Гастроезофагеалната рефлуксна болест (ГЕРБ) и ахалазията представляват две самостоятелни нозологични единици, характеризиращи се с различни патофизиологични механизми, но със значително припокриване на клиничната симптоматика. Прояви като киселини, ретростернална болка, регургитация и дисфагия могат да се наблюдават както при пациенти с ГЕРБ, така и в ранните стадии на ахалазията, което затруднява диференциалната диагноза и създава предпоставки за избор на неподходящ терапевтичен подход. Прецизното разграничаване между двете заболявания е от съществено значение при предоперативната оценка на пациентите, планирани за антирефлуксна хирургия, тъй като недиагностицираната ахалазия представлява противопоказание за извършване на стандартна фундопликация и налага прилагането на принципно различна хирургична стратегия. Високорезолюционната езофагеална манометрия (High-Resolution Manometry, HRM) се утвърди като златен стандарт за диагностика на моторните нарушения на хранопровода. Въвеждането на Chicago Classification версия 4.0 значително подобри диагностичната точност чрез стандартизиране на манометричните критерии и възможност за прецизно разграничаване на различните подтипове ахалазия и други нарушения на езофагеалната моторика. Съвременните диагностични алгоритми препоръчват комбинирането на HRM с горна ендоскопия, контрастно рентгеново изследване и при необходимост функционално лумен-имиджинг сонда (FLIP), което позволява комплексна оценка на структурните и функционалните нарушения. Настоящият обзор разглежда клиничното припокриване между ГЕРБ и ахалазия, диагностичните предизвикателства и ролята на високорезолюционната манометрия в предоперативната оценка на пациентите. Представени са актуалните международни препоръки относно диагностичния алгоритъм и значението на HRM за оптималния избор на хирургично лечение.
INTRODUCTION: In recent decades, the global geriatric population has been increasing. Surgical treatment for elderly patients with small and large bowel diseases is associated with an increased risk of perioperative morbidity and functional decline, necessitating the implementation of targeted optimization strategies. Frailty is the strongest predictor of these poor outcomes, requiring a shift in the approach to these patients.OBJECTIVE: To create a comprehensive overview of best practices, this review utilizes publications from the PubMed database, as well as expert consensus documents and clinical guidelines from leading international surgical and geriatric organizations.METHODS: The review focuses on the three main pillars of optimization: Comprehensive Geriatric Assessment (CGA), multimodal prehabilitation, and the implementation of modified ERAS (Enhanced Recovery After Surgery) protocols.RESULTS: Comprehensive Geriatric Assessment, especially frailty screening, is a fundamental tool for risk stratification and identifying high-risk groups requiring preoperative optimization. Prehabilitation has been proven to increase physiological reserve and functional capacity, allowing the body to withstand the stress of surgery. The integration of modified ERAS protocols, adequate anesthetic care, and the introduction of minimally invasive surgical techniques leads to reduced perioperative morbidity and mortality, shorter hospital stays, faster recovery, and preservation of quality of life following surgical intervention.CONCLUSION: The application of this integrated, multidisciplinary approach is key to achieving optimal surgical outcomes and maintaining functional independence in elderly patients. Despite a strong evidence base supporting optimization strategies, literature and experts consistently emphasize the need for further research focused on the specific needs of geriatric patients.
Въведение: Дефункциониращите стоми са утвърден метод за намаляване на клиничните последици от анастомозната инсуфициенция след предна резекция на ректума. При стандартните бримкови стоми обаче не винаги се постига пълно прекъсване на чревния пасаж към дисталния сегмент.Цел: Да се представи модифицирана техника за конструиране на бримкова трансверзостома, функционираща като едностволова стома с пълно изключване на дисталния пасаж, както и техниката за последващата ѝ реституция, чрез анализ на клиничните резултати.Материал и методи: Проведено е ретроспективно-проспективно проучване на пациенти, подложени на предна резекция на ректума в Първо хирургично отделение на МБАЛ „Княгиня Клементина“ за периода 2013–2025 г. Анализирани са две последователни серии пациенти, при които е приложена описаната модифицирана трансверзостома. Оценени са честотата на анастомозната инсуфициенция, следоперативните усложнения, смъртността и резултатите след възстановяване на чревния пасаж.Резултати: При пациентите с модифицирана протективна трансверзостома е постигнато пълно прекъсване на чревния пасаж към дисталното черво. Анастомозна инсуфициенция е наблюдавана при 1 от 44 пациенти (2%). Реституция на стомата е извършена при 33 пациенти (75%), като при 22 от тях (66%) не са регистрирани усложнения. Не е установена анастомозна инсуфициенция след възстановяване на чревния пасаж. Най-честите усложнения след реституцията са инфекции на оперативната рана, временен забавен чревен пасаж и следоперативна херния.Заключение: Представената модификация на бримковата трансверзостома осигурява надеждно изключване на дисталния чревен пасаж и позволява безопасно възстановяване на чревната непрекъснатост без необходимост от обширна резекция на червото. Методът демонстрира ниска честота на анастомозна инсуфициенция и добри ранни следоперативни резултати и представлява обещаваща алтернатива при необходимост от протективна колостома.
Chronic kidney disease (CKD) represents a major global health burden and is associated with increased morbidity, mortality, and adverse outcomes in surgical patients. Individuals with CKD undergoing abdominal surgery demonstrate a significantly higher risk of postoperative complications, including acute kidney injury, infectious complications, cardiovascular events, and increased hospital mortality. Reduced renal functional reserve, chronic inflammation, endothelial dysfunction, disturbances in fluid and electrolyte balance, and the frequent presence of comorbid conditions contribute to the elevated perioperative risk observed in this population. This review discusses the epidemiology, pathophysiological mechanisms, and clinical significance of chronic kidney disease as a risk factor for adverse postoperative outcomes in abdominal surgery. Additionally, current approaches to perioperative assessment and management of patients with CKD are presented to reduce complications and improve surgical outcomes.
OBJECTIVE:To evaluate the effectiveness of comprehensive treatment of mediastinal germ cell tumor in a child with emphasis on the role of neoadjuvant chemotherapy and total resection. MATERIAL AND METHODS:The authors present a boy with primary mediastinal germ cell tumor. RESULTS:Treatment of a 17-year-old patient with stage IVA anterior mediastinal choriocarcinoma was followed by complete clinical and laboratory remission. Intensive induction polychemotherapy according to the MAKEI 2005 protocol led to significant tumor shrinkage (~85.5%) for subsequent en bloc resection of tumor and adjacent tissues. Postoperative period and final course of chemotherapy were uneventful; follow-up examinations showed normalization of tumor markers, favorable clinical status and no signs of recurrence. CONCLUSION:This case demonstrates that comprehensive treatment, including induction chemotherapy and subsequent total resection, enables complete remission even in aggressive and advanced forms of mediastinal germ cell tumors in adolescents. This confirms high effectiveness of modern therapeutic approaches.
OBJECTIVE:To assess the incidence of postoperative hemothorax and influence of redo surgery timing on outcomes. MATERIAL AND METHODS:A multiple-center retrospective study included 70 out of 7.796 postoperative patients who underwent redo surgery for postoperative hemothorax following lung resection between 2019 and 2024 in four specialized thoracic centers in Russia. Of these, 57 (81.4%) patients underwent anatomical resections (including 45 lobectomies), and 13 (18.6%) underwent non-anatomical wedge resections. Patients were stratified into early (<24 hours) and delayed (≥24 hours) redo surgery groups. Postoperative complications were assessed using the Thoracic Morbidity and Mortality (TMM) classification. The primary outcome was 90-day mortality. RESULTS:The incidence of hemothorax was 1.1% after anatomical resections and 0.5% after non-anatomical resections. Ninety-day mortality was significantly lower in the early redo surgery group (12.5% vs. 36.6%, p=0.037). Early redo surgery was associated with higher rate of intraoperative identification of bleeding source (67.5% vs. 36.7%, p=0.030). The Charlson comorbidity index was significantly higher in the delayed group (p<0.001). Delayed interventions demonstrated a trend towards more severe complications and higher rates of pleural empyema. Delayed redo surgery beyond 24 hours was associated with more than threefold increase in the risk of death (OR 3.98; 95% CI 1.21-13.07). CONCLUSION:Early surgical intervention for postoperative hemothorax, especially within the first 24 hours, is associated with better clinical outcomes and significantly lower 90-day mortality.
OBJECTIVE:To identify the prevalence of venous thromboembolism (VTE) in patients with hypertensive intracerebral hematoma, aneurysmal subarachnoid hemorrhage and severe traumatic brain injury complicated by intracranial hemorrhage. MATERIAL AND METHODS:A non-randomized retrospective observational study recruited subjects between January 2020 and May 2024 (53 months). The study group included 311 patients with various intracranial hemorrhages: hypertensive intracerebral hematoma (n=194), ruptured intracranial aneurysm with subarachnoid hemorrhage (n=41), and traumatic brain injury complicated by intracranial hemorrhage (n=76). All patients underwent ultrasound of lower limb veins upon admission or within 24 hours, and then vein patency was checked every 7 days. In case of emergency or urgent surgery, ultrasound was performed on the first postoperative day and repeated every 7 days. The diagnosis of pulmonary embolism (PE) was established using CT pulmonary angiography or autopsy data. The primary endpoints were venous thrombosis in inferior vena cava system, nonfatal and fatal PE. Secondary endpoints included recurrent intracranial hemorrhage, any other clinically significant bleedings (gastrointestinal, nasal, etc.) and death. RESULTS:The incidence of VTE in patients with hypertensive intracerebral hematoma was 32.5% (50 patients with venous thrombosis and 13 patients with PE). Among patients with aneurysmal subarachnoid hemorrhage, the prevalence of VTE was 60.9% (21 patients with venous thrombosis and 4 patients with PE). In patients with traumatic intracranial hemorrhage, VTE was detected in 28.9% of cases (21 patients with venous thrombosis and 1 patient with PE). CONCLUSION:VTE remains one of the main and often fatal complications of various intracranial hemorrhages. Regular ultrasound of IVC system allows timely diagnosis of venous thrombosis in patients with intracranial hemorrhage, prescription of therapeutic doses of anticoagulants and minimization of risks of fatal PE.
Accessory spleen is a rare anomaly occurring in approximately 10% of people. Most often, accessory spleen can be located in spleen gate. However, localization in parenchymal abdominal organs, retroperitoneal space, pelvis and chest is also possible. Congenital accessory spleen is extremely rare, and only several cases are described in the literature. Diagnosis causes some difficulties. CT-based differentiation with malignant tumor is difficult. We present a 72-year-old patient with congenital intrathoracic accessory spleen.
OBJECTIVE:To identify the causes of cystic duct stump failure after cholecystectomy and diagnostic effectiveness of magnetic resonance cholangiography. MATERIAL AND METHODS:We retrospectively analyzed examination and treatment of 30 patients with cystic duct stump failure after cholecystectomy. Patients underwent ultrasound (30), CT (17), MR-cholangiography (25), transfistular cholangiography (3). Minimally invasive (83.33%) and open surgical interventions (16.67%) were used. The Statistica 10 program was used for statistical analysis. RESULTS:The causes of bile leakage from cystic duct stump were ligation defects in 60% and biliary hypertension in 40% of cases. MR-cholangiography allowed to exclude intersection of bile ducts in 24 out of 25 cases and to diagnose biliary hypertension in 10 cases. Specificity and negative prognostic value of MR-cholangiography for diagnosis of intersection of extrahepatic bile ducts was 96%. Patients with external biliary fistula (24) underwent endoscopic papillotomy and bile duct stenting with a stent above cystic stump (with removal of bile stones in 7 cases). A nitinol stent was installed in one case. Five (16.67%) patients underwent additional relaparoscopy for abdominal effusion. In all cases, bile leakage stopped within 1-5 (1 [0; 3]) days. Laparotomy, choledocholithotomy (1), transduodenal papillotomy (1), and external drainage of bile ducts (5) were performed for signs of peritonitis. CONCLUSION:Endoscopic papillotomy combined with bile duct stenting with or without lithoextraction makes it possible to early eliminate bile leakage in case of cystic duct stump failure with bile leakage.
The Russian consensus document on current issues in diagnosis and treatment of gastroduodenal ulcerative bleeding was prepared by a group of experts in surgery, endoscopy, interventional radiology and intensive care. The purpose of this consensus was to identify and consolidate opinions of Russian specialists on such current issues as diagnostic measures for gastroduodenal ulcerative bleeding, timing of diagnosis and order of diagnostic tests, as well as necessity and feasibility of conservative measures for gastroduodenal ulcerative bleeding, analysis of surgical strategy depending on severity of bleeding.
Congenital portosystemic shunts (CPSS) are rare vascular anomalies with portal blood bypassing hepatic filtration and subsequent various metabolic and developmental complications. Early diagnosis and timely intervention are crucial to prevent severe complications. We describe a 3-month-old boy with persistent jaundice and developmental delays. Laboratory tests revealed hyperbilirubinemia and elevated transaminases. Doppler ultrasound and contrast-enhanced computed tomography revealed a large intrahepatic PSS up to 25 mm in diameter with hypoplasia of the right liver lobe. Endovascular embolization was performed via transjugular approach. Postoperative migration of one coil into pulmonary artery required endovascular procedure. Gradual normalization of liver function tests, restoration of portal blood flow, regeneration of liver parenchyma and age-appropriate development were achieved. This case demonstrates technical feasibility and effectiveness of endovascular closure of large intrahepatic CPSS, even in infants. Key factors for successful outcomes include careful anatomical assessment, individual treatment plan and meticulous postoperative monitoring.
A 40-year-old men received a shrapnel wound of the neck with common carotid artery rupture on the left in 2023. Carotid artery replacement with a diepoxy-treated biological prosthesis was performed. After 6 months, transient ischemic attack developed. Ultrasound revealed 60% restenosis of prosthesis. After conservative treatment, he continued serving in the armed forces. In June 2025, CT angiography revealed 86% restenosis of prosthesis and occlusion of external carotid artery. Autovenous redo internal and external carotid artery replacement was performed at the military field hospital. Postoperative period was uneventful.
Diseases of the artificial esophagus can occur at different times after esophagoplasty. Their incidence varies widely from 10% to 50% and depends on plastic material and surgical technique. The authors present successful treatment of a patient with skin tube cancer after previous esophagoplasty with small bowel interposition back in the 40s of the 20th century.
The intensification of armed conflicts in recent years has led to an increase in the number of casualties with injuries to major vessels. The use and search for optimal regimens of angiotropic therapy in the early postoperative period for patients undergoing surgical interventions for injuries to major arteries remains a debatable issue. This article describes two successful clinical cases of using a vasoactive peptide complex in the postoperative period in patients who sustained gunshot wounds with injuries to the major arteries of the extremities, treated at different medical institutions.
OBJECTIVE:To establish a laboratory marker of infection in destructive pancreatitis based on peripheral blood macrophage response. MATERIAL AND METHODS:A prospective study (2019-2024) enrolled 78 patients with phase IB and II acute pancreatitis. Macrophage response was assessed three times (on days 1-2, 7-8, and 18-20) using native blood smears stained with methylene blue and examined under microscopy in six fields of view. Quantitative parameters (leukocytosis, leukocyte intoxication index, qSOFA, Dzhanelidze, Ranson, and Balthazar scores) were analyzed with correlation coefficients (Pearson and Spearman tests). RESULTS:In patients with infected necrosis, there was a significant increase in macrophage count (from 0.5±0.5 to 1.5±1.0 cells per six fields; p<0.001), whereas macrophage count remained unchanged in the aseptic group (0.1±0.3). Macrophage count moderately correlated with leukocytosis (r=0.48), leukocyte intoxication index (r=0.50), severity scores (ρ=0.34-0.49), and necrosis area (r≈0.50; p<0.001). CONCLUSION:Original method enables detection of infected necrosis as early as phase II of acute pancreatitis and may serve as a guide for timely surgical intervention.
OBJECTIVE:To compare the results of staged surgical treatment of patients with disseminated secondary peritonitis and to clarify the indications for open abdomen technique. MATERIAL AND METHODS:We analyzed treatment outcomes in 978 patients with disseminated peritonitis. The main causes of peritonitis were destructive appendicitis (430 patients, 43.9%) and gastroduodenal ulcer perforation (217 patients, 22.2%). RESULTS:Staged debridement in patients with high risk of death (WSES SSS score ≥ 9) significantly reduces in mortality in this group of patients (from 82.5% with traditional tactics to 62.1%). Staged debridement in patients with lower probability of death (WSES SSS score 7-8) does not significantly affect the outcomes. Open abdomen method significantly reduces mortality in patients with abdominal sepsis and septic shock compared to primary suturing and elective re-laparotomy from 75% to 35.3%. Open abdomen method in patients with intra-abdominal pressure >20 mmHg is associated with significantly lower mortality compared to primary suturing (traditional technique) and elective re-laparotomy. VAC systems significantly reduce mortality in patients with WSES SSS score ≥7 compared to anterior abdominal wall closure with local tissues during elective re-laparotomy. The benefit of VAC systems for milder manifestations of peritonitis is not significant. CONCLUSION:Indications for open abdomen technique include intraabdominal pressure >20 mmHg or abdominal compartment syndrome. This method prevents tissue ischemia, formation of purulent pockets and, consequently, progression of peritonitis in postoperative period. Open abdomen technique is advisable if hemodynamic instability makes surgery impossible.
Cefoperazone/sulbactam is widely prescribed for the treatment of moderate-to-severe infections caused by β-lactamase-producing organisms. It is one of most common antibiotics for hospitalized patients with complicated intra-abdominal infections. However, multiple reports on adverse events raised significant concerns among clinicians regarding safety profile. Data from the China National ADR Monitoring Network revealed that cefoperazone/sulbactam ranked among the top three drugs associated with reported adverse events. In addition to allergic reactions and gastrointestinal disturbances, coagulopathy has emerged as one of the most significant complications. Cefoperazone/sulbactam-induced coagulopathy may lead to serious bleeding episodes and pose a substantial risk to postoperative patients. International literature describes severe hematuria, abdominal wall hematomas, and upper gastrointestinal bleeding in patients treated with cefoperazone/sulbactam. Moreover, a recent study involving 6.191 patients demonstrated a higher risk of bleeding associated with cefoperazone/sulbactam compared to other antibiotics. Considering the lack of Russian data on this adverse effect, we present patients who developed significant coagulation disorders following pancreatic resections associated with cefoperazone/sulbactam administration in early postoperative period.
OBJECTIVE:To analyze the effect of Remaxol (Inosine + Meglumine + Methionine + Nicotinamide + Succinic Acid) in perioperative infusion therapy (PITh) on bilirubinemia in patients with cholelithiasis (CL) complicated by obstructive jaundice (OJ). MATERIAL AND METHODS:A multiple-center observational study included 283 patients with CL complicated by OJ. All patients underwent endoscopic papillosphincterotomy (EPST) with / without subsequent laparoscopic cholecystectomy (LC). Primary assessment of PITh efficacy was performed on days 6-7 after EPST. Bilirubinemia was compared with the day before EPST. A positive response to therapy was defined as normalization of total blood bilirubin or its reduction by 70%. RESULTS:Factors influencing the efficacy of PITh in patients with OJ were identified. Positive response rate was 100% in patients receiving PITh with Remaxol proportion exceeding 80% (p=0.005). In case of Remaxol proportion >50%, positive response rate was 96.88% (p=0.001). In the group with Remaxol proportion <50%, positive response rate was 68% compared to the group with proportion >50% (p<0.001). Each 10% increase in proportion of Remaxol increased the probability of positive response to treatment by 13% (p=0.017). CONCLUSION:Inclusion of Remaxol (Inosine + Meglumine + Methionine + Nicotinamide + Succinic Acid) in perioperative PITh for patients with OJ may have a positive effect on total blood bilirubin and increase the likelihood of normalization of this parameter or significant (by ≥70%) reduction in 6-7 days after successful EPST.
OBJECTIVE:To describe the concept of comprehensive left ventricular outflow tract reconstruction based on eliminating all obstructive mechanisms. MATERIAL AND METHODS:The authors analyzed own experience of left ventricular outflow tract reconstruction in patients with hypertrophic cardiomyopathy (over 400 surgeries). RESULTS:Complex left ventricular outflow tract reconstruction involves resection of interventricular septum and correction of papillary muscles, chordae tendineae and accessory muscle bundles. The described approach demonstrates high efficacy and safety and can be considered a modern standard. CONCLUSION:A personalized approach based on precise myectomy allows for optimal hemodynamic outcomes with minimal risk of complications.
OBJECTIVE:To study the immediate and long-term outcomes of segmentectomy and lobectomy for malignant lung tumors. MATERIAL AND METHODS:A retrospective study included patients with primary malignant lung tumors who underwent anatomical lung resection, including segmentectomy (335 patients) and lobectomy (1.238 patients) via thoracoscopic and open approaches between January 01, 2009 and December 31, 2022. Patients who required conversion to thoracotomy were included in the open surgery group. We enrolled 240 patients for analysis (120 after segmentectomy for non-small cell lung cancer (NSCLC) and 120 after lobectomy for NSCLC, ratio 1:1). RESULTS:The total number of complications in thoracoscopic segmentectomies differed from lobectomy (4.2% and 9%, respectively; p=0.047). The same trend was observed for open segmentectomies and lobectomies (4.8% and 9.6%, respectively; p=0.05). Recovery of external respiratory function occurred significantly faster after thoracoscopic segmentectomies compared to thoracoscopic lobectomies. Thus, preoperative forced expiratory volumes in 1 second (FEV1) were 85% (42-120) and 89% (80-97), respectively. After 6 months and 1 year, FEV1 after thoracoscopic segmentectomy reached 80% (40-111) and 84% (42-116), after thoracoscopic lobectomy - 80% (70-90) and 82% (72-94), respectively. The same trend was observed in groups of open segmentectomy and lobectomies. Preoperative FEV1 was 79% (39-125) and 90% (43-136), after 6 months - 75% (36-117) and 82% (36-121), after 1 year - 78% (37-123) and 83% (39-130), respectively. The overall 5-year survival rates for patients with stage Ia1 and Ia2 NSCLC after thoracoscopic segmentectomy and lobectomy were 90.4% and 91.5% (p=0.940), 5-year disease-free survival rates - 83.3% and 89.4%, respectively (p=0.949). The overall 5-year survival rates for patients with stage Ia1 and Ia2 NSCLC after open segmentectomy and lobectomy were 79.7% and 83.5% (p=0.951), 5-year disease-free survival rates - 74.5% and 76.9%, respectively (p=0.457). CONCLUSION:Segmentectomy is associated with lower complication rate than lobectomy, and long-term outcomes are comparable to those of lobectomy in patients with NSCLC <2 cm.
