[Endoscopic vacuum therapy in minimally invasive treatment of esophageal perforations]. / Effektivnost' endoskopicheskoi vakuumnoi terapii v kompleksnom minimal'no invazivnom lechenii perforatsii pishchevoda.

OBJECTIVE: To compare the results of endoscopic vacuum therapy (EVT) and open surgery for esophageal perforations. MATERIAL AND METHODS: The study included 60 patients with esophageal perforations between 2010 and 2022. The main group included 29 patients who underwent minimally invasive treatment with EVT, the control group - 31 patients after open surgical interventions. RESULTS: Pneumonia occurred in 21 (72%) and 14 (45%) patients (p=0.04), esophageal stenosis within the perforation zone - in 4 (13.8%) and 1 (3.2%) patient, respectively (p=0.188). Chronic esophageal fistulas were significantly more common in the control group (6 (20.7%) versus 15 (48.4%) patients, p=0.032). The overall duration of treatment (median) among survivors was significantly shorter in the main group: 33 (23; 48) versus 71.5 (59; 93.7) days (p=0.5). However, length of ICU-stay was slightly higher (11 (6; 16) versus 8.5 (5; 12.75) days, p=0.32). Mortality rate was 13.8% (n=4) and 29% (n=9), respectively (p=0.213). Minimally invasive technologies decreased the risk of fatal outcome by 10 times (OR 10.123, 95% CI 1.491-124.97, p=0.035) compared to traditional surgery. CONCLUSION: EVT in complex minimally invasive treatment of patients with mechanical esophageal injuries is an effective method significantly reducing mortality and duration of inpatient treatment compared to traditional surgical approach.

[Endoscopic treatment of bronchial complications after lung transplantation]. / Endoskopicheskoe lechenie bronkhial'nykh oslozhnenii posle transplantatsii legkikh.

OBJECTIVE: To analyze the incidence and structure of bronchial complications following lung transplantation and evaluate an effectiveness of endoscopic treatment of these events. MATERIAL AND METHODS: The study enrolled 50 patients after bilateral lung transplantation (24 men and 26 women). Mean age of patients was 35.4±5 (19; 61) years. Ischemia of bronchial mucous membrane of the transplant was intraoperatively and postoperatively analyzed. We also assessed severity and prevalence of anastomotic and non-anastomotic cicatricial bronchial stenoses. RESULTS: All patients after lung transplantation were diagnosed with bronchial complications, i.e. ischemia of bronchial mucous membrane of the transplant. In 76% of patients, these complications did not require endoscopic treatment. Surgical and endoscopic treatment was required in 24% of cases. Three patients (6%) underwent intraoperative correction of bronchial anastomosis. Bronchial suture failure was diagnosed in 3 patients (6%), cicatricial bronchial stenosis - in 6 (12%) cases. Endoscopic stenting was effective for recovery of bronchial patency with complete epithelialization of mucous membrane. Stenting of lobar bronchus with application of mitomycin C was effective in patients with non-anastomotic stenoses type III after lung transplantation. CONCLUSION: Major bronchial complications occurred in 24% of patients after lung transplantation. Endoscopic treatment of bronchial complications using a self-fixing silicone endoprosthesis after lung transplantation was effective in all patients with anastomotic and non-anastomotic cicatricial strictures. Mitomycin C prevented excessive growth of granulation and scar tissue.

[Surgical treatment of spontaneous esophageal rupture: long-term experience of the Sklifosovsky Research Institute for Emergency Care]. / Khirurgicheskoe lechenie spontannogo razryva pishchevoda: mnogoletnii opyt NII skoroi pomoshchi im. N.V. Sklifosovskogo.

OBJECTIVE: To analyze the treatment outcomes in patients with spontaneous esophageal rupture (SER). MATERIAL AND METHODS: The study included 106 patients with SER admitted to the Sklifosovsky Research Institute for the period from 1992 to 2015. The sample also included 91 patients who were referred from other hospitals. All patients were divided into 4 groups depending on surgical procedure: surgical drainage (Group I, n=19); suturing the esophageal defect without antireflux surgery (Group II, n=12); esophageal wall repair with fundoplication procedure (Group III, n=62); resection of the thoracic esophagus (Group IV, n=13). RESULTS: In the 1st group, complication rate was 100% and significantly exceeded these values in groups II, III, and IV (66.7%, 71%, and 69.2%, respectively; p=0.0318, p=0.0189, and p=0.0413). The length of hospital-stay was the lowest in group IV (mean 42 days) and group I (mean 55 days). Mortality rate in groups I, III and IV was 15-20% lower than in group II. Pneumonia and pleural empyema were significant predictors of poor outcome. Fundoplication improved postoperative outcomes in group III compared to group II. Resection of the thoracic esophagus performed in accordance with strict indications interrupts infectious process and shortens recovery period. Surgical drainage is followed by persistent contamination of mediastinum and pleural cavities that may quickly result a fatal outcome. CONCLUSION: A differentiated approach to SER treatment can reduce the risk of complications and mortality.

[Difficulties of differential diagnosis and treatment of achalasia cardia after previous hiatal hernia repair]. / Trudnosti differentsial'noi diagnostiki i lecheniia akhalazii kardii u patsientki, ranee operirovannoi po povodu gryzhi pishchevodnogo otverstiia diafragmy.

Esophagocardiomyotomy followed by anterior fundoplication is a standard treatment of achalasia cardia, whereas cruroraphy with complete or partial posterior fundoplication is carried out for hiatal hernia and gastroesophageal reflux disease. The most common postoperative complications of hiatal hernia repair are dysphagia due to malformed cuff, phenomenon of 'telescope' and slow gastric emptying syndrome. Recurrent hiatal hernia is observed in 3-15% of cases. Currently, there are a lot of reports devoted to redo antireflux procedures in patients with hiatal hernia. The goal of the study is to demonstrate difficulties of diagnosis and treatment in a patient with achalasia cardia after previous hiatal hernia repair.

[Spontaneous rupture of the esophagus in a patient with chronic obstructive pulmonary disease]. / Spontannyi razryv pishchevoda u patsienta s khronicheskoi obstruktivnoi bolezn'yu legkikh.

A case report of successful surgical treatment of spontaneous rupture of the esophagus in a patient with chronic obstructive pulmonary disease, bronchial asthma and obesity is presented. Rupture of the esophagus occurred during a coughing without vomiting.

[Esophageal achalasia]. / Akhalaziia kardii.

Prevalence, clinical manifestations and of modern classifications of achalasia are reviewed in the article. Diagnosis and treatment of this pathology were analyzed by using of 58 references.

[Features of diagnostic and surgical tactics for suicidal and autoaggressive thoracic and abdominal lesions]. / Osobennosti diagnostiki i khirurgicheskoi taktiki pri povrezhdeniiakh grudi i zhivota vsledstvie suitsidal'nykh i autoagressivnykh deistvii.

AIM: To analyze diagnostic and surgical tactics for suicidal and autoaggressive thoracic and abdominal lesions. MATERIAL AND METHODS: We have analyzed the features of emergency surgical care depending on type of patients' behavior at admission. There were 516 patients with suicidal and autoaggressive thoracic and abdominal lesions. RESULTS AND DISCUSSION: Depressive (34%) and adequate (46%) patients were examined routinely. Inadequate (aggressive) behavior is inappropriate for instrumental examination while medical sedation may be followed by significant hemodynamic disorders in patients with severe lesions. It was noted that indications for explorative surgery should be expanded in these patients and administration of sedatives should be combined with induction of general anesthesia. CONCLUSION: Severity of trauma and type of surgery affect mental state dynamics while the kind of psychopathy influences postoperative period course.

[The features of diagnosis and treatment of traumatic and non-traumatic pulmonary bleeding]. / Osobennosti diagnostiki i lecheniia legochnogo krovotecheniia travmaticheskoi i netravmaticheskoi étiologii.

AIM: To analyze an efficacy of differentiated approach for pulmonary bleeding of different etiology and severity. MATERIAL AND METHODS: The study included 134 cases of pulmonary bleeding for the period 2006-2015 including 53 patients with traumatic and 81 with non-traumatic etiology. Men/women ratio was 2.7:1, mean age was 43 years. Comparative retrospective analysis of X-ray and CT data in diagnosis of bleeding source was performed. Bronchoscopy was used to confirm these data. There were 43 endovascular examinations including 40 cases of bronchial arteriography (BAG). RESULTS AND DISCUSSION: X-ray and CT-signs of bleeding source were detected more often in case of traumatic pulmonary bleeding (62.3% and 93%) compared with non-traumatic (27.2 and 54%; p<0.05). Bronchoscopy revealed ongoing pulmonary bleeding in 40 (30%) patients, completed - in 94 (70%) patients. Indirect angiographic signs were the most frequent for pulmonary bleeding origin: hypervascularization (32.6%), bronchial-pulmonary shunts (23.2%) and bronchial artery dilatation (20.9%). 17 patients with ongoing bleeding underwent bronchial obstruction with adequate hemostasis in all cases. Endovascular interventions included bronchial arteries embolization (EBA) (33), occlusion of intercostal arteries (3) and segmental branches of low-lobar pulmonary artery (1), aortic stenting (1). Early efficacy of EBA was 97% with 2 month recurrence of pulmonary bleeding near 12.5%. Ongoing traumatic pulmonary bleeding was an indication for emergency thoracotomy in 18.9% compared with 12.3% for non-traumatic bleeding when surgery was made after endoscopic and endovascular hemostasis. CONCLUSION: Differentiated approach depending on etiology and severity of pulmonary bleeding improves outcomes and reduces the number of operations for ongoing severe bleeding.

[Risk factors of suppurative complications in case of thoracic injury].

It was performed retrospective analysis of 463 cases of suppurative thoracic complications after injury (232) and closed thoracic trauma (231) for 20-year period. Incidence of purulent complications was 3.2% and 1.6% in case of injury and closed thoracic trauma respectively including pleural empyema in 1.5 and 1.3%, pulmonary abscess in 0.3 and 0.4%, mediastinitis in 0.35 and 0.12%, pericarditis in 1.5 and 0.26%, osteomyelitis in 0.4 and 0.18% respectively. Factors preceding suppurative complications in case of injuries and closed trauma have been considered as predictors. Multivariant regression analysis established significant risk factors of suppurative thoracic complications. Clotted hemothorax, mediastinal hemorrhage, heart injury, late appeal for medical assistance and mechanical ventilation over 5 days were identified irrespective of character of trauma. In case of thoracic injury there were damage of osteochondrous frame, hollow thoracic and abdominal organs, gunshot wound of lung, delirium and injuries severity over 20 scores according to ISS scale. Pulmonary bleeding, sternal fracture and Glasgow Coma Scale rate<12 scores were identified as risk factors in case of closed trauma.