[Staged reconstructive surgery for bronchopleural fistula]. / Etapnaya rekonstruktivno-vosstanovitel'naya khirurgiya pri bronkhoplevral'nom svishche.

Treatment of bronchopleural fistula after pneumonectomy is still an urgent problem for thoracic surgeons. Transsternal bronchial stump occlusion should be preferable if possible. However, this is not enough for curing in some cases. We present a patient with concomitant cancer and tuberculosis of lungs whose postoperative period was complicated by bronchial stump failure. Preoperative diagnostic data are presented. We describe the indications for surgeries and main surgical stages. Some interventions including reconstructive surgery using a muscle flap led to recovery. Latissimus dorsi muscle flap on thoracodorsal artery is the best option for reconstructive surgical treatment in patients with extensive chest wall defects and thoracostomy.

[Reconstructive surgery for late complications after blunt chest wall trauma]. / Rekonstruktivno-vosstanovitel'nye vmeshatel'stva pri pozdnikh oslozhneniyakh zakrytoi travmy grudi.

OBJECTIVE: To analyze the incidence and structure of late complications after blunt chest trauma, feasibility of surgical correction and effectiveness of these interventions. MATERIAL AND METHODS: Treatment outcomes were analyzed in 26 patients with late complications of blunt chest wall trauma. Severe chest deformities were diagnosed in 8 patients, non-union rib fracture - 5, pulmonary hernia - 4, chronic abscesses and pseudocysts of soft tissues of the chest - 3, osteomyelitis of the ribs - 3, chronic recurrent pulmonary bleeding following damage to lung parenchyma by rib fragments - 2, persistent post-traumatic pleuritis - in 1 patient. RESULTS: Among 26 patients, 23 ones underwent surgical correction of complications. Reconstructive procedures were performed in 5 out of 8 patients with post-traumatic chest deformities. In 5 patients with non-union rib fractures, surgery consisted of resection of ribs, excision of capsule and scar tissue, osteosynthesis. Thoracic pulmonary hernia required thoracotomy, viscerolysis, chest wall defect closure by bringing together the ribs and fixing with pulley sutures or ZipFix system. In 2 patients, pulmonary hernia was combined with non-union rib fracture. These patients underwent additional resection of false joints and osteosynthesis. Three patients were diagnosed with chronic abscesses and pseudocysts of soft tissues of the chest. Surgical treatment was carried out according to the principles of staged debridement of chronic purulent foci. Osteomyelitis of ribs in 3 patients required resection within intact tissues. Fixation of ribs by metal structures was not performed in these patients, and we performed only muscle and soft tissue repair. Conservative treatment was carried out in 3 patients with chest deformity. There were no lethal outcomes. CONCLUSION: Pathological syndromes in long-term period after blunt chest trauma require surgical correction. Surgical treatment of patients with late complications of chest trauma should be aimed at chest stabilization, improving respiratory function and preventing secondary and tertiary complications. Osteosynthesis allows not only to eliminate pathological syndromes, but also increase tolerance to physical activity and quality of life.

[Diagnosis and treatment of bronchopleural fistula after anatomical lung resections]. / Khirurgiya bronkhoplevral'nogo svishcha posle anatomicheskikh rezektsii legkikh.

OBJECTIVE: To assess the factors causing air leakage after anatomical lung resections and present a rational tactical approach for timely establishing the cause and level of bronchial fistula. MATERIAL AND METHODS: We analyzed 723 patients who underwent anatomical lung resection (pneumonectomy - 136 patients, anatomical lobectomy and segmentectomy - 513, video-assisted anatomical resection - 74 patients). RESULTS: In 506 (69.9%) cases, complete lung inflation after surgery was observed within 24-48 hours. Persistent air discharge for more than 3 days was observed in 141 (19.5%) patients. Prolonged air leakage for more than 7 postoperative days occurred in 50 (6.9%) patients. Air discharge for more than 10 days was considered abnormal and observed in 20 (2.8%) patients. Redo surgeries were performed in 49 patients with bronchopleural fistula at the level of segmental bronchi. Forty-two patients after primary thoracoscopy and 6 ones after primary thoracotomy underwent video-assisted resection of the lung with bronchopleural fistula after previous surgery. In 11 patients, re-thoracotomy was performed: middle lobectomy after previous right-sided upper lobectomy in 2 patients, lung resection after previous segmentectomy in 8 cases and atypical resection of bulla after previous right-sided lower lobectomy in 1 case. CONCLUSION: Surgical approach for persistent postoperative air leakage involves various surgical interventions. The best option is minimally invasive thoracoscopic procedure. This method is valuable to visualize bronchopleural fistula, eliminate air leakage, additionally reinforce pulmonary suture and perform targeted adequate drainage of the pleural cavity.

[Surgical strategy for suppurative complications of pancreatic necrosis]. / Vybor khirurgicheskogo dostupa v lechenii gnoinykh oslozhnenii pankreonekroza.

Severe acute pancreatitis is one of the most difficult problems in emergency abdominal surgery. Mortality among patients with this disease ranges from 20 to 80 percent. The use of staged surgical intervention in the treatment of purulent complications of acute severe pancreatitis may affect not only the risk of open surgery, but also the number of post-operative complications. OBJECTIVE: Improving the results of treatment of patients with infected pancreatic necrosis by applying a step by step surgical approach and comprehensive correction of endotoxicosis. MATERIAL AND METHODS: The study was retrospectively prospective. All patients were divided into two clinical groups. The control group for the period from 2018 to 2019 included 31 patients for whom the standard surgical tactics of treating pancreatic necrosis were used: laparotomy, necrsecestrectomy and drainage of parapancreatic fluid accumulations, and, if necessary, repeated sanation. The main group included 26 patients, treated from 2019 to 2020. According to the developed step-by-step approach with the application of the correction of endogenous intoxication and enteral insufficiency syndrome. The choice of surgery for the patients of the main group depended on the type of parapancreatic fluid accumulation and included minimally invasive interventions in the first stage and, if necessary, the expansion of the amount of interventions (puncture and drainage under ultrasound control + video assisted retroperitoneal debridement, or ultrasound-controlled puncture and drainage + laparotomy). RESULTS: The effectiveness of the treatment in both groups was determined by changes in blood leukocyte and C-reactive protein values on the day of the operation, as well as on the 2nd, 4th, 6th day of the post-operative period. By the fourth day after the surgery, the main group patients' white blood cell and CRP blood levels were positively lower than in the control group: p=0.0001, t=9.65 and p=0.0001, t=9.02, respectively. Forty-eight hours after the operation, the dynamics of the EIS were determined. In the control group, where standard methods of treating enteral insufficiency were used, there was an increase in the number of patients with II and III degrees of severity, in comparison with patients of the main group (p<0.05). The number of complications of pancreonecrosis of IIIb and IVb of degrees on the Clavien-Dindo scale in patients of the major group was lower than in the control group: χ2=0.00021, p<0.05 and χ2=0.01553, p<0.05, respectively. 10 (32.3%) died in the control group, 2 (7.7%), χ2=0.04739, p<0.05. CONCLUSIONS: The choice of surgical intervention for pancreonecrosis should be determined taking into account the development phase of the disease, the type of location of the purulent-necrotic sinuses, and its delimitation from surrounding tissues. Phased surgical treatment with the initial application of minimally invasive technologies affects the number and severity of post-operative complications as well as the early start of correction of enteric insufficiency syndrome - the early relief of endogenous intoxication.

[Stenting of the main pancreatic duct for acute post-manipulation pancreatitis]. / Stentirovanie glavnogo pankreaticheskogo protoka v lechenii ostrogo postmanipuliatsionnogo pankreatita.

OBJECTIVE: To evaluate the results of stenting of the main pancreatic duct for acute post-manipulation pancreatitis. MATERIAL AND METHODS: There were 946 transpapillary interventions within 5-year period. Various risk factors of this complication and the role of stenting of the main pancreatic duct for prevention of acute post-manipulation pancreatitis were analyzed for the same period. Complication was predicted only in some cases. There were 10 patients with unpredicted acute pancreatitis for this period. In all cases, an attempt of stenting of the main pancreatic duct was made in the first hours after development of complication. Stenting was successful in 7 cases. Technical success of operation was 70%. Stenting was followed by clinical improvement and pain relief. RESULTS: The course of acute post-manipulation pancreatitis is milder in patients who underwent pancreatic stenting. There were no cases of purulent-necrotic complications in these patients (n=7). At the same time, 2 cases of pancreatic necrosis were observed in the control group. One patient died among those who did not undergo stenting of the pancreatic duct. CONCLUSION: Stenting of the main pancreatic duct is effective in patients with acute post-manipulation pancreatitis. The course of acute post-manipulation pancreatitis is milder in patients who underwent pancreatic stenting. Significant clinical improvement is observed the next day after stenting. Stenting of the pancreatic duct should be carefully considered early after development of complication.

[Ribs osteosynthesis in patients with isolated and combined chest trauma]. / Osteosintez reber u postradavshikh s izolirovannoi i sochetannoi travmoi grudi (s kommentariem).

INTRODUCTION: Rapid methods of costal fractures fixation using special costal plates are becoming more common. AIM: To evaluate the efficacy of ribs osteosynthesis in patients with isolated and combined chest trauma. MATERIAL AND METHODS: It is presented an experience of surgical treatment of patients with costal fractures in case of isolated (30) and combined (29) chest injury. System for ribs osteosynthesis was used predominantly in surgical tactics. RESULTS: Immediate surgical results were analyzed. Most patients had increase of blood gas parameters, oxygenation in the postoperative period. In case of isolated chest injury mean duration of mechanical ventilation was 1.3±1.1, incidence of complications - 3.3%, mortality rate - 0%. In group of combined injuries those indexes were 4.6±3.05, 13.8% and 13.8% respectively. CONCLUSION: The method of ribs osteosynthesis in patients with isolated and combined chest trauma showed high efficiency.

[Use of autologous progenitor cells of the bone marrow in treatment of patients with lower-limb atherosclerosis obliterans].

Presented herein are the outcomes of using autologous progenitor cells of the bone marrow in a total offorty-two male patients suffering from atherosclerosis obliterans of the lower-limb arteries with degree II B of ischaemia according to the classification of A. V. Pokrovsky, preconditioned by involvement of the femoropopliteal-tibial segment with no possibility to perform a reconstructive operation. It was a randomized, double-blind, placebo-controlled study limited by a clinical approbation of the method concerned. Bone marrow was sampled from the crests of the iffac bone. Exflisate was subjected to double centrifugation to obtain the leukocytic fraction of the bone marrow, immune magnetic separation--for obtaining the CD 133+ cells. The patients were subdivided into three groups, each consisting of 14 subjects. Group One patients received autologous progenitor cells CD133+, Group Two patients were given the leukocytic fraction of the marrow (CD34+), and Group Three patients (comparison group) received normal saline as aplacebo. The preparations were administered into the muscles of the internal and external surface of the crus. The clinical outcomes were evaluated according to the Rutherford scale and demonstrated that Group One and Group Two patients given the cellular material exhibited a statistically significant improvement of their clinical condition, as compared with the findings obtained in the placebo group (P < 0.001, by the Mann-Witney test). Based on the results of the treadmill tests performed after 1, 6 and 12 months, the distance of pain-free walk was noted to statistically significantly increase in Group One and Group Two patients, as compared with those from the placebo group. The proposed method of treatment may be recommended for multicenter clinical trials.

[Principles of differential diagnosis and strategy in acute intestinal obstruction]. / Printsipy differentsial'noi diagnostiki i taktiki pri ostroi kishechnoi neprokhodimosti.

Intestinal obstruction is diagnosed as one of two kinds--small intestine and large intestine obstruction. They differ in etiology of the obstacle, pathogenesis and degree of clinical picture. The cause of the small intestine obstruction in patients having laparotomy in medical history is the formation of commissures. In patients with intact abdomen the cause of low obstruction was torsion and intussusception, the cause of high obstruction was the obturation with a bile calculus and a foreign body. Causes of the large intestine obstruction were obturation with a tumor and torsion. Napalkov's test is expedient but when suspecting the small intestine obstruction. Conservative treatment is possible in commissural small intestine obstruction (12-24 h) and in large intestine obturation obstruction (not longer than 2h).

[The significance of thrombocytic and coagulative hemostasis in the pathogenesis of peptic gastroduodenal hemorrhages]. / Znachenie trombotsitarnogo i koaguliatsionnogo gemostaza v patogeneze iazvennykh gastroduodenal'nykh krovotechenii.

The state of thrombocytic and coagulation hemostasis was studied on 89 patients, operated on for ulcerative disease with or without bleeding. The role of thrombohemorrhagic syndrome in the development of ulcerative bleeding, prethrombosis and predisposition to bleeding was determined. The changes of hemostasiogram without clinical manifestations point to the necessity of early treatment and prophylaxis measures.