[Contrast-enhanced ultrasonographic study in patients with lower limb arterial lesions]. / Ul'trazvukovoe issledovanie s kontrastnym usileniem u patsientov s porazheniiami arterii nizhnikh konechnostei.

BACKGROUND: The introduction into clinical practice of contrast-enhanced ultrasonographic examination made it possible to assess patency of tibial arteries and perfusion of crural muscles in patients with occlusive lesions of lower-limb arteries. These findings are important for planning optimal treatment policy and assessing efficacy of operative or medicamentous treatment. OBJECTIVE: The study was aimed at investigating a possibility of contrast-enhanced ultrasound examination for assessment of patency of tibial arteries and quantitative assessment of perfusion of crural muscles in patient with occlusive lesions of lower-limb arteries. PATIENTS AND METHODS: We examined a total of 30 patients presenting with atherosclerotic-genesis occlusive lesions of lower limb arteries and symptomatic intermittent claudication. Five patients were examined in the postoperative period. All patients were subjected to quantitative analysis of crural muscle perfusion in the pre- and postoperative periods, determining the time of onset of contrast medium accumulation and the time to the peak of intensity. RESULTS: Contrast-enhanced ultrasound examination demonstrated that in patients with occlusive lesions of lower-limb arteries the start of contrast medium accumulation appeared to occur later than in apparently healthy people: on second 30-88, depending on the degree of limb ischaemia. The contrasting time-to-peak was also increased (from 36 to 120 s). In the postoperative period all patients were found to have improved perfusion of the crural muscles, which was confirmed by a decrease in time-to-peak contrasting. CONCLUSION: Contrast-enhanced ultrasonographic examination is currently the only non-invasive, safe method of determining perfusion of crural muscles, which may be used many times for assessment of viability of the ischaemised extremity, as well as for assessment of efficacy of the treatment performed.

[Use of an ex vivo technique in a patient with renal arteriovenous malformation in complication endovascular treatment]. / Ispol'zovanie tekhniki ex vivo u patsienta s arteriovenoznoi mal'formatsiei pochek pri oslozhnenii éndovaskuliarnogo lecheniia.

Renal arteriovenous malformation is a rarely encountered disease characterized by the presence of a direct arteriovenous shunt between the renal artery and vein. This nosology was first described by Varela in 1928, and by 1997 the number of such cases amounted to slightly more than 200. Endovascular closure of a fistula seems to be an attractive method of treatment in view of low traumaticity and a short period of rehabilitation. However, as shown by our case report, this type of intervention in large-diameter fistulas may be associated with the development of life-threatening complications. In case of rupture of the renal capsule and/or arteriovenous aneurysm, radical nephrectomy, unfortunately, remains to be a method of choice. Described below is a case concerning treatment of a female patient presenting with bilateral arteriovenous malformations and the world's first emergency operation for a ruptured intraparenchymatous arteriovenous aneurysm using an extracorporeal technique.

[Risk factors for aerostasis failure in case of lung resection].

The results of risk factors analysis of aerostasis failure in 141 patients are presented in the article. All patients were operated in the A.V. Vishnevskogo Institute of Surgery at the period from January 2009 to December 2010. During statistical analysis it was considered surgeries volume, presence of emphysema, respiratory function etc. Also it was defined the dependence of venting duration in patients with residual pleural cavity and long aerostasis failure.

[Diagnosis of neuroendocrine neoplasms of the pancreas].

The rare clinical case of multiple primary gastrointestinal stromal tumors (GIST) in one patient is presented in the article. The analysis of the available material confirmed that there is the problem of early detection of this type of tumors and their differential diagnosis. The minutes of outpatient radiological methods of research should include methods of identifying GIST in various locations. Early diagnosis of the disease allows you to make a radical mini-invasive intervention in the endoscopic or robotic-assisted version. This tactic is characterized by high efficiency in combination with the chemotherapeutic treatment.

[Diagnostics and tactics of gastrointestinal stromal tumor surgical treatment].

45 patients with gastrointestinal stromal tumors (GIST) were under observation. In 30 cases the GIST came from the stomach, in 8 cases - from the duodenum, and in 7 cases - from the small intestine. In all cases the diagnosis was confirmed by immunohistochemical study. Specific clinical manifestations of GIST were absent. Ultrasound detected the tumors that were more than 30 mm in diameter. The most informative diagnostic technique was computerized tomography with a contrast. All patients were operated. 29 patients with a diameter of tumor more than 50 mm had traditional open operation. In case the tumor oversteped the limits of the capsule or capsule's damage during the operation, the extirpation of the gastrocolic omentum was done. If the GIST were less than 50 mm they were extracted with the robot-assisted or laparoscopic methods. The long-term results of the treatment (from 3 to 60 months) of 28 patients were analyzed. 3 patients died of disease progression, 1 patient had metastasis in liver and 24 patients hadn't the signs of relapse.

[Problems of the diagnostics of perivascular epithelial cell tumors].

Perivascular epithelioid cell tumors is a group of rare tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells. There are no specific imaging sighs. In most cases, the final diagnosis is possible only after the immunihistochemical study. These tumors are extremely rare. We present imaging findings of two cases of perivascular epithelioid cell tumors of the liver.

[Pancreatectomy for the pancreatic tumors].

23 pancreatectomies were made on the reason of various tumors of the pancreas during the period of 2009-2012yy. 15 patients had duct adenocarcinoma, 4 - neuroendocrine neoplasia, 2 - intraductal papillary-mucinous tumor, 1 had metastase of renal-cell carcinoma and 1 was diagnosed with serous cystadenoma. Pancreatectomy was indicated in case of invasion of the whole pancreas or in case of multiple tumor focuses. By adenocarcinoma the pancreatecomy was abstained in case of large vessels (a. mesenterica suoerior, truncus coeliacus and hepatic arteries) invasion or remote metastases presense or impossibility of R0 resection. Metastases and vessel invasion were not considered as contraindication to pancreatectomy in patients with neuroendocrine lesions. 10 (43.5%) patients had postoperative complications; 2 patients died. The survival median was 7 months for the duct adenocarcinoma. Postoperative life duration for patients with other pancreatic tumors was 6-36 months.

[Comparative analysis of vascularization degree of hepatocellular carcinoma and focal nodular hyperplasia of the liver according to computed tomography and morphological studies].

OBJECTIVE: A comparative analysis of the degree of vascularization of hepatocellular carcinoma (HCC) and focal nodular hyperplasia (FNG) of the liver at carrying out multislice computed tomography (MCT) and morphological studies. PATIENTS AND METHODS: 34 patients operated on for HCC (19 patients) and FNG of liver (15 patients) were survey. Preoperative we were analyzed four phases of CT-research: native, arterial, venous, delayed. Degree of vascularization of tissue were evaluated for immunohistochemical preparations on the relative share of the area of blood vessels. RESULTS: In native phase of the MCT-study HCC was detected as hypodense or izodensnoe education. Growth of the blood CT density depend on the type and extent of tumor histological differentiation of cancer. The highest values are set in the fabric of FNG and moderately differentiated HCC. The highest levels of venous growth observed in well differentiated HCC. Indicators of vascularization by CT have maximum values in the unaffected liver parenchyma, and the minimum--in the group of poorly differentiated HCC variant. CONCLUSIONS: Use of computed tomography with bolus contrast enhancement allows to study the characteristics of blood supply of the liver and focal formations. Frequently only the use of this method helps to evaluate specific morphological structure of tumors--hepatocellular carcinoma or focal nodular hyperplasia. As an additional differential diagnostic feature is recommended to increase the density determination of tissue formation in the arterial phase computed tomography study. The maximum of vascularization by computed tomography and immunohistochemistry (with antibodies CD34) are installed in a tissue of highly differentiated hepatocellular carcinoma.

[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.

[The requirement for the CT-scan protocol for the proper assessment of pancreatic tumors resectability].

The study aims the determination of the CT-scan protocol for the proper assessment of pancreatic tumors respectability. The goal of the CT-scan is a proper visualization of the tumor spread onto the surgically important vessels of the hepatopancreatobiliary zone and remote metastases verification. The diagnostic algorithm of the pancreatic cancer is based on the analysis of the variety of cases and diagnostic means.

[The postoperative pancreatitis after the pancreatic surgery].

The results of 302 operations on the pancreas were analyzed: of them 107 were pancreatoduodenal resections; 67 were distal resections of the pancreas; 74 were various resections of the head of the pancreas and middle resections and 54 other operations. The postoperative pancreatitis was registered in 178 patients. The preventive use of the octreotide intraoperatively and in early postoperative period showed no influence on the frequency and severity of the postoperative pancreatitis. The ultrasound was the optimal screening diagnostig method, whereas the computed tomography was the best in pancreonecrosis diagnostics and the volume of the pancreatic tissue damaged. Of 178 patients with the postoperative pancreatitis 17 died, the lethality rate was 9.5%.

[The intermediate and long-term treatment results of solid-pseudopapillary tumors of pancreas].

15 patients with solid-pseudopapillary tumors of the pancreas (SPTP) were investigated. There were no specific clinical signs of the disease revealed; the major common clinical sign was the upper abdominal pain. Of the diagnostic methods the ultrasound together with endoscopic ultrasound, computed tomography and magnetic resonance imaging were used. Specific diagnostic feature of SPTP is the heterogenous structure and even contours and capsule. Any changes of pancreatic duct are untypical. All 15 patients were operated on. The intraoperative urgent histological analyze together with postoperative immunohystochemical investigation were performed in all cases. 11 patients developed the postoperative pancreatitis. The long-term follow up results were obtained in 15 patients. The disease progression was registered in one case.

[Possibilities of surgical management of paraganglioma of the neck extending to the base of the skull].

Presented in the article is a rare clinical case report concerning successful treatment of a female patient with vaginal paraganglioma of the neck - a tumour extending from the level of the trunk of the common carotid artery in cranial direction to the base of the skull. Mentioned are difficulties of carrying out an operational intervention requiring the use of certain surgical techniques. The tumour was removed as a single block with the involvement into the process of the major vessels of the neck and nervous formations. The reconstructive operation performed was common carotid - internal carotid prosthetic repair with a 6.3-4.5 mm cone-shape prosthesis 'Gore-tex' on the right.

[Intraductal papillary-mucinous tumor of the pancreas: difficulties and mistakes of diagnostics and treatment].

15 patients with intraductal papillary-mucinous tumors (IPMT) of the pancreas were observed. Clinical manifestation corresponded with chronic pancreatitis. Ultrasound study, including endosonography, contrast-enhanced computer and magnetic resonance tomography were used in complex observation of the patients. Dilation of main or lateral pancreatic ducts, connection of tumor with pancreatic duct system and absence of septal calcinosis are typical signs in radiodiagnostics of IPMT. Visualization of parietal papillary proliferations and their contrast enhancement are undeniable signs f or neoplastic character of pancreatic duct dilation. Sensitivity of CT, MRТ and endoUS amounted accordingly 66, 83 and 88%. All patients were operated. Extent of operation was determined by morphological character, localization and size of the tumor (pylorus-preserving pancreaticoduodenal resection was carried out to 6 patients, distal resection including robot-assisted - to 7 patients, midline resection - to 1 patient, duodenum-preserving resection of head and body of pancreas - to 1 patient). Intraoperative urgent histologic study of pancreatic section was carried out by all means. Tumors with borderline degree of malignancy were detected in 4 cases.

[The virtual modeling of the robotic-assisted operations in abdominal surgery].

The experience of single institution of 43 robotic-assisted operations in the abdomen and retroperitoneal space has been analyzed. The problem of port placement conditioned the preoperative computed 3D-modelling of the operative course. The procedure allowed to optimize the movements of the robotic manipulators, decrease the risk of organ injury and overall incidence of intra- an postoperative complications.

[Ultrasound diagnosis of extrahepatic portal hypertension in chronic pancreatitis].

AIM: To evaluate the potential of the color duplex scanning in revealing of the portal hypertension in patients with chronic pancreatitis. MATERIALS AND METHODS: 94 patients with chronic pancreatitis were investigated. In 61 patients (65%) pancreatitis was complicated by extrahepatic portal hypertension (EHPH) and 31 patients (35%) were without signs of rising of the portal pressure. RESULTS: Investigations in B-regime have shown that in patients with EHPH chronic calculous pancreatitis was revealed in 48%, development of pancreatic hypertension in 75%, increase of the pancreas head up to more than 40 mm in 58% of patients. We did not reveal statistically significant differences in pseudo-cysts in pancreas, extension of extrahepatic and intrahepatic ducts and infiltrative changes in parapancreatic cellular tissue in patients with and without EHPH. A development of EHPH in 31 (51%) patients was preconditioned by an extravasal compression of veins of portal system, combination of extravasal compression with thrombosis was found in 11 (18%) patients, in 12 (20%) patients thrombosis of the magistral veins of portal system was revealed and in 7 (11%) patients hemodynamics was not changed. Resections were found to be preferable operations for recovery of portal circulation. Increase and normalization of portal circulation found after transversal section of pancreas (Beger operation, pancreo-duodenal resection, distal resection of pancreas). A tendency to normalization of the blood flow was observed after the Frey operation.