[Diagnosis and surgical treatment of a patient with Castleman disease]. / Diagnostika i khirurgicheskoe lechenie patsienta s bolezn'yu Kastlemana: klinicheskoe nablyudenie.

Castleman disease (CD) is a benign lymphoproliferative disease. Small prevalence and diverse clinical course of disease makes it difficult to standardize diagnostics and treatment. Currently, the number of CD patients has increased with improvement in the quality of examination. Therefore, differential diagnosis of this disease is important. We present a young patient with CD and retroperitoneal non-organ neoplasm. Despite a thorough preoperative examination, the final diagnosis was established only after histological examination of surgical specimen. We discuss the diagnosis and surgical treatment of a patient with unicentric type of CD.

[Difficulties in diagnosis of neuroendocrine tumors of the gastrointestinal tract]. / Trudnosti diagnostiki neiroendokrinnykh opukholei zheludochno-kishechnogo trakta. Klinicheskoe nablyudenie.

We present diagnosis and complex minimally invasive surgical treatment of a patient with long-standing neuroendocrine tumor of the upper gastrointestinal tract. We followed-up a 50-year-old female patient after endoscopic resection of polypoid neoplasm of the stomach for 2 non-organ retroperitoneal neoplasms in the area of hepatogastric ligament. After a comprehensive examination and minimally invasive surgery including laparoscopic resection of retroperitoneal neoplasms, immunohistochemical examination, PET-CT and targeted endoscopic ultrasound of the stomach, we diagnosed a highly differentiated gastric neuroendocrine tumor with metastases into lymph nodes of hepatogastric ligament. Combination of endoscopic and morphological diagnosis with rigorous histological examination of specimen provided correct diagnosis and reasonable strategy of aggressive minimally invasive surgical treatment.

[Submucosal tunneling endoscopic resection for large esophageal leiomyoma: technical aspects and risk of complications]. / Endoskopicheskoe udalenie krupnoi leiomiomy pishchevoda metodom tonnel'noi dissektsii: tekhnicheskie osobennosti operatsii i risk vozmozhnykh oslozhnenii.

We analyzed the technical aspects and risk of possible complications after submucosal tunneling endoscopic resection for large esophageal leiomyoma. A patient with a 4-cm non-epithelial esophageal tumor underwent STER procedure in June 2018. Surgery time was 130 min. There were no intraoperative complications. Postoperative period was complicated with mediastinitis with reactive pneumonia and pleural effusion accompanied by episodes of hyperthermia up to 38°C for 5 days. The patient was discharged in 12 days after complete resolution of pneumonia confirmed by chest X-ray. Contrast-enhanced examination after 3 postoperative days revealed no contrast agent leakage outside the esophagus. The previously applied clips were visualized. Endoscopic examination in 3 months after surgery visualized postoperative scar without signs of deformation and narrowing of the esophagus. No complaints were observed throughout 3.5-year follow-up period. CONCLUSION: This report demonstrates the advantages of tunnel dissection ensuring organ-sparing procedure with the best functional result. However, intra- and postoperative complications are possible after STER. The risk of complications and complexity of surgery depend on transverse size (>3.5 cm), shape and localization of tumor. Larger neoplasm is accompanied by more difficult surgery and higher risk of complications. Therefore, adequate selection of patients for STER is essential.

[A rare variant of pancreatic serous cystadenoma]. / Redkii variant seroznoi tsistadenomy podzheludochnoi zhelezy.

The authors present a patient with serous cystadenoma of the pancreatic head. Atypical symptoms and CT data did not allow excluding pancreatic cancer. Thus, pancreaticoduodenectomy was performed.

[Effect of morphological state of pancreatic parenchyma on the long-term outcome of surgery for chronic pancreatitis]. / Vliyanie morfologicheskogo sostoyaniya parenkhimy podzheludochnoi zhelezy na otdalennye rezul'taty khirurgicheskogo lecheniya khronicheskogo pankreatita.

OBJECTIVE: To determine the effect of baseline morphological state of the pancreas on the long-term outcomes of duodenum-preserving pancreatic head resection (DPPHR). MATERIAL AND METHODS: The study included 104 patients with chronic pancreatitis (CP), who underwent DPPHR in 2014-2019. Pain syndrome, exocrine and endocrine pancreatic insufficiency and quality of life (QoL) were assessed in long-term postoperative period. Patients were stratified depending on CT enhancement of pancreatic parenchyma as an indicator of fibrosis and amount of preserved acinar cells in resected pancreatic tissue. RESULTS. S: Ignificant relief of pain syndrome in long-term period was observed in patients with higher density of pancreatic tissue in venous phase of CT compared to delayed phase. Moreover, these patients needed less additional enzyme intake and had higher QoL. Exocrine insufficiency depended on the number of preserved acinar cells. The percentage of preserved acinar cells also affects the QoL of patients with CP. There were no correlations between endocrine insufficiency and CT-findings, as well as the number of preserved acinar cells. CONCLUSION: Higher CT-density of pancreatic parenchyma in venous phase indicates a lesser degree of fibrosis. It is a favorable prognostic factor for postoperative pain relief and preservation of exocrine function. The percentage of preserved acinar cells in the resected pancreatic tissue is a reliable predictor of exocrine insufficiency.

[Massive localized lymphedema of anterior abdominal wall]. / Massivnaya lokalizovannaya limfedema perednei bryushnoi stenki.

Massive localized lymphedema (MLL) is a rare disease observed in people with morbid obesity. MLL is easily confused with soft tissue sarcoma. Therefore, MLL is sometimes called as pseudosarcoma in the literature. MLL was initially described by G. Farshid and S. Weiss in 1998. However, etiology of MLL is still unknown despite certain relationships with injuries, operations and hypothyroidism. Since the term «MLL¼ was introduced only 20 years ago, there are no reliable statistical data on the prevalence of MLL. According to the World Health Organization data (2016), 13% of the adult world population are obese. Therefore, the risk of MLL is increased in these people. Thigh is the most common site of lesion. Abdominal wall lesion is rare and can cause diagnostic difficulties due to large dimensions and appearance. We report a 50-year-old obese woman with MLL of anterior abdominal wall. She experienced discomfort while walking and sleeping due to giant MLL of anterior abdominal wall that significantly reduced quality of life. Removal of MLL (weight 22160 g) was followed by favorable cosmetic and functional outcome. Analysis of differences between MLL and soft tissue sarcoma in the era of «obesity epidemic¼ is valuable for correct diagnosis and treatment of this rare complication. This report is the first case of MLL, registered in Russia. In our opinion, this is associated with insufficient awareness of physicians about this complication of obesity. We hope our observation will help clinicians to identify and treat this complication.

Reproducibility of CT texture features of pancreatic neuroendocrine neoplasms.

PURPOSE: To evaluate the reproducibility of textural features of pancreatic neuroendocrine neoplasms (PNENs), obtained under various CT-scanning conditions. METHODS AND MATERIALS: We included 12 patients with PNENs and 2 contrast enhanced CT (CECT): 1) from our center according to standard CT-protocol; 2) from another institution. Two radiologists independently segmented the entire neoplasm volume using a 3D region of interest by LIFEx application on the arterial phase and then copied it to the other phases. 52 texture features were calculated for each phase. As a criterion for the segmentation consistency, a value of neoplasm volume was compared using the Bland-Altman method. The Kendall concordance coefficient was calculated to assess the texture features reproducibility in three scenarios: 1) different radiologists, same CECT; 2) same radiologist, different CECT; 3) different radiologists, different CECT. RESULTS: For the scenario 1 the neoplasm volumes (except one large PNEN) were found within two standard deviations; this indicates high consistency of the segmentation. For the first scenario, Kendall's coefficient exceeded a threshold of 0.7 for all 52 features for all CT phases. For the second and third scenario, the concordance coefficient exceeded a threshold of 0.7 in 38, 28, 42, 45 and in 36, 25, 36, 44 features for the native, arterial, venous and delayed phases, respectively. CONCLUSION: The highest reproducibility was found in the first scenario compared to the second and third: 100 % vs. 74 % and 67 %. Reproducible texture features can be reliably used to assess the PNENs structure.

[Predicting of pancreatic fistula after pancreatoduodenectomy]. / Prognozirovanie vozniknoveniya pankreaticheskogo svishcha posle pankreatoduodenal'noi rezektsii.

OBJECTIVE: Identifying the opportunity of objective prognosis of pancreatic fistula emergence after pancreatoduodenectomy. MATERIAL AND METHODS: In the department of abdominal surgery in 2016-2019, 177 pancreatoduodenectomies for pancreatobiliary tumors were performed. 4 risk factors were identified: type of tumor, preoperative CT with an accumulation coefficient in the pancreas of more than 1, soft pancreas, the number of functioning acinar structures identified during intraoperative histological examination. Statistical data processing and predictive modeling were performed using a binary logistic regression model. RESULTS: Clinically significant pancreatic fistula was developed in 47 (26,6%) patients. Risk indicators for the occurrence of pancreatic fistula depending on the presence or absence of risk factors were obtained. Groups of patients were identified that require various preventive and therapeutic measures aimed to treat postoperative pancreatitis and its consequences. CONCLUSION: Predicting the pancreatic fistula emergence allows to take timely preventive and therapeutic measures, both minimal and aggressive (early extracorporeal detoxification, pancreatectomy), which may lead to complications. Well-reasoned pancreatectomy and extracorporeal detoxification is a surgeon's defense in an insured case or legal conflict.

[Diagnostic and treatment of the intraductal papillary mucinous tumor of pancreas]. / Diagnostika i lechenie vnutriprotokovoi papilliarnoi mutsinoznoi opukholi podzheludochnoi zhelezy.

OBJECTIVE: Adjustment of diagnostics and management of the surgical treatment of patients with intraductal papillary mucinous tumor of pancreas. MATERIAL AND METHODS: From 2012 to 2018, 45 patients with intraductal papillary mucinous tumor were observed. During the observation the ultrasound examination, contrast-enhanced computed tomography and magnetic resonance tomography with contrast were used. In 29 cases radical surgery was performed, nonradical in 1 case; case follow-up is chosen for 15 patients. RESULTS: Intraductal papillary mucinous tumor was diagnosed and the definition of the type of tumor was made on the base of 2 types of imaging methods. Intraductal papillary mucinous tumor type 1 was founded in 5 (11%), whereas intraductal papillary mucinous tumor type 2 was founded in 20 (44,5%) and intraductal papillary mucinous tumor type 3 was observed in 20 (44,5%) cases. Intraductal papillary mucinous tumor associated with carcinoma was observed in 16 cases. Pancreaticoduodenal resection was performed in 20, distal exsection of pancreas was performed in 4 cases (2 in open manner access, 2 in robot-assisted manner), pancreatic head resection was performed in 3 cases (1 in open manner access, 2 in laparoscopic access) and in 2 cases the duodenopancreatectomy was performed. Explorative laparotomy was performed in case of intraductal papillary mucinous tumor type 2 associated with mucilaginous carcinoma and miliary metastasis in the liver. Early postoperative complications were observed in 5 cases (16, 6%): biliary fistula (n=2), postoperative wound infection (n=2), arrosive hemorrhage type B in ISGPS (n=1, was treated in an X-ray endovascular manner). Case follow-up was chosen in 15 cases of intraductal papillary mucinous tumor over the course of 6 to 74 months and disease progression was not observed. CONCLUSION: Intraductal papillary mucinous tumor is a condition associated with high risk of malignant change and demands early disease detection. The treatment should be provided in medical centers that specialize in the pancreas deceases, where a full patient examination as well as a clear-eyed understanding of diagnostic information with the execution of desirable type of surgical intervention with the guaranty of achievement R0 condition can be offered.

[Duodenopancreatectomy for pancreatic tumors - pros and cons]. / Duodenopankreatéktomiia pri opukholiakh podzheludochnoi zhelezy - PRO ET CONTRA.

AIM: To optimize surgical treatment of multiple and advanced pancreatic tumors. MATERIAL AND METHODS: There were 852 patients with various pancreatic tumors for the period 2011 - September 2019. Duodenopancreatectomy (DPE) was performed in 18 patients. Locally advanced ductal adenocarcinoma was diagnosed in 10 patients, acinar cell carcinoma - in 1 patient, multiple neuroendocrine tumors - in 4 cases, intraductal papillary mucinous tumor - in 2 patients, multiple metastases of renal cell carcinoma - in 1 patient. This procedure was avoided in 9 patients who underwent alternative operations: pancreatoduodenectomy (PDE) with pancreatic body resection for intraductal papillary mucinous tumor - 5 cases, two-stage (2) and one-stage (1) distal pancreatectomy and PDE for multiple neuroendocrine tumors - 2 patients, simultaneous pancreatic head resection and distal pancreatectomy for multiple metastases of renal cell carcinoma - 1 patient. RESULTS: Postoperative complications occurred in 14 patients after DPE (77.8%) and in 5 patients after alternative operations (55.5%). Alternative procedures in patients with neuroendocrine tumors, intraductal papillary mucinous tumors and metastases of renal cell carcinoma ensured radical surgical treatment. These patients did not need for insulin replacement therapy and enzyme drugs. CONCLUSION: Strict adherence to oncological canons and differentiated approach in patients with multiple neuroendocrine tumors, metastases of renal cell carcinoma and intraductal papillary mucinous tumors are essential to avoid DPE in some cases in favor of alternative operations.

[Nocturnal pulse oximetry indicators in the evaluation of obstructive sleep apnea syndrome in outpatients with concomitant diseases of the upper respiratory tract and overweight]. / Pokazateli nochnoi pul'soksimetrii v otsenke sindroma obstruktivnogo apnoé vo sne u ambulatornykh patsientov s soputstvuiushchei patologiei verkhnikh dykhatel'nykh putei i izbytochnoi massoi tela.

AIM: By using mathematical modeling, to evaluate the impact of upper respiratory tract diseases, retro- and micrognathia, and body mass index (BMI) on nocturnal pulse oximetry indicators (oxygen saturation level and oxygen desaturation index) in outpatients examined for suspected obstructive sleep apnea syndrome (OSAS). SUBJECTS AND METHODS: The study enrolled 260 subjects with a mean age of 47.8±12.0 years. All the examinees underwent outpatient pulse oximetry screening during nocturnal sleep because of suspected OSAS. Multislice spiral computed tomography was carried out to assess the paranasal sinuses and nasal septum. BMI was calculated. Variance factor analysis using an original programming application intended to create binary and ternary dispersion complexes was employed as a main mathematical tool. RESULTS: There were statistically significantly sets of risk factors for OSAS: nasal septum deviation + increased BMI + male gender = 68.66%; chronic allergic rhinitis + increased BMI + male gender = 63.09%; retromicrognathia + increased BMI + male ganger = 59.48%; and chronic tonsillitis + increased BMI + male gander = 60.88%. Higher BMI and male gender are a most statistically significant set of risk factors. CONCLUSION: Pulse oximetry screening during nocturnal sleep in snoring patients with suspected OSAS in combination with an assessment of age, sex, BMI, ENT comorbidity, retro- and micrognathia can predict the severity of the disease and serve as a basis for elaborating an OSAS screening program.

[Diagnosis and treatment of duodenal dystrophy in patients with chronic pancreatitis]. / Diagnostika i taktika lecheniya duodenal'noi distrofii u bol'nykh khronicheskim pankreatitom.

AIM: to define optimal treatment of duodenal dystrophy in patients with chronic pancreatitis. MATERIAL AND METHODS: 515 patients with chronic pancreatitis have been treated for the period 2004-2015 in A.V.Vishnevsky Institute of Surgery. Duodenal dystrophy (DD) was diagnosed in 79 (15.3%) of them. The diagnosis was confirmed by sonography, CT, MRI and endosonography. 5 patients are under observation without surgery. 74 patients were operated after previous medical therapy during 39 months on the average. Pancreatoduodenectomy was performed in 36 patients. Organ-sparing interventions were applied in 34 cases including different duodenal resections in 20 patients and pancreatic head resections in different modifications in 14 cases. 4 patients underwent palliative surgery. Chronic pancreatitis and DD were verified by morphological analysis of specimens. Long-term results were estimated in 47 patients. Median follow-up was 49.9 months. RESULTS: X-ray diagnostics showed that DD was combined with chronic pancreatitis in 87.3% of cases while morphological analysis revealed 93.8%. Clinical signs of DD were caused by striated pancreatitis in 69.6% and ectopic pancreatic tissue in 30.4%. Clinical manifestations of DD did not depend on its cause and were presented by symptoms of chronic pancreatitis. Postoperative complications occurred in 25 (34.7%) patients. There were 33.5% of complications after pancreatoduodenectomy and 70% after duodenal resection. 1 patient died. Overall mortality was 1,3%. In long-term period complete regression of symptoms was observed in 66% of cases, significant improvement - in 32%, absence of the effect - in 2%. CONCLUSION: Medical therapy should be preferred for patients with DD and chronic pancreatitis. Surgery is indicated in case of persistent pain, complicated course of chronic pancreatitis and duodenal obstruction. Pancreatoduodenectomy and pancreatic head resection are preferred.

[Risk factors and prevention of postoperative pancreatitis after pancreatectomy]. / Faktory riska i profilaktika posleoperatsionnogo pankreatita pri rezektsionnykh vmeshatel'stvakh na podzheludochnoi zheleze.

AIM: to improve the results of pancreatic resections through decrease of postoperative pancreatitis incidence. MATERIAL AND METHODS: It was analyzed 207 patients who underwent pancreatic surgery for pancreatic tumor (n=137) or chronic pancreatitis (n=70). 22 risk factors of postoperative pancreatitis were analyzed in 112 patients retrospectively. In prospective study of 95 patients the efficacy of lornoxicam to prevent postoperative pancreatitis was assessed. 68 parameters of immune state were studied to estimate effect of lornoxicam. RESULTS: Significant factors were mellow pancreatic parenchyma, tumoral disease, pancreatic duct diameter over 3 mm, pancreatric duct index over 0.2, body mass index over 27 kg/m2. Likelihood of postoperative pancreatitis was 40%, 63%, 74.3% and 88.9% if 2, 3, 4 and 5 factors were combined respectively. Preventive use of lornoxicam reduced significantly incidence of postoperative pancreatitis (p=0.042). Incidence of pancreatic fistula and arrosive bleeding was decreased insignificantly due to small number of observations. CONCLUSION: Assessment of significant risk factors and use of medical prevention are available to decrease likelihood of postoperative pancreatitis.

[Possibilities of automated image analysis in pathology].

Pathology is one of the most dynamically developed medical specialties. The wide spread of whole-slide imaging systems has leaded to the development of microscopic image analysis software. This review shows the possibilities of these programs and their role in the routine work of a pathologist.

[Nesidioblastosis (diagnosis, surgical treatment)]. / Nezidioblastoz (diagnostika i khirurgicheskoe lechenie).

INTRODUCTION: Nesidioblastosis (NB) is rare disease with organic hyperinsulinism syndrome and caused by diffuse hyperplasia and/or hypertrophy of pancreatic islands of Langerhans. MATERIAL AND METHODS: The results of surgical treatment of 3 patients with NB are presented. In all patients the diagnosis was suspected at the preoperative stage and confirmed by histological examination later. Herewith in 2 patients NB was combined with insulinoma. All patients underwent corpora-caudal pancreatectomy. RESULTS: In postoperative period one patient hadn't episodes of hypoglycemia for the entire follow-up period (5 months), in another patient hypoglycemic states occurred at 1.5 months after surgery. The third patient required pancreatic head extirpation at 11 days after surgery due to persistent severe course of organic hyperinsulinism. In immediate postoperative period in the same patient hyperinsular hypoglycemia was observed that pointed on extrapancreatic source of insulin secretion. However contrast-enhanced CT did not reveal any formations. CONCLUSION: Thus, corpora-caudal pancreatectomy is preferable as surgical treatment. Results of surgical management can provide a complete regression of the symptoms, but do not guarantee absence of recurrence and even any changes in frequency and severity of hypoglycemic states.

[ROLE OF FACTORS OF THE ENVIRONMENT OF EDUCATION AND TRAINING IN THE FORMATION OF THE DYSPLASIA OF THE CONNECTIVE TISSUE IN TEENAGE YEARS].

Negative trends of indices of the incidence in children and teenagers in the Russian Federation are caused by essential changes in the system of training and medical care of school students. In cases of connective tissue dysplasia (CTD) when the gene defect is remains to be unascertained, there is a great role of environmental factors contributing to the implementation of pathology and hygienic measures of the prevention of complications. There was performed the hygienic assessment of sanitary-epidemiologic welfare (SEW) of the educational institutions (EI) of the city of Omsk (n = 76), including the study of environmental factors, health and performance of adolescents. For the correction priority factors for SEW were "medical care", "mode and organization of the educational-training process", "conditions and organization of nutrition", "conditions and organization of physical education." There are determined the most important for the occurrence of CTD indices lifestyle factors and "indicators" of the risk for the progression of pathological processes in adolescents.

[Benign mimics of prostatic adenocarcinoma].

Prostate cancer occupies 2nd place on the prevalence and 6th place on mortality among all cancers in men. That is not to deny the social importance of prostate cancer, but attention is drawn to significant advantage of newly detected cases above the cancer-specific mortality. "Gold standard" for diagnosis includes morphological study of tissue fragments after transrectal multifocal prostate biopsy. The importance of the differential diagnosis is particularly relevant when analyzing fragments of prostate tissue obtained from biopsies as a false positive result may cause unnecessary and excessive treatment. This article presents the most common benign processes that can simulate various grade adenocarcinoma. Awareness about the presence of such cancer mimics and careful examination of micropreparations in most cases allows to come to the correct conclusion.

[Efficiency of complex rehabilitation in chronic obstructive pulmonary disease and occupational bronchitis].

AIM: To evaluate the efficiency of the rehabilitation in patients with obstructive pulmonary disease (COPD) and occupational bronchitis (OB) and the disabled due to these diseases, which was based on the authors' developed procedure and criteria for evaluating the efficiency of rehabilitative measures. MATERIALS AND METHODS: The efficiency of implementation of 55 individual rehabilitation programs (RP) elaborated by the Medicosocial Examination Bureau for the disabled due to COPD and OB was evaluated. RESULTS: The authors have determined qualitative criteria for evaluating the efficiency of rehabilitation: the extent to which the recommended rehabilitation measures being implemented, the trend in the magnitude of various vital activity categories and social inadequacy and in the disability group on regular examination, the results of implementation of some parts of an individual RP, the conformity of the achieved results to the rehabilitation potential of a disabled patient. The evaluation procedure supposes a unified quantitative gradation of each criterion. Overall, rehabilitation is more effective in COPD than in OB. CONCLUSION: The developed criteria and procedures for evaluating the efficiency of rehabilitation in patients with COPD and OB show a great informative value and practical content richness, which permits one to make corrections into the rehabilitation process. Functional impairments, the degree of vital activity restrictions and social inadequacy, as well as the rehabilitation potential and rehabilitation prognosis are concomitantly evaluated, which allows minor changes to be assessed in the clinical, personality, and social status of a patient.

[Influence of medical rehabilitation under conditions of sanatorium on life quality indices in adolescents with connective tissue dysplasia].

Maximal phenotypic manifestation of connective tissue dysplasia (CTD) is noticed in adolescence. But there are no clear conceptions about efficiency of rehabilitation programs for these patients. Indices of life quality (LQ) of adolescents with CTD, adolescents with CTD and concomitant pathology before and after medical rehabilitation are analyzed in the work. Indices of LQ in healthy children and adolescents with CTD are compared. Life quality is described both by its separated indices and by integral index. Assessment of influence of concomitant pathology in CTD patients on performed treatment is given. It shown that use of complex of physical factors can be considered as high effective method of treatment of young patients with various clinical variants of CTD.