[Endoscopic subfascial dissection of venous perforants in treatment of venous trophic ulcers of the legs].

Endoscopic subfascial dissection was performed in patients with chronic venous insufficiency of CEAP class 4-6. 76 surgeries were performed in 68 patients. Mean age of the patients was 56 years. The causes of chronic venous insufficiency were varicose (37) and postthrombotic diseases. Trophic ulcers were in 46 patients. Thirty patients underwent earlier various phlebectomies, including Linton's surgery (6 patients). In 33 patients endoscopic subfascial dissection of venous perforants was combined with various phlebectomy, in 37 patients -- with excision of ulcer with following autodermoplasty few days after surgery. Endoscopic subfascial dissection was carried out with special surgical R.Wolf endoscope with 6 mm instrumental canal, and also standard laparoscopic optical devices "Olympus". Complications during surgery were seen in 2 patients: bleeding in subfascial space (1.3%) and perforation of tissues in ulcer zone (1.3%). In postoperative period long (up to 14 days) lymphorrhea and suppuration of surgical wound were in 2 (2.6%) patients. It is concluded that endoscopic approach is optimal for elimination of pathological reflux through venous perforants in complicated forms of chronic venous insufficiency of the lower extremities, including trophic ulcers resistant to treatment.

[Results of laparoscopic cholecystectomy]. / Rezultaty laparoskopicheskoi kholetsistéktomii.

The paper provides the results of two-year use of laparoscopic cholecystectomy as a treatment of calculous cholecystitis in patients with various clinical and morphological types of calculous cholecystitis. Less intraoperative trauma, a mild postoperative period, and early activization of patients, good cosmetic effect are indisputable advantages of this therapeutical method which is an alternative to an open operation for calculous cholecystitis.

[Hyperplastic changes in the mucosa in colon cancer]. / Giperplasticheskie izmeneniia v slizistoi obolochke pri rake tolstoi kishki.

67 segments of rectum and sigmoid removed surgically because of carcinoma were examined: the surface of intestinal mucosa stained with methylene-blue was studied in order to determine the number and localization of focal changes in the macroscopically unchanged areas. Colon microscopy was performed clinically in 24 patients with carcinoma of the rectum and in 24 control individuals. 28 hyperplastic polyps and 1037 microscopic hyperplastic foci were found in operative material. An active metabolism is established by means of electron autoradiography in the cells of hyperplastic focus. Areas of dysplastic epithelium were rarely found in big hyperplastic polyps. Areas of diffuse hyperplasia (transitional mucosa) with crypt deepening and presence of a high number of goblet cells were found near tumour. A certain role of hyperplastic processes in carcinogenesis is forwarded. Numerous microscopic changes in the mucosa epithelium may testify against the carcinoma development de novo.

[Growth rate of malignant tumors of the large intestine]. / Kvoprosu o tempakh rosta rakovykh opukholei tolstoi kishki.

The rates of colonic tumor growth were studied on the basis of evaluation of the case histories of 19 cancer patients in whom dynamic endocolonoscopy had been carried out. In some cases, malignant tumors appeared in the colon within 12 months after previous colonoscopy. Tumors were under 2.0 cm in size and were not accompanied by any clinical symptoms. Repeated endoscopic examinations performed within a period of 1-3 years detected large tumors which caused the constriction of colonic lumen. Clinical symptoms developed in such patients approximately 1-4 months prior to tumor detection. It is concluded that although the rates of growth of colonic malignancies are rather high, tumorigenesis is preceded by a long-term stage of preclinical disease.

[Endo-microscopic characteristics of the superficial epithelium in patients with cancer of the large intestine]. / Endomikroskopicheskaia kharakteristika poverkhnostnogo épiteliia u bol'nykh s opukholiami tolstoi kishki.

In vivo studies of the large bowel mucosa in 127 patients, using colon microscopy, showed the superficial epithelium to have a heterogeneous structure comprising three major types of cellular patterns. There is a relationship between said patterns and morphological structure in the most frequent neoplasms of the large bowel.

[Results of removal of malignant polyps of the large intestine]. / Rezul'taty udaleniia malignizirovannykh polipov tolstoi kishki.

As a result of endoscopic removal of 238 malignant polyps of the large bowel, malignant tumors in other parts of this organ were found in 6 out of 142 cases (67.7%) followed-up during terms ranging 6 months--10 years. More polyps in different parts of the bowel were found during operation in 27 cases. A procedure for follow-up of cases of malignant polyps is discussed. Endoscopic removal of malignant polyps of the large bowel should be used as a method of choice, particularly, in aged patients suffering concomitant grave diseases.

[Future trends in the development of endoscopic studies of digestive tract organs]. / Perspektivnye napravleniia v razvitii éndoskopicheskikh issledovanii organov pishchevaritel'nogo trakta.

Presented in the paper are new promising endoscopic devices for examinations of the digestive tract organs. Special attention is paid to one of the important directions, the development of endoscopes for peroral examinations of hepatic passages, the intraoperation choledochoscopy. In order to improve the diagnostic capabilities of the small intestine endoscopy the development of a long controllable endoscope is advisable. A new trend in endoscopy, the endoscopic microscopy, is noted to be of great research importance. This trend calls for creation of not only new methodologic basis but of new types of endoscopes as well. They should be capable of detecting changes in both structural formations and cell structures.

[Study of the movements of flexible endoscopes]. / Issledovanie dvizhenii gibkikh éndoskopov.

Examinations of the intestinal tract by conventional clinical endoscopic methods have shown that in the course of observations colonoscopes are subjected to a greater load than esophagogastroscopes. The load is greater by a factor of 2.2 in a number of translational motions and by a factor of 4.4 in a number of rotatory motions. Control grips are subjected to 2.5 times as much load as esophagogastroscopic controls, and colonoscopic tube bending is 2.8 times greater than that of esophagogastroscope.

[Results of endoscopic interventions in large and giant epithelial neoplasms of the large intestine]. / Rezul'taty éndoskopicheskikh vmeshatel'stv pri bol'shikh i gigantskikh épitelial'nykh novoobrazovaniiakh tolstoi kishki.

The paper presents the analysis of the results obtained for 319 patients at endoscopic interventions for large and giant tumors of the colon. Altogether 415 neoplasms were removed: 207 nodular, 126 creeping and 82 flat. The latter two were removed using specially developed technique of endoscopic electroresection of the intestinal mucosa along with the tumor. Malignancy was established in 16.1% of the cases. During the endoscopic procedure 2 patients were diagnosed to have colon perforations, 24 intensive hemorrhage which was stopped endoscopically in 22 cases. One patient developed subsequently necrosis of the intestinal wall. Surgical treatment was performed in 5 patients: for hemorrhage, colon wall perforation, malignancy in 2, 2 and 1 patient, respectively. One-eight-year follow-up of 316 patients reports cure in 217 (68.6%), relapses in 79 patients (71 of them were endoscopically successfully retreated), cancer in 15 and corrosive strictures in 5 patients.

[Development of metachronous tumors of the colon]. / O razvitii metakhronnykh rakovykh opukholei tolstoi kishki.

Clinical and endoscopic evidence gained at the follow-up of 93 patients with metachroneous colon cancer suggests that at present there is minimal change to predict the occurrence, time of onset and site of emergence of the secondary tumors as the latter grow rapidly and rise in macroscopically free-of-tumor colon segments. In some patients metachroneous tumors were associated with long histories of benign adenomas. The authors hold that patients operated on for colon cancer should remain under life-long clinical and endoscopic observation.

[Long-term results of endoscopic polypectomy of the colon]. / Otdalennye resul'taty éndoskopicheskoi polipéktomii iz tolstoi kishki.

Follow-up of 835 patients in periods of 1 to 11 years after endoscopic removal of polyps from the large intestine revealed no new tumors in 44.2% of them. More than half of patients had new polyps (45.3%) and carcinoma (4.1%) in various periods. The number of cases with new tumors increases with the increase of the duration of the dynamic follow-up.

[Choice of surgical approach in laparoscopic cholecystectomy]. / Vybor operativnogo dostupa pri laparoskopicheskoi kholetsistéktomii.

A definition of a surgical access in laparoscopic interventions is formulated. The importance of use of various surgical accesses is stressed. The results of treatment of 410 patients with calculous cholecystitis are analysed. 72 of the patients have been previously operated on abdominal cavity. The cause of technical mistakes and failures are analysed. The original method of ultrasound evaluation of abdominal cavity adhesions in patients, who had been operated on previously is proposed. The method was used in 45 patients, and in 95% of the cases the evaluation was perfectly accurate. Indications for use of a particular surgical access, depending on a site of a previous operation, are formulated. The method of an open laparoscopy is described. It is indicated in case of previously performed low-middle laparotomy and ultrasonic picture of adhesions in the umbilical region; in umbilical hernias; in big and multiple choleliths (more than 30 cubic cm of total volume).

[Results of laparoscopic cholecystectomy]. / Rezul'taty laparoskopicheskoí kholetsistéktomii.

Laparoscopic cholecystectomy (LCE) was performed in 410 patients with calculous cholecystitis. Acute phlegmonous cholecystitis was in 14 patients. The indications for the LCE were similar to the indications for "open" cholecystectomy. The specific features of LCE are analysed. The long-term follow up period was from 3 to 16 months. Good functional results were achieved in 98% of the patients.

[Bronchoscopy in inhalation burns]. / Bronkhoscopiia pri ozhogakh verkhnikh dykhatel'nykh putei.

The treatment of burns of various depth and location which are combined with thermoinhalation affections of the respiratory organs is a serious problem during the entire course of burn disease. Despite advances in modern treatment of burns, the death rate of pulmonary complications is still high. Pulmonary disorders encountered in inhalation of chemical toxic products of burning, smoke and its finely divided components increase the fatal outcomes by 30-100% in different periods of the burn disease. Until recently, thermoinhalation affections were not often taken into account in analysis of the causes of death of patients with burns, and the diagnosis was based on scanty historical data and late clinical symptoms. In works published from the beginning of the eighties, bronchoscopy was assigned secondary significance. Evaluation of the character of the lesion, the extent and depth of pathological changes in the tracheobronchial tree in thermoinhalation affections is based in most cases on the post-mortem findings. The purpose of this work was to evaluate clinically and by laboratory studies the role and significance of bronchoscopy in establishing the diagnosis in individuals with burns and thermoinhalation damage during life, in the treatment and prevention of the expected complications in the respiratory organs, and to promote wide use of a bronchoscope in this category of seriously ill patients. On the basis of the study, the authors revealed a close correlation between respiratory insufficiency of various degree and extent and the depth of the affection of the tracheobronchial tree. They also substantiated indications for systemic bronchoscopic treatment of thermoinhalation lesions.

[Endoscopic polypectomy in the surgical treatment of diffuse polyposis of the large intestine]. / Endoskopicheskaia polipéktomiia pri khirurgicheskom lechenii diffuznogo polipoza tolstoi kishki.

The article analyses experience in the treatment of 81 patients with diffuse polyposis who underwent subtotal resection of the colon with abdominoanal resection of the rectum and downward displacement of the right parts into the anal canal. It is shown that growth of the remaining occasional polyps and appearance of new polyps are encountered in the maintained parts of the colon and upper parts of the gastrointestinal tract in the postoperative period. The authors found that endoscopic polypectomy allows the right colon to be preserved in 92.6% of cases and the upper digestive tract in 97.5% of cases at a minimum risk of a surgical intervention.

[Laparoscopic cholecystectomy in choledocholithiasis and stricture of the terminal part of the common bile duct]. / Laparoskopicheskaia kholetsistéktomiia pri kholedokholitiaze i strikture terminal'nogo otdela obshchego zhelchnogo protoka.

The authors offer the treatment and diagnostic algorithm in choledocholithiasis, stricture of a terminal portion of the common hepatic duct and papilla stenosis revealed in laparoscopic cholecystectomy (LCE). With the purpose of intraoperative assessment of bile ducts states during LCE, the diagnostic system including laparoscopic and ultrasonic examinations, cholangiography and choledochoscopy was developed and applied. In intraoperative revealing of choledocholithiasis without bile outflow disorders and wide cystic duct the authors prefer to remove the concrements during choledochoscopy through cystic duct without intervention on Vater's papilla (VP). In combination of choledocholithiasis with bile outflow disorders and also in isolated papilla stenosis and stricture of a terminal portion of the common hepatic duct, one-stage laparoscopic cholecystectomy, intraoperative antegrade papillosphincterotomy and retrograde calculus extraction is optimal. In cases when complete endoscopic calculus extraction is impossible, the drainage of the common hepatic duct by Cholsted's with subsequent delayed endoscopic papillosphincterotomy (EPST) is acceptable. During intraoperative examination in 49 patients (57.6%) the concrements in choledochus, not diagnosed earlier, were revealed, in 21--stricture of terminal choledochus portion and in 19 patients--papilla stenosis. In 12 cases the concrements were removed during choledochoscopy through the cystic duct stump, 4 patients with big concrements required laparoscopic choledocholithotomy. In 16 cases LCE with various variants of choledochus drainage was performed as the first stage, as the second stage--EPST and lithoextraction. Antegrade papillosphincterotomy was performed in 15 patients during LCE. In 12 cases intraoperatively revealed choledocholithiasis combined with papilla stenosis (7) and choledochus stricture (5) was the indications to intraoperative papillosphincterotomy. Papilla stenosis was the indication to antegrade papillosphincterotomy in 3 patients.

[Diverticuli of duodenal papillar region and their role in development of choledocholithiasis and strictures of bile and pancreatic ducts]. / Divertikuly papilliarnoi oblasti dvenadtsatiperstnoi kishki i ikh rol' v razvitii kholedokholitiaza, striktur zhelchnogo i pankreaticheskogo protokov.

Up to present time there is no common view on the role of diverticuli of the papillar region of the duodenum (DPRD) in development of the strictures of terminal parts of the common bile duct and major pancreatic duct. The main method for the diagnosis of DPRD is fibroduodenoscopy (FDS). Relaxational FDS is the most informative method for detailed examination of diverticulum and for assessment of its interrelations with longitudinal crease and the major duodenal papilla (MDP). During the last 2 years all patients with DPRD underwent ERCPG, which helped to obtain more complete information of the presence and the character of the strictures of terminal parts of the common bile duct and the pancreatic duct. DPR has been revealed in 5% of patients with calculous cholecystitis and in 9.5% of patients with choledocholithiasis. Of the patients, admitted to the Institute for postcholecystectomy syndrome from 1994 to 1999, DPRD were revealed in 30% of cases. The patients with DPR and chronic pancreatitis of nonalcoholic and nonlithogenic etiology, made up 9% of all patients with DPR and chronic pancreatitis. In 87 patients with DPR, suffering from various surgical diseases, following changes of bile and pancreatic ducts were revealed: choledocholithiasis (47%), stenosis of the large bile duct (15%), strictures of terminal parts of the large bile duct and major pancreatic duct (10%). There is evidence, that para- and peripapillary diverticuli deteriorate evacuatory function of the bile and pancreatic tracts due to compression of terminal parts of the choledochus and the pancreatic ducts with strictures formation, which promote disturbances of the bile and pancreatic juice passage. Biliary stasis and pancreatic juice passage disturbances create favorable conditions for lithogenesis and promote development of cholangitis, mechanical jaundice and chronic pancreatitis. Patients with choledochal and major pancreatic duct strictures and stenoses of the papilla in DPR underwent EPST with favorable initial and long-term results. The authors suggest, that DPR are an important etiopathogenetic link in the development of many diseases of the organs of hepatobiliary region, associated with biliary and pancreatic hypertension.

[Videothoracoscopy in diagnosis and treatment of small peripheral pulmonary masses]. / Videotorakoskopiia v diagnostike i lechenii malykh perifericheskikh obrazovanii legkikh.

This study was devoted to examination of efficacy of modern methods of diagnosis and surgical treatment of patients with small peripheral pulmonary masses (SPPM) with the use of videothoracoscopy. The results of examination and treatment of 126 patients with SPPM (80 patients underwent videothoracoscopy) were analysed. This study demonstrated high-quality of modern complex of clinicoradiological investigations for diagnosis of SPPM. The reliability of the complex is 91%. The necessity of immediate elective operation of the patients with SPPM is shown for verification of the process and adequate surgery. Videothoracoscopic surgery is effective method of treatment in patients with SPPM.

[Ultrasonic diagnosis of focal damages in thoracoscopic operations]. / Ul'trazvukovaia diagnostika ochagovykh porazhenii legkogo pri torakoskopicheskikh operatsiiakh.

5-year experience of developed in PAMS A.V. Vishnevsky Institute of Surgery RAMS ultrasonic examination (USE) of the lung in thoracoscopic operations for focal lung lesions (FLL) is presented. Pilot experience of ultrasonic topical and differential diagnosis of FII opens a new page in diagnosis of respiratory diseases. Over 5 years 74 USE of FLL were performed. FLL were found in 91% cases. Detailed topical diagnosis of allows to design the lung resection with the best functional result. In postoperative X-ray examination neither atelectases nor zones of stable hypoventilation were detected. Normal echographic picture of lung tissue and echosemiotics of different focal lesions are descubed. The experience of diagnosis by echographic signs of FLL shows teasibility of differentiation of hamartomas from tuberculomas and focal metastatic lesions. The payential of differential diagnosis is illustrated. Differential diagnosis supported enucleation in superficial hamartomas and resection in suspected malignant tumor or tuberculosis. Use of intraoperative USE in the majority of cases of focal lesions located both in depth of lung tissue and subpleurally warrants the success of operation in thoracoscopic variant.

[Current possibilities in the diagnosis and treatment of appendiceal mucocele]. / Sovremennye vozmozhnosti v diagnostike i lechenii mukotsele cherveobraznogo otrostka.

The authors present an original experience of using an ultrasonography and a computer scan for a preoperative diagnosis of VP mucocele. The laparoscopy has been used as a method for the final diagnosis as for an appendectomy. The authors also describe their understanding of VP mucocele pathogenesis and their opinion about diagnosis and treatment of such kind of a case.