There are no absolute contraindications to surgical treatment. Stages and tasks of preoperative preparation, indications and contraindications for surgery

Indications for surgery. It is necessary to distinguish indications that are of a general nature, for example, emergency care, and special ones, depending on the characteristics of each disease.

The need for surgical intervention dictates the disease itself, its nature and course. As in adults, there are three groups of diseases.

1. Diseases requiring emergency or urgent surgery, such as strangulated hernia, congenital atresia of the gastrointestinal tract, perforated appendicitis, penetrating wound, etc.

2. Diseases that require surgery, but not in an urgent or urgent manner, for example, an incarcerated hernia, hydrocephalus, polydactylism, hemangioma.

3. Diseases in which it is expedient to postpone surgical interventions until the child reaches a certain degree of development, for example, cleft palate, anomalies in the development of the genitourinary organs, malformations of the heart and great vessels.

Contraindications for surgery. An absolute contraindication is a preagonal or atonal state, as well as a state of shock or collapse. First, it is necessary to remove the child from them, and then to understand the expediency and possibility of surgical intervention.

Unpromising operations are contraindicated, for example, in non-viable newborns, complex reconstructive operations in children with severe mental development disorders.

Along with contraindications, depending on the general condition of the body and local changes, children have a number of relative contraindications. These include:
1) malnutrition (dystrophy), insufficient general development, weight loss;
2) anemia;
3) digestive disorders, diarrhea;
4) diseases of the respiratory organs, their catarrhal conditions;
5) unsatisfactory condition of the skin: pyoderma, recent phenomena of exudative diathesis;
6) active rickets;
7) infectious diseases in the acute period, during incubation and for the first time after the transfer of their so-called goiter-lymphatic state.

In addition to those mentioned, there may be other unfavorable conditions for the operation. However, with a threat to life, for example, with intussusception, acute appendicitis, strangulated hernia, all of them cannot be an obstacle to the production of the necessary surgical intervention.

Parental Consent. Surgical interventions in children should be performed after obtaining written permission from parents or responsible caregivers. Deviation from this rule is permissible in the absence of them in cases of emergency or urgent surgery. If it is impossible to issue their written consent, it is recommended to urgently convene a council of at least two doctors, notify the head of the department and the chief physician of the hospital.

Terms of the operation. The duration of the operation depends on the nature of the disease and on the indications for the operation. Surgical intervention can be performed in a child at any age, even in a newborn.

In an urgent and urgent manner, it is necessary to operate children with a threat to life. They depend on the nature of the disease, the development and general health of the child, as well as on the capabilities of the surgical technique and the state of anesthesiology.

Research before surgery. In most cases, a general clinical examination is sufficient. However, in a number of cases, with anomalies, injuries or diseases accompanied by a significant impairment of the functions of the corresponding organ systems (blood circulation, respiration, excretion, etc.), special studies are required.

For some diseases hematological and biochemical blood tests are of great importance A: sugar and blood proteins, colloid resistance; determination of chlorides, potassium, sodium, calcium, inorganic phosphorus, alkaline phosphatase, acid-base balance, blood enzymes, etc. Monograms and osmograms are also of great importance in the practice of pediatric surgical clinics. In some diseases, methods of functional diagnostics of the liver, kidneys, endocrine glands, methods of cytological, chemical, microbiological studies are indicated.

In the indicated cases, X-ray examination methods are used: fluoroscopy, radiography, the use of contrast agents, tomography, ascending and descending urography, bronchography, angiography, angiocardiography, etc. X-ray examination for the presence of an enlarged goiter gland is of particular importance in children.

Endoscopic research methods: sigmoidoscopy, cystoscopy, esophagoscopy, tracheo- and bronchoscopy are widely used. Smaller special tools are used. Sufficient experience of the doctor is required during production.

Preparing for the operation depends on the nature of the intervention itself, the disease, the age and general condition of the child. Before serious operations, a detailed check of the child's health using functional diagnostic methods is necessary.

In case of urgent surgical interventions for acute appendicitis, intussusception, strangulated hernia, etc., it is necessary to restore the disturbed water-salt metabolism by introducing Ringer-Locke solution or isotonic sodium chloride solution and blood transfusion.

Responsibility for proper preparation for surgery, for the correct conduct of it, and for the correct postoperative care, both the attending surgeon and the anesthesiologist bear the same responsibility.

As soon as the child begins to navigate the environment, it is necessary to reckon with his emotional state. In mental preparation, the assistance of parents and educators is of great importance. Children should be prepared both for hospitalization and for the upcoming operation.

Name surgical operation is made up of the name of the organ on which it is performed and the term that denotes the operational technique being performed.

The following terms are used:

Tomia- dissection, incision, opening;

ectomy- excision;

extirpation- isolation, husking;

resection- partial excision;

amputation- removal of the peripheral part of the organ;

stomia- creation of an artificial fistula;

centes- puncture.

This is where the following names come from:

rumenotomy(rumen - scar, tomia - dissection) - dissection of the scar;
enterectomy(enteron - gut, ectomia - excision) - excision of the intestine.
urethrostomy(urethra - the urethra, stomia - the creation of an artificial fistula) - the creation of an artificial fistula of the urethra.

Indications and contraindications for operations

Each surgical operation preceded by a diagnosis based on clinical, laboratory or radiological examination.

After that operation substantiate with relevant evidence. In all difficult and doubtful cases of determining indications for surgery, it is necessary to resort to a consultation.

« A cleverly performed surgical operation does not give the right to the title of an experienced clinician. Only a doctor with good clinical training can be a good surgeon.».

Indications for surgery- these are cases when surgical operations are necessary or can be performed.

Indications may be:

absolute(indicatio vitalis) - those cases in which there is no other way to cure the animal (malignant neoplasms, bleeding, suffocation, pneumothorax, tympania of the scar, prolapse of internal organs);
relative- those cases in which the operation can be omitted without causing significant damage to the health and productivity of the animal, or when the operation is not the only method of treatment (benign tumor, not strangulated hernia).

NB! You can not resort to surgery when the animal can be cured in an easier and safer way, but do not neglect the operation when it is the only method of treatment.

Contraindications for surgery- these are cases when the operation cannot or is undesirable to perform.

They are divided into:

Contraindications due to the serious condition of the animal:

With exhaustion, old age, exacerbation of the inflammatory process, fever, infectious disease, a large amount of damage, the second half of pregnancy, sexual hunting in females.

An exception is urgent operations (strangulated hernia, phlegmon, malignant tumor). In these cases, the entire risk must be explained to the owner of the animal.

Contraindications due to economic and organizational factors:

when imposing a quarantine for an infectious disease characteristic of this type of animal (erysipelas, plague, washing horses, anthrax);
before the transfer and regrouping of animals;
2 weeks before and within 2 weeks after preventive vaccination;
in the absence of appropriate sanitary conditions for the postoperative maintenance of animals.

The exception is urgent cases that require emergency intervention, in which the operation must be performed in compliance with all the rules of one's own protection and prevention of the further spread of the disease.

Mass operations cannot be carried out in farms that do not have the proper conditions for the postoperative maintenance of animals (calves cannot be castrated if they are kept knee-deep in slurry).

Any surgical operation involving a risk to the life of the animal must be performed only with the written consent of the legal owner of the animal or his representative (head of the farm, private owner of the animal).

If we are talking about an animal that is state property, then the doctor, who imagines the whole need for an operation, must insist on its performance, and, if necessary, operate without waiting for consent.

Any surgical operation has a relative degree of risk.

1 degree - easy.

The risk is negligible. The existing disorders do not affect the general condition and do not cause disorders in other organs and tissues. This group also includes planned operations.

Grade 2 - moderate.

This applies to emergency operations that cannot be postponed, and the animal has moderately severe cardiac or respiratory failure.

Grade 3 - severe.

A sick animal had local lesions of vital organs (myocardial infarction, acute respiratory failure, diabetes).

Childbirth is the most natural and most unpredictable process. Even a woman who becomes a mother not for the first time cannot predict exactly how her child will be born. There are many cases when a woman, despite the plans of doctors, gave birth safely on her own, but it happens that successful, at first glance, childbirth ended in an emergency caesarean section. Let's find out what are the indications (and contraindications) for a caesarean section.

Elective caesarean section

There is a division into absolute and relative indications for this operation.

Absolute indications for planned caesarean section

Absolute indications for caesarean section include reasons when natural childbirth is impossible or carries a very high risk to the health of the mother or fetus.

narrow pelvis

Sometimes the anatomical structure of a woman does not allow the child to pass through the pelvic ring: the dimensions of the mother's pelvis are smaller than the presenting part (usually the head) of the child. There are criteria for the size of a normal and narrow pelvis according to the degree of narrowing.

With an anatomically very narrow pelvis:

III-IV degree, the operation will be carried out in a planned manner;
II degree of narrowing, the decision will be made during childbirth;
I degree childbirth will take place naturally in the absence of other indications.

Mechanical obstacles interfering with natural childbirth

This may be uterine fibroids in the isthmus (i.e., in the area where the uterus passes into the cervix), ovarian tumors, tumors and deformities of the pelvic bones.

Threat of uterine rupture

It most often occurs when there is a scar on the uterus, for example, due to a previous caesarean section, as well as due to numerous previous births, when the walls of the uterus are very thin. The consistency of the scar is determined by ultrasound and its condition before and during childbirth.

placenta previa

Sometimes the placenta is attached in the lower third and even directly above the cervix, blocking the fetus's exit. This is fraught with severe bleeding, dangerous for the mother and child, and can lead to placental abruption. Diagnosed by ultrasound, the operation is prescribed for a period of 33 weeks of pregnancy or earlier if blood discharge is detected, indicating placental abruption.

In these cases, it is necessary to perform an operative delivery using a caesarean section, regardless of all other conditions and possible contraindications.

Relative indications for surgery

Chronic diseases of the mother

Cardiovascular diseases, diseases of the kidneys, eyes, diseases of the nervous system, diabetes mellitus, oncological diseases - in a word, any pathologies that can worsen during contractions and attempts. Such conditions include exacerbation of diseases of the genital tract (for example, genital herpes) - although childbirth in this case does not significantly aggravate the condition of the woman, but when passing through the birth canal, the disease can be transmitted to the child.

Certain complications of pregnancy that threaten the life of the mother or child.

The possibility of delivery through caesarean section is offered in severe forms of preeclampsia with dysfunction of vital organs, especially the cardiovascular system.

Recently, pregnancy after prolonged infertility or after in vitro fertilization has become a relative indication for delivery through caesarean section. Women who are carrying a long-awaited child are sometimes so worried because of the fear of losing him that, in the absence of physical disorders, they cannot “tune in” to the birth process in any way.

Malposition

Rupture of the anal sphincter in history

large fruit

A large child is considered to be a child whose birth weight is 4 kilograms or more, and if its weight is more than five kilograms, then the fetus is considered gigantic.

Emergency caesarean section

Sometimes the impossibility of spontaneous childbirth becomes known only at the time of contractions. Also during pregnancy, situations may arise when the life of the mother and the unborn child is at risk. In these cases, an emergency delivery by caesarean section is performed.

Persistent weakness of labor activity

If natural childbirth goes without progress for a long time, despite the use of medications that enhance labor activity, then a decision is made about a caesarean section.

Premature placental abruption

Separation of the placenta from the uterus before or during childbirth. This is dangerous both for the mother (massive bleeding) and for the child (acute hypoxia). An emergency caesarean section is being performed.

Presentation and prolapse of the umbilical cord

Sometimes (especially with the baby's foot presentation), the umbilical cord or its loops fall out before the widest part of the baby is born - the head. In this case, the umbilical cord is clamped and, in fact, the child is temporarily deprived of blood supply, which threatens his health and even life.

Clinically narrow pelvis

Sometimes, with normal dimensions of the pelvis at the time of childbirth, it turns out that the internal ones still do not correspond to the size of the fetal head. This becomes clear when there are good contractions, there is an opening of the cervix, but the head, with good labor activity and attempts, does not move along the birth canal. In such cases, they wait about an hour and, if the baby's head does not move forward, an operation is recommended.

Premature (before contractions) rupture of amniotic fluid in the absence of the effect of cervical stimulation

With the outpouring of water, regular labor can begin, but sometimes contractions do not begin. In this case, intravenous stimulation of labor is used with special preparations of prostaglandins and oxytocin. If there is no progress, then a caesarean section is performed.

Anomalies of labor activity that are not amenable to drug exposure

The operation has to be resorted to if the strength of the contractions is insufficient, and they themselves are very short.

Acute fetal hypoxia

In childbirth, the condition of the child is controlled by the heartbeat (the norm is 140-160 beats per minute, during labor - up to 180 beats per minute). The deterioration of the heartbeat indicates hypoxia, that is, a lack of oxygen. An emergency caesarean section is required to prevent intrauterine death of the child.

Previously undiagnosed threat of uterine rupture

The contractions are frequent and painful, the pain in the lower abdomen is permanent, the uterus does not relax between contractions. When the uterus ruptures, the mother and child show signs of acute blood loss.

Contraindications for caesarean section

There are no absolute contraindications to a caesarean section - after all, this is often the only way to preserve the health and life of a woman and her child.

However, there are contraindications in which a caesarean section is undesirable.

Fetal Health Problems

If it becomes clear that it is impossible to save the child (intrauterine fetal death, severe prematurity, malformations leading to early postnatal death of the child, severe or long-term fetal hypoxia), then the choice is made in favor of the mother's health, and natural delivery as opposed to traumatic surgery.

High risk of purulent-septic complications in the postoperative period

These include infections of the birth canal, purulent diseases of the abdominal wall; amnionitis (inflammation of the fetal membranes of an infectious nature).

Whether a pregnant woman needs a caesarean section can only be judged by the doctor observing her!

In any case, remember, no matter how your baby was born, naturally or through a caesarean section, it is important that both he and his mother are healthy!

General anesthesia is an artificial immersion of the patient into sleep with a reversible decrease in all types of sensitivity due to the use of pharmacological preparations. Drugs used in anesthesia are called anesthetics. For anesthesia, inhalation and non-inhalation anesthetics are used.

Inhalation anesthetics- these are drugs that are injected into the patient's body directly through the respiratory tract, through gas. Inhalation anesthetics are used as monoanesthesia, i.e. using only gas, or as part of a combination with other drugs. The most commonly used inhalation anesthetics are nitrous oxide (NO), sevoflurane (sevoran), isoflurane, halothane, desflurane.

Non-inhalation anesthetics- These are drugs that are administered directly to the patient by a vein (intravenously). Drugs used for non-inhalation anesthesia: a group of barbiturates (sodium thiopental and hexonal), ketamine, propofol (Pofol, Diprivan), a group of benzodiazepines (dormicum). They can also be used as monoanesthesia, or as part of a combination (for example, propofol + sevoran).

Individually, each drug has its own spectrum of pharmacological effects.

With a combination of inhalation and non-inhalation anesthetics, anesthesia will be called general combined anesthesia.

General anesthesia is most often supplemented with two more important components - these are muscle relaxants and narcotic analgesics.

Muscle relaxants are pharmacological drugs administered intravenously that cause a reversible relaxation of all muscle fibers, with a further inability to contract. This component of anesthesia is necessary when it comes to a major operation, such as abdominal surgery, on the abdominal wall (stomach) and there is a need to perform tracheal intubation.

Tracheal intubation is a medical manipulation necessary to maintain airway patency. A tube is inserted through the mouth into the trachea. After that, the cuff at the tube is inflated to create an airtight circuit. The other end of the tube is connected through a system of circuits (hoses) to an artificial lung ventilation (ALV) machine.

In such a situation, the complete absence of independent muscle contractions by the patient is necessary.

Narcotic analgesics, such as fentanyl, are used as a component of anesthesia to completely relieve pain in a patient during surgery.

Indications for general anesthesia

Indications for general inhalation anesthesia (monoanesthesia): minimally invasive operations, i.e. operations with minimal damage to the skin, small access. Such operations include: removal of superficially located structures and neoplasms; gynecological operations in the form of curettage of the uterus; traumatological operations - reduction of dislocations; also heavy bandages.

Indications for General Non-Inhalation Anesthesia similar to gas monoanesthesia. They are supplemented by various instrumental studies (gastroscopy, colonoscopy).

Indications for general combined anesthesia with tracheal intubation and mechanical ventilation: surgical interventions of an average degree, these include - operations in the region of the facial skull; ENT operations; some gynecological operations; amputation of segments of the upper and lower extremities; operations in the abdominal cavity (appendectomy, cholecystectomy, hernia repair, etc.); diagnostic laparotomy, laparoscopy; in the chest cavity in the form of diagnostic thoracotomies and thoracoscopy. Major surgical operations: extended operations in the abdominal and chest cavities; extended limb amputations; brain surgery. As well as operations on the heart, spinal cord, large vessels and other complex surgical interventions that require additional special conditions - the attachment of a heart-lung machine (AIC) or the creation of hypothermia conditions.

Contraindications for general anesthesia

Contraindications for elective general anesthesia are:

From the side of the cardiovascular system: recent (1-6 months) myocardial infarction, unstable angina or angina pectoris 4 functional class, low blood pressure, progressive heart failure, severe heart valve disease, conduction and heart rhythm disturbances, failure of the contractile function of the heart.

From the nervous system: psychiatric illnesses, severe injuries and brain contusions (1-6 months).

From the respiratory system: bronchial asthma in the acute stage, pneumonia, severe bronchitis.

Narcosis is not harmless and not safe, but the potential danger of anesthesia is thousands of times less than the harm that the disease bears if its surgical treatment is refused. Another thing is that the probable harm and danger of anesthesia can always be minimized, for this you just need to trust an anesthesiologist-resuscitator who knows his business.

Please note that there are no contraindications for emergency surgery and emergency anesthesia, and in cases of progression of the cancer patient's disease. In such situations, the conversation is about saving the patient's life, and not about assessing his contraindications.

Preparing the patient for the upcoming elective surgery under general anesthesia

Most often, all the preparation of the patient for a planned operation takes place immediately on the eve of the operation in the hospital. The day before, the anesthesiologist-resuscitator talks to the patient, collects an anamnesis, talks about the upcoming anesthesia, fills in the necessary medical documentation, takes the patient's written consent to anesthesia.

Your doctor will ask you if you are allergic to anything. Any allergies the patient has should be reported, especially to medications. Food allergies are also important. For example: a non-inhalation anesthetic - propofol (hypnotic) is produced on the basis of egg lecithin. Accordingly, for patients with an allergy to egg yolk, this drug will be replaced with another hypnotic, such as sodium thiopental, but this is an extremely rare situation.

Any manifestation of allergy is necessarily recorded in the medical history and is strictly not allowed to be taken or administered to the patient.

If you have a pathology of any system, and you are taking drugs according to the prescription of a specialist, then you must definitely inform your anesthesiologist-resuscitator about this, and then follow his instructions. The anesthesiologist-resuscitator either completely cancels your medication and you already resume it only after surgery, when you are allowed, or continue to take your medications according to the scheme that your specialist has developed.

The main preparation of the patient for the upcoming operation is to strictly comply with all the requirements of the anesthesiologist-resuscitator.

They include: in the evening before going to bed and in the morning - a ban on taking any food and water. In the morning, brush your teeth and rinse your mouth. Be sure to remove all jewelry: rings, earrings, chains, piercings, glasses. Remove removable dentures.

Another important component of preoperative preparation for the patient is premedication.

Premedication is the final stage of preoperative preparation. Premedication consists in taking pharmacological drugs to relieve psycho-emotional stress before surgery and improve the introduction to general anesthesia. The preparations can be in the form of tablets for oral administration, or in the form of injections for intravenous or intramuscular administration. The main groups of drugs for premedication are tranquilizers. They help the patient fall asleep quickly in the evening before the operation, reduce anxiety and stress. In the morning, these drugs are also prescribed for a softer and more comfortable introduction to anesthesia for the patient.

How anesthesia is done

Let's look at the example of general combined anesthesia with tracheal intubation and mechanical ventilation.

After the planned preparation of the patient for surgery, compliance with all the requirements of morning premedication, the patient, lying on a stretcher, accompanied by medical personnel, is fed into the operating unit. In the operating room, the patient is transferred from the gurney to the operating table. An anesthetic team consisting of a doctor and a nurse anesthetist awaits him there.

Mandatory, the first manipulation, with which it all begins, is obtaining vascular (venous) access. This manipulation consists in the percutaneous insertion of a sterile vascular catheter into a vein. Next, this catheter is fixed and a system for intravenous infusion with saline sodium chloride is connected to it. This manipulation is necessary in order to have constant access for the administration of drugs intravenously.

After that, a cuff is connected to the patient to change blood pressure (BP) and electrode sensors are connected to the chest for continuous recording of the electrocardiogram (ECG). All parameters are displayed to the doctor directly on the monitor.

After that, the doctor instructs the nurse to collect drugs. While the nurse is busy, the doctor begins preparations for introducing the patient into anesthesia.

The first stage of anesthesia is preoxygenation. Preoxygenation is as follows: an anesthesiologist-resuscitator connects a face mask to the circuit system and sets parameters with a high oxygen supply on the ventilator monitor, after which he applies the mask to the patient's face. At this moment, the patient needs to breathe as usual, take standard, normal life breaths and exhalations. This procedure lasts 3-5 minutes. After the nurse and the surgical team are ready, the introduction of the patient into anesthesia begins.

The first drug to be given intravenously is narcotic analgesic. The patient at this moment may feel a slight feeling in the form of dizziness and a slight unpleasant feeling in the form of a burning sensation in the vein.

After that, enter hypnotic drugs(non-inhalation anesthetic). The patient is warned that his head will now begin to spin and he will slowly fall asleep. There will be a feeling of heaviness of the head, facial muscles, a feeling of euphoria and fatigue. Time is counted in seconds. The patient falls asleep. The patient is sleeping.

The patient will not feel and remember further manipulations of the anesthesia team.

The next drug administered intravenously is a muscle relaxant.

After its introduction, the anesthesiologist-resuscitator performs tracheal intubation And connects the patient through the tube to the sealed circuit of the ventilator, turns on the supply of inhalation anesthetics through a special evaporator. After that, he checks the uniformity of the patient's breathing, using a phonendoscope (a medical device for listening to respiratory and heart sounds), fixes the endotracheal tube to the patient, and sets the necessary parameters on the ventilator. After the anesthesiologist-resuscitator has made sure that the patient is completely safe and checked everything, he gives the command to the surgical team to start the operation.

With inhalation monoanesthesia, the scheme is simplified.

The duration of the operation is determined by the qualification level of the surgical team, the complexity of the surgical intervention and the anatomical features of the patient.

Complications during general anesthesia

The main danger of any anesthesia is hypoxia (lack of oxygen consumption by the patient) and hypercapnia (an increase in the body of excess carbon dioxide). The causes of these severe complications can be: malfunction of anesthesia equipment, impaired airway patency, excessive immersion of the patient in anesthesia sleep.

There are also complications of anesthesia in the form of:

Retraction of the tongue, which contributes to impaired airway patency, most often this complication occurs when monoanesthesia is performed only with inhalation anesthetics using gas supply through a face mask;

Laryngospasm - closure of the vocal cords of the larynx. This complication is associated with a reflex reaction of the body to excessive irritation of the mucous membranes of the larynx, or excessive pain effects on the body during surgery with too superficial medication sleep;

- obstruction of the airways by vomiting during regurgitation. Regurgitation is the entry of stomach contents into the oral cavity and possible entry into the respiratory tract;

- respiratory depression- a complication associated with too deep immersion of the patient in anesthesia;

- changes in blood pressure and heart rate in the form of tachycardia (rise in heart rate) and bradycardia (decrease in heart rate), which is directly related to surgical intervention and the most painful stages of the operation.

Possible consequences of general anesthesia after surgery

The most common consequences are drowsiness, dizziness, weakness. They pass on their own. On average, after a planned, moderately severe operation without complications, patients come to a state of clear consciousness in 1-2 hours.

After general anesthesia, nausea and vomiting may occur. Treatment of this complication is reduced to the use of antiemetic drugs, such as, for example, metoclopromide (cerucal).

Headache (cephalgia) after anesthesia, it manifests itself in the form of a feeling of heaviness in the head and pressure in the temples. This consequence passes on its own and does not require additional use of drugs. If the headache does not go away, your doctor will most likely prescribe you analgin.

Pain in the postoperative scar (wound)- the most pronounced, frequent consequence of the operation, when the effect of anesthesia ends. Pain in the wound will persist until the formation of the primary scar, because. it is not the wound itself that hurts, but directly the skin that was cut. To prevent postoperative pain, during operations of moderate degree, it is sufficient to use antispasmodic, analgesic drugs. In some cases, stronger opioid drugs (eg, promedol, tramadol) may be used. In case of extensive operations, anesthesiologists-resuscitators perform catheterization of the epidural space. This method consists in inserting a catheter into the spine and prolonged pain relief by injecting local anesthetics into the catheter.

Rise or fall in blood pressure (BP). A decrease in blood pressure is typical for patients who underwent surgery with extensive blood loss and blood transfusions (multiple injuries, operations associated with internal and external bleeding). The total volume of circulating blood is gradually restored and the patient feels better the next day after the operation without additional medications. Elevations in blood pressure are typical for patients after operations on the heart and large blood vessels. Most often, such patients are already receiving the necessary treatment and their blood pressure indicators are under constant control.

Increase in body temperature is the norm and most often indicates the operation. It is necessary to pay attention only to an increase in body temperature if it has reached subfebrile numbers (above 38.0 C), which most likely indicates an infectious complication of the operation. In this situation, do not panic. Your doctor will definitely prescribe you antibiotic therapy and eliminate the cause of the fever.

In foreign literature, there are reports of the negative consequences of anesthesia in children, in particular, that anesthesia can cause the development of cognitive disorders in a child - impaired memory, attention, thinking and learning ability. In addition, there are suggestions that anesthesia transferred at an early age may be one of the reasons for the development of attention deficit hyperactivity disorder. This leads to recommendations to postpone the planned surgical treatment of the child until the age of four, on the clear condition that the delay of the operation will not harm the child's health.

The well-coordinated and professional work of the anesthesiological and surgical teams guarantees a safe, painless, comfortable performance of any operation without any medical complications. A patient psychologically tuned to general anesthesia will only help the anesthesiologist-resuscitator to work efficiently. Therefore, it is important to ask all the questions of interest to the specialist before the operation and strictly follow the prescribed recommendations.

Anesthesiologist - resuscitator Starostin D.O.

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 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 and others) believe that 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.