CAROTIDSCORE.RU-The first Russian computer program for risk stratification of postoperative complications of carotid endarterectomy.

GOAL: Presentation of the first Russian computer program (www.carotidscore.ru) for risk stratification of postoperative complications of carotid endarterectomy (CEE). MATERIAL AND METHODS: The present study is based on the analysis of a multicenter Russian database that includes 25,812 patients after CEE operated on from 01/01/2010 to 04/01/2022. The following types of CEE were implemented: 6814 classical CEE with plastic reconstruction of the reconstruction zone with a patch; 18,998 eversion CEE. RESULTS: In the hospital postoperative period, 0.18% developed a lethal outcome, 0.14%-myocardial infarction, 0.35%-stroke. The combined endpoint was 0.68%. For each factor present in patients, a predictive coefficient was calculated. The prognostic coefficient was a numerical indicator reflecting the strength of the influence of each factor on the development of postoperative complications. Based on this formula, predictive coefficients were calculated for each factor present in patients in our study. The total contribution of these factors was reflected in "%" and denoted the risk of postoperative complications with a minimum value of 0% and a maximum of 100%. On the basis of the obtained calculations, a computer program CarotidSCORE was created. Its graphical interface is based on the QT framework (https://www.qt.io), which has established itself as one of the best solutions for desktop applications. It is possible not only to calculate the probability of developing a complication, but also to save all data about the patient in JSON format (for the patient's personal card and his anamnesis). The CarotidSCORE program contains 47 patient parameters, including clinical-demographic, anamnestic and angiographic characteristics. It allows you to choose one of the four types of CEE, which will provide an accurate stratification of the risk of complications for each of them in person. CONCLUSION: CarotidSCORE (www.carotidscore.ru) is able to determine the likelihood of postoperative complications in patients undergoing CEE.

[Transposition of internal carotid artery over hypoglossal nerve in eversion carotid endarterectomy]. / Eversionnaya karotidnaya endarterektomiya: transpozitsiya vnutrennei sonnoi arterii nad pod"yazychnym nervom.

OBJECTIVE: To analyze in-hospital and long-term results of eversion carotid endarterectomy (CEE) with transposition of internal carotid artery (ICA) over hypoglossal nerve. MATERIAL AND METHODS: A cohort prospective open-label study included 919 patients with severe ICA stenosis for the period from January 2017 to April 2020. The 1st group (n=172) included patients who underwent eversion CEE with ICA transposition over hypoglossal nerve; the 2nd group (n=747) - who underwent conventional eversion CEE. ICA transposition technique included standard mobilization of the carotid arteries, cross-clamping, arterial wall incision, removal of atherosclerotic plaque and ICA translocation above the hypoglossal nerve for subsequent anastomosis. All patients were examined every 6 months. Mean follow-up period was 17.5±6.9 months. RESULTS: There were no significant between-group differences in cardiovascular morbidity. However, all complications occurred in the 2nd group (traditional eversion CEE). Nevertheless, incidence of adverse events was minimal and combined endpoint did not exceed 0.6% (n=5). Both groups were also comparable by overall incidence of cardiovascular events in long-term period. All ICA restenoses (over 70%) were symptomatic with similar incidence (4 (2.3%) vs. 18 (2.4%), respectively, p=0.83; OR 0.96; 95% CI 0.32-2.88). Mean restenosis-free period was 7.2±2.6 months. In case of significant restenosis, redo CEE with patch repair was performed. There were no cardiovascular complications. All cases of hypoglossal nerve injury occurred in the 2nd group (0 vs. 18 (100%), respectively; p=0.0001; OR 0.003; 95% CI=5.21-0.17) without ICA transposition over the hypoglossal nerve. CONCLUSION: Eversion CEE with ICA transposition over the hypoglossal nerve ensures optimal conditions for successful redo CEE in case of restenosis. This technique facilitates ICA mobilization without hypoglossal nerve injury. This aspect is valuable for successful postoperative outcome and adequate quality of life. ICA transposition is not difficult and does not require additional experience. Transposition per se is not a risk factor of ICA restenosis. Thus, ICA transposition may be routinely recommended in patients eligible for eversion CEE.

[Endoscopic and roentgenovascular interventions in treatment of patients with bleeding from a gastroduodenal ulcer].

The authors analyzed the results of treatment of 965 patients with bleeding from gastroduodenal ulcers. The endoscopic hemostasis was carried out in 20.2% patients, however a recurrence of bleeding was noted in 12.8% cases. The combined endoscopic hemostasis was performed in 76.9% patients, though the relapse of bleeding had only 4.2% and 49 patients were safe. A surgery was required for 3.2% patients.

[Multilevel drainage of bile ducts in obstructive jaundice and cholangitis].

The data of combined application of low invasive intervention on bilious tree were analyzed in 63 patients with the obstructive jaundice and cholangitis. An indication for operation and the option of performing multilevel drainage were validated in patients with the obstruction of bile-excreting system and cholangitis. The technique of percutaneous intraluminal biopsy of hepaticocholedoch with atherectomic camera was supposed. The data obtained allow the application of given approach during the treatment of patients with the severe stage of the disease.

[Systemic and regional directed transport of autologous modified leukocytes in correction of hepatic failure and systemic inflammatory reaction in patients with obstructive jaundice].

The author shows the efficacy of using the technology of systemic and regional directed transport of medicinal modified autologous leukocytes in correction of hepatic failure and systemic inflammatory reaction in 81 patients with obstructive jaundice.

[Differential diagnostic strategy in obstructive jaundice].

An analysis of effectiveness of diagnostic noninvasive and invasive measures for obstructive jaundice was made using clinical findings of 383 patients. The efficacy of these measures was assessed and limits were determined in relation to etiology of obstructive jaundice and the condition of extrahepatic bile ducts. The criteria of selection of diagnostic methods were detected on preoperative and intraoperative stages. The rational report of diagnostic strategy was formulated.

[Long-term results conventional and eversion carotid endarterectomy]. / Otdalennye rezul'taty klassicheskoi i eversionnoi karotidnoi endarterektomii.

OBJECTIVE: To analyze immediate and long-term results of conventional and eversion carotid endarterectomy (CEA) within a multicenter registry. MATERIAL AND METHODS: This retrospective, multi-center, comparative study included 375 patients who underwent CEA between February 1, 2018 and February 1, 2022. Depending on the type of operation, the sample was stratified into the eversion CEA (group 1, n=218) and conventional CEA with plasty of the reconstruction area with a diepoxy-treated xenopericardium patch (group 2, n=157). The long-term follow-up period was 26.5±18.3 months. Information about the condition of patients and the development of complications was obtained by telephone questioning and calling patients to the clinic for a follow-up examination. RESULTS: No myocardial infarction was diagnosed in the hospital postoperative period. There were no statistically significant differences in the frequency of acute cerebrovascular accident. The only cause of death after conventional CEA was hemorrhagic stroke. According to the section study, the cause of death was edema with dislocation of the brain stem. The remaining strokes in both groups (1 case each) were of the ischemic type. The probable cause was a distal embolism following the use of a temporary shunt. During conservative treatment, the neurological deficit completely regressed on days 21 and 26, respectively. In the late postoperative period, significant differences were obtained in the incidence of stroke (group 1: n=2; 0.91%; group 2: n=6; 3.8%; p=0.05; OR - 0.23; 95% CI=0.04-1.17) and restenosis of the internal carotid artery (ICA) more than 60% (group 1: n=0; group 2: n=11; 7.0%; p<0.0001; OR - 0.03, 95% CI=0.001-0.49). CONCLUSION: The eversion CEA technique demonstrated a lower risk of developing hemodynamically significant restenosis of the internal carotid artery in the long-term follow-up period. To obtain convincing evidence of the effectiveness of eversion or conventional CEA, additional randomized multicenter trials with the inclusion of results in clinical guidelines are required.

Carotid Enadrterectomy for Thrombosis of the Internal Carotid Artery in Patients With COVID-19.

Analysis of the results of emergency carotid endarterectomy (CEE) against the background of internal carotid artery (ICA) thrombosis in the acute period of acute cerebrovascular accident (ACVA) in patients with COVID-19. During the COVID-19 pandemic (April 1, 2020-May 1, 2021), 43 patients with ICA thrombosis and a positive polymerase chain reaction (PCR) result for SARS-CoV-2 were included in this prospective study. In all cases, CEE was performed in the acutest period of ACVA. These patients were included in group 1. The comparison group was represented by 89 patients who underwent CEE in the acute period of stroke, in the period before the COVID-19 pandemic (April 1, 2019-March 1, 2020). According to laboratory parameters, patients with COVID-19 had severe coagulopathy (with an increase in D-dimer: 3832 ± 627.2 ng/mL, fibrinogen: 12.6 ± 3.1 g/L, prothrombin: 155.7 ± 10, 2%), inflammatory syndrome (increased ferritin: 646.2 ± 56.1 ng/mL, C-reactive protein: 161.3 ± 17.2 mg/L, interleukin-6: 183.3 ± 51.7 pg/mL, leukocytosis: 27.3 ± 1.7 10E9/L). In the hospital postoperative period, the groups were comparable in terms of the incidence of deaths (group 1: 2.3%, n = 1; group 2: 1.1%, n = 1; P= 0.81; OR=2.09; 95 % CI = 0.12-34.3) myocardial infarction (group 1: 2.3%, n = 1; group 2: 0%; P= 0.7; OR = 6.3; 95% CI = 0.25-158.5), CVA (group 1: 2.3%, n = 1; group 2: 2.2%, n = 2; P= 0.55; OR = 1.03; 95% CI = 0,.09-11.7). ICA thrombosis and hemorrhagic transformations were not recorded. However, due to severe coagulopathy with ongoing anticoagulant/antiplatelet therapy, patients with COVID-19 more often developed bleeding in the operation area (group 1: 11.6%, n = 5; group 2: 1.1%, n = 1; P= 0.02; OR = 11.5; 95% CI = 1.3-102.5). In all cases, the flow of hemorrhagic discharge came from the drainage localized in the subcutaneous fat. This made it possible to remove skin sutures in a dressing room, suturing the source of bleeding and applying secondary sutures under local anesthesia. Emergency CEE in the acute period of stroke is an effective and safe method of cerebral revascularization in case of ICA thrombosis in conditions of COVID-19.

[Diaphragmatic hernias. Diagnosis and surgical treatment].

The authors present results of the examination and treatment of 106 patients with hernias of the diaphragm of different genesis. In 79 of them there were non-incarcerated hernias, in 27--there were incarcerated hernias. The authors suggest necessary medico-diagnostic measures with rational application of endovideosurgical technologies such as thoraco- and laproscopy which were used in 74%.

[Ways of optimization of standards of treatment of acute cholecystitis].

The article presents an analysis of tactical approaches in patients with acute cholecystitis on the basis of an experience with treatment of acute cholecystitis under conditions of multiprophile hospital in Saint Petersburg and modern ideas of the problem in the world.

[Choice of the kind of bone cavity replacement in the treatment of patients with chronic osteomyelitis].

Results of surgical treatment of 197 patients with osteomyelitis by bone autoplasty, plasty with Osteoset T and combined kinds of plasty were analyzed. Persistent positive effect was obtained in 89.8% of cases in patients after bone plasty, in 86.9% of cases after plasty with Osteoset T and in 85.3% of cases after using combined kinds of plasty. The proposed succession of actions in decision on different kinds of bone plasty and bone-muscular plasty in patients with chronic osteomyelitis is in line with the requirements of the national directions on traumatology and orthopedics and allows the interventions in question to be performed with minimal risk for the patients.

[Thoracoscopy in verification and treatment of pleural exudate syndrome under conditions of a multifield hospital].

Under an analysis of results of treatment of 186 patients with pleural exudate syndrome there were 139 patients treated by traditional methods, 47 patients treated using the proposed medico-diagnostic program based on using thoracosopy under local anesthesia. Using the proposed medico-diagnostic measures can be used at any multifield hospital where patients with pleural exudate syndrome are admitted although the hospital has neither phthisiatrical nor phthisiothoracic departments.

[Carotid endarterectomy in patients with internal carotid artery thrombosis in the acutest period of ischemic stroke with COVID-19]. / Karotidnaya endarterektomiya u patsientov s trombozom vnutrennei sonnoi arterii v ostreishem periode ishemicheskogo insul'ta na fone COVID-19.

OBJECTIVE: Analysis of the results of emergency carotid endarterectomy (CEE) in internal carotid artery (ICA) thrombosis in the acute period of acute cerebrovascular accident (ACVI) in patients with COVID-19. MATERIAL AND METHODS: During the COVID-19 pandemic (April 1, 2020 - May 1, 2021), 43 patients with ICA thrombosis and a positive polymerase chain reaction (PCR) result for SARS-CoV-2 were included in this prospective study. In all cases, CEE was performed in the acutest period of ACVA. These patients were included in group 1. The comparison group was represented by 89 patients who underwent CEE in the acute period of stroke, in the period before the COVID-19 pandemic (April 1, 2019 - March 1.2020). RESULTS: In the hospital postoperative period, the groups were comparable in terms of the incidence of deaths (group 1: 2.3%, n=1; group 2: 1.1%, n=1; p=0.81; OR=2.09; 95% CI=0.12-34.3) myocardial infarction (group 1: 2.3%, n=1; group 2: 0%; p=0.7; OR=6.3; 95% CI=0.25-158.5), CVA (group 1: 2.3%, n=1; group 2: 2.2%, n=2; p=0.55; OR=1.03; 95% CI=0.09-11.,7). ICA thrombosis and hemorrhagic transformations were not recorded. However, in view of severe coagulopathy with ongoing anticoagulant/antiplatelet therapy, patients with COVID-19 more often developed bleeding in the operation area (group 1: 11.6%, n=5; group 2: 1.1%, n=1; p=0.02; OR=11.5; 95% CI=1.3-102.5). CONCLUSION: Emergency CEE in the acute period of stroke is an effective and safe method of cerebral revascularization in case of ICA thrombosis in conditions of COVID-19.

[A multicenter study on the influence of different kinds of carotidal endarterectomy on the course of resistant arterial hypertension]. / Mnogotsentrovoe issledovanie vliyaniya razlichnykh vidov karotidnoi endarterektomii na techenie rezistentnoi arterial'noi gipertenzii.

OBJECTIVE: To analyze the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (CEE) in patients with resistant arterial hypertension (RAH). MATERIALS AND METHODS: The study included 1577 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RAH for more than 3 years. Patients were enrolled from January 2014 to December 2020. Depending on the implemented revascularization strategy, 5 groups were formed: group 1 (n=289 (18.3%)) with classical CEE with plasty of the reconstruction zone with a patch, group 2 (n=472 (29.9%)) with eversional CEE with cut-off of carotid glomus (CG); group 3 (n=109 (6.9%)) with the formation of a new bifurcation; group 4: (n=117 (7.4%)) with autoarterial reconstruction; group 5: (n=590 (37.4%)) with glomus-saving CEE. RESULTS: In the postoperative period, no significant differences were obtained in the frequency of deaths (0.34% for group 1; 0.63% for group 2; 0% for groups 3, 4 and 5), myocardial infarction (0.34%, 0.84%, 1.83, 0.85%, 0.33%, respectively); ischemic stroke (0.34%, 1.27%, 0.91%, 0.85%, 0.17%, respectively), hemorrhagic transformation (0%, 0.84%, 0.91%, 0.85%, 0%, respectively). However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (1.03%, 3.6%, 3.67%, 2.56%, 0.5%, respectively). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG. CONCLUSION: Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE.

[Criteria of decision on the access for laparoscopic choledocholithotomy].

The article presents an experience with operative treatment of 187 patients for choledocholithiasis using endovideosurgical technology. The conditions influencing the optimal choice of places for introduction of trocars responsible for maximal efficiency of the intervention were analyzed. Principal criteria of the operative access were established: the depth of operative procedure, distance between the xiphoid process and the place of introduction of the epigastral trocar, the angle of operative procedure, the angle of ascent.

[Specific features of strategy of treatment of acute cholecystitis under conditions of multifield hospitals: unsolved problems].

An experience with different approaches to treatment of acute cholecystitis under conditions of multifield hospitals is described. On the basis of comparative data of treatment of 10518 patients the optimal strategy of treatment of acute cholecystitis was determined.

[15-year experience of using relaparoscopy in the diagnostics and treatment of complications after laparoscopic choledoholithotripsy].

Results of relaparoscopy were analyzed in 42 patients with complications appearing after using 297 laparoscopic choledocholithotomies. Relaparotomies were classified according to the indications and terms from the main interventions. An analysis of complications after laparoscopic choledocholithotomy was made. The authors made a conclusion that relaparoscopy was an effective little-invasive method of diagnostics and correction of postoperative complications.

[Surgical strategy for external biliary fistulas].

The authors have analyzed results of the diagnostics and treatment of 68 patients with external biliary fistulas developed after operative procedures on the liver, bile ducts and duodenum. The character of operative interventions was established to depend, first of all, on the causes of the development of biliary fistula. After different surgical procedures in the postoperative period there were 16.2% of complications with 4.4% of lethal outcomes.

[Surgical treatment in chronic gastroduodenal ulcers]. / Khirurgicheskoe lechenie pri khornicheskikh gastroduodenal'nykh iazvakh.

Operative treatment was carried out in 1197 patients with chronic gastroduodenal ulcers. Among the most frequent complications of the ulcers there were penetration of the III-IV degree, compensated, subcompensated and decompensated pyloroduodenal stenosis. The operative interventions included Billroth-II resections of the stomach in modification of Hofmeister-Finsterer, Billroth-I, with saving the pyloric sphincter, after Roux and gastrectomies. Postoperative complications developed in 127 (10.6%) patients, postoperative lethality was 0.7%. Excellent and good long-term results were noted in 846 (94.5%) patients, in 14 (1.6%) patients they were estimated as satisfactory and in 35 (3.9%) as unsatisfactory. The causes of unsatisfactory results were recurrent ulcers (0.7%), peptic ulcer of the gastroenteroanastomosis (0.6%), dumping-syndrome of a severe and medium degree (1.5%), diarrhea of a severe degree (0.3%) and erosive-ulcerous reflux-esophagitis (0.3%).