[Endoscopic vacuum therapy in minimally invasive treatment of esophageal perforations]. / Effektivnost' endoskopicheskoi vakuumnoi terapii v kompleksnom minimal'no invazivnom lechenii perforatsii pishchevoda.

OBJECTIVE: To compare the results of endoscopic vacuum therapy (EVT) and open surgery for esophageal perforations. MATERIAL AND METHODS: The study included 60 patients with esophageal perforations between 2010 and 2022. The main group included 29 patients who underwent minimally invasive treatment with EVT, the control group - 31 patients after open surgical interventions. RESULTS: Pneumonia occurred in 21 (72%) and 14 (45%) patients (p=0.04), esophageal stenosis within the perforation zone - in 4 (13.8%) and 1 (3.2%) patient, respectively (p=0.188). Chronic esophageal fistulas were significantly more common in the control group (6 (20.7%) versus 15 (48.4%) patients, p=0.032). The overall duration of treatment (median) among survivors was significantly shorter in the main group: 33 (23; 48) versus 71.5 (59; 93.7) days (p=0.5). However, length of ICU-stay was slightly higher (11 (6; 16) versus 8.5 (5; 12.75) days, p=0.32). Mortality rate was 13.8% (n=4) and 29% (n=9), respectively (p=0.213). Minimally invasive technologies decreased the risk of fatal outcome by 10 times (OR 10.123, 95% CI 1.491-124.97, p=0.035) compared to traditional surgery. CONCLUSION: EVT in complex minimally invasive treatment of patients with mechanical esophageal injuries is an effective method significantly reducing mortality and duration of inpatient treatment compared to traditional surgical approach.

[Post-intubation rupture of thoracic trachea in a patient with iatrogenic esophageal perforation and mediastinitis]. / Postintubatsionnyi razryv grudnogo otdela trakhei u bol'noi s perforatsiei pishchevoda pri fibroendoskopii i mediastinitom.

Iatrogenic injuries of the esophagus and trachea are rare. However, these are life-threatening events due to severe complications. The authors report iatrogenic perforation of cervical esophagus with a long false passage in posterior mediastinum in an 83-year-old patient undergoing endoscopic retrograde cholangiopancreatography for choledocholithiasis. Post-intubation rupture of thoracic trachea was diagnosed early after suturing the defect of esophagus and drainage of mediastinum. Treatment strategy was analyzed and conservative management of tracheal injury was substantiated.

[AQUATIC AND ELECTROLYTE DISORDERS AT THE PATIENT WITH SEVERE TRAUMATIC BRAIN INJURY.]

This article is dedicated to the problem ofwater and electrolyte disturbances in patient with acute severe head trauma. We present the case study of patient with severe head injury who consistently developed diabetes insipidus and cerebral salt wasting syndrome. His water and electrolyte disorders were successfully corrected by target-oriented intensive care. Constant tight monitoring and of intensive care allowed to avoid secondary ischemic injuries till the water and electrolytic homeostasis regulation mechanisms restoration.

[Diagnostics and treatment of traumatic retroperitoneal bleedings].

Treatment results of 403 patients with the closed abdominal trauma, complicated by the retroperitoneal bleeding, was performed. Two types of echographic and CT picture of the retroperitoneal bleeding were distinguished - with clot formation and of impregnation type. The diagnostic and treatment algorithm was suggested. The use of the least allowed the location of the bleeding source in 40% of the operated patients and in 100% of those, who were treated conservatively. The indications to the retroperitoneal surgical revision were set basing on the information about the bleeding source or the localization and spreading of the hematoma. The use of the algorithm was successful in 98.9-100% of cases.

[Computed tomography in diagnostics and treatment of traumatic retroperitoneal hemorrhage].

Causes of retroperitoneal bleeding (RB) were specified basing on retrospective analysis of 60 observations of closed abdominal injury. Two types of RB, with formation of blood packets and "impregnation", were marked out each having their computer tomography singes, changing during treatment. Contrast-enhanced computer tomography enabled to detect persisting bleeding from kidney or spleen, set indications for urgent laparotomy and reveal traumatic renal artery thrombosis even in the absence of hemoperitoneum.

[Diagnostics and surgical treatment of the posttraumatic septic mediastinitis].

Treatment results of 38 cases of septic mediastinitis for the last 17 years were analyzed. The frequency of mediastinitis as a complication of the penetrating wound was 0.28%, and of the closed thoracic trauma - 0.1%. Reasons and risk factors of the mediastinitis development have been revealed. The enlargement of the mediastinum on the X-ray allowed the primary diagnostics of suspicion on the mediastinitis in 39.5% of cases. The spiral computed tomography provided information for the further treatment options. The mediastinum drainage was an effective method of treatment, providing the improvement in 69.6% patients after penetrating wound and in 73.3% after the closed thoracic trauma.

[Adrenal injury in blunt abdominal trauma].

10 patients with adrenal damage were observed during 2.5 years. It amounted 0.93% of all patients with closed abdominal injuries. The right adrenal gland was traumatized in all cases evidently due to it's compression between right lobe of liver and vertebral column. Adrenal damage is observed quite often in combination with injuries of right liver lobe, right kidney and retroperitoneal hematoma formation. 5 patients underwent laparotomy on account of intra-abdominal bleeding, but adrenal damage was never revealed. Ultrasound and tomographic semiotics of adrenal damage was worked out, which allowed ascertaining diagnosis in 80% on application of ultrasound study and in 100% at computer tomography. Injury of one adrenal gland was not accompanied by adrenal failure and did not require hormonal replacement therapy.

[Diagnostics and treatment of abdominal injuries with retroperitoneal organs involvement].

The results of treatment of 66 patients with non-gunshot abdominal injuries, involving retroperitoneal organs, are described. Preoperative clinical and ultrasound investigations are not accurate enough to diagnose retroperitoneal lesions, which were diagnosed intraoperatively in 57,6% of patients. In 97% retroperitoneal haematoma was located 2-10 sm from the posterior parietal peritoneum. In case of aorta injury, postcava or renal injury grade IV, retroperitoneal haematoma is large and bulging, though absence of these signgns does not exclude serious injuries of retroperitoneal organs and structures. Retroperitoneal cavity revision by the dissection of the wound canal can provoke further bleeding, so it should be performed only after visualization and cross-clamping the afferent vessel.

[Role of spiral computed tomographic angiography in the diagnosis of aortic aneurysmal complications].

The paper considers the basic diagnostic capacities of computed tomographic angiography (CTA) in aortic aneurysmal complications. The results of emergency of CTA were analyzed In 63 patients with suspected aortic aneurysmal dissection and rupture. CTA provides complete information on the site, extent, and spread, form and sizes of an aneurismal process, on the presence of intraluminal thrombi, on the presence or absence of aortic wall dissection and rupture, on the involvement of aortic branches, and the state of adjacent tissues and organs.

[Diagnosis and treatment of post-traumatic coagulated hemothorax]. / Diagnostika i lechenie posttravmaticheskogo svernuvshegosia gemotoraksa.

Analysis of 102 cases of coagulated hemothorax (CH) are presented: 32--after penetrating wounds and 70--after closed chest injury. In 57% patients with chest wounds and 72% patients with closed injury the cause of CH was to applying late for medical care. Diagnostic value of X-ray, ultrasonic methods, CT and pleural puncture was studied. Depending on the patients state severity, CH volume and stage of it formation conservative treatment, streptase administration, thoracoscopy and thoracotomy with pleurectomy and lung decortication were performed. Lethality was 2.9%.

[X-ray computed tomography in the diagnosis of mediastinitis]. / Rentgenovskaia komp'iuternaia tomografiia v diagnostike mediastinita.

Results of X-ray computed tomography (RCT) use in 21 patients treated for acute mediastinitis in N.V. Sklifosovsky Emergency Care Research Institute have been analyzed retrospectively. RCT proved able to defect accurate location, spreading and sizes of inflammatory disorders in the mediastinum are demonstrated. Semiotics of mediastinitis depending on location, spreading and phase of inflammatory process is presented.

[20-year experience with diagnosis and treatment of different forms of purulent mediastinitis]. / Dvadtsatiletnii opyt diagnostiki i lecheniia pri razlichnykh formakh gnoinogo mediastinita.

An experience of many years has shown that the most severe clinical course is observed in patients with mediastinitis due to injuries of the esophagus, and with odontogenous and tonsillogenous mediastinitis. Using the ultrasound method of investigation and computed tomography made the possibility to early diagnose this disease considerably wider. Treatment of patients with mediastinitis included surgical sanitation of the purulent focus, antibacterial, detoxicating and immune therapy, the central role being given to active drainage of the mediastinum with lavage and aspiration. In patients with mediastinitis resulting from rupture of the inferiorthoracic portion of the esophagus the isolation of the injured wall of the esophagus from the aggressive influence of gastric juice is an important measure. This problem can be solved by ligation of the abdominal part of the esophagus or by Nissen's fundoplication. Severe complications of mediastinitis such as empyema of the chest, purulent peritonitis and arrosive bleedings require active surgical strategy.