[Laparoscopic transchiatal access in Boerhaave syndrome]. / Laparoskopicheskii transkhiatal'nyi dostup pri sindrome Burkhave.

Diagnosis of spontaneous rupture of the esophagus (Boerhaave syndrome) followed by purulent mediastinitis and pleural empyema has now been greatly simplified due to CT. The main thing is to suspect this syndrome in a timely manner. Methods of surgical treatment of this disease are still being discussed. We present successful laparoscopic treatment of spontaneous rupture of the esophagus.

[Diagnostic and treatment approaches for acute appendicitis in the Russian Federation. Results of the all-Russian survey]. / Diagnosticheskie i lechebnye podkhody pri ostrom appenditsite v praktike khirurgov Rossiiskoi Federatsii. Rezul'taty obshcherossiiskogo oprosa.

OBJECTIVE: To improve treatment outcomes in patients with acute appendicitis (AA). MATERIAL AND METHODS: An internet survey was performed. Questionnaire consisted of 15 questions concerning diagnosis and treatment of AA: application of prognostic scales, incidence and technical aspects of laparoscopic appendectomy (LA), antibiotic prophylaxis, postoperative management, compliance with international and national clinical guidelines. A total of 690 questionnaires were received and analyzed (3.67% of all surgeons in the Russian Federation). RESULTS: Eighteen percent of respondents use at least one prognostic scale. The vast majority of surgeons (92%) use antibiotic prophylaxis. Almost half of respondents place trocars in the triangulation position (44%), one third of surgeons ligate the mesentery of the appendix (35%), most respondents perform mesoappendectomy (60%) with monopolar and bipolar cautery. Forty-five percent of all respondents do not invert the appendix stump. Significant number of respondents use abdominal drainage routinely. Only 3.5% of surgeons use multimodal postoperative analgesia. Less than 22% of patients are operated under low-pressure pneumoperitoneum. Standardization of surgical technique and perioperative approaches including those specified in the guidelines is absent. We also found insufficient awareness of surgeons about international and national clinical guidelines. CONCLUSION: This study may be useful for standardizing treatment approaches, choosing the best practice, popularizing and improving of current clinical guidelines.

[Acute appendicitis during pregnancy]. / Ostryi appenditsit u beremennykh.

Acute appendicitis is the most frequent surgical disease complicating pregnancy. Accurate diagnosis is difficult due to atypical and misleading clinical manifestations. Surgeons frequently do not know about advantages and disadvantages of different diagnostic methods applied during pregnancy. Treatment of acute appendicitis in pregnant women remains the real challenge for surgeons. There are enough researches indicating on benefits and risks of both open and laparoscopic operations. The main risk is due to fetal loss after laparoscopic procedure. Safety of diagnostic techniques and laparoscopic procedures, surgical tactics and independent risk factors of pregnancy loss are touched in the article.

Polymorphism of Matrix Metalloproteinases Genes MMP1, MMP2, MMP3, and MMP7 and the Risk of Varicose Veins of Lower Extremities.

We studied the effects of single nucleotide polymorphisms in the promoter regions of matrix metalloproteinase genes rs1799750 (-1607dupG) MMP1, rs243865 (C-1306T) MMP2, rs3025058 (-1171dupA) MMP3, and rs11568818 (A-181G) MMP7 on the risk of varicose vein of the lower extremities in ethnical Russians, residents of the Russian Federation. We genotyped 536 patients with this pathology and 273 healthy participants without history of chronic venous disease. Association was examined using logistic regression analysis. None of the studied polymorphisms showed statistically significant association with the risk of varicose veins of the lower extremities. Our results provide evidence that these polymorphisms are not involved in the pathogenesis of varicose veins and cannot serve as markers of predisposition to this pathology.

Polymorphic Variants rs13155212 (T/C) and rs7704267 (G/C) in the AGGF1 Gene and Risk of Varicose Veins of the Lower Extremities in the Population of Ethnic Russians.

We analyzed associations between single nucleotide polymorphisms (SNP) rs13155212 and rs7704267 in the AGGF1 gene (angiogenic factor with G patch and FHA domains 1) and the risk of risk of varicose veins of the legs in ethnic Russians. Frequencies of alleles, genotypes, and haplotypes were estimated in the sample of patients with this disease (474 patients) and in the control group of participants (478 volunteers) without a history of chronic venous disease. None of the studied polymorphisms was associated with the risk of this pathology. The whole AGGF1 gene sequence lies in a single block of high linkage disequilibrium, and both studied polymorphic variants are representative of all other SNP within this region. From these results, a conclusion was made that AGGF1 gene polymorphism does not affect the risk of varicose veins of the legs in ethnic Russians, or its contribution is low and can be revealed only after analysis of larger cohorts.

[Incidence of abdominal wall hernias: the results of population study]. / Rasprostranennost' gryzh perednei bryushnoi stenki: rezul'taty populyatsionnogo issledovaniya.

AIM: to define the incidence of abdominal wall hernias among ethnically homogeneous population older than 10 years within single locality. MATERIAL AND METHODS: One-stage investigation of abdominal wall hernias incidence was performed in June-July 2015 in the Kryukovskoye rural settlement of the Borisovskiy district of the Belgorod region. Citizens were examined in FAPs or at home. Specially designed questionnaire was used for every person. Presence of hernia was confirmed by clinical signs or anamnestic data about previous abdominal wall repair. RESULTS AND DISCUSSION: 783 (86.6%) persons were surveyed. There were 298 (38%) men and 485 (62%) women among them aged 10-90 years. Clinical signs or anamnestic data were revealed in 164 (20.9%) persons. Inguinal (n=80, 10.2%) and umbilical (n=65, 8.3%) hernias were predominant. Postoperative ventral hernia was diagnosed in 19 (2.4%) humans. CONCLUSION: Incidence of abdominal wall hernias was 20.9% in our study.

[Clinical diagnosis and prognosis of pulmonary thromboembolism].

Pulmonary thromboembolism (PTE) is a nosological entity that complicates the course of many diseases. This circumstance determines difficulties in the diagnosis and determination of further patient management tactics. Bolus-enhanced computed tomography of pulmonary arteries, a method having high resolution and high accuracy, is presently accepted to be the gold standard to verify the diagnosis. At the same time this radiocontrast study cannot be used as a screening tool by economic and other reasoning, which determines the importance of the clinical diagnosis of the disease. This review considers different approaches to diagnosing PTE and a base of elaborated clinical algorithms and comparatively assesses empirical and scoring systems for the diagnosis and prediction of a disease course characterized by the rapidness and unpredictability of an outcome even in correctly made diagnosis.

["Evidance"--Russian national epidemiological study].

UNLABELLED: The article deals with results of epidemiological study of 2516 ICU patients received prophylaxis of a deep vein thrombosis (DVT) and venous thromboembolic complications (VTEC). RESULTS: The frequency of renal failure was 19.8%. Mortality rate in patients with acute renal failure (ARF) was 34% and in patients without ARF 17%. CONCLUSIONS: An analysis of drugs for prophylaxis of DVT and VTEC which were used in patients with ARF showed that the prophylaxis was performed without a taking in account a significance of such complication.

[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.

[How real is the prevention of postoperative venous thromboembolic complications].

The article represents the results of the Study "The safety territory of venous thromboembolic complications". 59 surgical hospitals took part in the multi-centered study. The risk assessment of the venous thromboembolic complications and prevention measured were analyzed in 53, 596 patients.

[Lower limb varicose disease in men and women: findings of prospective study SPECTRUM].

AIM: The study was aimed at comparing peculiarities of varicose disease, its complications, treatment policy in men and women. MATERIAL AND METHODS: The prospective observational study SPECTRUM follows up a total of 866 patients with venous chronic disease. Of these, 615 were found to have varicose disease (VD) (486 (79.0%) women and 129 (21.9%) men). The patients' age varied from 12 to 83 years old (mean age 46.1, median 46). The body weight index ranges from 15.7 to 62.0 (average 27.2, median 26.0). The duration of the disease from the moment of being included into the program ranges from 0.1 to 53 years (mean 14.5, median 11, interquartile range from 5 to 20). RESULTS: No differences by age, body mass index were observed. Men consulted the phebologist averagely at earlier stages of the disease onset (after 10.9 years as compared with 15.5 years for women; p=0.00001). The frequency of detecting subjective symptoms does not differ along the majority of the measures, with men less often reporting the development of pain syndrome (45.7 versus 65.2% for women; p=0.0001). The proportion of patients with class C4-C6 amongst men and women does not differ (29.5% and 24.1%, respectively; p=0.211). No differences in the incidence of varicosephlebitis, external bleeding from the venous node were revealed. Men were found to have more often total reflux along the great saphenous vein on the right leg (35.7% as compared with 25.1 % for women; p=0.017) and insufficiency of perforants (72.9% versus 59.7%; p= 0.006). Women were more often found to have isolated varicosity of inflows-confluents. 47.3% of men had not previously attended presented consulted for VD, amongst women the proportion of such cases was considerably lower (28.6%; p = 0.000001). Only 6.0% of women had previously not undergone any treatment for VD. Amongst men the share of previously not treated amounts to 23.3% (p=0.000001). Women were statistically significantly more often prescribed phleboscleroobliteration the inflows confluents. The recommendations of phlebologists on using compression, pharmacotherapy, surgical methods did not differ in men and women. CONCLUSION: The obtained differences are not principal. The course of VD is similar in patients of different gender, which is confirmed by identity of treatment policy.

[Micronized purified flavonoid fraction in treatment of pelvic varicose veins].

Presented herein are the results of studying efficacy of micronized purified flavonoid fraction (MPFF) in treatment of pelvic varicose veins (PVV) using reference ray-tracing methods of study. We examined a total of 85 patients with PVV. Of these, 65 subjects were found to have isolated dilatation of pelvic venous plexuses (study group), and 20 were diagnosed as having combined dilation of gonadal veins and venous plexuses of the pelvis (control group). Besides clinical examination, the patients were subjected to ultrasonographic angioscanning (USAS) and emission computed tomography (ECT) of pelvic veins before treatment and 2, 6, 12, 24, 36 and 60 months after the beginning of phlebotrophic therapy. Based on the findings of the clinical and instrumental studies, it was determined that MPFF was most efficient in patients with isolated dilatation of uterine and parametrial veins. In this group of patients, pelvic pain and other symptoms of the disease disappeared completely and the clinical effect persisted for a long time (up to 6-9 months). In the control group, venotonic therapy had a positive effect which was less pronounced as compared to the control group, and pelvic pain reappeared in the nearest time (up to 3 weeks) after withdrawal of MPFF.

[Prolongation of enoxaparin therapy to one month promotes recanalization of the occlusively thrombosed deep veins].

AIM: To compare effects of prolongation of the treatment with therapeutic doses of enoxaparin to 1 month on recanalization of occlusively thrombosed deep veins (OTDV) of the limbs with results of standard therapy with unfractionated heparin (UFH). Both treatments were followed by warfarin administration. MATERIAL AND METHODS: Thirty patients were selected from 111 patients with a history of deep vein thrombosis (DVT) and/or pulmonary artery embolism according to the following criteria: the presence of occlusive thrombosis of one deep vein minimum; the absence of DVT for 12 months of follow-up. Patients of group 1 (n = 15) received standard therapy (UFH for at least 5 days) with switch to warfarin. Patients of group 2 (n = 15) received therapeutic doses of enoxaparin (1 mg/kg each 12 hours) for 30 days minimum with switch to warfarin. Follow-up was 12 months. Ultrasonic duplex angioscanning of the limbs was made at baseline, 1, 3, 6 and 12 months after treatment start. RESULTS: After follow-up month 1, 3 and 6 number of patients with occlusive DVT was significantly less in group 2. All the patients given enoxaparin achieved recanalization of OTDV within 3 months of treatment. OTDV recanalization was not achieved in 20% patients of group 1 even 12 months after treatment start. CONCLUSION: Prolongation of enoxaparin treatment to 1 month followed by warfarin treatment is superior to standard UFH treatment followed by warfarin in providing recanalization of OTDV within 3 months of treatment. Moreover, this treatment predicts persistence of recanalization within 12 months of anticoagulant therapy.

[Polymorphisms of genes CYP2C9 and VKORC1 in patients with venous thromboembolic complications in Moscow population: effects on stability of anticoagulant therapy and frequency of hemorrhage].

AIM: To investigate frequency of carriage of genetic polymorphisms CYP2C9 and VKORC1 in patients with venous thromboembolic complications (VTEC) in Moscow population given warfarin treatment and effects of this carriage on stability of anticoagulation and frequency of hemorrhagic complications (HC) in warfarin treatment. MATERIAL AND METHODS: The study included 111 patients with the history of deep vein thrombosis and/ or pulmonary artery thromboembolism. All the patients received non-fractionated or low-molecular heparin for at least 5 days, then warfarin (target INR 2.0-3.0). Warfarin dose was selected empirically. Gene CYP2C9 and VKORC1 polymorphisms were studied. HC were endpoints. RESULTS: Genotype CYP2C9*1/*1 (a "wild" type) was detected in 94 (84.7%) patients. Of other genotypes - heterozygotes CYP2C9*1/*2 (4.5%) and CYP2C9*1/*3 (10.8%). Genotyping by VKORC1 detected genotype GG (a wild type) in 42.3%, genotype GA--in 48.6%, genotype AA--in 9.1% patients. A mean warfarin dose, supporting an adequaite INR, was asspciated with both genotype CYP2C9 and VKORC1. Warfarin doses were highest in carriers of wile genotypes CYP2C9 and VKORC1 (6,9 and 8,8 mg/day), the lowest--in patients with genotypes CYP2C9*1/*3 and VKORC1 (4,5 and 4,0 mg/day). The carriers of polymorphisms CYP2C9*1/*3 and VKORC1 showed less stable anticoagulation vs carriers of allele variants CYP2C9*1/*1, CYP2C9*1/*2 and genotypes GG, GA VKORC1. An HC rate depended, as a rule, on carriage of genotypes CYP2C9*1/*3 and AA VKORC1. The highest risk of HC was associated with genotype CYP2C9*1/*3. The results of multifactorial regression analysis also indicated that carriage of genotype CYP2C9*1/*3, a female gender and the range of INR in warfarin treatment > or = 2,66 are independent predictors of HC in VTEC patients on warfarin treatment. CONCLUSION: Carriage of gene CYP2C9 and VKORC1 polymorphisms affects suppoting dose of warfarin and rate of hemorrhage in patients with VTEC in Moscow population. Frequency of HC is the highest in carriers of genotypes CYP2C9*1/*3 and AA VKORC1, they need minimal supporting dose of warfarin. Carriage of genotype CYP2C9*1/*3 in line with a female gender and instability of INR is an independent predictor of HC in VTEC patients in Moscow population on warfarin treatment.

[Thrombin-activated inhibitor of fibrinolysis and efficacy and safety of long-term warfarin treatment in patients with venous thromboembolic complications].

AIM: To study effects of thrombin-activated fibrinolysis inhibitor (TAFI) on efficacy and safety of long-term anti-coagulant treatment in patients with venous thromboembolic complications (VTEC). MATERIAL AND METHODS: A total of 111 patients with a history of an episode of deep vein thrombosis (DVT) and/or pulmonary artery thromboembolism (PATE) entered the study. All the patients received unfractionated or low-molecular heparin for at least 5 days than switch on warfarin (target values of INR 2.0-3.0). Baseline blood levels of TAFI were measured. The patients were followed up for 18 months. Recurrent (DVT/TAFI and hemorrhagic complications (HC) were endpoints. Also, frequency of complete lysis of deep vein thrombi was assessed after 12 months of treatment. RESULTS: A TAFI level varied from 50 to 217% (median 106%, interquartile rage 90-133%). TAFI concentration positively correlated with fibrinogen and thromb size. The patients were divided into two groups depending on TAFI content: group 1 patients had low TAFI (under 25th percentile; < 90%); patients of group 2 had high TAFI (above 25th percentile; > 90%). Group 1 patients were characterized by less stable anticoagulation. This association did not depend on genetic characteristics which determine sensitivity to warfarin (CYP2C9 and VKORC1). Low TAFI was associated with reduced risk of DVT for 18 months and higher probability of complete lysis of the thrombi after 12 months of anticoagulant therapy compared to VTEC patients with high TAFI. No differences were found by TAFI level in patients with HC and without HC, but in HC patients low TAFI was associated with spontaneous hemorrhages and bleeding in therapeutic INR values. CONCLUSION: The results of this pilot study evidence that a TAFI level can be one of the factors influencing efficacy and safety of long-term anticoagulant therapy in patients with VTEC on warfarin treatment.

[Risk factors for venous thromboembolic complications and their association with D-dimer level].

AIM: to study the prevalence of various risk factors (RF) for venous thromboembolic events (VTEE) and their association with D-dimer levels. SUBJECTS AND METHODS: The clinical, demographic, anthropometric, anamnestic, and laboratory data were analyzed in 106 patients (73 men and 33 women) aged 18 to 78 years admitted to hospital with the first or recurrent episode of VTEE. RESULTS: RF and VTEE-associated diseases were identified in all patients. Over 90% of the patients had more 2 RFs. The most common RFs were the age above 40 years (85%) and overweight (82%), including obesity (42%). There was a preponderance of cardiovascular diseases in the pattern of VTEE-associated diseases. The direct causes (precipitating factors) of thrombosis were revealed in 57% of cases; the thrombotic episode was classified as idiopathic in 43%. Elevated D-dimer levels were found in 74% of the patients. Higher D-dimer content was seen in women, non-smokers, patients operated on for thrombosis, those who had 2 precipitating factors or more, and those who had a less than 30-day history of thrombosis. There was an inverse correlation between the elevated level of D-dimer and the duration of thrombosis by the moment of its identification (thrombus age). CONCLUSION: All patients who have experienced a venous thrombotic episode have various RFs for VTEE The content of D-dimer exceeds the normal value in most patients with VTEE. Among the RFs studied, thrombus age is the most important factor associated with elevated D-dimer levels in patients with VTEE