STUDY OF THE HEMOMICROCIRCULATORY CHANNEL IN PATIENTS WITH DIABETES AND THREATENING ISCHEMIA OF THE LOWER LIMB.

Purpose of work - to investigate the hem microcirculatory channel (HCMC) in chronic critical lower extremity ischemia (CHLIC) in patients with diabetes mellitus (DM). To develop a method for calculating the indicator of the degree of diabetic microangiopathy (PSDMAP). Skin and muscle samples of 63 patients with type 2 diabetes mellitus with CKD and skin and muscle samples of 30 patients without systemic diseases. Histological and immunohistochemical studies were conducted to detect type IV collagen, CD31, and smooth muscle action. We measured the diameters of blood vessels of the skin and muscles, the density of capillaries per unit area for the calculation of PSDMAP. Characteristic changes were revealed in the morphometric parameters of the HCMC of the skin in patients with type II diabetes mellitus with CKD. A method for calculating PSDMAP was developed. It was revealed a correlation between the type of diabetic microangiopathy and the probability of thrombosis after hybrid arterial reconstruction, and an algorithm for the examination of patients in the postoperative period was developed.

[VALUE OF INTRAOPERATIVE DEBITOMETRY IN SELECTING OF SURGICAL TREATMENT TACTICS FOR PATIENTS WITH DIABETES MELLITUS WITH CHRONIC CRITICAL ISCHEMIA OF THE LOWER LIMB].

Aim - analyze the results of surgical treatment of patients with diabetes mellitus (DM) with chronic critical lower limb ischemia (CCLLI) against the background of the combined stenotic-occlusive lesions (SOL) of the femoral arterial segment (FAS) and popliteo-tibial arterial segment (PTAS), considering the data of the intraoperative debitometry (ID). The results of surgical treatment of 97 patients with diabetes mellitus with CCLLI caused by combined SOL of FAS and PTAS arteries after 1 month and 12 months of treatment were analyzed. All patients were treated at the Vascular Surgery Center of the Clinical Hospital "Feofania" of State Directorate for Affairs, Kiev, Ukraine during 2014 - 2018yrs. All patients underwent femoro-popliteal bypass grafting without intervention on arteries of PTAS.According to the obtained results of the ID, the patients were divided into groups: group 1 - 32 patients with a debit of the shunt (SD) greater than 60 ml/min, group 2 - 35 patients with SD 30-60 ml/min, group 3 - 30 patients with SD lesser than 30 ml/min. In case of the femoro-popliteal shunt (FPS) thrombosis, performed repeated surgery as a hybrid revascularization (HR) - thrombectomy from the shunt and endovascular balloon angioplasty of the arteries of PTAS. The primary patency of the arterial reconstruction zone of the patients from group 1 after 1 month was 93.75% (30 of 32), after 12 months - 78.13% (25 of 32); group 2 - after 1 month it was 82.8% (29 out of 35), after 12 months - 68.57% (24 out of 35); group 3 - after 1 month it was 46.66% (14 out of 30), after 12 months - 23.33% (7 out of 30). Thrombosis of the femoropopliteal shunt (FPS) within 12 months was diagnosed in 41 (42.27%) of 97 patients, within these patients 1 month after primary shunting in 26 (63.41%), and during the next 11 months in 15 (36.59 %)cases.With repeated intervention on thrombosis ofFPSin form ofHR, secondary patency within 12 months was 78.05% (32 of 41 patients).Restoration of the outflow from the popliteal artery in one of the tibial arteries by HR was possible in 28 of 41 (68.29%) patients, within 12 months rethrombosis of the arterial reconstruction zone occurred in 8 patients (28.57%) - with secondary patency after 12 months of 71.43% (20 of 28 patients). The restoration of the outflow from the popliteal artery into two tibial arteries by HR was possible in 13 of 41 (31.71%) patients, from them rethrombosis of the FPS within 12 months occurred in 1 patient (7.69%) - the secondary patency within 12 months was 92.31% (12 of 13 patients). In the case of combined SOL of FAS and arteries of PTAS, reconstruction of FAS without intervention on the arteries of PTAS requires performing of ID with determining of SD. Performing of ID with determining of SD is an effective diagnostic technique that allows to formulate a differentiated approach to the tactics of surgical treatment of patients with diabetes mellitus with CCLLI, caused by the SOL of FAS and PTAS. The indicator which allows to restore the patency of FAS without intervention on the arteries of the PTAS is SD>60 ml/min; with SD 30-60 ml/min, the reconstruction of the arteries of the PTAS after the restoration of the patency of FAS can be delayed and performed as elective surgery at the second stage; with SD<30 ml/min, simultaneous reconstruction of FAS and PTAS arteries is required by performing HR or two-stage open arterial reconstruction. The HR is an effective method of blood circulation restoration in patients with diabetes mellitus with CCLLI, caused by a combined SOL of FAS and PTAS, and according to the results: the patency of the FPS within 12 months is 78.05% and does not significantly differ from the results of FAS reconstruction in 1st group of patients with SD>60 ml/min - where patency of the FPS within 12 months is 78.13% (p>0.05). In case of thrombosis of the FPS, thrombectomy from the shunt, supplemented by the restoration of the magistral blood flow from the popliteal artery into two tibial arteriesby the method of balloon angioplasty, demonstrates reliably better secondary patency of the femoropopliteal shunt after 12 months - 92.31% in comparison with the secondary patency of the FPS within 12 months after restoration of the magistral blood flow from the popliteal artery into one tibial artery - 71.43% (p<0.05).

[Diagnostic and conservative treatment nuances in patients with obstructive jaundice: in the wake of Russian consensus].

The research was performed at the Loginov Moscow Clinical Scientific Center. It is based on Russian obstructive jaundice (OJ) consensus results, considered at the 45th annual Central Research Institute of Gastroenterology Scientific session Oncological issues in the gastroenterologist practice (1 March 2019). The article objective is to note the diagnostic and conservative treatment current issues in patients with OJ. The increase in the number of patients with OJ of different etiology provides problem actuality. In a large number of cases, medical treatment is delayed due to inadequate diagnostic and management, while correct patients routing today can be provided regardless of medical institution level. In this article the examination steps and conservative treatment role in patients with biliary obstruction management are presented.

[Chronic intestinal pseudoobstruction: difficulties in diagnosis and treatment. Case report].

The article presents a clinical case of a 23-year-old patient with an extremely severe congenital form of chronic intestinal pseudoobstruction coupled with a neuromyopathy,colon malrotation, malabsorption, bacterial overgrowth syndrome, cholelithiasis and gastrostasis, which excluded bowel transplantation. Long-term treatment in the intensive care unit with combined, mainly parenteral nutrition for 6 months, using antibiotics, prokinetics, intestinal decompression allowed to achieve partial stabilization of the patients condition and transfer to home treatment with the continuation of adequate complex therapy.

[Treatment of severe post-resection liver failure. Analysis of the specialized center]. / Lechenie postrezektsionnoi pechenochnoi nedostatochnosti tyazheloi stepeni. Analiz spetsializirovannogo tsentra.

Posthepatectomy liver failure is one of the most serious complications of large liver resections. OBJECTIVE: The analyzes the management and results of treatment of patients with severe posthepatectomy liver failure (Grade C ISGLS) in a specialized hepatosurgical department. MATERIAL AND METHODS: In the period from January to December 2019, 175 liver resections were performed in the Department of liver and pancreatic surgery at the A.S. Loginov Moscow Clinical Scientific Center. Major-volume liver resections (hemihepatectomies and resections of more than three liver segments) were performed in 80 (45%) patients. In 125 (71%) cases liver resctions were performed for malignant liver and bile duct diseases. Laparoscopic liver resections were performed in 77 (44%) patients. RESULTS: Postresection liver failure developed in 18 (10.2%) patients. Severe (class C according to ISGLS) developed in 6 (3.4%) patients. In the postoperative period (90-day mortality), 4 patients (2.3%) died, while in two patients, mortality was not associated with liver failure. Hyperbilirubinemia was observed for more than 5 days in 2 (33.3%), coagulopathy in 4 (66.6%), ascites in 5 (83.3%), encephalopathy in 5 (83.3%), hypoglycemia in 3 (50%), and uncontrolled sepsis in 2 (33.3%) patients, respectively. Correction of surgical complications was required in 100% of cases, which consisted in drainage of abscesses and abdominal bylomas, and the the bilio-digestive anastomosis fistulas. Inotropic support was required in all 6 (100%) patients, invasive ventilation in 4(66.6%), and extracorporeal detoxification in 5 (83.3%). CONCLUSIONS: Posthepatectomy liver failure is a complex problem even in a specialized center. A comprehensive approach to treatment allows to achieve noticeable results and reduce mortality.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]. / Rossiiskii konsensus po aktual'nym voprosam diagnostiki i lecheniya sindroma mekhanicheskoi zheltukhi.

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

[Intraoperative fluid therapy during esophagectomy followed by repair]. / Intraoperatsionnaia infuzionnaia terapiia pri ézofagéktomii s odnomomentnoi plastikoi pishchevoda.

AIM: To optimize fluid therapy in transhiatal eshophagectomy by using of goal-oriented infusion therapy based on stroke volume variation. MATERIAL AND METHODS: Our trial enrolled 30 patients who underwent transhiatal esophagectomy followed by repair for the period 2011-2014. Patients were divided into 2 groups. The first group (LT) included 16 patients with liberal fluid therapy. The second group (GDT) consisted of 14 patients in whom goal-oriented fluid therapy was performed. Goal-oriented fluid therapy was implemented via stroke volume variation (SVV). RESULTS: Infusion rate was 6.7 ml/kg/h and 11.5 ml/kg/h in the main and control groups, respectively. Morbidity rate was 28.6% (n=4) and 62.5% (n=10) in the main and control groups respectively. Clavien-Dindo IV complications were lung atelectasis (n=2, 14%), pneumonia (n=1, 7%). Hydrothorax required puncture was noted in 1 (7%) case. Acute respiratory failure as complication IVa was in 1 (9%) patient. In the control group complications were registered in 10 (62.5%) patients. Complications I-II degree included lung atelectasis (n=4, 25%), cervical anastomosis failure (n=1, 6%); complications IVa were observed in 8 cases (50%). It was significant respiratory failure with reduced PO2/FiO2<300. Patients of the main group required less time for postoperative mechanical ventilation (120 [90-300] vs. 315 [215-810] min (p=0.02) and ICU-stay (0.83 [0.7-0.8] vs. 1.75 [1.25-2.75] (p=0.0022).

[SUPPORT LUNG VENTILATION IN COMPLEX OF ANESTETIC MANAGEMENT DURING HIGH TRAUMATIC OPERATIONS IN VASCULAR SURGERY.]

BACKGROUND: Rejection from prolonged mechanical ventilation with conversion to support ventilation modes during the surgery and subsequent immediate extubation at the end of the surgery could be the method ofprophylaxis ofpostoperative respiratory complications. THE AIM: To improve the results of surgical treatment of patients with infrarenal aorta injury due to the development and implementation to the anesthetic management complex the modes of support ventilation. MATERIALS AND METHODS: 2-staged clinical trial on patients undergoing surgery on infrarenal aorta was conducted. At the 1st stage patients were assessed for opportunity of immediate or early extubation and support ventilation initiation. At the 2nd stage support modes during the intraoperative ventilation were introducted into clinical praxis. RESULTS: Based on received data we concluded that not everyone patient needed intra- and postoperative mechanical ventilation in spite ofprolonged duration of the surgery and large surgical trauma. Inclusion in the protocol of anesthesia support ventilation strategy decreases requirement ofparalytic agents and their side effects. CONCLUSION: Applying the support ventilation modes during the anesthesia gives a chance of immediate and early extubation after the surgery and decreases the number of critical events and respiratory complications.

[Liver resection in patient with hcc and right atrium thrombosis].

Presented herein is a case report concerning tumorous thrombosis of the inferior vena cava and right atrium, which is rather an uncommon but severe complication of primary hepatic cancer. The purpose of the article is to demonstrate successful surgical management of locally disseminated hepatic carcinoma complicated by tumorous thrombosis of the inferior vena cava and portal vein, as well as thrombosis of the right atrium. The patient was subjected to dextral hemihepatectomy with thrombectomy from the right portal vein, resection of the right cupola of the diaphragm, marginal resection of the lower lobe of the right lung, thrombectomy from the inferior vena cava and right atrium. The outcome of our case report, as well as literature data suggest that in case of resectability of hepatic tumour complicated by thrombosis of major vessels and even the heart, surgical intervention is justified if there is a possibility to completely remove thrombotic masses along with the primary tumour.

[PERIOPERATIVE CARE FOR PATIENTS WITH UNDERLYING ARTERIAL HYPERTENSION (CLINICAL GUIDELINES)].

These clinical guidelines apply to the implementation of health care for all patients with concomitant hypertension in the perioperative period in a hospital. The guidelines specify the method of stratifying the risk of perioperative cardiac complications. We described methods for the treatment of urgent conditions with hypertension and hypertensive crises and identified the main features of the preoperative evaluation and preparation of patients with concomitant hypertension. The clinical guidelines contain recommendations on the management of intra- and postoperative period

[A case of the cerebral vasculitis at the late stage of Kawasaki disease].

A description of the clinical observation of the child at the late stage of Kawasaki disease is presented. In our observation, an aneurysm of the circumflex branch of the left coronary artery was discovered on the echocardiography of the child. MRI results of the brain with vascular program revealed a picture of vasculitis, fusiform expansion of the A1 segment of the right anterior cerebral artery, M1 segment of the left middle cerebral artery. Systemic vasculitis was diagnosed at the late stage of disease. This case shows the importance of better awareness of pediatricians, cardiologists, neurologists about Kawasaki disease, its manifestations at the early stage and possible long-term complications, as well as modern approaches to treatment.

[Angiodysplasias of the head and neck: present-day principles of treatment using elements of plastic surgery].

The authors assessed the outcomes of treatment of fifty-one patients presenting with angiodysplasias of the head and neck. Of these, 24 patients suffered from the venous form and 27 had the arteriovenous form. The 51 patients accounted for 23.5% of the total number of patients with congenital vascular malformations over a five-year period. The topicity and angioarchitectonics of the lesion were specified by means of the standard diagnostic complex (i. e., duplex scanning of the vessels, ultrasonographic study of the soft tissues and osseous structures, computed and magnetic resonance tomography, echocardiography, and angiography). Radical excision of the angiomatous tissues was performed in 15 patients and palliative one - in 36 cases. Eight patients were subjected to stagewise resection interventions, ten patients underwent stagewise sessions of laser coagulation, and seven patients endured stagewise roentgenoendovascular embolisations of the afferent arteries. Two patients with the venous form were postoperatively subjected to sessions of sclerotherapy of the residual venous caverns. Two patients in the remote period (7-10 days) underwent autodermoplasty with a free perforated cutaneous flap. This technique was used while closing the wound surface after removing the angiomatous tissues of the parotid region and hairy portion of the head. In five patients the wound surface was closed with a mobilized cervical fat-cutaneous flap. Taking into consideration the importance of the cosmetic outcome after excising the angiomatous tissues on the face and neck, it is necessary to seek for wide application of plastic methods of closing the wound. These methods simultaneously allow of making operative interventions for angiodysplasias more radical.

Production and decay of the heaviest nuclei (293,294)117 and (294)118.

Two years after the discovery of element 117, we undertook a second campaign using the (249)Bk+(48)Ca reaction for further investigations of the production and decay properties of the isotopes of element 117 on a larger number of events. The experiments were started in the end of April 2012 and are still under way. This Letter presents the results obtained in 1200 hours of an experimental run with the beam dose of (48)Ca of about 1.5×10(19) particles. The (249)Bk target was irradiated at two energies of (48)Ca that correspond to the maximum probability of the reaction channels with evaporation of three and four neutrons from the excited (297)117. In this experiment, two decay chains of (294)117 (3n) and five decay chains of (293)117 (4n) were detected. In the course of the long-term work, (249)Cf-the product of decay of (249)Bk (330 d)-is being accumulated in the target. Consequently, in the present experiment, we also detected a single decay of the known isotope (294)118 that was produced during 2002-2005 in the reaction (249)Cf((48)Ca,3n)(294)118. The obtained results are compared with the data from previous experiments. The experiments are carried out in the Flerov Laboratory of Nuclear Reactions, Joint Institute for Nuclear Research, using the heavy-ion cyclotron U400.

New insights into the 243Am + 48Ca reaction products previously observed in the experiments on elements 113, 115, and 117.

Results of a new series of experiments on the study of production cross sections and decay properties of the isotopes of element 115 in the reaction (243)Am+(48)Ca are presented. Twenty-one new decay chains originating from (288)115 were established as the product of the 3n-evaporation channel by measuring the excitation function at three excitation energies of the compound nucleus (291)115. The decay properties of all newly observed nuclei are in full agreement with those we measured in 2003. At the lowest excitation energy E*=33 MeV, for the first time we registered the product of the 2n-evaporation channel, (289)115, which was also observed previously in the reaction (249)Bk+(48)Ca as the daughter nucleus of the decay of (293)117. The maximum cross section for the production of (288)115 is found to be 8.5 pb at E*≈36 MeV.

[The clinical picture, diagnostic and treatment of the acute iliopsoitis].

The treatment results of the acute iliopsoitis in 29 patients were analyzed. The right side inflammation was observed more frequently (n=17). The most common infectious agent was the Staphylococcus aureus. The source of the inflammation was septic lesions of the lower body, whereas the perdisposal factors were considered to be the diabetes mellitus, drug abuse and immunodeficiency. The cardinal diagnostic sign of the acute iliopsoitis proved to be the psoas-symptom. The main diagnostic instruments were the ultrasound investigation, CT and MRI. 1 patient was successfully treated conservatively, though the rest 28 demanded surgical opening and drainage of m. iliopsoas. The lethality rate was 3,4%. 96,6% of the treated patients were successfully cured.

Synthesis of a new element with atomic number Z = 117.

The discovery of a new chemical element with atomic number Z=117 is reported. The isotopes (293)117 and (294)117 were produced in fusion reactions between (48)Ca and (249)Bk. Decay chains involving 11 new nuclei were identified by means of the Dubna gas-filled recoil separator. The measured decay properties show a strong rise of stability for heavier isotopes with Z > or = 111, validating the concept of the long sought island of enhanced stability for superheavy nuclei.

[EEG bispectral index as an indicator of the electrical activity of the central nervous system in children during anesthetic maintenance and intensive care].

The paper presents different investigators' data on the use of the bispectral (BIS) index in children during anesthetic maintenance and intensive care. The most of publications deal with the use of the BIS index during anesthesia with sevoflurane, which shows its high efficiency in estimating the depth of sleep. There are positive aspects in the use of the BIS index in the evaluation of sedative tolerance and central nervous system function, when brain death is diagnosed, cerebral oxygenation adequateness, etc. Data are given on the ambiguity of BIS index values in infants less than a year of age.