patency and bronchial drainage function; stabilize central hemodynamics to reduce peripheral circulatory disorders; prevent complications from the gastrointestinal tract, thromboembolic complications; prevent complications from the postoperative wound. Conclusions: Development of a rehabilitation program is a mandatory component in operated patients. Particular attention is paid to elderly and senile patients, who require a set of rehabilitation measures to be minimal, but sufficient to restore lost or reduced body functions in the early postoperative period, but at the same time, it should not exceed the patient's capabilities and ensure maximum efficiency. restoration. Start a rehabilitation program (breathing exercises, kinesiotherapy, massage, inhalation in combination with physiotherapy procedures) should be 12 - 16 hours after surgery. Prospects for further development Continue to develop a rehabilitation program for elderly and senile patients, taking into account the functional capabilities of the body in the long period of rehabilitation.

THE PRINCIPLES OF DIAGNOSIS AND SURGICAL TREATMENT OF COMPLICATED FORMS OF GALLSTONE DISEASE

Проанализированы за последние три года результаты оперативного лечения 200 больных с осложненными формами желчнокаменной болезни. Доказано, что риск возникновения гнойно-деструктивных форм острого калькулезного холецистита зависит от характера патологического процесса в желчном пузыре. По поводу гнойно-деструктивных форм заболевания при острого калькулезного холецистита оперировано 79,7% больных и 38,9% при необструктивной форме холецистита. Риск интраабдоминальных осложнений зависит от наличия обструкции, выявленное у 18,1% больных с обтурационнной и 5,6% у пациентов с необтурационнной формой. Госпитализация при гнойно-деструктивных формах 63,5% пациентов в первые 2 часа и 85,7% в первые 6 часов от момента заболевания, дает возможность своевременно оперировать больных до развития его интраабдоминальных осложнений. The results of treatment of 200 patients with complicated forms of gallstone disease were analyzed. It is proved that the risk of purulent-destructive forms of acute calculous cholecystitis depends on the nature of the pathological process in the gallbladder. For purulent-destructive forms of the disease in acute calculous cholecystitis, 79.7% of patients and 38.9% of patients with non-obstructive form of cholecystitis were operated on. The risk of intra-abdominal complications depends on the presence of obstruction, identified in 18.1% of patients with obstructive and 5.6% in patients with non-obstructive form. Hospitalization with purulent-destructive forms of 63.5% of patients in the first 2 hours and 85.7% in the first 6 hours from the time of the disease makes it possible to timely operate patients before the development of its intra-abdominal complications.

DETERMINATION OF PAIN IN PATIENTS WITH ACUTE CALCULOUS CHOLECYSTITIS IN PATIENTS WITH CHRONIC HEPATITIS

The aim. To establish the diagnostic value of the scale for assessing the severity of pain by determining the intensity of pain in patients with acute calculous cholecystitis in patients with chronic viral hepatitis. Materials and methods of research. The study was conducted in the period from 2016 to 2021 in the Department of Emergency Surgery of the Military Medical Clinical Center. In the first stage, the diagnostic scheme included only surveys to identify potential risk factors for infection and anamnestic data on the presence of HCV diagnosed in the past. In the second stage, rapid tests for antigens and antibodies to HCV were introduced into the diagnostic scheme along with the survey. Research results. Patients respond differently to pain, and the sen sation of pain is individual and subjective. Conclusions. Quantitative assessment and registration of the inten sity of pain using a visual-analog scale can supplement the comprehensive information about the general condition of the patient, which is necessary to select the optimal treatment in emergency surgery.

P-BN42 Percutaneous cholecystostomy - A practice review

Background Percutaneous cholecystostomy (PC) is performed occasionally in a highly selected group of patients with variable outcomes. The World Society of Emergency Surgery (WSES) updated guidelines(2020) has recommended PC as a treatment modality in patients admitted with ‘acute calculous cholecystitis’(ACC) with who are not fit for surgery, including septic patients and those who show no improvement on conservative management within 48 hours. An audit was organised to review our patient selection for PC in the last 5 years in comparison to the latest WSES recommendations. Methods A retrospective observational study was conducted using a prospectively collected hospital database on patients who underwent PC between March 2016 and March 2021 in a teaching hospital. The patient cohort who underwent PC were compared and analysed against the set WSES guidelines. Results Some 23 patients were included. The median age was 82 years (range-61-90), with 13 females (56.5%) and 10 males (43.5%).19/23(82.6%) patients were at risk of sepsis on presentation, with two or more amber flag symptoms, whereas 4/23(17.4%) patients presented with confirmed sepsis. 19/23 (82.6%) were deemed unfit for surgery against 4/23 who were deemed fit based on the surgeons assessment. Patients unfit for surgery were treated with antibiotics following a diagnosis of ACC. The median time for patients to undergo PC from admission was 4 days. The 30-day mortality rate was 13 % (n = 3/23). Conclusions The study has demonstrated that our current practice for managing patients admitted with ACC and performing PC are mostly in line with the WSES guidelines. Considering individuals presentation and the surgeons clinical judgement into account, the practice was also likely impacted by COVID-19 the global pandemic. Further clinical studies may be required to determine specific patient groups who would benefit from PC.

LAPAROSCOPIC CHOLECYSTECTOMY OF SINGLE INCISION

this article presents the results of laparoscopic cholecystectomy on technology one access in 27 patients with chronic calculous cholecystitis. The conclusion about possibility of its successful application in clinical practice in patients without complications of gallstone disease and concomitant diseases.

INFORMATIVE VALUE OF COMPARATIVE ASSESSMENT OF GENERAL CLINICAL INDICATORS IN PATIENTS WITH DESTRUCTIVE CHOLECYSTITIS

Purpose: comparative assessment of clinical manifestations of the course of destructive calculous cholecystitis before surgical operation. Methods. The study involved 86 patients with destructive cholecystitis (55 women and 31 men). 18 patients with destructive cholecystitis made up group 1, and 14 healthy people formed the control group. Patients with cholecystitis underwent cholecystectomy. The age groups were as following: 18-25, 26-40, 41-60 and 61-75 years. Grouping patients by age and sex enabled to reveal related concomitant diseases and complications of cholecystitis. 48 patients underwent open cholecystectomy, and 38 had laparoscopic cholecystectomy. The study determined the quantitative parameters of various enzymes in blood samples from patients with destructive cholecystitis, and the control group. Results. Standard open cholecystectomy was performed on in 55.8% of cases; consequently, laparoscopic cholecystectomy was performed in 44.2% of cases. A retrospective analysis of the surgical interventions performed has demonstrated 54 (62.8% ) patients had gallstones as a leading cause in the development of cholecystitis; 15 (17.4%) patients had phlegmon, 11 (12.8%) patients had gangrene, 4 (4.7%) patients had polyps, and 2 (2.3%) had gallbladder hypertrophy and complete closure of the lumen. 18 patients who underwent cholecystectomy, had developed various preoperative complications: 13 of them had local peritonitis, 2 patients had partial intestinal obstruction, and 3 were diagnosed as having mechanical jaundice. Local peritonitis was found out as the most common preoperative complication. 16 people had various comorbidities and made 18.6% of all patients. 8 (9.3%) out of 16 of the patients had diagnosis of diabetes mellitus. Conclusion. It should be noted that among all patients who underwent cholecystectomy, various preoperative complications were diagnosed, but local peritonitis was the commonest one. Diabetes mellitus against the background of impaired motility or tone of the intestines, bile ducts and the gallbladder leads to cholestasis and gallbladder inflammation.

Histopathological and Histochemical Study of Human Cholecystitis

In our study the following inferences were made. Chronic calculous cholecystitis was seen in the age group of 41 to 50 years. A female preponderance was noted with male to female ratio of 2:3. The most common signs and symptoms were upper abdominal tenderness and right hypochondria pain. The mucosa showed ulceration in 63%, hyperplastic mucosa in 34% and metaplasia in 5%. 22% of cases showed mild (Grade-I) inflammation while 41 % of cases and 27% of cases showed moderate(Grade-2) and severe (Grade-3) inflammation respectively. 44 % of cases showed mild (Grade-I) fibrosis while 22% of cases and 15% of cases showed moderate (Grade-2) and severe (Grade-3) fibrosis. With increase 1n severity of inflammation and fibrosis, the total acid mucin content decreased while the neutral mucin content increased. Similar changes were observed in cases of metaplasia too.

The timing of laparoscopic cholecystectomy and nano-ligation clip for acute calculous cholecystitis under guidance of Tokyo guidelines 2018 (multi-center retrospective analysis)

Laparoscopic cholecystectomy (LC) has been recognized as the standard surgical method for cholecystectomy. A nano-absorbable ligation clip. The material used in the ligation clip is composed of basic materials (poly(p-dioxanone), poly trimethylene carbonate or polycaprolactone) and nano-short fibers (Polyglycolide acid or polylactide). The short nano-fibers maintain the crystalline form evenly dispersed in the base material. The diameter of short nano-fibers is 300–500 nm and the length is 20–50 µm. The nano-absorbable ligation clip has strong closing force and will not cause closure failure. However, there are still some controversies about the optimum time for LC treatment of acute calculous cholecystitis (ACC) patients, and the optimum time for performing LC based on evidence-based medicine has not been unanimously recognized. Here, we explore LC timing for ACC treatment under the guidance of the Tokyo Guidelines for Acute Cholecystitis 2018 (TG18). We retrospectively analyzed the data of 3,147 ACC cases undergoing LC in eight hospitals in China. According to the time from the onset of the patient’s symptoms to the operation, they were divided into the following three groups: Group A (onset to operation time of ≤3 days), Group B (onset to operation time of 4–7 days), and Group C (onset to operation time of >7 days). There was no obvious statistical difference in preoperative indicators, such as gender ratio, history of hypertension, diabetes, and abdominal operation; ASA Classification; and TG18 Classification between the three groups. Similarly, the results of preoperative laboratory indices (e.g., white blood cell, C-reactive protein, procalcitonin, platelet, serum creatinine, and international normalized ratio) showed no obvious statistical difference between the three groups. The comparison of gallbladder characteristics under B-ultrasound showed no significant statistical difference between the three groups. However, the conversion rate in Group C was significantly higher than that in Groups A and B, the incidence of complications (e.g., bile leakage, bile duct injury, and wound infection) was significantly higher in Group C than that in Groups A and B, and the postoperative hospital stay was significantly shorter in Group A than that in Groups B and C. A comprehensive analysis of patients’ medical records in multiple medical centers confirms that it is safe and feasible to perform early LC 7 days before the onset of ACC, which can significantly decrease postoperative complications and shorten the postoperative hospital stay for ACC patients. Performing early LC for ACC patients under the TG18 guidelines is safe and feasible. Additionally, since TG18 has obvious practicability and guidance for the clinical practice of hepatobiliary surgery, it is worthy of popularization and application in China.