[Endoscopic vacuum therapy in minimally invasive treatment of esophageal perforations]. / Effektivnost' endoskopicheskoi vakuumnoi terapii v kompleksnom minimal'no invazivnom lechenii perforatsii pishchevoda.

OBJECTIVE: To compare the results of endoscopic vacuum therapy (EVT) and open surgery for esophageal perforations. MATERIAL AND METHODS: The study included 60 patients with esophageal perforations between 2010 and 2022. The main group included 29 patients who underwent minimally invasive treatment with EVT, the control group - 31 patients after open surgical interventions. RESULTS: Pneumonia occurred in 21 (72%) and 14 (45%) patients (p=0.04), esophageal stenosis within the perforation zone - in 4 (13.8%) and 1 (3.2%) patient, respectively (p=0.188). Chronic esophageal fistulas were significantly more common in the control group (6 (20.7%) versus 15 (48.4%) patients, p=0.032). The overall duration of treatment (median) among survivors was significantly shorter in the main group: 33 (23; 48) versus 71.5 (59; 93.7) days (p=0.5). However, length of ICU-stay was slightly higher (11 (6; 16) versus 8.5 (5; 12.75) days, p=0.32). Mortality rate was 13.8% (n=4) and 29% (n=9), respectively (p=0.213). Minimally invasive technologies decreased the risk of fatal outcome by 10 times (OR 10.123, 95% CI 1.491-124.97, p=0.035) compared to traditional surgery. CONCLUSION: EVT in complex minimally invasive treatment of patients with mechanical esophageal injuries is an effective method significantly reducing mortality and duration of inpatient treatment compared to traditional surgical approach.

[Adventitial cyst of the popliteal artery]. / Adventitsial'naya kista podkolennoi arterii.

Vascular cystic adventitious degeneration (CAD) is a rare disease of unclear etiology that affects mainly the popliteal artery (up to 85-90% of cases). Clinical manifestations are similar to aneurysm of the popliteal artery. CAD occurs mainly in males of the 4th and 5th decades of life (range 10-77 years). These patients usually have no risk factors of cardiovascular diseases. Unilateral symptoms prevail. We report a review and a 46-year-old patient with CAD of the popliteal artery.

[Videolaparoscopic and morphological parallels in diagnosis of different forms of acute appendicitis].

AIM: To compare results of macroscopic assessment and materials of histological examination of 1635 appendices removed using videolaparoscopy in patients with acute appendicitis. All patients have been treated in N.V.Sklifosovsky Research Institute of Emergency Care for the period from 2002 to 2014. MATERIAL AND METHODS: Intraoperative macroscopic assessment of appendix's inflammatory changes was performed using some conventional signs. Сatarrhal, phlegmonous and gangrenous changes were suspected in 77 (4.7%), 1432 (87.5%) and 126 (7.7%) cases respectively. RESULTS: Histological examination revealed catarrhal, phlegmonous and gangrenous changes in 86 (5.3%), 1338 (81.8%) and 115 (7.0%) cases respectively. In 65 (4.0%) patients changes were estimated as chronic, 31 (1.9%) patients had not inflammation. Intraoperatively suspected diagnosis of different forms of appendicitis was confirmed by histological survey in 94.1%. Most cases of matched intraoperative and histological diagnosis were observed in case of phlegmonous appendicitis (88.2%). Only 5.9% of patients had not acute inflammation of appendix that may be explained by overdiagnosis and excess of indications for appendectomy.

[Surgery of pancreatic injuries]. / Khirurgiya povrezhdenii podzheludochnoi zhelezy.

AIM: To estimate different approaches to treatment of victims with pancreatic trauma with pancreatic trauma. MATERIAL AND METHODS: It was analyzedthe results of treatment of 342 victims with pancreatic trauma in N.V. Sklifosovskiy Research Institute of Emergency Care for the period 1991-2012. RESULTS: It was concluded that for the las decade curative and diagnostic tactics for pancreatic injury in victims with combined abdominal trauma has been changed; current diagnostic markers of pancreatic lesion and adequate intraoperative diagnosis are used. All of this together with timely specific therapy and adherence to guidelines of surgical treatment decreased mortality rate from 17.0 to 11.1% and suppurative complications incidence from 43.8 to 19.9%.

[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.

[The difficulties of diagnosis and treatment of non-occlusive mesenteric circulatory disorders].

AIM: To review one of actual problems of emergency surgery - diagnosis and treatment of patients with non-occlusive mesenteric circulatory disorders. MATERIAL AND METHODS: The article presents the clinical observations showing the ambiguity of clinical picture, features and challenges of diagnosis, treatment of disease and opportunities for positive outcomes. Diagnostic methods are x-ray, abdominal ultrasonography according to which acute abdominal ischemia may be assumed. However, in all unclear cases diagnostic videolaparoscopy is mandatory to determine further tactics. Unfortunately diagnostic videolaparoscopy is not always interpreted comprehensively and not a definitive method of diagnosis. Wide surgical access is usually necessary for non-occlusal acute violation of mesenteric circulation and volume of surgery varies from segmental to subtotal intestinal and colic resection with obligatory enteral intubation and decompression. Thus, complex pre- and postoperative treatment is required.

[Morphological changes in the wall of the aorta in its dissecting aneurysm].

The paper describes 144 autopsy materials and 69 biopsy ones and shows possible morphological changes in the wall of the aorta in its dissecting aneurysm. Examinations were made by light and electron microscopy using special stains. Cases of arterial hypertension without aortic dissection were selected as a group of comparison. Varying degrees of structural changes were found in all layers of the aortic wall. In accordance with the predominant involvement of this or that component, the authors identified three types of changes: 1) those with the predominant involvement of the elastic skeleton; 2) necrotic and dystrophic changes in the smooth muscle cells to give rise to medial laminar and focal necroses; 3) nonspecific diffuse changes in all layers of the aortic wall, which are characteristic of aging processes. Comparison of morphological changes with those in the comparison group revealed those that appeared to be caused by previous aortic wall structural damages that gave rise to impaired elastic and collagen formation not only in patients with previously found connective tissue dysplasias.

[Microbiological diagnosis of gas gangrene caused by Clostridium septicum (a clinical case)].

Microscopy of gram-stained impression smears is used for the rapid diagnosis of microorganisms in the wound. The shin tissues of patient P. with suspected gas gangrene of lower extremity soft tissues were microscopically found to have gram-positive spore-forming bacteria that were morphologically similar to C. bifermentans that were identified as C. septicum on cultural diagnosis. The pathogenic C. septicum strain spores were likely to be formed in the macroorganism upon exposure of the pathogen to a patient's defense factors and to a package of therapeutic measures. Microbiological data should be used only in combination with clinical and instrumental findings and the results of other laboratory studies when the optimal technology is chosen to treat gas infection. By keeping in mind that there may be clostridial gangrene in the patients and the experience of clinicians and bacteriologists may be insufficient in diagnosing this pathology, it is necessary to strengthen the training of physicians in the diagnosis of this pathology.

A new method for surgical treatment of the short bowel syndrome.

This study was aimed to investigate the electrophysiological and morphological characteristics resulting from the structural and functional transformation of gastric tissue transplanted to the small intestine. Twelve adult mongrel dogs were studied up to 3 years. Gastric transplants preserved its main microstructure and minimal compensatory-adaptive processes developed in the mucosa and muscle layers of the graft. A significant influence on the electrical activity of the small intestine was observed, with a 10% reduction of the slow wave frequency (SWF) in the proximal and distal jejunum adjacent to the graft after meals. The SWF of the gastric graft itself, however, corresponded to the frequency of the native stomach, did not depend and was not associated with adjacent intestinal areas. In summary, the stomach graft transplanted to the small intestine keeps the properties of gastric tissue, there are functional adaptations to conditions of digestion in the small intestine and the graft has minimal effects on intestinal motility.

[Morphofunctional characteristics of the intestinal insufficiency syndrome]. / Morfofunktsional'naia kharakteristika sindroma kishechnoi nedostatochnosti.

Phase morphofunctional alterations determining the stages of development of the intestinal deficiency syndrome were detected in a composite investigation of the motor, evacuatory, secretory, digestive and absorbing functions of the small intestine in experimental animals in the immediate period after operations on the gastrointestinal tract organs and elimination of acute mechanical ileus, as well as morphological (histological and electron microscopic) examinations of small intestine mucous membrane biopsies taken at various stages of the disease.

[Changes in urethral and bladder mucosa in a urethral syndrome]. / Izmeneniia slizistoi obolochki uretry i mochevogo puzyria pri uretral'nom sindrome.

The mucous membrane of the urinary bladder and urethra was studied histologically and electron microscopically in 20 women varying in age from 17 to 70 years who suffered from the urethral syndrome. Chronic urethritis was found in 19 patients, fibrosis of the submucous layer of the urethra in one. In 8 cases urethritis was combined with diffuse cystitis, in 4 with focal inflammation of the urinary bladder neck. Inflammatory changes in the mucous membrane were characterized by diffuse-focal lymphoplasma cell infiltrates, desquamation of transitional epithelium of the bladder and urethra, parapedesis of lymphocytes and polymorphonuclear leukocytes into the urethra lumen, activation of the fibroblast synthesis with excessive formation of collagen, proliferation of tegmental epithelium of the urethra with formation of deep pockets. The inflammatory etiology of the urethral syndrome of obscure origin is supposed.

[Clinico-anatomical analysis of the complications and causes of death in pancreonecrosis]. / Kliniko-anatomicheskii analiz oslozhnenii i prichin smerti pri pankreonekroze.

The results of the clinico-anatomical analysis of 228 autopsy cases of pancreonecrosis identified during 20 years are presented. The authors put forward their own classification of pancreonecrosis based on the degree of the pancreas affection: diffuse small-focal, large-focal and subtotal with the distinguishing their haemorrhagic and ischemic (fat) types. Early (up to 7 days) and late (more than 7 days) complications with typical clinico-morphological manifestations are distinguished depending upon the time when the death occurred. The main cause of "early" death was a pancreatogenic shock with the morphological manifestations of the enzymatic polyserositis, acute pulmonary thrombo-hemorrhagic complications and degenerative alterations in the parenchymatous organs. Late complications of pancreonecrosis were manifested by a purulent-necrotic destruction of the pancreas and retroperitoneal fat with the abscesses, purulent peritonitis, inner fistulas of the alimentary canal organs and erosive hemorrhages.

[Thrombohemorrhagic syndrome in emergency gynecology]. / Trombogemorragicheskii sindrom v neotlozhnoi ginekologii.

The paper presents a clinico-anatomical analysis of 18 autopsy cases of thrombo-hemorrhagic syndrome (THS) in patients operated because of uterine fibromyoma (n = 11) and altered tubal pregnancy (n = 7) and a surgical material (uterus with a tumor) from 21 patients. Multiple thromboembolic and hemorrhagic complications with degenerative visceral alterations after the operation were manifestation of generalized THS. Thromboembolic complications with organ damages dominated among patients with uterine fibromyomas, hemorrhagic complications with diffuse degenerative changes and visceral lesions were observed in patients with tubal pregnancy. Local THS is determined by degenerative and vascular changes in the pelvic organs with primary pathology (fibromyoma, endometrial lesions).

[Non-occlusive dyscirculatory intestinal necrosis ]. / Neokkliuzionnyi distsirkuliatornyi nekroz kishechnika.

70 autopsy cases of NDIN are analysed. Necrosis in 85% of cases was observed against basic pathology, mainly cardiovascular diseases (45.7%) and after surgery in the thoracic and abdominal cavities. NDIN was considered as a main disease in the remaining 15% of cases, with its duration from 1 to 7 days. Morphologically NDIN was revealed in the colon in 71.2% of cases, in combination with the small intestine in 30.5%. Predominance of the small intestine was in 28.8%, ileum 64%. Primary circulatory disturbances in the capillary-venule system of the mucous membrane and submucosa were found histologically.

[Morphology of pulmonary atelectasis in patients operated on and not operated on taking into account pulmonary surfactant state]. / Morfologiia atelektaza legkikh u operirovannykh i neoperirovannykh bol'nykh s uchetom sostoinaiia legochnogo surfaktanta.

The results of clinico-anatomical analysis and of histological examinations of 210 cases of atelectasis with simultaneous study of lung surfactant (126 cases) are described. Electron microscopic examinations of lung tissues were conducted in 8 cases of early autopsy. The postoperative atelectases were compared with those in nonoperated patients. The postoperative atelectases were characterized by substantially larger lesions and prevalence of reflectory, aspiratory, and polyetiological types of lesions. A certain dynamics of changes in the lung surfactant activity was established: a substantial increase of the activity during in the acutest phase of atelectasis and its significant decline towards the end of the first week of the disease. The changes of the surfactant indices directly depend on the synthesizing activity of type II pneumocytes. The decrease of the surfactant occurs secondarily as atelectasis advances.

[Pathological anatomy and pathogenesis of experimental pancreatitis]. / Patologicheskaia anatomiia i patogenez éksperimental'nogo pankreatita.

The necrotic and inflammatory processes in the albino rats pancreas were studied by histological, immunomorphological and electron microscopic techniques after freezing of the pancreas. Early morphological sings of acinar cells destruction were revealed. The mechanism of secret "leakage" from zimogen granules into acinar cell cytoplasm was shown. The stages of pathologic process corresponding to different types of pancreatitis were established. The inflammatory reaction formed in the stage of parenchymal necrosis was characterised by an early activation of fibroblastic and macrophagal cells and by the delay of necrotic tissue elimination with their following calcification. The chronic pancreatitis developed on the immune basis in the intact parts of the pancreas.

[Bacterial shock]. / Bakterial'nyi shok.

Bacterial shock (BS) is a complication of infectious and suppurative surgical diseases caused mainly by gram-negative bacterial flora. The leading role in the pathogenesis of BS belongs to intoxication of the host by bacterial endotoxins resorbed from the primary focus, by products of protein disintegration, as well as hyperproduction of biologically active substances in the patient. The clinico-anatomical variants of BS are adequate to the quantity and quality of toxins resorbed from the primary focus. An accurate pathoanatomical diagnosis of BS is mandatory for its profound investigation. This diagnosis is possible on the basis of a careful clinico-anatomical analysis with due consideration of the morphological criteria of hemocoagulation and peripheral hemodynamics disorders (the liquid state of cadaver blood, disseminated intravascular coagulation, blood sequestration in some bassins, and intraorgan shunt of the bloodstream).

[The morphogenesis of pancreonecrosis]. / Morfogenez pankreonekroza.

Pancreas was studied histologically, histochemically and electron microscopically in 117 autopsy cases and in the experiment (25 dogs and 60 white rats). Morphogenesis of pancreonecrosis proceeds through certain stages. The initial stages of an acute pancreatic edema is characterized by degenerative and necrotic changes of pancreocytes with parapedesis of pancreatic enzymes into the interstitium and a reactive stromal edema. The following stages are distinguished in the progressing phase of pancreonecrosis: hemorrhagic pancreonecrosis when the proteolytic enzymes provoke a colliquation necrosis of the acinar tissue, fibrinoid necrosis of vascular walls and disturbances of the intravascular hemorheology resulting in the enhancement of destructive processes and hemorrhagic inhibition of tissues; fat pancreonecrosis in which lipolytic enzymes lead to the coagulation necrosis of the acinar and fat tissue while a non-completed proteolysis of necrotic tissues stipulates the intensity of the reactive inflammation.

[Role of ischemic cerebral infarction in the development of lethal outcomes in ruptured intracranial arterial aneurysm]. / Rol' ishemicheskogo infarkta mozga v razvitii letal'nykh iskhodov pri razryve vnutricherepnykh arterial'nykh anevrizm.

Analysis of 320 autopsy cases of death after the rupture of brain arterial aneurysms (AA) without a surgical treatment is performed. The frequency of ischemic infarction among these cases was 15.3% and in 11.2% the infarction was an immediate cause of death. The lethal outcome due to the infarction occurred at the end of the 1st and during the 2nd week with a maximum at 9-12 days. Ischemic infarction as a cause of death usually had a wide zone of spread involving 2 and more brain lobes. The thrombosis of the big brain artery was a cause of ischemic complications in 19.4% of cases. Morphological alterations of the basis cerebri in such cases consisted of changes in the intima, elastic membrane, medial layer and adventitia resulting in the lumen narrowing.

[Morphology of thrombolysis as affected by a plasmakinase preparation]. / Morfologiia lizisa tromba pod deistviem preparata plazmakinazy.

The effect of a new thrombolytic preparation, plasmakinase, on experimental coagulates and thrombi was studied morphologically. Histological and electron microscopic studies revealed changes in the structure of fibrin fibers in the form of separation of fibers into individual protofibrils and subsequent degradation into globular particles. There were disorders in the fibrin association with blood cells, washing out of partially hemolyzed red blood cells into the bloodstream, decrease in the size of thrombi and restoration of the vessel lumen.