Browsing by Author "Plaudis, Haralds"

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    Abdominal negative-pressure therapy : A new method in countering abdominal compartment and peritonitis - prospective study and critical review of literature
    (2012) Plaudis, Haralds; Rudzats, Agris; Melberga, Liene; Kazaka, Ita; Suba, Olegs; Pupelis, Guntars
    Background: Application of abdominal negative-pressure therapy (NPT) is lifesaving when conservative measures fail to reduce sustained increase of the intra-abdominal pressure and it is impossible to achieve source control in a single operation due to severe peritonitis. The aim of this study is to share the initial experience with abdominal NPT in Latvia and provide a review of the relevant literature. Methods: In total, 22 patients were included. All patients were treated with KCI® ABThera™ NPT systems. Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission, daily sequential organ failure assessment score and Mannheim peritonitis index (MPI) were calculated for severity definition. The frequency of NPT system changes, daily amount of aspirated fluid effluent and the time of abdominal closure were assessed. The overall hospital and ICU stay, as well as the outcomes and the complication rate, were analysed. Results: A complicated intra-abdominal infection was treated in 18 patients. Abdominal compartment syndrome due to severe acute pancreatitis (SAP), secondary ileus and damage control in polytrauma were indications for NPT in four patients. The median age of the patients was 59 years (range, 28 to 81), median APACHE II score was 15 points (range, 9 to 32) and median MPI was 28 points (range, 21 to 40), indicating a prognostic mortality risk of 60%. Sepsis developed in all patients, and in 20 of them, it was severe. NPT systems were changed on a median of every 4 days, and abdominal closure was feasible on the seventh postoperative day without needing a repeated laparotomy. Two NPT systems were removed due to bleeding from the retroperitoneal space in patients with SAP. Intestinal fistulae developed in three patients that were successfully treated conservatively. Incisional hernia occurred in three patients. The overall ICU and hospital stay were 14 (range, 5 to 56) and 25 days (range, 10 to 87), respectively. Only one patient died, contributing to the overall mortality of 4.5%. Conclusions: Application of abdominal NPT could be a very promising technique for the control of sustained intra-abdominal hypertension and management of severe sepsis due to purulent peritonitis. Further trials are justified for a detailed evaluation of abdominal NPT indications.
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    Agrīnas perorālas barošanas pielietojums smaga akūta pankreatīta slimniekiem. Promocijas darba kopsavilkums
    (Rīgas Stradiņa universitāte, 2010) Plaudis, Haralds; Pupelis, Guntars
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    Agrīnas perorālas barošanas pielietojums smaga akūta pankreatīta slimniekiem. Promocijas darbs
    (Rīgas Stradiņa universitāte, 2010) Plaudis, Haralds; Pupelis, Guntars
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    Anal Sphincter Muscle Activity Changes in Women after Delivery. Doctoral Thesis
    (Rīga Stradiņš University, 2022) Začesta, Vita; Rezeberga, Dace; Plaudis, Haralds
    An episiotomy is one of the most common surgical interventions in obstetrics. Mediolateral episiotomy is usually performed on the right side. Recent advances in pelvic floor electromyography (EMG) allow to perform functional analysis of external anal sphincter with a minimally invasive anal probe. An individual asymmetry of the sphincter exists, and it is strongly associated with postpartum incontinence, primarily when the trauma occurs on the dominant side of innervation. This Thesis aims to evaluate the external anal sphincter innervation zone distribution and EMG amplitude before and after delivery and to observe the effect of episiotomy on changes of sphincter innervation. The study is a prospective cohort study. Three hundred pregnant women were recruited to the study, and two surface EMG measurement sessions (before and 6–8 weeks after delivery) with multichannel cylindrical anal probes were performed. One hundred women participated in the third measurement session at one-year follow-up. The distribution of innervation zones and global EMG signal amplitude average rectified value was assessed, and the amplitude asymmetry index was calculated. The outcomes were compared before and after delivery between different delivery types (caesarean section, mediolateral episiotomy, spontaneous lacerations and intact perineum) and according to the asymmetry index. Additionally, the anal incontinence score was evaluated before and after delivery. The results showed a significant reduction of innervation zones in the right ventral quadrant after delivery with right side episiotomy. After delivery, a significant decrease in global EMG amplitude was observed in women with amplitude asymmetry on the right side and in those who underwent mediolateral right episiotomy. The incontinence score slightly but not significantly increased 6–8 weeks after the delivery in 20 % of caesarean and 30 % of vaginal deliveries. The main conclusions of the study are that 1) episiotomy reduces external anal sphincter muscle activity, 2) multichannel surface electromyography is a promising method to analyse the anal sphincter activity. EMG signals detected during pregnancy could be used to decide the optimal side of episiotomy, thus reducing the damage to the sphincter innervation caused by the episiotomy itself.
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    Anal Sphincter Muscle Activity Changes in Women after Delivery. Summary of the Doctoral Thesis
    (Rīga Stradiņš University, 2022) Začesta, Vita; Rezeberga, Dace; Plaudis, Haralds
    An episiotomy is one of the most common surgical interventions in obstetrics. Mediolateral episiotomy is usually performed on the right side. Recent advances in pelvic floor electromyography (EMG) allow to perform functional analysis of external anal sphincter with a minimally invasive anal probe. An individual asymmetry of the sphincter exists, and it is strongly associated with postpartum incontinence, primarily when the trauma occurs on the dominant side of innervation. This Thesis aims to evaluate the external anal sphincter innervation zone distribution and EMG amplitude before and after delivery and to observe the effect of episiotomy on changes of sphincter innervation. The study is a prospective cohort study. Three hundred pregnant women were recruited to the study, and two surface EMG measurement sessions (before and 6–8 weeks after delivery) with multichannel cylindrical anal probes were performed. One hundred women participated in the third measurement session at one-year follow-up. The distribution of innervation zones and global EMG signal amplitude average rectified value was assessed, and the amplitude asymmetry index was calculated. The outcomes were compared before and after delivery between different delivery types (caesarean section, mediolateral episiotomy, spontaneous lacerations and intact perineum) and according to the asymmetry index. Additionally, the anal incontinence score was evaluated before and after delivery. The results showed a significant reduction of innervation zones in the right ventral quadrant after delivery with right side episiotomy. After delivery, a significant decrease in global EMG amplitude was observed in women with amplitude asymmetry on the right side and in those who underwent mediolateral right episiotomy. The incontinence score slightly but not significantly increased 6–8 weeks after the delivery in 20 % of caesarean and 30 % of vaginal deliveries. The main conclusions of the study are that 1) episiotomy reduces external anal sphincter muscle activity, 2) multichannel surface electromyography is a promising method to analyse the anal sphincter activity. EMG signals detected during pregnancy could be used to decide the optimal side of episiotomy, thus reducing the damage to the sphincter innervation caused by the episiotomy itself.
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    Anālā sfinktera muskuļa aktivitātes izmaiņas sievietēm pēc dzemdībām. Promocijas darba kopsavilkums
    (Rīgas Stradiņa universitāte, 2022) Začesta, Vita; Rezeberga, Dace; Plaudis, Haralds
    Anālā sfinktera muskuļa aktivitātes izmaiņas sievietēm pēc dzemdībām Epiziotomija ir viena no biežākajām ķirurģiskajām manipulācijām dzemdniecībā. Mediolaterālo epiziotomiju parasti veic labajā pusē. Jaunākie atklājumi iegurņa pamatnes elektromiogrāfijā (EMG) ļauj veikt ārējā anāla sfinktera funkcionālu analīzi ar minimāli invazīvu anālo detektoru. Pastāv funkcionāla sfinktera asimetrija, un tā ir cieši saistīta ar inkontinenci sievietēm pēc dzemdībām, īpaši tad, ja trauma bijusi dominējošajā inervācijas pusē. Darba mērķis ir novērtēt ārējā anālā sfinktera inervācijas zonu sadalījumu un EMG signālu amplitūdu pirms un pēc dzemdībām, kā arī noteikt epiziotomijas ietekmi uz anālā sfinktera inervācijas izmaiņām. Šis ir prospektīvs kohortas pētījums, kurā tika iekļautas trīssimt grūtnieces, kas piedalījās divās EMG mērījumu sesijās (grūtniecības 3. trimestrī un 6–8 nedēļas pēc dzemdībām). Trešajā mērījumu sesijā, kas notika gadu pēc dzemdībām, piedalījās simts sieviešu. EMG mērījumus veica ar cilindriskiem daudzkanālu anāliem detektoriem. Tika novērtēts inervācijas zonu sadalījums un globālās EMG signālu amplitūdas vidējā rektificētā vērtība, un noteikts amplitūdas asimetrijas indekss. Rezultātus salīdzināja pirms un pēc dzemdībām starp šādām grupām: dzemdības ar ķeizargriezienu, mediolaterālu epiziotomiju, spontāniem plīsumiem, un dzemdībām bez plīsumiem, kā arī un atbilstoši asimetrijas indeksam. Novērtēja arī anālās inkontinences skalu pirms un pēc dzemdībām. Rezultāti liecina par ievērojamu inervācijas zonu samazināšanos labās puses ventrālajā kvadrantā pēc dzemdībām ar labās puses epiziotomiju. Ievērojama globālās EMG amplitūdas samazināšanās pēc dzemdībām tika novērota sievietēm, kurām bija amplitūdas asimetrija dominējoši labajā pusē un kurām dzemdībās veica mediolaterālu labās puses epiziotomiju. Anālās inkontinences rādītāji nedaudz, bet ne statistiski ticami, pieauga 6–8 nedēļas pēc ķeizargrieziena dzemdībām 20 % un pēc vaginālo dzemdībām 30 % sieviešu. Šā pētījuma galvenie secinājumi ir šādi: pirmkārt, epiziotomija samazina ārējā anālā sfinktera muskuļa aktivitāti, otrkārt, daudzkanālu virsmas elektromiogrāfija ir daudzsološa metode ārējās anālās sfinktera aktivitātes analīzei, un grūtniecības laikā reģistrētos EMG signālus varētu izmantot, lai noteiktu epiziotomijas grieziena optimālo pusi, tādējādi samazinot epiziotomijas iespējami radītos inervācijas bojājumus.
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    Artificial Deformity Creation as a Method for Limb Salvage for Patients with Massive Tibial and Soft Tissue Defects : A Report of 26 Cases
    (2023-09-01) Plotnikovs, Konstantins; Kamenska, Jekaterina; Movcans, Jevgenijs; Pasters, Vitalijs; Solomin, Leonid; Plaudis, Haralds; Department of Surgery
    Soft tissue and bone defects that occur consequence of high-energy trauma are serious and challenging problems. The aim of this retrospective cohort study is to show that the artificial deformity creation (ADCr) method allows the closure of soft-tissue defects, avoids amputation, and can facilitate the reconstruction of bone defects and restore limb length. Patients and methods: Twenty-six adult patients (age range 20–81 years) with soft tissue defects of the lower limb were treated at the Riga East University Hospital from 2018 to 2021. All patients were treated using the ADCr method which is the technique of establishing an interim deformity for resolving tissue loss. The lower extremity functional scale (LEFS) and application of methods of ilizarov (ASAMI) criteria were used for the evaluation of bone healing and lower extremity function. Results: Complete union was achieved in all cases. The functional evaluation showed that most patients could achieve excellent and good results and return to activities of daily living. The functional result was poor in one case of a multi-fragmentary distal tibial articular fracture for which an ankle fusion was performed. Final union in this case was achieved with some residual deformity. Conclusion: The method of ADCr is an effective surgical technique in cases of severe tibial injuries with concomitant loss of bone and soft tissues. This method could be used in cases when either a plastic or microsurgeon is not available or for instances when closing the defect with a flap is either impossible or contraindicated. Excellent and good functional results are possible without severe complications.
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    The Course and Surgical Treatment of Acute Appendicitis during the First and Second Wave of the COVID-19 Pandemic : A Retrospective Analysis in University Affiliated Hospital in Latvia
    (2023-02-05) Lescinska, Anna Marija; Sondare, Elza; Ptasnuka, Margarita; Mukāns, Maksims; Plaudis, Haralds; Faculty of Medicine
    Background and Objectives: Acute appendicitis is the most common abdominal emergency requiring surgery and it has an estimated lifetime risk of 6.7 to 8.6%. The COVID-19 pandemic has transformed medical care worldwide, influencing diagnostic tactics, treatment modalities and outcomes. Our study aims to compare and analyze management of acute appendicitis before and during the first and second waves of the pandemic. Materials and Methods: Patients suffering acute appendicitis were enrolled retrospectively in a single-center study for a 10-month period before the pandemic (pre-COVID-19 period: 1 March to 31 December 2019) and during the pandemic (COVID-19 period: 1 March to 31 December 2020). The total number of patients, disease severity, diagnostic methods, complications, length of hospitalization and outcomes were analyzed. Results: A total number of 863 patients were included, 454 patients in the pre-COVID-19 period and 409 patients in the COVID-19 period. Compared to the pre-COVID-19 period, the number of complicated appendicitis increased in the COVID-19 period (24.4% to 37.2%; p < 0.001). The proportion of laparoscopic appendectomies increased during the COVID-19 period but did not show statistically significant differences between periods. In both time periods, we found that open technique was the chosen surgical approach more frequently in elderly patients (p < 0.001). Generalized peritonitis was significantly more common during the COVID-19 period (3.5% vs. 6.1%, p < 0.001). The postoperative course of patients was similar in the pre-COVID-19 period and during the COVID-19 period, with no significant differences in ICU admissions, overall hospital stay or morbidity. Conclusions: The COVID-19 pandemic has led to a significant increase in complicated forms of acute appendicitis; however, no significant impact was observed in terms of diagnostic or treatment approach.
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    Early continuous veno-venous haemofiltration in the management of severe acute pancreatitis complicated with intra-abdominal hypertension : Retrospective review of 10 years’ experience
    (2012) Pupelis, Guntars; Plaudis, Haralds; Zeiza, Kaspars; Drozdova, Nadezda; Mukans, Maksims; Kazaka, Ita
    Background: Conservative treatment of patients with severe acute pancreatitis (SAP) may be associated with development of intra-abdominal hypertension (IAH), deterioration of visceral perfusion and increased risk of multiple organ dysfunction. Fluid balance is essential for maintenance of adequate organ perfusion and control of the third space. Timely application of continuous veno-venous haemofiltration (CVVH) may help in balancing fluid replacement and removal of cytokines from the blood and tissue compartments. The aim of the present study was to determine whether CVVH can be recommended as a constituent of conservative treatment in patients with SAP who suffer IAH. Methods: A retrospective analysis of 10 years’ experience with low-flow CVVH application in patients with SAP who develop IAH was. In all patients, measurement of the intra-abdominal pressure (IAP) was done indirectly through the urinary bladder. Sequential organ failure assessment (SOFA) score was calculated for severity assessment, and necrotizing forms were verified by contrast-enhanced computed tomography. Dynamics of IAP were analysed in parallel with signs of systemic inflammation, dynamics of C-reactive protein and cumulative fluid balance. All variables, complication rate and outcomes were analysed in the whole group and in patients with IAH (CVVH and no-CVVH groups). Results: From the total of 130 patients, 75 were treated with application of CVVH and 55 without CVVH. Late hospitalization was associated with application of CVVH. Infection was observed in 28.5% of cases regardless of the type of treatment received, with a similar necessity for surgical intervention. IAH was observed in 68.5% of patients, and they had significantly higher SOFA scores compared to patients with normal IAP. CVVH treatment resulted in negative cumulative fluid balance starting from day 5 in patients with IAH, whereas without this treatment, fluid balance remained increasingly positive after a week. Finally, application of CVVH resulted in a lower infection rate and shorter hospital stay, 26.7% vs. 37.9%, and a median of 32 (interquartile range (IQR) = 60 to 12) days vs. 24 (IQR = 34 to 4) days, p = 0.05, comparing CVVH vs. no-CVVH group. Mortality rate reached 11.7% in the CVVH group and 13.8% in the no-CVVH group. Conclusions: Early application of CVVH facilitates negative fluid balance and reduction of IAH in patients with SAP; it is not associated with increased infection or mortality rate and may reduce hospital stay.
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    Early Oral Feeding in Patients with Severe Acute Pancreatitis. Summary of the Doctoral Thesis
    (Rīga Stradiņš University, 2010) Plaudis, Haralds; Pupelis, Guntars
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    Endoscopic Retrograde Cholangiopancreatography Versus Laparoscopic Transcystic Balloon Dilatation of Papilla Vateri in Patients with Choledocholithiasis
    (2024-08) Aleksandrovs, Dmitrijs; Ivanovs, Igors; Plaudis, Haralds; Fokins, Vladimirs; Kaminskis, Aleksejs; Faculty of Medicine
    Two-step therapy, endoscopic retrograde cholangiopancreatography with papillotomy and stone evacuation from common bile duct (CBD), and laparoscopic cholecystectomy (ERCP/LC) is standard treatment of choledocholithiasis and acute cholecystitis in our hospital, Rīga East University Hospital Gaiļezers. The one-step method, LC with intraoperative transcystic balloon dilatation of the papilla Vateri and anterograde evacuation of gallstones to duodenum (BD/LC), has been introduced in our hospital. The aim of this study was to compare two-step and BD/LC methods and report the outcomes from hospital’s clinical experience. A retrospective, comparative study was done from 01.2021 to 10.2023. Patients with acute calculous cholecystitis and choledocholithiasis with gallstone diameter in CBD cm, ASA score I-III were included. Gallstone’s diameter and number, hospitalisation time, and success rate were analysed. A total of 95 patients were included in our study, of which 46 patients underwent BD/LC and in 49 patients ERCP/LC was used. Median diameter of gallstones in the CBD was 6.1 mm in BD/LC and 6.3 mm in the ERCP/LC group ( p = 0.38). Median hospitalisation time for patients with single-step treatment was seven days, and two-step therapy — 14 days ( p = 0.001). The complication rate in BD/LS was 4.34% but in ERCP/LC group — 10.2% after ERCP ( p = 0.049). The success rate in BD/LC was 95.6% and in ERCP/LC group — 89.6% ( p = 0.145). BD/LC is associated with a shorter hospitalisation time, similar success rate and lower complication rate compared with an ERCP/LC.
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    Fluorescence Cholangiography for Extrahepatic Bile Duct Visualization in Urgent Mild and Moderate Acute Cholecystitis Patients Undergoing Laparoscopic Cholecystectomy : A Prospective Pilot Study
    (2025-01-16) Pāvulāns, Jānis; Jain, Nityanand; Zeiza, Kaspars; Sondare, Elza; Cerpakovska, Krista Brigita; Opincāns, Jānis; Atstupens, Kristaps; Plaudis, Haralds; Department of Surgery; Department of Doctoral Studies; Statistics Unit
    Background: Laparoscopic cholecystectomy for acute cholecystitis carries an increased risk of biliovascular injuries. Fluorescence cholangiography (FC) is a valuable diagnostic tool for identifying extrahepatic bile ducts (EHBD). The objective of this study was to evaluate the efficacy of FC in delineating EHBD anatomy, both before and after dissection, based on the critical view of safety (CVS) principles. Methods: Urgently admitted patients were prospectively stratified into two groups, depending on whether they had mild or moderate acute cholecystitis, in accordance with the 2018 Tokyo guidelines. All patients were scheduled for an early laparoscopic cholecystectomy using FC and were administered a fixed dose of indocyanine green (ICG) intravenously 12 h prior to the surgical procedure. Results: A total of 108 patients—75 patients with mild acute cholecystitis and 33 patients with moderate acute cholecystitis—were included. More than four CVS steps were performed in 101 patients (93.5%). Less than four CVS steps were performed only in seven patients—three (2.5%) patients with mild acute cholecystitis and four (4%) patients with moderate acute cholecystitis. The achievement of the CVS principles and the visualization rate using FC significantly increased in both patient groups, ranging from 3% before CVS to 100% after CVS (p < 0.001). In both groups, the cystic duct was visualized in most patients after CVS and FC, followed by the common bile duct and the common hepatic duct. Conversely, even after using CVS and FC, the visualization of the confluence of the cystic and common hepatic ducts remained less likely and challenging in both groups (57.3% in mild patients vs. 33.3% in moderate patients; p = 0.022). Background liver fluorescence disturbance was observed equally in both patient groups (6–11%), but it did not reach statistical significance. The median operative time was 60 ± 25 min in patients with mild acute cholecystitis compared to 85 ± 37 min in patients suffering from moderate acute cholecystitis (p < 0.001). No postoperative complications or biliovascular injuries were observed. Conclusions: FC is a convenient, safe, and efficacious procedure for attaining CVS principles and identifying the EHBD anatomy in most patients. The procedure showed superior results in mild acute cholecystitis patients in comparison to moderate acute cholecystitis patients.
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    Focused open necrosectomy in necrotizing pancreatitis
    (2013) Pupelis, Guntars; Fokin, Vladimir; Zeiza, Kaspars; Plaudis, Haralds; Suhova, Anastasija; Drozdova, Nadezda; Boka, Viesturs
    Background: The control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with abs focused open necrosectomy (FON) in patients with infected necrosis. Method: A prospective pilot study conducted to compare a semi-open/closed drainage laparotomy and FON with the assistance of peri-operative ultrasound. The incidence of sepsis, dynamics of C-reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed. Results: From a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post-operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139. Discussion: FON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis.
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    Intraoperatīvas ultrasonogrāfijas pielietošana laparoskopiskas holecistektomijas laikā pacientiem ar aizdomām par holedoholitiāzi. Promocijas darba kopsavilkums
    (Rīgas Stradiņa universitāte, 2020) Atstupens, Kristaps; Pupelis, Guntars; Plaudis, Haralds
    Holelitiāze jeb žultsakmeņu slimība ir viena no biežākajām slimībām Eiropā, kam nepieciešama ķirurģiska ārstēšana. Holelitiāzes prevelence Latvijā un Eiropā ir augsta. Tā pieaug līdz ar iedzīvotāju demogrāfiskās struktūras izmaiņām, galvenokārt liela vecu cilvēku īpatsvara dēļ dominējoši sieviešu dzimumam, kā arī asociējas ar rietumniecisku diētu un dzīvesveidu. Statistikas dati liecina, ka Eiropas populācijā vidēji ir 5,9–21,9 % pacientu ar žultsakmeņu slimību (Aerts and Penninckx, 2003) un 11–21 % ir sastopami konkrementi žultsvados jeb holedoholitiāze operācijas laikā (Costi et al., 2014). Holedoholitiāze ir viena no biežākajām žultsakmeņu slimības komplikācijām, kas var radīt biliāru obstrukciju un žults atteces traucējumus. Parasti tā manifestējas ar biliāru pankreatītu un ascendējošu biliāru infekciju, bieži vien attīstoties arī mehāniskai dzeltei, ko klīniski definē kā holangītu. Visos šajos gadījumos ir augsts sepses un multiorgānu disfunkcijas risks. Bieži ir nepieciešama intensīvās terapijas speciālistu līdzdalība un nepieciešamība ārstēties intensīvās terapijas nodaļā, pielietojot dārgas un laikietilpīgas diagnostikas un ārstēšanas metodes. Šādu pacientu aprūpē nereti tiek iesaistīti ne tikai ķirurgi, bet arī radiologi, invazīvie radiologi, invazīvās endoskopijas speciālisti, gastroenterologi un intensīvās terapijas speciālisti. Kopējās ārstēšanas izmaksas ir lielas, ārstēšana ir ilgstoša un saistīta ar augstu letalitāti. Holedoholitiāzes attēldiagnostikas zelta standarts pirms operācijas ir magnētiskās rezonanses holangiopankreatogrāfija (MRHPG), kaut gan pētījumos ir pierādīts, ka intraoperatīvā atradne 15–20 % gadījumu nesakrīt ar preoperatīvi MRHPG sniegtajiem datiem (Costi et al., 2014). Tā var nebūt pietiekami informatīva gadījumos, kad konkrementi kopējā žultsvadā ir mazāki par 5 mm (Costi et al., 2014), kā arī neapšaubāms ir fakts, ka MRHPG pielietojums ir ierobežots akūtās plūsmas slimniekiem. Iepriekš minētais liek meklēt jaunus risinājumus efektīvākai holedoholitiāzes diagnostikai. Apzinoties mūsdienās pieejamo plašo holedoholitiāzes diagnostikas un ārstēšanas metožu spektru, joprojām bez skaidri definētas atbildes paliek jautājumi: kā lētāk un precīzāk diagnosticēt holedoholitiāzi un kāda efektīvākā ārstēšanas metode būtu jāizvēlas? Attīstoties dažādām attēldiagnostikas metodēm, endoskopijai un laparoskopiskajai ķirurģijai, holedoholitiāzes pacientu aprūpes modelis pēdējo 30 gadu laikā ir ļoti mainījies. Laparoskopiskas holecistektomijas laikā žultsceļu izmeklēšana, kontrolējot holedoholitiāzi, praksē netiek veikta visiem pacientiem. Vadlīnijās šāda taktika ir rekomendēta pacientiem ar zemu holedoholitiāzes risku, kā arī pacientiem pēc preoperatīvas endoskopiskas papilotomijas un žultsceļu sanācijas (Costi et al., 2014). Šī taktika var būt izvēlēta arī pacientiem ar MRHPG nediagnosticētu holedoholitiāzi. Savukārt endoskopiska retrogrāda holangiopankreatogrāfija (ERHP) ar endoskopisku papilotomiju (EP) mūsdienās ir izmantojama tikai kā ārstnieciska procedūra pacientiem ar pierādītu holedoholitiāzi, jo 9,8 % pacientu ERHP ir saistīta ar potenciāli dzīvību apdraudošām komplikācijām – pēc-ERHP pankreatītu, asiņošanu no papilotomijas vietas vai 12-pirkstu zarnas perforāciju uz retroperitoneālo telpu (Freeman et al., 1996). Jāatzīmē, ka ERHP izmantošana ir ierobežota arī pacientiem ar biliāru pankreatītu (Laura and Eldon, 2012; Anu and Kapoor, 2012; Sgouros and Bergele, 2006). Rūpīgi izvērtētas endoskopiskas metodes indikācijas un speciālista pieredze ir galvenais, kas nosaka ERHP izmantošanas sekmes, mazākā mērā saistot to ar pacienta vecumu un vispārējo stāvokli (Laura and Eldon, 2012). Arvien biežāk tiek publicēti ziņojumi par vienetapa laparoskopiskas komplicētas žultsakmeņu slimības diagnostikas un ārstēšanas iespējām, operācijas laikā veicot gan holecistektomiju, gan precīzu holedoholitiāzes diagnostiku un nepieciešamības gadījumā arī veicot žultsvadu sanāciju. Pastāv divas galvenās intraoperatīvās žultsceļu attēldiagnostikas metodes – intraoperatīva holangiogrāfija (IOH) un intraoperatīva ultrasonogrāfija (IOUS). Lai gan IOH tiek plaši pielietota, 5,1 % gadījumu tā var būt nepilnvērtīga un 15–20 % gadījumu holedoholitiāzi var nediagnosticēt (Bencini et al., 2014; Costi et al., 2014; Tazuma, 2006). Izpētot literatūras datus, var secināt, ka IOUS ir efektīva un droša, ko arī apliecina mūsu pieredze. IOUS ir ātri veicama, lēta un precīza holedoholitiāzes diagnostikas metode. Operējošam ķirurgam tā sniedz ne vien svarīgu informāciju par žultsvada saturu, bet arī palīdz orientēties netipiskas anatomijas gadījumos, diagnosticējot žultsvadu anatomiskas variācijas un asinsvadu lokalizāciju. Turklāt izmeklējumu iespējams atkārtot jebkurā operācijas etapā. Latvijā IOUS ir uzskatāma par salīdzinoši jaunu un iepriekš nepētītu intraoperatīvu holedoholitiāzes diagnostikas metodi.
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    Intraoperatīvas ultrasonogrāfijas pielietošana laparoskopiskas holecistektomijas laikā pacientiem ar aizdomām par holedoholitiāzi. Promocijas darbs
    (Rīgas Stradiņa universitāte, 2020) Atstupens, Kristaps; Pupelis, Guntars; Plaudis, Haralds
    Holelitiāze jeb žultsakmeņu slimība ir viena no biežākajām slimībām Eiropā, kam nepieciešama ķirurģiska ārstēšana. Holelitiāzes prevelence Latvijā un Eiropā ir augsta. Tā pieaug līdz ar iedzīvotāju demogrāfiskās struktūras izmaiņām, galvenokārt liela vecu cilvēku īpatsvara dēļ dominējoši sieviešu dzimumam, kā arī asociējas ar rietumniecisku diētu un dzīvesveidu. Statistikas dati liecina, ka Eiropas populācijā vidēji ir 5,9–21,9 % pacientu ar žultsakmeņu slimību (Aerts and Penninckx, 2003) un 11–21 % ir sastopami konkrementi žultsvados jeb holedoholitiāze operācijas laikā (Costi et al., 2014). Holedoholitiāze ir viena no biežākajām žultsakmeņu slimības komplikācijām, kas var radīt biliāru obstrukciju un žults atteces traucējumus. Parasti tā manifestējas ar biliāru pankreatītu un ascendējošu biliāru infekciju, bieži vien attīstoties arī mehāniskai dzeltei, ko klīniski definē kā holangītu. Visos šajos gadījumos ir augsts sepses un multiorgānu disfunkcijas risks. Bieži ir nepieciešama intensīvās terapijas speciālistu līdzdalība un nepieciešamība ārstēties intensīvās terapijas nodaļā, pielietojot dārgas un laikietilpīgas diagnostikas un ārstēšanas metodes. Šādu pacientu aprūpē nereti tiek iesaistīti ne tikai ķirurgi, bet arī radiologi, invazīvie radiologi, invazīvās endoskopijas speciālisti, gastroenterologi un intensīvās terapijas speciālisti. Kopējās ārstēšanas izmaksas ir lielas, ārstēšana ir ilgstoša un saistīta ar augstu letalitāti. Holedoholitiāzes attēldiagnostikas zelta standarts pirms operācijas ir magnētiskās rezonanses holangiopankreatogrāfija (MRHPG), kaut gan pētījumos ir pierādīts, ka intraoperatīvā atradne 15–20 % gadījumu nesakrīt ar preoperatīvi MRHPG sniegtajiem datiem (Costi et al., 2014). Tā var nebūt pietiekami informatīva gadījumos, kad konkrementi kopējā žultsvadā ir mazāki par 5 mm (Costi et al., 2014), kā arī neapšaubāms ir fakts, ka MRHPG pielietojums ir ierobežots akūtās plūsmas slimniekiem. Iepriekš minētais liek meklēt jaunus risinājumus efektīvākai holedoholitiāzes diagnostikai. Apzinoties mūsdienās pieejamo plašo holedoholitiāzes diagnostikas un ārstēšanas metožu spektru, joprojām bez skaidri definētas atbildes paliek jautājumi: kā lētāk un precīzāk diagnosticēt holedoholitiāzi un kāda efektīvākā ārstēšanas metode būtu jāizvēlas? Attīstoties dažādām attēldiagnostikas metodēm, endoskopijai un laparoskopiskajai ķirurģijai, holedoholitiāzes pacientu aprūpes modelis pēdējo 30 gadu laikā ir ļoti mainījies. Laparoskopiskas holecistektomijas laikā žultsceļu izmeklēšana, kontrolējot holedoholitiāzi, praksē netiek veikta visiem pacientiem. Vadlīnijās šāda taktika ir rekomendēta pacientiem ar zemu holedoholitiāzes risku, kā arī pacientiem pēc preoperatīvas endoskopiskas papilotomijas un žultsceļu sanācijas (Costi et al., 2014). Šī taktika var būt izvēlēta arī pacientiem ar MRHPG nediagnosticētu holedoholitiāzi. Savukārt endoskopiska retrogrāda holangiopankreatogrāfija (ERHP) ar endoskopisku papilotomiju (EP) mūsdienās ir izmantojama tikai kā ārstnieciska procedūra pacientiem ar pierādītu holedoholitiāzi, jo 9,8 % pacientu ERHP ir saistīta ar potenciāli dzīvību apdraudošām komplikācijām – pēc-ERHP pankreatītu, asiņošanu no papilotomijas vietas vai 12-pirkstu zarnas perforāciju uz retroperitoneālo telpu (Freeman et al., 1996). Jāatzīmē, ka ERHP izmantošana ir ierobežota arī pacientiem ar biliāru pankreatītu (Laura and Eldon, 2012; Anu and Kapoor, 2012; Sgouros and Bergele, 2006). Rūpīgi izvērtētas endoskopiskas metodes indikācijas un speciālista pieredze ir galvenais, kas nosaka ERHP izmantošanas sekmes, mazākā mērā saistot to ar pacienta vecumu un vispārējo stāvokli (Laura and Eldon, 2012). Arvien biežāk tiek publicēti ziņojumi par vienetapa laparoskopiskas komplicētas žultsakmeņu slimības diagnostikas un ārstēšanas iespējām, operācijas laikā veicot gan holecistektomiju, gan precīzu holedoholitiāzes diagnostiku un nepieciešamības gadījumā arī veicot žultsvadu sanāciju. Pastāv divas galvenās intraoperatīvās žultsceļu attēldiagnostikas metodes – intraoperatīva holangiogrāfija (IOH) un intraoperatīva ultrasonogrāfija (IOUS). Lai gan IOH tiek plaši pielietota, 5,1 % gadījumu tā var būt nepilnvērtīga un 15–20 % gadījumu holedoholitiāzi var nediagnosticēt (Bencini et al., 2014; Costi et al., 2014; Tazuma, 2006). Izpētot literatūras datus, var secināt, ka IOUS ir efektīva un droša, ko arī apliecina mūsu pieredze. IOUS ir ātri veicama, lēta un precīza holedoholitiāzes diagnostikas metode. Operējošam ķirurgam tā sniedz ne vien svarīgu informāciju par žultsvada saturu, bet arī palīdz orientēties netipiskas anatomijas gadījumos, diagnosticējot žultsvadu anatomiskas variācijas un asinsvadu lokalizāciju. Turklāt izmeklējumu iespējams atkārtot jebkurā operācijas etapā. Latvijā IOUS ir uzskatāma par salīdzinoši jaunu un iepriekš nepētītu intraoperatīvu holedoholitiāzes diagnostikas metodi.
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    The role of the open abdomen procedure in managing severe abdominal sepsis : WSES position paper
    (2015-08-12) Sartelli, Massimo; Abu-Zidan, Fikri M.; Ansaloni, Luca; Bala, Miklosh; Beltrán, Marcelo A.; Biffl, Walter L.; Catena, Fausto; Chiara, Osvaldo; Coccolini, Federico; Coimbra, Raul; Demetrashvili, Zaza; Demetriades, Demetrios; Diaz, Jose J.; Di Saverio, Salomone; Fraga, Gustavo P.; Ghnnam, Wagih; Griffiths, Ewen A.; Gupta, Sanjay; Hecker, Andreas; Karamarkovic, Aleksandar; Kong, Victor Y.; Kafka-Ritsch, Reinhold; Kluger, Yoram; Latifi, Rifat; Leppaniemi, Ari; Lee, Jae Gil; McFarlane, Michael; Marwah, Sanjay; Moore, Frederick A.; Ordonez, Carlos A.; Pereira, Gerson Alves; Plaudis, Haralds; Shelat, Vishal G.; Ulrych, Jan; Zachariah, Sanoop K.; Zielinski, Martin D.; Garcia, Maria Paula; Moore, Ernest E.
    The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.
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    Safe laparoscopic clearance of the common bile duct in emergently admitted patients with choledocholithiasis and cholangitis
    (2016) Atstupens, Kristaps; Plaudis, Haralds; Fokins, Vladimirs; Mukans, Maksims; Pupelis, Guntars
    Backgrounds/Aims: Laparoscopic treatment of patients with choledocholithiasis and cholangitis is challenging due to mandatory recovery of the biliary drainage and clearance of the common bile duct (CBD). The aim of our study was to assess postoperative course of cholangitis and biliary sepsis after laparoscopic clearance of the CBD in emergently admitted patients with choledocholithiasis and cholangitis. Methods: Emergently admitted patients who underwent lapa-roscopic clearance of the CBD were included prospectively and stratified in 2 groups i.e., cholangitis positive (CH+) or negative (CH-) group. Patient demographics, comorbidities, preoperative imaging data, inflammatory response, surgi-cal intervention, complication rate and outcomes were compared between groups. Results: Ninety-nine of a total 320 patients underwent laparoscopic clearance of the CBD, of which, 60 belonged to the acute cholangitis group (CH+) and 39 to the cholangitis negative group (CH-). Interventions were done on average 4 days after admission, operation duration was 95-105 min, and the conversion rate was 3-7% without differences in the groups. Preoperative in-flammatory response was markedly higher in the CH+ group. Inflammation signs on intraoperative choledochoscopy were more evident in patients with cholangitis. Postoperative inflammatory response did not differ between the groups. The overall complication rate was 8.3% and 5.1%, respectively. Laparoscopic clearance of the CBD resulted in 1 lethal case (CH+ group), resulting in 1% mortality rate and a similar 12-month readmission rate. Conclusions: Single-stage laparoscopic intraoperative US and choledochoscopy-assisted clearance of the CBD is feasible in emergently admitted patients with choledocholithiasis and cholangitis. (Korean J Hepatobiliary Pancreat Surg 2016;20:53-60)
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    Sporadic pancreatic neuroendocrine neoplasms : A retrospective clinicopathological and outcome analysis from a Latvian study group
    (2023-03-20) Ptasnuka, Margarita; Truskovs, Arturs; Ozolins, Arturs; Narbuts, Zenons; Sperga, Maris; Plaudis, Haralds; Department of Surgery
    BACKGROUND: Although pancreatic neuroendocrine neoplasms (PNEN) are rare, there has been a constant increase in incidence. Furthermore, PNEN present unique clinical behaviors and long-term survival can be expected even in the presence of metastases as compared with ductal adenocarcinoma of the pancreas. Determining the best therapeutic approach and proper timing of therapy requires knowledge of reliable prognostic factors. Therefore, the aim of this study was to explore clinicopathological features, treatment, and survival outcomes of patients with PNEN based on Latvian gastroenteropancreatic neuroendocrine neoplasm (GEP-NEN) registry data. METHOD: Patients with confirmed PNEN at Riga East Clinical University Hospital and Pauls Stradins Clinical University Hospital, between 2008 and 2020, were retrospectively analyzed. Data were collected and included in EUROCRINE, an open-label international endocrine surgical registry. RESULTS: In total, 105 patients were included. The median age at diagnosis was 64 years (IQR 53.0-70.0) for males and 61 years (IQR 52.5-69.0) for females. In 77.1% of patients, tumors were hormonally nonfunctional. Among those with functioning PNEN, 10.5% of patients presented with hypoglycemia and were diagnosed with insulinoma, 6.7% of patients presented with symptoms related to carcinoid syndrome; 30.5% of patients showed distant metastases at the time of diagnosis, and surgery was performed in 67.6% of patients. Notably, for five patients with nonfunctional PNEN <2 cm, a "watch and wait" approach was used; none of the patients developed metastatic disease. The median length of hospital stay was 8 days (IQR 5-13). Major postoperative complications were found in 7.0% of patients, and reoperation was conducted for 4.2% of patients, due to postpancreatectomy bleeding (2/71) and abdominal collection (1/71). The median follow-up period was 34 months (IQR 15.0-68.8). The OS at the last follow-up was 75.2% (79/105). The observed 1-, 5- and 10-year survival rates were 87.0, 71.2 and 58.0, respectively. Seven of the surgically treated patients had tumor recurrence. The median time of recurrence was 39 months (IQR 19.0-95.0). A univariable Cox proportional hazard analysis provided evidence that a nonfunctional tumor, a larger tumor size, the presence of distant metastases, a higher tumor grade, and the tumor stage were strong, negative predictors of OS. CONCLUSION: Our study represents the general trends of clinicopathological features and treatment of PNEN in Latvia. For PNEN patients, tumor functionality, size, distant metastases, grade, and stage may be useful to predict OS and must be confirmed in further studies. Furthermore, a "surveillance" strategy might be safe for selected patients with small asymptomatic PNEN.
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    The Role of Laparoscopic Intraoperative Ultrasonography in Patients with Suspected Choledocholithiasis. Summary of the Doctoral Thesis
    (Rīga Stradiņš University, 2020) Atstupens, Kristaps; Pupelis, Guntars; Plaudis, Haralds
    One of the most common conditions in Europe that requires surgical intervention is cholelithiasis or gallstone disease. The prevalence of gallstone disease in Latvia and European countries is high. Increase of gallstone disease is associated with specific demographic pattern due to the large proportion of old people especially female gender and is associated with Western diet and life style. According to the statistics, about 5.9–21.9 % of the European population may suffer from cholelithiasis (Aerts and Penninckx, 2003), and 11–21 % of patients who undergo cholecystectomy may have stones in the common bile duct (CBD) (Costi et al., 2014). Choledocholithiasis is one of the most common complications of gallstone disease and may couse biliary obstruction. Usually it manifests with biliary pancreatitis and ascending biliary infection frequently accopanied by mechanical jaundice and clinical presentation of cholangitis. In all of these clinical conditions risk of development of sepsis and multiorgan disfunction is increased. So, frequently it requires treatment in the intensive care unit and expensive as well as time-consuming diagnostic and therapeutic methods. This category of patients requires multidisciplinary approach involving radiology, endoscopy, gastroenterology and intensive care specialists who collaborate with surgeons. Overall treatment costs are significant, hospital stay is prolonged and associated with high mortality. Radiological imaging of choledocholithiasis by magnetic resonance cholangiopancreatography (MRCP) is a golden standard for patients with gallstone disease in preoperative setting, however, some studies have reported unconformity between preoperative MRCP and intraoperative finding up to 15–20 %, as well as MRCP may miss stones less then 5 mm especially in patients with biliary pancreatitis (Costi et al., 2014). Moreover, application of MRCP in urgently admitted patients has its limits. According to the abovementioned facts the requirement for new solutions in more precise detection of choledocholithiasis is crucial. Despite the wide spectrum of the different diagnostic and treatment modalities, the question remains, how cheaper and more accurately confirm bile duct stones and what is the most effective treatment method? Over the last 30 years, many diagnostic modalities, endoscopy and laparoscopy has changed, so the management of the choledocholithiasis has become different. During the laparoscopic cholecystectomy intraoperative control of CBD stones is not performed routinely. It is not recommended in patients who are in low risk of choledocholithiasis and in patients after preoperative endoscopic papillotomy and clearance of the CBD (Costi et al., 2014). Intraoperative control of the choledocholithiasis is also deemed to be unnecessary in patients with MRCP proved absence of biliary stones before surgery. Endoscopic retrograde cholangio-pancreatography (ERCP) typically combined with sphincterotomy, is a routine therapeutic procedure in the cases of proven stones in the CBD. However, it is associated with up to a 9.8 % complication rate, including post-ERCP pancreatitis, bleeding and duodenal perforation (Freeman at al., 1996) as well as restrictions in patients with biliary pancreatitis (Laura and Eldon, 2012; Anu and Kapoor, 2012; Sgouros and Bergele, 2006). Technical skills and proper clinical indications for the procedure is a major determinant of its success, rather than the age or the general medical condition of the patients (Laura and Eldon, 2012). Laparoscopic option of treatment of emergent patients with a complicated gallstone disease and suspected choledocholithiasis is more challenging due to the limited time for preoperative MRCP or ERCP. Surgical intervention is often more complicated due to oedema and inflammation. Most common intraoperative diagnostic methods of choledocholithiasis are intraoperative cholangiography (IOC) and intraoperative ultrasound (IOUS). Although IOC may improve the diagnostic accuracy, it is associated with a 5.1 % unsuccessful procedure rate, increased operative time and a 15–20 % rate of overlooked biliary stones (Bencini et al., 2014; Costi et al., 2014; Tazuma, 2006). Development of the laparoscopic IOUS was an essential and reasonable alternative to IOH and mostly to preoperative specific imaging. It provides not only information about the content of the bile duct, but also helps to navigate in caes of ambiguous anatomy. In addition, IOUS can be repeated at any stage of operation. In Latvia IOUS regarded as a relatively new diagnostic modality for detection of common bile duct stones and previously have not been studied.