[Laparoscopy in emergency surgery of rare atypical diseases]. / Videolaparoskopiya v ekstrennoi khirurgii redko vstrechayushchikhsya, atipichnykh zabolevanii.

OBJECTIVE: To analyze the capabilities of laparoscopy in the diagnosis and treatment of atypical diseases. MATERIAL AND METHODS: Laparoscopy was performed in 5188 patients with established, suspected and unclear diagnosis of acute surgical diseases for the period from 2008 to 2018. Rare atypical diseases were diagnosed in 114 (2.2%) patients. These diseases simulated established and suspected clinical diagnoses in 100 (87.7%) cases, and the diagnosis was unclear in 5 (4.4%) cases. In 9 (7.9%) patients, atypical diseases were concomitant. In 7 cases, atypical diseases competed with the underlying disease and required emergency surgery. Conservative treatment was required in 2 cases. Seventy (61.4%) patients with atypical diseases needed emergency surgery, and 44 (38.6%) patients required conservative treatment. Laparoscopic operations were performed in 61 (87.1%) patients including simultaneous procedures in 8 cases and video-assisted interventions in 2 (2.9%) patients. Laparotomy was applied in 7 (10.0%) patients. RESULTS: Histological examination confirmed laparoscopic diagnosis in 66 out of 68 specimens. Cells of mucus-forming adenocarcinoma were detected in one resected epiploic appendix, carcinomatosis - in one segment of resected omentum. CONCLUSION: Video-assisted laparoscopy was valuable to establish a diagnosis and determine surgical strategy, detect competing and concomitant diseases, perform operations including simultaneous procedures.

[Ultrasound in the diagnosis and treatment of abdominal abscesses]. / Ul'trazvukovoe issledovanie v diagnostike i lechenii abstsessov briushnoi polosti.

OBJECTIVE: To improve the results of surgical treatment of abdominal abscesses using ultrasound-assisted drainage. MATERIAL AND METHODS: There were 103 cases of percutaneous ultrasound-assisted drainage of intraperitoneal abscesses for the period from 2012 to 2017. Patients who underwent drainage of intraorganic and retroperitoneal abscesses associated with pancreatic necrosis were excluded from the study. RESULTS: Complete recovery was observed in 101 (98%) out of 103 patients within 10-73 days. CONCLUSION: Ultrasound-assisted drainage is an effective procedure for abscesses. This method has demonstrated high efficiency, availability and safety without need for open approach. This method may be a reliable alternative to open surgery, for example in emergency surgical hospitals.

[Laparoscopy in emergency abdominal surgery]. / Videolaparoskopiya v ekstrennoi khirurgii organov bryushnoi polosti.

OBJECTIVE: To evaluate the possibilities of laparoscopy in the diagnosis and treatment of acute abdominal surgical diseases. MATERIAL AND METHODS: A retrospective analysis of laparoscopic procedures in 4655 patients with confirmed or suspected acute abdominal surgical diseases for the period 2008-2017 was performed. Laparoscopy was applied to confirm or to determine unclear diagnosis. RESULTS: Diagnosis was established and confirmed in 4526 (97.2%) patients. Advisability of laparoscopic surgery was confirmed in 3091 (68.3%) patients, laparotomy - in 491 (10.8%) patients. Surgical treatment was not required in 944 (20.9%) patients. Laparoscopic procedures were performed in 3050 (98.7%) patients, 41 (1.3%) patients required conversion to laparotomy. Laparoscopic approach failed to define diagnosis in 129 (2.8%) patients that required conversion to diagnostic laparotomy. CONCLUSION: Laparoscopic was valuable to establish the diagnosis and determine surgical strategy, diagnose concomitant diseases, perform operations including simultaneous ones.

[Optimized approach to the surgical treatment of patients with large and giant postoperative ventral hernia]. / Khirurgicheskoe lechenie patsientov s bol'shimi i gigantskimi posleoperatsionnymi ventral'nymi gryzhami.

OBJECTIVE: To optimize surgical approach in patients with large and giant postoperative ventral hernias through an analysis of early and long-term results of modern techniques of hernia repair. MATERIAL AND METHODS: There were 680 patients with postoperative ventral hernia over a 15-year period who underwent surgery in the Sklifosovsky Research Institute for Emergency Care and Medical Unit of the Ministry of Internal Affairs (445 (65.4%) women, 235 (34.6%) men). Mean age of patients was 63.2±14.2 years. Middle and elderly (employable) age patients (45-74 years) prevailed in the study (n=510, 75%). Hernia repair using «sublay¼ technique was performed in 490 (72%) patients without severe comorbidities and relative volume of hernial protrusion up to 18%. Submuscular-inlay technique was used in 95 (14%) patients with significant comorbidities and those over 50 years old or with a relative volume of hernial protrusion over 18%. We have applied a modified repair technique for the last 3 years in 5 (0.75%) patients with a giant postoperative ventral hernia and anterior abdominal tissue deficiency (partial or complete absence of some anatomical structures, for example, rectus muscle). A hybrid technology was applied in 12 patients with severe concomitant diseases, hernias W2 according to European qualifications or recurrent hernias, significant adhesions in the abdominal cavity or hernial sac. RESULTS: Early postoperative wound complications occurred in 27 (5.5%) patients including hematoma (n=12, 2.5%), infiltration (n=7, 1.4%), wound suppuration (n=8, 1.6%). Other complications were observed in 6 (1.2%) patients: pneumonia, pulmonary embolism, intestinal obstruction. Lethal outcomes were absent. Recurrences in long-term period were found in 18 (3.7%) patients. Submuscular-inlay technique of hernia repair was followed by early postoperative wound complications in 5 (5.1%) patients including hematoma (n=3, 3.2%), infiltration (n=1, 1%), wound suppuration (n=1, 1%). There was no mortality. No other early postoperative complications were observed. Recurrences were detected in 5 (5.2%) patients. Preoperative intra-abdominal pressure was 7-10 mm Hg in all patients with tissue deficit. This value did not exceed 12 mm Hg after repair due to creation of a «specified diastasis¼. Lethal outcomes were absent. There were no early and long-term recurrences or wound complications. Analysis of early and long-term results of the modified hybrid repair of the anterior abdominal wall did not reveal recurrences, local and systemic complications. Persistent minor diastasis between rectus muscles reinforced with a mesh implant was observed in 3 (25%) out of 12 patients. CONCLUSION: Thus, optimized and personalized approach in patients with large and giant postoperative ventral hernias considers all intra- and postoperative risk factors.

[Laparoscopy for perforated gastroduodenal ulcers]. / Videolaparoskopiia pri perforativnykh gastroduodenal'nykh iazvakh.

AIM: To assess laparoscopy in diagnosis and treatment of patients with perforated gastroduodenal ulcers. MATERIAL AND METHODS: There were 273 patients with perforated gastroduodenal ulcers who underwent laparoscopy at the Sklifosovsky Research Institute for Emergency Care in 2010-2016. Sample included patients with clinical and instrumental diagnosis of perforated gastroduodenal ulcers, suspected hollow organ perforation including perforated ulcer and other acute abdominal diseases followed by perforated ulcer. RESULTS: Laparoscopy confirmed diagnosis of perforated gastroduodenal ulcer in 82.5% of patients with clear preoperative diagnosis and in 54.2% of patients with suspected perforated ulcer. Video-assisted closure of the ulcer is possible in 81.7% of patients. Any endoscopic procedure should be started from diagnostic measures. Diagnostic laparoscopy followed by curative laparotomy in 14.6% of patients was able to clarify diagnosis, suture technically difficult perforated ulcer and prevent possible complications.

[Postoperative ventral hernia - unsolved issues of surgical tactics]. / Posleoperatsionnye ventral'nye gryzhi - nereshennye voprosy khirurgicheskoi taktiki.

Currently, there is no unified opinion on some problematic issues of surgical treatment of postoperative ventral hernias. Current approaches and surgical aspects of primary and recurrent postoperative ventral are reviewed in the article.

[Ileocecal intussusceptions]. / Ileotsekal'naia invaginatsiia kishechnika.

AIM: To present treatment of patients with ileocecal intussusception. MATERIAL AND METHODS: There were 3 patients with ileocecal intussusception for the period from June 2016 to August 2017. CONCLUSION: Abdominal sonography is main diagnostic method for intestinal intussusception. X-ray examination including contrast-enhanced irrigography gives more complete information about suspected intussusception. It is necessary to differentiate intestinal intussusception from other diseases accompanied by abdominal pain, vomiting, bloody discharge from rectum, abdominal neoplasm. Minimally invasive laparoscopic approach is advisable for diagnosis and treatment of intestinal intussusception.

[Videolaparoscopy in diagnosis and treatment of diseases simulating acute appendicitis]. / Vozmozhnosti videolaparoskopii v diagnostike i lechenii zabolevanii, simuliruiushchikh ostryi appenditsit.

AIM: To analyze videolaparoscopic diagnosis and treatment of abdominal pathology simulating acute appendicitis (AA). MATERIAL AND METHODS: For the period 2008-2015 at Sklifosovsky Research Institute of Emergency Care 2784 patients with suspected AA underwent clinical, laboratory and ultrasonic examination. Depending on survey results patients were divided into 2 groups. Group I included 1352 (48.6%) patients with AA, group II - 1432 (51.4%) patients with suspected AA. All of them underwent videolaparoscopy. RESULTS AND DISCUSSION: Videolaparoscopy confirmed AA in 1308 (96.7%) patients of group I and 856 (59,8%) patients of group II. In the 1st group 36 (2.7%) patients had pathology simulating AA and 8 (0.6%) patients had not organic changes; in the 2nd group these values were 462 (32.3%) and 114 (7.9%) respectively. Absence of organic changes was explained by functional bowel disorders. In 95 (3.4%) out of 498 (17.9%) patients of both groups with simulating diseases videolaparoscopy was made and in 49 (1.8%) cases indications for laparotomy were established. In 354 (12.7%) patients with simulating diseases and 122 (4.4%) patients without organic changes operations were not carried out. CONCLUSION: Videolaparoscopy in patients scheduled for appendectomy or with unclear clinical picture allows to diagnose various forms of AA, simulating diseases and to perform necessary surgery.

[External pancreatic fistulas management]. / Printsipy lecheniya bol'nykh s naruzhnymi pankreaticheskimi svishchami (s kommentariem).

The main principles of treatment of external postoperative pancreatic fistulas are viewed in the article. Pancreatic trauma was the reason of pancreatic fistula in 38.7% of the cases, operations because of acute pancreatitis - in 25.8%, and pancreatic pseudocyst drainage - in 35.5%. 93 patients recovered after the treatment. Complex conservative treatment of EPF allowed to close fistulas in 74.2% of the patients with normal patency of the main pancreatic duct (MPD). The usage of octreotide 600-900 mcg daily for at least 5 days to decrease pancreatic secretion was an important part of the conservative treatment. Endoscopic papillotomy was performed in patients with major duodenal papilla obstruction and interruption of transporting of pancreatic secretion to duodenum. Stent of the main pancreatic duct was indicated in patients with extended pancreatic duct stenosis to normalize transport of pancreatic secretion to duodenum. Surgical formation of anastomosis between distal part of the main pancreatic duct and gastro-intestinal tract was carried out when it was impossible to fulfill endoscopic stenting of pancreatic duct either because of its interruption and diastasis between its ends, or in the cases of unsuccessful conservative treatment of external pancreatic fistula caused by drainage of pseudocyst.

[Long-term results of severe acute pancreatitis management]. / Otdalennye rezul'taty lecheniya tyazhelogo ostrogo pankreatita.

AIM: To assess the long-term results and quality of life of patients after different medical and tactical approaches in treatment of severe acute pancreatitis. MATERIAL AND METHODS: Long-term outcomes were studied in 210 patients with severe acute pancreatitis for the period 2003-2013. There were 144 (68.6%) men. RESULTS: The quality of life of patients undergoing both aseptic (GIQLI - 112.9±1.3 points) and infected (GIQLI - 108.8±2.2 points) destructive complications of severe pancreatitis is lower (p=0.00001) compared with healthy population. Reccurence of acute pancreatitis was observed in 27.6% of patients. Diabetes mellitus developed in 40.5% and 23.6% of patients after infected and aseptic complications of severe pancreatitis respectively. Exocrine insufficiency was detected in 32.6% and 38.2% of patients who underwent aseptic and infected complications respectively. Postoperative hernia was observed in 30.8% of patients. Herewith, hernias (p<0.05) are predominantly formed after open operations (73,6%) than minimally invasive procedures (2.6%). Chronic pseudocyst was detected in 13.0% of patients after aseptic complications of severe pancreatitis and in 17.6% after infected complications. CONCLUSION: Quality of life and long-term outcomes are better in patients who were treated using only conservative methods and/or minimally invasive surgical interventions.

[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%.

[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.

[Mini-invasive technologies in treatment of acute cholecystitis in patients with high operational and anesthetic risk].

The treatment results of 769 patients with acute calculous cholecystitis and high operational and anesthetic risk at admission are presented in the retrospective study. High risk was determined by expressed comorbidities, diseases' terms, the complications of acute cholecystitis, age, which was more than 60 years in most cases. The patients were divided into 2 groups depending on the severity of comorbidity and the possible effects of its correction. The first group included 617 perspective patients for cholecystectomy. And the second group included 152 patients unpromising for this. Concept of stage treatment was used in the first group including primary decompression of the gallbladder by using of percutaneous transhepatic micro-cholecystostomy under ultrasound guidance. Cholecystectomy was performed after correction of comorbidities, complications of acute cholecystitis, and readjustment of extrahepatic bile ducts by endoscopy if necessary. Laparoscopic cholecystectomy was successfully performed in 587 patients. There was open cholecystectomy in 11 cases. Cholecystectomy was done in 19 patients as a result of conversion. Cholecystostomy from minimal access with extraction of stones under local anesthesia was performed in the second group for decompression and as definitive treatment. There was not observed deaths in patients with high operational and anesthetic risk as a result of such tactics. Postoperatively 1.7% of patients had complications that were successfully resolved.

[20 years emergency surgery of abdominal organs in Moscow].

The analysis of emergency surgical care in medical institution of Moscow for the last 20 years is presented in the article. There were 912 156 patients with acute appendicitis, strangulated hernia, perforated gastro-duodenal ulcer, gastro-duodenal bleeding, acute cholecystitis, acute pancreatitis, acute intestinal obstruction on treatment during this period. It was observed reduction overall and postoperative mortality. It was concluded that positive results are caused by development of material and technical base, transition on clock mode of diagnostic units, increase of patients? number hospitalized in department of intensive care for operation training and after it, using of modern diagnostic and therapeutic methods, edit documents regulating of health facilities activity according to medicine development.

[The combined endoscopic hemostasis in case of gastroduodenal ulcerative bleeding].

It was done the retrospective analysis of the endoscopic hemostasis effectiveness in 207 patients with gastroduodenal bleeding in the period from November 2011 to April 2013. The differential approach to the choice of hemostasis methods and consistency of their application were developed. It was done the comparative analysis of two- and three-stages combined hemostasis results. The analysis included the infiltration of the submucosal layer by 0.01% solution of adrenaline, argon-plasma coagulation and hemostatic glue applique.

[Tactics of treatment of the acute cholecystitis complicated by choledocholithiasis].

In this article is present the comparative analysis of the results of different surgical approaches of 201 patients with acute cholecystitis complicated by choledocholithiasis. In the 1st group of 70 (34.8%) patients in the first stage of treatment applied percutaneous cholecystostomies (PC). Retrograde endobiliary interventions endoscopic sphincterotomy (ES) were performed in the second stage before LC. In the 2nd group 131 (65.2%) patients underwent for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy (LC). The complications of retrograde interventions was higher by 3.5 times in the group of patients without prior decompression of the gallbladder. The surgical treatment was performed by 70 patients of the first group and by 79 (60.3%) patients of the second group. LC was performed by 66 (94.2%) patients with percutaneous cholecystostomies. Proved highly effective percutaneous cholecystostomy and low risk of complications stage treatment.