[Endovascular surgery for critical ischemia of lower extremities with suppurative-necrotic lesion of the feet]. / Rentgenoéndovaskuliarnaia khirurgiia pri kriticheskoi ishemii nizhnikh konechnostei s gnoino-nekroticheskim porazheniem stop.

AIM: To improve treatment of patients with grade IV chronic ischemia of lower extremities via endovascular angioplasty combined with surgical methods for suppurative-necrotic lesions of the feet. MATERIAL AND METHODS: 51 patients with grade IV chronic ischemia of lower extremities underwent endovascular interventions (balloon angioplasty, stenting). A total of 23 stents were deployed in 16 patients including 12 stents in superficial and common femoral arteries, 5 in popliteal artery, 6 in iliac artery. There were no stents in crural arteries. The most perspective artery for wound healing was preferred in case of revascularization below popliteal segment. Necrectomy was performed along with angioplasty in patients with suppurative-necrotic lesion of the feet followed by delayed reconstructive operations if it was necessary. RESULTS: Endovascular surgery for grade IV chronic ischemia of lower extremities was associated with good immediate results in most cases due to revascularization and organ-sparing interventions for suppurative lesions of the feet. Current endovascular methods allow to perform successful re-operations to restore blood flow in previously repaired arteries and implanted stents with restenosis or thrombosis.

[Infectious arthritis of sternoclavicular joint: surgical approach to the issue].

AIM: To study the features of occurrence, diagnosis, clinical course of infectious arthritis of sternoclavicular joint, as well as to develop differentiated therapeutic tactics depending on the clinical form and stage of disease. MATERIAL AND METHODS: It was analyzed treatment of 18 patients with infectious arthritis of sternoclavicular joint aged 27 to 88 years who were hospitalized for the period 2008-2014. Acute or chronic forms were determined depending on clinical course and serous arthritis, para-articular phlegmon and osteoarthritis--according to nature of tissue damage. Hypothermia and blunt trauma were often preceded to onset of disease. Diabetes and drug addiction were present as comorbidities. Also disease as the variant of purulent metastasis in case of sepsis was noted. Bone scintigraphy, CT and magnetic resonance imaging are the most informative. RESULTS: Infectious arthritis of sternoclavicular joint often had hematogenous origin, and Staphylococcus aureus was the most common cause. At the stage of serous arthritis antibacterial therapy was effective. Incision and drainage were performed urgently in case of para-articular phlegmon. Sternoclavicular joint resection was performed usually in 2-3 months after subsidence of inflammation.

[Streptococcal infection in surgery].

INTRODUCTION: Despite the advances of modern medicine purulent-inflammatory diseases of soft tissues continue to occupy a leading position in surgical practice. Streptococcal surgical infection does not refer to specific category, but it has a number of significant features and its definition as separate type is necessary. MATERIAL AND METHODS: Based on the results of treatment of 312 patients with streptococcal infection of soft tissues we studied the prevalence of this disease in overall structure of surgical infection of soft tissue, main clinical courses are defined. We performed molecular genetic typing of pathogens that allows to predict the course of pathological process taking into account microorganism's characteristics. RESULTS AND DISCUSSION: On the basis of obtained data basic medical and diagnostic concept of surgical care for these patients depending on clinical course of disease was formulated. It allowed to improve significantly the results of treatment of such patients.

[The thoracoscopy in complex treatment of non-specific pleural empyema and purulent-destructive diseases of lungs].

The results of treatment of 697 patients with different kinds of non-specific pleural empyema and gangrenous lesions of lungs are presented in the article. Need for complex and differentiated treatment of pleural empyema with obligatory use of thoracoscopy is revealed. High efficiency of early thoracoscopic sanitation improving outcomes and length of hospital stay is proved. Thoracoscopic necrosectomy is alternative and effective surgery in treatment of gangrenous lesions of lungs.

[Predicting the risk of septic and necrotic complications in femoral amputation stump].

Treatment results of 430 patients with ischemic gangrene of lower limbs were analyzed and major risk factors of postoperative complications considering the femoral amputation stump were outlighted. These are: the high level of artery occlusion, ligature muscle compression in the stump, absence of active drainage and elderly age (more than 80 years), anemia. The intraoperative use of laser Doppler flowmetry gives the possibility to assess the potential viability of muscles at the amputation level. Predicting the risk of local postoperative complications allowed the differential approach to the stump formation and improved the treatment results.

[Metabolic immunocorrection treatment of experimental widespread purulent peritonitis].

The effect of citoflavin and neoton preparations on the migration activity of neutrophil granulocytes under action of mitogen-induced immunocompetent blood cells, Peyer's patches, spleen and inguinal lymph was studied on a group of 55 male chinchilla rabbits with experimental model of widespread purulent peritonitis. It is established that the regulating action of immunocompetent cells on the migration of neutrophil leukocytes under the conditions of widespread purulent peritonitis is stable and widespread process, which is observed within 5 days of the postoperative period. The use of citoflavin and neoton during the postoperative period produces correction of the activity of immunocompetent cells, changing their properties in regulation of the migratory activity of neutrophil granulocytes. The effect is characteristic of both preparations and it is observed in all investigated organs, being manifested to a greater degree in immunocompetent cells of peripheral blood and Peyer's patches. Metabolic preparation citoflavin exhibits a more pronounced immunotropic action in comparison to neoton, which contains creatine phosphate.

[Changes in the cytokine profile in residents with chronic obstructive lung disease exposed to urban air pollutants].

The complex of urban air pollutants was established to affect the cytokine profile in Moscow residents with chronic obstructive pulmonary disease (COPD)), as it causes a significant reduction of L-6 and TNF-alpha in their blood samples. The identified changes indicate to inhibition of the functional activity of cells of the reticuloendothelial system, which can lead to the persistence of seasonal bacterial-viral infections and more rapid chronization of the basic disease.

[Pelvic ostheomyelitis: diagnostics and treatment].

Results of treatment of 223 patients with ostheomyelitis of various etiology and localization were analyzed. Such aspects as diagnostic difficulties, polifocal type of the disease, sepsis development on the background of pelvic ostheomyelitis were discussed. Ostheoscintygraphy, magnetic resonance imaging and computed tomography proved to be of highest diagnostic value by pelvic ostheomyelitis. The original method of surgical treatment of purulent sacroileitis with the use of combined (pelvic and extrapelvic) access was represented.

[Treatment tactics by frostbites].

317 patients with frostbitten limb injuries of various severity were healed. A differential treatment tactics were worked out, basing on localization, area, time of frost exposure and concurrent vascular disease. Surgical treatment of IV stage congelation stipulates early necrectomy by lower limbs affection, whereas, congelation of the upper limbs requires delayed necrectomy; both should be followed by appropriate wound healing and early reconstructive operations. Indications for primary amputations by deep congelation were formulated.

[Plastic surgery in patients with surgical wound infection].

Results of various skin plastic operations performed in 312 patients with soft-tissue infection were analyzed. The choice of the method depended on size and site of the wound, predisposing pathological process, age and general patient's condition. Differential approach to the choice of reconstruction method allowed satisfactory short-term results in 91,4% of patients. 80% of patients demonstrated good long-term results.

[Radical operative treatment of perforative gastroduodenal ulcer disease].

Data of 363 patients operated on for perforated gastric or duodenal ulcers were analyzed. Immediate and follow-up results were obtained after simple suture plication, Jadd's ulcer excision combined with stem vagotomy and after distal gastric resection. Predictors of the unfavourable outcome were determined. These are: Mannheim peritonitis index >20, surgical risk of IV-V grade, signs of multiple organ failure and symptomatic character of the ulcer. The comparison of long-term results revealed that patients after suture plication experienced the ulcer recurrence in 78,4% and necessity of further operation occurred in 21,5%. Every third patient after stem vagotomy experienced postvagotomic disorders and ulcer recurrence. Primary gastric resection demonstrated the best long-term results concerning ulcer disease. The algorithm of treatment modalities of the perforative ulcer desease was worked. The algorithm is based on stage-by stage determination of indications and contraindications to gastric resection.

[Choice of treatment method at acute gastroduodenal ulcerous bleedings].

Experience of treatment of 1307 patients with acute gastroduodenal ulcerous bleedings is analyzed. Three variants of treatment tactics are compared: expectant, active and differential. Differential tactics based on prediction of bleeding recurrence and assessment of patient's condition severity permit to improve the treatment results. Original clinical-endoscopic system of hemostasis stability assessment was used for prediction of bleeding recurrence, integral scale APACHE III--for assessment of patient's condition severity. Algorithm of treatment at acute gastroduodenal ulcerous bleedings is offered. Principles of differential treatment tactics have permitted to reduce overall lethality at acute gastroduodenal ulcerous bleedings to 3.2%, postoperative lethality--to 6.2%.

[Tertiary peritonitis: aspects of prophylaxis].

Thirteen patients with generalized purulent peritonitis were treated with multiple staging sanation of abdominal cavity and special bacteriophages with high activity to 4 nosocomial bacterium strains. The phages permitted to prevent infection with these nosocomial strains. Three new phages with high bacteriolytic activity were identified. Antibacterial activity "in vitro" of all phages was higher than antibiotic susceptibility. It is concluded that bacteriophages are promising method of treatment and prevention of complications associated with nosocomial infection at surgical patients with long-time purulent processes.

[Bacterial translocation under the conditions of acute bowel obstruction].

The article is dedicated to bacterial translocation under the conditions of acute small and large bowel obstruction, studied in experiment using bacteriological methods. The degree of contamination of internal organs, blood, and peritoneal exudate in the dynamics of the pathological process was determined. The study found that the use of allopurinol, a xanthine oxidase inhibitor, reduced the intensity of bacterial translocation.

[Diagnosis and treatment of complicated postnecrotic cysts of pancreas].

Experience of complex treatment of 137 patients with complicated postnecrotic pancreatic cysts (PPC) is analyzed. Indications to different surgical methods are formulated differentially depending on complications of cysts, localization, sizes, "maturity" of cyst walls, communication with main pancreatic duct. Treatment of festered PPC should be started with minimally-invasive methods; at negative result the omentobursocystostomy with staged endoscopic sanations should be done that permits to decrease the number of postoperative complications and to reduce lethality from 14.3 to 4.5%. Resection of pancreas along with cyst is the operation of choice at pancreatic cysts complicated with bleeding; lethality has been reduced from 28.6 to 5.6%. Perforation of cysts into abdominal cavity is the indication to omentobursocystostomy with staged sanations of omental bursa, perforation into pleural cavity -- to distal resection of pancreas.

[Antisecretory therapy as a component of hemostasis in acute gastroduodenal ulcer bleedings].

Results of antisecretory therapy (pyrenzepin, H(2)-blockers, inhibitors of proton pump, octreotid) in 962 patients with acute gastroduodenal ulcer bleedings (AGDUB) were analyzed over 14-years period. Antisecretory treatment in AGDUB has principally different goals and potential depending on risk of bleeding's recurrence and morphological changes in tissue of gastroduodenal ulcer. Antisecretory therapy is the main treatment in high risk of AGDUB recurrence or before urgent surgery. Intravenous infusion of omeprazol has demonstrated the highest clinical efficacy due to maximal inhibition of gastric secretion and absence of negative influences on oxygen regimen in tissue of ulcer.

[Pathogenesis of recurrences of acute gastroduodenal ulcerous bleedings]. / Patogenez retsidiva ostrykh gastroduodenal'nykh iazvennykh krovotechenii.

Based on analysis of morphologic data, oxygen regime and redox potential it is demonstrated that progressive ischemic necrosis in periulcerous zone is the basis of recurrence of gastroduodenal ulcerous bleedings. Systemic hemostatic therapy, antisecretion drugs, endoscopic methods of hemostasis don't guarantee absence of bleeding recurrence. Prognosis of recurrence of gastroduodenal ulcerous bleedings must be based on evaluation of clinical and endoscopic data. Partial pressure of oxygen and redox potential in ulcer's crater are the objective criteria of threat of bleeding's recurrence.

[Recurrence of acute gastroduodenal ulcer bleedings]. / Retsidiv ostrykh gastroduodenal'nykh iazvennykh krovotechenii.

Multifactor analysis of 818 cases of acute gastroduodenal ulcer bleedings (clinical and laboratory examination, gastroscopy, morphological studies) was carried out, 97 of these patients had recurrence of bleeding. It is demonstrated that recurrence of gastroduodenal ulcer bleeding is cause by progressed ischemic necrosis in periulcerous zone in condition of local hypoperfusion as a result of systemic hemodynamic disorders due to acute blood loss syndrome and chronic ischemia dueto ulcerous process. Systemic hemostatic therapy, antisecretory drugs, methods of endoscopic hemostasis don't guarantee absence of bleeding recurrence. Prognosis of the recurrence must be based on assessment of significant clinical and gastroscopic data. Dynamical determination of pO2 in periulcerous zone is an additional prognostic criterion. Recurrence of gastroduodenal ulcer bleeding increases general and postoperative lethality 2 times as minimum. Active surgical policy based on prognosis of bleeding recurrence probability permitted us to reduce total lethality in acute gastroduodenal ulcer bleedings to 6.2%, postoperative lethality to 8.5%.

[Features of surgical strategy in acute cholecystitis in old patients]. / Osobennosti khirurgicheskoi taktiki pri ostrom kholetsistite u bol'nykh starcheskogo vozrasta.l

Results of treatment of 197 patients at the age of 75-years and older with acute cholecystitis in terms of active (early operations) and active-delaying (delayed and elective operations) policy were analyzed. It was established that changes of gall bladder wall in old patients with acute cholecystitis are of ischemic genesis, of primary-destructive and irreversible nature leading to gangrene and phlegmon of gall bladder wall in 84% cases. In 2/3 cases clinical picture doesn't reflect destructive nature of the disease. Severity of the patients state and its dynamics may be assessed most objectively by APACHE III. Conservative treatment doesn't prevent progress of destructive-inflammatory process and complications development. Cholecystectomy from laparotomy is the operation of choice in this group of patients. Early radical operation for acute cholecystitis in old patients permits to decrease postoperative lethality to 3.3%. The score of APACHE III at hospitalization is the criterion of the scope and terms of surgery. If APACHE III is more than 55 points, it is necessary to carry out complex preoperative correction of somatic disorders. Minimally invasive palliative operations are indicated for 10% patients of this category.