[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.

[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.

[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.