[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.

[Endovascular and surgical treatment of a patient with traumatic rupture of the aorta and hepatic artery].

Traumatic rupture of the aorta is the second most common cause of death in closed chest injury. The latest findings of autopsy showed that 80% of lethal outcomes in aortic injury occur in the prehospital period. Taking into consideration the incidence and high rate of death prior to the diagnosis stage, aortic rupture in closed thoracic injury is an important problem. Due to the characteristic mechanism of the development (during sharp deceleration of the body) this type of traumatic lesion of the aorta became known as "deceleration syndrome". The most vulnerable to tension aortic portion is its neck where the mobile part of the thoracic aorta is connected to the fixed arch in the place of the arterial ligament attachment. Open surgical intervention in patients with severe closed chest injury (often concomitant injury) is associated with high mortality and complications. Currently endovascular prosthetic repair of the aorta is a method of choice at the primary stage of treatment of patients with aortic injury. In this article we present a rare case report of concomitant lesion of large vessels (the descending aortic portion and proper hepatic artery) in a patient with severe concomitant injury, as well as peculiarities of diagnosis and combined treatment (endovascular prosthetic repair of the aorta and hepatic artery with an aotovein).

[Features of severe surgical infections of soft tissues].

AIM: To analyze clinical and microbiological examinations in severe soft tissues infections and their significance in predictors of outcomes. MATERIAL AND METHODS: Treatment of 19 patients with severe suppurative infection and suspected non-clostridial anaerobic flora with different causes of soft tissues infection was analyzed. All patients were treated in N.V. Sklifosovskiy Research Institute of Emergency Care for the period 2010-2012. Diagnosis was based on X-ray survey, sonography and CT data. Multicomponent management included surgery, intensive therapy, proteinic and water-electrolyte balance correction, deintoxication, nutritive support and immune therapy.Microbiological diagnosis was performed using Bactec-9050, Multiscan and WalkAway-40 analyzers. Culture mediums and microanaerostats to detect aerobic and obligately-anaerobic pathogens certified in Russia were used. Of 19 patients bacteriological examination was performed in 11 patients. So 107 specimens from wounds predominantly and blood were studied. 91 strains were revealed and identified. RESULTS: 8 of 11 patients in group 1 were operated. Three patients were inoperable due to severe condition and endotoxic shock. Despite complex treatment inflammation progressed in 5 of 8 patients followed by death. The second group consisted of 8 survivors. Staphylococcus aureus played leading role. There were no significant differences related to obligately-anaerobic pathogens. Mixed populations of aerobic and facultative anaerobic pathogens were diagnosed in 45% of specimens sampled from deads that is significantly greater than from survivors (8.7%). Leading pathogens of severe suppurative infections of soft tissues were more frequent revealed in mono-culture. Early diagnosis of tissue infections caused by nonsporeforming microorganisms should be based on clinical instrumental data, microbiological and morphological examinations.

[Postoperative complications of heart and pericardial injuries].

The 31-year experience of 839 cases of heart and pericardial injuries was analyzed. The complicated course was registered in 36%. Such factors as patient's age, blood loss, severity of injury and patient's condition on admission, defined the possibility of complications. No less important were the characteristics of postoperative treatment and early diagnostics of the injury. The thorough analysis of reasons of the complications' development allowed to work out some prophylactic measures and to decrease the frequency of postoperative lethality from 13.8 to 6.8%, whereas the complications rate was decreased from 43.8 to 32.3%.

[Traumatic hemobilia].

Authors describe experience of diagnosis and treatment of hemobilia at 10 of 743 patients with trauma of liver. At 7 patients hemobilia was due to closed trauma, and at 3--due to injuries. For diagnosis of hemobilia the USE, Doppler examination of hepatic vessels, esophagogastroduodenoscopy, selective angiography of liver were used. Selective embolization was effective at 7 of 8 patients. Hemobilia has been cured conservatively at 2 patients. Two patients died. It is concluded that complex examination including dopplerography of hepatic liver, esophagogastroduodenoscopy, selective angiography is necessary for diagnosis of traumatic hemobilia. Traumatic hemobilia must be suspected at patients with symptoms of gastrointestinal bleeding in postoperative (posttraumatic) period, and diagnosis of other sources of bleeding does not exclude hemobilia. Selective angiography and embolization of afferent arterial branch is the most effective and safe method of traumatic hemobilia treatment.

[Impact of blood loss on lipid peroxidation and on the antioxidative system in victims with isolated injury to the chest and abdomen]. / Vliianie krovopoteri na sostoianie protsessov perekisnogo okisleniia lipidov i antioksidantnoi sistemy u postradavshikh s izolirovannoi travmoi grudi i zhivota.

The paper deals with the impact of the volume of blood loss on the time course of changes in the parameters of lipid peroxidation (LPO) and the antioxidative system (AOS) in the sera of 22 and 31 victims with isolated chest and abdominal injuries, respectively, on days 1, 3, 7, and 14 days after injury. All the victims were found to have enhanced LPO processes and altered AOS. The severity of disorders in the LPO-AOS system depends on the size of blood loss, the disorders manifest themselves to a greater extent with over 2-liter brisk bleeding and enhance on days 7 and 14 after injury. In mild blood loss equal to as low as 1.0 liters, there was a mobilization of AOS components, such as (-tocopherol and ceruloplasmin, to the blood bed in the victims with both isolated chest and abdominal injury. AOS failure remaining during all periods of the study was detected in victims with abdominal organs and over 2-liter blood loss. Disorders in the LPO-AOS system were pronounced in abdominal injury. Multimodality treatment in victims with isolated injury of the chest and abdomen does not normalize impaired LPO processes and AOS, which makes it necessary to include into antioxidative therapy for brisk bleeding.

[Ultrasound methods of examination in the determination of therapeutic strategy in patients with spleen injuries]. / Ul'trazvukovye metody issledovaniia v opredelenii lechebnoi taktiki u postradavshikh s povrezhdeniem selezenki.

Based on experience of ultrasonic diagnosis of spleen damages in 86 patients it was established that specificity of the method is 99%, accuracy--97%, sensitivity--83%. Dynamic ultrasonic examinations identify to the group of patients with severe combined trauma and spleen damage who may be treated conservatively. This group consists of patients with small quantity of free fluid in left subdiaphragmatic space and stable changes in splenic parenchyma. Increase of hematoma, presence of blood flow in it, increase of spleen sizes are the indications for surgical treatment.

[Diagnosis and treatment of diaphragm ruptures]. / Diagnostika i lecheniie razryvov diafragmy.

72 cases of diaphragm's ruptures in patients with serious combined trauma illustrated basic methods of diagnosis in this condition including X-ray, ultrasonic methods, computed tomography and thoracoscopy. In 26.3% of the patients the diagnosis was made during laparotomy or thoracotomy for massive bleeding because of injury of other organs. In the absence of bleeding the diagnosis was based on signs of the abdominal organs dislocation into the pleural cavity. The differential diagnosis between right-sided coagulated hemothorax and diaphragm's right cupula ruptures was the most difficult.

[Specialized surgical aid in peace-time firearm wounds of thorax and abdomen]. / Spetsializirovannaia khrurgicheskaia pomoshch' pri ognestrel'nykh raneniiakh grudi i zhivota.

The experience with 504 cases of fire-arm wounds of the thorax and the abdomen in peace-time, peculiarities of organization of surgical aid and management of victims in conditions of a big city are reviewed. Principal difference with war-field tactics of surgeons is shown.

[Surgical tactics in closed injuries of the liver]. / Khirurgicheskaia taktika pri zakrytykh povrezhdeniiakh pecheni.

The results of treatment of 116 patients with closed liver injuries are available. 6 types of liver injuries have been determined, depending on location, rupture and safety of certain intraliver structures. To evaluate the rate of seriousness of a liver injury and decrease the rate of blood loss methods of a temporary haemostasis were used; after that the location and depth of the ruptures were estimated; safety of the vessels, bile tracts and liver parenchyma was evaluated. Nonviable parts of the parenchyma were resected. Various methods of haemostasis were used: ligating, laser and plasma coagulation, use of synthetic films. The external liver compression with an elastic splint was used in case of ineffectiveness of the methods mentioned above. The ligating of the hepatic artery should be used in case of the afferent liver vessels injury.

[The surgical treatment of retroperitoneal phlegmons]. / Khirurgicheskoe lechenie zabriushinnykh flegmon.

Based on the experience with treatment of 112 patients with retroperitoneal phlegmons of different etiology the authors distinguish and describe the diffuse and complicated forms of the disease. In treatment of phlegmons special importance is attached to the optimal surgical access. The article describes main principles of performing sanitation of the suppurative foci of the retroperitoneal space, variants of the aspiration-irrigation methods of treatment of the suppurative process. The authors believe that their original differentiated surgical method using different variants of the aspiration-irrigation drainage is effective in treatment of patients with retroperitoneal phlegmons. This method of treatment gave 23.2% lethality while after the traditional methods of treatment 90% of the patients died.

[Laparocentesis and laparoscopy in the diagnosis of abdominal injuries in patients with combined trauma]. / Laparotsentez i laparoskopiia v diagnostike povrezhdenii organov briushnoi polosti i postradavshikh s sochetannoi.

Experience in laparocentesis (152 cases) and laparoscopy (40 cases) in persons with concurrent trauma is discussed. Laparocentesis with lavage of the abdominal cavity is the method of choice in such patients because it ensures correct diagnosis in 98% of cases and does not distort the clinical picture on the abdomen during the subsequent surveillance.

[Diaphragmatic ruptures in combined injuries to the chest and abdomen]. / Razryvy diafragmy pri sochetannykh povrezhdeniiakh grudi i zhivota.

An experience with diagnosing and surgical treatment of 16 patients with rupture of the diaphragms is described. Operations were performed on 13 patients, 10 of them by the laparotomy access, 3 patients by the transpleural access. In patients with an extensive rupture of the diaphragm continuous respiratory insufficiency was observed in the postoperative period which required the artificial ventilation of the lungs. Eight patients died, 3 of them without an operative treatment, 3--from pulmonary complications and 2--from a cerebro-cranial trauma.

[Injuries of blood vessels of the liver during hepatic trauma]. / Povrezhdenie sosudov pecheni pri ee travme.

Radio-angiograms of 33 severe hepatic trauma casualties were analysed. Five types of injury to the liver were identified according to the anatomical disorders of the organ and their localization: 1) complete rupture of the organ; 2) central ruptures with extension of deep fissures from the caval porta along the hepatic vein and formation of intraparenchymal cavities; 3) multiple moderate and small ruptures of both hepatic lobes; 4) ruptures of the peripheral part of the liver; 5) subcapsular and intrahepatic hematomas, contusion of the liver. Injury to vessels of the first-second order were encountered in complete ruptures of the organ, in all other cases intactness of the vascular system was disturbed at the parenchymatous interlobular level.

[Characteristics of the diagnosis and surgical treatment of injuries of the duodenum]. / Osobennosti diagnostiki i khirurgicheskogo lecheniia povrezhdenii dvenadtsatiperstnoi kishki.

Specific features of diagnostics and surgical treatment of injuries of the duodenum in 41 patients with open and closed traumas of the abdomen are described. A wide access by means of mobilization of the right colic flexure should be used for the revision of the duodenum. In cases with closed injuries of the duodenum, in addition to maintenance of its reliable decompression, it is necessary to exclude the intestine from the passage of the gastric content. In order to prevent postoperative pancreatitis cholecystostoma should be made.