[Surgical treatment of hemodynamically significant kinking of internal carotid arteries].

38 patients with different forms of vascular cerebral insufficiency, caused by kinking and atherosclerotic changes of internal carotid arteries were operated on. Various types of reconstructive operation on extracranial carotid arteries were performed. The color duplex ultrasound scanning and computed tomography proved to be highly informative noninvasive means for detecting carotid pathology in patients with vascular cerebral insufficiency. Reconstructive operations on internal carotid arteries can serve as prophylactic and treatment measure of chronic cerebral insufficiency. Authors propose the principle of "six types" of reconstructive operations which individualizes the surgical approach. Carotid surgery for asympomatic patients should be performed on strict indications.

[The efficacy of alteplase in pulmonary embolism treatment].

The results of pulmonary embolism treatment with streptase in 76 patients are discussed. All patients had submassive or massive pulmonary embolism. 66 (86%) of patients recovered. Thrombolysis with the use of heparin was performed in 9 patients, death occurred in 5 of them. Of 20 patients treated with "Actilize", death was reported in three cases. Authors consider alteplase to be highly effective in the treatment of massive pulmonary embolism. In case of late diagnostics of pulmonary embolism, especially recurrent, thrombolytic therapy remains to be effective up to 2 weeks after primary embolization.

[3-D X-ray contrast rotational angiography in vascular pathology diagnostics].

The experience of 3-D X-ray contrast rotational angiography use is analysed. The case examples of virtual applications use on various anatomic areas are described. Informational value of routine and 3-D angiography is comparatively evaluated. The preferences of modern technology is showed.

[Use of implanted intravascular catheters with subcutaneous "ports" in the treatment of surgical diseases].

Special implanted vascular catheters with subcutaneous "ports" were used in 120 patients for infusions into arteries, veins and abdominal cavity. The results demonstrate high efficacy of this method in the treatment of surgical and cancer patients.

[Laparoscopy and puncture biopsy in diagnosis of focal lesions of the liver]. / Laparoskopicheskoe issledovanie i punktsionnaia biopsiia v diagnostike ochagovykh porazhenii pecheni.

Based on the results of examination of 208 patients with different tumors of the liver it is concluded that in the majority of cases it is possible to avoid puncture biopsy of the liver and laparoscopy for diagnosis of focal lesion of the liver (FLL) before surgery because these invasive procedures don't improve efficacy of diagnosis. On the contrary it may lead to complications including implantation metastases (3.33%). Correct appliance of modern diagnostic algorithms permits to increase efficacy of FLL diagnosis to 82.27% without invasive procedures.

[Cytoreductive surgery of liver metastasis from colorectal cancer: principles of intra-arterial regional chemotherapy]. / Tsitoreduktivnaia khirurgiia metastazov kolorektal'nogo raka v pecheni: printsipy i intra-arterial'naia regionarnaia khimioterapiia.

A significant number of patients with colorectal cancer have metastases (MTS) to the liver. Cytoreductive surgery (CRS) and new antitumor drugs provide promising results. The aim of the study was to evaluate clinical results of CRS in combination with modern antitumor drug irinotekan (kampto). Forty-seven patients suffering from colorectal cancer with MTS to the liver were treated. Primary focus was resected. All the patients were divided into 4 groups depending on combination of surgical treatment and chemotherapy: with liver resection and complete removal (or devitalization) of metastatic lesions in combination with postoperative intravenous (group 1) or intraarterial regional (group 2) injection of Irinotekan and without resection of the liver with implantation of a catheter to the hepatic artery with postoperative intraarterial (group 3) or systemic intravenous (group 4) therapy with Irinotekan. Mean dose of kampto was 350 mg per 1 m2 of body surface. It was demonstrated that intraarterial infusion was highly effective. The follow-up in group 1 was 9.5 +/- 3.75 months, in group 2--11.3 +/- 4.2, in group 3--6.5 +/- 5.3, in group 4--4.6 +/- 2.3 months. It is concluded that cytoreduction of the the liver with intraarterial intrahepatic regional chemotherapy is an effective method of treatment of patients with metastatic colorectal cancer of the liver.

[Abnormalities of the pericardium]. / Poroki razvitiia perikarda.

By 2000 there have been at least 187 cases of rare pericardial malformations (of them there were 5 cases of the authors) and 1047 cases of celomic pericardial cysts (CPC) (43 cases of the authors) in the literature. Of them 18 (9.6%) patients were found to have no pericardium, the absence of its left half was in 76 (40.6%). No left pericardium was more common in men (61.04%) than in women (38.96%). The literature reports about the absence of the right pericardium only in one case. Partial pericardial defects were encountered in 30.48% of patients with rare pericardial malformations. In general, malformations in the left pericardium were 10 times more common often than those in the right one. The absence of the pericardium or its half most commonly requires no surgical correction. In partial defects, suturing or plastic closure must be performed due to a risk for strangulation and a possible fatal outcome. CPC are not clinically manifested in more than 50% of the patients with CPC, but in some cases dyspnea, dry cough, palpitation may be caused by other causes. Cystectomy yields good results.

[Is reliable prophylaxis of postoperative venous thromboembolic complications possible?]. / Vozmozhna li nadezhnaia profilaktika posleoperatsionnykh venoznykh tromboémbolicheskikh venoznykh oslozhnenii?.

Thrombosis of deep veins of lower extremities and pelvis is found in every third operated patient on the average, pulmonary embolism--in 0.5-0.8% cases. The results of nonspecific and specific prophylaxis of these complications are reviewed in the article. Intermittent pneumatic compression, compressive elastic stockings and standard or low-molecular heparin administration are most effective. Prophylactic measures do not exclude completely possibility of venous thromboembolic complications, but permit to control reliably this danger. The author has an experience of cavafilter implantation in 147 patients.

[Prospects for surgical and combined methods for treating acute coronary syndrome]. / Vozhmosnosti khirurgicheskikh i kombinirovannykh metodov lecheniia ostrogo koronarnogo sindroma.

From 1997 to 2000 diagnostic coronaroangiography was performed in 334 patients with acute coronary syndrome (ACS) which is the group of diseases with common pathophysiological mechanism, namely coronary artery thrombosis. ACS needs revascularization of the affected artery as quickly as possible. 26.6% patients underwent balloon angioplasty (BAP). 14.9% patients underwent emergency and urgent coronary artery bypasses with cold and pharmacological cardioplegia. Minimally invasive coronary bypass (MICB) was used in 4.2% patients. Combined BAP + MICB were performed in 2.1% patients. Indications, terms, sequence and future of ACS surgical treatment are discussed.

[Analysis of mental functions in patients after coronary bypass surgery]. / Analiz psikhicheskikh funktsii u patsientov, perenesshikh aortokoronarnoe shuntirovanie.

The neuropsychological examination was carried out in 18 men (study group), mean age 59.7 +/- 6.6 years, before and after aorto-coronary bypass. The neuropsychological tests were carried out 2-3 days before operation and 14-16 days after it. 12 non-operated men with coronary artery disease, mean age 60.0 +/- 6.7 years, were studied as a control group. In control group the neuropsychological tests were conducted with a 16-19 day interval. The tests examined short-term verbal and visual memory, semantic memory. At statistical analysis of the results the mean values and confidential intervals were calculated allowing for Student's coefficient. In control group at consecutive tests the negative dynamics of the results was not revealed. The comparison of the tests results in the study group patients before and after operation revealed the a decrease of neuropsychological parameters by 20-40% on the average irrespective of material modality. Features of cognitive changes revealed in early postoperative period, testifies to diencephalic type of the disorders.

[Treatment of acute destructive alimentary pancreatitis]. / Lechenie ostrogo destruktivnogo alimentarnogo pankreatita.

The paper reports treatment of 52 patients with acute destructive pancreatitis for the period from 1993 to 1999. Up to 1997 conservative policy for management of such patients was used, operative treatment was carried on only in pyoseptic complications (43 patients, group 1). Later on early video-endoscopic procedures (9 patients) aimed at removal of toxic exudate from the abdominal cavity, its sanation and drainage with the use of not less than 5 drainage tubes were employed. From 43 patients of group 1 10 died. There were no lethal outcomes in group 2. The authors believe that early evacuation of the toxic purulent exudate with lavage and drainage of the abdominal cavity promotes more effective elimination of multiorganic insufficiency and decreases the risk for development of pyoseptic complications.

[Pulmonary artery embolism]. / Emboliia legochnoi arterii.

The authors have an experience in diagnosis and treatment of pulmonary embolism in 194 patients. Much attention is paid to diagnosis of thrombosis of the deep veins, phlebography and duplex scanning as the most informative methods. Due to regular unspecific and specific prophylaxis of deep phlebothrombosis in operated patients, pulmonary artery embolism occurred only in 2 patients for 12 years. Valid diagnosis of pulmonary artery embolism is thought possible only in application by pulmonary scanning and angiopulmonography. Mostly conservative method of treatment was used, only in 2 patients successful embolectomy was performed. Anticoagulation (heparin) and fibrinolytic (streptase) therapy was carried out. The results of streptase administration were superior to those of heparin injections. Recovery rate after fibrinolytic therapy made up 86.4%.

[An algorithm for differential diagnosis searching in space-occupying lesions of the liver]. / Algoritm differentsial'no-diagnosticheskogo poiska pri ob''emnykh obrazovaniiakh pecheni.

The experience of examination of 584 patients with volumetric masses of the liver (VML) of various origin is presented. For successful differential diagnosis of VML and definition of rational surgical policy the algorithm of examination was considered with due regard for diagnostic stages, each of them being characterized by definite complex of tests. It is thought necessary to begin examination with noninvasive and highly informative tests. Complex of radioimmunologic evaluation of tumor markers level is advisable to include in diagnostic algorithm of patients with VML. The use of invasive methods of diagnostics is justified in complicated diagnostic situation. For evaluation of regional function of the liver radionuclear examination should be used. Liver puncture are feasible only whenever parasitic nature of cystic masses of the liver is excluded. If it is found to be impossible to determine the character of VML the question of advisability of diagnosis laparotomy should be resolved in its favour. The most efficient use of various methods of examination in 584 patients with VML of various genesis made it possible to increase accuracy of diagnosis of hepatic hemangioma, in nonparasitic cysts--1.7 times and in parasitic cysts--1.2 times.

[The results of treating stomach cancer at a medical center]. / Rezul'taty lecheniia raka zheludka v meditsinskom tsentre.

Results of diagnosis and treatment of gastric cancer according to the program of screening in permanently followed-up population group during 1980-1995 years, developed and introduced into practice of Medical Center of the President of Russia Administration, are analysed. According to the Cancer Register data through this period, total number of cases of this disease comprised 896 patients. Active revealing of cancer of the stomach made up 61%. The causes of advanced disease in patients with stage IV cancer have been thoroughly analysed, their share being high enough--23.5%. Due to achieved level of early diagnosis (I stage) the possibility of only radical surgical treatment rises up to 83.5%, allowing to receive a high percent of corrected 5-year (92-93%) and 10-year (83-88%) survival. Every third patient with cancer of the stomach succumbs due to causes unconnected with the progression of the disease.

[The clinical picture and treatment of destructive pancreatitis]. / Klinika i lechenie destruktivnogo pankreatita.

The results of treatment of 319 patients with acute pancreatitis are analyzed, 48 from them (15.1%)--with pancreanecrosis. Etiologic factors in destructive pancreatitis were alcohol addiction (41.67%), cholelithiasis (37.5%), hyperlipidemia (10.41%), hypercalcemia (4.17%), postoperative (4.17%). Location of the necrosis in parapancreatic fat cellular tissue was detected in 6 patients, in pancreatic head--in 8 and both in pancreatic head and corpus--in 11, in corpus and in tail--in 10; total pancreo-necrosis was observed in 5 patients. Therapeutic measures were conservative and only in cholelithiasis cholecystectomy was performed as well as drainage of the choledochus and abdominal cavity. Intensive care was aimed at blocking pancreatic and gastric secretion, inhibition of pancreatic enzymes ferments and suppressing mediators of inflammation, immunocorrection, prophylaxis of infection in the necrotic tissues. Desintoxication was carried out by combination of infusion therapy with forced diuresis, usage of extracorporeal methods and laparoscopic sanation of the abdominal cavity with subsequent lavage. Surgical interventions were carried out in far-off period only for complications of pancreanecrosis. Mortality rate in pancreanecrosis made up 20.85% and in total number of patients with acute pancreatitis--3.13%.

[Diagnosis and surgical policy in benign lesions of liver]. / Diagnostika i khirurgicheskaia taktika pri dobrokachestvennykh ob''emnykh obrazovaniiakh pecheni.

The results of the treatment of 430 patients with benign tumors of the liver (BTL), including hemangiomas (41), nonparasitic solitary cysts (49), polycystosis (65) and parasitic hepatic lesions (alveococcosis-91, echinococcosis-184). To determine the character of a volume structure the accuracy of ultrasound and duplex sonography was tested (87.1-91.7%), as well as the accuracy of computer tomography (91.4-96.8%), angiography (90.6-96.3%), serological and radioimmunoassays. The use of these methods has increased the accuracy of diagnosis 2.2 times (in hemangiomas), nonparasitic cysts-to 1.2 times. The proposed methods of differential diagnosis and choosing of a proper treatment policy in patients with BTL made it possible to formulate indications and contraindications for the surgery, work out an optimal treating policy, depending on a character, location of BTL. The improvement of the surgical technique has decreased the rate of morbidity and mortality (2.5 and 1.5 times respectively).

[Antiseptics on the base of Octenidine Hydrochloride]. / Antisepticheskie preparaty na osnove Oktenidingidrokhlorida.

Comparative evaluation of laboratory and clinical investigation of antiseptic preparations on the base of octenidin-hydrochloride and bigluconate chlorhexidine in 537 patients was carried out. Statistically valid decrease in dissemination through the operation field and surgical wound after application of octenidin containing solutions was determined. It was established as well that these preparations were more effective fools of protection of the operation wound from its microbial contamination in comparison with antiseptic solutions widely spread to date in surgical practice.

[Immunotherapy of surgical sepsis]. / Immunoterapiia khirurgicheskogo sepsisa.

The results of treatment of 73 patients with surgical sepsis are analysed. 57% of the patients were older than 60 years. In 35.6% of the cases sepsis was caused by soft tissue infection, in 35.6%-pyo-inflammation of the blood vessels. In 81% of the cases infective agents were verified; in 45.2% they were found in associations. In 35.1% of the cases there were gram-positive microorganisms, in 40.5%-gram-negative and in 17.0%-asporogenic anaerobes. The count of T- and B-lymphocytes was low (60.0% and 45.7%), the count CD4 was decreased in 40.2% of the patients, CD8-in 31.6%, the content of M-and G-immunoglobulins was also decreased on a background of a slightly increased CD3-activator. Polyorganic insufficiency has been detected in all the patients, predominantly-kidney and liver insufficiency. Septic metastases were detected in 26% of the cases, septic shock-10%. Early treatment of abscesses, adequate antibacterial and detoxication therapy are major tasks in the treatment of sepsis. Intravenous injections of immunoglobulins (Endobulin., Intraglobin and Pentaglobin), extracorporeal detoxcication and polyorganic disorders correction have led to positive results in most cases. The mortality rate in this group was 14.5% compared with 38.5% in the control group.

[The problem of acute pain in postoperative period]. / Problema ostroi boli v posleoperatsionnom periode.

The problem of postoperative pain remains actual despite the existence of a variety of pharmaceutical and nonpharmaceutical methods of anesthesia. Acute postoperative pain is an essential component of the surgical stress syndrome. Opioid analgetics (Buprenorfin, Nubain, Tramal, Promedol, Morphine) take the leading position among other types of analgetics. Present-day individual approach to administration of analgetics is still imperfect. The use of a standard dose of analgetics appears to be inadequate in a number of patients. The increase of opioids dose may lead to adverse reactions. In view of this it is valid to use nonsteroid antinflammatory medicines (Ketorolac). The choice of a proper dose of an analgetic is critically important in achieving adequate anesthesia. Patient-controlled analgesia (PCA) or "analgesia on demand" is an alternative to administration of analgetics. The major advantage of PCA is the opportunity to achieve the rate of analgesia, according to individual demand of a patient. Besides, PCA allows to reach the desired effect much faster and to maintain the stable plasma level of an analgetic. 2-year experience of the PCA use in more than 200 patients of the National Research Centre for Surgery ICU has been analysed. The authors advocate use of PCA in clinical practice.