Introduction. In the development of post-traumatic pancreatitis, an important role is played by microcirculatory disorders, developing against the background of inflammation and decreased capillary blood flow not only in the tissues of the pancreas, but also in other organs, including the intestine, which leads to neuroendocrine dysregulation, dysfunction and/or death of intestinal epithelial cells, disruption of the motor and evacuation functions of the intestine, and, as a consequence, the development of intestinal insufficiency syndrome.The objective was to demonstrate the effectiveness of enteral therapy in a patient with a closed abdominal injury, liver injury and posttraumatic pancreatitis.Materials and methods. We analyzed a clinical case of hospitalization of patient K., 38 years old, with the following diagnosis: “Closed abdominal trauma. Liver trauma of the S6 segment. Hemoperitoneum 1000 ml. Complication: right-sided segmental pneumonia. Bilateral hydrothorax. Posttraumatic pancreatitis”. The patient was admitted with complaints of upper abdominal pain and nausea two weeks after blunt abdominal trauma. She was treated as an outpatient. During the last two days she started to notice nausea, increased pain syndrome in the right side and upper parts. She was brought by an ambulance. Hybrid surgical intervention was performed: endovascular celiacography, superselective embolization of the right hepatic artery branch and diagnostic videolaparoscopic sanation and drainage of the abdominal cavity. In the postoperative period, treatment was performed according to the National Clinical Guidelines, supplemented with enteral therapy.Conclusion. This clinical observation demonstrated the effectiveness of including enteral therapy in a complex of therapeutic measures in the patient with closed abdominal trauma, liver trauma, posttraumatic pancreatitis, which was expressed in a decrease in the level of lactate, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, C-reactive protein, leukocytes on the 3rd day of dynamic observation. At the same time, an increase in the absolute number of lymphocytes, the concentration of total protein and albumin was noted. The proposed scheme contributed to the regression of signs of intestinal insufficiency syndrome, normalization of intra-abdominal pressure by the 7th postoperative day, prevention of the development of purulent-septic complications and multiple organ failure, a successful outcome of hospitalization.

Relevance. Intestinal obstruction can occur in all age groups, but most often it occurs at the age of 40–70 years and one of the causes of colonic obstruction may be volvulus of the sigmoid or cecum. Volvulus of the sigmoid colon is most common and reaches 15% of all types of strangulation intestinal obstruction. The mortality rate in sigmoid colon volvulus reaches 14–16%. In cases of necrosis of the sigmoid colon, the mortality can reach 70–78%. Aim of study. To evaluate the results of diagnosis and treatment of patients with sigmoid volvulus. Material and methods. In 2015–2020 at the N.V. Sklifosovsky Research Institute for Emergency Medicine we treated 28 patients with volvulus of the sigmoid colon. Of these, there were 13 women (46.4%) and 15 men (53.6%). The average age of the patients was 69 years. Upon admission to the hospital, patients underwent a clinical examination, basic laboratory and instrumental methods of examination. If volvulus of the sigmoid colon was suspected, colonoscopy, irrigoscopy, computed tomography of the abdominal organs with contrast enhancement, and diagnostic laparoscopy were additionally performed. In the department, patients underwent fluid maintenance, antispasmodic and symptomatic therapy, cleansing enemas. According to the indications, an operative benefit was provided by open and laparoscopic accesses. Results. The sensitivity of the x-ray method was 88%, but the sensitivity of the plain x-ray examination, supplemented with a barium enema (irrigoscopy), was 100%. The sensitivity of the ultrasound method was 57%, however, when supplemented with a Doppler study, the sensitivity increases to 72%. The sensitivity of CT was 100%. The sensitivity of colonoscopy among those studied is 96%. Operations performed in patients with volvulus of the sigmoid colon: endoscopic detorsion in 15 patients (64.3%), video-laparoscopic elimination of volvulus of the sigmoid colon in 3 (10.7%) patients. Midline laparotomy in 17 patients (60.7%). Among patients after endoscopic bowel detorsion, no complications were observed in the early period. After laparotomy and elimination of volvulus of the sigmoid colon, postoperative complications were observed in 3 (17.7%) patients. There were 3 deaths (10.7%). Conclusion. High mortality does not allow us to call the results of treatment satisfactory, and a small number of observations does not allow us to obtain statistically significant results, which requires further case recruitment and data analysis.

The purpose of the study. To clarify the possibilities of using radiation research methods in the framework of complex diagnostics of local peritonitis for timely recognition and treatment of intra-abdominal abscesses and infiltrates.Materials and methods. The analysis of the results of a complex radiation examination in 61 patients with local peritonitis of various etiologies who were treated at the N.V. Sklifosovsky Research Institute for Emergency Medicine was carried out. The complex of radiation diagnostics included ultrasound and X-ray examinations, computed tomography (CT). The studies were performed both initially at admission and in dynamics.Results. The diagnostic algorithm for local peritonitis is analyzed, three stages are identified with the determination of the method of choice on each of them. Ultrasound and X-ray examination methods are mainly used at the stage of primary diagnostics and for dynamic control. CT allows you to clarify the type, localization and volume of inflammatory changes, their relationship with the surrounding organs and structures. When analyzing the results of radiation diagnostics, it was determined the need to identify and evaluate the main signs of local peritonitis, both direct: the presence of voluminous formation of inflammatory genesis (infiltrate and/or abscess); and indirect: changes in the source organ of peritonitis; changes in structures adjacent to the infiltrate /abscess; the presence of reactive effusion into the thoracic and abdominal cavities.Conclusion. Comprehensive radiation diagnostics for local peritonitis makes it possible to obtain complete information about the nature of both inflammatory changes in local peritonitis and the causes of them. The obtained data of complex diagnostics help the surgeon to choose a rational treatment strategy for these patients, including minimally invasive. Diagnostic monitoring allows you to evaluate the effectiveness of treatment and carry out timely correction of tactics.

On the example of a clinical case, the possibilities of radiation diagnosis of a rare type of injury received from a construction and installation gun are shown. The modern possibilities of radiation diagnostics in the detection of injuries and complications in a gunshot wound of the chest are shown. Ultrasound data on the presence of intrapleural contents allowed us to determine the penetrating nature of the wound. The data obtained by polypositional chest radiography gave an idea of the localization and size of the foreign body. During chest CT, an accurate anatomical characteristic of the wound canal was given, the exact localization of the foreign body was indicated, an intrapulmonary hematoma, a lung contusion were identified, the exact nature and volume of the intrapleural contents were determined. In the postoperative period, CT revealed PE and infarct pneumonia, and scintigraphy assessed the total deficit of lung perfusion, which affected the treatment tactics. In the diagnosis of complications of breast injury such as intrapulmonary hematoma, infarction pneumonia, inflammatory changes in the soft tissues of the chest wall, ultrasound diagnostic data are comparable with CT results.

Abnormal localization of the appendix in hernial sac occurs in 2-4% of cases. Appendix is often found in inguinal and femoral hernias. Localization of the appendix in diaphragmatic hernia is described as a casuistic case. Case report of successful surgical treatment of a patient with perforated appendicitis in the left diaphragmatic hernia is presented.

The aim of the study was to show the capabilities of endovascular occlusion of giant posttraumatic pseudo-aneurysm of superior mesenteric artery (SMA) connected to a mesenteric arteriovenous fistula (AVF) under the conditions of portal hypertension and life-threatening esophageal variceal bleeding. Materials and Methods. A 27-old male patient underwent endovascular occlusion; the patient being hospitalized with a clinical picture of gastrointestinal bleeding. The examinations: ultrasound, esophagogastroduodenoscopy, multispiral computed tomography with angiography - revealed the source of bleeding to be esophageal varices against the background of portal hypertension caused by massive arteriovenous shunt, its source being AVF with an aneurysmal component (32x35 mm in size) between SMA and superior mesenteric vein (SMV) dilated up to 50 mm in diameter. Patient's past medical history recorded that 4.5 years ago the patient had undergone the resection of a small intestine area due to a penetrating stab wound in the abdominal cavity. Taking into consideration an extremely high operative intervention risk due to the condition severity related to blood loss, portal hypertension, and ascites, it was decided to embolize AVF with a vascular occluder-Amplatzer Vascular Plug II (USA), 14x10 mm in size. Results. A unique endovascular intervention - transcatheter occlusion of pseudo-aneurysm and AVF separation - was performed in life-threatening esophageal variceal bleeding under the condition of a giant post-traumatic aneurysm of SMA and mesenteric AVF. Due to an extremely large-sized SMV and an arterial pseudo-aneurysm, first ever we used the technique applied for transcatheter occlusion of a cardiac septum defect. Occluder implantation enabled to completely close the communication of aneurysmatic AVF with SMV, and occlude the aneurysm cavity. During an immediate postoperative period portal hypertension was arrested. No recurrent bleedings occurred within 4 postoperative months.

The last decades are characterized by advanced incidence of injuries with the share of abdominal injuries 1.5-18%. Blunt abdominal trauma is characterized by high incidence of complications and mortality due to severity of injury of internal organs and difficult diagnosis. The article presents 3 case reports of isolated and combined abdominal trauma followed by intestinal injury. Patients were treated at the department of emergency surgical gastroenterology of Sklifosovsky Research Institute for Emergency Care in for the period from August 2017 to February 2018.

Materials and methods. The paper presents three clinical observations of the development of intestinal obstruction with thin-colonic intussusception during the period from June 2016 to August 2017. Conclusion. The main method in the diagnosis of intussusception is the ultrasound of the abdominal cavity. For additional diagnostics the use of radiography is permissible, more complete information on suspicion of intussusception of the intestine a contrast irrigation gives. Differentiate the intussusception of intestines with diseases accompanied by attacks of pain in the abdomen, vomiting, spotting from the rectum, the presence of a tumor-like formation in the abdominal cavity. The introduction of endosurgical technologies into clinical practice increases the possibility of using low-traumatic laparoscopic interventions both for diagnosing the cause of intussusception and for eliminating intestinal obstruction.

The paper describes the first lung transplantation at the N.V. Sklifosovsky Research Institute of Emergency Care in a female patient with endstage pulmonary lymphangioleiomyomatosis, which has shown a good result during a 6-month follow-up.

AIM:To present treatment of patients with ileocecal intussusception.MATERIAL AND METHODS:There were 3 patients with ileocecal intussusception for the period from June 2016 to August 2017.CONCLUSION:Abdominal sonography is main diagnostic method for intestinal intussusception. X-ray examination including contrast-enhanced irrigography gives more complete information about suspected intussusception. It is necessary to differentiate intestinal intussusception from other diseases accompanied by abdominal pain, vomiting, bloody discharge from rectum, abdominal neoplasm. Minimally invasive laparoscopic approach is advisable for diagnosis and treatment of intestinal intussusception.

Traumatic rupture of the aorta is the second most common cause of death in closed chest injury. The latest findings of autopsy showed that 80% of lethal outcomes in aortic injury occur in the prehospital period. Taking into consideration the incidence and high rate of death prior to the diagnosis stage, aortic rupture in closed thoracic injury is an important problem. Due to the characteristic mechanism of the development (during sharp deceleration of the body) this type of traumatic lesion of the aorta became known as "deceleration syndrome". The most vulnerable to tension aortic portion is its neck where the mobile part of the thoracic aorta is connected to the fixed arch in the place of the arterial ligament attachment. Open surgical intervention in patients with severe closed chest injury (often concomitant injury) is associated with high mortality and complications. Currently endovascular prosthetic repair of the aorta is a method of choice at the primary stage of treatment of patients with aortic injury. In this article we present a rare case report of concomitant lesion of large vessels (the descending aortic portion and proper hepatic artery) in a patient with severe concomitant injury, as well as peculiarities of diagnosis and combined treatment (endovascular prosthetic repair of the aorta and hepatic artery with an aotovein).

ABSTRACT. The paper describes the first experience of successful small bowel transplantation in the Sklifosovsky Research Institute for Emergency Medicine. It contains a brief review of literature on essential aspects of small bowel transplantation, presents the donor’s case history, specific features of anesthesia, surgical procedure, and postoperative course, including the immunosuppression scheme, diagnosis and treatment of evolved complications. The paper provides in-detail results of morphological control over rejection development, presents the data of ultrasonographic observation of the changes in the transplanted intestine in the course of its adaptation to new requirements, covers the tactics of parenteral and enteral nutrition.

ABSTRACT. The paper describes the first experience of successful small bowel transplantation in the Sklifosovsky Research Institute for Emergency Medicine. It contains a brief review of literature on essential aspects of small bowel transplantation, presents the donor’s case history, specific features of anesthesia, surgical procedure, and postoperative course, including the immunosuppression scheme, diagnosis and treatment of evolved complications. The paper provides in-detail results of morphological control over rejection development, presents the data of ultrasonographic observation of the changes in the transplanted intestine in the course of its adaptation to new requirements, covers the tactics of parenteral and enteral nutrition.

Aim of investigation. To characterize radiological methods of diagnostics of surgical complications after simultateous pankreas-kidney transplantation (SPKT).Material and methods. From January, 2008 to June, 2014 overall 40 patients with the type 1 diabetes mellitus complicated by terminal diabetic nephropathy, underwent SPKT, including 17 cases (42,5%) — of intraperitoneal transplantation and 23 (57,5%) — of retroperitoneal transplantation. Mean age of patients was 35,7±6,36 year. Of all recipients 19 were women (47,5%) and 21 — men (52,5%). Results. Of 15 patients after SPKT 21 surgical complications were diagnosed, overwhelming majority of them have been corrected successfully. Only in one case the pancreatic transplant was lost due to postoperative surgical complications.Conclusions. Duly diagnostics and the proven choice of miniinvasive techniques for treatment of surgical complications became possible due to wide and urgent application of the whole spectrum of available radiological methods.

AIM:To review one of actual problems of emergency surgery - diagnosis and treatment of patients with non-occlusive mesenteric circulatory disorders.MATERIAL AND METHODS:The article presents the clinical observations showing the ambiguity of clinical picture, features and challenges of diagnosis, treatment of disease and opportunities for positive outcomes. Diagnostic methods are x-ray, abdominal ultrasonography according to which acute abdominal ischemia may be assumed. However, in all unclear cases diagnostic videolaparoscopy is mandatory to determine further tactics. Unfortunately diagnostic videolaparoscopy is not always interpreted comprehensively and not a definitive method of diagnosis. Wide surgical access is usually necessary for non-occlusal acute violation of mesenteric circulation and volume of surgery varies from segmental to subtotal intestinal and colic resection with obligatory enteral intubation and decompression. Thus, complex pre- and postoperative treatment is required.

Одной из редких причин развития острой кишечной непроходимости является инвагинация тонкой кишки. Инвагинация определяется как внедрение дистального участка кишки в проксимальном направлении, при этом наряду с кишечной стенкой одновременно происходит сдавление брыжейки между внутренним и средним цилиндрами инвагината [3—5, 22]. Данный вид кишечной непроходимости составляет 15% всех случаев механической кишечной непроходимости [7]. Инвагинация тонкой кишки после операций на органах брюшной полости встречается в 1—5% наблюдений [11, 16, 20]. По сообщению T. Pavlidis и соавт. [19], инвагинация кишечника у взрослых за последние 12 лет была диагностирована у 7 (1,9%) из 368 пациентов, оперированных по поводу тонкокишечной непроходимости. Механизм инвагинации до конца неясен. Частой причиной инвагинаций являются полипы, расстройства кровоснабжения отдельных участков кишки, первичные и метастатические опухоли тонкой кишки, дивертикул Меккеля [1, 2, 20]. В некоторых наблюдениях не удается установить провоцирующую причину нарушения перистальтики, трудно бывает найти тот пусковой механизм, который привел к инвагинации. При этом возможно говорить о «первичной инвагинации», которая встречается в 8—20% всех случаев инвагинации кишки [13, 15]. Другой причиной развития инвагинации может явиться тонкокишечная непроходимость при спаечной болезни брюшной полости, когда существует механическое препятствие со сдавлением просвета кишки. При этом в проксимальном отделе тонкой кишки происходит усиление перистальтики, что приводит к инвагинации в аборальном направлении [10]. Клиническая картина инвагинации соответствует таковой при кишечной непроходимости. У пациентов со спаечной болезнью брюшной полости и после неоднократных оперативных вмешательств диагностика крайне затруднительна, диагноз зачастую устанавливается на операционном столе. Классическая триада (схваткообразная боль, стул с кровью «малиновое желе» и пальпируемая опухоль — инвагинат), описанная в клинической картине инвагинации у детей, у взрослых практически не встречается [13, 18]. Диагностика инвагинации по данным рентгенологического, ультразвукового методов исследования и мультиспиральной компьютерной томографии (МСКТ) основывается на выявлении признаков высокой или низкой (дистальной или проксимальной) тонкокишечной непроходимости в сочетании с типичными признаками инвагинации [6, 12, 14, 15, 19, 21]. Следует отметить, что эхографическое исследование органов брюшной полости и МСКТ — равнозначные по чувствительности методы [13—16]. При УЗИ признаками инвагинации является «гиперэхогенный центр»; слабовыраженная или отсутствующая концентричность слоев в кишечном конгломерате; нечеткость, размытость контура и наличие жидкости между цилиндрами инвагината, что является прямыми ультразвуковыми признаками выраженных циркуляторных нарушений в стенке ущемленной кишки. Максимальная точность исследования установлена при выявлении симптомов «мишени» (100%), «псевдопочки» (98,9%), «щипцов» (68,8%). Все перечисленные признаки обладают высокой специфичностью и чувствительностью [6, 14, 15]. МСКТ позволяет также оценить нарушения кровообращения внутри инвагината с определением кровотока в сегменте брыжейки, сжатой между стенками кишки [6, 12, 14]. Операцией выбора при вторичных инвагинациях является дезинвагинация (при возможности ее выполнения), оценка жизнеспособности сегмента кишки и адгезиолиз [8, 9, 15, 17, 21]. Представляем 2 клинических примера инвагинации тонкой кишки в раннем послеоперационном периоде у взрослых пациентов. Больная Л., 72 лет, поступила через 6 ч от начала заболевания с жалобами на боли схваткообразного характера в нижних левых отделах живота, тошноту, многократную рвоту, задержку отхождения стула и газов, общую слабость. В анамнезе: в 2012 г. — пангистерэктомия по поводу опухоли яичника, 2013 г. — нефрэктомия по поводу опухоли почки. После последней операции в раннем послеоперационном периоде у пациентки был отмечен эпизод спаечной кишечной непроходимости, проведено консервативное лечение. При осмотре в приемном отделении состояние больной средней степени тяжести. Язык влажный, обложен беловатым налетом. Живот вздут, мягкий, при пальпации болезненный в мезогастральной и гипогастральной области, больше слева. Перитониальных симптомов нет. Определяется шум плеска. Перистальтика выслушивается, вялая. После очистительной клизмы был стул в небольшом количестве, частично отошли газы. Рек-

The article deals with results of fiberoptic bronchoscopyusing during treating ofpatients suffering atelectasis. According to the research atelectasis is likely to advance in the first three days after serious patients have been admitted to the intensive therapy unit or after operative treatment. Left-sided atelectasis is half as widespread again the right-sided one. The research highlights the effectiveness of atelectasis X-ray diagnosis. Fiberoptic bronchoscopy in almost all the cases allowed diagnosing the degree of tracheobronchial tree obstruction and its causes. Single suction fiberoptic bronchoscopy leads to normalization and encouraged positive dynamics in 76% of all the cases (57 patients). Repeated endoscopic sanation in the first two days was necessary for 25 patients (25,3%) with unresolved or reoccurring atelectasis. The effectiveness of second research was to 84%. It’s important to add that mostly patients with serious chest injury were subjected to unresolved or reoccurring atelectasis. And mainly in these cases blood was seen through the tracheobronchial tree lumen.

The article deals with results of fiberoptic bronchoscopy using during treating of patients suffering atelectasis. According to the research atelectasis is likely to advance in the first three days after serious patients have been admitted to the intensive therapy unit or after operative treatment. Left-sided atelectasis is half as widespread again the right-sided one. The research highlights the effectiveness of atelectasis X-ray diagnosis. Fiberoptic bronchoscopy in almost all the cases allowed diagnosing the degree of tracheobronchial tree obstruction and its causes. Single suction fiberoptic bronchoscopy leads to normalization and encouraged positive dynamics in 76% of all the cases (57 patients). Repeated endoscopic sanation in the first two days was necessary for 25 patients (25.3%) with unresolved or reoccurring atelectasis. The effectiveness of second research was to 84%. It's important to add that mostly patients with serious chest injury were subjected to unresolved or reoccurring atelectasis. And mainly in these cases blood was seen through the tracheobronchial tree lumen.