[Peculiarities of diagnosis and emergency surgical care in aorto-oesophageal fistula]. / Osobennosti diagnostiki i neotlozhnoi khirurgicheskoi pomoshchi pri aorto-pishchevodnom svishche.

An aorto-oesophageal fistula is a rare but life-threatening pathological condition developing on the background of diseases of the aorta and oesophagus, as well as after surgical interventions on the aorta. The article deals with a clinical case report regarding management of a patient presenting with an aorto-oesophageal fistula resulting from a thoracic artery aneurysm. The main clinical manifestations of the diseases included dysphagia (due to oesophageal obstruction caused by thrombotic masses of the aneurysm) and the occurring gastrointestinal haemorrhage. Comprehensive instrumental diagnosis was performed using roentgen examination of the oesophagus, oesophagoscopy, and contrast-enhanced computed tomography of the chest. The obtained findings made it possible to objectively assess the patient's state, to carry out timely treatment in conditions of a surgical hospital, and to avoid severe complications.

[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.

[Postoperative complications in patients with cervicothoracic injuries].

The results of the diagnosis and treatment of 117 patients with cervicothoracic injuries were analyzed. Different complications were observed in 51 (43.6%) cases. The main reasons contributing to the development of complications included late diagnosis of lesions of trachea and esophagus, acute blood loss, inadequate hemostasis during surgery.

[Diagnosis and treatment of cervicothoracic injuries].

It analyzed the diagnosis and treatment results of 123 patients with cervicothoracic injuries for 21 years. The frequency of cervicothoracic injuries among all patients with cervical injuries was 5.7%. Preoperative and postoperative diagnosis included radial and endoscopic methods. The complications rate was 43.6%. The most severe complications were observed in patients with delayed diagnosis of trachea and esophagus injuries.

[The immune reactions by the esophagus injuries, complicated by mediastinitis].

The comparative analysis of 56 immunograms of patients with mediastinitis, caused by the esophagus trauma is represented. The mean values of 9 immunologic parameteres (the so called "norm of the pathology") were set for patients with noncomplicated mediastinitis. A novel method of the immune status evaluation for the patients with the acute surgical conditions and SIRS has been suggested. If early applied, the method allows substantive immunotherapy for such patients.

[Diagnostics and surgical treatment of the posttraumatic septic mediastinitis].

Treatment results of 38 cases of septic mediastinitis for the last 17 years were analyzed. The frequency of mediastinitis as a complication of the penetrating wound was 0.28%, and of the closed thoracic trauma - 0.1%. Reasons and risk factors of the mediastinitis development have been revealed. The enlargement of the mediastinum on the X-ray allowed the primary diagnostics of suspicion on the mediastinitis in 39.5% of cases. The spiral computed tomography provided information for the further treatment options. The mediastinum drainage was an effective method of treatment, providing the improvement in 69.6% patients after penetrating wound and in 73.3% after the closed thoracic trauma.

[Diagnosis and treatment of lung injuries].

Overall 1218 patients with lung injuries were treated during 11 years. The rate of deep wounds and injuries of central zone and root of lung was 24.9%. Endoscopic and x-ray methods (especially computed tomography) were used for diagnosis. Surgical tactics depended on type of injury. Resection of lung and pneumonectomy were performed at 10.2% patients, closure of lung wound--at 41.3%. Surgical treatment of lung wound with dissection and revision of wound canal was performed at 42.6% patients with deep injuries. Classified surgical tactics permits to reduce the rate of postoperative pulmonary complications from 62 to 11.6%, and lethality--from 11.2 to 3.1%.

[Closed tracheal injury--surgical or anesthesiologic-and-resuscitative problem].

Closed chest injury with rupture of the trachea and main bronchi is a rare and extremely life-threatening pathology. In suspected tracheal injury, as well as in severe closed chest injury with the gas syndrome, diagnostic tracheobronchoscopy with possible intubation is indicated in order to isolate the airway lumen from the paratracheal space. Tracheal intubation through a fibrobronchoscope should be considered to be the first aid. Tracheostomy is not the operation of choice and it is indicated only when there is no available technology or experience in intubating the airways under endoscopic guidance. Most small tracheal ruptures in closed chest injury, as well as those of iatrogenic postintubational genesis, may be medically eliminated. A surgeon jointly with an anesthetist and a bronchological endoscopist should determine indications for the operation. The operation should be performed as early as possible. It should be started from the intubation of the airways and the insertion of the end of an intubational tube caudally the rupture. When the breathing circuit is depressurized, all alternative gas exchange maintenance techniques available at an anesthetist's disposal, including high-frequency artificial ventilation and a shunt-breathing system, are indicated, which should provide a patient's safety and surgical comfort.

[Iatrogenic postintubation tracheal rupture].

Iatrogenic damage to the trachea in its intubation and during artificial lung ventilation ,is a rare, severe and commonly fatal complication in resuscitative care. The risk for tracheal damage increases in emergency, time shortage and hypoxia in a patient, while intubating with a double-lumen tube, using rigid mandrin guides without a safety limit stop, and having difficulties in intubating the patient due to his/her anatomic features. Fibrotracheoscopy is the principal diagnostic techniques that may cause tracheal rupture, which may be transformed to a therapeutic measure, by placing an intubation tube caudally at the site of tracheal rupture. Among 33 patients, only 6 underwent surgical defect suturing. When the trachea is ruptured, surgery is indicated for respiratory hemorrhage unstopped by inflating the cuff of an intubation tube and, perhaps, associated with the damage to a large vessel; for progressive gas syndrome, extensive rupture of the membranous part with the involvement of the tracheal bifurcation and main bronchus or with the interposition of paratracheal tissues; for a concomitant damage to the esophagus; for rupture of the tracheal membranous part during intubation before thoracotomy or for rupture detected during thoracotomy for another cause. Correct and timely care may eliminate this life-threatening iatrogenic complication, by yielding a good effect.

[The relationship of the nitric oxide level with angiotensin-converting enzyme activity in the chest injury].

We have studied NO production, ACE activity and their correlation in pleural fluid of patients with and without lung wound, in the blood serum of the wounded and blood donors. Chest wound was associated with a significant elevation of NO levels in all study groups versus controls. The greatest increase of ACE activity was observed in pleural fluid of patients with a lung wound. There was a negative correlation between NO and ACE in pleural fluid of patients with a lung wound. In all the other groups, a positive correlation between NO and ACE was revealed. ACE overactivity in the pleural fluid may be one of the factors of impaired relationship between NO and ACE in lung wound. Determination of ACE activity in the pleural fluid may serve as a diagnostic criterion of the lung injury.

[The endoscopic and morphological diagnostics of gastroesophageal reflux]. / Endoskopicheskaia i morfologicheskaia diagnostika gastroézofageal'nogo refliuksa.

The experiences with endoscopic examinations of 140 patients with gastroesophageal reflux followed by the development of reflux-esophagitis (RE) of different degree are presented. The authors describe the complicated and uncomplicated forms of RE. The uncomplicated forms include RE with unimpaired integrity of the epithelium, erosive RE, erosive-ulcerous RE. The complicated forms include peptic ulcer of the esophagus, peptic stricture and Barrett esophagus. The degree of RE was found to depend on the character and degree of impairment of the obturating function of the cardia. The morphological examination of the esophagus mucosa was performed in 35 patients. Morphological heterogeneity of the so called "catarrhal RE" was shown that makes the expedience of using this term in clinical practice doubtful. Exact endoscopic and morphological criteria of the differential diagnostics of erosive and erosive-ulcerous RE, erosive-ulcerous RE and peptic ulcer of the esophagus are described.

[Instrumental diagnosis of reflux esophagitis]. / Instrumental'naia diagnostika refliuks-ézofagita.

One hundred and forty patients with clinical symptoms of gastroesophageal reflux disease were examined. Instrumental examination included esophagogastroduodenoscopy (140 patients) with target biopsy (44 patients), x-ray study of the esophagus and stomach (95), intragastric pH-metry (74), esophagomanometry (67). It is demonstrated that all the patients with clinical picture of gastroesophageal reflux disease suffer from reflux-esophagitis (RE) of various severity. Definite morphological equivalents correspond to each of endoscopic forms of RE. Complex instrumental diagnosis of RE must include intragastric pH-metry and esophagomanometry in line with esophagogastroduodenoscopy and morphological study. It is necessary to perform x-ray study in peptic strictures of the esophagus and in combination of RE with large axial hiatal hernias. Cardial or cardial-fundal hiatal hernia, increase of intragastric pressure and hyperacidity promote development of the most severe (destructive) forms of RE.

[Diagnosis and treatment of post-traumatic coagulated hemothorax]. / Diagnostika i lechenie posttravmaticheskogo svernuvshegosia gemotoraksa.

Analysis of 102 cases of coagulated hemothorax (CH) are presented: 32--after penetrating wounds and 70--after closed chest injury. In 57% patients with chest wounds and 72% patients with closed injury the cause of CH was to applying late for medical care. Diagnostic value of X-ray, ultrasonic methods, CT and pleural puncture was studied. Depending on the patients state severity, CH volume and stage of it formation conservative treatment, streptase administration, thoracoscopy and thoracotomy with pleurectomy and lung decortication were performed. Lethality was 2.9%.

[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.

[20-year experience with diagnosis and treatment of different forms of purulent mediastinitis]. / Dvadtsatiletnii opyt diagnostiki i lecheniia pri razlichnykh formakh gnoinogo mediastinita.

An experience of many years has shown that the most severe clinical course is observed in patients with mediastinitis due to injuries of the esophagus, and with odontogenous and tonsillogenous mediastinitis. Using the ultrasound method of investigation and computed tomography made the possibility to early diagnose this disease considerably wider. Treatment of patients with mediastinitis included surgical sanitation of the purulent focus, antibacterial, detoxicating and immune therapy, the central role being given to active drainage of the mediastinum with lavage and aspiration. In patients with mediastinitis resulting from rupture of the inferiorthoracic portion of the esophagus the isolation of the injured wall of the esophagus from the aggressive influence of gastric juice is an important measure. This problem can be solved by ligation of the abdominal part of the esophagus or by Nissen's fundoplication. Severe complications of mediastinitis such as empyema of the chest, purulent peritonitis and arrosive bleedings require active surgical strategy.

[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.

[Use of leukinferon for prophylaxis of pyogenic complications in victims with thoracic wounds]. / Primenenie leikinferona dlia profilaktiki gnoinykh oslozhnenii u postradavshikh s raneniiami grudi.

The results of treatment of 131 victims with penetrating wounds of the thorax complicated by profuse bleeding, are presented. 36 of them after surgery to prevent pyogenous complications received 5 injections of leukinferon (test group); 95 patients who were not treated by leukinferon made up control group comparable with the test group by sex, age and character of wounds. Comparative analysis of the results showed that treatment with leukinferon has resulted in decrease of postoperative complications. In the test group the number of complications made up 47.2%, in control group--61%. Al the same time in the former group there was only one pyogenous complication (2.9%), while in control group--10 (10.6%). After the course of leukinferon leucocytic formula of the blood has become normal, the number of patients with immunodeficiency and imbalance of proteins markers of the acuteness of inflammatory process has decreased.