[Surgery for mediastinal teratoma containing pancreatic tissue]. / Khirurgiya teratomy sredosteniya, soderzhashchei tkan' podzheludochnoi zhelezy.

Surgery for mediastinal tumors is still one of the most difficult in modern medicine. This is due to vital organs and various nature of tumors in this area. Teratomas are relatively rare among mediastinal tumors. However, they have certain features that is important for treatment strategy and management of possible complications. This can complicate diagnostic algorithm, exclude transthoracic biopsy and contribute to active surgical approach even for benign process. Oncogenesis of teratoma has its own characteristics. Tissues of different organs are always present in this tumor. Among these, pancreatic tissue inclusions are rare. A few data in the world literature on the treatment of such patients do not allow to develop a universally accepted algorithm of diagnosis and treatment. The authors present two patients with mediastinal teratoma. The second patient had teratoma with pancreatic tissue. The authors discuss the diagnostic algorithm for similar cases. A special attention is paid to description of possible complications throughout long-term follow-up period. Surgical aspects including the choice of access and local spread of process (adhesions in the area of surgical interest) are considered. The report on the treatment of two patients with rare mediastinal tumors containing pancreatic tissue will be useful for primary care physicians, thoracic surgeons, oncologists and morphologists.

[Giant traumatic diaphragmatic hernia as a complication after laparoscopic liver surgery]. / Gigantskaya travmaticheskaya diafragmal'naya gryzha kak oslozhnenie posle laparoskopicheskoi operatsii na pecheni.

Laparoscopic surgery is now one of the main options for patients with surgical diseases of abdominal cavity, pelvis and retroperitoneal space. Postoperative complications are known, and methods for their prevention after such interventions are well developed. However, there are rare complications, and their management deserves a special attention. The authors present a patient with giant traumatic hernia in long-term period after laparoscopic liver surgery. Clinical manifestations of disease are retrospectively analyzed. The authors discuss surgical aspects of treatment, i.e. choice of access, repair of diaphragmatic defect and peculiarities of postoperative period associated with non-anatomic return of abdominal organs through the diaphragmatic defect. This report will be useful for radiologists, thoracic and abdominal surgeons, anesthesiologists and intensive care specialists.

[Feasibility of cardiac surgical techniques for intrathoracic tumors]. / O tselesoobraznosti ispol'zovaniya kardiokhirurgicheskikh tekhnologii pri vnutrigrudnykh opukholyakh.

OBJECTIVE: To analyse safety and expediency of cardiac surgical technologies including cardiopulmonary bypass (CPB) in patients with locally advanced lung cancer and invasive tumors of the mediastinum. MATERIAL AND METHODS: Cardiac surgical techniques and CPB were used in 23 patients (group 1) with locally advanced thoracic tumors between 2005 and 2015. For the same period, there were 22 patients (group 2) who underwent combined surgeries and could have had similar techniques. However, these techniques were not used for various reasons. Mediastinal malignancies and non-small cell lung cancer were diagnosed in 26 (57.8%) and 19 (42.2%) patients, respectively. Invasion of superior vena cava (n=15), aorta (n=13) and pulmonary artery (n=12) was the most common. Lesion of innominate vein (n=8), left atrium (n=6) and innominate artery (n=4) was less common. A total of 21 pneumonectomies were performed (14 in the first group and 7 in the second group). Lobectomy was less common (one patient in each group). Sublobar lung resection was performed in 10 patients (2 patients in the first group and 8 ones in the second group). All resections were total in the first group (R0) that was confirmed by routine morphological examination of resection margins of different organs and vessels. The situation was worse in the second group (R1 in 19 (86.4%) patients, R2 in 3 (13.6%) patients). RESULTS: Total postoperative morbidity was 53.3%, mortality - 8.2%. These values are higher compared to patients undergoing surgical treatment for thoracic malignancies. Incidence of postoperative complications was higher in the first group (16 (69.6%) and 8 (36.4%), respectively). Four patients died in the first group. Sepsis (n=2), acute right ventricular failure (n=1) and acute myocardial infarction (n=1) caused death. There were no lethal outcomes in the second group. Various postoperative complications were diagnosed only in 8 (36.4%) patients. The long-term results were followed-up in 80% of patients. In the first group, 3- and 5-year survival rates were 30.5% and 25%, respectively (median 43.8 months). In the second group, these values were 25% and 2%, respectively (median 24.9 months). Long-term mortality in the second group was caused by progression of malignant process, including local recurrence, after palliative surgery (R1, R2 resection). CONCLUSION: Higher risk of postoperative complications and mortality in patients undergoing on-pump surgery is compensated by significantly better long-term results. Further progress is associated with higher safety of CPB, as well as solving some organizational and educational problems.

[Solitary mediastinal fibrous tumor complicated by hypoglycemic crises (Doege-Potter syndrome)]. / Solitarnaya fibroznaya opukhol' sredosteniya, oslozhnennaya gipoglikemicheskimi krizami (sindrom Doge­Pottera).

Diagnostic and treatment algorithms for large mediastinal tumors are clear. However, long-term results are not always good. They largely depend on early diagnosis and morphological structure of tumor. Neoplasms may be asymptomatic for a long time, especially in case of slow growth. These tumors are usually diagnosed as soon as complications occur (for example, compression syndrome). Routine X-ray screening is rarer situation. Paraneoplastic syndromes are rare, and some ones are casuistic and unknown to surgical community. We describe the diagnosis and treatment of a patient with giant solitary mediastinal tumor complicated by hypoglycemic crises (Doege-Potter syndrome). This complication was life-threatening and required a multidisciplinary approach. Aggressive surgical approach cured the patient and returned her to normal lifestyle. The proposed algorithm for perioperative drug therapy was effective and deserves attention. This report will be useful for surgeons, oncologists, anesthesiologists, intensive care specialists and endocrinologists.

[Treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia]. / Lechenie rubtsovogo stenoza trakhei i trakheopishchevodnogo svishcha u bol'nykh, perenesshikh COVID-19-pnevmoniyu.

OBJECTIVE: To describe treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia. MATERIAL AND METHODS: There were 91 patients with cicatricial tracheal stenosis for the period from August 2020 to April 2022 (21 months). Of these, 32 (35.2%) patients had cicatricial tracheal stenosis, tracheoesophageal fistula and previous coronavirus infection with severe acute respiratory syndrome. Incidence of iatrogenic tracheal injury following ventilation for viral pneumonia in the pandemic increased by 5 times compared to pneumonia of other genesis. Majority of patients had pneumonia CT grade 4 (12 patients) and grade 3 (8 patients). Other ones had pulmonary parenchyma lesion grade 2-3 or mixed viral-bacterial pneumonia. Isolated tracheoesophageal fistula without severe cicatricial stenosis of trachea or esophagus was diagnosed in 4 patients. In other 2 patients, tracheal stenosis was combined with tracheoesophageal fistula. Eight (25%) patients had tracheostomy at the first admission. This rate was almost half that of patients treated for cicatricial tracheal stenosis in pre-pandemic period. RESULTS: Respiratory distress syndrome occurred in 1-7 months after discharge from COVID hospital. All patients underwent surgery. In 7 patients, we preferred palliative treatment with dilation and stenting until complete rehabilitation. In 5 patients, stent was removed after 6-9 months and these ones underwent surgery. There were 3 tracheal resections with anastomosis, and 2 patients underwent tracheoplasty. Resection was performed in 3 patients due to impossible stenting. Postoperative course in these patients was standard and did not differ from that in patients without viral pneumonia. In case of tracheoesophageal fistula, palliative interventions rarely allowed isolation of trachea. Four patients underwent surgery through cervical approach. There were difficult surgeries in 2 patients with tracheoesophageal fistula and cicatricial tracheal stenosis. One of them underwent separation of fistula and tracheal resection via cervical approach at primary admission. In another patient with thoracic fistula, we initially attempted to insert occluder. However, open surgery was required later due to dislocation of device. CONCLUSION: Absolute number of patients with tracheal stenosis, tracheoesophageal fistula and previous COVID-19 has increased by several times compared to pre-pandemic period. This is due to greater number of patients requiring ventilation with risk of tracheal injury, non-compliance with preventive protocol for tracheal injury including anti-ischemic measures during mechanical ventilation. The last fact was exacerbated by involvement of allied physicians with insufficient experience of safe ventilation in the «red zone¼, immunodeficiency in these patients aggravating purulent-inflammatory process in tracheal wall. The number of patients with tracheostomy was 2 times less that was associated with peculiarity of mechanical ventilation in SARS-CoV-2. Indeed, tracheostomy was a poor prognostic sign and physicians tried to avoid this procedure. Incidence of tracheoesophageal fistula in these patients increased by 2 times compared to pre-pandemic period. In subacute period of COVID-associated pneumonia, palliative measures for cicatricial tracheal stenosis and tracheoesophageal fistula should be preferred. Radical treatment should be performed after 3-6 months. Absolute indication for circular tracheal resection with anastomosis is impossible tracheal stenting and ensuring safe breathing by endoscopic methods, as well as combination of cicatricial tracheal stenosis with tracheoesophageal fistula and resistant aspiration syndrome. Incidence of postoperative complications in patients with cicatricial tracheal stenosis and previous mechanical ventilation for COVID-19 pneumonia and patients in pre-pandemic period is similar.

[Surgery of primary tracheal tumors]. / Khirurgiya pervichnykh opukholei trakhei.

OBJECTIVE: To determine the main forms of primary tracheal cancer (PTC), to specify the indications for various surgeries in these patients depending on extent and localization of lesion. MATERIAL AND METHODS: There were 263 PTC patients. Benign tumors were diagnosed in 68 (25.9%) patients, malignancies - in 195 (74.1%) cases. Tracheal cancer includes 3 basic morphological variants - adenocystic cancer (49.7%), carcinoid (18.7%) and squamous cell carcinoma (19.0%). Other forms of malignancies were much less common. We applied endoscopic intraluminal and open surgeries. In malignant PTC, open surgeries were performed in 165 (84.6%) out of 195 patients. Baseline palliative endoscopic treatment was performed in 30 patients. They underwent airway recanalization (with subsequent tracheal stenting in 19 patients). Endoscopic resection was preferred for benign tumors. RESULTS: Twenty (12.1%) patients died after open surgery, and 1 (3.3%) patient died after endoscopic procedure. Most lethal outcomes occurred in early years of development of tracheal surgery. The causes of mortality were tracheal anastomotic failure in 12 patients, pneumonia in 6 patients, and arterial bleeding in 2 patients. Severe postoperative period was observed in all 3 patients after tracheal replacement with a silicone prosthesis. Long-term treatment outcomes depended on morphological structure of PTC. Favorable results were observed in patients with neuroendocrine tumor (carcinoid), worse outcomes in adenocystic cancer and unfavorable results in squamous cell carcinoma (p<0.0013). Five-year survival rates were 75%, 65.6%, and 13.3%; 10-year survival rates were 75%, 56.2%, and 13.3%, respectively. These outcomes after combined treatment of primary tracheal cancer were significantly better compared to lung cancer (p<0.05 when compared to global data). CONCLUSION: Treatment of primary tracheal cancer should be based on classical principles of modern oncology (combined therapy, tumor resection with lymphadenectomy). Open and endoscopic interventions are justified. PTC is characterized by more favorable outcomes compared to lung cancer. It is difficult to analyze long-term results in tracheal cancer depending on various features of tumor process due to small number of observations. Accurate conclusions require multiple-center studies, preferably with international participation, which can convincingly prove certain concept.

[Postoperative drainage of the pleural cavity with aspiration of the contents by high-tech mobile devices]. / Posleoperatsionnoe drenirovanie plevral'noi polosti s aspiratsiei soderzhimogo vysokotekhnologichnymi mobil'nymi apparatami.

Postoperative drainage of pleural cavity is currently a common component of treatment of patients with surgical diseases of thoracic organs. Peculiarities of suctioning (aspiration parameters, passive drainage or active aspiration, the degree of discharge in the device-pleural cavity system, as well as the possibility of early patient activation, no need to «attach¼ him to the electric stationary suction) remain topical and continue to be discussed. New devices - aspirators, including mobile ones with digital control and rarefaction control component, appear in the market. MATERIAL AND METHODS: Between May and September 2021, 65 patients aged from 23 to 88 years with various oncological and non-oncological diseases of the thoracic cavity followed by drainage underwent resection operations with a volume less than pneumonectomy or lung decortication for empyema, parietal pleurectomy for recurrent pneumothorax. Six patients (4 after pneumonectomy and one with postoperative complications (1 after retoracotomy for hemothorax and 1 after laparoscopic cholecystectomy for acute destructive cholecystitis in the immediate postoperative period) were excluded from the study. The patients were divided into 2 groups. The first group consisted of 22 patients in whom in the early postoperative period we used continuous active pleural content aspiration with the help of high-tech mobile devices Atmos. The second group included 37 patients in whom we used drainage by means of medical suction of Lavrinovich or Visma-Planar design (Belarus). RESULTS AND CONCLUSION: Soft drainage by modern systems of pleural cavity content evacuation provides the best conditions for stopping air leakage from the lung tissue as well as for preventing pneumothorax when transporting a patient from the operating room and around the clinic for examination. The early activation of the patient with the connected mobile digital aspirator not only promotes the Fast-track surgery concept but also the ERAS program, i.e. accelerated rehabilitation, as recommended by the European Society of Thoracic Surgeons (ESTS). These designs also have advantages over stationary devices, such as subjective factors based on the relative ease of operation of mobile systems in their use, accessibility not only for medical staff, but also for the patient himself.

[Assessment of tracheal elasticity and tracheal anastomosis tension in cicatricial stenosis]. / Otsenka elastichnosti trakhei i natyazheniya trakheal'nogo anastomoza pri rubtsovom stenoze.

OBJECTIVE: To assess the tracheal elasticity and tracheal anastomosis tension for prevention of anastomosis-related complications and estimation of the maximum length of resection. MATERIAL AND METHODS: At the first stage, 20 patients with cicatricial tracheal stenosis underwent tracheoscopy in usual position, under maximum flexion and extension of the head for the period from September 2017 to December 2019. We measured the total length of trachea and length of stenotic segment. Tracheal extensibility was assessed considering the difference in measurements. At the second stage, anastomosis tension was intraoperatively measured using a dynamometer in normal head position, as well as at maximum flexion in 22 patients who underwent tracheal resection. Unlike multiple other studies, we studied tissue tension intraoperatively. RESULTS: Mean length of trachea was 12.8 cm, extensibility - 1.3 cm. Tracheal elasticity was greater in patients with a longer trachea and in patients under 40 years old. Mean length of resection was 3.9 cm (30% of mean length of trachea), anastomosis tension - 2.7 H or 270 g. Head flexion was followed by tension decrease by 0.7 H (26.9%), i.e. 70 g. This approach is less effective in case of resection of more than 30% of trachea length in a particular patient. CONCLUSION: Further experience in measurement of tracheal extensibility and anastomosis tension will make it possible to establish clinical significance of these indicators for prevention of complications.