TREATMENT OF COMBAT GUNSHOT SHRAPNEL TRAUMA OF LARGE DEFECTS OF THE SOFT TISSUES OF THE LOWER EXTREMITIES WITH PLASTIC SURGERY IN COMBINATION WITH VACUUM ASSISTED WOUND CLOSURE (VAC).

OBJECTIVE: The aim: To evaluate efficacy of the tissue defect closure techniques in combination with VAC in the treatment of battle casualities of the lower extremities. PATIENTS AND METHODS: Materials and methods: The results of wound healing until complete wound closure, of 62 patients with shrapnel defects of the lower extremities where assessed. RESULTS: Results: Treatment of patients with soft tissue defects of the lower extremities using rotational flaps on the vascular pedicle and VAC significantly reduces the incidence of infectious complications (18.75% in the main group vs. 30% in the control group (p<0.05)), reduces the intensity of pain according to the VAS scale during the first week of treatment in the main group to 5±0.5 versus 7±0.8 in the control group (p<0.05) and reduces the length of hospital stay by 7 days. CONCLUSION: Conclusions: The use of rotational flaps on the vascular pedicle and local tissue closure techniques in combination with VAC is an effective method of treating patients with combat gunshot wounds of the soft tissues of the lower extremities.

MANAGEMENT OF MINIINVASIVE TREATMENT OF PRIMARY VARICOSE SUPERFICIAL VEINS.

OBJECTIVE: The aim: Determination of the optimal method for surgical correction of stages C2-C6s varicose superficial veins. PATIENTS AND METHODS: Materials and methods: The treatment results of 228 patients with stages C2-C6 of primary varicose according to the CEAP classification using thermal and non-thermal treatment methods were analyzed. RESULTS: Results: All patients underwent operations under the control of ultrasound scanning. In patients after EVLA, total trunk obliteration was detected in 148 patients (98.7%) after 1 week, and in 100% after a year. In 2 patients, reflux was diagnosed in the PDSV and in the ZDSV after 1 week. In patients after RFA, inflow reflux on the leg was in 1 patient (5.2%), in others - complete obliteration (18 patients - 94.7%). In patients after MOCA, recanalization was performed in 5 patients (19.2%) with a control ultrasound investigation after 1 month. In patients after cyanoacrylate obliteration, inflow reflux on the leg after 1 month was in 2 patients (14.2%). In patients who underwent UGS of the GSV trunk, 5 patients (33.3%) had persistence of pathological reflux after 1 month with control ultrasound. All corrections were performed using Foam form sclerotherapy. CONCLUSION: Conclusions: EVLA is the most effective method of treating varicose veins and gives the best long-term results. The advantage of non-thermal methods is the lack of influence on paravenous structures and no need for tumescent anesthesia, which is important in case of an allergic history. After applying cyanoacry¬late, there is no need for mandatory compression. The advantage of foam scleroobliteration is its lowest cost among all methods. Foam sclerotherapy was the method of choice for correction of postoperative treatment.

ONE-STAGE PROSTATECTOMY ACCOMPANIED BY HERNIOPLASTY TO IMPROVE QUALITY-OF-LIFE OUTCOMES OF PATIENTS WITH COMBINED SURGICAL PATHOLOGIES.

OBJECTIVE: The aim: To evaluate whether simultaneous inguinal hernioplasty during prostatectomy confers benefits on quality-of-life outcomes. PATIENTS AND METHODS: Materials and methods: 152 patients with prostatic adenoma were observed. The general group included 32 (21%) patients with prostatic adenoma and hernia inguinalis, who underwent one-stage prostatectomy accompanied with hernioplasty. 120 (79%) persons of comparison group underwent a prostatectomy only. The average age of the comparison group was 68.0±7.0 years, the general group - 67.1±6.9 years; the average prostate volume was 94.4±42.3 cm3 and 91.2±32.6 cm3 respectively. Hernia inguinalis was in 32 patients of the general group, in 4 of them - on both sides (36 cases totally). RESULTS: Results: The average time of retropubic prostatectomy in both groups was the same, and simultaneous hernioplasty took 35.0±17.4 minutes. The frequency of early and late bleeding after prostatectomies in the general group was 6.25% (2 cases) and 7.5% (9 cases) in the comparison group. No deaths were noted in two groups. The quality-of-life outcomes after the one-stage prostatectomy accompanied with hernioplasty in 6 and 12 months were statistically better than before these operations. CONCLUSION: Conclusions: Performing one-stage prostatectomy accompanied with hernioplasty does not worsen the immediate and long-term results of operation, instead it helps to eliminate two diseases at the same time from one surgical approach.

RESULTS OF PREVENTIVE METHODS OF OCCURRENCE CERVICAL ANASTOMOTIC COMPLICATIONS IN ESOPHAGOPLASTY.

OBJECTIVE: The aim: The aim of the study was to improve the results of surgical treatment in patients with corrosive esophageal strictures using the designed comprehensive surgical management program in esophagoplasty to decrease cervical anastomotic complications. PATIENTS AND METHODS: Materials and methods: The results of surgical treatment of 116 patients with esophageal strictures were studied. 45 patients had post-burn corrosive strictures, 17 - postoperative corrosive strictures, 10 - peptic strictures due to reflux esophagitis and 44 patients - esophageal cancer. All patients were divided into two groups: the control group, consisting of 55 patients who underwent conventional surgical treatment of corrosive esophageal strictures during 2005-2011, and experimental group involving 61 patients operated on during 2012- 2020, in whom an individual approach to the choice of surgical method was applied using diagnostic and treatment algorithm as well as the designed surgical management program. RESULTS: Results: In early postoperative period the proportion of specific and non-specific complications was significantly lower in experimental group as compared to the control group: cervical anastomotic leak - 16.36 % versus 4.392 %; strictures of cervical anastomosis - 20.0% versus 6.56 % (p<0.05). There were six postoperative deaths - four in the control group and two in experimental group. CONCLUSION: Conclusions: To prevent the development of cervical anastomotic complications and mortality in esophagoplasty proper therapeutic approach with consideration of all prognostic criteria and risk factors should be chosen and designed surgical management program should be applied.

MODERN METHODS OF PREVENTION AND TREATMENT OF COMPLICATIONS OF CERVICAL ESOPHAGO-ORGAN ANASTOMOSIS AT ESOPHAGOPLASTY.

OBJECTIVE: The aim: To improve the results of operative treatment of esophageal strictures by decreasing the rate of failure and stricture of cervical esophago-organ anastomoses. PATIENTS AND METHODS: Materials and methods: There were 45 patients with post-burn corrosive gullet strictures, 17 patients with postoperative corrosive strictures, 10 patients with peptic strictures secondary to reflux-esophagitis, 42 patients with esophageal cancer strictures. The patients were divided into two groups: the comparison group - 55 persons and the main group - 59 persons. Patients of comparison group underwent surgical treatment of esophageal strictures according to classic protocols and standards. In the main group of patients we applied proposed diagnostic algorithm with prediction of complication risk and the designed method of esophago-organ anastomosis formation. RESULTS: Results: The results of operative treatment in patients with esophageal strictures showed the development of early postoperative complications in 59 individuals (51.75 %). In the postoperative period six patients died: four - in the comparison group and two - in the main group. Failure of cervical esophago-organ anastomosis and esophageal strictures occurred in 7 patients (11.86 %) of main group and 20 patients (36.36 %) of the comparison group (p<0.05). CONCLUSION: Conclusions: Application of method predicting the risk of complications of cervical anastomosis, treatment program and instrumental method of formation anastomosis resulted in reduced incidence of failure and strictures of esophago-organ anastomosis from 36.36 % to 11.86 % (p<0.05); decreased time of hospitalization - from 28.2 ± 1.1 to 21.5 ± 0.5 bed-days (p<0.001), postoperative period - from 20.5 ± 1.1 to 16.1 ± 0.7 bed-days (p<0.01); decreased postoperative mortality - from 7.27 % to 3.39 %.

Complex treatment of purulent wounds with the use of high-pressure aerodisperse mixture.

OBJECTIVE: The aim: To investigate the effectiveness of complex treatment of purulent wounds with the use of high pressure aerodispersed mixture of antibacterial drug using sorbents and correction of hydrogen index. PATIENTS AND METHODS: Materials and methods: In total, 54 patients were treated, out of which there were 26 patients with purulent wounds in the main group and 28 patients in the control group. Patients in the main group were treated according to the developed method, patients in the control group were treated with traditional antiseptics and water soluble ointments. RESULTS: Results: Within patients of the main group, there was a decrease in the duration of inflammatory process, decrease in the quantity of microorganisms in the wound; slight changes in the sensitivity of the microorganisms to antibacterial preparations, compared with the control group, which showed a high percentage of development of resistant strains; decreased edema and secretion from wounds, the early appearance of granulation. CONCLUSION: Conclusions: The use of the proposed approach reduces the microbial burden on the wound, accelerates its purification from purulent-necrotic tissues and reduces the duration of the inflammatory process due to the presence of the microbial factor.

Experience in treatment of patients with esophageal achalasia.

OBJECTIVE: Introduction: Esophageal achalasia is a neuromuscular disease, which is characterized by persistent impaired reflex opening of esophageal sphincter. Disease incidence is 0.6-2.0 per 100 000 population with no tendency to decrease. The aim of the study was to improve the results of treatment in patients with achalasia of cardia by differentiated approach in the choice of therapy method. PATIENTS AND METHODS: Materials and methods:148 patients with esophageal achalasia aged 18 - 67 were studied between 2003 and 2018. The following degrees of the disease were determined (by Petrovskyi's classification): first - in 8, second - in 59, third - in 70, fourth - in 11 patients. Drug therapy was administered in achalasia of first degree, and cardiodilatation courses - in second and third degree of the disease. Indications for surgical treatment were: impossibility to perform cardiodilatation, S-shaped esophageal deformation (stage IV), complications associated with cardiodilatation, achalasia combined with other surgical pathology, recurrence of disease. RESULTS: Review: Cardiodilatation therapy resulted in sustained clinical effect in stages I and II of the disease. In case of unsatisfactory results of cardiodilatation patients underwent elective operations. 18 patients underwent Heller-Dor plastic surgery, 4 - Heller-Petrovskiy operation, 1 - Besley plastic repair, 2 - Nissen fundoplication. In early postoperative period no failure or perforation of the esophagus occurred. The following complications developed: seroma - in 3 patients, postoperative wound infection - in 1 case. In one patient (4%) the recurrence of disease was due to scar deformation of esophagogastric junction after Heller-Petrovskiy operation on the cardia. CONCLUSION: Conclusions: Cardiodilatation is an effective method of conservative therapy in stages I and II of the disease, while in stages III and IV it is warranted as preoperative preparation measure. We think Heller-Dor operation to be the best method of plastic repair in esophageal achalasia.

Operative treatment of corrosive esophageal strictures.

OBJECTIVE: Introduction: Nowadays operative treatment of corrosive esophageal strictures remains one of the difficult and unsolved problems in surgery. The level of postoperative complications such as anastomotic leak (develops in 7-30% of cases), infections, pneumonia, pleural empyema, mediastinitis, peritonitis, postoperative corrosive strictures is still rather high. The aim of our work was to improve the results of surgical treatment of patients with corrosive esophageal strictures by analyzing and refining on conservative therapy options as well as differentiated approach to each operative treatment method. PATIENTS AND METHODS: Materials and methods: 44 patients with corrosive esophageal strictures operatively treated during the period of 1993-2017 were examined. Indications for each of esophagoplasty techniques were established. In colon bypass of the esophagus (26 patients) infusion therapy for prevention of ischemic transplant disorders, roentgenologic and prevascular preparation of future colonic transplant, anti-reflux colonogastric anastomosis were suggested. In gastric esophagoplasty (10 patients), clinically modified transhiatal extirpation of the esophagus with gastric tube plastics, an original method of lengthening of gastric graft, is preferred in clinical practice. Two patients underwent ileocecal segment esophagoplasty because of simultaneous esophageal and gastric lesion or colon diseases. RESULTS: Results: The best method of esophagoplasty associated with a small number of postoperative complications is clinically modified gastric tube esophagoplasty with formation of single extrapleural esophagogastric anastomosis. In cases when the stomach cannot be used and the marginal artery is well marked, isoperistaltic retrosternal colonoplasty with preservation of blood supply due to the left colonic artery is indicated. Suggested method of ileocecal segment esophagoplasty is used in simultaneous esophageal and gastric lesion, providing the formation of relevant reservoir (the cecum instead of the stomach), antireflux mechanism and preventing the development of peptic ulcers and transplant strictures. CONCLUSION: Conclusions: Operative treatment of corrosive esophageal strictures remains a great challenge for surgeons and should be based on individual choice of proper method of esophagoplasty and final intraoperative decision making.

Histomorphologic changes of esophageal mucosa in experimental third degree stricture.

INTRODUCTION: Nowadays the level of early and late complications after the operations for esophageal corrosive strictures such as esophago-organ anastomotic leak, development of infections, pneumonia, pleural empyema, mediastinitis, peritonitis, postoperative corrosive stricture development etc. remains rather high. Besides, postoperative mortality rate is high as well - 3.5-30 %. For that reason, an experimental model of esophageal stricture was suggested and ultrastructural mucosal changes in the stricture itself were studied to elaborate the unified pathogenic approach in treatment of esophageal stricture and improvement of its results. The aim of our work was to study the dynamics of ultrastructural changes both in normal esophageal walls and in third degree esophageal stricture Materials and Methods: The experiment was carried out on white male rats weighting 250-300 grams, to whom the third degree esophageal stricture model was created. After layer-by-layer incision of anterior abdominal wall abdominal portion of the esophagus was completely ligated (10 rats). In the control group (6 rats) anterior abdominal wall was opened with its subsequent layered closure. The animals were withdrawn from the experiment on the third day by ketamine overdose, and the samples were taken for ultrastructural study. RESULTS: Electron microscopic study of submicroscopic organization of basal, prickle, superficial epithelial cells in stratified non-squamous epithelium, smooth myocytes of muscle plate and contractile elements in esophageal muscular layer was carried out. Nuclear membrane, membranes of mitochondria, endoplasmic reticulum and cytoplasmic Golgi complex were found to be subjected to focal lysis. The third degree esophageal stricture caused destructive lesions in ultrastructural architectonics of stratified non-squamous epithelium cells, smooth myocytes of muscle plate and contractile elements in esophageal muscular layer of rats. CONCLUSION: Thus, catabolic processes leading to organelle disintegration develop in esophageal cells of rats with third degree stricture.