[Unformed conglomerate debilitating jejunal fistulas and their two-stage surgical treatment via posterolateral laparotomy]. / Nesformirovannye konglomeratnye istoshchayushchie toshchekishechnye svishchi i ikh dvukhetapnoe khirurgicheskoe lechenie iz zadnebokovogo laparotomnogo dostupa.

OBJECTIVE: To create a method of two-stage repair of high unformed conglomerate delimited debilitating jejunal fistulas via posterolateral laparotomy with low risk of surgical complications. MATERIAL AND METHODS: Methodology and treatment outcomes were analyzed in 37 patients with unformed conglomerate high debilitating delimited jejunal fistulas. Of these, 22 patients underwent one-stage treatment through 2 converging incisions and/or two-stage treatment through anterolateral access. They made up a control group. Fifteen patients in the main group underwent two-stage treatment via posterolateral left-sided laparotomy with unilateral disconnection of jejunum with fistula. In most patients of both groups, fistulas complicated surgery for acute adhesive intestinal obstruction. Topography of adhesions that caused acute intestinal obstruction in both groups was studied in 172 other patients. Identical jejunal fistulas and two different surgical approaches made it possible to consider our groups representative. RESULTS: Two-stage treatment via posterolateral left-sided laparotomy reduced mortality from 63.6±10.2% to 20.0±10.3% (t=11.8; p<0.001). This approach simplified intraoperative diagnostics that became more informative. Posterolateral access increased the quality of anastomosis and safety of viscerolysis. CONCLUSION: A new two-stage approach with posterolateral left-sided laparotomy allowed atraumatic imposing of inter-intestinal anastomosis with proximal disconnection of jejunal fistula. This exclusion turns the fistula into analogue of the definitive Meidl's jejunostomy, unloads the intestinal anastomosis and increases the quality of suture. New strategy reduced the risk of complications and mortality.

[New approaches in surgery for osteomyelitis of the femoral neck and head via anterior access]. / Perednii dostup v khirurgii osteomielita sheiki i golovki bedra.

OBJECTIVE: To analyze an effectiveness of anterior approach to the hip joint for sequestrectomy with myoplasty. MATERIAL AND METHODS: We have developed anterior surgical access for osteomyelitis of the femoral neck and head. Semi-oval incision is made in projection of the femoral head. Tendons of sartorius muscle and rectus femoris muscle are cut off from anterior spine of the iliac wing. Surgical field ensures sequestrectomy for osteomyelitis of the hip joint. Closure of osteomyelitis cavity is performed by the proximal parts of two anterior iliacus muscles. Surgical field may be enlarged by temporary intersection of iliopsoas muscle tendon. RESULTS: The key to anterior surgical approach to the hip joint is sartorius muscle and rectus femoris muscle. The length of surgical wound reaches 17-22 cm, width - 16-18 cm. The mobilized proximal part of sartorius muscle is used for closure of the entire bone cavity in femoral neck and head. Stable long-term remission was observed in 11 (91.7±7.6%) out of 12 patients. CONCLUSION: Original surgical approach is less traumatic and ensured manipulations under an angle of about 90°. This access complements the advantages of the well-known anterior approaches and has no their disadvantages.

[Surgical resolutions determining outcomes of infected pancreatic necrosis]. / Khirurgicheskie resheniia, opredeliaiushchie iskhod lecheniia infitsirovannogo pankreonekroza.

AIM: To evaluate technology, indications and time of minimally invasive semi-closed and laparotomic sanations for infected pancreatic necrosis (IP). MATERIAL AND METHODS: Initially it was used sonography-assisted minimally invasive semi-closed drainage of IP with gradual augmentation of catheters' diameter. In 462 patients with IP liquid pus prevailed over sequesters in epigastric localized pancreatonecrotic phlegmon (ELPF) and pancreatonecrotic abscesses. So, minimally invasive approach may be definitive. Epigastric advanced pancreatonecrotic phlegmon with predominant sequesters is often followed by conversion to transverse omentobursopancreatostomy (OBPS) to open all purulent accumulations. RESULTS: Surgical treatment immediately after parapancreatic infiltrate suppuration (i.e. within 3-4 weeks after onset of the disease) is associated with reduced mortality. Absent result of minimally invasive drainage is followed by mortality from the 11th day and maximum in 14 days after treatment onset. Therefore, focal IP resistant to minimally invasive drainage requires conversion to transverse OBPS or video-assisted sequestrectomy after 10-13 days. The lowest mortality (14.8±2.5%) was observed in patients who underwent minimally invasive drainage or transverse OBPS within 10-13 days. Ineffective prolonged minimally invasive drainage was accompanied by high mortality rate (60.7±3.2%, p<0.001). CONCLUSION: Conversion to transverse OBPS or video-assisted sequestrectomy are required if minimally invasive drainage of IP is ineffective after 10-13 days. Clear understanding of indications for closed and open drainage of PI helps to avoid tactical and technological errors.

[Surgical treatment of diabetic neuroosteoarthropathy (DNOAP) and its long-term results]. / Khirurgicheskoe lechenie diabeticheskoi neiroosteoartropatii i ego otdalennye rezul'taty.

AIM: To develop pathogenetically justified surgical treatment of diabetic neuroosteoarthropathy (DNOAP). MATERIAL AND METHODS: 52 patients were operated and long-term results were studied in 36 of them. 2 groups were assessed depending on completeness of surgical treatment including changed synovial structures removal. Tarso-metatarsal arthrodesis was created after synovectomy in median foot to restore longitudinal arch. Cruro-calcaneal neoarthrosis was performed after elimination of posterior focus of DNOAP. Excision of large, deep plantar ulcer (or osteomyelitic fistula) was completed by tissues tension with needles for primary wound healing. RESULTS: DNOAP patients are tolerant against surgical infection that is decreased in patients with neuropathic form of diabetic foot syndrome. Skin plasty is followed by rejection in DNOAP that was cured with prednisolone. Deep suppurations complicating foot skeleton fragmentation have subacute course and do not lead to sepsis. Infected wounds heal by primary intention in 98% after closure with primary suture. It was empirically found that synovectomy and osteochondral detritus removal discontinue DNOAP course. Reconstructive surgical stage is aimed to restoring the shape and function of the foot. Analysis of long-term outcomes showed absence of DNOAP signs in 76.2±9.2% of cases after radical surgery and positive results of treatment in 97.2±2.7% of patients. CONCLUSION: Our data conceptually assume the possibility of autoimmune mechanism in DNOAP pathogenesis. On this basis pathogenetically reasonable surgical procedures are established to interrupt pathological process. These interventions differ by technological aspects only depending on middle or rear foot destruction.

[Laparotomy closure in advanced peritonitis]. / Sposoby zakrytiya laparotomnoi rany pri rasprostranennom peritonite.

AIM: to improve the results of advanced peritonitis management. MATERIAL AND METHODS: 743 patients with advanced peritonitis were studied. Patients were divided into 2 groups depending on treatment strategy. RESULTS: Programmed relaparotomy combined with removable draining musculoaponeurotic seams during laparotomy closure decreased mortality from 47.8±2.7% to 24.1±2.3% (p<0.001) and provided 4-fold reduction of postoperative suppuration incidence (p<0.001). Refusal from removable draining musculoaponeurotic seams and use of only cutaneous seams in persistent abdominal hypertension were associated with further decrease of mortality to 15.8±2.7% (p<0.05). CONCLUSION: Programmed relaparotomy combined with removable draining musculoaponeurotic seams are advisable for advanced peritonitis management. Laparotomy closure with only cutaneous seams is indicated in case of persistent abdominal hypertension. Large eventration always requires abdominal wall repair. APACHE-III scale scores have significant prognostic value in patients with advanced peritonitis.

[The choice of tactical decisions in surgical treatment of massive infected pancreonecrosis].

Treatment results of 368 patients with infected pancreonecrosis were analyzed. Overall lethality was 29.6 ± 3.4%. Maximal lethality was among patients with phlegmona - 43.6 ± 5%, minimal (12.9 ± 3.8%) among patients with abscess. Spread phlegmonas, when closed sequestrectomy was impossible, were treated by transversal omentobursopancreatostomy. When the closed drainage of infected pancreonecrosis areas was not effective after 10-13 days, conversion to the omentobursopancreatostomy was performed. Lethality among patients with non-alternative closed drainage was 50.0 ± 4.5%. Lethality after omentobursopancreatostomy was 19.0 ± 4.2%.

[Debatable questions in diabetic foot syndrome classification].

The experience of treatment of 705 patients with the diabetic foot syndrome (DFS) determined the necessity of reviewing the existing classifications of the disease. Main features of clinics and pathology define three basic forms of the DFS: neuropathic, neuroischemic and ischemic. The new ischemia classification is brought forward. It is based on reliable micro- and macrogemodynamic criteria, which are also important for clinical decision making.

[Differential surgical treatment of idiopathic megadolichocolon in adults]. / Differentsial'noe khirurgicheskoe lechenie idiopaticheskogo megadolikhokolon vzroslykh.

An analysis of results of surgical treatment of 158 adult patients with the syndrome of chronic colostasis (SCC) has shown that the rectal form of Hirschsprung's disease (RFH) was diagnosed in 57 patients while idiopathic megadolichocolon (IMC)--in 101 patients. There were two types of SCC: proctogenic and cologenic. The proctogenic type appears in patients with RFH due to hypogangliosis and agangliosis, and in patients with IMC--as a result of dystrophy of ganglionic neurons of the Meissner plexus of the rectum. The computed morphometry and histochemical investigations have shown that hypogangliosis and agangliosis in RFH were of congenital origin while dystrophy of the rectal ganglia in many patients with IMC was an acquired pathology. The marginal variant of the second type of the colon structure can be considered as a cause of SCC. A new operation--endofascial resection of the rectum--is proposed for treatment of proctogenic SCC. The differential surgical strategy with pathomorphogenesis of SCC taken into account allowed to get satisfactory results in 73% of cases.

[Removable draining aponeurotic and muscular-aponeurotic sutures in the prevention of suppuration of laparotomy wounds]. / S"emnye dreniruiushchie aponevroticheskie i myshechno-aponevroticheskie shvy v profilaktike nagnoenii laparotomnykh ran.

Clinico-instrumental investigations and experimental studying of the regeneration of laparotomy wounds sutured by removable draining aponeurotic and muscular-aponeurotic sutures have shown less pronounced course of aseptic inflammation in the wounds. It has been established that the removable aponeurotic sutures substantially decrease the frequency of postoperative suppurations of laparotomy wounds in patients operated on the colon mainly for colorectal carcinoma. The original authors' sutures provide the formation of a cicatrix of the laparotomy wound by the 20th day of the postoperative period and completely prevent the appearance of ligature fistulas.

[Prevention of extremities amputation in patients with diabetic foot complications]. / Predotvrashchenie amputatsii konechnostei u bol'nykh s oslozhneiiem "diabeticheskoi stopy".

In order to decrease the number of amputations for "diabetic foot", these patients should undergo elective or delayed operations. It is obligatory before the operation to correct carbohydrate metabolism and hemodynamics. Sodium succinate in combination with conventional angioprotective treatment is used for this purpose. Microcirculation is evaluated using oxymonitor ISM-2 and tetrapolar rheography. Blood flow disturbances are evaluated according to ultrasound dopplerography data. Operations are performed with the use of a primary or delayed suture at the definite level of the extremity where oxygen tension of the skin is not lower than 33 mm Hg, and the index of minute blood flow--not lower than 1.8 ml/min per 100 cm3 of the tissue. When operating on the foot it is obligatory to leave loose excessive brims of tissues to facilitate the placement of broad-grip sutures without tension. It is advisable to use through flowing--aspiration drainage and to perform surgical treatment of the deep phlegmon of the foot through club-shaped approach.

[Sodium hypochlorite in the treatment of suppurative wounds]. / Gipokhlorit natriia v lechenii gnoinykh ran.

Under observation there were 174 patients with purulent wounds, 54 of them were treated with application of 0.06% solution of sodium hypochlorite, and 20 patients made up a control group and were treated by traditional methods. It was found that the application of the solution of sodium hypochlorite results in sharp elevation of susceptibility of wound microflora to antibiotics and facilitates more rapid debridement of the wounds and makes the treatment at the hospital 3.7 and 2.4 times shorter correspondingly (as compared with the control group).