[Comparison of early operative treatment and 48-hour conservative treatment in small bowel obstruction (COTACSO): intermediate results]. / Promezhutochnye rezul'taty otkrytogo prospektivnogo randomizirovannogo mnogotsentrovogo sravnitel'nogo issledovaniya rannei operatsii i 48-chasovogo neoperativnogo lecheniya spaechnoi kishechnoi neprokhodimosti.

Optimal treatment for adhesive small bowel obstruction (SBO) is not defined. Surgery is the only method of treatment for obvious strangulating SBO. Non-operative management (NOM) is widely used among patients with low risk of strangulation, i.e. no clinical, laboratory and CT signs. Randomized controlled trials (RCTs) are recommended to determine the optimal method (early intervention or NOM), but their safety is unclear due to possible delay in surgery for patients needing early intervention. MATERIAL AND METHODS: A RCT is devoted to outcomes of early operative treatment and NOM for adhesive SBO. The estimated trial capacity is 200 patients. Thirty-two patients were included in interim analysis. In 12 hours after admission, patients without apparent signs of strangulation were randomized into two clinical groups after conservative treatment. Group I included 12 patients who underwent immediate surgery, group II - 20 patients after 48-hour NOM. The primary endpoint was success of non-surgical regression of SBO and reduction in mortality. To evaluate patient safety, we analyzed mortality, complication rates and bowel resection in this RCT with previously published studies. RESULTS: In group I, all 12 (100%) patients underwent surgery. Only 4 (20%) patients required surgery in group II. Mortality, complication rates and bowel resection rates were similar in both groups. Strangulating SBO was found in 8 (25%) patients. Overall mortality was 6.3%, bowel resection rate - 6.3%, iatrogenic perforation occurred in 3 (18.8%) patients. These values did not exceed previous findings. CONCLUSION: Non-operative management within 48 hours prevented surgery in 80% of patients with SBO. Interim analysis found no significant between-group differences in mortality, complication rates and bowel resection rate. Patients had not been exposed to greater danger than other patients with adhesive SBO. The study is ongoing.

[Possibilities of local phlebectomy in correction of pelvioperineal venous reflux]. / Vozmozhnosti lokal'noi flebéktomii v korrektsii pel'vio-perineal'nogo venoznogo refliuksa.

The work was based on the results of examination and treatment of 43 female patients presenting with varicose transformation of pelvic, perineal, and lower-limb veins. The inclusion criteria were as follows: the presence of visually determined varicose transformation of the veins of the external genital organs, perineum, posterior surface of the thighs, as well as valvular insufficiency of the mentioned veins by the findings of ultrasonographic angioscanning (USAS). The following exclusion criteria were applied: the presence of pregnancy, symptoms of pelvic venous plethora (PVP), and varicothrombophlebitis. In 33 women correction of the pelvioperineal reflux (PPR) was performed with the help of local phlebectomy on the large pudendal lips and perineum, with the maximally possible mobilization of the vessel within the limits of the operative wound. Miniphlebectomy with the use of Varady phleboextractors was performed in 10 women presenting with isolated varicose transformation of the subcutaneous veins of the posterior femoral surface. The duration of follow up of patients amounted to 3 years. The criteria for efficiency of the carried out treatment were as follows: freedom from varicose syndrome both in the perineum and on the lower extremities, as well as no PVP symptoms during the whole term of follow up. Varicose syndrome of the external genital organs, perineum and posterior surface of the femurs was successfully eliminated in 100% of patients. Meticulous mobilization and removal of the veins of the labia majora, perineum and subcutaneous femoral veins is a reliable method of removing pathological reflux of blood from the intrapelvic to superficial veins of the perineum and lower limbs. 100% of our patients were found to be free from relapses of either vulvar or perineal varicosity, with no evidence of lower limb varicose veins. Local phlebectomy is an efficient method of elimination of varicose syndrome induced by PVP in patients with dilatation of intrapelvic, vulvar and perineal veins.

[Optimal time of surgery for acute adhesive small bowel obstruction]. / Vybor sroka operativnogo lecheniia pri ostroi spaechnoi tonkokishechnoi neprokhodimosti (mul'titsentrovoe prospektivnoe randomizirovannoe issledovanie).

AIM: To define optimal terms of surgery for acute adhesive non-strangulatory small bowel obstruction. MATERIAL AND METHODS: The analysis included 703 publications from e-LIBRARI.RU (342 works) and NCBI (361 works) databases for acute adhesive intestinal obstruction. The vast majority of articles presented retrospective analysis of single-center experience. RESULTS: It has been established that short course of medication is predominantly used for acute adhesive intestinal obstruction in the Russian Federation. International studies point 2-5 days for conservative treatment. The advantages and disadvantages of short and long courses of medication were analyzed. Therefore, multicenter, prospective, randomized trial 'Comparison of early operative treatment (12-hour medication) and long-term conservative treatment (48 hours) for acute adhesive small bowel obstruction' (COTACSO) was planned and registered (Unique Protocol ID: 14121729). The study protocol involves clinical, laboratory and instrumental exclusion of strangulation, randomization and conservative treatment of 2 groups of patients for 12 and 48 hours. Patients will undergo surgical interventions if obstruction will be present by that date. The main endpoint is mortality rate in both groups. The end of the study is December 2020.

[Von Korff questionnaire in assessment of social disadaptation and therapeutic results in women with pelvic varicose veins]. / Anketa Van Korffa v otsenke sotsial'noi dezadaptatsii i rezul'tatov lecheniia patsientok s varikoznoi bolezn'iu taza.

AIM: The present study was conducted to examine the possibilities of the Von Korff questionnaire in assessing the impact of pelvic pain on social activity and working ability of women with pelvic varicose veins (PVV) and evaluating the results of treatment of the pathology involved. PATIENTS AND METHODS: The Von Korff questionnaire was administered in a total of 80 women presenting with PVV in order to assess the results of conservative and surgical treatment of PVV. RESULTS: Using the Von Korff questionnaire made it possible to objectively evaluate the psychosocial impact of chronic pelvic pain (CPP). It was determined that in 56 patients the presence of PVV and CPP was accompanied by a low level of social disadaptation and formation of grade I disability. 24 women were found to have moderate and high levels of social disadaptation and grade II-IV disability. Studying the outcomes of conservative and surgical treatment of PPV as assessed by means of the Von Korff questionnaire demonstrated high efficacy of the therapeutic techniques used. In patients subjected to surgical interventions, the CPP degree decreased from 7.6±0.9 to 1.6±0.9 points, the level of social disadaptation fell from 2.8±0.6 to 0.5±0.3 points, and the grade of disability decreased from 2.9±0.4 to 0.8±0.4, which may be regarded as complete restoration of social activity. DISCUSSION: The Von Korff questionnaire used in our study made it possible to objectively evaluate the impact of CPP related to pelvic varicose veins on formation of social disadaptation in women and a decrease in their working ability. In the general structure of the disease, 75% of women appeared to have a low level of social disadaptation and grade I disability, with a third having grade II, III and IV disability and a moderate-to-high level of social disadaptation. In 25% of women, the determined degree of disability averagely amounted to 2.9±0.4, thus suggesting their significant social disadaptation. CONCLUSION: The carried out study showed that the Von Korff questionnaire is an objective and demonstrative tool of clinical determination of the severity of pelvic varicose veins, as well as the effect of CPP on both everyday and social activity of women suffering from the pathology concerned.

[How to validate the symptoms of pulmonary thromboembolism: how diagnostic scales help].

AIM: To detect the most important clinical symptoms suggesting pulmonary thromboembolism (PTE) and to determine the diagnostic value of the scales used to estimate the likelihood of its occurrence. MATERIALS AND METHODS: The prospective study included 130 patients admitted to hospital with a diagnosis of PTE and a referral for a surgery clinic. Scores of the likelihood of PTE were estimated using the Canada and Geneva scales in all the patients on admission. RESULTS: In all the patients with suspected PTE, the Canadian and revised Geneva scores averaged 4.2 +/- 0.48 and 6.21 +/- 0.5, respectively. These scores correspond to the intermediate clinical probability of PTE. In 96 patients whose diagnosis was verified by instrumental studies, the Canadian and Geneva scores were 4.41 +/- 0.57 and 6.17 +/- 0.63, respectively, which was also consistent with the intermediate clinical probability of PTE. In 34 patients, whose diagnosis of PTE was ruled out, the average scores did not virtually differ from those in the patients with the verified diagnosis and were 6.14 +/- 1.3 and 4.18 +/- 0.87, respectively. The area under characteristic curve for the Canadian scale was 0.428 and that for the Geneva scale was 0.512. With the use of a two-level interpretation system, a total of more than 6 Canadian scores and 10 Geneva scores suggested that there was a high probability of PTE. CONCLUSION: The investigation indicated the low value of integral systems for estimating the likelihood of PTE in the total population of patients with this disease. The authors recommend the two-level interpretation system, in which a total of more than 6 Canadian scores and 10 Geneva scores were identified with a high probability (up to 80%) of PTE.

Is the endovascular embolization of tributaries of the internal iliac veins essential in the treatment of isolated pelvic-perineal reflux?

Aim: The aim of study was to investigate the opportunities of local phlebectomy in the elimination of isolated pelvic-perineal reflux (PPR), as well as to determine the feasibility of endovascular embolization of the tributaries of internal iliac veins in PPR. Clinical trial no. NCT01598051.Materials and methods: The work is based on the results of examination and treatment of 43 female patients with varicose veins of the pelvis, perineum, and lower extremities. Patients had no signs of pelvic congestion syndrome (PCS). All patients underwent duplex ultrasound scanning (DUS) and ovariography with pelvic phlebography (OPP). For the elimination of PPR, local phlebectomy was performed in the major labia and perineal area, with maximal possible mobilization of the vessel within the operative wound (33 patients). In 10 patients with isolated varicose transformation of the superficial veins on the posterior thigh, mini-phlebectomy was performed using the Varady phlebectomy extractors.Results and discussion: The varicose syndrome of the external genitalia, perineum, and posterior thigh was successfully treated in 100% of patients. Findings suggest that thorough mobilization and excision of the veins of the pudendal labia, perineum, and subcutaneous veins of the thigh is a reliable method for eliminating the pathological reflux from the intrapelvic veins to the superficial veins of the perineum and lower extremities. No recurrences of vulvar, perineal varices or dilation of the veins of the lower extremities were observed in 100% of patients over the 3-year follow-up period.Conclusion: Local phlebectomy is an effective technique for eliminating the isolated PPR in patients with varicose transformation of intrapelvic, vulvar, or perineal veins. Endovascular embolization of the tributaries of the internal iliac veins is not an essential component in the treatment of PPR. The present study has a limitation due to the absence of patients with PCS. The effectiveness of phlebectomy in the treatment of isolated PPR was studied.

[Treatment of inferior vena cava thrombosis. How to avoid errors?].

Unsatisfactory results of acute thrombosis treatment in inferior vena cava system are attributed to inadequate diagnosis, poor compliance with approved clinical practice guidelines and secondary preventive measures, as well as to excessive adherence to surgical methods of pulmonary embolism prophylaxis. Diagnostic strategy, which combines compressive duplex scanning and D-dimer test, can improve diagnosis and reduce its cost. Various molecular weight heparins and vitamin K antagonists are still the main means of venous thrombosis therapy. Appropriate medical treatment in many cases helps to avoid surgical interventions for pulmonary embolism prophylaxis and to reduce the rate of recurrent thromboses.

Evaluation of the efficacy of heparins of varying molecular mass and duration of their use in the treatment of patients with acute venous thrombosis.

This paper analyses the results of examination and treatment of 90 patients with acute thrombosis in the inferior vena cava system. To verify the diagnosis, use was made of contrast phlebography (retrograde iliocavography), ultrasound angioscanning, and perfusion scanning of the lungs, The treatment was carried out using heparins of varying molecular mass given for a short and longer time together with indirect anticoagulants. It has been demonstrated that the use of low-molecular heparin does not produce any noticeable changes in the hemostatic system, which can be revealed by standard coagulation tests. In the authors opinion, a differentiated approach is required to the choice of the regimes of heparin therapy. The indications for the use of heparins have been worked out. Early administration of vitamin K raises the efficacy of anticoagulant therapy and shortens the time of heparin therapy. The use of low-molecular heparin allows to minimize the incidence of thromboembolic and hemorrhagic events without an increase in the total expenses for treatment.