[Synchronous left atrial myxoma and gastric cancer: a case report]. / Sinkhronnye miksoma levogo predserdiya i rak zheludka. Klinicheskii sluchai.

The authors present a 57-year-old patient with synchronous left atrial myxoma and gastric cancer undergoing staged treatment. Distal gastrectomy with gastroduodenostomy at the first stage was followed by resection of the left atrial myxoma after 22 days. Postoperative period was uneventful after both interventions. The follow-up examination revealed favorable clinical status and no cancer progression.

Long-Term Results of the First Clinical Application of Stereotactic Radioablation Using a Linear Electron Accelerator for the Treatment of Ventricular Tachycardia.

We present the first clinical application of non-invasive stereotaxic radioablation of ventricular tachycardia (VT) refractory to medical and surgical treatment. Based on the results of invasive navigational activation mapping, a pericicatrical zone in the interventricular septum associated with VT was verified. Radiosurgical irradiation of the target in the region of the interventricular septum and the posterior apical segment of the left ventricle was performed on a TrueBeam linear electron accelerator (Varian) in accordance with the segmental scheme of the left ventricle. Irradiation doses for 95% of the internal target volume (ITV, 17 cm3) and planned target volume (PTV, 46 cm3) (31.2 and 25 Gy, respectively) were delivered by two full coplanar arches in 1 session. Irradiation was performed during expiration using a respiratory control system. The loading dose to critical structures was within tolerance. The planned follow-up period is 6 months. According to remote monitoring, the intensity of VT paroxysms over 48 days after treatment was from daily to 2-3 per day. Then, the incidence of VT paroxysms decreased (1-3 per week), and from the 64th to the 185th day (the end of the observation period), no VT paroxysms were recorded, which suggests that the impact was highly precise, conformal, and involved the total wall thickness. No undesirable effects and damage to adjacent organs were observed.

[Mortality in acute appendicitis in Russia]. / Letal'nost' pri ostrom appenditsite v Rossii.

OBJECTIVE: To analyze the causes of mortality in patients with acute appendicitis in Russia. MATERIAL AND METHODS: We retrospectively studied mortality in patients with acute appendicitis in the Russian Federation in 2020. We surveyed the hospitals with mortality reported in the electronic database of annual reports to the chief surgeon of the Ministry of Health of the Russian Federation. RESULTS: There were 259 deaths among 150.393 patients with acute appendicitis aged ≥18 years (in-hospital mortality 0.17%). We obtained data about 95.8% (n=248) of lethal cases including 86.3% (n=214) complicated and 13.7% (n=34) uncomplicated forms of disease. Two patients died without surgery (0.8%). Among the deceased, 58.2% (n=145) were men and 41.8% (n=103) were women. Mean patient age was 66.2 years [0.95% CI 64.2-68.1]. The main cause of death in complicated appendicitis was late presentation (after 4.9 days [0.95% CI 4.3-5.4]) that resulted peritonitis and sepsis in 71.5% (n=153) of patients. Cardiovascular diseases were noted in 23.4% (n=50) of cases. A new coronavirus infection was detected in 7.0% (n=15) of patients. However, COVID-19 as a direct cause of death was recognized in 2.8% (n=6) of cases. Other reasons accounted for 2.3% (n=5). In uncomplicated appendicitis, cardiovascular diseases were the main cause of mortality (73.5%, n=25). Peritonitis and sepsis were found in 11.8% (n=4) of cases, COVID-19 - in 5.9% (n=2). Other causes accounted for 8.8% (n=3). Diagnostic, tactical, technical problems and their combination were revealed in 54.4% of lethal outcomes. CONCLUSION: Mortality from acute appendicitis in the Russian Federation is low, comparable with international data, and mainly associated with delayed treatment and complicated course of disease. However, the impact of diagnostic, tactical and technical errors on the outcome of acute appendicitis is significant.

[Endovascular treatment of delayed arterial bleeding after pancreatic surgery: single-center experience]. / Rezul'taty rentgenendovaskulyarnogo lecheniya pozdnego arterial'nogo krovotecheniya posle operatsii na podzheludochnoi zheleze. Opyt odnogo tsentra.

OBJECTIVE: To evaluate technical aspects and clinical results of transcatheter arterial embolization (TAE) for delayed postoperative arterial bleeding after pancreatic surgery. MATERIAL AND METHODS: There were 821 pancreatectomies between 2012 and 2020. Delayed bleeding occurred in 106 (12.9%) patients; 74 patients were included in the study. Previous pancreatic head resection was carried out in 75.7% of cases, pancreatic body resection - in 17.6% of cases, pancreatic tail resection - in 6.8% of patients. Primary endpoint was technical success of TAE, secondary endpoints - complications after TAE, as well as recurrent bleeding after embolization. RESULTS: Angiography of celiac-mesenteric arterial system was performed in 74 patients (91 procedures). The most common sources of bleeding were gastroduodenal and superior mesenteric arteries (35.7%), jejunal arteries (13.1%), common hepatic artery (11.9%). Combination of embolization agents was applied for TAE (metal coils and non-calibrated PVA particles, 48.6%). In 11 (14.9%) patients, we applied stent-grafts. Technical success rate was 100%. Recurrent bleeding occurred in 13 (17.6%) patients. In-hospital mortality was 12.2% (n=9). CONCLUSION: TAE is an effective treatment procedure in patients with arrosive bleeding. This method is characterized by high technical efficiency and low in-hospital mortality, but it does not affect recurrence of bleeding.

Development of Noninvasive Technology of Stereotaxic Radioablation Using Linear Accelerators for the Treatment of Life-Threatening Ventricular Tachycardias in Experiment.

We developed a new technique of noninvasive stereotactic radioablation for the treatment of life-threatening tachyrhythmias. The study is performed on pigs (Sus scrofa domesticus). The zones of planned exposure were atrioventricular node (heart loading dose 40 Gy) and the apex of the left ventricle with a part of the interventricular septum (35 Gy) in animal No. 1 and atrioventricular node (45 Gy) and free wall of the left ventricle (40 Gy) in animal No. 2. The study was conducted on the Varian TrueBeam linear accelerator. The planned follow-up duration was 6 months. Delivery of 40 Gy to the atrioventricular node did not lead to persistent electrophysiological effect due to the development of transient third-degree atrioventricular block. The dose of 45 Gy resulted in permanent third-degree atrioventricular block followed by development of ventricular standstill on day 21 of observation. Histological examination confirmed transmurality and high precision of performed intervention.

[Surgical care in the Russian Federation during the pandemic - the main results of 2020]. / Khirurgicheskaya pomoshch' v Rossiiskoi Federatsii v period pandemii ­ osnovnye itogi 2020 goda.

OBJECTIVE: To study the impact of the SARS-CoV-2 pandemic on surgical care in the Russian Federation. MATERIAL AND METHODS: A retrospective cohort study of surgical care in state medical organizations of the Russian Federation in 2020 was conducted in comparison with 2019. The electronic database of the annual reports of the Chief surgeon of the Ministry of Health of the Russian Federation was used, which includes data from 3.232 surgical departments and 413 outpatient clinics in all regions of the country. The main working hypothesis of the study: during the COVID-19 pandemic, the number of hospitalizations to general surgical departments decreases, but the hospital and postoperative mortality for any reason increases both in emergency and elective surgery. RESULTS: During the pandemic, the number of hospitalizations of patients with surgical diseases decreased by 21.0%. At the same time, there was a significant increase in mortality among the entire population of patients in surgical hospitals. Surgical activity decreased, but the share of minimally invasive operations increased and there was no predicted increase in the share of late treatment in emergency surgery. The percentage of planned operations decreased by 40.8%, and the increase of postoperative mortality was registered at the same time. CONCLUSION: The presented data may be valuable for surgical care managers in emergency situations such as the COVID-19 pandemic. The long-term negative consequences of the pandemic for surgical practice are still difficult to evaluate.

[History of development of ventricular arrhythmias diagnostics].

This review shows historical steps in the development of topical diagnostics for ventricular arrhythmias, the current status of this issue, and the relevance of developing topical, noninvasive electrophysiological cardiac mapping.

Reproducibility of CT texture features of pancreatic neuroendocrine neoplasms.

PURPOSE: To evaluate the reproducibility of textural features of pancreatic neuroendocrine neoplasms (PNENs), obtained under various CT-scanning conditions. METHODS AND MATERIALS: We included 12 patients with PNENs and 2 contrast enhanced CT (CECT): 1) from our center according to standard CT-protocol; 2) from another institution. Two radiologists independently segmented the entire neoplasm volume using a 3D region of interest by LIFEx application on the arterial phase and then copied it to the other phases. 52 texture features were calculated for each phase. As a criterion for the segmentation consistency, a value of neoplasm volume was compared using the Bland-Altman method. The Kendall concordance coefficient was calculated to assess the texture features reproducibility in three scenarios: 1) different radiologists, same CECT; 2) same radiologist, different CECT; 3) different radiologists, different CECT. RESULTS: For the scenario 1 the neoplasm volumes (except one large PNEN) were found within two standard deviations; this indicates high consistency of the segmentation. For the first scenario, Kendall's coefficient exceeded a threshold of 0.7 for all 52 features for all CT phases. For the second and third scenario, the concordance coefficient exceeded a threshold of 0.7 in 38, 28, 42, 45 and in 36, 25, 36, 44 features for the native, arterial, venous and delayed phases, respectively. CONCLUSION: The highest reproducibility was found in the first scenario compared to the second and third: 100 % vs. 74 % and 67 %. Reproducible texture features can be reliably used to assess the PNENs structure.

[Current trends in emergency abdominal surgery in the Russian Federation]. / Sovremennye tendentsii v neotlozhnoi abdominal'noi khirurgii v Rossiiskoi Federatsii.

OBJECTIVE: To analyze morbidity and factors affecting mortality in emergency abdominal surgery in the Russian Federation. MATERIAL AND METHODS: The study included patients with acute abdominal diseases aged 18 years and older. All patients were hospitalized in emergency surgical care departments of 3.194 state healthcare institutions in 84 regions of the Russian Federation in 2018. Morbidity, surgical activity and mortality were analyzed. RESULTS: There were 680.337 cases of hospitalization in emergency surgical department, morbidity rate was 582 cases per 100 000. The most common emergency surgical diseases were acute appendicitis (142.3 cases per 100 000), acute cholecystitis (139.0 cases per 100 000) and acute pancreatitis (131.2 cases per 100 000). Surgery was performed in 399.051 (58.7%) patients. In-hospital mortality rate was 2.4% (16 051 cases). CONCLUSION: There are certain factors affecting mortality rate in acute abdominal diseases. The leading problems in organizing emergency surgical care in Russia are insufficient equipment of rural and small municipal surgical hospitals, different staffing with surgeons in rural areas and large cities and late hospitalization of patients.

Assessment of Biocompatibility and Local Action of Biomaterial for Production of an Envelope for Implanted Heart Electronic Devices.

We studied a biomaterial for a new domestic product, a biological envelope for implantation of cardiac electronic devices. The product is designed to prevent complications after pacemaker implantation and to facilitate the reimplantation procedure. By chemical and biological processing of raw materials (submucosa of porcine small intestine), an acellular extracellular collagen matrix was obtained. The biocompatibility of the material was tested in vitro using stem cell cultures. The biomaterial for fabrication of the envelope is not cytotoxic, biocompatible, and represents a suitable substrate for attachment, growth, and reproduction of stem cells. The biological effect of the material was studied in vivo on the model of heterotopic implantation in small laboratory animals. The biomaterial did not induce inflammation and tissue reaction and was completely transformed into healthy vascularized tissue without scars in 90 days after implantation.

[Modern trends in development of surgical and endovascular treatment of patients with arterial pathology]. / Sovremennye tendentsii razvitiia khirurgicheskogo i éndovaskuliarnogo lecheniia bol'nykh s arterial'noi patologiei.

The last decade has seen distinct dynamics of the worldwide growth of the number of endovascular interventions and a decrease in the number of 'open' surgical operations for pathology of the aorta and peripheral arteries. The world trends of treatment of patients presenting with pathology of the aorta and peripheral arteries are indicative of a steadily growing amount of operations, most of which are performed in an endovascular manner. In the Russian Federation, the past decade has also witnessed a noticeable jump of the amounts of endovascular interventions. Thus, the number of operations from 2008 to 2017 increased from 15 094 to 37 109 (2.5-fold). Nevertheless, in Russia there is a significant lag in both the total amount and the ratio of the performed surgical and endovascular operations in patients with pathology of the aorta and peripheral arteries. The article analyses the world and Russian trends in the development of surgical and endovascular treatment of patients with pathology of the aorta and peripheral arteries.

[Combined thoracoplasty using titanium mesh implant in patients with total sternal instability following postoperative sternomediastinitis]. / Kombinirovannaia torakoplastika setchatym titanovym éndoprotezom u patsientov s total'noi nestabil'nost'iu grudiny v iskhode khronicheskogo posleoperatsionnogo sternomediastinita.

OBJECTIVE: To analyze the results of chest wall reconstruction with titanium mesh implant in patients with total sternal instability following postoperative sternomediastinitis. MATERIAL AND METHODS: There were 100 patients with total sternal instability for the period from January 2016 to December 2018. Median of age was 62 (58; 68) years. Male/female ratio was 82/18. All patients were treated in accordance with standardized protocol. Postoperative complications were assessed using Clavien-Dindo scale. Staged surgical treatment including one or more debridement procedures before the final thoracoplasty was performed in 62 (62%) out of 100 patients. Aseptic sternal instability was observed in 38 patients. RESULTS: Follow-up period ranged from 3 weeks to 35 months after the final thoracoplasty. Complicated postoperative period occurred in 15 (15%) out of 100 patients (95% CI 9.3-23.3). One patient died in 9 days after surgery from acute heart failure. Complications without need for redo surgery, postoperative wound suppuration and seroma were noted in 3 patients. Redo surgery was required in 11 patients due to postoperative wound suppuration, eventration after thoracoomentoplasty, intermuscular hematoma and delayed divergence of major pectoral muscles. Removal of mesh implant was performed in 1 out of 100 patient (95% CI 0.2-5.5) in 7 days after surgery due to suppuration. There was no recurrent sternal instability within 30 days. CONCLUSION: Anterior chest wall reconstruction using titanium mesh implant is an effective and safe procedure in patients with postoperative sternal instability following postoperative sternomediastinitis.

[Emergency surgery in Russian Federation (in Russian only)]. / Sostoianie ékstrennoi khirurgicheskoi pomoshchi v Rossiiskoi Federatsii.

In the following article, we present the key trends in emergency surgical care in the Russian Federation between 2000 and 2017. The study used data from federal statistical observations and a survey of state medical institutions in 80 regions encompassing 99.3% of the country's population. We discovered a change in the correlation between acute abdominal diseases, particularly a significant reduction in the occurrence of acute appendicitis and perforated peptic ulcer. Reduction in the number of emergency surgeries by 27.8% annually was also observed. Mortality rate decreased in cases of strangulated hernia, acute cholecystitis and acute pancreatitis, while it is stable for bowel obstruction and acute appendicitis and increasing in perforated peptic ulcer cases. The total annual number of lethal outcomes due to acute abdominal diseases was decreased by 1900 cases. Significant changes were observed in mortality rate and minimally invasive surgeries proportions between federal districts and individual regions of the country. The range of administrative measures was proposed.

[Diagnosis and treatment of pancreatic head cancer followed by mesenteric-portal vein invasion]. / Diagnostika i lechenie raka golovki podzheludochnoi zhelezy, prorastaiushchego mezenteriko-portal'nyi segment ven.

AIM: To evaluate the outcomes of pancreaticoduodenectomy with mesenteric-portal vein resection for pancreatic head cancer. MATERIAL AND METHODS: Retrospective analysis included 124 patients with pancreatic head cancer for the period 2010-2017. Mesenteric-portal vein (MPV) invasion was diagnosed in 37 (29.8%) patients, tumor contact with superior mesenteric artery as a borderline resectable state was noted in 11 cases. All patients underwent pancreaticoduodenectomy with mesenteric-portal vein resection. RESULTS: Vein invasion was histologically confirmed in 19 (51.3%) out of 37 patients. At the same time, arterial invasion was absent in 11 patients with a borderline resectable tumor. CT-associated overdiagnosis of venous wall invasion was 6.4%, intraoperative overdiagnosis - 87.5%. R0-resection was achieved in 88.5% after conventional pancreaticoduodenectomy and in 78.4% after pancreaticoduodenectomy followed by MPV resection. Median survival was 17 months, 2-year survival - 41%. Among 11 patients with a borderline resectable tumor median survival was 11 months. Pancreaticoduodenectomy without vein resection was followed by 2-year survival near 68.1%. Differences were significant (p=0.02). CONCLUSION: Pancreaticoduodenectomy followed by MPV resection as the first stage of combined treatment of pancreatic head cancer is absolutely justified if circumferential involvement of the vein and contact with superior mesenteric artery or celiac trunk do not exceed 50%. Vein resection can provide R0-surgery in these cases.

[Current issues in pancreatic surgery]. / Aktual'nye voprosy khirurgii podzheludochnoi zhelezy.

AIM: To present own experience of pancreatic surgery and to analyze literature data for this issue. MATERIAL AND METHODS: We have analyzed work of abdominal surgery department over the last 5 years. Moreover, MEDLINE and RSCI databases regarding surgical treatment of pancreatic diseases were assessed. RESULTS: There were 456 pancreatectomies. Postoperative complications arose in 176 (38.6%) patients, 11 patients died (2.4%). According to world data, mortality after pancreatectomy reaches 10%. Only creation of specialized centers is proven way to improve the outcomes. CONCLUSION: Current medical assistance for pancreatic disease may be only achieved in specialized centers with large number of various pancreatic procedures. The organization of such centers is required throughout the country and certain accreditation criteria should be developed for this purpose. Targeted routing of patients to specialized pancreatology centers will be able to reduce incidence of diagnostic, tactical and technical errors.

[Infectious complications after endoprosthetic repair of the thoracic aorta]. / Infektsionnye oslozhnenii pri éndoprotezirovanii grudnoi aorty.

Presented herein is a review of publications of foreign authors on the problem of infectious complications after endoprosthetic repair of the thoracic aorta. The problem discussed is of current importance, however in the Russian literature it is covered insufficiently. The article contains the data on frequency, terms and possible causes of the development of complications, also discussing the problems of diagnosis. The authors demonstrate extreme danger of infection of an aortic stent graft, difficulty of early diagnosis and mostly unsatisfactory therapeutic outcomes. Also noted are possible ways of prevention of complications and aimed at improving the results of this extremely severe patient cohort.

[Endovascular procedures in pancreatic surgery]. / Éndovaskuliarnye vmeshatel'stva v khirurgii podzheludochnoi zhelezy.

AIM: To evaluate an effectiveness of endovascular techniques in pancreatic surgery. MATERIAL AND METHODS: For the period 1995-2017 at Vishnevsky Institute of Surgery endovascular treatment (EVT) was applied in 51 patients with chronic pancreatitis complicated by false aneurysms (FA) and postoperative hemorrhage after pancreatectomy. Various methods of embolization and stenting were used in 24 and 11 cases respectively in order to exclude FA of celiac trunk and superior mesenteric artery from blood flow. Endovascular hemostasis for postoperative hemorrhage was carried out with embolization of damaged vessel in 11 patients. Stent-grafts were deployed in 5 patients with marginal defect of the wall of hepatic/superior mesenteric arteries. RESULTS: In all 35 patients with chronic pancreatitis complicated by false aneurysms EVT ensured thrombosis of the aneurysm's cavity. EVT was final in 14 patients with FA and absent communication with pancreatic duct. Radical surgical treatment was required after 7-10 days for FA communicated with pancreatic duct due to lysis of thrombotic masses by pancreatic enzymes. Spleen infarction was diagnosed in 3 patients. Two of them did not require treatment while 1 patient underwent splenectomy in view of splenic abscess. 1 patient died from liver cirrhosis followed by severe hepatic failure, death was not associated with bleeding. In 16 patients with post-pancreatectomy bleeding hemostasis was achieved in all cases with EVT. However, recurrent bleeding occurred in 2 patients who underwent successful redo endovascular intervention. Complications after EVT were observed in 2 patients: duodenal wall necrosis followed by fistula which was closed spontaneously (n=1); advanced intestinal infarction (n=1) followed by fatal outcome; pulsating hematoma within cubital fossa that required brachial artery ligation and autovenous bypass. CONCLUSION: EVT provides thrombosis of FAs of celiac trunk and superior mesenteric artery branches in patients with chronic pancreatitis, as well as hemostasis for postoperative bleeding after pancreatectomy.

The Case of Successful Surgical Treatment of a Patient With Thoracic Endograft Infection in 5 Years After Thoracic Endovascular Aortic Repair.

We present here a case of successful staged treatment of a patient with para-aortic abscess that arose 5 years after thoracic endovascular aortic repair because of thoracic aortic aneurysm. After stabilization of the patient's condition by intensive antibiotic therapy we performed left-subclavian extra-thoracic debranching as the first stage of the surgical treatment. In 2 weeks via median sternotomy and on-pump we removed the infected endograft and performed extraanatomical ascending-to-descending aortic bypass with good postoperative result.

[Morphological features of the myocardium of the atrial appendages in patients with different forms of atrial fibrillation]. / Morfologicheskie osobennosti miokarda ushek predserdii u patsientov s raznymi formami fibrilliatsii predserdii.

AIM: to analyze the morphological features of the myocardium of the atrial appendages in patients with different forms of atrial fibrillation (AF) and to compare the findings with the clinical parameters of patients. MATERIAL AND METHODS: Light and electron microscopies were used to examine the myocardium of the atrial appendages in adult patients with paroxysmal (PAF), persistent (PrAF), or long-standing persistent atrial fibrillation (LPAF) and in comparison group patients with sinus rhythm without history of AF. A morphometric method was employed to evaluate myocardial fibrosis and to measure the diameter of cardiomyocytes (CMCs); the degree of lipomatosis and amyloidosis was semiquantitatively determined; and the content of CMC myofibrils was estimated. Atrial natriuretic peptide content in the myocytes was measured by immunoconfocal microscopy. RESULTS: In all groups, the patients with AF were found to have signs of atrial structural remodeling: fibrosis, lipomatosis, isolated atrial amyloidosis, CMC hypertrophy with the phenomena of a partial loss of myofibrils without significant differences between these parameters in different groups. In PAF patients, atrial remodeling was accompanied by hypertrophy of a number of CMCs with their higher myofibrilar mass; the increased CMC size in the left atrial appendage prevented left atrial enlargement; the degree of amyloidosis negatively correlated with the CMC myofibrillar loss that was recorded in the minor CMCs; the degree of CMC myolysis positively correlated with mitral valve insufficiency and left atrial enlargement. In contrast to the clinical and morphological changes that are typical of PAF, in LPAF the increase in CMC sizes was positively correlated with left atrial enlargement and mitral annular dilatation; while the myofibrillar loss phenomenon was noted in the most hypertrophied CMCs; the degree of amyloidosis was positively correlated with CMC myofibrillar loss. In the patients with PrAF, the size of CMCs did not correlate with their myofibril content. CONCLUSION: The patients with PAF were ascertained to have opposite changes in the ratio of CMC hypertrophy to left atrial enlargement, amyloidosis, and CMC myofibrillar loss, hypertrophy of CMCs and their myofibril content in comparison with these indicators in LPAF.

[Haemangioma of the left atrium]. / Gemangioma levogo predserdiia.

Presented herein is a clinical case report concerning successful surgical management of a rare variety of a primary tumour of the heart, i. e., a capillary haemangioma of the left atrium, simulating by the contours and localization a myxoma. The final diagnosis was verified only by histological examination. The authors describe difficulties of diagnosis of the disease involved, underlying the necessity of plastic correction for restoration of the normal anatomical configuration of the heart. This is followed by a review of the literature, reflecting a possible course of the disease, problems of diagnosis, and therapeutic policy.