[Clinical and economic aspects of laparoscopic surgery for acute cholecystitis in delayed presentation]. / Kliniko-ekonomicheskie aspekty laparoskopicheskikh operatsii pri ostrom kholetsistite v usloviyakh pozdnei gospitalizatsii.

OBJECTIVE: To study the clinical and economic features of laparoscopic surgery for acute cholecystitis in delayed presentation. MATERIAL AND METHODS: A prospective non-randomized study (2020-2021) included 101 patients (73.2% (n=74) men and 26.8% (n=27) women, mean age 58±14.9 years) with acute cholecystitis who underwent laparoscopic cholecystectomy. Cost-effectiveness analysis of laparoscopic cholecystectomy at various periods after clinical manifestation was performed. RESULTS: Surgical treatment within 72 hours was performed in 15% (n=16) of cases (group 1), within 4-10 days - in 57.5% (n=58) (group 2), after 10 days - in 26.7% (n=27) of patients (group 3). Overall incidence of postoperative complications was 2.9%, postoperative mortality - 1.9% (two patients died from widespread peritonitis). Surgery time was 70 [65-83], 85 [69-110] and 115 [80-125] min (H=15.55, p<0.001), hospital-stay - 6 [5-7], 9 [7-10] and 11 [7-14] days, respectively (H=21.86, p<0.001). Cost of direct (medical and non-medical) treatment amounted to 29484 [27 509-33 885], 41265 [34 306-48 301] and 50591 [37 069-62 483] rubles, respectively (H=29.71, p<0.001)). CONCLUSION: Delayed hospitalization and surgical treatment of acute cholecystitis after 72 hours are accompanied by higher treatment costs by 29% in the period up to 10 days and by 58% after 10 days. These results require further validation and adjustment in large samples.

Should we encourage the use of robotic technologies in complicated diverticulitis? Results of systematic review and meta-analysis.

Introduction: Complicated diverticulitis is a common abdominal emergency that often requires a surgical intervention. The systematic review and meta-analysis below compare the benefits and harms of robotic vs. laparoscopic surgery in patients with complicated colonic diverticular disease. Methods: The following databases were searched before 1 March 2023: Cochrane Library, PubMed, Embase, CINAHL, and ClinicalTrials.gov. The internal validity of the selected non-randomized studies was assessed using the ROBINS-I tool. The meta-analysis and trial sequential analysis were performed using RevMan 5.4 (Cochrane Collaboration, London, United Kingdom) and Copenhagen Trial Unit Trial Sequential Analysis (TSA) software (Copenhagen Trial Unit, Center for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark), respectively. Results: We found no relevant randomized controlled trials in the searched databases. Therefore, we analyzed 5 non-randomized studies with satisfactory internal validity and similar designs comprising a total of 442 patients (184 (41.6%) robotic and 258 (58.4%) laparoscopic interventions). The analysis revealed that robotic surgery for complicated diverticulitis (CD) took longer than laparoscopy (MD = 42 min; 95% CI: [-16, 101]). No statistically significant differences were detected between the groups regarding intraoperative blood loss (MD = -9 mL; 95% CI: [-26, 8]) and the rate of conversion to open surgery (2.17% or 4/184 for robotic surgery vs. 6.59% or 17/258 for laparoscopy; RR = 0.63; 95% CI: [0.10, 4.00]). The type of surgery did not affect the length of in-hospital stay (MD = 0.18; 95% CI: [-0.60, 0.97]) or the rate of postoperative complications (14.1% or 26/184 for robotic surgery vs. 19.8% or 51/258 for laparoscopy; RR = 0.81; 95% CI: [0.52, 1.26]). No deaths were reported in either group. Discussion: The meta-analysis suggests that robotic surgery is an appropriate option for managing complicated diverticulitis. It is associated with a trend toward a lower rate of conversion to open surgery and fewer postoperative complications; however, this trend does not reach the level of statistical significance. Since no high quality RCTs were available, this meta-analysis isnot able to provide reliable conclusion, but only a remarkable lack of proper evidence supporting robotic technology. The need for further evidence-based trials is important.

[Perforated peptic ulcer in patients with cancer: prediction of postoperative morbidity and mortality]. / Probodnaya yazva u patsientov s onkologicheskimi zabolevaniyami: prognozirovanie posleoperatsionnykh oslozhnenii i letal'nogo iskhoda.

OBJECTIVE: To analyze treatment outcomes and approaches to predicting the postoperative morbidity and mortality in patients with perforated ulcers and cancer. MATERIAL AND METHODS: A non-randomized trial included 194 patients. The first group enrolled 45 (23%) patients with perforated ulcers and concomitant cancer who underwent at the oncology center; the second group included 149 (77%) patients with perforated ulcers and no cancer who underwent surgery in general surgical hospitals. Organ-sparing procedures prevailed (40 (88.9%) and 138 (92.6%) cases, respectively). Resections were performed in 5 (11.1%) and 11 (7.4%) patients respectively. Analyzing the factors affecting treatment outcomes, we studied crude (COR) and adjusted (AOR) odds ratios. ROC-analysis was used to assess diagnostic significance of the models for prognosis of morbidity and mortality. RESULTS: Length of hospital-stay was 10 (range 9-14) and 8 (range 7-9) days respectively. Postoperative complications (Clavien-Dindo grading system) occurred in 18 (40%) in 37 (24.8%) patients, respectively. According to multivariate analysis, predictors of complications in patients of the first group were treatment with NSAIDs/glucocorticoids and Charlson-Deyo index >3. Sensitivity of this model was 82.4%, specificity - 75.0%. Postoperative mortality was 15.6% (n=7) and 7.4% (n=11) respectively. According to multivariate analysis, predictors of mortality were age over 65 years and more than 5 chemotherapeutic courses. Sensitivity of the model was 85.7%, specificity - 97.4%. CONCLUSION: The stratified approach makes it possible to improve prediction of postoperative morbidity and mortality in patients with perforated ulcers.

[Comparison of robot-assisted and conventional endoscopic surgeries in the Russian Federation. (A systematic review and meta-analysis)]. / Sravnenie robot-assistirovannykh i traditsionnykh videoendoskopicheskikh operatsii v RF. (Rezul'taty sistematicheskogo obzora i metaanaliza).

OBJECTIVE: Comparative assessment of immediate and long-term results of robot-assisted and conventional endoscopic technologies in the Russian Federation. MATERIAL AND METHODS: Searching for primary trials devoted to robot-assisted (RAE) and traditional video endoscopic (TVE) surgeries in the Russian Federation was carried out in the e-library and CENTRAL Cochrane databases. We used the recommendations of the Center for Expertise and Quality Control of Medical Care (2017, 2019) and the current version of the Cochrane Community Guidelines (2021). These guidelines define the features of meta-analysis of non-randomized comparative studies. Review Manager 5.4 software was used for statistical analysis. RESULTS: We enrolled 26 Russian-language primary sources (3111 patients) including 1174 (38%) ones in the RAE group and 1937 (62%) patients in the TVE group. There were no randomized controlled trials in the Russian Federation, and all primary studies were non-randomized. We found no significant between-group differences in surgery time, incidence of intraoperative complications, intraoperative blood loss in thoracic surgery, urology and gynecology, conversion rate, postoperative hospital-stay, postoperative morbidity (in abdominal surgery, urology and gynecology), postoperative mortality. We observed slightly lower intraoperative blood loss for RAE in abdominal surgery and lower incidence of postoperative complications in robot-assisted thoracic surgery. These results can be compromised by methodological quality of comparative studies, significant heterogeneity and systematic errors. CONCLUSION: Currently, we cannot confirm the benefits of robot-assisted technologies, since this approach does not worsen or improve treatment outcomes. Further high-quality studies are needed.

[Open and laparoscopic surgery via minimally invasive approach in the treatment of perforated ulcer: a systematic review and metaanalysis]. / Laparotomnye i laparoskopicheski assistirovannye operatsii iz minidostupa v lechenii probodnoi yazvy. Sistematicheskii obzor i metaanaliz.

OBJECTIVE: Systematic review and metaanalysis of the effectiveness of open and minimally invasive laparoscopic suturing of perforated peptic ulcer. MATERIAL AND METHODS: Searching for Russian and English language reports included Scientific Electronic Library, Cochrane Collaboration Library and PubMed databases. We have analyzed contents of specialized journals, reviews and their references. Unpublished data were obtained via communication with chiefs of national surgical hospitals. RevMan 5.3 software was used for metaanalysis. RESULTS: We found no international randomized trials in available literature. Metaanalysis was based on national non-randomized studies. Total sample was 1177 cases. Laparoscopic minimally invasive surgery was performed in 43% of cases (n=503), open suturing - in 57% (n=674) of patients. Choice of these procedures is not currently not standardized. Minimally invasive procedures are shorter in time (mean difference -8.02, 95% CI -11.26 - -4.77, p<0.00001) and ensure less hospital-stay (mean difference -1.93, 95% CI -2.97 - -0.88, p=0.0003). Complications were less common (OR 0.14, 95% CI 0.07-0.27, p<0.00001) after minimally invasive operations (2.4%, 12/503) compared to laparotomy (11.4%, 77/674). Incidence of suture failure was similar (OR 0.4, 95% CI 0.1-1.6, p=0.2) (0.4% (2/503) vs. 0.7% (5/674)). Postoperative mortality was higher (OR 0.14, 95% CI 0.05-0.37, p<0.0001) after laparotomy (8%, 54/674) compared to laparoscopy (0.8%, 4/503). CONCLUSION: A metaanalysis indicates the advantage of laparoscopy-assisted suturing of perforated ulcer via minimally invasive approach over laparotomy. The absence of a standardized approach in choosing of minimally invasive laparotomy and conventional approach is a limitation of these results.

[Distal subtotal gastrectomy and gastreectomy in surgical treatment of patients with gastric cancer: a systematic review and meta-analysis]. / Sravnitel'naya otsenka subtotal'noi distal'noi rezektsii i gastrektomii v khirurgicheskom lechenie bol'nykh rakom zheludka.

OBJECTIVE: To analyze the randomized controlled trials (RCTs) devoted to distal subtotal gastrectomy and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer. MATERIAL AND METHODS: RCTs were searched in the electronic library, the Cochrane Community database, and PubMed database. A systematic review and meta-analysis were carried out in accordance with the recommendations of the Cochrane Community experts (Higgins et al. 2019). Mathematical calculations of a meta-analysis were made using RevMan 5.3 software package. Statistical criteria were calculated for relative risk (RR), hazard ratio (HR), 95% confidence interval (95% CI) and significance level (p). RESULTS: Seven primary RCTs were selected. A total number of 1463 surgical interventions with D2 lymphadenectomy were observed (805 patients underwent distal subtotal gastrectomy, 658 - gastrectomy). Postoperative mortality is significantly higher (6.5% and 2.6%) after gastrectomy compared to subtotal distal gastrectomy (RR 2.2, 95% CI 1.34-3.64, I2 0%, fixed effect model). Postoperative complications are also significantly more common (28% and 14%) after gastrectomy (RR 1.72, 95% CI 1.16-2.55, I2 heterogeneity 49%, random effect model). Differences in overall five-year survival after gastrectomy and subtotal distal resection (51.6% and 60.8%) are insignificant (HR 0.74, 95% CI 0.45-1.22, I2 90%, random effect model, general reverse inversion). CONCLUSION: The choice of distal subtotal gastrectomy and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer is not regulated by evidence-based medicine. The boundaries of minimal surgical clearance from the tumor edge vary from 2.5 cm to 6 cm. An updated meta-analysis shows that postoperative mortality and morbidity are significantly higher after gastrectomy compared to distal subtotal gastrectomy while overall 5-year survival is similar.

[The first episode of spontaneous pneumothorax (errors, hazards, complications)]. / Oshibki, opasnosti, oslozhneniia pri pervom épizode spontannogo pnevmotoraksa.

AIM: To analyze the errors and complications of surgical care in patients with the first episode of spontaneous pneumothorax at different hospitals. MATERIAL AND METHODS: From 2005 to 2015 three hundreds and seventeen patients with the first episode of spontaneous pneumothorax have been treated at the thoracic department of Volgograd State Medical University. Patients were divided into 2 groups: 79 of them underwent thoracotomy while in 238 cases minimally invasive technologies were applied. Faster preoperative management and earlier active surgical tactics were suggested. RESULTS: There were 6 the most typical violations of surgical care in 42% of patients with the first episode of spontaneous pneumothorax. Medical and diagnostic violations at regional centers and central district hospitals were the same, but there were differences in certain types of errors and their incidence. Minimally invasive technologies do not significantly affect the number of violations of thoracic surgery principles. Early procedures against the recurrence by using of thoracoscopic interventions reduce postoperative morbidity from 1.2 to 0.3% and mortality by 8.25 times.

Role of Progenitor Cells in Liver Regeneration after Subtotal Resection.

In the liver of rats subjected to subtotal liver resection (80% organ weight), the expression of sox9 gene and SOX9 protein content increased and cells with hepatocyte morphology expressing SOX9 appeared; the proportion of cells expressing cytokeratin-19 also increased. Based on these data, we cannot completely exclude the involvement of resident progenitor cells and hepatocyte reprogramming in liver regeneration after subtotal resection, however, the contribution of these processes seems to be insignificant. The leading mechanism of liver mass recovery after subtotal resection is proliferation of hepatocytes.

Multiple scattering effects in Doppler optical coherence tomography of flowing blood.

We investigate the effect of multiple scattering on the optical coherence tomography (OCT) signal and the Doppler OCT signal of flowing blood. Doppler OCT measurements at 1300 nm are performed on flowing diluted porcine blood with hematocrit ranging between 0% and 15%. Measured blood hematocrit and mean red blood cell volume are used to calculate, using the discrete dipole approximation model, the (single) scattering coefficient and scattering anisotropy of blood. Monte Carlo simulations, based on the calculated scattering coefficients and scattering anisotropies, are compared to Doppler OCT measurements for hematocrit smaller than 10%. Good quantitative agreement between Doppler OCT measurements and Monte Carlo simulations is observed. Our measurements, calculations and simulations explain the relatively low attenuation coefficients and well preserved flow profiles measured with Doppler OCT for flowing blood. Monte Carlo simulations demonstrate the effect of the scattering anisotropy of the medium on the strength of multiple scattering effects in Doppler OCT signals. With increasing scattering anisotropy the OCT attenuation decreases; the distortion of the flow profile is strongest at intermediate scattering anisotropies (≈0.6).

Multiple and dependent scattering effects in Doppler optical coherence tomography.

Doppler optical coherence tomography (OCT) is a technique to image tissue morphology and to measure flow in turbid media. In its most basic form, it is based on single (Mie) scattering. However, for highly scattering and dense media multiple and concentration dependent scattering can occur. For Intralipid solutions with varying scattering strength, the effect of multiple and dependent scattering on the OCT signal attenuation and Doppler flow is investigated. We observe a non-linear increase in the OCT signal attenuation rate and an increasingly more distorted Doppler OCT flow profile with increasing Intralipid concentration. The Doppler OCT attenuation and flow measurements are compared to Monte Carlo simulations and good agreement is observed. Based on this comparison, we determine that the single scattering attenuation coefficient micros is 15% higher than the measured OCT signal attenuation rate. This effect and the distortion of the measured flow profile are caused by multiple scattering. The non-linear behavior of the single scattering attenuation coefficient with Intralipid concentration is attributed to concentration dependent scattering.

[Evolution of approaches to surgical treatment of complicated cholecystitis]. / Evoliutsiia podkhodov k khirurgicheskomu lecheniiu oslozhnennogo kholetsistita.

More than 17 thousand surgeries for calculous cholecystitis and its complications including 560 repeated surgeries on the major bile ducts were performed. Based on this experience three stages in treatment of complicated cholecystitis are distinguished. Principal changes of surgical policy are the criteria of this division. From 1993 a tendency towards mini-invasive surgery in complicated cholecystitis was developing. Optimal terms of surgery, adequate scope improved technique improve significantly results of surgical treatment of complicated cholelithiasis.

[The role of the vascular factor in the reorganization of water metabolism in denervated liver after bacterial endotoxin poisoning].

Intoxication with bacterial lipopolysaccharide (endotoxin) is accompanied by considerable rearrangements in the systems of blood microcirculation and water metabolism of the liver. These rearrangements are manifested as increased sinusoid area, changed total area of the cytoplasm and nuclei as well as the nucleocytoplasmic ratio in hepatocytes, increased content of total water in the organ, and changed magnetic relaxation properties (spin-lattice and spin-spin relaxation times). Preliminary parasympathetic denervation of the liver (vagotomy) changes the pattern of the organ response to bacterial endotoxin poisoning as indicated by the kinetics of studied morphological and biophysical parameters.

[Morpho-biochemical study of the liver and serum albumins during tetrachloromethane intoxication and administration of antihypoxants, antioxidants, and actoprotectors]. / Morfobiokhimicheskoe issledovanie sostoianiia pecheni i sistemy syvorotochnykh al'buminov v usloviiakh intoksikatsii tetrakhlorometanom i vvedeniia antigipoksantov, antioksidantov i aktoprotektorov.

Organism intoxication with tetrachloromethane induces a complex of transformations in the liver and serum albumins system manifested in the liver as necroses in the central lobe, dilatation of sinus capillaries and blood stasis in them, increased content of total water, and changed magneto-relaxation properties indicating decreased structurization of water. The system of serum albumins shows decreased total concentration of albumins in the serum, decreased constant of 1-(phenylamino)-8-sulfonaphthalene probe binding, increased mean number of probe binding per albumin molecule, and increased accessibility of probe in the protein-probe complex for the quencher indicating changed type of interaction between the protein and fluorescent probe. Introduction of a antihypoxant, antioxidant, or actoprotector has a positive effect on the condition of the liver and serum albumins system: The studied indices are nearly completely normalized.

[Changes in the morphofunctional status of the liver in rats with acute tetrachloromethane poisoning and their correction with antihypoxants, antioxidants and actoprotectors]. / Izmeneniia morfofunktsional'nogo sostoianiia pecheni krys pri ostroi intoksikatsii tetrakhlormetanom i ikh korrektsiia antigipoksantami, antioksidantami i aktoprotektorami.

The acute tetrachlormethane intoxication leads to structural and metabolic alterations in the rat liver. Morphological changes include centrolobular necroses and blood stasis in dilated sinusoidal capillaries. Metabolic changes are manifested by an increase in the water content and time of the spin-lattice (T1) and spin-spin (T2) relaxation (this indicates a lesser degree of water structuralization and its enhanced lability), and distortion of the correlation between T1 and T2. The prophylactic administration of one of the antihypoxants, antioxidants or actoprotectors normalizes the morphofunctional condition of the liver. According to the degree of the therapeutic efficacy, the examined preparations form the following series: dibunol > gamma-sodium hydroxybutyrate > tomerzol.

[Dirithromycin in the treatment of infections of the lower respiratory tract]. / Diritromitsin v lechenii infektsii nizhnikh dykhatel'nykh putei.

Good results of the treatment of patients with lower respiratory tract infections with dirithromycin (Eli Lilly, USA), a new semisynthetic macrolide, were recorded. The trial included 15 patients: 6 with acute bronchitis (AB) and 9 with exacerbation of chronic bronchitis (AB) and 9 with exacerbation of chronic bronchitis (ECB). The antibiotic was administered orally in a single dose of 500 mg once a day for 7 days. The treatment efficacy was estimated by the clinical results and laboratory findings. The sputum specimens were investigated bacteriologically with testing the microflora for the drug susceptibility by using the diffusion disks. 50 per cent of the patients with AB isolated Streptococcus viridans with low (the diameter of the growth inhibition zones < 16 mm) and intermediate (16-17 mm) susceptibility to the antibiotic, 33.3 per cent of the patients isolated highly susceptible (19 mm) strains of Str. pneumonia and 16.7 per cent of the patients isolated resistant (15 mm) strains of Staphylococcus epidermidis. Highly susceptible (17-19 mm) strains of Haemophilus influenzae and Str. viridans were isolated respectively from 55.5 and 45.5 per cent of the patients with ECB. In 4 patients with ECB a clinical improvement of the state was recorded. In the other patients with AB and ECB the recovery was stated. The bacteriological tests revealed a new pathogen in 2 patients with ECB and the failure of the treatment in another 2 patients with ECB. In all the other patients the pathogen was shown to be eradicated. In the patients isolating the new pathogen the symptomatic recovery was stated in the posttherapeutic period. Therefore, diritromycin proved to be efficient in 13 out of the 15 patients with lower respiratory tract infections. It should be noted that the drug tolerance was excellent. None of the patients showed any adverse reactions.

[Errors in ultrasonic diagnosis of abdominal diseases]. / Oshibki ul'trazvukovoi diagnostiki zabolevanii organov briushnoi polosti.

Errors in the ultrasonic diagnosis of diseases of the abdominal organs in 2,218 patients were analysed in comparison to endoscopic and operative findings. The errors were few in number. A precise diagnosis was established in 99.6% of cases with acute cholecystitis and in 78% of those with a pathological process in the biliary tract. A maximum number of errors (7 per 42 cases) was encountered in carcinoma of the gallbladder. Ultrasonic examination may serve as the basis for choosing the method of rational therapy in diseases of the liver, pancreas, and complications in the postoperative period. Thus, the results of ultrasonic examination may be fully relied on or may be used as a basis for choosing manipulations which are more invasive in character.

[Contact dissolution of gallstones]. / Kontaktnoe rastvorenie kamnei zhelchnogo puzyria.

The techniques and results of contact dissolution of stones in the gallbladder of 27 patients subjected to laparoscopic cholecystostomy for acute cholecystitis were analysed. It was found that the main factors impeding effective dissolution were: the size of the stones over 1.5 cm and admixture of pigment in the concrements. The first Soviet produced litholytic preparation Oktalgin, synthesized by the authors jointly with the Zelinsky IOCh, AMS USSR, was used as the main solvent. The principal possibility of dissolving multiple stones of the gallbladder through laparoscopic cholecystostomy is proved.