ABDOMINAL SURGERY
Introduction. Increase in application frequency of minimally invasive including endoscopic surgical techniques warrants the dilemma of choice the most rational, safe and effective surgical approach. The aim of the study was to compare the results of the two techniques of percutaneous puncture endoscopic gastrostomy (PPEG) – the «pull-technique» and «push-technique».
Material and methods. The results of PPEG were analyzed in 103 patients. All patients were divided into two groups: group 1 – 53 patients who underwent «pull-technique» PPEG and group 2 – 50 patients after PPEG by «push-technique». Treatment results. Technical results were achieved in 100 % of cases, upon that the «pull-technique» PPEG showed evident advantages. Accomplishment of the procedure was clinically effective in 100 % of patients of the 1st group and in 98 % of cases in the 2nd group (p > 0,05). Time of the procedure was 12,2±3,4 min in group 1 and 22,3±3,6 min in group 2 (p > 0,05). Overall complication rate comprised 13,5 % in both groups: 6 complications in group 1, 8 complications in the 2nd group. Incidence of 30-day mortality in group 1 was 5,7 % (3 patients) and 2 % in group 2 (1 patient).
Conclusion. PPEG in patients with dysphagia of various etiology is characterized by good results independently of whatever technique is applied. The «pull-technique» of PPEG is technically more simple.
Introduction. Acute pancreatitis is one of the most severe surgical diseases, often leading to death. An in-depth study of the pathogenesis of acute pancreatitis has not only theoretical but also practical significance.
The purpose of the work: to study changes in the plasma membrane of the erythrocyte with varying degrees of severity of acute pancreatitis, in order to further use it for early diagnosis of pancreatic necrosis.
Materials and methods. The study included 32 patients with mild acute pancreatitis. The erythrocytes of patients with mild acute pancreatitis were compared with the erythrocytes of practically healthy people. For the study, electron microscopy of erythrocytes with additional atomic force microscopy was performed.
Conclusion. According to the conducted research, it seems possible to assume that an increase in the number of lipid peroxidation products in the erythrocyte membrane leads to deformation of its surface. In patients with mild acute pancreatitis, defects (erosion) of the plasma membrane of the erythrocyte are noted. The use of AFM to assess the microstructure of the erythrocyte can be recommended for early prediction of the development of pancreatic necrosis.
CARDIOVASCULAR SURGERY
Introduction. In the approach to indications when deciding on surgical intervention, there are different opinions about the expediency of its use and the effectiveness of this method of treating patients with neurovascular syndrome.
The purpose of the study. Improving the results of surgical treatment of patients with neurovascular syndrome based on a comparative analysis of hemodynamics according to ultrasound dopplerography before and after various surgical methods.
Materials and methods of research. The study was conducted among 155 patients with neurovascular syndrome. Two groups were formed: 88 patients (56,8 %) who underwent surgery, and 67 patients (43,2 %) who underwent conservative treatment. The subgroups were divided similarly by type of surgery: 24 (27,3 %) patients who initially underwent surgery on the sympathetic trunk (cervical and thoracic sympathectomy), and 64 (72,7 %) underwent sympathectomy in a different levels (from distal to proximal). Blood flow was assessed by ultrasound dopplerography.
Treatment results. Perioperative complications after stages 1 and 2 were minimal and rare, mainly in the form of limited hematomas in the area of surgical access. The immediate results, comparing cervical or thoracic sympathectomy with periarterial, had no significant differences in the linear velocity of blood flow on the arteries of the hand.
Conclusion. Cervical or thoracic sympathectomy is not the preferred option for primary surgery for the treatment of patients with neurovascular syndrome, as it is more traumatic than peripheral periarterial sympathectomy.
ОНКОЛОГИЯ
Introduction. Bladder cancer is currently an important medical and social problem due to the rapid growth of the incidence and prevalence of this malignant neoplasm on a global scale.
Radical cystectomy is the surgery of choice for the treatment of patients with muscle-invasive bladder cancer, as well as with continuously recurrent course of superficial bladder cancer.
Radical cystectomy is currently considered the most time-consuming operation in urological practice with a large number of possible complications. With the accumulation of world experience, heterotopic reconstruction of the bladder using a segment of the ileum has become the most popular method of urine derivation.
Over the past 10 years, V-shaped heterotopic ileocystoplasty has been mastered and introduced into routine practice in our center, as opposed to the classic Bricker conduit.
The purpose of the study. To compare the number of early complications in patients who underwent radical cystoprostectomy with the formation of a heterotopic reservoir according to Bricker and patients with a V-shaped heterotopic reservoir.
Materials and methods. A retrospective analysis of patients from 2 groups was carried out: control group I – patients after cystectomy with Bricker ileocystoplasty (n=72). Group II of the study – patients after cystectomy with V-shaped heterotopic ileocystoplasty (n=74).
Treatment results. There is a significant decrease in the number of adaptive pyelonephritis in the study group. The number of pyelonephritis in the group of patients with separate urine derivation is 5,4 %, the number of adaptive pyelonephritis in the control group is 20,8 % of the total number of operated patients. The number of complications III-IV according to Clavien-Dindo in the group of V-shaped ileocystoplasty is 10.8%, in the control group 18 %, as a result of which V-shaped ileocystoplasty can be recommended for daily practice.
Conclusion. Modified V-shaped heterotopic urine derivation is easily feasible. This method should be used in daily practice.
Introduction. The standard of treatment for solitary metastases of colorectal cancer in the liver is a combination of liver resection and polychemotherapy. If surgery is not possible, stereotactic radiotherapy (SBRT) may be used.
The purpose of the study. To evaluate the results of SBRT and liver resection in patients with solitary metastases of colon cancer in the liver.
Materials and methods of research. Local control (LC), overall survival (OS), and progression-free survival (PFS), and the incidence of complications in the liver resection (n = 32) and SBRT (n = 26) groups were retrospectively assessed. The median dose was 54 Gy into 3 factions.
Results. Median follow-up - 33.6 months. in the SBRT group and 30,5 months in the surgery group (p>0,05). No grade 3 toxicity was noted. Three-year LC in the CRT group reached 64,2 % (95 % CI = 46–89,6 %) and 72,8 % (95 % CI = 56,7–93,6 %) in the surgery group (p = 0,53), the median LC has not been reached. Three-year OS in the SBRT group was 67,9 % (95 % CI = 50,8–90,7 %) and 64,4 % (95 % CI = 44,5–93,2 %) in the surgical group (p = 0,85). The 3-year PFS for SBRT was 5,8 % with a median of 9,2 months and 15,6 % in the surgery group with a median of 16,5 months (p=0,44). There were no statistically significant differences between SBRT and liver resection in LC and OS.
Conclusion. For solitary metastases of colon cancer in the liver, SBRT can provide results comparable to those of surgical treatment.
Introduction. In the surgical treatment of colorectal cancer, lymph node dissection is very important.
Study Objective. To determine the advantages of personalized 3D-modeling of mesenteric vessels for performing vascular-oriented extended lymph node dissection in the treatment of colorectal cancer.
Materials and methods. The patients with verified adenocarcinoma of colon or rectum underwent the construction of 3D-models of mesenteric vascular bloodstream. At the preoperative stage, the types of the superior mesenteric artery (SMA) and the inferior mesenteric artery (IMA) were evaluated. The operative time and the number of harvested lymph nodes were compared between the groups with and without 3D-CT.
Results. A total of 146 patients with colorectal cancer were included in the study. E1-type of the IMA was found in 28 (41,1 %) patients, E2 in 3 (4,4 %), E3 in 6 (8,8 %), K-type in 11 (16,2 %), and H-type in 20 (29,5 %). For SMA, the presence of the right colic artery was detected in 5 (22,7 %) cases. The middle colic artery was absent in one patient (5,5 %). The average duration of surgery did not differ significantly between the groups with and without 3D-CT. The number of harvested lymph nodes was higher in the groups with 3D-CT (26±13 and 19±7, p value = 0.00139 for left-sided cancer, and 41±26 and 17±5, p value <0.00001 for right-sided cancer).
Conclusion. Routine examination of 3D-reconstructions allows preoperative determination of vessel’s structure in the lymph node dissection zone, which improves intraoperative navigation.
MILITARY FIELD SURGERY
Introduction. It is with great regret that armed conflicts continue to arise in the modern world. There is no doubt that under such conditions, not only military personnel directly involved in hostilities, but also civilians are injured.
The purpose of the study. To characterize the injuries in pelvic gunshot wounds in patients from the civilian population, received in the conditions of local armed conflict.
Materials and methods of research. The study included 112 wounded civilians with gunshot wounds to the pelvic region. The injured were included in different periods of armed conflicts: in the territories of Grozny (Chechen Republic) in the period from 2000 to 2003, Lugansk People's Republic, Donetsk People's Republic, Zaporizhzhya and Kherson regions during a special military operation. Of the total number of wounded men there were 64 (57,1 %), women – 48 (42,8 %). All the wounded with penetrating character in the given anatomical area, whose age was not less than 18 years, were included. The wounded with combined injuries to the head, chest, and extremities were excluded.
Results. All pelvic wounds can be divided into three groups: wounds of the external genitalia, wounds of the internal pelvic organs, and wounds of the external genitalia and internal organs. Complications from wounds to this anatomical region occur in 34.8%, and the mortality rate is 18,7 %.
Conclusion. Thus, the presented study shows that gunshot wounds to the pelvic region are severe wounds, accompanied by a fairly large number of complications and fatalities.
Introduction. The problem of traumatic injuries of the pelvic girdle, until now still does not lose its relevance.
The purpose of the study. To study changes in hormonal background in women with penetrating gunshot wounds of the small pelvis in the immediate postoperative period.
Materials and methods of research. Forty female patients from the civilian population who were treated for penetrating gunshot wounds of the small pelvis received as a result of localized combat operations were selected. The mean age was 36±4 years. The immediate postoperative period depends on the time factor occupying the interval from the moment of wounding to the surgical intervention. Based on this, we formed two clinical groups of 20 people each. The first group (A) included the wounded, whose time interval did not exceed 60 min, and the second group (B) included the wounded, whose time interval exceeded 60 min.
Results. Starting from the first day after surgery, the increase of hormones in the two groups differed: in group A, where help was provided more quickly, respectively, the traumatic factor was less, the amount of hormones increased compared to normal values, however, compared to group B.
Conclusion. The study shows that pelvic gunshot wounds in women lead to changes in the hormonal background that depend on the time elapsed from the time of wounding to the start of surgical treatment and vary depending on the day elapsed since the surgical intervention was performed.
ПЛАСТИЧЕСКАЯ ХИРУРГИЯ
Introduction. Blepharoplasty occupies one of the leading positions in plastic surgery. Functional blepharoplasty is becoming especially relevant in connection with a special military operation, which significantly increased post-traumatic scarring of the eyelids after receiving mine-explosive, gunshot and burn injuries to the face. One of the surgical methods of treatment is the excision of pathological scar tissue with simultaneous repair of the defect with a free skin flap.
The aim of the work is to compare the results of blepharoplasty used to correct defects in the eyelid and periorbital region, depending on the sampling zone of the free flaps used.
Materials and methods. A prospective clinical study included 52 patients who underwent blepharoplasty with a free skin flap between 2020 and 2023.
Results and discussion. Positive functional and aesthetic results depend on the initial state of the scar-altered zone, the mechanism of traumatic injury, as well as on the zone of intake of the autodermal flap.
Conclusion. Blepharoplasty with a free flap, which gives good immediate and long-term results. According to our observations, the optimal plastic material is an autodermal flap from the retroauricular zone and the perineal zone. Despite the good results, it is necessary to continue the search for the best blepharoplasty methods to reduce the risk of complications.
ХИРУРГИЧЕСКАЯ ЭНДОКРИНОЛОГИЯ
Introduction. Endogenous hypercorticism is a relatively rare pathological condition, while in terms of severity of the course and labor prognosis it has a significant place among all endocrinopathies.
A clinical case. A clinical case of ACTH-independent hypercorticism (Itsenko-Cushing syndrome), as well as the complexity of its diagnosis and differential diagnosis, is presented. During the examination, bilateral adrenal hyperplasia was revealed. The lateralization of cortisol hyperproduction was determined by the method of comparative selective blood sampling from the adrenal veins and the inferior vena cava. In addition, as an additional test for the differential diagnosis of primary and secondary hypercorticism, the steroid profile of blood and urine was evaluated by HPLC, which confirmed the patient's ACTH-independent hypercortisolism (Itsenko-Cushing syndrome). Thanks to the use of the CVD method, it was possible to resolve the issue of the volume of surgical intervention and prevent possible unjustified bilateral adrenalectomy with hormonal inactive formation of the right adrenal gland. When conducting a comparative selective blood sampling from the adrenal veins (CVD) in order to determine lateralization with the "reference hormone" in this patient, androstenedione was selected, which was not previously described in the literature. Surgical treatment was performed and information about the patient's postoperative period was provided.
Conclusions. The above clinical case demonstrates an algorithm for diagnosing the causes of hypercorticism, possible errors and the use of time-consuming and high-tech diagnostic methods. The importance of a multidisciplinary approach is also indicated, despite the isolated endocrine pathology.
LITERARY REVIEWS
Non-epithelial malignant breast tumors include both non-epithelial and fibroepithelial tumors, primarily phylloid tumors (0,3–1 %) and sarcomas (0,2–0,6 %) [1, 2]. Phylloid tumors are considered in this group due to the fact that they are rare, fibroepithelial tumors that they have a biphasic structure and a peculiar clinical course [3]. Due to the with a small number of randomized research studying this pathology, there is currently no standardized approach to diagnosis and little-studied tactics of their complex treatment [4].
Relevance. According to statistics from international studies, the frequency of malignant variants of phylloid tumors varies widely: from 2 % to 45 %. The malignant potential of the tumor is determined by the malignancy of the non-epithelial component, to which a relatively small part of the tumor is most often exposed, while the rest of it may have morphological signs of a benign process. This is the reason for the difficulty of verifying the tumor process at the diagnostic stage. Taking into account the various options of the clinical course and morphological features, phylloid tumors should be considered as a whole complex of tumors of fibroepithelial origin.
The purpose of the study. To analyze and systematize data on the features of instrumental diagnosis and morphological structure of phylloid tumors of the mammary glands.
Materials and methods of research. The search for literary sources was carried out in PubMed according to the following dictionary queries: "phylloid tumors", "leaf-shaped tumors", "breast sarcomas". The search time interval was 2005–2023.
Introduction. The use of noble gases as organ-protective agents is a new method in various fields of medicine. This technique can be used effectively for myocardial protection and be widely introduced into clinical practice, including cardiac surgery. Mixtures of oxygen and argon in different concentrations are inhaled through the mask. Among other gases, argon stands out for its low cost, affordability, no narcotic effects, and no effects on hemodynamics.
The objective was to study effects of inhalation of argon oxygen mixtures for pre- (PreC) and post-conditioning (PostC) on cellular objects and laboratory animals, as well as in clinical studies.
Materials and methods. A review of literary sources among Russian- and English-language publications was conducted. Pubmed, Web of Science, RSCI databases were used.
Results. The protective effects of argon on cardiomyocytes and myocardium are confirmed. Argon does not affect brain and kidney cells. The cellular model shows that apoptosis rates are decreasing, and proliferation rates increase but mentions cases of necrosis. There is no information about the perioperative use of argon.
Conclusion. Based on our review, we found the problem to be relevant and further research on the effects of oxygen-argon mixtures is needed, including their potential use in clinical practice with cardioprotective purposes.
Introduction. One of the important and discussed topics in modern medicine, according to research results, are diseases of the pancreas – their diagnosis and treatment. Currently, between 27 and 50 cases of diseases per 100,000 population are detected in Russia.
The main part. The classification, forms and complications of acute pancreatitis are considered. A modern view of the pathogenesis of the development of destructive pancreatitis and the role of pancreatic enzymes in the development of pancreatic necrosis and complications is described. The analysis of the literature data on changes in laboratory blood parameters and their prognostic value is carried out. Modern instrumental research methods are analyzed, their diagnostic value in choosing a treatment method, as well as in identifying postoperative complications.
Conclusion. The diagnosis of acute pancreatitis should be carried out comprehensively and include both clinical and laboratory data, as well as the results of instrumental studies. Conducting further research in the field of diagnosis of acute pancreatitis will allow us to formulate a clear algorithm of actions, which as a result will contribute to early prediction of the course of the disease.
Introduction. Chronic ischemia of the lower extremities is one of the most common manifestations of atherosclerotic disease in patients of the older age group. Stenotic-occlusive lesion of the aorto-iliac segment can be observed in more than 30 % of such patients. Currently, such patients can be treated by surgical methods (endarterectomy, aorto-iliac or aorto-femoral bypass surgery). Long-term postoperative studies show satisfactory results, but these operations are associated with a high risk of complications and mortality. Recently, there have been changes in views on approaches to the treatment of this pathology. Endovascular methods are becoming increasingly preferred, especially in elderly patients with severe concomitant pathology, even with extensive atherosclerotic vascular lesions.
Conclusion. Currently, given the tendency to increase the number of elderly patients with concomitant pathology, the occurrence of severe prolonged atherosclerotic disease, the use of endoprosthesis may be the preferred strategy, especially in highly calcified lesions, when there is an increased risk of vessel rupture. This is the safest and most effective method of revascularization.
ПРАВОВЫЕ АСПЕКТЫ МЕДИЦИНСКОЙ ДЕЯТЕЛЬНОСТИ
Informed voluntary consent is an important legal document that protects doctor, medical organization and patient. Due to a great number of controversial issues and defects in filling out the form, it is necessary to discuss this theme in details.
Informed voluntary consent is the voluntary and conscious acceptance by the patient of medical interventions proposed by a medical professional (medical organization), based on his receipt of complete, objective and comprehensive information about the upcoming treatment, its possible complications and alternative methods. Voluntariness and awareness are the two main conditions for obtaining medical consent. Properly executed informed voluntary consent allows medical organizations to avoid adverse consequences, including financial ones. Properly compiled documentation is a powerful tool for protecting the doctor and the medical organization in future possible conflicts with patients.
The article examines the evolution of ideas about the role of patient consent to treatment. The main features of the category “informed voluntary consent” are highlighted. Some approaches to its definition are presented. The main regulatory legal acts regulating the subject area under consideration are described. The content of the informed consent form is considered. Problematic issues such as carrying out medical interventions without consent, issues related to the legal capacity of patients, issues of re-signing informed voluntary consent when replacing the attending physician, inclusion of insurers in the system of legal relations, etc. are covered.