Automated Assessment of the Area of Infiltration by CD8+ Cells in Gastric Carcinoma and Areas of Normal Mucosa as a Significant Prognostic Factor.

In 139 patients with verified gastric cancer, the infiltration of the postoperative material with CD8+ cells was analyzed. Automated morphometric analysis of immunostained slides was performed separately in different specimen sites (tumor center, invasive edge, and peritumoral mucosa). The mean area of infiltrating CD8+ cells in the tumor center and in the invasive edge was not predictive, while in the peritumoral mucosa it provided a new negative predictive factor (hazard ratio 2.10; confidence interval 0.87-4.92, Cox regression) reliably associated with the TNM stage (hazard ratio 1.91; confidence interval 0.91-4.61, Cox regression).

[The adaptation of methodology of expert selection of indicators for integral evaluation of effectiveness and efficiency of organization of medical care support at the level of subject of the Russian Federation at the "pediatrics" profile].

The adaptation of methodology of expert selection of indicators for integral evaluation of efficiency of organization of medical care on profile "pediatrics" at the level of the Subject of the Russian Federation. The study was organized as expert survey using structured interview technique. At the first stage, primary selection of indicators carried out. At the second stage, selection of experts in accordance with inclusion criteria and assessment of level of expert competence was organized. Then, criteria of expert evaluation of significance of selected indicators in accordance with international principles applied in of bench-marking systems construction were formulated. The Kendall's concordance coefficient (W) was calculated for quantitative assessment of degree of agreement between the experts answers. The non-parametric Friedman test was applied to evaluate significance of differences. The indicators with high degree of agreement between opinions of experts and availability of statistical significance according concordance coefficient are recommended as indicators for assessment of efficiency of organization of medical care of children at the level of the Subject of the Russian Federation. The following indicators satisfy these requirements: mortality of children aged 0-17 years (per 100 000 of population of corresponding age), mortality of children aged 0-1 year (per 1000 live births), mortality of children aged 0-4 years (per 1000 live births), support of population with beds for children, percentage of children aged 0-17 years under dispensary observation with diagnosis established for the first time. The study permitted to select indices (indicators) that can be applied both for integral rating of the Subjects of the Russian Federation and in formation of Federal projects or departmental target programs in pediatrics. The study results can also be applied in development of system of monitoring efficiency of implementation of these projects and programs.

[Ergonomic parameters of the pathologist's workplace as important factors in the prevention of occupational musculoskeletal diseases]. / Ergonomicheskie parametry rabochego mesta vracha-patologoanatoma kak vazhnye faktory profilaktiki professional'nykh zabolevanii oporno-dvigatel'nogo apparata.

BACKGROUND: More than 80% of pathologists suffer from various manifestations of disorders of the musculoskeletal system. The daily duties of pathologists include several hours of work at a microscope and a computer. Microscopes are often not optimized for ergonomics and do not allow the doctor to take the correct sitting position, most often working with a microscope requires leaning forward. OBJECTIVE: To study the ergonomic properties of the workplace of a pathologist and develop specific practical recommendations for long-term work at a microscope. MATERIAL AND METHODS: The study included microscopes with an adjustable and non-adjustable angle of inclination of the tube and height-adjustable chairs. We identify following ergonomic parameters: pathologist height; angle of inclination of the back of the chair; angle of inclination of the microscope tube; angle of inclination of the neck; chair height. The study included 21 participants. Statistical processing and analysis were made using single-factor and multifactorial correlation analysis. RESULTS: A strong positive linear correlation was identified (r=0.80; p<0.05) between the height of test person and angle of inclination of the microscope tube. A strong positive linear correlation was established (r=0.91; p<0.05) between the test person height and the angle of inclination of the neck for microscopes with non-adjustable 31°-angle of inclination of the tube. For microscopes with non-adjustable 45°-angle of inclination of the tube a strong polynomial correlation of the second degree (r=0.85; p<0.05) was found. A moderate negative linear correlation was found between the height of the pathologist and his tilt angle neck with both adjustable and non-adjustable tube angle of the microscope. CONCLUSION: In this study for the first-time exact correlation dependencies between key ergonomic parameters of pathologist's workplace were evaluated. This study showed that only microscopes with an adjustable angle of inclination of the tube allow to achieve an optimal body position.

[Methodical approaches to annotation and labeling of histological images in order to automatically detect the layers of the stomach wall and the depth of invasion of gastric cancer]. / Metodicheskie podkhody k annotirovaniyu i razmetke gistologicheskikh izobrazhenii v tselyakh avtomaticheskogo raspoznavaniya sloev stenki zheludka i glubiny invazii raka zheludka.

OBJECTIVE: Development of original methodological approaches to annotation and labeling of histological images in relation to the problem of automatic segmentation of the layers of the stomach wall. MATERIAL AND METHODS: Three image collections were used in the study: NCT-CRC-HE-100K, CRC-VAL-HE-7K, and part of the PATH-DT-MSU collection. The used part of the original PATH-DT-MSU collection contains 20 histological images obtained using a high performance digital scanning microscope.Each image is a fragment of the stomach wall, cut from the surgical material of gastric cancer and stained with hematoxylin and eosin. Images were obtained using a scanning microscope Leica Aperio AT2 (Leica Microsystems Inc., Germany), annotations were made using Aperio ImageScope 12.3.3 (Leica Microsystems Inc., Germany). RESULTS: A labeling system is proposed that includes 5 classes (tissue types): areas of gastric adenocarcinoma (TUM), unchanged areas of the lamina propria (LP), unchanged areas of the muscular lamina of the mucosa (MM), a class of underlying tissues (AT), including areas of the submucosa, own muscular layer of the stomach and subserous sections, image background (BG). The advantage of this marking technique is to ensure high efficiency of recognition of the muscularis lamina (MM) - a natural «line¼ separating the lamina propria of the mucous membrane and all other underlying layers of the stomach wall. The disadvantages of the technique include a small number of classes, which leads to insufficient detailing of automatic segmentation. CONCLUSION: In the course of the study, an original technique for labeling and annotating images was developed, including 5 classes (types of tissues). This technique is effective at the initial stages of teaching mathematical algorithms for the classification and segmentation of histological images. Further stages in the development of a real diagnostic algorithm to automatically determine the depth of invasion of gastric cancer require the correction and development of the presented method of marking and annotation.

[Study of gastric adenocarcinomas association with the Epstein-Barr virus-encoded small RNAs]. / Issledovanie assotsiatsii adenokartsinom zheludka s malymi virusnymi RNK virusa Epshteina­Barr.

OBJECTIVE: Assessment of the incidence of EBV-associated gastric adenocarcinomas in a sample of Russian patients, as well as clarification of the clinical and morphological characteristics and median survival of patients with EBV-associated gastric cancer. MATERIAL AND METHODS: We used samples of surgical material from 282 patients with a verified diagnosis of gastric cancer. Each sample was stained by in situ hybridization using primers for the Epstein-Barr virus-encoded small RNAs (EBER). The results obtained were compared with the main clinical and morphological characteristics of gastric cancer. RESULTS: The detection rate of EBV-associated gastric adenocarcinoma in our sample was 9.57%. EBER-positive tumors much more often (p=0.021) belong to the intermediate type according to the P. Lauren classification (66.67%) in comparison with EBER-negative tumors (38.82%). EBER-positive tumors significantly more often (p=0.035) belong to high-grade tumors - 75.00% in comparison with EBER-negative tumors (52.13%). The overall median survival of all patients with EBER-positive tumors (53.5 months) was higher compared to the overall median survival of all patients with EBER-negative tumors - 36.5 months (p=0.5379). The median survival of patients with EBER-positive stage III tumors (30.0 months) was also higher compared to that for patients with EBER-negative tumors - 20.0 months (p=0.5622). It was found that a single EBER status is not a significant prognostic factor (HR=1.0143; CI: 0.9897-1.0196). CONCLUSION: Separately taken EBER-status is not a significant independent prognostic factor and can be considered only in conjunction with the «classical¼ clinical and morphological characteristics, primarily with the stage of the tumor process, since it is they that determine the prognostic properties of the tumor.

[METHODOLOGICAL APPROACHES TO THE FORMATION OF THE RATING OF THE CONSTITUENT ENTITIES OF THE RUSSIAN FEDERATION, REFLECTING THE EFFICIENCY AND QUALITY OF MEDICAL CARE BY PROFILE].

Aim of the study - determination of approaches to the formation of the rating of the constituent entities of the Russian Federation, reflecting the state of medical care in various profiles (the effectiveness and quality of medical care in various profiles). The study included a comprehensive analysis of the structure and content of the reports based on the results of national medical research centers field events using classification and grouping methods. Assessment of the advantages and disadvantages of the used variants of the methodology for forming the subject rating of the Russian Federation used the method of selective SWOT analysis of methodologies published in the form of scientific articles. Further, based on the results obtained, the main requirements for building a rating system for subjects of the Russian Federation based on the indicators of efficiency (performance) and the quality of medical care were formulated. The possibility of applying international experience in building benchmarking systems in the Russian Federation is analyzed and requirements are formulated for building a subject rating system of the Russian Federation, taking into account the peculiarities of the domestic healthcare system. There are 3 main methodological approaches to the formation of the subject rating of the Russian Federation: a quantitative score rating assessment of quantitative indicators without weight coefficients, a qualitative rating assessment of the effectiveness of medical care in a profile without weight coefficients, and a mixed score-rating assessment of quantitative and qualitative indicators using weight coefficients determined only by an expert method. It has been established that many of the existing approaches to the formation of the subject rating of the Russian Federation are based on a combination of a point rating and weight coefficients established by an expert method. Since different indicators have different contributions to the final integral value of the subject rating of the Russian Federation, it is advisable to conduct another study to establish weight coefficients for indicators.

[E-cadherin expression in tumor emboli in gastric cancer]. / Ekspressiya E-kadgerina v opukholevykh embolakh pri rake zheludka.

OBJECTIVE: To determine the level of E-cadherin expression in tumor emboli, to compare it with expression in a tumor, to determine the dependence of E-cadherin expression in tumor emboli on the clinical and morphological characteristics of gastric cancer. MATERIAL AND METHODS: We used samples of surgical material from 280 patients with a verified diagnosis of gastric cancer. E-cadherin expression was determined by immunohistochemical method. The results of the reactions were assessed semi-quantitatively and compared with the main clinical and morphological characteristics of gastric cancer (histological type according to the WHO classification 2019, histological type according to the classification of P. Lauren, clinical stage, depth of invasion (T), number of metastases in lymph nodes (N), presence or/absence of distant metastases (M), tumor localization in the stomach). RESULTS: Among 280 cases of cancer, emboli were detected only in 67 cases, used for further analysis. The rest of the samples were excluded from the analysis, since emboli did not get into the sections during the cutting of immunohistochemical preparations. The expression of E-cadherin in tumor emboli was significantly higher (p<0.001) than in tumor tissue. At the same time, no cases identified where the level of E-cadherin decreased in emboli compared to the tumor. A significant increase in the expression of E-cadherin in tumor emboli compared to the primary tumor was noted for all histological types according to WHO 2019, for intermediate and diffuse types according to the P. Lauren classification (p<0.001). Comparison of expression in emboli and tumors for neoplasms with different depths of invasion (T), different stages and different localizations did not reveal statistically significant differences. An increase in the expression of E-cadherin in emboli compared to tumors was characterized by a higher level of significance in the presence of metastases (N1, N2, N3a, N3b; p<0.001) than in the absence of metastases (N0; p=0.016). CONCLUSION: The study revealed a statistically significant increase in the expression of E-cadherin in tumor emboli compared to the primary tumor, which is evidence of its important role in maintaining the integrity of emboli and tumor dissemination.

[Podoplanin`s expression in cancer-associated fibroblasts close to tumor budding of invasive edge]. / Ekspressiya podoplanina v opukholeassotsiirovannykh fibroblastakh vblizi opukholevykh pochkovanii invazivnogo kraya.

INTRODUCTION: Tumor budding was declared as independent prognostic factor for early cancer in 2016. Tumor-associated fibroblasts (CAFs) are one of the main components of tumor microenvironment. Plenty of different markers are used for detection of CAFs, including podoplanin (POD). OBJECTIVE: The aim of this study is to identify correlation between tumor budding, that indicates tumor invasive potential and is considered to be a negative prognostic factor, and CAFs near tumor buds using POD. MATERIAL AND METHODS: 43 cases of colon adenocarcinoma are included in the study. Double staining immunohistochemical technology with PCK and POD was used for detection of tumor budding and evaluation of POD expression near tumor buds. RESULTS: Significant correlations are revealed between tumor budding and depth of tumor invasion (p=0.023)/regional lymph node metastasis (p=0.068), but between POD expression and depth of tumor invasion (p=0.088) only a tendency of correlation is identified. These facts demonstrate critical prognostic value of tumor budding instead POD expression near tumor buds. It was found that intensity of POD expression near tumor buds is statistically analogous to POD expression in the invasive margin (p=0.0016). That means it is not necessary to evaluate POD expression exactly near tumor buds. For the first time stronger POD expression near mucin complexes is reported. That, probably, will allow to use mucin complexes as alternative prognostic factor instead tumor budding, as tumor buds are absent in mucinous adenocarcinoma.

[Persistence of Epstein-Barr virus antigens in gastric cancer: characteristic of inflammatory cellular reactions in tumor]. / Persistentsiya antigenov virusa Epshteina­Barr pri rake zheludka: kharakteristika vospalitel'nykh kletochnykh reaktsii v opukholi.

THE AIM OF THE STUDY: Is to establish the relationship between the persistence of viral antigens of the Epstein-Barr virus (EBV) and the cellular composition of the immune microenvironment of tumor tissue and the mucous membrane of peritumoral area in gastric cancer. MATERIAL AND METHODS: We used samples of surgical material from 55 patients with a verified diagnosis of gastric cancer. The expression of CD4, CD8, CD68, CD1a and LMP-1 was assessed. The results were assessed by the morphometric method. We selected three fields of view (magnification x200) in tumor tissue and in peritumoral areas separately and counted an absolute number of cells with positive staining with further calculation of the average number of cells and the median. RESULTS: LMP-1-negative tumors with LMP-1 expression in epithelium of peritumoral area were characterized by the highest density of CD4+ lymphocyte infiltration in the central part of the tumor; the highest density of CD8+ lymphocyte infiltration in the mucous membrane of peritumoral area (p=0.0190); the highest density of infiltration by macrophages in the mucous membrane of peritumoral area (p=0.2492); the highest density of infiltration by CD1a+ cells in the mucous membrane of peritumoral area (p=0.1503). The highest density of infiltration with CD1a+ cells was characteristic for LMP-1-positive and LMP-1-negative tumors (p=0.0813). The persistence of the LMP-1 viral antigen in the glandular epithelium of the peritumoral area in our sample does not have a statistically significant effect on the prognosis of the disease (RR=1.7718; p=0.0885) but there is a tendency towards a negative predictive value. CONCLUSION: High density of infiltration of glandular epithelium of peritumoral area with the expression of LMP-1 by CD4+ and CD8+ lymphocytes is most likely associated with the activation of the cellular immune response and may be one of the signs of the persistence of viral antigens. It was shown for the first time that the phenomenon of persistence of the LMP-1 viral antigen is characterized by a trend towards negative predictive value for patients with gastric cancer.

[Leptin and leptin receptor evaluation in atherosclerotic plaques in patients with type 2 diabetes mellitus].

BACKGROUND: Diabetes mellitus (DM) is a significant predictor of atherosclerosis, cardiovascular disease, and cardiovascular mortality. It is known that atherosclerosis occurs earlier in patients with diabetes, reducing the duration of their life. Leptin as well as other inflammatory markers can contribute to the progression of atherosclerosis in patients with DM, participate in the development of a local inflammatory reaction. AIM: Determine the cells immunophenotype of atherosclerotic plaques in patients with diabetes. MATERIALS AND METHODS: We analyzed 24 patients (20 men and 4 women), who underwent aortofemoral bypass, femoral-tibial bypass or carotid endarterectomy. During the operation, a fragment of the arterial wall with an atherosclerotic plaque was obtained for further immunohistochemical studies. Five histologic plaque characteristics (CD68+, -SMA, CD34, leptin and leptin receptor) were compared. RESULTS: No difference in the expression of CD68 (p=0.922), -SMA (p=0.192), CD34 (p=0.858), leptin receptor (p=0.741) and leptin (p=0.610) in atherosclerotic plaques were observed between patients with and without DM. The lack of significant differences between the two groups was possibly due to the small number of observations with DM. In particular, when assessing the expression of selected markers in atherosclerotic plaques, patients with DM showed significantly more leptin receptors than patients without DM (2160.716 and 1205.88 respectively); and also significantly less CD68+ (0.39 and 0.98 respectively) and -SMA+ (6.5 and 13.5 respectively). CONCLUSION: Based on the expression of CD68, -SMA, CD34, leptin receptor and leptin, no significant differences were observed in atherosclerotic plaque between patients with and without DM. At the same time, despite the limitations of the study (a small number of patients, moderate severity of DM, elderly patients in the DM group), we found a tendency in the increased number of leptin receptors and a decreased number of -SMA+, CD68+ in DM atherosclerotic plaques. Further study needed, taking into account the limitations of this work.

[Cancer-associated fibroblasts and their significance in tumor progression]. / Opukhol'-assotsiirovannye fibroblasty i ikh znachenie v progressii zlokachestvennykh novoobrazovanii.

Carcinogenesis and tumor progression are not caused not only by malignant epithelial cells, but also by the tumor stroma around cancer stem cells which performs regulatory, nutritional and 'framework' functions. It is represented by mesenchymal cells of various types predominantly by cancer-associated fibroblasts (CAF). αSMA, FAP-1, desmin, podoplanin, neuron-glial antigen 2 (NG2), PDGFR-α and -ß are used for CAF identification but there is no universal markers due to the plasticity of the cell population that underlies the subpopulation division CAF. CAF subpopulations are not described for many tumor types. Recently, evidence has accumulated that CAFs mediate many adverse processes in the tumor, including can support stromal inflammation and cause fibrosis. By forming a niche in cancer stem cells, CAFs mediate chemoresistance and the appearance of dormant metastases. The study of the role of CAF will allow not only to form a fundamentally new understanding of the mechanisms of carcinogenesis, but also to create new diagnostic and therapeutic targets for treating tumors.

[Epstein-Barr virus-associated gastric adenocarcinoma]. / Adenokartsinoma zheludka, assotsiirovannaia s virusom Épshteina-Barr.

EBV-associated gastric adenocarcinoma accounts for 10% of all gastric adenocarcinomas. The main known facts about the pathogenesis of EBV-associated gastric adenocarcinoma are presented. There are two main morphological types: gastric carcinoma with lymphoid stroma - GCLS (including lymphoepithelioma-like carcinoma; carcinoma with Crohn's disease-like lymphoid reaction; EBV-associated carcinoma with osteoclast-like giant cells) and conventional type adenocarcinoma. EBV-associated gastric adenocarcinomas predominantly express markers of gastric differentiation (MUC5AC, MUC6, CLDN-18) and a number of viral markers (EBER-1, EBNA-1 and BART mRNA). Three types of EBV latent cycle depending on the set of expressed viral transcripts are distinguished. It is believed that EBV-associated gastric adenocarcinoma is characterized by an intermediate position between latent cycles of types 1 and 2. The main method of virus identification is in situ hybridization with the detection of Epstein-Barr virus-encoded small RNAs (EBER-ISH).

[Expression of LMP-1 protein in tumor cells and glandular epithelium of the peritumoral tissue in gastric cancer]. / Ékspressiia belka LMP-1 v opukholevykh kletkakh i zhelezistom épitelii peritumoral'noi oblasti pri rake zheludka.

OBJECTIVE: To study the relationship of LMP-1 expression with the clinical and morphological characteristics of gastric cancer and to study LMP-1 expression in the glandular epithelium of the peritumoral tissue. MATERIAL AND METHODS: Samples of gastric cancer surgical material from 67 patients were included in this study. Primary mouse monoclonal antibodies to LMP-1 protein were used. LMP-1 expression was considered as positive if at least in one of the selected 10 fields of view (lens magn. ×40) ratio of the number of cells with LMP-1 expression to the total number of cells exceeded 10%. RESULTS: Nine cases of LMP-1 positive tumors, 32 cases of LMP-1 negative tumors and 26 cases of LMP-1-negative tumors with LMP-1-expression in the epithelium of the peritumoral tissue were detected. Last group was described for the first time; 4 of these were intestinal type tumors, 19 tumors were 'intermediate' type and 3 tumors were diffuse type, the prevalence of 'intermediate' type tumors was statistically significant. CONCLUSION: LMP-1-negative tumors with LMP-1-expression in the epithelium of the peritumoral tissue were identified and described for the first time. This group was predominantly represented by tumors of an 'intermediate' histological type of gastric cancer. EBV antigens may have any direct oncogenic effects, or play the role of the background or the concomitant processes. No significant relationship was found between the LMP-1 expression and depth of invasion (T), lymph nodes metastasis (N), distant metastasis (M), clinical stages. This fact can be explained by the high heterogeneity of molecular and genetic properties of gastric cancer.

Detection, Role and Prognostic Value of Cancer-associated Fibroblasts in Colorectal Cancer.

Cancer-associated fibroblasts (CAFs) - mesenchymal cells in the tumor stroma, play one of the leading roles in tumor progression in many different tumors, including colorectal cancer. Scientists have described many markers for CAFs, but none of them is specific. We performed immunohistochemistry tests using five antibodies (αSMA, POD, FAP, PDGFRα, PDGFRß) to investigate CAFs in three zones of 49 colorectal adenocarcinomas: apical, central, and invasive edge. We revealed the reliable correlation between high PDGFRß and PDGFRα value in the apical zone and deeper invasion (T3-T4) (p = 0.0281 and p = 0.0137). High αSMA level in apical zone (p = 0.0001), αSMA level in central zone (p = 0.019), POD level in apical zone (p = 0.0222), POD level in central zone (p = 0.0206) and PDGFRß level in apical zone (p = 0.014) correlated reliably with the presence of metastasis in lymphatic nodules. For the first time, focused on the inner layer of CAF adjacent to tumor complexes. We observed that cases with inner αSMA expression were significantly more often (p = 0.023) characterized by the presence of regional lymph node metastasis compared with cases with mix of CAF markers (p = 0.007) and with cases with inner POD expression (p = 0.024). The found relationships between the level of markers and the presence of metastases indicate their clinical significance.

[Allotransplantation of testicle].

Allotransplantation of vascularized testicle with mild immune suppression was performed at 132 patients with primary hypogonadism associated with androgenic deficient and endocrine form of impotence. This method permits to achieve stable engraftment in early postoperative period at 83% patients. Acute immunologic rejection crisis and secondary wound disruption are the most frequent complications at early postoperative period. The rate of these complications may be reduced with more intensive immune suppression. At the patients with smooth recovery the testosterone level starts to increase in 1 week after allotransplantation and stabilizes during all first year on the level of normal and subnormal parameters.

[Allotransplantation of testicle in clinical practice. Part 2].

Long-term results of 90 allotransplantations of vascularized testicle are analyzed. The operations were performed at the patients with primary hypogonadism, androgenic deficient and endocrine form of impotence. Maximal follow-up period is 21 years. Sexual activity and adequate erections were seen at the majority of the patients (67 of 90). At 11 cases in 5 years and at 12 cases in 10 years the erections were absent. The problem of fibrous transformation of vascular pedicle of transplant is discussed. Fibrous process was not diagnosed at all the patients and should be probably regarded as the reaction of chronic rejection.

[Vascular pedicle assessment during microsurgical autotransplantation of tissue complexes].

The paper describes vascular pedicle patency assessment after autotransplantation of 107 free soft tissue complexes to neck, upper and lower limb areas. In early postoperative period pedicles were patent in 82 (76.6%) patients; in 25 cases thrombosis has developed in 36 hours after surgery. Timely diagnosis of this complication and reanastomosing helped to preserve transplants in 9 (36%) patients and to increase the total rate of successful transplantations up to 85% (91 cases). The role of diagnostic imaging (Doppler ultrasound, duplex scanning and polarography) in early postoperative evaluation of vascular pedicles is analyzed, as well as the role of oxygen tension measurement, which reflects the circulation character in autotransplants of different size. One must take into account the possibility of prolonged circulatory disturbances unrelated to anastomotic thromboses that can take place in large flaps.

[Microsurgical elimination of foot soft tissue defects with free vascularized flaps]. / Mikrokhirurgicheskoe ustranenie defektov miagkikh tkaneí stopy svobodnymi vaskuliarizirovannymi loskutami.

The results of 40 microsurgical transplantations of complex flaps in 37 patients with cicatricial-ulcerous foot deformations are analysed. The surgery was indicated in cicatricial soft tissues defects, unhealing trophic ulcers, inability to use local tissues for plastic surgery. The scapular flap was used in 34 cases, thoraco-dorsal flap in 5 cases, deltoid flap in 1 case. It was necessary to increase the square of the scapular flap in case of a vast cicatricial soft tissue defect of the talocrural joint and dorsal surface of the foot and the sole. A special expander was used for this purpose. The importance of ultrasound methods for evaluation of the vessels supplying the sole, as well as the state of the microvascular anastomoses in postoperative period is stressed. The long-term results were followed up for 1.5 to 5 years in 29 of 37 patients. The good results was noted in 18 patients, satisfactory in 7 patients, complications (unhealed trophic ulcers) in 4 patients. The complications were caused by calcanel tuber deformation with osteophyte, osteomyelitis, inradically removed scars.

[Surgical treatment of extensive defects of the tissues and trophic ulcers in the area of the heel tendon using an L-shaped flap]. / Khirurgicheskoe lechenie obshirnykh defektov tkanei i troficheskikh iazv oblasti piatochnogo sukhozhiliia L-obraznym loskutom.

Operations were conducted on 22 patients with defects in soft tissues and trophic ulcers of cicatrix in the region of the calcaneal tendon. In 16 patients with extensive cicatricial lesions occupying two distal thirds or the whole region, an L-shaped flap of skin and fat was used, it was formed on the postero-lateral distal third of the leg, in the zone of the lateral malleolus and the lateral surface of the foot. The flap measured 20-22 cm in length and 6-7 cm in width. The ratio of the vertical part of the flap to the horizontal part was 3:1, 2:1, or 1:1 depending on the level of the defect and the area of the wound. The flap is mobilized strictly along the fascia so as not to injure the subcutaneous fat. The sural nerve is included in the flap to preserve its sensitivity, the rich venous network of the small saphenous vein provides for drainage, while the perforating arteries of the anterior tibial and fibular arteries, entering the base of the flap, ensure a sufficiently stable collateral circulation. Necrosis of the end of the flap occurred in 2 among 16 patients, in obliteration of the leg arteries (1) and cutting of tissues in the zone of the flap base (1) during previous surgical intervention. Complete healing was achieved in all cases; there were no recurrences in follow-up periods of 6 months to 8 years. The L-shaped flap retained its normal properties, the deformity of the donor site was negligible.

[Prevention of complications in reconstructive surgery of burn injuries]. / Profilaktika oslozhnenii v vosstanovitelnoi khirurgii posledstvii ozhogov.

On the basis of treatment of more than 5,000 patients with postburn cicatricial contractures of the joints, deformities and defects of the soft tissues the authors studied the complications and their causes. Suppuration of the operative wounds, necrosis of grafts and the edges of the wound, and hematomas are the main complications. The character of the complications and their sequelae are connected directly with the specific features of the surgical intervention and type of plastics (free, flap, microsurgical, dermatotensia), as well as with the anatomical features of the tissues and vessels damaged by the burn, which reduce the resistance to infection and facilitate the appearance of circulatory disorders. Preventive measures are suggested which excluded purulent complications and reduced tissue necrosis to minimum. Therapeutic measures reducing sharply the sequelae of the complications are discussed. Preeminence of preventive measures over therapeutic measures is emphasized. Their timely application helps in attaining good outcomes of restorative and reconstructive operations in patients who had suffered from burns.