[Therapeutic and diagnostic complex in intestinal failure syndrome in patients with closed abdominal trauma]. / Lechebno-diagnosticheskii kompleks pri sindrome kishechnoi nedostatochnosti u patsientov s zakrytoi travmoi zhivota.

Currently, severe combined abdominal trauma ranks third among all causes of mortality In Russia, second only to cardiovascular and oncologic diseases. In the period from 2019 to 2020 in our country, a slight decrease in traumatism is noted due to a decrease in the number of traffic accidents as the main cause of combined and multiple trauma. The number of abdominal injuries from the total number of injuries In Russian regions ranges from 1.5 to 36.5% and is accompanied by a high level of disability (25-80% in combined trauma and 5-8% in isolated trauma). Despite modern medical advances, lethality in combined trauma of abdominal organs varies from 10.7 to 69.7%, with closed abdominal trauma accounting for up to 6% of fatal outcomes. OBJECTIVE: Improving treatment outcomes in patients with closed abdominal trauma through comprehensive diagnosis of SCN and optimization of enteral therapy in patients with closed abdominal trauma. MATERIAL AND METHODS: The study included 40 patients (29 (72.5%) men and 11 (27.5%) women), who underwent examination and treatment at the State Budgetary Institution "Research Institute of SP. Im. N.V. Sklifosovsky Research Institute of St. Petersburg State Medical Center with the diagnosis: Closed abdominal trauma. The age of the patients varied from 25 to 81 years (Mean age was 49.6±13.1). To evaluate the effectiveness of intensive therapy, the patients were divided into 2 groups: the comparison group (n=26) included patients who were treated with complex conservative therapy. Patients of the main group (n=14) conservative therapy was supplemented with the use of ER to restore the functional activity of the intestine under the control of ultrasound and assessment of the degree of intra-abdominal hypertension, as well as with Intestamine to stimulate the intestinal trauma. RESULTS: In the course of the study it was found that, as a result of complex enteral therapy in the patients of the main group, starting from the 7th day of stay in the ORIT, positive dynamics was observed, consisting in a statistically significant decrease in the levels of lactate, ALT, AST, LDH, and CRP. By the 14th day there was also a statistically significant decrease in leukocyte and PCT levels. The lethality in the main group amounted to 7.2%, n=1. At the same time, in patients of the comparison group only by the 7th day there was a decrease in concentration of CRP (p=0.065), by the 10th day - ALT (<0.001) and by the 14th day there was a decrease in leukocytes level (p=0.038). Lethality in this group amounted to 23.1%, n=6. CONCLUSION: Timely initiation of pathogenetic enteral therapy contributes to faster normalization of clinical and laboratory parameters, protection of intestinal barrier function, prevention of complications associated with bacterial translocation and bacterial overgrowth syndrome, increase in immunoresistance of the organism.

[Bilateral stenting for malignant tracheal and bronchial stenosis]. / Bilateral'noe stentirovanie opukholevogo stenoza trakhei i glavnykh bronkhov: pervyi opyt (klinicheskoe nablyudenie).

Malignant lesions of tracheal bifurcation usually lead to respiratory failure and risk of mortality. Airway stenting is the only minimally invasive method for these patients. The authors present a patient with T4N3M0 left-sided lung cancer (inoperable stage IIIc) complicated by respiratory failure due to tracheal bifurcation obstruction. Bilateral stenting by self-expanding stents with perforated coatings was effective for airway recanalization and provided subsequent chemotherapy.

[The first Russian experience of radiofrequency ablation in the treatment of adenoma of the major duodenal papilla with intraductal growth in the common bile duct]. / Pervyi v Rossii opyt primeneniya radiochastotnoi ablyatsii v lechenii adenomy bol'shogo sosochka dvenadtsatiperstnoi kishki s vnutriprotokovym rostom v kholedokh.

Adenoma of the major duodenal papilla can cause bile flow blockade and obstructive jaundice. We present successful endoscopic radiofrequency ablation for adenoma of the major duodenal papilla with intraductal growth in the common bile duct.

[Complications of percutaneous endoscopic gastrostomy in intensive care patients with dysphagia associated with neurological disorders]. / Oslozhneniya chreskozhnoi endoskopicheskoi gastrostomii u reanimatsionnykh bol'nykh s sindromom disfagii tsentral'nogo geneza.

OBJECTIVE: To develop an effective method for percutaneous endoscopic gastrostomy using gastropexy technology. MATERIAL AND METHODS: We retrospectively analyzed 260 ICU patients with dysphagia associated with neurological disorders between 2010 and 2020. All patients were divided into two groups: the main group (n=50) - percutaneous endoscopic gastrostomy with gastropexy, control group (n=210) - surgery without fixing the anterior wall of the stomach to the abdominal wall. RESULTS. G: Astropexy significantly reduced the incidence of postoperative complications (p=0.045) and severe complications (grade IIIa and higher) (χ2=3.701, p=0.055). Early postoperative complications occurred in 20 (7.7%) patients. Surgery and subsequent treatment were associated with normalization of leukocyte count (p=0.041), C-reactive protein (p=0.024) and serum albumin (p=0.0012). Mortality was similar in both groups. Overall 30-day mortality rate in both groups was 20.8% that was associated with clinical severity of patients. Percutaneous endoscopic gastrostomy was not the direct cause of death in any case. However, complications of endoscopic gastrostomy aggravated the underlying disease in 2.9% of cases. CONCLUSION: Percutaneous endoscopic gastrostomy with gastropexy reduces the incidence of postoperative complications.

[Locoregional anesthesia in endoscopic surgery of intracerebral hypertensive hemangiomas]. / Lokoregionarnaya anesteziya v endoskopicheskoi khirurgii vnutrimozgovykh gipertenzivnykh gematom.

INTRODUCTION: Currently, minimally invasive methods of surgical treatment of hypertensive intracerebral hematomas (ICHs) are actively used. However, anesthetic management of these surgeries are unclear. Moreover, advisability of locoregional anesthesia (LRA) for endoscopic aspiration of hypertensive ICHs has not been studied. OBJECTIVE: To analyze application of regional anesthesia in minimally invasive surgery of hypertensive intracerebral hematomas. MATERIAL AND METHODS: Patients were divided into 2 groups. Group 1 included 45 patients who underwent surgery under total intravenous anesthesia with mechanical ventilation (TIVA + mechanical ventilation), group 2 (n=43) - surgery under LRA. The incidence of pneumonia and postoperative outcomes in accordance with the GOS grading system were analyzed depending on the method of anesthesia. RESULTS: Pneumonia was 3 times more common in the first group (33%) that required prolonged ventilation and tracheostomy. Thus, there were 9 tracheostomies (20%) in the first group. In the second group, one patient required mechanical ventilation on the second postoperative day due to severe chronic obstructive pulmonary disease followed by deterioration of respiratory failure. Tracheostomy was also performed in this case. According to analysis of GOS outcomes, the LRA group was characterized by 4 times lower mortality and 1.5 times greater number of patients with good recovery and moderate disabilities compared with the first group. CONCLUSIONS: LRA is a feasible and effective method for the anesthetic management of minimally invasive surgery in patients with hypertensive ICHs. This approach ensures decrease of mortality rate, increase of good neurological outcomes and reduce pulmonary infectious complications.

[Prognostic significance of leukocyte count in the venous blood in the acute stage of cerebral aneurism rupture]. / Prognosticheskaia znachimost' kontsentratsii leikotsitov v venoznoi krovi v ostrom periode razryva tserebral'nykh anevrizm.

AIM: To determine a prognostic role of leukocyte count in the venous blood in the acute stage of cerebral aneurysm (CA) rupture. MATERIAL AND METHODS: Fifty-one patients with CA rupture, aged from 20 to 65 years, hospitalized in the first 72 h over the period from 01.10.12 to 01.02.16 were examined. The severity of disease and anatomical form of hemorrhage was corresponded to III-IV degree on the W. Hunt - R. Hess scale and Fisher scale. All patients underwent surgery. Outcomes after open and endovascular surgeries were similar. RESULTS: Normal leukocyte number in the venous blood at admission was identified in 12 (24%) of patients (on average 7.3±1.4·109/L), leukocytosis in 39 (76%) (14.3±3.1·109/L) (p<0.0001). Leukocyte number in the acute stage of CA rupture was correlated with the frequency and severity of the vessel spasm. In 28 (55%) of patients with ischemic lesions of the brain matter, mean leukocyte number in the first 72 h after hemorrhage was higher by 2-24% (3±4.8·109/L) compared to patients without ischemia (11.9±2.5·109/L) (p=0.06). The level of leukocytes in survivors was lower by 3 - 28% (122±3.4·109/L) compared to patients with fatal outcome and patients with severe neurological deficit after the surgery (14.5±3.9·109/L) (p>0.05). CONCLUSION: The increase in leukocyte number in the venous blood in the first 72 h after CA rupture ≥10,1·109/L is a reliable risk factor of marked vessel spasm. The level of leukocytes in patients with cerebral ischemia and poor prognosis in the first 72h after aneurysmal hemorrhage was higher by 2-28% compared to survivors without neurological impairment or mild neurological deficit.

[POSITIVE END-EXPIRATORY PRESSURE (PEEP) INFLUENCES ON INTRACRANIAL PRESSURE, SYSTEMIC HEMODYNAMICS AND PULMONARY GAS EXCHANGE IN PATIENTS WITH INTRACRANIAl HEMORRHAGE IN CRITICAL STATE].

Positive end-expiratory pressure is one of the main parameters of respiratory support influencing the gas exchange. However, despite the number ofpositive effects, PEEP can compromise venous outflow from the cranial cavity, increased intracranial pressure, decreased venous return and cardiac output and, consequently, reduced blood pressure and cerebral perfusion. The article presents the results of a survey of 39 patients with intracranial hemorrhage in critical state, undergoing respiratory support with different levels of positive end-expiratory pressure. Increasing of PEEP to 15 cm H2O had no adverse effect on mean arterial pressure, heart rate and cerebral perfusion pressure and led only to an clinical insignificant increase (maximum on 2.4 +/- 5.1 mmHg) in intracranial pressure. The greatest hemodynamic changes were observed with increasing PEEP up to 20 cm H2O in patients with preserved compliance ofthe respiratory system. The instability of cerebral perfusion and intracranial pressure associated with a decrease in cardiac output and preload and the exhaustion of compensatory mechanism of peripheral vascular resistance. High levels of PEEP despite the trend towards Cstat reduction will not lead to an increase in the content of extravascular lung water Thus a gradual increase of PEEP to 15 cm H2O can be safe and effective method of improving pulmonary gas exchange in patients with intracranial hemorrhage in critical state.

[Decompressive craniotomy in the complex intensive treatment of malignant forms of massive ischemic stroke].

A group of patients with benign course of massive ischemic stroke (MII) without development of the dislocation syndrome and a group of patients with malignant course with development of the hemispheric brain edema with the following transtentorial herniation were singled out. Risk factors for the development of malignant form of MII and its fatal outcomes were specified as lateral dislocation (>7 mm), more than 70% of ischemia size in frontal and parietal lobes and more than 80% - in temporal lobes, the disturbance of wakefulness up to moderate coma or more. Based on these results, it was selected patients for decompressive craniotomy in the affected hemisphere that allowed to reduce the fatality rate by more than twice compared to patients treated without surgery.