OBJECTIVE:To evaluate clinical efficacy and cost-effectiveness of vTAPP for small/M3W1 hernias compared to IPOM.MATERIAL AND METHODS:We retrospectively analyzed a prospectively recruited group of patients. Study objects were patients undergoing ventral laparoscopic transabdominal preperitoneal hernia repair (vTAPP) for primary Midline/Lateral Small hernias up to 2 cm. The control group comprised patients after IPOM procedure.RESULTS:We analyzed 179 patients: vTAPP (n=132) and IPOM groups (n=47). The vTAPP group was characterized by significantly shorter hospitals-stay (Q1-Q3: 8-70 hours, p<0.001), fewer relapses (n=2, p=0.047) and slightly longer surgery (Q1-Q3: 40-80 min, p=0.037). Cost-effectiveness analysis revealed 3.39 times more profitable vTAPP compared to IPOM.CONCLUSION:Laparoscopic preperitoneal hernia repair is a safe and effective method not requiring special tools and consumables. This approach is applicable as an outpatient (or <24h hospital-stay) method.

ntroduction. The diagnosis of acute pancreatitis poses no significant difficulties. Nonetheless, accurately predicting the potential severity of the disease during its early stages remains a challenge with existing diagnostic methods. Delayed diagnosis of pancreatic necrosis and the late initiation of intensive therapy contribute to a more severe disease course.Materials and methods. The paper presents a case of recurrent choledocholithiasis as a complicating factor in acute biliary pancreatitis in a 58-year-old woman. A standardized technique of endoscopic ultrasound allowed for the timely identification of signs indicative of developing pancreatic necrosis, enabling the prevention of its progression through papillary sphincterotomy, choledocholithotripsy, and pancreatic stenting.Results and discussion. Endosonographic features of pancreatic necrosis are visualizable in the early stages of acute pancreatitis. Changes such as Wirsung duct dilation and hypoechoic lesions in the pancreatic parenchyma provide grounds for pancreatic duct stenting with an expected clinical efficacy. The performance of endoscopic retrograde interventions in acute pancreatitis, including pancreatic stenting in particular, can halt the progression of pancreatic necrosis and contribute to a more rapid clinical and laboratory recovery.Conclusion. The presented case demonstrates the high informativeness and effectiveness of endoscopic methods in the early diagnosis and treatment of acute biliary pancreatitis.

OBJECTIVE:To evaluate the results of surgical treatment of arterial acute mesenteric ischemia in a single hospital over a 15-year period (from 2007 to 2022).MATERIAL AND METHODS:There were 385 patients with acute occlusion of superior or inferior mesenteric artery over a 15-year period. The causes of acute mesenteric ischemia were thromboembolism of superior mesenteric artery (51%), its thrombosis (43%) and thrombosis of inferior mesenteric artery (6%). Female patients predominated (258 or 67%), while male patients comprised 33% (n=127). Age of patients ranged from 41 to 97 years (mean 74±9). The main diagnostic method for acute intestinal ischemia was contrast-enhanced computed tomography or CT angiography. Intestinal revascularization was performed in 101 patients: 10 patients - open embolectomy or thrombectomy from superior mesenteric artery, 41 patients - endovascular intervention, 50 patients - combined surgery (revascularization with resection of necrotic bowel segments). Isolated resection of necrotic intestines was performed in 176 patients. Exploratory laparotomy was performed in 108 patients with total bowel necrosis. Prevention and treatment of reperfusion and translocation syndrome after successful intestinal revascularization implied extracorporeal hemocorrection for extrarenal indications (veno-venous hemofiltration or veno-venous hemodiafiltration).RESULTS:Overall 15-year mortality rate (385 patients) for acute SMA occlusion was 71% (256 out of 360 patients), postoperative mortality excluding exploratory laparotomies for the same time period - 59%. Mortality rate for inferior mesenteric artery thrombosis was 88%. Routine CT angiography of mesenteric vessels, active and effective early intestinal revascularization (open or endovascular surgery), as well as extracorporeal hemocorrection methods for reperfusion and translocation syndrome reduced mortality rate to 49% over the past 10 years (from 2013 to 2022). Mortality in acute mesenteric ischemia in the first 5 years of this study (from 2007 to 2012) was 64% (p=0.16). The main cause of death was intestinal gangrene with multiple organ failure. Reperfusion syndrome after effective endovascular revascularization complicated by severe pulmonary edema and acute respiratory distress syndrome resulted death in 15% of patients.CONCLUSION:Acute mesenteric ischemia is followed by high mortality rates and extremely poor prognosis. Early diagnosis of acute intestinal ischemia using modern diagnostic methods (CT angiography of mesenteric vessels), effective revascularization of superior mesenteric artery (open, hybrid or endovascular), prevention and treatment of reperfusion and translocation syndrome can improve postoperative outcomes.

OBJECTIVEMorphological substantiation of laparoscopic suturing of gastric ulcer with formation of a covered perforation.MATERIAL AND METHODSTo analyze morphological tissue reaction in surgical area, we used 12 Chinchilla rabbits. All animals were divided into 2 groups by 6 animals. The main group enrolled rabbits undergoing suturing of perforated gastric ulcer with formation of a covered perforation by anterior stomach wall. In the control group, gastric perforation was sutured by conventional double-row suture. For histological analysis, 2 animals in each group were withdrawn from the experiment after 7, 14 and 21 days. We excised gastric wall within the area of perforation closure. Morphological data on healing process were compared between both groups.RESULTS. STomach deformation after 7 days was more severe in the main group compared to simple suturing. However, these differences were absent after 21 days. Morphological analysis revealed postoperative transmural necrosis after 7 days. Signs of early epithelialization were more obvious in the main group. After 21 postoperative days, we observed almost completely restored differentiation of stomach wall layers in both groups of animals.

Перфоративная язва (ПЯ) является потенциально летальным осложнением язвенной болезни (ЯБ), смертность при котором достигает 30%. На долю ПЯ приходится от 2 до 20% осложнений и до 70% летальности, связанной с ЯБ. ЦЕЛЬ ИССЛЕДОВАНИЯ Улучшение результатов хирургического лечения пациентов с перфоративной дуоденальной язвой (ПДЯ) путем применения программы ускоренной реабилитации (ПУР). МАТЕРИАЛ И МЕТОДЫ Моноцентровое проспективное клиническое исследование выполнено на клинической базе кафедры хирургии и эндоскопии ФДПО ФГАОУ ВО «РНИМУ им. Н.И. Пирогова» Минздрава России (ГБУЗ «ГКБ им. В.М. Буянова ДЗМ»). Проанализированы результаты хирургического лечения 102 пациентов с ПДЯ в период с января 2015 по январь 2020 г. РЕЗУЛЬТАТЫ Пациенты в обеих клинических группах были сопоставимы по возрасту, полу, длительности перфорации, лейкоцитозу, оценкам по прогностическим шкалам American Association of Anaesthetists (ASA), J. Boey, mBoey, Peptic Ulcer Perforation Score (PULP) (p>0,05). Достоверных различий между клиническими группами по распространенности и характеру перитонита, продолжительности операции, числу баллов DEP-классификации, индекса брюшной полости, Мангеймского перитонеального индекса, World Society of Emergency Surgery Sepsis Severity Score (WSES SSS) не выявлено (p>0,05). В основной группе продолжительность госпитализации составила 3,86±1,14 (95% ДИ 3,53—4,18) койко-дня, в контрольной группе — 6,62±2,05 (95% ДИ 6,04—7,18) койко-дня (p<0,00001) при сопоставимом уровне повторных госпитализаций: 2 (4,0%) случая в основной группе и 1 (1,92%) — в контрольной (p>0,05). Послеоперационные осложнения в основной группе выявлены в 4 (8,0%) случаях, в контрольной — в 12 (23,09%) (p<0,05). Летальных исходов в обеих клинических группах не было. ЗАКЛЮЧЕНИЕ Применение ПУР в хирургическом лечении пациентов с ПДЯ позволяет достоверно уменьшить продолжительность госпитализации, число послеоперационных осложнений, способствует ранней и безопасной выписке пациентов из хирургического стационара.

ЦЕЛЬ ИССЛЕДОВАНИЯ Анализ частоты выявления венозных тромбоэмболических осложнений (ВТЭО) у стационарных пациентов с разрывом аневризмы головного мозга с образованием нетравматического субарахноидального кровоизлияния (САК) и оценка исходов антикоагулянтной профилактики и лечения ВТЭО. МАТЕРИАЛ И МЕТОДЫ Проведено одноцентровое когортное ретроспективное исследование. В основу положен анализ результатов диагностики, профилактики и лечения ВТЭО у 36 пациентов с нетравматическим САК на фоне разрыва артериальной аневризмы головного мозга, находившихся на лечении в клинике с января 2020 по март 2022 г. Медикаментозную профилактику ВТЭО осуществляли с помощью низкомолекулярных гепаринов (НМГ), которые начинали вводить в зависимости от тяжести кровоизлияния, данных коагулограммы, выполнения оперативного вмешательства или отказа от него. Назначали антикоагулянты максимально рано от момента внутричерепного кровоизлияния (в промежутке до 24 ч) или максимально рано после оперативного вмешательства (1-е или 2-е сутки). При выявлении венозного тромбоза рассматривали возможность назначения НМГ в лечебной дозировке. РЕЗУЛЬТАТЫ У 7 (19%) больных венозный тромбоз выявили при поступлении. НМГ в лечебных дозах назначили 6 пациентам, одному пациенту имплантировали съемный кава-фильтр на 2-е сутки после эмболизации аневризмы головного мозга в связи с развитием двусторонней субмассивной тромбоэмболии легочной артерии (ТЭЛА). Летальность у этих пациентов составила 71,4%. Получили антикоагулянтную профилактику 23 (64%) пациента, на фоне которой у 13 (57%) больных развился тромбоз глубоких вен, у 2 из них — немассивная ТЭЛА. В этой группе умерли 9 (39%) пациентов. Клинически значимых геморрагических осложнений на фоне введения антикоагулянтов зафиксировано не было. ЗАКЛЮЧЕНИЕ Частота ВТЭО у пациентов с нетравматическим САК высока, что требует целенаправленного поиска венозного тромбоза и фармакопрофилактики с использованием НМГ.

OBJECTIVETo study the outcomes of fast-track recovery in patients with perforated duodenal ulcer (PDU).MATERIAL AND METHODSThere were 138 patients with PDU who underwent surgical treatment for the period from January 1, 2015 to December 31, 2019. Patients were divided into 3 groups: main group, control group 1 (CG-1) and control group 2 (CG-2). The main group (fast-track group, FT-group) included 51 patients who underwent laparoscopic suturing of PDU followed by enhanced recovery (fast-track). CG-1 comprised 44 patients who underwent open suturing of PDU and conventional perioperative treatment. CG-2 consisted of 43 patients who underwent laparoscopic suturing and conventional perioperative treatment. Complications were assessed using Clavien-Dindo grading system.RESULTSIn the FT group, postoperative complications were observed in 2 patients (3.92%). Anemia of mixed genesis (Clavien-Dindo grade II) was diagnosed in 1 patient and left-sided lower lobe pneumonia in another one (grade II). There were no deaths. Mean length of hospital-stay was 3.86 days. In the 1st control group, the largest number of complications was observed (n=12, 27.27%) including 9 extra-abdominal complications (pulmonary disorders (II) - 7 patients (15.9%); sepsis (IVB) - 1 (2.27%), delirium (IVA) - 1 patient (2.27%), postoperative wound seroma (IIIA) - 1 (2.27%) patient). Intra-abdominal complications consisted of compensated pyloroduodenal stenosis (II) in 1 (2.27%) case, recurrent bleeding from acute gastric and duodenal ulcers (IIIB) in 1 (2.27%) patient. Mortality rate was 4.54% (n=2) in this group (progressive multiple organ failure). Mean length of hospital-stay was 7.56 days. In the 2nd control group, postoperative complications included extra-abdominal (pulmonary disorders (II) - pneumonia in 4 (9.3%) cases, spontaneous pneumothorax (IIIA) in 1 (2.32%) case) and intra-abdominal events (duodenitis (II) in 1 (2.32%) patient and compensated pyloroduodenal stenosis (II) in another 1 (2.32%) patient). There were no lethal outcomes in this group. Mean length of hospital-stay was 6.7 days.CONCLUSIONTreatment outcomes in patients with perforated duodenal ulcer confirmed an effectiveness of laparoscopic suturing and complete abdominal sanitation. These measures create the prerequisites for fast track recovery in urgent surgical practice. FT-protocol of inpatient management is followed by reduced hospital-stay and less incidence of postoperative complications. Moreover, this approach promotes early and safe discharge of patients.

THE OBJECTIVE was to report our experience of endovascular treatment in patients with acute thromboembolic occlusion of the superior mesenteric artery (SMA).METHODS AND MATERIALS. 13 patients with acute thromboembolic occlusion of the SMA underwent endovascular intervention. There were 4 (31 %) men and 9 (69 %) women. The average age was 76±9 years. The time from the beginning of the disorder to intervention and mechanical reperfusion of the SMA ranged from 4 to 65 hours, averaging (22±17) hours. Initial leukocytosis was (16.5±5.8)·10/9 l (from 9.2 to 28.8·10/9 l). Various endovascular manipulations were applied to achieve artery reperfusion: mechanical recanalization, balloon angioplasty, aspiration thrombectomy and stenting.RESULTS. Complete recovery of antegrade blood flow through the SMA and its main branches was achieved at all 13 (100 %) patients. Laparotomy was executed at 4 (31 %) patients, thus the intestinal necrosis after endovascular intervention developed in 3 (23 %) cases. The lethal outcome was 46 %. The main reason for a lethal outcome was reperfusion syndrome (4 patients, 31 %).CONCLUSION. Endovascular methods of treatment of patients with acute thromboembolic occlusion of the SMA can be considered as the first step in medical algorithm. They allow to save intestinal viability in most patients. Reperfusion syndrome was the main reason for a lethal outcome. The development of methods for the prevention and treatment of reperfusion syndrome in acute thromboembolic occlusion of the SMA has to become the basis for successful treatment of these patients.

OBJECTIVETo demonstrate the results of endovascular treatment of 15 patients with acute mesenteric ischemia.MATERIAL AND METHODSThere were 15 patients with acute mesenteric ischemia who underwent surgery (9 men and 6 women). Mean age was 77±11 years. Acute intestinal ischemia was caused by thromboembolism of superior mesenteric artery (9 patients), thrombosis of superior mesenteric artery (5 patients) and critical stenosis of the ostia of superior mesenteric artery and celiac trunk (1 patient). Mean time from clinical manifestation of disease to admission to the hospital was 13 hours (range 2-72 hours). In-hospital development of acute mesenteric ischemia was noted in 2 patients. Indications for endovascular intervention and techniques of endovascular revascularization of superior mesenteric artery are described in the article.RESULTSBlood flow restoration in superior mesenteric artery was achieved in 14 (93%) out of 15 patients. Laparotomy was required in 4 (27%) patients for extensive resection of necrotic intestine (n=1, 6.7%), local resection of small bowel (n=2, 13%). In another (6.7%) patient, intestine was recognized as viable after laparotomy. A bulk of intestine was preserved in most patients (n=14, 93%). In-hospital mortality rate was 47% (7 patients died). The main cause of nosocomial death (6 cases) was reperfusion syndrome followed by respiratory distress syndrome and multiple organ failure.CONCLUSIONNew methods of prevention and treatment of reperfusion syndrome can improve the results of treatment of acute mesenteric ischemia.

Presented herein is a clinical case report concerning endovascular treatment of severe chronic ischaemia of digestive organs in a patient with lesions of all three visceral arteries. Peculiarities of endovascular technique in mechanical revascularization of the superior mesenteric artery are described. Restoration of blood flow through even one visceral artery, i. e., superior mesenteric artery, is an effective and safe method of treatment for chronic intestinal ischaemia.

The remote results of immunity investigation in 30 patients after organ-preserving surgery and in 30 patients after splenectomy forspleen rupture are presented in the article. Indexes of cellular and humoral immunity were normal and life quality did not differ from that in healthy individuals after organ-preserving operations with splenic artery ligation. Splenectomy leads to deterioration of life quality and disorders in cellular immunity including decrease of T-helpers/inductors cells (CD4), immunoregulatory index (CD3/CD4) and general number of T-lymphocytes (CD3) in some cases on background of compensatory increase of normal killers (CD16). It was observed significant decrease of IgG and IgM levels. Values of IgA and cytokines IL-1, IL-2, IL-6 and TNF remained normal. Level of immunosuppression is reduced due to development of splenosis.

It was proposed the medical and diagnostic tactic in patients with acute mesenteric ischemia on basis of efficiency results of modern laboratory markers and instrumental methods. Positive laboratory D-dimer-test with computed tomography of abdominal organs or abdominal aorta and its branches CT-angiography led to diagnose thrombosis or embolism of mesenteric arteries at early terms and to reduce preoperative period. The authors presented the variant of isolated endovascular intervention in case of superior mesenteric artery thrombosis. This technique may be regarded as the method of choice in the treatment of patients with acute mesenteric ischemia.

It was analyzed the results of diagnosis and prevention of venous thromboembolic complications in 248 patients with intracranial hemorrhages of different etiology (hemorrhagic stroke, subarachnoid hemorrhage, craniocerebral injury, hemorrhages in the tumors of brain and spinal cord). The overall frequency of venous thrombosis in the vessels of the inferior vena cava pool was 24.6% (in 61 patients), the majority of patients had the asymptomatic thrombosis. The crural veins were the main localization of venous thrombosis. Also it was the main origin of thromboembolic complications (60.7%). Surgical treatment in different amount was an independent predictor of venous thromboembolic complications in neurosurgical patients according to the multivariate variance analysis. The frequency of thrombosis was significantly higher in the group of operated patients in comparison with non-operated group (37.1 vs. 17.6% (p=0.008). Early prevention by geparin (the use of direct anticoagulants for 2-4-th day of the founding of an intracranial hematoma) did not reduce the frequency of venous thrombosis in operated patients, but significantly reduced the frequency of fatal pulmonary embolism: 0 vs. 9.1% (p=0.002). Patients with intracranial hemorrhage are the one of the most unfavorable groups in terms of their venous thromboembolic complications.

The outcomes of 383 cases of heavy combined traumas (n=273) and isolated (n=110) closed injuries of the abdomen with spleen damage were analyzed. The overall mortality was 11.74% (n=45), whereas the mortality rate during the first day after admission was 7.83% (n=30). Removal of a spleen was executed at 228 patients. The spleen-preserving operation with ligation of splenic artery, was performed in 155 patients. The optimal level of the splenic artery ligation proved to be in its proximal and median parts. The postoperative CT-angiogarphy and Doppler US scanning together with the three-dimensional reconstruction confirmed that blood supply of the body and tail of the pancreas was satisfactory thanks to the natural collateral blood circulation. The dramatic decrease in lethality and of postoperative complication rates allows to consider spleen-preserving resections to be a good alternative to spleenectomy.

The results of the treatment of 378 patients with severe combined (n=270) and isolated (n=108) close abdominal trauma with an injury of the spleen are analyzed. Overall lethality was 11.9% including 7.41% during the first 24 hours. Spleen-preserving surgery was performed in 150 patients, 98% of them had severe injuries of this organ. Splenectomy was performed in 228 patients. Ligation of splenic artery is the indispensable condition of spleen-saving surgery. The level of ligation was validated by the data of own 102 x-ray and 73 anatomic examinations. Optimal level of ligation is located in proximal and middle part of the splenic artery. Spleen-preserving surgeries (especially laparoscopic procedures) significantly reduced lethality, number of postoperative complications and hospital stay.