[Surgical treatment of spontaneous esophageal rupture: long-term experience of the Sklifosovsky Research Institute for Emergency Care]. / Khirurgicheskoe lechenie spontannogo razryva pishchevoda: mnogoletnii opyt NII skoroi pomoshchi im. N.V. Sklifosovskogo.

OBJECTIVE: To analyze the treatment outcomes in patients with spontaneous esophageal rupture (SER). MATERIAL AND METHODS: The study included 106 patients with SER admitted to the Sklifosovsky Research Institute for the period from 1992 to 2015. The sample also included 91 patients who were referred from other hospitals. All patients were divided into 4 groups depending on surgical procedure: surgical drainage (Group I, n=19); suturing the esophageal defect without antireflux surgery (Group II, n=12); esophageal wall repair with fundoplication procedure (Group III, n=62); resection of the thoracic esophagus (Group IV, n=13). RESULTS: In the 1st group, complication rate was 100% and significantly exceeded these values in groups II, III, and IV (66.7%, 71%, and 69.2%, respectively; p=0.0318, p=0.0189, and p=0.0413). The length of hospital-stay was the lowest in group IV (mean 42 days) and group I (mean 55 days). Mortality rate in groups I, III and IV was 15-20% lower than in group II. Pneumonia and pleural empyema were significant predictors of poor outcome. Fundoplication improved postoperative outcomes in group III compared to group II. Resection of the thoracic esophagus performed in accordance with strict indications interrupts infectious process and shortens recovery period. Surgical drainage is followed by persistent contamination of mediastinum and pleural cavities that may quickly result a fatal outcome. CONCLUSION: A differentiated approach to SER treatment can reduce the risk of complications and mortality.

[Difficulties of differential diagnosis and treatment of achalasia cardia after previous hiatal hernia repair]. / Trudnosti differentsial'noi diagnostiki i lecheniia akhalazii kardii u patsientki, ranee operirovannoi po povodu gryzhi pishchevodnogo otverstiia diafragmy.

Esophagocardiomyotomy followed by anterior fundoplication is a standard treatment of achalasia cardia, whereas cruroraphy with complete or partial posterior fundoplication is carried out for hiatal hernia and gastroesophageal reflux disease. The most common postoperative complications of hiatal hernia repair are dysphagia due to malformed cuff, phenomenon of 'telescope' and slow gastric emptying syndrome. Recurrent hiatal hernia is observed in 3-15% of cases. Currently, there are a lot of reports devoted to redo antireflux procedures in patients with hiatal hernia. The goal of the study is to demonstrate difficulties of diagnosis and treatment in a patient with achalasia cardia after previous hiatal hernia repair.

[Spontaneous rupture of the esophagus in a patient with chronic obstructive pulmonary disease]. / Spontannyi razryv pishchevoda u patsienta s khronicheskoi obstruktivnoi bolezn'yu legkikh.

A case report of successful surgical treatment of spontaneous rupture of the esophagus in a patient with chronic obstructive pulmonary disease, bronchial asthma and obesity is presented. Rupture of the esophagus occurred during a coughing without vomiting.

[Thoracic and abdominal injuries caused by air weapons]. / Pulevye raneniia grudi i zhivota iz pnevmaticheskogo oruzhiia.

Thoracic and abdominal injuries caused air weapons are rarer compared with gunshot wounds. Nevertheless, pneumatic weapons are able to inflict potentially fatal lesions despite small mass and dimension of projectile. Three clinical cases of patients with various internal injuries are presented in the article. Differentiated diagnostic and surgical approach is suggested.

[Diagnosis and treatment of suppurative mediastinitis - a special chapter in the history of surgery (in Russian only)]. / Diagnostika i lechenie gnoinogo mediastinita - osobaia glava v istorii khirurgii.

It was reviewed a history of diagnosis and treatment of suppurative mediastinitis from ancient times to our time depending on inflammation type, localization and clinical features. An important role of national surgical school in the development of surgical treatment was emphasized.

[The outcomes of different surgical procedures for thoracic injuries]. / Rezul'taty primeneniia razlichnykh vidov khirurgicheskikh vmeshatel'stv pri raneniiakh grudi.

AIM: To assess the outcomes of video-assisted techniques compared with conventional procedures. MATERIAL AND METHODS: 596 victims with thoracic injuries were enrolled. Video-assisted techniques were applied in 236 cases, conventional procedures - 360 patients. Groups were standardized by the type of surgery. Morbidity, hospital-stay and mortality according to Clavien-Dindo classification have been analyzed. RESULTS: There was similar incidence of complications in both groups. However, severe adverse events followed by redo surgery under general anesthesia occurred in 1.2% and 7.1% of cases respectively (p<0.05). Hospital-stay was 11.3±3.6 and 14.5±5.3 days respectively (p<0.05). Mortality was 0.58% vs. 1.08% respectively (p>0.05). CONCLUSION: In victims with thoracic injuries and no need for urgent thoracotomy video-assisted techniques are preferable for diagnosis and treatment.

[Features of diagnostic and surgical tactics for suicidal and autoaggressive thoracic and abdominal lesions]. / Osobennosti diagnostiki i khirurgicheskoi taktiki pri povrezhdeniiakh grudi i zhivota vsledstvie suitsidal'nykh i autoagressivnykh deistvii.

AIM: To analyze diagnostic and surgical tactics for suicidal and autoaggressive thoracic and abdominal lesions. MATERIAL AND METHODS: We have analyzed the features of emergency surgical care depending on type of patients' behavior at admission. There were 516 patients with suicidal and autoaggressive thoracic and abdominal lesions. RESULTS AND DISCUSSION: Depressive (34%) and adequate (46%) patients were examined routinely. Inadequate (aggressive) behavior is inappropriate for instrumental examination while medical sedation may be followed by significant hemodynamic disorders in patients with severe lesions. It was noted that indications for explorative surgery should be expanded in these patients and administration of sedatives should be combined with induction of general anesthesia. CONCLUSION: Severity of trauma and type of surgery affect mental state dynamics while the kind of psychopathy influences postoperative period course.

[The features of diagnosis and treatment of traumatic and non-traumatic pulmonary bleeding]. / Osobennosti diagnostiki i lecheniia legochnogo krovotecheniia travmaticheskoi i netravmaticheskoi étiologii.

AIM: To analyze an efficacy of differentiated approach for pulmonary bleeding of different etiology and severity. MATERIAL AND METHODS: The study included 134 cases of pulmonary bleeding for the period 2006-2015 including 53 patients with traumatic and 81 with non-traumatic etiology. Men/women ratio was 2.7:1, mean age was 43 years. Comparative retrospective analysis of X-ray and CT data in diagnosis of bleeding source was performed. Bronchoscopy was used to confirm these data. There were 43 endovascular examinations including 40 cases of bronchial arteriography (BAG). RESULTS AND DISCUSSION: X-ray and CT-signs of bleeding source were detected more often in case of traumatic pulmonary bleeding (62.3% and 93%) compared with non-traumatic (27.2 and 54%; p<0.05). Bronchoscopy revealed ongoing pulmonary bleeding in 40 (30%) patients, completed - in 94 (70%) patients. Indirect angiographic signs were the most frequent for pulmonary bleeding origin: hypervascularization (32.6%), bronchial-pulmonary shunts (23.2%) and bronchial artery dilatation (20.9%). 17 patients with ongoing bleeding underwent bronchial obstruction with adequate hemostasis in all cases. Endovascular interventions included bronchial arteries embolization (EBA) (33), occlusion of intercostal arteries (3) and segmental branches of low-lobar pulmonary artery (1), aortic stenting (1). Early efficacy of EBA was 97% with 2 month recurrence of pulmonary bleeding near 12.5%. Ongoing traumatic pulmonary bleeding was an indication for emergency thoracotomy in 18.9% compared with 12.3% for non-traumatic bleeding when surgery was made after endoscopic and endovascular hemostasis. CONCLUSION: Differentiated approach depending on etiology and severity of pulmonary bleeding improves outcomes and reduces the number of operations for ongoing severe bleeding.

[Re-operations in patients with heart wounds]. / Povtornye operatsii u postradavshikh s raneniiami serdtsa i perikarda.

AIM: To define the risk factors of complications which are followed by re-operations in patients with cardiac and pericardial wounds and to prevent these complications. MATERIAL AND METHODS: Retrospective and prospective analysis of 1072 victims with cardiac and pericardial injuries for 35 years was performed. Overall mortality was 17.2%. 98 patients died during surgery. Postoperative bleeding was observed in 38 (3.9%) cases. RESULTS: In 28 cases re-operations were performed for bleeding-related complications. Indications for re-thoracotomy were one-time drainage from pleural cavity over 500 ml or bleeding rate over 100 ml per hour for 4 hours. Prevention of postoperative bleeding in case of cardiac and pericardial wounds was developed on basis of analysis of these observations. CONCLUSION: Risk factors of complications requiring re-operation are cardiomyopathy of different etiology, technical and tactical errors during primary intervention and hypocoagulation with massive blood loss. Prevention of these complications includes careful heart wound closure, comprehensive intraoperative control, correction of hemostatic system.

[Treatment of upper esophageal sphincter achalasia as a little-known chapter of surgery].

It is presented the results of survey and treatment of 32 patients with upper esophageal sphincter achalasia. In 29 of them achalasia was consequence of stroke in brain stem (Zakharchenko-Wallenberg syndrome). 28 patients were operated using P. Chodoch method in 7 cases and author's technique of myotomy with pharyngoesophageal junction plasty in 21 patients. Plastic myotomy gives excellent and good results in 81% of observations due to preservation of innervation of muscles providing function of epiglottis and pharyngeal constrictors. Severe condition of patients and elderly age are indication for P. Chodoch myotomy.

[Risk factors of suppurative complications in case of thoracic injury].

It was performed retrospective analysis of 463 cases of suppurative thoracic complications after injury (232) and closed thoracic trauma (231) for 20-year period. Incidence of purulent complications was 3.2% and 1.6% in case of injury and closed thoracic trauma respectively including pleural empyema in 1.5 and 1.3%, pulmonary abscess in 0.3 and 0.4%, mediastinitis in 0.35 and 0.12%, pericarditis in 1.5 and 0.26%, osteomyelitis in 0.4 and 0.18% respectively. Factors preceding suppurative complications in case of injuries and closed trauma have been considered as predictors. Multivariant regression analysis established significant risk factors of suppurative thoracic complications. Clotted hemothorax, mediastinal hemorrhage, heart injury, late appeal for medical assistance and mechanical ventilation over 5 days were identified irrespective of character of trauma. In case of thoracic injury there were damage of osteochondrous frame, hollow thoracic and abdominal organs, gunshot wound of lung, delirium and injuries severity over 20 scores according to ISS scale. Pulmonary bleeding, sternal fracture and Glasgow Coma Scale rate<12 scores were identified as risk factors in case of closed trauma.

[Possibilities of videothoracoscopy for penetrating thoracic injuries].

It was analyzed the medical reports of 596 victims with thoracic injuries including 360 cases with following conventional therapeutic approach and 236 patients who underwent videothoracoscopy. We estimated condition severity in case of injuries of thoracic wall, lungs, pericardium and heart. Hemodynamic disorders were estimated according to Allgower-Burri shock index. Intrapleural bleeding was calculated using volume of hemothorax and time before injury and operation. Severity of physiological damages was determined using RTS criterion, anatomic--using ISS criterion. We estimated possibility for videothoracoscopy in patients with conventional therapeutic approach comparing severity of injuries, severity of condition in both groups and volume of surgery. Retrospective analysis revealed possibility of videothoracoscopy in 86.7% of victims with pulmonary injury, in 83.3% with bleeding at the muscular vessels of thoracic wall, in 40.3% with intercostal vessels injury, in 31.2% with heart injury, in 27.3% with damage of pericardium and in 18.8% with internal thoracic vessels injury. Our investigation revealed that videothoracoscopy may be used more widely in case of thoracic injury.

[Surgical accesses to retroperitoneal organs and anatomic structures in case of abdominal trauma].

It is presented the detailed description with illustrations of 3 surgical accesses which are used by authors to dissect retroperitoneal organs and anatomic structures in victims with closed trauma and abdominal injury. We reported clinical observations of successful use of developed accesses.

[Diagnosis and treatment of cervicothoracic injuries].

It analyzed the diagnosis and treatment results of 123 patients with cervicothoracic injuries for 21 years. The frequency of cervicothoracic injuries among all patients with cervical injuries was 5.7%. Preoperative and postoperative diagnosis included radial and endoscopic methods. The complications rate was 43.6%. The most severe complications were observed in patients with delayed diagnosis of trachea and esophagus injuries.

[Esophageal stenting complications].

The aim of the study was to analyze esophageal stenting complications in case of cancer and benign diseases. It was investigated complications in 8 patients in terms from 7 days to 1 year after intervention. In 4 patients esophageal stenting was performed for constrictive esophageal cancer and compression with pulmonary cancer metastases into mediastinal lymphatic nodes. 2 patients had esophageal stenting for post-tracheostomy tracheo-esophageal fistula, 1 patient - for spontaneous esophageal rupture, 1 patient - for post-burn scar narrowing of esophagus and output part of the stomach. Severe patients' condition with tumor was determined by intensive esophageal bleeding in 2 cases, bilateral abscessed aspiration pneumonia, tumor bleeding, blood aspiration (1 case), posterior mediastinitis (1 case). Severe patients' condition with benign disease was associated with decompensated esophageal narrowing about proximal part of stent (1 case), increase of tracheo-esophageal fistula size complicated by aspiration pneumonia (1 case), stent migration into stomach with recurrence of esophago-mediastino-pleural fistula and pleural empyema (1 case), decompensated narrowing of esophagus and output part of the stomach (1 case). Patients with cancer died. And patients with benign diseases underwent multi-stage surgical treatment and recovered. Stenting is palliative method for patients with esophageal cancer. Patients after stenting should be under outpatient observation for early diagnosis of possible complications. Esophageal stenting in patients with benign diseases should be performed only by life-saving indications, in case of inability of other treatment and for the minimum necessary period.

[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.

[Medico-social characteristics of patients with septic complications after penetrating thoracic wounds].

232 cases of septic complications after penetrating thoracic injury were analyzed. All patients were divided into groups according to the injury mechanism and inhabitancy. Patients with medico-social deviations, as well as patients with hemocontact infections, mental insanity and social deviations were marked out. 75% of patients were reported to have any medico-social deviations. Among them the distributing was as follows: persons with no fixed abode (100%), women (91%), patients over 50 years (86.2%) and patients after knife thoracic injury (77.4%). Among patients with hemocontact infection the majority were incomers from the near-abroad countries (37%), victims of assault (20%) and patients aged 31-40 years (18.4%).