[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.

[Complex treatment of patients with pyo-necrotic complications of the neuropathic form of diabetic foot syndrome]. / Kompleksnoe lechenie bol'nykh s gnoino-nekroticheskimi oslozhneniyami pri neiropaticheskoi forme sindroma diabeticheskoi stopy.

OBJECTIVE: Of study is improving the results of treatment of patients with pyo-necrotic complications of diabetic foot syndrome by including the method of negative pressure wound treatment in the complex treatment program in combination with using of the combined antibacterial drug Cifran ST and immunocorrective therapy. MATERIAL AND METHODS: The results of examination and treatment of 184 patients with pyo-necrotic complications of the neuropathic form of diabetic foot syndrome were analyzed. According to choice of treatment methods in the postoperative period all patients were divided into two groups. In 95 patients (group I), iodine-containing ointments based on polyethylene glycol were used for local treatment of purulent foot wounds and standard systemic antibacterial therapy was performed. In 89 patients (group II), negative pressure wound treatment (NPWT) was used to treat wounds in the postoperative period. In addition to standard parenteral antimicrobial therapy, these patients also received an oral combined antibacterial drug Cifran ST and immunocorrective cytokine therapy (Leukinferon). The analysis of the dynamics of the wound process was carried out based on the clinical picture and the results of cytological, bacteriological and immunological studies of the wound exudate. RESULTS: The presented strategy of complex treatment of pyo-necrotic complications of the neuropathic form of diabetic foot syndrome allowed group II patients to significantly reduce the degree of microbial contamination of wounds, to achieve a faster regression of the content of proinflammatory and inflammatory cytokines in the wound exudate, as well as to reduce the time of wound cleansing and the transition of the pyo-necrotic process to the reparative stage in comparison with group I patients. This allowed group II patients to reduce the time of plastic closure of the wound from 24.3±0.5 to 15.6±1.7 days, to avoid generalization of infection, death and high level amputation of the limb. At the same time, 11.6% of patients in group I had high level limb amputation due to generalization of infection. The mortality rate in group I was 5.3%. CONCLUSIONS: Adding of vacuum therapy of wounds, systemic antimicrobial therapy using the combined antibacterial drug Cifran ST and immunocorrective cytokine therapy in the complex treatment program for patients with neuropathic form of diabetic foot syndrome after radical surgical treatment of the pyo-necrotic lesion allows reducing the time of wound cleansing and the transition of the pyo-necrotic process to the reparative stage. On the other hand, this makes it possible for this category of patients to perform plastic closure of the wound at an earlier date, avoid generalization of infection and high level amputation of the limb.

[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.

[CONTROL OF APPLICATION EFFICACY OF THE ASCENDING GAS--FLUID STREAM METHOD IN TREATMENT OF DIFFUSE PERITONITIS].

The ascending gas and fluid stream method was applied in 12 patients with repeated purulent diffuse peritonitis. The number of leukocytes was determined in lavage fluid in order to estimate the efficacy of the method. Dynamics of general laboratory and clinical indices was compared with dynamics of leukocytes quan- tity. The research showed the adequacy of investigation results of lavage fluid to the course of inflammatory process in the abdominal cavity. The study presented an application possibility of given test for regulation usage correction of the ascending gas- fluid stream method.