[Recurrent bacterial abscess of the left liver lobe caused by a foreign body (fish bone)]. / Retsidivnyi bakterial'nyi abstsess levoi poloviny pecheni, obuslovlennyi inorodnym telom (ryb'ya kost') ­ taktika rentgenokhirurgicheskogo lecheniya.

The authors present minimally invasive surgical treatment of recurrent liver abscess caused by migration of fish bone from the upper gastrointestinal tract. Two-stage treatment implied small-caliber transparietal drainage of abscess with evacuation of purulent detritus at the first stage. At the second stage, primary percutaneous approach was transformed into access of sufficient diameter for flexible or rigid optics for visually controlled bone extraction. Foreign body removal through the drainage tube with endoscopic capture under visual control is preferable regarding safety compared to removal under ultrasound and/or X-ray control. Indeed, endoscopic approach is valuable for optimal positioning of the object and prevention of damage to liver parenchyma during extraction.

Psychological Continuum of Elderly Patients Suffering from Arterial Hypertension with Metabolic Syndrome, Against the Background of Chronotherapy with a Fixed Combination of Amlodipine, Lisinopril and Rosuvastatin.

Aim        To study the psychological continuum in elderly patients with arterial hypertension associated with metabolic syndrome during the chronotherapy with a fixed combination (FC) of amlodipine, lisinopril, and rosuvastatin.Material and methods        In the inpatient conditions, 63 patients aged 60-74 years with arterial hypertension associated with metabolic syndrome were treated with chronotherapy with a FC of amlodipine, lisinopril, and rosuvastatin (5 / 10 / 10 mg/day in the evening). These patients composed the main group. The control group (58 patients aged 60-74 years with arterial hypertension associated with metabolic syndrome) was treated with the FC of amlodipine, lisinopril, and rosuvastatin at the same dose of 5 / 10 / 10 mg/day in the morning.Results   At one year, the disorders of psychological continuum were significantly decreased with the chronotherapy (evening dosing) with the antihypertensive FC of amlodipine, lisinopril, and rosuvastatin compared to the traditional treatment (morning dosing) at the same dose of 5 / 10 / 10 mg/day in both groups. With the chronotherapeutic approach, the dynamic of cognitive disorders in patients aged 60-74 years with arterial hypertension associated with metabolic syndrome was characterized by a significant increase in the Mini-Mental-State-Examination scale score from 17.8±0.3 at baseline to 23.5±0.4 with the evening dosing (р<0.001) vs. the increase from 16.9±0.3 to 20.4±0.4 (р<0.001) with the morning dosing. The situational anxiety score decreased from 40.0±2.2 to 30.6±1.8 (р<0.05) and from 40.8±2.5 to 33.5±1.9  (р<0.05), and the trait anxiety score decreased from 48.8±2.0 to 26.4±1.9 (р<0.001) and from 44.9±1.9 to 30.7±1.7  (р<0.01) with the evening and morning dosing, respectively. Depressive disorders slightly decreased with the chronotherapy by 14.1 % vs. 7.7 % with the traditional regimen; nevertheless, they were consistent with depressive spectrum disorders in both groups.Conclusion            The study results showed a higher effectiveness of the chronotherapeutic treatment compared to the traditional treatment with FC of amlodipine, lisinopril, and rosuvastatin in arterial hypertension with metabolic syndrome.

[Diagnostic and conservative treatment nuances in patients with obstructive jaundice: in the wake of Russian consensus].

The research was performed at the Loginov Moscow Clinical Scientific Center. It is based on Russian obstructive jaundice (OJ) consensus results, considered at the 45th annual Central Research Institute of Gastroenterology Scientific session Oncological issues in the gastroenterologist practice (1 March 2019). The article objective is to note the diagnostic and conservative treatment current issues in patients with OJ. The increase in the number of patients with OJ of different etiology provides problem actuality. In a large number of cases, medical treatment is delayed due to inadequate diagnostic and management, while correct patients routing today can be provided regardless of medical institution level. In this article the examination steps and conservative treatment role in patients with biliary obstruction management are presented.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]. / Rossiiskii konsensus po aktual'nym voprosam diagnostiki i lecheniya sindroma mekhanicheskoi zheltukhi.

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

[X-ray-surgery of diverticular disease complicated by abscess formation]. / Rentgenokhirurgiia divertikuliarnoi bolezni, oslozhnennoi abstsedirovaniem.

PURPOSE: Show the possibility of an alternative use of interventional radiology techniques in complex treatment of patients with inflammatory complications of the diverticular disease of the colon. MATERIAL AND METHODS: In 2012-2016, there were 87 patients under our supervision with complicated diverticular disease. In 57 (65.5%) cases were diagnosed infiltrate, in 24 (27.6%) cases - abscess of paracolon area (Ib-II type by Hinchey), in 6 (6.9%) cases (III-IV type according Hinchey) generalized peritonitis have been identified. RESULTS: Emergency laparotomy was performed in 13 patients. Abscesses of paracolon (Ib-II type by Hinchey) area were diagnosed sonographically during the initial examination in 17 patients. 26 percutaneous drainage of diverticulogenous abscesses of different localizations self-locking drainage #8Fr 'pig tail' was carried out under the combined ultrasonic and X-ray control in this group of patients. The technical success of percutaneous drainaging of the abscesses was achieved in all manipulations. 13 patients had a single drainaging, and for diverticular disease - disease-free during the observation period of 1 year to 5 years. Resection of the colon in a planned manner after percutaneous drainage of recurrent abscess of paracolon area was performed in 4 patients. Complications related with the technique of installing drainage were not reported, mortality in the group of drained patients was absent. CONCLUSION: Ultrasound examination of patients with suspected inflammatory complications of diverticular disease - a necessary and sufficient method for initial diagnosis of the disease. Percutaneous drainage of diverticulogenous abscesses (Hinchey Ib-II) is represented by the pragmatic 'first line' choice in patients with complicated diverticular disease, that allows to treat the pathology steadfastly in most of the cases.

[The development of diagnostic of acute endometritis on the basis of modeling and cluster analysis of parameters of local immunity.]

The acute endometritis provoking expressed disorders of local immunity is considered as one of the prevalent complications of postnatal period and abortions. The purpose of study is to develop diagnostic of acute endometritis on the basis of applied correlation modeling and cluster analysis techniques diagnostically priority-driven immunological indices of vaginal cervical mucus. The sample included main group (154 patients with acute endometritis) and control group (103 patients with uncomplicated post-natal period). Both groups were subjected to enzyme-linked immunosorbent assay to analyze content of immunoglobulins, components of complement and lysozyme in vaginal cervical mucus. The sampling of diagnostically significant indices was implemented using correlation and cluster analysis techniques. It is established that chief diagnostic indices of local immunity in case of acute endometritis are IG M, sIg A, С4 components of complement and lysozyme. The established diagnostically significant parameters of local immunity provide development of detection of acute endometritis according less number of indices.

[Percutaneous cholangiostomy for portal cholangiocarcinoma]. / Chreskozhnaya kholangiostomiya pri vorotnoi kholangiokartsinome.

AIM: to analyze the efficacy of interventional methods in treatment of Klatskin tumor patients. MATERIAL AND METHODS: Treatment of 133 patients with Klatskin tumor for the period 2000-2015 was analyzed. Bismuth I type was revealed in 28 (21.1%) cases, type II  - in 45 (33.8%) cases, type III - in 51 (38.3%) cases, type IV - in 9 (6.8%) cases. All patients underwent sonofluoroscopy-assisted percutaneous transhepatic cholangiostomy using self-fixing Pig tail 8Fr drains at the first stage followed by externointernal drainage or antegrade biliary stenting. We deployed 1-6 drains simultaneously or step by step depending on severity of biliary occlusion. RESULTS: Technical success was achieved in all patients. Major postoperative complication such as drain dislocation followed by advanced biliary peritonitis was observed in 1 (0.8%) case. Minor complications occurred in 22 (16.5%) patients. In-hospital mortality was 7.5% (10 patients). The cause of death was severe liver-renal failure. Liver abscesses occurred in 13 patients after transpapillary externointernal drainage on background of temporary occlusion of biliary drain. This required interventional surgery. CONCLUSION: Obstructive jaundice management should be performed using interventional techniques simultaneously or step by step if unresectable tumor or inoperable patient are present. Herewith it is advisable to restore bile flow in maximal volume of liver parenchyma. Use of uncovered self-expanding biliary stents for palliative treatment of Klatskin tumor may be realized in «hybrid¼ variant to control stent patency as well as for neoadjuvant therapy of tumor.

[Interventional radiology in treatment of biliodigestive anastomoses strictures].

AIM: To analyze efficacy of interventional methods via antegrade transhepatic approach in treatment of patients with strictures of biliodigestive anastomoses. MATERIAL AND METHODS: 24 patients aged 47.2 years were treated for the period 2002-2015. Average time from extrahepatic biliary reconstruction using transhepatic stented tubes to strictures appearance varied from 9 months to 12 years. One- and double-sided percutaneous transhepatic cholangiostomy was performed to abort biliary hypertension. Stricture recanalization was achieved using «catheter-wire¼ system. Antegrade dilatation of stricture was made using balloon catheter 8 mm and pressure up to 6 atm and stage exposition up to 10 minutes. Balloon repair of anastomosis was supplemented by stented outer-inner drainage of the area of stricture. RESULTS: Restoration of patency of stricture area using antegrade interventional methods was effective in 22 patients. Recurrent stricture occurred in 2 cases within 1.5 years that required repeated biliary reconstruction including antegrade extraction of blocked uncovered stent in 1 patient. There were no major postoperative complications and deaths. Maximal recurrence-free follow-up after stent installation was 11 years.

[Antegrade endobiliary interventions in undilated bile ducts]. / Antegradnye endobiliarnye vmeshatel'stva pri nerasshirennykh zhelchnykh protokakh.

AIM: To show advisability of antegrade transhepatic approach to bile ducts for benign and malignant biliary diseases if endoscopic technique is impossible or ineffective. MATERIAL AND METHODS: 38 patients underwent external biliary drainage followed by endobiliary interventions for the period 2009-2016. RESULTS: In all patients treatment was effective and included following manipulations: antegrade balloon dilatation of stricture of biliodigestive anastomosis, papillodilatation, antegrade dislocation of calculuses from common bile duct to duodenum. There were 2 cases of complications after antegrade interventions. 1 woman died from severe pancreatic necrosis. CONCLUSION: Percutaneous transhepatic cholangiostomy on undilated bile ducts is effective for temporary biliary drainage in closure of external duodenal or biliary fistula, treatment of intra-abdominal bilema. The method is indicated in elective endobiliary interventions for choledocholithiasis management, elimination of stricture of biliodigestive anastomosis of major duodenal papilla if endoscopic or conventional approaches are impossible or ineffective.

[Ultrasound and X-ray-cholangiography diagnostic of Mirizzi syndrome].

Objective: To improve the results of preoperative diagnosis of Mirizzi syndrome. Material and Methods: Under our supervision for 2006­2015 we had 23 patients with the Mirizzi syndrome. Verification of cholecystolithiasis, condition of gallbladder's wall and biliary tract dilatation degree was evaluated sonographically. Biliary decompression was realised by percutaneous transhepatic cholangiostomy that was implemented under the combined ultrasonic and X-ray control by the Seldinger technique for self-locking pigtail drainages 8 F. As a method for direct visualization of the bile ducts was used antegrade cholangiography. Results: Preoperative diagnosis was verified in 18 (78.3%) patients, based on the results of ultrasound and data of antegrade cholangiography. In I type of Mirizzi syndrome (prefistule form) was revealed a combination of non-standard ultrasonic symptoms: if there were signs of "high" extrahepatic block of bile ducts (area of liver gate and confluence of hepatic ducts) there was recorded actual intravesical bile hypertension. Lack of lymphadenopathy near the choledoch and focal lesions of liver parenchyma in the goal area confirmed the benign character of the "high" bile ducts block. II type of Mirizzi syndrome (fistula form) was characterized by the presence of megacholelitiasis combined with a lack of intravesical bile hypertension. Antegrade cholangiography in combination with intra-ductal diagnostic catheters and manipulation wires and in some cases with cholecystography allowed to differentiate types of Mirizzi syndrome. In 5 cases Mirizzi syndrome was an intraoperative finding. Antegrade minimal-invasive access to the biliary tree was used in patients with high risk of surgery for subsequent X-ray interventions (lithotripsy, balloon dilatation of major duodenal papilla, dislocation of stones to the duodenum). Conclusions: Effective preoperative diagnosis of Mirizzi syndrome can be successful more than in half cases of the combined use of ultrasonography of the biliary tract and the results of antegrade dynamic cholangiography. That was carried out through percutaneous transhepatic cholangiostomy in conjunction with additional diagnostic intraluminal manipulations (wires and catheter inspection and palpation).

[Possibilities of endoscopic surgery in treatment of chronic venous insufficiency of the lower extremities].

The authors present their experiences with endoscopic dissection of perforating veins in patients with severe forms of chronic venous insufficiency with special reference to the peculiarities of blood supply of the extremity superficial tissue. The generalized morphological description of the perforating arteriovenous structures of the leg is presented as a vascular formation including the arteries and veins put in the general connective-tissue vagina and beginning from the profound or/and muscular veins and arteries. Operations were made on 56 patients aged 25-76 years, 40 of them had postthrombotic disease, 16 - varicose disease. The endoscopic subfascial dissection of the perforating veins was conducted using the standard set of tools for laparoscopic surgery of K. Storz Company. During the surgical procedure the perforating vascular bunch in the subfascial space was isolated, the veins were intersected electrosurgically, the other parts of the vascular bunch were preserved. On the average, the patients were in the hospital for 7+/-2 days. Trophic ulcers healed up during 7-30 days. Long-term results were good in 30%, satisfactory in 64%, unsatisfactory - in 6%. So, the selective endoscopical dissection of perforating veins is thought to be a radical, minimally invasive, anatomically and functionally reasonable method of elimination of the horizontal venous blood regurgitation. This technique resulted in a considerably decreased number of postoperative complications and less time of hospital treatment.

[Minimally invasive surgery of liver abscesses]. / Maloinvazivnaia khirurgiia abstsessov pecheni.

Results of the examination and treatment of 49 patients with abscesses of the liver are presented. Clinical-laboratory findings, specific features of localization, sizes and genesis of the disease are described. The criteria of the conservative and open surgical methods of treatment of abscesses of the liver are established, the advantages and shortcomings of USI for diagnosis of the disease are shown. An analysis of the data obtained allowed a conclusion that the percutaneous drainage under the ultrasonic control is an effective and perspective method of treatment, but requires further investigation, improvement and wide introduction into practice.