Storosios žarnos išemijos rizika ir prevencija pilvo aortos rekonstrukcijos operacijų metu

Show simple item record Abromaitis, Darius 2017-08-21T08:06:40Z 2017-08-21T08:06:40Z 2005
dc.description.abstract 1. INTRODUCTION Most complications after elective or urgent reconstructive operations on abdominal aorta are predictable and it is possible to prevent them. The development of the operating techniques, a good preoperative preparation of patients and post-operative nursing of patients enables to achieve good results of treatment when the post-operative death-rate is from 0 to 12 percent [Hallin A., 2001]. The better results depend on the prevention of especially dangerous complications, such as colon ischemia, apropos diagnostics and adequate treatment. The selection of patients of high risk becomes extra important. The proper evaluation of preoperative aortography while being aware of the fact that the reconstruction of IMA is needed, and following the specific requirements for the operating techniques strictly, enables to avoid ischemia of the gut completely or to reduce its frequency to a minimum [Belov I.V., 2002]. Post-operative GIC can be especially serious. Due to them the hospitalization period can prolong and the post-operative mortality generally increases [Chan K.H., 1989; Huddy S.P., 1991; Christenson J.T., 1994; Mercado P.D., 1994; Lubetkin E.I., 1996]. Less seldom but very difficult GIC occur to those patients for whom have been made none abdominal high coverage operations. The given frequency of the spread of GIC is about 2 percent after open heart operations [Huddy S.P., 1991; Christenson J.T., 1994; Mercado P.D., 1994], 7 percent after neurosurgical operations [Chan K.H., 1989], 20 percent after heart transplantation [Huddy S.P., 1991] and more than 50 percent after orthotropic lungs transplantation [Lubetkin E.I., 1996]. The most widely is analysed the occurrence of GIC after cardiosurgical operations. In the study including 4473 patients, Huddy and colleagues [Huddy S.P., 1991] indicate that the proportion of GIC development OR after closed heart operations is 1 : 249, after open heart operations – 1 : 66, and after heart transplantation – 1 : 5. After GIC development, for a half of such patients is made abdominal cavity operation in order to treat this complication [Chan K.H., 1989; Huddy S.P., 1991; Mercado P.D., 1994; Lubetkin E.I., 1996], and the presented post-operative mortality is from 16 to 67 percent [Chan K.H., 1989; Christenson J.T., 1994; Mercado P.D., 1994; Lubetkin E.I., 1996]. In some cases GIC leads to the development of MOF, consequently here given frequencies of mortality are small and can contravene the reality [Baue A.E., 1994]. Most frequent GIC after heart operations are paralytic ileus, gastrointestinal bleeding and acute cholecistitis [Christenson J.T., 1994; Mercado P.D., 1994]. Greatest death-rates (> 60 percent) are after development of acute hepatic dysfunction or intestinal ischemia [Christenson J.T., Schmuziger M., 1994]. Most authors indicate GIC developments due to several possible risk factors after heart operations: arrhythmias, prolonged low cardiac output which requires pharmacological inotropic support or aortic contrapulsation, post-operative systemic arterial hypotension and afterwards following visceral hypotension and hypoperfusion [Spotnitz W.D., 1995; Lazar H.L., 1995]. GIC occurs more frequently to the patients operated due to the pathology of abdominal cavity organs, and especially for those for whom through the laparotomy is made abdominal aortic reconstruction because of AAA or AIOD. In the case of heart operations as well as in aorta operations, GIC risk is increased by the same factors leading to the visceral hypoperfusion. Operative arterial hypotension and arrhythmias are the most typical for the patients with GIC. Here GIC is usually related to the higher operative bleeding and greater volume transfusion of post-operative, accordingly is natural that visceral hypoperfusion follows these patients alongside with perioperative hypovolemia and shock [Valentine R.J., 1998]. The stenoses of various degrees of mesenteric arteries are very typical to the patients’ operative due to the aorta pathology. Those setenoses are very important risk factor of visceral hypoperfusion too [Valentine R.J., 1991], however, it was noticed that asymptomatic mesenteric arterial stenoses do not increase the risk of GIC. Most probably it is so, because of a very good collateral circulation [Valentine R.J., 1998]. During the recent quinquennial there appeared works in the scientific literature, in which there is stated that one of the post-operative reasons of the complications is massive embolism in cholesterol crystals. It can happen in any visceral arteries or arteries of the limbs and cause sharp or even fatal disorder of their functions [Jaeger H.J., 1999; Fernandez Suarez F.E., 2000]. Dominant GIC after heart as well as after aorta operations are the same. More frequent GIC after aortic reconstruction are: gastrointestinal bleeding, mechanical ileus, paralytic ileus, and intestinal ischemia, more seldom - acute cholecistitis, acute pancreatitis, and enterocolitis. These complications are quite rare if taken each separately. However, while counting all of them in common, they not just increase mortality after aorta operations signally, but exacerbate the treatment results signally as well, and raise the cost of patient’s hospitalization a lot, because the number of manipulations done to the patient increase, prolongs time spent in the intensive care unit, and prolongs the total time of hospital stay [Valentine R.J., 1998]. Talking about mortality after cardiovascular operations it is necessary to say that OR of lethal end if GIC occurs is 5.397; CI - [2.147 – 13.564]; p < 0.05, i.e. the probability of death in the case of GIC increases more than 5 times. When different GIC develop after operation for rAAA, there are given such frequencies of mortality: intestinal ischemia – 100 percent, gastrointestinal bleeding – 60 percent, abdominal compartment syndrome and laparostomia – 50 percent, prolonged paralytic ileus – 50 percent, abscess of the abdominal cavity – 100 percent, jaundice – 33 percent [Bown M.J., 2004]. Most frequent occurring localization of intestinal ischemic damage after reconstructive operations of abdominal aorta is the left side of the large intestine. In 1954 Moore was the first to describe IC as a complication after the operation of abdominal aorta [Moore S.W., 1954]. That was one year after the first successful operation of the AAA. Since then IC has been a well known complication in the surgery of abdominal aorta very increasing the post-operative mortality and due to the diagnostic criteria occurring in a frequency from 0.2 to 32 percent [Ernst C.B., 1976; Hagihara P.F., 1979; Zelenock G.B., 1989]. It is not known completely what forms the pathogenesis of IC, but today it is thought that the basis of this complication and its systematic effects is ischemic – reperfusion damage. In the works of recent decade pathophysiologists there was determined that during the reperfusion there occurs an active aggregation of neutrofils and adhesion with intestinal endothelial cells, the decay of cells, the formation of free oxygenous radicals and the release of protheases, and due to this - intestinal damage [Grace P.A., 1994; Simonian G.T., 1997; Cavanagh C.P., 1998]. Though, mucous membrane of the intestine is very sensitive to the changes of the supply of oxygen, reperfusion of the intestine just deepens the barrier function disorder of the mucous membrane. The translocation of the intestinal substance and bacterial proceeding products happens through the ischemic wall of the intestine as a result of which the endotoxaemia progresses [Antonsson J.B., 1991; Horton J.W., 1992]. Endotoxins stimulate the disengagement of cytokines as TNF, IL – 6, that has a great importance for the development of septic shock and MOF [Hirano T., 1990; Soong C.V., 1993]. Thereby, it has been proved that the disorder of the microcirculation of the intestine lead to the most serious multiple organ function disorder. [Haglund U., 1993; Baguneid M.S., 2001]. Being aware of this pathophysiological chain makes obvious what importance has the right evaluation of the risk of IC and adequate prevention means while seeking to avoid the complication, decline the mortality and improve the treatment results of the patients who are operated according to the abdominal aorta pathology. 2. THE AIM AND THE OBJECTIVES The Aim To define the clinical factors which depend on the patient, surgeon and on the nature of disease, which can influence the development of colon ischemia for the patients after the reconstructive operations of the abdominal aorta, and to evaluate the prognostic value of these factors. The Objectives 1. To find out the importance of preoperative factors for the development of colon ischemia for the patients for whom reconstructive operations of abdominal aorta are made. 2. To find out the importance of operative factors for the development of colon ischemia for the patients for whom reconstructive operations of abdominal aorta are made. 3. To find out the importance of postoperative factors for the development of colon ischemia for the patients for whom reconstructive operations of abdominal aorta are made. 4. To ascertain the prognostic value of colon ischemia risk factors. 5. To recommend the means of colon ischemia prevention after abdominal aortic reconstructive surgery. The novelty and originality of the paper Although the scientists from many countries have been analysing the frequency of colon ischemia after open and endovascular surgery of the abdominal aorta, pathogenetic mechanisms, risk factors and means to avoid them for 50 years, however, there is no united opinion what patients this complication faces more and what the means of prevention are. This work is the first clinical investigation among the vascular surgeons of Lithuania, during which were investigated all patients operated due to aortoiliac occlusive disease and abdominal aortic aneurysm. We t
dc.language.iso lit
dc.subject Abdominal aorta
dc.subject Colon ischemia
dc.subject Aortic surgery
dc.subject Storosios žarnos išemija
dc.subject Aortos rekonstrukcija
dc.subject Pilvo aorta
dc.title Storosios žarnos išemijos rizika ir prevencija pilvo aortos rekonstrukcijos operacijų metu
dc.title.alternative Risk and prevention of colon ischemia during abdominal aortic reconstructive surgery
dc.type Daktaro disertacija

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