[Enhanced recovery after lung resection in high-risk patients]. / Kontseptsiya programmy uskorennogo vyzdorovleniya torakal'nykh patsientov vysokogo operatsionnogo riska.

OBJECTIVE: To study the possibilities of the ERAS program and immediate results in high-risk patients undergoing lung resection. MATERIAL AND METHODS: The prospective study included 76 high-risk patients. All patients required lobar resection for various lung diseases. The risk of postoperative complications and mortality was stratified using the Thoracoscore and Thoracic Revised Cardiac Risk Index systems, as well as the American Society of Anesthesiologists Outcome Prediction Scale. At all perioperative stages, we assessed the possibilities for accelerated recovery and postoperative complications using the Thoracic Morbidity and Mortality System. RESULTS: Patients were characterized by multiple comorbidities requiring long-term and individual preoperative correction. This prevented adherence to a single protocol at the outpatient stage. We intraoperatively observed severe adhesive process up to complete obliteration of pleural cavity that complicated the use of minimally invasive technologies. Lung tissue was characterized by emphysematous lesions and reduced elasticity that caused prolonged air release and formation of residual cavities. These features required two pleural drains in 42 (52.3%) cases that increased hospital-stay. Multimodal analgesia and early activation with rehabilitation were optimal elements of ERAS. Various postoperative abnormalities developed in 31 (40.8%) patients, mortality rate was 7.9% (n=6). Minor and serious complications prevailed (21 (27.6%) cases). Their correction was effective and not accompanied by fatal outcomes. Critical complications occurred in 10 (13.1%) patients and caused fatal outcomes in 6 (7.9%) cases. CONCLUSION: ERAS protocol among high-risk patients in thoracic surgery is possible in the form of separate elements included in perioperative support.

[Reconstruction of post-resection chest wall defects in surgical treatment of invasive non-small cell lung cancer]. / Rekonstruktsiya postrezektsionnykh defektov grudnoi stenki pri khirurgicheskom lechenii bol'nykh invazivnym nemelkokletochnym rakom legkogo.

OBJECTIVE: To present the results of reconstruction of post-resection chest wall defects with nickel-titanium (TiNi) implants in patients with invasive NSCLC and to analyze the features of perioperative management. MATERIAL AND METHODS: We enrolled 9 patients with NSCLC involving the ribs after lobectomy or pneumonectomy with chest wall reconstruction. Defects were closed used TiNi mesh and rib prostheses. We selected the shape and dimensions of artificial ribs individually before surgery according to CT data and 3D models of reinforcing elements. RESULTS: There were male smokers aged 64.6±4.6 years among patients (range 58-73). T3N0M0 was diagnosed in 6 patients, T3N1M0 - 2, T3N2M0 - 1. Squamous cell carcinoma was verified in 4 (44.4%) patients, adenocarcinoma - in 5 (55.6%) patients. All patients had comorbidities. Mean Charlson's comorbidity index was 6.56±4.6. Dimension of chest wall defect varied from 78 to 100 cm2. Postoperative period was uneventful without signs of respiratory failure. There were no lethal outcomes. Complications occurred in 33.3% of patients (prolonged air discharge through the drains, pleuritis and atrial fibrillation). CONCLUSION: Surgical treatment of NSCLC spreading to the chest wall is a complex task requiring further improvement. Bioadaptive TiNi implants are a promising reinforcing material that allows successful reconstruction of post-resection chest wall defects with good anatomical, functional and cosmetic results. «Sandwich¼ technology is advisable for extensive defects. This approach includes 2 layers of knitted mesh and rib prostheses between these layers.

[A non-standard approach in the treatment of post-traumatic multifocal cicatricial tracheal stenosis with atresia of subglottic larynx, involvement of vocal cords and 33-year cannulation]. / Nestandartnyi podkhod v lechenii posttravmaticheskogo mul'tifokal'nogo rubtsovogo stenoza trakhei s atreziei podskladochnogo otdela gortani, vovlecheniem golosovykh svyazok i 33-letnim kanyulenositel'stvom.

The report presents a case of non-standard two-stage treatment of post-traumatic multifocal cicatricial tracheal stenosis with atresia of subglottic larynx, involvement of vocal cords, and 33-year cannulation. At the first stage, bougienage through a tracheostomy, endoscopic argon plasma exposure, circular tracheoglottic resection with tracheostomy and 3/4 circle anastomosis, formation of a laryngotracheostomy with endoprosthetics were applied simultaneously. The second step was to eliminate the extensive fenestrated tracheo-laryngeal defect using titanium nickelide reinforcing implants. The individual algorithm made it possible to successfully eliminate complex tracheo-laryngeal stenosis with long-term cannulation and demonstrate excellent long-term treatment results.

[Immediate results of angio- and bronchoplastic lobectomies for non-small cell lung carcinoma in patients over 70 years old]. / Neposredstvennye rezul'taty angio- i bronkhoplasticheskikh lobektomii pri nemelkokletochnom rake legkogo u patsientov starshe 70 let.

OBJECTIVE: To study the immediate results of angio- and bronchoplastic lobectomies for non-small cell lung carcinoma (NSCLC) in patients over 70 years old. MATERIAL AND METHODS: Thirty-one extended angio- and/or bronchoplastic lobectomies were performed in patients with NSCLC over 70 years old between January 2015 and December 2020. Mean age of patients was 74.5 ± 3.2 years. NSCLC stage IA was found in 5 (16.1%) cases, IB - 11 (35.5%), IIA - 12 (38.7%), IIB - 3 (9.7%) patients. Squamous cell carcinoma was diagnosed in 19 (61.3%) patients, adenocarcinoma - in other ones (n=12). All patients had concomitant diseases with predominance of cardiorespiratory pathology. Severity of postoperative complications was assessed according to the Clavien - Dindo grading system. RESULTS: Mean Charlson index was 5.34 ± 1.46 scores. ASA grade III was observed in 21 patients, grade IV - in 10 patients. Postoperative complications occurred in 12 (38.7%) patients, mortality rate was 6.4%. Prolonged air discharge through pleural drainage tubes (12.9%) and paroxysms of atrial fibrillation (16.1%) were the most common complications. Cardiac arrhythmia is a serious and fatal complication. CONCLUSION: Anatomical lung resections for NSCLC in patients over 70 years old have certain features of surgical technique and postoperative management. Prevention and prediction of postoperative complications along with rational perioperative management are of priority importance for increasing the safety of these interventions. Angio- and/or bronchoplastic lobectomy should be considered as the only surgical option characterized by high quality and satisfactory immediate results. This procedure is an adequate alternative to pneumonectomy.

[Treatment of post-intensive care tracheal stenosis after previous covid-19 pneumonia]. / Lechenie postreanimatsionnykh rubtsovykh stenozov trakhei posle perenesennoi koronavirusnoi pnevmonii Covid-19.

OBJECTIVE: To analyze postoperative outcomes and perioperative management of patients with post-intensive care tracheal stenosis and previous COVID-19 pneumonia. MATERIAL AND METHODS: There were 8 patients with post-intensive care tracheal stenosis and previous COVID-19 pneumonia aged 34-61 years between January 2021 and April 2021. Lung damage CT-3 was observed in 2 (25%) patients, CT-4 - in 5 (62.5%) patients. In one case, COVID-19 pneumonia with lung damage CT-2 joined to acute cerebrovascular accident. Post-tracheostomy stenosis was detected in 7 (87.5%) cases, post-intubation stenosis - in 1 patient. Duration of invasive mechanical ventilation ranged from 5 to 130 days. In 75% of cases, tracheal stenosis was localized in the larynx and cervical trachea. Two patients admitted with tracheostomy. In one case, an extended tracheal stenosis was combined with atresia of infraglottic part of the larynx. One patient had tracheal stenosis combined with tracheoesophageal fistula (TEF). Length of tracheal stenosis was 15-45 mm. Tracheomalacia was observed in 4 (50%) patients. All patients had severe concomitant diseases. RESULTS: To restore airway patency, we used circular tracheal resection with anastomosis, laryngotracheoplasty and endoscopic methods. Tracheal resection combined with TEF required circular tracheal resection with disconnection of fistula. Adequate breathing through the natural airways was restored in all patients. There was no postoperative mortality. Three patients with baseline tracheal stenosis had favorable postoperative outcomes after circular tracheal resection. Four patients are at the final stage of treatment after laryngotracheoplasty and tracheal stenting. CONCLUSION: Patients after invasive mechanical ventilation for COVID-19 pneumonia are at high risk of cicatricial tracheal stenosis and require follow-up. Circular tracheal resection ensures early rehabilitation and favorable functional results. Laryngotracheoplasty is preferred if circular tracheal resection is impossible. This procedure ensures adequate debridement of tracheobronchial tree and respiratory support. Endoscopic measures are an alternative for open surgery, especially for intrathoracic tracheal stenosis and intractable tracheobronchitis.

[Treatment of laryngotracheal and tracheal cicatricial stenosis: 10-year experience]. / Lechenie trakheogortannykh i trakheal'nykh rubtsovykh stenozov.

OBJECTIVE: To describe 10-year experience of treating the cicatricial tracheal stenosis (CTS) in a regional multi-field hospital. MATERIAL AND METHODS: There were 120 CTS patients aged 13-75 years. In 8 (6.7%) patients, CTS was combined with tracheoesophageal fistula (TPF). Post-intubation stenosis was diagnosed in 16 (13.3%) cases, post-tracheostomy - in 102 (85%) ones, post-traumatic - in 2 (1.7%) patients. CTS length ranged from 1.2 to 8 cm. Fifty (41.7%) patients had cervical CTS, 40 (33.3%) patients - cervico-thoracic tracheal stenosis, 11 (9.2%) patients - tracheal stenosis at the thoracic level. Nineteen (15.8%) patients had multifocal stenoses. We used endoscopic techniques, circular tracheal resection (CTR) and laryngotracheal reconstruction. RESULTS: Postoperative mortality rate was 0.83%. CTR was performed in 33 patients, laryngotracheal reconstruction - 77, endoscopic stenting - 6 patients. In 4 cases, local CTS was eliminated by bougienage and argon plasma exposure. CTS was successfully disconnected with TEF using CRT in 3 cases, laryngotracheoplasty and stenting - in 5 cases. The fenestrated tracheal defect was closed by a three-layer autologous flap in 59 patients. Of these, autologous flap was reinforced with porous nickel-titanium implants in 17 patients. Postoperative complications after CRT occurred in 6 (16.7%) patients (anastomotic leakage - 2, anastomositis - 1, restenosis - 2). No patients died. Postoperative complications after laryngotracheal reconstruction were observed in 18 (23.4%) patients including 5 ones with restenosis who underwent CTR with a favorable outcome. CONCLUSION: CTS treatment requires a multidisciplinary approach. Each surgery has certain indications and place in treatment algorithm. CTR is highly effective, but may be accompanied by complications associated with tracheal anastomosis. Decrease of postoperative morbidity will improve immediate and long-term results of CTS treatment. The chosen treatment algorithm ensured good and satisfactory results in 98% of patients.

[Thoracoscopic repair of posttraumatic phrenic hernia in 62 years after injury of the diaphragm]. / Videotorakoskopicheskaya korrektsiya posttravmaticheskoi diafragmal'noi gryzhi cherez 62 goda posle raneniya grudobryushnoi pregrady.

Diagnosis of diaphragmatic injury is difficult in some cases. Symptoms of chronic posttraumatic diaphragmatic hernia are very diverse and associated with dysfunctions of the displaced abdominal organs and compression of thoracic organs. Previous blunt or open chest and abdominal trauma, as well as visible scars as a result of injury should be considered. Treatment concept assumes surgical correction of posttraumatic diaphragmatic hernia. Choice of surgical approach and type of intervention are determined individually. Despite the global trend towards minimally invasive endoscopic surgery, there are few reports on thoracoscopic correction of posttraumatic phrenic hernia. The authors report a rare case of thoracoscopic correction of posttraumatic diaphragmatic hernia in an 81-year-old man in 62 years after abdominal injury. Assuming degenerative changes in tissues and risk of defect enlargement following suture eruption, we used titanium nickelide reinforcing protectors. Video-assisted double port thoracoscopic access allowed minimally traumatic and successful correction of diaphragmatic hernia, that ensured early medical and social rehabilitation of the patient.

[Results and features of surgical treatment of lung cancer after previous COVID-19 pneumonia]. / Rezul'taty i osobennosti khirurgicheskogo lecheniya raka legkogo posle perenesennoi COVID-19 assotsiirovannoi pnevmonii.

OBJECTIVE: To evaluate the features of preoperative preparation and postoperative outcomes in patients with lung cancer and previous COVID-19 pneumonia. MATERIAL AND METHODS: There were 7 patients with non-small cell lung cancer and previous bilateral viral pneumonia between June 2020 and January 2021. In 3 cases, lung cancer was detected in a hospital for COVID-19 patients. Four patients had persistent structural changes in X-ray images. After appropriate preparation, all patients underwent total resection. RESULTS: At admission, all patients had severe physical and functional exhaustion associated with prolonged hypoxia and adynamia that required preoperative rehabilitation. Considering high risk of thromboembolic complications, we administered anticoagulation throughout the entire perioperative period and after discharge. Surgical treatment included anatomical resection (extended lobectomy). Postoperative complications occurred in 2 cases and were associated with prolonged air discharge through the pleural drainage tube. CONCLUSION: As we study the consequences of the new coronavirus infection COVID-19, it becomes obvious that a new category of patients requiring specific diagnosis and treatment has emerged.

[ERAS protocol for perioperative management of patients with non-small cell lung cancer]. / Opyt primeneniya printsipov ERAS dlya perioperatsionnogo soprovozhdeniya patsientov s nemelkokletochnym rakom legkogo.

OBJECTIVE: To evaluate an effectiveness of enhanced recovery program for perioperative support of patients with lung cancer. MATERIAL AND METHODS: A prospective single-center study on effectiveness of ERAS protocol in perioperative support of patients with lung cancer was conducted at the Tomsk Regional Cancer Center. According to the study design, patients were divided into three groups. The first group included patients after VATS surgery followed by accelerated recovery. The second and the third groups comprised of patients after open interventions. In these groups, patients were randomized into traditional management or accelerated recovery management groups using the blind envelope method. Patients with indicated lobectomy or bilobectomy were included only. In postoperative period, we analyzed morbidity, pain syndrome and hospital-stay. RESULTS: A total of 235 patients were treated. VATS surgery followed by enhanced recovery program was applied in 61 patients. Eighty-seven patients underwent open operations followed by accelerated recovery protocol and traditional management. ERAS protocol ensured less postoperative morbidity compared to traditional management (p<0.001). Pain syndrome was less pronounced after VATS surgery and did not require an appointment of narcotic analgesics. In the group of open surgery followed by accelerated recovery protocol, narcotic analgesics within 3 postoperative days were required in 38 (43.6%) cases, in the group of traditional management - in 63 (72.4%) patients. Mean postoperative hospital-stay after VATS operations was 6.4 days, after open interventions followed by ERAS protocol - 8.7 days. In patients after open surgery and traditional postoperative management, mean hospital-stay was 14.2 days. One patient died after open surgery followed by ERAS protocol and 3 patients died in the group of traditional management. CONCLUSION: ERAS protocol ensures less postoperative morbidity, early activation of patients and reduced hospital-stay.

Tissue reaction to a titanium-nickelide mesh implant after plasty of postresection defects of anatomic structures of the chest.

We studied morphological features of the regenerate formed after postresection defect plasty of the pericardium, diaphragm, and thorax with a mesh implant made of nanostructural titanium-nickelide threads. The newly formed tissue grew through the implant with the formation of an integrated tissue regenerate ensuring anatomic and physiological restoration of this area.