[Open and laparoscopic surgery via minimally invasive approach in the treatment of perforated ulcer: a systematic review and metaanalysis]. / Laparotomnye i laparoskopicheski assistirovannye operatsii iz minidostupa v lechenii probodnoi yazvy. Sistematicheskii obzor i metaanaliz.

OBJECTIVE: Systematic review and metaanalysis of the effectiveness of open and minimally invasive laparoscopic suturing of perforated peptic ulcer. MATERIAL AND METHODS: Searching for Russian and English language reports included Scientific Electronic Library, Cochrane Collaboration Library and PubMed databases. We have analyzed contents of specialized journals, reviews and their references. Unpublished data were obtained via communication with chiefs of national surgical hospitals. RevMan 5.3 software was used for metaanalysis. RESULTS: We found no international randomized trials in available literature. Metaanalysis was based on national non-randomized studies. Total sample was 1177 cases. Laparoscopic minimally invasive surgery was performed in 43% of cases (n=503), open suturing - in 57% (n=674) of patients. Choice of these procedures is not currently not standardized. Minimally invasive procedures are shorter in time (mean difference -8.02, 95% CI -11.26 - -4.77, p<0.00001) and ensure less hospital-stay (mean difference -1.93, 95% CI -2.97 - -0.88, p=0.0003). Complications were less common (OR 0.14, 95% CI 0.07-0.27, p<0.00001) after minimally invasive operations (2.4%, 12/503) compared to laparotomy (11.4%, 77/674). Incidence of suture failure was similar (OR 0.4, 95% CI 0.1-1.6, p=0.2) (0.4% (2/503) vs. 0.7% (5/674)). Postoperative mortality was higher (OR 0.14, 95% CI 0.05-0.37, p<0.0001) after laparotomy (8%, 54/674) compared to laparoscopy (0.8%, 4/503). CONCLUSION: A metaanalysis indicates the advantage of laparoscopy-assisted suturing of perforated ulcer via minimally invasive approach over laparotomy. The absence of a standardized approach in choosing of minimally invasive laparotomy and conventional approach is a limitation of these results.

[The role of in-hospital protocols in diagnosis and treatment of ulcerative gastroduodenal bleeding]. / Rol' vnutribol'nichnykh protokolov v diagnostike i lechenii iazvennogo gastroduodenal'nogo krovotecheniia.

AIM: To improve immediate results in patients with acute ulcerative gastroduodenal bleeding. MATERIAL AND METHODS: The study enrolled 91 patients with ulcerative gastroduodenal bleeding. RESULTS: Diagnostic and curative procedures should be related to hospital's equipment, specialists' qualification and comprehensive development and application of accepted tactical approaches. 20-year development of this protocol which includes original low-temperature irrigator of stomach and duodenal mucous membranes, objective choice of endoscopic hemostasis technique depending on bleeding source in gastroduodenal wall, early administration of proton pump inhibitors significantly increases efficacy and reliability of endoscopic hemostasis. It was followed by improved early outcomes: recurrent bleeding incidence was 4.2%, surgical activity decreased by 68% up to 13.2%, overall and postoperative mortality was 2.2% and 8.3% respectively.

[Is medication possible for acute appendicitis?] / Vozmozhna li konservativnaia terapiia ostrogo appenditsita?

AIM: To study the possibility of antibacterial therapy for acute appendicitis as an alternative to surgical treatment. MATERIAL AND METHODS: For the period 1985-2010 diagnostic laparoscopy was performed in 5548 patients with suspected acute appendicitis. Acute phlegmonous or gangrenous appendicitis was observed in 2275 (41.0%) patients who underwent laparoscopic appendectomy. Other acute diseases occurred in 2458 (44.3%) patients. Acute catarrhal appendicitis or secondary inflammation of the appendix were diagnosed in 815 (14.7%) patients; they did not get appendectomy. In-hospital antibacterial therapy has been administered for 1-2 days followed by discharge for outpatient treatment. One patient with acute destructive appendicitis who refused surgery was treated with antibiotics. RESULTS: Antibacterial therapy in 815 patients with acute catarrhal appendicitis allowed to avoid surgical treatment. Complications (appendicular infiltration, abscess), repeated hospitalizations within 1 month were absent. Antibacterial treatment provided recovery in 1 patient with destructive appendicitis who refused surgical treatment. CONCLUSION: Patients with acute catarrhal appendicitis diagnosed with laparoscopy do not need for appendectomy and can be cured by antibacterial therapy.

[The use of computed tomography in the diagnosis of acute appendicitis]. / Komp'iuternaia tomografiia v dagnostike ostrogo appenditsita (s kommentariem).

AIM: To present the use of computed tomography in the diagnosis of acute appendicitis. MATERIAL AND METHODS: The study was conducted in 139 patients who were hospitalized with suspected acute appendicitis. However, the diagnosis was not clearly confirmed by clinical and ultrasonic data. RESULTS: Computed tomography confirmed/rejected presumptive diagnosis in 90.8% of patients. It was concluded that CT has high diagnostic accuracy to confirm acute appendicitis.

DIAGNOSTIC TRENDS IN ACUTE APPENDICITIS.

The authors presents the results of application of ultrasound investigation, diagnostic laparoscopy and multi-helical computer tomography in diagnostics of acute appendicitis. The research was applied on 139 patients whom clinical diagnosis was hard to establish using clinical - laboratory criteria. Ultrasound signs of acute appendicitis were revealed in 44 patients out of 139 (31,6%). Diagnostic laparoscopy was performed in 37 (26,6%) patients. According to the results of laparoscopy, the diagnosis of acute appendicitis was сonfirmed in 22 (70,2%) cases. The application of CT allowed the authors to confirm or reject the supposed diagnosis in 90,8% patients. The authors came to conclusion that this non-invasive method facilitated to diagnostics of vermiform appendix inflammation and had a high diagnostic accuracy.

[Improvement of treatment results of acute cholecystitis].

The aim of this study was investigation of treatment results of acute cholecystitis according to suggested forms of cholecystitis by international experts in the research (Tokyo-2007). It was analyzed the immediate treatment results of 1399 patients with acute cholecystitis for the last 4 years in the Chelyabinsk Regional Hospital No3. 912 patients had acute cholecystitis I degree (easy cholecystitis), 270 patients--II (moderate) degree and 217 patients--III degree (severe cholecystitis). It was operated 1281 patients. Operating activity was 91.5%. Postoperative mortality in whole patients group was 0.78%. The authors suggested the main principles such as early, differentiated by the volume operative interventions according to graduations of investigation "Tokyo-2007". Controlled trial of treatment results of patients randomized on three degrees of acute cholecystitis observed appropriateness of allocation of these groups. It is necessary for differentiated treatment and improvement of treatment results of patients with acute cholecystitis.

[Management of perforative gastroduodenal ulcer].

AIM: To study the immediate results of surgical treatment of patients with perforative gastroduodenal ulcer. MATERIAL AND METHODS: It was analyzed immediate results of surgical treatment of 646 patients with perforative gastroduodenal ulcer. Ulcer suturing predominated as surgical technique (358 patients, 55.5%), in other observations there were different types of vagotomy (215 cases, 33.3%), partial gastrectomy in 73 (11.2%) patients. RESULTS: In early postoperative period 36 (5.62%)patients died, incidence of complications was 6.2%. Following aspects effect on choice of surgical techbique including laoarotomy or minimally invasive approach, conventional suturing, vagotomy, partial gastrectomy: 1. presence of shock or unstable hemodynamics; 2. life-threating comorbidities (ASA class 3 and higher); 3. degree of abdominal bacterial contamination; 4. pre-hospital duration of disease; 5. dimension and type of ulcer; 6. ulcerative history or intraoperative evidence of chronic ulcer. Implementation or absolute predominance of surgery of the same type (suturing of perforative ulcer) leads to great number of poor long-term results (up to 60-70%) and requires repeated interventions.

[Cholecystitis in high risk patients].

Basing on the analysis of treatment results of 5129 patients with acute cholecystitis, major factors, influencing the outcome, were revealed. These were: age, severity of concomitant diseases, presence of the destruction in the abdominal cavity, late terms of the hospitalization, type and volume of surgical intervention, ASA stage III-IV, SIRS criteria. According to the revealed factors, different approaches to the surgical tactics of the acute cholecystitis treatment, were suggested. The suggested differential approach provided good immediate results with postoperative lethality level of 1.0±0.2%.

[The acute appendicitis: what has changed since the beginning of the new century?].

In spite of the dramatic improvement of the instrumental and diagnostic possibilities in surgery, the part of diagnostic mistakes, leading to the unreasonable operations, still remains 10-20%. New data of etiopathogenesis of the acute appendicitis, possibilities of noninvasive diagnostic means, such as CT and US were critically assessed. Basing on the performed analysis, the author suggests to start treatment of patients suspected of havinh the acute appendicitis, with conservative therapy including antibioticsts.

[New approach to treatment of patients with chronic fibrosing pancreatitis by laser tunneling of the pancreas].

Laser tunneling of the pancreas for stimulation of neoangiogenesis, regeneration and reverse of sclerotic changes was performed in 20 patients with fibrosclerotic pancreatitis. Nine of them were men and eleven were women. The age of the patients ranged from 27 to 71 years. The results of clinical trial testify for the possibility of safe and effective application of laser tunneling of the pancreas in patients with chronic pancreatitis. One of the significant features of the treatment was pain relief and improved quality of life of these patients.

[Laser tunneling of pancreas in chronic pancreatitis].

Obstructive chronic pancreatitis was reproduced in canine model, with the subsequent laser tunneling of pancreas tissue. It was shown, that in the zone of sclerotic changes in pancreas, laser irradiation caused hyperplasia and hypertrophy of acinous cells, augmentation of blood vessels and excretory channels numbers in the reference area, decrease of volume fraction of fibrous tissue that promotes augmentation of pancreas parenchyma.

[Laparoscopic-assisted method of surgical treatment of perforated gastric and duodenal ulcer].

Conversion (laparoscopic-assisted) method of surgical treatment of perforated gastric and duodenal ulcer was used at 103 patients. This method combines minilaparotomy with videolaparoscopy. Mean duration of surgery was 53 min, mean hospital stay - 6 bed-days. Postoperative complications were seen at one patient. There was no lethal outcome whereas lethality after open surgeries was 3.8%. It is concluded that mini-invasive methods of perforated ulcers suturing can not be oppose to traditional laparotomy; each method has own indications and contraindications. But mini-invasive surgical procedures may be regarded as real alternative to traditional open surgeries because of minimal approach, minimal surgical trauma and high economic effect in treatment and rehabilitation of these patients.

[Diagnostic value of Dopplerography in mechanical intestinal blockage]. / Diagnosticheskaia tsennost' dopplerografii pri mekhanicheskoi kishechnoi neprokhodimosti.

With intestinal obstruction taken into consideration, it is thought to be expedient to study changes to hemodynamics occurring in the basin of the superior mesenteric artery (SMA) with the help of dopplerography. A reliable elevation was noted in indices of the peak systolic circulation rate in SMA, mean linear circulation rate in SMA, correlation between the peak systolic rate in SMA and the systolic rate in the abdominal aorta, volume circulation rate in SMA. In addition, these indices were shown to depend on the level of the obstacle resulting in intestinal obstruction.

[Acute appendicitis: disputable problems]. / Ostryi appenditsit: spornye voprosy.

Latest Russian publications about pathogenesis of acute appendicitis, surgical policy and new approaches to its treatment are discussed. Based on many-year experience of surgical treatment of abdominal diseases and literature data, the author gives his opinion about inexpedience of appendectomy for cataral and unchanged appendix. Unfounded proposals towards changed diagnosis formulation in various forms of destructive appendicitis are subjected to criticism. It is concluded that it is necessary to use traditional approaches to diagnosis and treatment of acute appendicitis.

[Main principals of clinical diagnosis formation in peritonitis]. / Osnovnye printsipy formirovaniia klinicheskogo diagnoza pri peritonitakh.

Based on great clinical experience (more 1000 patients) the author makes attempt to standardize classification of peritonitis. Bearing in mind the critical analysis of available peritonitis classifications, it is proposed to divide toxic phase of peritonitis (by K.S. Simonyan) into two variants--with poliorganic insufficiency or without it. This elaboration permits to make the treatment of the patients with general peritonitis more detailed. Besides, the changes were made in division of peritonitis by degree of generalization along peritoneum, it is proposed to distinguish only 4 types by abdominal exudate character that also determine the actions of surgeon. Individual surgical situations in various forms and types of peritonitis are analyzed. The own model of peritonitis classification permits to receive comparable immediate results of treatment.

[Principles of medical care of patients with gastrointestinal ulcer hemorrhage]. / Printsipy okazaniia khirurgicheskoi pomoshchi bol'nym s iazvennymi zheludochno-kishechnymi krovotecheniiami.

A new protocol of treatment policy is proposed based on the results of treatment of 518 patients with gastrointestinal ulcer bleedings. All the patients are divided into 3 groups: with continued bleeding, with unstable spontaneous hemostasis, and with stable spontaneous hemostasis. Corresponding policy of treatment was used: surgery, endoscopic hemostasis, conservative treatment. In endoscopic hemostasis we preferred to clamp vessel or ulcer leading to hemostasis in all 36 cases. Hemostasis was not achieved in 6% patients, recurrence of bleeding was in 4.2% patients, 24.6% patients underwent emergency operations. The majority of operated patients underwent stomach resection (51.6%). The proposed principles of treatment permitted to decrease overall lethality from 5.2 to 2.6%, postoperative lethality--from 15.7 to 7.5%.