Improvement of Russian clinical guidelines and reduction of mortality in perforated ulcers / O perspektivakh sovershenstvovaniya rossiiskikh klinicheskikh rekomendatsii i snizheniya letal'nosti pri probodnoi yazve.

OBJECTIVE: To analyze the results of laparoscopic surgery in patients with perforated ulcers using evidence-based medicine approaches. MATERIAL AND METHODS: We compared the efficacy and effectiveness of laparoscopic and open surgeries in patients with perforated ulcers. Meta-analysis of mortality after laparoscopic surgeries (randomized controlled trials) and trial sequential analysis were carried out. RESULTS: We clarified the differences between the efficacy and effectiveness of laparoscopic surgeries regarding postoperative mortality. In the Russian Federation, mortality after laparoscopic surgery is 9-11 times lower compared to open procedures. According to evidence-based researches (efficacy of laparoscopic interventions in 10 meta-analyses), these differences are less obvious (1.4-3.0 times) and not significant. The diversity-adjusted required information size to draw reasonable conclusions about differences in mortality in trial sequential analysis was 68 181 participants. Meta-analyses of RCTs also demonstrate lower incidence of wound complications (1.8-5.0% after laparoscopic surgery and 6.3-13.3% after laparotomy), shorter hospital-stay (mean difference from -0.13 to -2.84) and less severe pain syndrome (mean difference in VAS score from -2.08 to -2.45) after laparoscopic technologies. CONCLUSION: The obvious advantage of laparoscopic surgery in patients with perforated ulcers is fast-truck recovery following shorter hospital-stay, mild pain and rarer wound complications. Comparison of postoperative mortality regarding efficacy and effectiveness is difficult due to insufficient introduction of laparoscopic technologies in clinical practice and diversity-adjusted required information size.

[Emergency surgical care in the Volgograd region between 2017 and 2021]. / Sravnitel'nye rezul'taty okazaniya neotlozhnoi khirurgicheskoi pomoshchi naseleniyu Volgogradskoi oblasti v period 2017­2021 gg.

OBJECTIVE: To analyze the indicators of emergency surgical care in the Volgograd region between 2017 and 2021. MATERIAL AND METHODS: We summarized and analyzed primary statistical data presented in annual analytical collections of the chief surgeon of the Ministry of Healthcare of Russia «Surgical care In Russian Federation¼ (Revishvili A.Sh. et al.) and the Rosstat collections «Regions of Russia. Socio-economic indicators¼. RESULTS: According to analytic system outworked in the Vishnevsky National Research Medical Center of Surgery, surgical service in the Volgograd region dropped from the 64th to the 82nd place among other entities between 2017 and 2021. Insufficient innovative development of surgical service is evidenced by small number of surgeons, common part-time work, no dynamics in introduction of laparoscopic surgeries and high in-hospital mortality in some acute abdominal disease. Work of regional surgical service was compared with socio-economic development of region and monitoring indicators in the «Health¼ national project. CONCLUSION: Improving the efficacy of surgical service in the Volgograd region requires joint efforts of the entire regional healthcare system.

[Impact of late admission on mortality from acute abdominal diseases in the Central Federal District of the Russian Federation]. / Vliyanie pozdnei gospitalizatsii na letal'nost' pri ostrykh abdominal'nykh zabolevaniyakh v TsFO Rossiiskoi Federatsii.

OBJECTIVE: To analyze the effect of late hospitalization on mortality from acute abdominal diseases in the Central Federal District of the Russian Federation. MATERIAL AND METHODS: Analysis of late hospitalizations and in-hospital mortality was based on metadata (616.742 clinical observations between 2017 and 2021). Primary statistical data were obtained from reports of chief surgeons in 18 regions of the Central Federal District of the Russian Federation and presented in analytical collections «Surgical care in the Russian Federation¼. RESULTS: The number of patients admitted to surgical hospitals of the Central Federal District with acute abdominal diseases later than 24 hours from clinical manifestation varies depending on the underlying disease. The greatest number of late hospitalizations was observed in acute intestinal obstruction (50.82%), acute adhesive intestinal obstruction (48.49%) and acute pancreatitis (47.36%). In acute cholecystitis, gastrointestinal bleeding and acute appendicitis, admission after 24 hours was observed in 44.72, 38.65 and 33.83% of cases, respectively. Late hospitalization is even less typical for strangulated hernia (27.43%) and perforated ulcer (26.23%). In-hospital mortality significantly differs in both groups (within and after 24 hours) for all acute abdominal diseases. Extended surgery and widespread peritonitis increase these differences for strangulated hernia by 9.2 times (0.92% within 24 hours and 8.48% after 24 hours), for acute appendicitis by 8 times (0.05% within 24 hours and 0.40% after 24 hours) and for perforated ulcer by 6.3 times (4.50% within 24 hours and 28.59% after 24 hours). CONCLUSION: In the Central Federal District, about 25-50% of patients with acute abdominal diseases admitted to the hospital later than 24 hours after clinical manifestation depending on disease. We found the highest in-hospital mortality following late hospitalization in patients with strangulated hernia, acute appendicitis and perforated ulcers.

[Clinical and economic aspects of laparoscopic surgery for acute cholecystitis in delayed presentation]. / Kliniko-ekonomicheskie aspekty laparoskopicheskikh operatsii pri ostrom kholetsistite v usloviyakh pozdnei gospitalizatsii.

OBJECTIVE: To study the clinical and economic features of laparoscopic surgery for acute cholecystitis in delayed presentation. MATERIAL AND METHODS: A prospective non-randomized study (2020-2021) included 101 patients (73.2% (n=74) men and 26.8% (n=27) women, mean age 58±14.9 years) with acute cholecystitis who underwent laparoscopic cholecystectomy. Cost-effectiveness analysis of laparoscopic cholecystectomy at various periods after clinical manifestation was performed. RESULTS: Surgical treatment within 72 hours was performed in 15% (n=16) of cases (group 1), within 4-10 days - in 57.5% (n=58) (group 2), after 10 days - in 26.7% (n=27) of patients (group 3). Overall incidence of postoperative complications was 2.9%, postoperative mortality - 1.9% (two patients died from widespread peritonitis). Surgery time was 70 [65-83], 85 [69-110] and 115 [80-125] min (H=15.55, p<0.001), hospital-stay - 6 [5-7], 9 [7-10] and 11 [7-14] days, respectively (H=21.86, p<0.001). Cost of direct (medical and non-medical) treatment amounted to 29484 [27 509-33 885], 41265 [34 306-48 301] and 50591 [37 069-62 483] rubles, respectively (H=29.71, p<0.001)). CONCLUSION: Delayed hospitalization and surgical treatment of acute cholecystitis after 72 hours are accompanied by higher treatment costs by 29% in the period up to 10 days and by 58% after 10 days. These results require further validation and adjustment in large samples.

[Laparoscopic versus laparoscopy-assisted suturing of perforated peptic ulcers (meta-analysis)]. / Laparoskopicheskoe i laparoskopicheski assistirovannoe ushivanie probodnoi yazvy (metaanaliz).

OBJECTIVE: To compare laparoscopic and laparoscopy-assisted repair of perforated peptic ulcer using evidence-based methods. MATERIAL AND METHODS: A systematic review and meta-analysis were carried out in accordance with the recommendations of the Ministry of Health of Russian Federation and Cochrane Handbook for Systematic Reviews.Data searching was carried out in Russian and English languages using the E-library, Cochrane Library and PubMed databases. We analyzed titles and references in specialized journals and thematic reviews, respectively. Clarifying information was obtained via personal contacts with the heads of surgical hospitals. The RevMan 5.4 software was used for statistical analysis. RESULTS: We found no randomized trials devoted to comparison of laparoscopic and laparoscopy-assisted surgeries in patients with perforated peptic ulcer. Meta-analysis was based on non-randomized trials with satisfactory methodological quality according to the I-ROBINS formalized assessment. Overall clinical material included 478 observations: 229 (47.9%) laparoscopic surgeries and 249 (52.1%) laparoscopy-assisted procedures via minimally invasive access. There were no conversions. Incidence of postoperative complications was 4.36 and 8.83% (OR=0.39, 95% CI 0.08, 1.87), postoperative mortality 0.87 and 0.81%, respectively (OR=1.26, 95% CI 0.08, 8.24). Laparoscopic surgeries were shorter (MD= -8 min, 95% CI -9.7, -6.4). Length of hospital-stay was also shorter after laparoscopic surgery (MD= -4.6, 95% CI -9.7, -6.4). CONCLUSION: Laparoscopic operations are shorter and accompanied by lower incidence of postoperative complications and less hospital-stay. Large statistical power is required to confirm these differences.

[Prospects for development of laparoscopic surgery in the Central Federal District of the Russian Federation]. / O perspektive razvitiya laparoskopicheskoi khirurgii v Tsentral'nom federal'nom okruge Rossiiskoi Federatsii.

OBJECTIVE: To analyze the achievements of laparoscopic surgery in the Central Federal District of Russia and outline perspective trends for further application. MATERIAL AND METHODS: The study included adult patients with abdominal surgical diseases hospitalized in general surgical departments of the Central Federal District between 2014 and 2021. We analyzed the prevalence of elective and emergency laparoscopic surgeries. Incidence and results of laparoscopic interventions between 2018 and 2021 were estimated considering primary statistical data presented in the annual collections of the Chief Surgeon of the Ministry of Health of Russia «Surgical care in the Russian Federation¼. RESULTS: The absolute number of laparoscopic surgeries in the Central Federal District increased from 23.686 to 80.489 (by 3.4 times) between 2014 and 2021. The annual number of elective laparoscopic surgeries exceeded the number of emergency ones up to 2019. In 2020-2021, this situation changed in favor of emergency abdominal procedures. Laparoscopic surgeries are the most common for in acute cholecystitis (71.06-81.10% of all laparoscopic interventions annually) and acute appendicitis (46.85-55.60%). In 2020 and 2021, the absolute number of laparoscopic appendectomies exceeded the number of laparoscopic cholecystectomies. These values are lower for perforated ulcers (15.44-20.39%) and acute pancreatitis (32.40-36.71%). Laparoscopic operations are rare for acute intestinal obstruction, strangulated hernia and ulcerative gastroduodenal bleeding. In elective surgery, high availability of laparoscopic surgeries was noted in patients with cholelithiasis (89.40-93.78%), hiatal hernia (62.12-77.27%) and adrenal gland diseases (64.23-87.25%). The most intensive increment of availability (by 2.4 times) was noted for inguinal hernia from minimum level (10.98%) in 2018 to 26.00% in 2021. Mortality after some laparoscopic operations decreased in comparison with laparotomy by 12-45 times (2018-2021). However, this aspect and results of laparoscopic surgeries in case of delayed hospitalization require additional study. CONCLUSION: Analysis of laparoscopic surgery showed the timeliness of beginning and development of this direction In Russia. The prospect of further development of laparoscopic surgery for abdominal diseases is determined by modern trends. These are increase in the number of laparoscopic operations for acute appendicitis, acute cholecystitis and perforated ulcers, as well as higher number of early (after admission) operations.

[In-hospital mortality in acute abdominal diseases in the Central Federal District of Russia depending on availability of laparoscopic procedures]. / Dinamika gospital'noi letal'nosti pri ostrykh abdominal'nykh zabolevaniyakh v Tsentral'nom federal'nom okruge Rossii v zavisimosti ot chastoty primeneniya laparoskopicheskikh operatsii.

OBJECTIVE: To study in-hospital mortality in acute abdominal diseases in the Central Federal District and compared effectiveness of laparoscopic and open surgeries. MATERIAL AND METHODS: The study was based on the previous data for 2017-2021. The odds ratio (OR) was used to assess significance of between-group differences. RESULTS: The absolute number of deceased patients with acute abdominal diseases increased significantly and exceeded 23 thousand in the Central Federal District between 2019 and 2021. This value approached 4% for the first time over the last 10 years. In-hospital mortality from acute abdominal diseases in the Central Federal District increased for 5 years and reached maximum value in 2021. The greatest changes occurred in perforated ulcers (mortality increased from 8.69% in 2017 to 14.01% in 2021), acute intestinal obstruction (from 4.7% to 9.0%) and ulcerative gastroduodenal bleeding (from 4.5% to 5.5%). In other diseases, in-hospital mortality is lower, but trends are similar. Laparoscopic surgeries are common in acute cholecystitis (71-81%). At the same time, in-hospital mortality is significantly lower in regions with more active use of laparoscopy (0.64% and 1.25% in 2020; 0.52% and 1.16% in 2021). Laparoscopic surgeries are significantly less actively used for other acute abdominal diseases. We analyzed availability of laparoscopic surgeries using the «Hype Cycle¼. Percentage range of introduction reached conditional «productivity plateau¼ only in acute cholecystitis. CONCLUSION: Most regions are stagnating in laparoscopic technologies for acute appendicitis and perforated ulcers. Laparoscopic operations are actively used for acute cholecystitis in most regions of the Central Federal District. Annual increase in the number of laparoscopic operations and their technical improvement are promising in reducing in-hospital mortality associated with acute appendicitis, perforated ulcers and acute cholecystitis.

[Impact of staffing on the results of treatment among surgical patients. Statistical study]. / Vliyanie kadrovoi ukomplektovannosti na rezul'taty lecheniya khirurgicheskikh bol'nykh. Statisticheskoe issledovanie.

OBJECTIVE: To study the influence of staffing index on the results of surgical treatment. MATERIAL AND METHODS: The study was based on the data of surgical service in the Russian Federation upon 2018 (A.Sh. Revishvili et al., 2019). Correlation and regression analysis was carried out using the Microsoft Excel 2019 software. To assess between-group differences, we analyzed odds ratio (OR) and contingency table using χ2 test. RESULTS: Correlation and regression analysis revealed strong direct functional relationships (r=0.889) between the staffing of surgical service and in-hospital mortality rates. We distinguished 3 formalized levels of surgical staffing (high, medium and low). Gradation of these categories depends on the annual average reference indicator of staffing (88.4% in 2018). In high level of surgical staffing (≥88.4%), in-hospital mortality was 2.19%. Low level of surgical staffing (<88.4%) is accompanied by in-hospital mortality of 2.65% (OR 0.83; 95% CI 0.81-0.84; p<0.05). CONCLUSION: We confirmed the hypothesis about correlation of in-hospital mortality and staffing of surgical personnel. Validation of scientific data requires further studies with multivariate analysis of various covariates. Long-term prospects of surgical personnel policy in Russia are associated with formulation of specific tasks for surgical services at each level of surgical care.

[Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]. / Dokazatel'naya meditsina zhelchnokamennoi bolezni v sfere sozdaniya otechestvennykh klinicheskikh rekomendatsii.

OBJECTIVE: To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications. MATERIAL AND METHODS: We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021. RESULTS: There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses. CONCLUSION: We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.

[Perforated peptic ulcer in patients with cancer: prediction of postoperative morbidity and mortality]. / Probodnaya yazva u patsientov s onkologicheskimi zabolevaniyami: prognozirovanie posleoperatsionnykh oslozhnenii i letal'nogo iskhoda.

OBJECTIVE: To analyze treatment outcomes and approaches to predicting the postoperative morbidity and mortality in patients with perforated ulcers and cancer. MATERIAL AND METHODS: A non-randomized trial included 194 patients. The first group enrolled 45 (23%) patients with perforated ulcers and concomitant cancer who underwent at the oncology center; the second group included 149 (77%) patients with perforated ulcers and no cancer who underwent surgery in general surgical hospitals. Organ-sparing procedures prevailed (40 (88.9%) and 138 (92.6%) cases, respectively). Resections were performed in 5 (11.1%) and 11 (7.4%) patients respectively. Analyzing the factors affecting treatment outcomes, we studied crude (COR) and adjusted (AOR) odds ratios. ROC-analysis was used to assess diagnostic significance of the models for prognosis of morbidity and mortality. RESULTS: Length of hospital-stay was 10 (range 9-14) and 8 (range 7-9) days respectively. Postoperative complications (Clavien-Dindo grading system) occurred in 18 (40%) in 37 (24.8%) patients, respectively. According to multivariate analysis, predictors of complications in patients of the first group were treatment with NSAIDs/glucocorticoids and Charlson-Deyo index >3. Sensitivity of this model was 82.4%, specificity - 75.0%. Postoperative mortality was 15.6% (n=7) and 7.4% (n=11) respectively. According to multivariate analysis, predictors of mortality were age over 65 years and more than 5 chemotherapeutic courses. Sensitivity of the model was 85.7%, specificity - 97.4%. CONCLUSION: The stratified approach makes it possible to improve prediction of postoperative morbidity and mortality in patients with perforated ulcers.

[Comparison of robot-assisted and conventional endoscopic surgeries in the Russian Federation. (A systematic review and meta-analysis)]. / Sravnenie robot-assistirovannykh i traditsionnykh videoendoskopicheskikh operatsii v RF. (Rezul'taty sistematicheskogo obzora i metaanaliza).

OBJECTIVE: Comparative assessment of immediate and long-term results of robot-assisted and conventional endoscopic technologies in the Russian Federation. MATERIAL AND METHODS: Searching for primary trials devoted to robot-assisted (RAE) and traditional video endoscopic (TVE) surgeries in the Russian Federation was carried out in the e-library and CENTRAL Cochrane databases. We used the recommendations of the Center for Expertise and Quality Control of Medical Care (2017, 2019) and the current version of the Cochrane Community Guidelines (2021). These guidelines define the features of meta-analysis of non-randomized comparative studies. Review Manager 5.4 software was used for statistical analysis. RESULTS: We enrolled 26 Russian-language primary sources (3111 patients) including 1174 (38%) ones in the RAE group and 1937 (62%) patients in the TVE group. There were no randomized controlled trials in the Russian Federation, and all primary studies were non-randomized. We found no significant between-group differences in surgery time, incidence of intraoperative complications, intraoperative blood loss in thoracic surgery, urology and gynecology, conversion rate, postoperative hospital-stay, postoperative morbidity (in abdominal surgery, urology and gynecology), postoperative mortality. We observed slightly lower intraoperative blood loss for RAE in abdominal surgery and lower incidence of postoperative complications in robot-assisted thoracic surgery. These results can be compromised by methodological quality of comparative studies, significant heterogeneity and systematic errors. CONCLUSION: Currently, we cannot confirm the benefits of robot-assisted technologies, since this approach does not worsen or improve treatment outcomes. Further high-quality studies are needed.

[Pneumomediastinum in patients with a novel coronavirus infection (COVID-19)]. / Pnevmomediastinum u bol'nykh s koronavirusnoi infektsiei (COVID-19).

OBJECTIVE: To determine the optimal management of pneumomediastinum in patients with a novel coronavirus infection (COVID-19). MATERIAL AND METHODS: There were 14 patients with pneumomediastinum and COVID-19 infection without mechanical ventilation. We discussed the world data on pneumomediastinum in patients with coronavirus infection. RESULTS: Before the COVID-19 pandemic, the annual number of own observations of spontaneous pneumomediastinum did not exceed 1-2 patients. The mechanism of pneumomediastinum is explained by the Macklin effect. COVID-19 pandemic in the Russian Federation was followed by increase of the number of patients with pneumomediastinum up to 2.4% of the total number of patients in the thoracic department. In this sample, pneumomediastinum occurred at all variants of the course of coronavirus infection. The timing of pneumomediastinum ranged from 2 to 18 (median 14) days after clinical manifestation of COVID-19. In 2 out of 14 cases, pneumomediastinum was the main symptom of coronavirus infection at admission. One patient had a combination of pneumomediastinum and pneumothorax. In 6 cases, pneumomediastinum was stable and regressed under conservative therapy. Eight patients underwent Razumovsky suprajugular mediastinotomy. There were no postoperative deaths. Recurrent pneumomediastinum was noted in one patient. CONCLUSION: The causes of pneumomediastinum in some patients with coronavirus infection, peculiarities of diagnosis and treatment and clarification of indications for invasive interventions require further study.

[Effectiveness of laparoscopic cholecystectomy for acute cholecystitis]. / Sravnitel'naya effektivnost' laparoskopicheskoi kholetsistektomii pri ostrom kholetsistite.

OBJECTIVE: To analyze the impact of laparoscopic cholecystectomy on in-hospital and postoperative mortality in patients with acute cholecystitis. MATERIAL AND METHODS: Comparative analysis was based on primary statistical data presented in public available analytical collections «Surgical care in the Russian Federation¼ (Revishvili A.Sh. et al. 2019, 2020). Depending on introduction of laparoscopic surgery, all regions were divided into 4 groups. Between-group analysis of differences was carried out using χ2 test. Statistical processing was performed using SPSS Statistics software package for Windows. RESULTS: According to 2-year follow-up data (2018, 2019), in-hospital mortality was 0.97 and 0.95% and postoperative mortality was 1.36 and 1.47%, respectively, in the regions with percentage of laparoscopic surgery for patients with acute cholecystitis was less than 25%. In the second group (percentage of laparoscopic surgery 25.01 - 50%), in-hospital mortality was 0.95 and 1.14%, postoperative mortality - 1.38 and 1.71%. In the third group (percentage of laparoscopic surgery 50.01 - 75%), in-hospital mortality was 0.92 and 0.99%, postoperative mortality - 1.27 and 1.38%. In the fourth group, percentage of laparoscopic surgery exceeded 75%. In-hospital mortality was 0.61 and 0.74%, postoperative mortality - 0.76 and 0.98%, respectively. Analysis of multi-field contingency tables revealed non-random between-group differences of in-hospital (p<0.001) and postoperative (p<0.001) mortality, as well as significant decrease of mortality following laparoscopic surgery. We also analyzed mortality after laparoscopic surgery considering technology maturity curve. CONCLUSION: In-hospital and postoperative mortality in acute cholecystitis depend on availability of laparoscopic technologies.

[Influence of the incidence of ulcerative gastroduodenal bleeding on the effectiveness of treatment. Statistical surveillance]. / Vliyanie zabolevaemosti yazvennym gastroduodenal'nym krovotecheniem na effektivnost' lecheniya. Statisticheskoe nablyudenie.

OBJECTIVE: To study and to justify statistically the influence of the incidence of ulcerative gastroduodenal bleeding on the results of treatment. MATERIAL AND METHODS: The results of treatment of 56.233 patients with ulcerative gastroduodenal bleeding in the Central Federal district have been analyzed throughout a 5-year follow-up period. Statistical analysis was performed in Microsoft Excel 2007 and Review Manager 5.3. RESULTS: Overall in-hospital mortality (r=0.871) and surgical activity (r=0.725) depend on the number of patients with ulcerative bleeding. Active surgical approach was followed by overall in-hospital mortality 6.9%, moderate surgical approach - 5.3% (OR 1.3%, 95% CI 1.18-1.4, p<0.05). CONCLUSION: The correlations between the number of patients with ulcerative bleeding and surgical activity, overall in-hospital and postoperative mortality were identified in a large sample.

[Koblenz algorithm for open abdomen management]. / «Koblentsskii algoritm¼ lecheniya bol'nykh s laparostomoi.

The issue of laparostomy treatment is still controversial, since there are insufficient evidence-based data. German military surgeons have developed and implemented the «Koblenz algorithm¼ of laparostomy treatment into everyday practice. The algorithm was developed at the Bundeswehr Central Hospital in Koblenz (Germany). Today, approximately 50% of German civilian hospitals use the «Koblenz algorithm¼. The database for laparostomy treatment was created on the basis of international platform European Registry of Abdominal wall Hernias (EuraHS) in May 2015. These data will be valuable for further multipla-center studies. This manuscript is devoted to analysis of clinical effectiveness of the «Koblenz algorithm¼ in the treatment of patients with laparostomy. Searching of Russian, English and German studies devoted to «Koblenz algorithm¼ in the treatment of patients with laparostomy was carried out in the eLIBRARY, Elektronische Zeitschriftenbibliothek, the Cochrane Library and the PubMed databases. The authors comprehensively described «Koblenz algorithm¼. Mortality in the group of VAC - therapy was 57% (31/54), in case of «Koblenz algorithm¼ - 33% (33/100). Between-group differences were significant (OR 0.36, 95% CI 0.18-0.72, p=0.003). However, an efficacy of «Koblenz algorithm¼ should be confirmed in further multiple-center studies including national evidence-based trials.

[Laparoscopic subtotal distal gastrectomy for distal gastric cancer]. / Opyt vypolneniya laparoskopicheskoi subtotal'noi distal'noi rezektsii v lechenii bol'nykh rakom antral'nogo otdela zheludka.

OBJECTIVE: To analyze the primary results of laparoscopic distal gastrectomy in patients with distal gastric cancer. MATERIAL AND METHODS: There were 21 laparoscopic distal gastrectomies in patients with distal gastric cancer. Mean age of patients was 63.7±6.3 years. According to TNM staging system, cancer stage 1 was detected in 90% of patients (n=19), stage 2a - in 10% (n=2) of patients. RESULTS: Time of distal gastrectomy was 190.4±51.6 min, blood loss - 90.3±51.2 ml. The number of excised lymph nodes was 21.2±5.1. We were able to achieve R0 resection edge in all patients. Length of hospital-stay was 7.6±2.3 days, incidence of postoperative complications - 23.8%. Complications Clavien-Dindo grade IIIb-V were observed in 9.5% of patients (n=2). Overall postoperative mortality was 4.7% (n=1). No progression of the underlying disease has been revealed in any patient throughout the follow-up period (since May 2018). To date, the maximum median follow-up is 25 months of overall and disease-free survival. CONCLUSION: Laparoscopic subtotal distal resection is an appropriate intervention ensuring R0 resection edge in most cases.

[Laparoscopic subtotal distal resection for distal gastric cancer]. / Opyt vypolneniya laparoskopicheskoi subtotal'noi distal'noi rezektsii v lechenii bol'nykh rakom antral'nogo otdela zheludka.

OBJECTIVE: To analyze the primary experience of laparoscopic distal gastrectomy in patients with distal gastric cancer. MATERIAL AND METHODS: There were 21 laparoscopic distal gastrectomies in patients with antrum malignancies. Mean age of patients was 63.7±6.3 years. According to TNM staging system, cancer stage I was detected in 90% of patients (n=19), stage IIa - in 10% (n=2) of patients. RESULTS: Duration of distal gastrectomy was 190.4±51.6 minutes, blood loss - 90.3±51.2 ml. The number of harvested lymph nodes was 21.2±5.1. We were able to reach R0 resection edge in all patients. Length of hospital-stay was 7.6±2.3 days, incidence of postoperative complications - 23.8%. Complications Clavien-Dindo grade IIIb-V were observed in 9.5% of patients (n=2). Overall postoperative mortality was 4.7% (n=1). No progression of the underlying disease has been revealed in any patient throughout the follow-up period (since May 2018). To date, the maximum median follow-up is 25 months of overall and disease-free survival. CONCLUSION: Laparoscopic subtotal distal resection is appropriate intervention ensuring R0 resection edge in most cases.

[Modern aspects of the complex treatment of perforated gastric and duodenal ulcer]. / Sovremennye aspekty kompleksnogo lecheniya perforativnoi yazvy zheludka i dvenadtsatiperstnoi kishki.

OBJECTIVE: To study the effectiveness of pharmacotherapy for perforated gastric ulcer in a surgical hospital. MATERIAL AND METHODS: A retrospective analysis of the treatment of 693 patients with perforated gastric and duodenal ulcers was carried out. Laparoscopic and open surgeries were performed. Statistical analysis was performed using the Statistica and MS Excel software packages. Student t-test was applied for independent samples and Fisher's F-test was calculated. RESULTS: Combined therapy included surgical treatment (suturing of the ulcer as a rule) and medication with proton pump inhibitors, antibacterial drugs. Over the past 5 years, postoperative quality of life has been significantly improved in patients with perforated ulcers. Stomach resection and vagotomy for perforated ulcers will become historical in the near future. Laparoscopic and open procedures ensure similar periods of ulcer closure. CONCLUSION: Currently, successful treatment of perforated gastric and duodenal ulcers requires an integrated approach at all levels of specialized care and is impossible without modern pharmacotherapy.

[Open and laparoscopic surgery via minimally invasive approach in the treatment of perforated ulcer: a systematic review and metaanalysis]. / Laparotomnye i laparoskopicheski assistirovannye operatsii iz minidostupa v lechenii probodnoi yazvy. Sistematicheskii obzor i metaanaliz.

OBJECTIVE: Systematic review and metaanalysis of the effectiveness of open and minimally invasive laparoscopic suturing of perforated peptic ulcer. MATERIAL AND METHODS: Searching for Russian and English language reports included Scientific Electronic Library, Cochrane Collaboration Library and PubMed databases. We have analyzed contents of specialized journals, reviews and their references. Unpublished data were obtained via communication with chiefs of national surgical hospitals. RevMan 5.3 software was used for metaanalysis. RESULTS: We found no international randomized trials in available literature. Metaanalysis was based on national non-randomized studies. Total sample was 1177 cases. Laparoscopic minimally invasive surgery was performed in 43% of cases (n=503), open suturing - in 57% (n=674) of patients. Choice of these procedures is not currently not standardized. Minimally invasive procedures are shorter in time (mean difference -8.02, 95% CI -11.26 - -4.77, p<0.00001) and ensure less hospital-stay (mean difference -1.93, 95% CI -2.97 - -0.88, p=0.0003). Complications were less common (OR 0.14, 95% CI 0.07-0.27, p<0.00001) after minimally invasive operations (2.4%, 12/503) compared to laparotomy (11.4%, 77/674). Incidence of suture failure was similar (OR 0.4, 95% CI 0.1-1.6, p=0.2) (0.4% (2/503) vs. 0.7% (5/674)). Postoperative mortality was higher (OR 0.14, 95% CI 0.05-0.37, p<0.0001) after laparotomy (8%, 54/674) compared to laparoscopy (0.8%, 4/503). CONCLUSION: A metaanalysis indicates the advantage of laparoscopy-assisted suturing of perforated ulcer via minimally invasive approach over laparotomy. The absence of a standardized approach in choosing of minimally invasive laparotomy and conventional approach is a limitation of these results.

[Cholecystostomy in acute cholecystitis in modern surgical practice]. / Kholetsistostomiya pri ostrom kholetsistite.

OBJECTIVE: To improve the results of treatment of acute cholecystitis. MATERIAL AND METHODS: A historical cohort study (1965-2016) included 1248 patients with acute obstructive cholecystitis and 154 patients with acute obstructive cholecystitis combined with ductal complications and obstructive jaundice. Cholecystostomy was used in all patients. A systematic review of the evidence base on the use of cholecystostomy in high-risk patients was carried out. RESULTS: Cholecystostomy through laparotomy was performed in 240 patients for the period 1965-1981. Overall mortality was 3.6%. Staged treatment strategy has been applied since 1982. Laparoscopic cholecystostomy followed by cholecystectomy through laparotomy was performed in 225 patients for the period from 1982 to 1992. Overall mortality rate was 3.2%. Laparoscopic cholecystostomy (n=617) followed by staged laparoscopic cholecystectomy has been applied for the period from 1993 to 2007. Overall mortality decreased up to 1.1%. Indications for laparoscopic cholecystostomy and staged treatment have been limited since 2008 (n=166). Overall mortality rate was 0.6%. The maximum postoperative mortality after cholecystostomy in some years reached 14.8%.Simultaneous surgeries through laparotomy in patients with acute obstructive cholecystitis and ductal complications were followed by mortality rate 8%, staged laparoscopic cholecystostomy and other minimally invasive technologies (endoscopic papillosphincterotomy with lithoextraction and laparoscopic cholecystectomy) - 4.7%. CONCLUSION: External drainage of the gallbladder is more effective as additional method within staged minimally invasive treatment of complicated cholecystitis rather separate operation. Further analysis of treatment of high-risk patients with acute cholecystitis (as most often selected for cholecystostomy) is required considering the absence of evidence base on this issue.