[Non-functioning parathyroid cysts]. / Nefunktsional'nye kisty okoloshchitovidnykh zhelez.

OBJECTIVE: To study the features of clinical course, diagnosis and treatment of true non-functioning parathyroid cysts. MATERIAL AND METHODS: We retrospectively analyzed 18 patients with non-functioning true parathyroid cysts. Inclusion criteria: US-confirmed anechoic lesion of the neck without tissue component, cytological data on cystic lesion, high cystic parathyroid hormone and no laboratory signs of hyperparathyroidism. RESULTS: Non-functioning parathyroid cysts were asymptomatic and diagnosed accidentally after ultrasound of the neck. All patients were women aged 35-77 years. Four patients had cysts near the upper parathyroid glands, 14 patients - near the lower parathyroid glands. Of these, 2 ones had cysts below the level of the clavicle. Cyst volume was 4.3-110.3 cm3 (24.1±26.2 cm3). High cystic parathyroid hormone (2012.5±946.7 pg/ml) was observed in all patients. Simple aspiration was performed in 5 patients, aspiration with sclerotherapy - in 10 patients, cystectomy - in 3 patients. Recurrence was diagnosed in 1 patient after aspiration and 2 patients after sclerotherapy. CONCLUSION: No pathognomonic clinical and ultrasonic symptoms, as well as specific cytological data lead to misdiagnosis. Analysis of PTH in non-functioning parathyroid cysts is essential for diagnosis. Minimally invasive treatment is preferable for true parathyroid cysts. However, these approaches are not radical.

[Diagnostic and conservative treatment nuances in patients with obstructive jaundice: in the wake of Russian consensus].

The research was performed at the Loginov Moscow Clinical Scientific Center. It is based on Russian obstructive jaundice (OJ) consensus results, considered at the 45th annual Central Research Institute of Gastroenterology Scientific session Oncological issues in the gastroenterologist practice (1 March 2019). The article objective is to note the diagnostic and conservative treatment current issues in patients with OJ. The increase in the number of patients with OJ of different etiology provides problem actuality. In a large number of cases, medical treatment is delayed due to inadequate diagnostic and management, while correct patients routing today can be provided regardless of medical institution level. In this article the examination steps and conservative treatment role in patients with biliary obstruction management are presented.

[Management of surgical complications following prolonged warfarin therapy in a general surgical hospital]. / Lechenie khirurgicheskikh oslozhnenii prolongirovannoi terapiei varfarinom v obshchekhirurgicheskom statsionare.

OBJECTIVE: To analyze an effectiveness of algorithm for complex treatment of patients with surgical complications of prolonged warfarin therapy in a general surgical hospital. MATERIAL AND METHODS: The study included 138 patients with surgical complications of prolonged warfarin therapy. All patients received warfarin for at least 6 months (49.5% of patients - over 5 years). Warfarin therapy was indicated for deep vein thrombosis in 54 patients and various cardiac diseases in 84 patients. Examination included clinical and instrumental survey, laboratory tests and coagulation tests - thromboelastography (TEG) and thrombodynamics test (TT). RESULTS: Recurrent VTEC occurred in 24 out of 138 patients, hemorrhagic complications - in 114 patients. Therapeutic management was applied in 111 patients, 27 ones underwent surgery (emergency treatment - 25 patients, after two days - 2 patients). Ten patients underwent endoscopic hemostasis, two patients - ultrasound-assisted percutaneous drainage of hematoma. Recurrent VTECs were caused by inadequate laboratory control and violations of warfarin therapy. Most of these patients underwent therapeutic management (only 3 patients required surgery for life-threatening flotation in great veins). Treatment of 114 patients with hemorrhagic complications of prolonged warfarin therapy depended on features of bleeding and severity of warfarin-induced coagulopathy. Depending on these factors, warfarin was discontinued and intravenous administration of vitamin K / FFP / prothrombin complex concentrate was applied. This approach ensured successful therapeutic measures in 90 patients of this group. Twenty-four patients underwent surgery after correction of hemostatic disorders. TT was characterized by high efficiency in analysis of thrombotic predisposition and prediction of the risk of VTEC. TEG was valuable for assessment of warfarin-induced coagulopathy and treatment of patients with hemorrhagic complications of prolonged warfarin therapy. CONCLUSION: The developed clinical and diagnostic algorithm for management of hemorrhagic complications of prolonged warfarin therapy ensures positive clinical results even in a general surgical hospital.

[Two unusual causes of peptic anastomotic ulcer]. / Dve neobychnye prichiny pepticheskoi yazvy anastomoza.

Two unusual cases of anastomotic ulcer complicated by bleeding after gastric resection are reported. There were retained antrum in one patient and long 'dry' intestinal loop after laparoscopic Roux resection in another one. Emergency gastric stump resection with Haberer procedure were successfully performed in both cases.

[Metastasis of clear cell renal cell carcinoma into small bowel in 5 years after nephrectomy]. / Metastaz svetlokletochnogo pochechnokletochnogo raka v podvzdoshnuyu kishku spustya 5 let posle nefrektomii.

Small bowel tumor causes gastrointestinal bleeding in 1-4% of cases. Gastrointestinal bleeding from metastases of renal cell carcinoma is a rare and little-known manifestation of this disease. We report a rare clinical case of a solitary metastasis of clear cell renal cell carcinoma into small bowel in 5 years after nephrectomy. The first symptom was intestinal bleeding. This example emphasizes the need for more thorough examination of patients with symptoms of latent and anamnestic blood loss.

[Optical sonography in differential diagnosis of thyroid nodes]. / Optosonografiya v differentsial'noi diagnostike uzlovykh obrazovanii shchitovidnoi zhelezy.

OBJECTIVE: To develop a non-invasive method for differential diagnosis of thyroid nodes. MATERIAL AND METHODS: Optical sonography was made in 623 patients with thyroid nodes including 374 women (60%) and 249 men (40%) aged 19-79 years (mean 64±15 years). All patients underwent ultrasound-assisted fine-needle aspiration biopsy. Cytological examination revealed cystic colloidal goiter (CCG) in 317 (51%) cases, follicular adenoma (FA) - in 197 (31.5%) cases, thyroid cancer - in 109 (17.5%) cases. All patients underwent surgery. Histological examination verified cystic colloidal goiter in 354 (56.8%) cases, follicular adenoma - 75 (12.0%) cases, thyroid cancer - 194 (31.2%) cases. Follicular cancer was diagnosed in 120 cases, papillary cancer - 70 cases, undifferentiated cancer - 4 cases. RESULTS AND CONCLUSION: Sensitivity, specificity and accuracy of optical ultrasonography in differential diagnosis of thyroid nodules were estimated. Sensitivity of ultrasonography in the diagnosis of thyroid malignancies was 0.75, specificity 0.62, accuracy 0.67. Sensitivity of ultrasonography in the diagnosis of thyroid adenoma was 0.85, specificity 0.62, accuracy 0.73. Sensitivity of optical sonography in the diagnosis of CCH was 0.62, specificity 0.61, accuracy 0.7. Optical sonography ensures differentiation of CCH and follicular adenoma, CCH and thyroid cancer, follicular adenoma and thyroid cancer. Sensitivity, specificity and accuracy of ultrasonography in differential diagnosis of FA and thyroid cancer are 0.85, 0.62, 0.73 and 0.8, 0.71, 0.7, respectively.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]. / Rossiiskii konsensus po aktual'nym voprosam diagnostiki i lecheniya sindroma mekhanicheskoi zheltukhi.

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

[Extensive purulent processes after combined phlebectomy]. / Obshirnye nagnoitel'nye protsessy posle kombinirovannoi flebéktomii.

OBJECTIVE: To analyze the causes and develop methods for the treatment of extensive purulent processes after combined phlebectomy in patients with lower limb varicose veins. MATERIAL AND METHODS: The authors reported 3 cases of extensive phlegmon after phlebectomy for the period from 2014 to 2018. It is shown that comprehensive debridement of purulent-inflammatory lesion with application of additional methods including high-energy exposure by the air-plasma flow is essential for effective treatment of this complication. In addition, literature review showed only few observations of severe septic complications after traditional varicose vein surgery. RESULTS: Radical debridement of purulent wounds with wide excision of necrotic subcutaneous tissue and fascia, combination of standard surgical technique and plasma scalpel, as well as subsequent plasmodynamic staged wound repair in a therapeutic mode prevented severe purulent-inflammatory process, stopped systemic inflammatory syndrome and resulted fast wound healing. CONCLUSION: Active surgical approach combined with air-plasma technology was followed by high-quality correction of extensive suppurative process. Minimally invasive management of varicose disease with improvement of surgical techniques will minimize the likelihood of these complications.

[Transoral endoscopic thyroid surgery]. / Transoral'nyi éndoskopicheskii dostup k shchitovidnoi zheleze.

OBJECTIVE: To analyze own initial experience of transoral thyroid surgery. MATERIAL AND METHODS: There were 7 patients thyroid nodules who underwent surgery for the period from March 2018 to May 2019. All patients signed an informed consent to be included in the study. Surgical approach was performed through three incisions in the lower arch of the vestibule of the mouth with deployment of 10 mm endoscope and two 5 mm tools. Gas insufflation was used. All patients were females aged 43.3±11.8 years. Thyroidectomy was performed in 2 cases, hemithyroidectomy - in 5 patients. Dimensions of nodules varied from 10 to 42 mm. RESULTS: Mean time of hemithyroidectomy and thyroidectomy was 206.4±63.8 and 232±37.5 min, respectively. Papillary carcinoma was histologically verified in 1 case. Injuries of recurrent laryngeal nerve, postoperative hypocalcemia and local complications were absent. Drainage was not applied. Postoperative hospital-stay was 3.7±1.1 days. CONCLUSION: Transoral approach to the thyroid gland is technically feasible with standard endoscopic instruments, safe for important anatomical structures and more precise due to the optical capabilities of endoscopic equipment. Any types of procedures are possible. Undoubtedly, aesthetic outcome is also favorable.

[Ultrasound assessment of vocal cords function after thyroid surgery]. / Pervyi opyt otsenki funktsii golosovykh sviazok ul'trazvukovym metodom issledovaniia u bol'nykh posle operatsii na shchitovidnoi zheleze.

OBJECTIVE: To analyze vocal cords function after thyroid surgery by using of ultrasound examination. MATERIAL AND METHODS: Assessment of voice quality according to GRBAS scale, ultrasound examination of vocal cords and indirect laryngoscopy were performed in 57 patients after thyroid surgery. RESULTS: Postoperative indirect laryngoscopy and ultrasound revealed normal mobility of vocal cords in all patients. However, 98.3% of patients subjectively noted deterioration of voice quality due to hoarseness and fatiguein early and long-term period, respectively. Complete restoration of vocal function occurred after 6 months postoperatively. Impaired voice quality is probably due to edema of vocal cords after intubation that is manifested by unclear contours during ultrasound. Ultrasound is useful to diagnose shortening and displacement of paretic vocal cords. CONCLUSION: Ultrasound of vocal cords could be alternative to indirect laryngoscopy for postoperative assessment of vocal cords function in patients after thyroid surgery.

[The 'missing' of the duodenum]. / Sluchai 'otsutstviia' dvenadtsatiperstnoi kishki.

The article presents the outcome in patient with duodenal congenital abnormality caused by defective intrauterine rotation of the intestinal tube with premature turn of back intestine.

[Transhiatal esophagectomy for cardia and esophagus cancer]. / Transkhiatal'naya ezofagektomiya pri rake kardii i pishchevoda.

AIM: To present the result of transhiatal esophagectomies with simultaneous repair. MATERIAL AND METHODS: The study included 67 procedures. In 35 cases surgery was carried out for adenocarcinoma of distal esophagus or cardia with high transition to esophagus, in 32 cases - for epidermal carcinoma of the esophagus. Gastric graft and left half of the colon were used in 60 and 7 cases respectively for simultaneous repair. 29 patients underwent transhiatal instrumental esophagectomy using author's original technique.

[Plasma management in complex treatment of late inflammatory complications after injection contour plasty with polyacrylamide gel]. / Plazmennaia obrabotka pri lechenii pozdnikh vospalitel'no-gnoinykh oslozhnenii in''ektsionnoi konturnoi plastiki poliakrilamidnym gelem.

AIM: To improve the results of treatment of late inflammatory complications after injection contour plasty with polyacrylamide gel. MATERIAL AND METHODS: The authors analyze treatment of 21 patients with late septic complications of body contour plasty with polyacrylamide gel (PAGE) for the period 2010-2015. Mean age of women was 47.4 years. Time after primary intervention was 10-22 years. The depth of soft tissue lesion corresponded to II-III grade by D. Ahrenholz classification (1991), length - from 67 to 180 cm2. Mammary glands were the most common area of augmentation (18 cases). Besides antibiotic therapy and surgery complex treatment included exposure with plasma flows in various modes. RESULTS: Plasma technology significantly accelerated regenerative processes and provided stable microbial decontamination in 100% patients. High-energy vaporization was associated with maximum possible removal of PAGE from the tissues that was confirmed by histological examination.

[Transoral approach to thyroid gland in the experiment]. / Transoral'nyi dostup k shchitovidnoi zheleze v eksperimente (s kommentariem P.S. Vetsheva).

AIM: To develop minimally invasive and safe endoscopic access to thyroid gland. MATERIAL AND METHODS: Transoral pre-mandibular video-assisted gas-free access to thyroid gland was developed in experimental study that included 19 human cadavers. Stereometric modeling defined the evaluation criteria including the form of basal arch of lower jaw and its height. There was no conflict of instruments in working chamber under platysma. Additional trocar was deployed to resolve the conflict between working parts of instruments during thyroid gland mobilization. The angle of operative action between the instruments is close to 90°. Trocar hole is used for drainage. RESULTS: The access provides good visualization of recurrent laryngeal nerve, upper and lower thyroid arteries and parathyroid gland. It is less traumatic compared with other extra-cervical accesses to thyroid glands.

[Evolution of complex treatment of patients with non-specific pleural empyema]. / Évoliutsiia metodov kompleksnogo lecheniia bol'nykh s nespetsificheskoi émpiemoi plevry.

AIM: To analyze long-term own experience of NPE treatment in view of evolution of surgical sanitation of pleural cavity. MATERIAL AND METHODS: The analysis included 5115 patients with NPE for the last 39 years (1977-2015). Morbidity, features of microflora of purulent exudate, changes in the structure of surgical methods were assessed. The role of computed tomography in the diagnostic algorithm and treatment of NPE was studied. RESULTS: The evolution of NPE surgical management includes introduction of video technologies, thermal surgical instruments and widespread use of computed tomography in the diagnosis of pleural empyema. So, significant reduction of patients who were discharged with residual cavities was observed. Postoperative mortality was 19.5% for the period 1977-1996 when traumatic open surgery was used. At the same time there were no deaths within 1997-2015 due to introduction of VATS pleural drainage. Overall mortality decreased from 4.9% to 3.2% for the same period due to reduced postoperative complications. CONCLUSION: The introduction of minimally invasive technologies, new thermal surgical instruments changed management of NPE patients, reduced the number of traumatic open procedures. So, improved outcomes were achieved.

[Coagulological aspects of treatment of complications of prolonged therapy with warfarin]. / Koagulologicheskie aspekty lecheniia oslozhnenii prolongirovannoi terapii varfarinom.

The authors analysed the results of treating a total of 116 patients (68 men and 48 women aged from 20 to 84 years, mean age 59.5±15.5 years) presenting with various complications of prolonged therapy with warfarin. Prescription of prolonged therapy with warfarin had been caused by various cardiac diseases and lower extremity deep vein thromboses. The duration of anticoagulant therapy at the time of onset of complications was different and depended on the underlying disease. The majority of patients included into the study had been taking warfarin for one year and more, with nearly half of patients (48.1%) - for more than 5 years. Examination of patients included clinical, instrumental and laboratory studies, among which we determined standard laboratory parameters of haemostasis [activated partial thromboplastin time (APTT), international normalised ratio (INR), prothrombin index, prothrombin time, thrombin time, fibrinogen, etc.] and global tests (the thrombodynamics test and thromboelastogram). Amongst complications of prolonged warfarin therapy, 10 patients were found to have various thrombotic complications and 106 patients were diagnosed as having various by localisation and intensity haemorrhage. The obtained results of the study have demonstrated that the appearance of any thrombotic complications takes place occurs on the background of insufficient hypocoagulation and often require only correction of warfarin therapy. Whereas floating thrombi developing on the background of inadequate warfarin therapy require surgical management. Once haemorrhagic complications have developed, beside appropriate correction of warfarin therapy it is necessary to carry out correction of coagulopathies, which is done by means of different drugs and therapeutic regimens, whose choice should be based on assessing the clinical findings (localization and severity of haemorrhage) and laboratory indices, the main of which are local coagulologic tests, as well as global tests. The thrombodynamics test proved highly efficient for assessing the state of plasma haemostasis and predicting danger of the development of venous thromboembolic complications in patients with lower extremity deep vein thrombosis on the background of hyper- and hypocoagulation.

[Surgical and combined correction of tracheal and laryngotracheal cicatricial stenosis and restenosis]. / Lechenie trakheal'nykh i laringotrakheal'nykh rubtsovykh stenozov i restenozov.

AIM: To improve treatment of patients with cicatricial tracheal stenosis using different methods of recanalization and circular resection. MATERIAL AND METHODS: Analysis involved 57 patients with cicatricial tracheal stenosis including 2 post-traumatic cases, 27 post-intubation cases, 25 cases after tracheostomy and 3 restenoses after previous circular resection. There were 5 cases of tracheal stenosis combined with tracheoesophageal fistula, 1 patient with chest nodular goiter, 8 cases of unclosed tracheostomy and 3 patients with long-existing laryngotracheal fissure. There were 25 women and 32 men aged 15-65 years. Stenosis length ranged from 3.0 to 4.5 cm in 66.6% of patients. There were 13 (22.8%) patients with subcompensated stenosis (d=0.5-0.7 cm) and 44 (77.2%) cases of decompensated stenosis (d<0.5 cm) combined with suppurative tracheobronchitis that required endosurgical recanalization with stenting or balloon dilatation. 45 patients underwent upper tracheal third resection, 9 - middle third resection, 3 - upper third and cricoid cartilage resection. Length of excised segment was 2.5-9.5 cm. Simultaneous suturing of esophageal anterior wall defect was performed in 5 cases. RESULTS: Complete recovery of tracheal lumen was achieved in 54 patients (93%). Restenosis occurred in 4 (7%) cases (3 of them underwent repeated resection with good results and 1 - stenting). CONCLUSION: Circular resection is optimal treatment of cicatricial tracheal stenosis. Endosurgical recanalization is preparatory method prior to radical surgery.

[Criteria for efficacy of anticoagulant therapy in patients with thromboses of deep veins of lower limbs].

The authors analysed the results of a prospective study of dynamics of laboratory indices of plasma haemostasis on the background of anticoagulant therapy in a total of 60 patients (23 women and 37 men) presenting with idiopathic thromboses of deep veins of lower limbs in order to work out criteria for its efficacy and safety. Anticoagulant therapy was carried out using nonfractionated heparin according to the standard regimens. The patients' mean age amounted to 57.4±13.6 years. Studying the system of haemostasis along with generally known standard laboratory indices (activated partial prothrombin time, D-dimer, fibrinogen, prothrombin level, INR, PTI) included one of the global coagulogical tests - a method of thrombodynamics whose main parameter was Vs (stationary clot growth rate). The results of anticoagulant therapy were assessed by dynamics of clinical symptomatology, the findings of ultrasonographic angioscanning, and by the dynamics of laboratory parameters of plasma haemostasis. The obtained findings demonstrated that anticoagulant therapy with nonfractionated heparin followed by switching to warfarin is an effective method of conservative treatment of patients with idiopathic thromboses, making it possible to attain laboratory confirmed hypocoagulation accompanied by both clinical and US-controlled improvements. The results of the thrombodynamics assay by the dynamics of a decrease in the D-dimer level made it possible to statistically significantly single out a group with no effect of heparin (no effect of hypocoagulation) and high sensitivity in singling out groups of ineffective therapy with warfarin, which on the background of normo- or hypercoagulation is a marker of increased fibrinogenesis and, consequently, of high risk for the development of recurrent thrombosis in such patients.

[Risk of hypocalcemia after thyroid surgery].

AIM: To reveal calcium metabolism disorders that frequently occur after thyroid surgery. MATERIAL AND METHODS: The study included 202 patients who underwent thyroid surgery for different diseases and had normal calcium level in peripheral blood at baseline. RESULTS: Based on laboratory data postoperative hypocalcemia was diagnosed in 57 (28.8%) patients. It was not always accompanied by clinical symptoms. Clinical picture depended on degree of hypocalcemia. Symptoms was diagnosed more frequently if calcium concentration was less than 2.1 mmol/l. Clinical manifestations were absent in 64.9% of cases on background of hypocalcemia. Incidence of hypocalcemia was higher after thyroidectomy compared to organ-preserving surgery. Symptoms of hypocalcemia occurred after thyroidectomy only. Casual parathyroidectomy does not always cause hypocalcemia. Only in 14% of patients with hypocalcemia excised parathyroid was identified in specimen. At the same time 7.6% of patients with postoperative normocalcaemia also had excised parathyroids in specimens. Symptoms of hypocalcemia does not always occur at 1 day after surgery. They can appear later, for example at 5 days postoperatively and depend on severity of hypocalcemia. Thyroidectomy has high risk of postoperative hypocalcemia with clinical symptoms (19.6%) that is transient in 15.5% of cases and permanent in 4.1% of patients.

[The comparative analysis of laparoscopic and minilaparotomic techniques in emergency abdominal surgery].

Owing the experience of 16 101 miniinvasive operations by acute diseases of the abdominal cavity, the authors pose that the introduction of polytechnological methods has certain perspectives. The combination of different methods with the use of modern technologies lead to better results.