[Consequences of the COVID-19 pandemic for surgical service]. / Posledstviya pandemii COVID-19 dlya khirurgicheskoi sluzhby.

The COVID-19 pandemic has a serious impact on surgical service, emergency and especially elective surgical care. Many hospitals were re-designated as COVID hospitals due to resource constraints and large number of COVID-19 patients requiring hospitalization. This led to cancellation or postponement of scheduled surgeries. In addition, restrictions in elective surgery were associated with the risk of infection in surgical patients. Various protocols and guidelines recommended non-surgical or outpatient treatment if possible. During the pandemic, postoperative morbidity and mortality in emergency surgery increased significantly. The same is true for elective surgeries in 7-8 weeks after previous coronavirus infection. The authors analyze the issues of organization, priorities for restoration of elective surgery and criteria for patient selection.

[Modern principles of safety in laparoscopic cholecystectomy]. / Sovremennye printsipy bezopasnosti pri vypolnenii laparoskopicheskoi kholetsistektomii.

Laparoscopic cholecystectomy has many advantages over open surgery. Nevertheless, incidence of intraoperative bile duct injury is consistently higher for laparoscopic technique. This review is devoted to modern principles of identifying the anatomical elements in hepatoduodenal ligament and rules for safe tissue dissection in this area. The last ones mainly consist in formation of «critical view of safety¼ before clipping and transection of tubular structures. The key for «critical view of safety¼ is mobilization of fatty and fibrous tissues of hepatocystic triangle starting from the lower third of the gallbladder.

[Severe pseudomembranous colitis in patients with previous coronavirus infection]. / Psevdomembranoznyi kolit na fone perenesennoi koronavirusnoi infektsii.

OBJECTIVE: To analyze treatment outcomes in patients with severe pseudomembranous colitis and previous coronavirus infection. MATERIAL AND METHODS: We retrospectively analyzed treatment outcomes, clinical, laboratory and histological data in convalescents of COVID-19 who admitted to the department of coloproctology for moderate-to-severe pseudomembranous colitis confirmed by endoscopic examination between 2020 and 2021. RESULTS: There were 13 patients with moderate pseudomembranous colitis and 6 ones with severe pseudomembranous colitis. Mean period after recovery from coronavirus infection was 19 days. Endoscopy revealed whitish-yellow or gray raised plaques on colonic mucosa in all cases. Four patients with signs of peritonitis underwent emergency surgery. Three patients had perforation of caecum; one patient had perforation of sigmoid colon and widespread peritonitis. Two patients underwent urgent surgery for progressive toxic megacolon and ineffective therapy. Subtotal colectomy and ileostomy were performed in all cases. Histological examination revealed necrosis of not only superficial layer of colon mucosa typical for clostridial colitis, but also the entire thickness of mucosa, as well as submucosal and partially muscular layers in some cases. Mucosal crypt atrophy, fibrinoid effusion in muscular layer, diffuse polymorphonuclear cell infiltration and necrosis of muscular and submucosal nerve plexuses, as well as necrosis of vascular walls with deposition of hyaline-like structures characterize microcirculatory ischemic processes in the colon wall. CONCLUSION: Severe pseudomembranous colitis associated with COVID-19 may not be associated with clostridial infection. Further analysis of possible ischemic etiology and pathogenesis of gastrointestinal lesions in COVID-19 is needed for preventive and therapeutic measures.

[The Capsule Endoscopy Crohn's Disease Activity Index, clinical activity and fecal calprotectin level in patients with isolated small intestine lesions]. / Vzaimosvyaz' endoskopicheskoi aktivnosti, klinicheskoi aktivnosti bolezni Krona i urovnya fekal'nogo kal'protektina.

OBJECTIVE: To identify a correlation between diagnostic markers of Crohn's disease and endoscopic data using the Capsule Endoscopy Crohn's Disease Activity Index for isolated small intestine lesions. MATERIAL AND METHODS: We studied 127 patients over previous 19 years. All patients were divided into 2 groups: isolated Crohn's disease of small intestine (group 1) and lesion of small and large intestine or large intestine only (group 2). All patients underwent capsule enteroscopy (MiroCam system, South Korea). Clinical activity of Crohn's disease was determined using the Best's scale, endoscopic activity - using the the Capsule Endoscopy Crohn's Disease Activity Index. We also analyzed fecal calprotectin and other laboratory markers. RESULTS: We found moderate correlation between fecal calprotectin and clinical activity of Crohn's disease, as well as endoscopic activity, C-reactive protein and leukocytes in overall sample of patients. There was moderate correlation between endoscopic activity and clinical activity in overall sample of patients. We found no correlation between fecal calprotectin and endoscopic activity, endoscopic activity and clinical activity, endoscopic activity and C-reactive protein and leukocytes in patients with isolated small bowel disease. Isolated small intestine lesion is accompanied by significantly lower level of fecal calprotectin compared to lesion of small and large intestine. CONCLUSION: In isolated small intestine lesion, endoscopic data do not correlate with clinical symptoms and fecal calprotectin level. Thus, analysis of severity of disease using the Crohn's Disease Clinical Activity Scale alone and fecal calprotectin may not always be effective for isolated small bowel lesion.

[Risk factors of local infection after cholecystectomy and criteria of smooth postoperative period]. / Faktory riska razvitiya infektsii oblasti khirurgicheskogo vmeshatel'stva posle kholetsistektomii i opredelenie kriteriev normal'nogo techeniya posleoperatsionnogo perioda.

OBJECTIVE: To identify the criteria of smooth postoperative period after cholecystectomy and risk factors of local surgical infection. MATERIAL AND METHODS: A prospective analysis included 680 patients after laparoscopic cholecystectomy. We assessed incidence and risk factors of infectious complications. Major markers of acute inflammation, ultrasonic features of surgical site in early postoperative period were analyzed. RESULTS: Postoperative infectious complications developed in 35 patients (5.1%). All studied risk factors except an age (obesity, cardiorespiratory diseases, surgery time over 150 min, violation of the principles of antibiotic therapy, intraoperative blood loss over 50 ml, drainage time over 5 days) significantly affected the development of infectious complications. Surgery time over 150 min and violation of the principles of antibiotic therapy were the most significant factors. Serum procalcitonin, erythrocyte sedimentation rate and C-reactive protein were characterized by the highest prognostic value on the 3rd postoperative day. Threshold values were defined. CONCLUSION: Surgery time and violation of the rules of antibiotic prophylaxis were the most significant risk factors of postoperative infectious complications. We determined the criteria of smooth postoperative period: procalcitonin <1.5 mg/l, C-reactive protein <50 mg/l, erythrocyte sedimentation rate <39 mm/h, ultrasonic pattern of hypoechoic accumulation within the bed of the bladder (dimension <10 mm) without signs of intestinal insufficiency, abdominal or subhepatic effusion on the 3rd day after surgery.

[Redo surgery after laparoscopic fundoplication]. / Povtornye operatsii posle laparoskopicheskikh fundoplikatsii.

OBJECTIVE: To analyze the results of redo surgeries after previous laparoscopic fundoplication. MATERIAL AND METHODS: A retrospective analysis included 37 repeated anti-reflux surgeries. Control group consisted of 38 patients after the first anti-reflux surgery performed on the same clinical base. The causes of unsatisfactory results of the first operations were studied. Intraoperative data, immediate and long-term results of surgical treatment were compared in both groups. Quality of life in both groups was studied before surgery and in long-term period using GIQLI questionnaire. RESULTS: The most common cause of recurrent reflux was a hernia recurrence combined with slipping or destruction of the fundoplication cuff. Dysphagia was usually a result of compression of the esophagus by tightly sutured diaphragmatic crura and recurrent paraesophageal hernia. The main group was characterized by significantly greater surgery time, hospital-stay, incidence of intraoperative and postoperative complications. However, a more significant improvement of quality of life (∆GIQLI) was observed in the main group due to the low QOL index before redo surgery. CONCLUSION: Redo surgeries are effective and safe procedures. These operations significantly improve QOL in long-term period despite certain technical difficulties. Repeated surgeries for dysphagia accounted for 2%, for recurrent reflux - 6%. Persistent postoperative dysphagia is usually associated with diaphragm repair rather fundoplication cuff. Reflux recurrence is often caused by cuff slippage and recurrent hernia.

[Classification of surgical complications]. / Klassifikatsiia khirurgicheskikh oslozhnenii (s kommentariem redkollegii).

AIM: To develop classification of surgical complications. MATERIAL AND METHODS: The most common and recently proposed classifications of surgical complications (Clavien-Dindo, Occordion, R. Satava, et al., A. Kazaryan, et al.) were analyzed. Postoperative complications in 25 556 patients were retrospectively assessed. Incidence and severity of complications, methods of their correction, effect of complications on length of hospital-stay were analyzed. RESULTS: As a result of comprehensive analysis, new classification of surgical complications was proposed. 5 grades of complications were identified. Classification is based on anatomical features, type of complications (within surgical access, organ or cavity), correction depending on this type, severity of complications. Causal relationship of complication with type of repair and increased length of hospital-stay was considered. CONCLUSION: Classification proposed is anatomically justified, considers causal relationship of complications and their repair, as well as length of hospital-stay.

[Discussion about therapeutic tactics in case of acute appendicitis].

The authors' opinion about conservative treatment of acute appendicitis is presented in the article. Conservative treatment of acute appendicitiswas proposed by K. Varadhan, etc. (2009). It was presented the examination results of 7216 patients who werehospitalized with suspected acute appendicitis. Also it was analyzed the results of appendectomy, which were performed in 5172 patients. Validity of diagnostic laparoscopy, informational content of ultrasonic scanning and Alvarado scale were discussed in the article. The authors propose that wide application of conservative treatment of acute appendicitis is premature in Russian Federation. Technique approbation is necessary on base of several medical organizations with discussion of its results within the Russian Society of Surgeons.

[Choice of surgical method of treatment of cholelithiasis].

This article presents results of surgical treatment of 2963 patients with cholelithiasis. The majority of them (71.8%) had an elective surgery, though 28.2% of patients underwent an emergency operation. A comparative assessment of obligate treatment criteria was made in 2 groups. A first group consisted of 803 patients and it was before introduction of Roman selection criteria used for surgical treatment of patients. A second group included 2963 patients in the period after introduction of selection criteria. Preoperative planning of surgery with evaluation of technical complexity of all stages of intervention with prognosis for possible complications should be the base of reasonable choice of surgical method of treatment of cholelithiasis and safety protection of surgery. The study completed and results obtained allowed decrease of the rate of postoperative complications to 1.4% and lethality--to 0.3%, respectively.

[The influence of the surgical access on the endotoxemia level].

The systemic inflammatory response, induced by the lipopolysaccharides of the normoflora of the operated patients was studied on the example of the plasma changes in 107 patients. All patients were divided in 4 groups, depending on the level of lipopolysaccharides in plasma. Thus, patients with the complicated course of the acute cholecystitis, demonstrated the increased lipopolysaccharides levels. The last correlates with the surgical access, the duration of the operation and early complications development. The results may be used for the diagnostics and decision making in emergency situations.

[Emergency abdominal surgery in the region of Russian Federation (an analysis of 40 years)].

An analysis of the condition of emergency surgery for the patients with acute abdominal diseases was made in the period of 1972-2012. The dynamics of surgical beds provision and surgical personnel were taken into account. The authors investigated the rate of general and postoperative lethality, tendencies and regular occurrences and leading reasons of negative results in given diseases. Reserves of further decrease of the lethality were considered and it was associated with shortening of hospitalization part later than 24 hours. The future improvement of intensive therapy and resuscitation, more wide application of minimally traumatic techniques of surgical treatment could give better results in this group of patients.

[Etiology and pathogenesis of Mallory-Weiss syndrome].

Treatment results of 405 patients with Mallory-Weiss syndrome, X-ray gastric investigation in patients with severe bloating reflex were analyzed. Experimental part of the study involved rats and pigs, modeling esophageal and gastric rupture. Cardioesophageal and gastric cardial rupture happen in case of simultaneous sudden intragastric and intraabdominal hypertension, following the rule of Laplace.

[The Fournier's gangrene].

Data of 17 patients with the Fournier's gangrene are described and analyzed. The incidence of the disease is lesser then 0,09% of patients of urological and proctological departments. Patients with the Fournier's gangrene are to be treated and monitored at the intensive care units. Early and radical necrectomy, massive systemic antibiotic therapy and therapy of the systemic inflammatory response syndrome are the mainstay of the successful Fournier's gangrene treatment. Lethality of the disease amounted up to 17,6%.

[Validation of spleen-saving operations and spleen re-plantation in surgical treatment of stomach cancer].

The report presents an evaluation of the surgery given to 587 stomach cancer patients at the Republican Oncological Dispensary (1995-2005). There were 2 groups--surgery for tumor combined with lymph dissection D2 and cytoreduction (R1 and R2), on the one hand, and controls (standard, palliative and diagnostic operations), on the other. Splenectomy was performed in group 1 in 71.4%. According to complication and lethality assessment, surgery for tumor combined with splenectomy involved relatively higher complication incidence. Moreover, the end results of such treatment were as good as those in cases without splenectomy. Hence, spleen re-plantation into the round ligament of the liver may be a procedure of choice when the spleen cannot be saved.

[The ways of purulent spread in necrotizing pancreatitis].

Results of examination of 206 patients with destructive pancreatitis are presented. On the basis of complex research it has been allocated five most significant variants of distribution of purulent process to retroperitoneal space. Existence of correlation of morphological changes in pancreas and retroperitoneal cellular tissue has been shown. Contrast ductography allowed to identify more precisely a place of defect in a wall of a duct and to predict the ways of purulent spread in retroperitoneal space. In view of it surgical tactics allows to improve results of treatment.

[Comparative analysis of the scores of severity of acute pancreatitis].

Based on an analysis of case histories of 45 patients with destructive pancreatitis and coexisting peritonitis the authors have proposed a score assessment of the disease severity. It is based on accounting the morphological alterations in the pancreas and retroperitoneal fat, statistical data from case histories of the patients. This method of assessing the severity of acute pancreatitis is good for specification of the management of the patient in the hospital and for a retrospective analysis of the case history.

[Laparoscopic splenectomy in a general surgery department of a hospital]. / Laparoskopicheskaia splenéktomiia v obshchekhirurgicheskom statsionare.

The results of treatment of 32 patients with spleen diseases who have undergone laparoscopic splenectomy (LSE) are analyzed. Surgery was performed most often for idiopathic thrombocytopenic purpura. Some technical features of surgery are discussed. It is demonstrated that high-technology methods (suturing device "EndoGia", electrosurgical unit "LigaSure") increase reliability of hemostasis, decrease blood loss during surgery and reduce time of surgery. Complications during surgery were seen in 3 (9.3%) cases, conversion - in 2 (6.3%). Mean time of surgery was 121.3 min, mean blood loss - 346 ml, postoperative complications were seen in 4 (12.5%) patients, mean hospital stay - 5.7 days. There were no lethal outcomes. It is concluded that LSE is safe and effective procedure reducing rate of infectious and hemorrhagic complications after surgery.