Abstract A clinical observation of the successful treatment of an HIV-infected patient with esophageal-pleural fistula and pleural empyema after diverticulectomy is presented, where the key tactical decision was the use of transluminal vacuum therapy together with adequate drainage of the pleural cavity and correct drug therapy. When analyzing the available literature, no publications concerning the treatment of HIV-infected patients with the discussed esophageal pathology were found.Aim of study To discuss the Results of treatment of postoperative esophageal-pleural fistula using transluminal vacuum therapy in a patient with HIV infection.

BACKGROUND: Primary hyperparathyroidism (PHPT) is a common endocrinological disease that is characterized by autonomic increased synthesis of parathyroid hormone (PTH) with elevated or upper-normal levels of blood calcium [1]. In 80–85% of cases, the cause of sporadic PHPT is an adenoma of one parathyroid gland (PTG) (sigle-gland parathyroid disease), in 20–25% — a lesion of a larger number of PTGs (hyperplasia of all glands or double adenomas — multigland parathyroid disease) [2]. The complexity of clinical and laboratory prediction, low sensitivity of imaging methods, poor assessment of the radicalness of the operation by intraoperative monitoring of intact PTH (IMiPTH) are the components of the problem of multiple lesions in PHPT. Therefore, the improvement of existing and the development of new methods for diagnosing and treating this variant of the disease are urgent tasks of modern endocrine surgery.AIM: To develop an algorithm for the diagnosis and treatment of PHPT, aimed at preoperative detection of multigland parathyroid disease.MATERIALS AND METHODS: The study was based on a study of a continuous sample of 208 patients, of which 34 with multigland parathyroid disease in PHPT, 95 with single-gland parathyroid disease in PHPT, 69 with secondary hyperparathyroidism on renal replacement therapy (RRT) with hemodialysis, and 10 with tertiary hyperparathyroidism on RRT of LT. The work was performed on the basis of clinical, laboratory, instrumental, morphological and immunohistochemical studies. The nature of the expression of the calcium-sensitive receptor and the vitamin D receptor in the studied groups was studied as a pathogenetic substantiation of the proposed algorithm [3]. Based on the study of clinical and laboratory parameters and the results of preoperative imaging methods, predictors of multigland parathyroid disease in PHPT [4,5] were established, and a method for differential diagnosis of PTG lesions in PHPT was developed [6]. In addition, the results of surgical treatment of patients with multiple PTG lesions in various clinical variants of hyperparathyroidism were studied [7]. RESULTS: The proposed algorithm is used when the diagnosis of PHPT is already established and there are indications for surgical treatment. First of all, the level of GFR (CKD-EPI) is assessed in conjunction with the results of the “gold standard” preoperative imaging methods (ultrasound and scintigraphy), with an assessment of the number of localized increased PTG and the consistency of the results of preoperative methods.At a GFR level of more than 73 ml/min/1.73 m2, an increase of only 1 PTG according to the results of 2 imaging methods, provided that they are consistent, the PHPT variant is defined as a sigle-gland parathyroid disease. If there is an inconsistency between the 2 methods of preoperative imaging, we recommend calculating the scores according to the differential diagnosis scale for multiple lesions in PHPT [6]. At a GFR level of less than 73 ml/min/1.73 m2, an increase of >1 PTG according to the results of 2 imaging methods, we recommend calculating points according to the proposed scale [6].With the established variant of PHPT — sigle-gland parathyroid disease, the patient undergoes selective parathyroidectomy (PTE) with IMiPTH. When iPTH drops to reference values, the test is considered positive, and the operation ends there. If the test result is negative, a second test is required after 10 minutes. In the event that the repeated test is also negative, then the patient is shown a bilateral neck exploration (BNE) in accordance with the tactics for multigland parathyroid disease (see below).With the established variant of PHPT — multigland parathyroid disease, the following tactics are used:BNE with obligatory exploration of all four PTGs;Macroscopic assessment of the PTG found.When making a decision about 2 pathologically changed enlarged PTG, and 2 others are intact and not enlarged, a double PTE with IMiPTH is performed. If after the removal of 2 pathologically altered PTGs, the IMiPTH test is negative, then a second one is necessary after 10 minutes. In the event that the repeated test is negative, then from the 2 recognized intact ones, the least altered is determined and the scope of the operation is expanded to subtotal PTE (3.5 PTG), leaving ½ of the least altered PTG. The operation ends here.When deciding that 3 or more PTG are pathologically changed and enlarged, a subtotal PTE with IMiPTH is performed. In case of a negative IMiPTH test, the places of possible ectopic location of the PTG are examined: thyrothymic ligaments, upper thymus horns, fatty tissue along the carotid arteries. If there are no ectopically located PTGs in the indicated places, the operation is completed.CONCLUSION: The proposed treatment and diagnostic algorithm is pathogenetically substantiated, aimed at preoperative detection of multiple PTG lesions in PHPT and will improve the quality of life of this group of patients by reducing the persistence of the disease.

The article presents a clinical case of the treatment of a 30-year-old patient with a newly diagnosed diaphragmatic Morgagni – Larrey hernia. Among diaphragmatic hernias, Morgagni – Larrey pathology occurs in 26 % of cases, mostly on the right side. The article includes data on the options for surgical approach in abdominomediastinal hernias. In the described clinical observation, the planned surgical intervention was performed through laparotomy access. The hernia content included the transverse colon and the greater omentum, as it was in most cases presented in the literature. We removed the hernial sac and repaired the defect using local tissues of the diaphragm. Taking into account the decrease in the quality of life in this pathology, as well as the risks of complications, it is advisable for such patients to perform surgical intervention in an elective manner. The issues of choosing a surgical approach, the method of diaphragm plasty and the advisability of excising the hernial sac remain unresolved.

According to the modern literature, mediastinal parathyroid glands are diagnosed in 2-20% of cases. In the available Russian-language literature, there are few reports on successful resection of mediastinal parathyroid glands in impossible surgery through cervical approach. Despite the development of minimally invasive surgical approaches and their advantages, traumatic sternotomy was used in these cases. We report a successful thoracoscopic resection of mediastinal parathyroid gland in a patient with persistent hyperparathyroidism. Preoperative topical diagnosis was essential for successful surgery. Favorable postoperative outcome was confirmed by regression of symptoms and vascular calcification, as well as improved densitometric parameters in one year after surgery.

Parathyroidectomy is the leading treatment for drug-refractory secondary and tertiary hyperparathyroidism in patients with chronic kidney disease. Difficulties in performing this surgery are mainly associated with the anatomical features of the parathyroid glands, in particular with the variability of their number and topographic anatomy. Ectopic parathyroid glands are one of the most common causes of persistence or recurrence of secondary hyperparathyroidism after surgery. One of the common variants of ectopia is the localization of the parathyroid gland in the anterior-superior mediastinum. The article discusses the features of surgical treatment of secondary hyperparathyroidism in patients with end-stage chronic kidney disease with this ectopia. A new method of treating hyperparathyroidism in patients with an atypical location of the parathyroid gland in the anterior-superior mediastinum is presented. This method is characterized by low invasiveness of access, ease of implementation without using special equipment and instruments. The proposed method was used in the treatment of a patient with secondary hyperparathyroidism due to chronic renal failure as a result of chronic glomerulonephritis. The duration of hemodialysis at the time of the surgery was more than 17 years. In the presented clinical case, ectopia of one of the pathologically altered parathyroid glands in the anterior-superior mediastinum was found at the preoperative stage. As a method of surgical treatment, we carried out total parathyroidectomy with autotransplantation of a fragment of parathyroid tissue into the brachioradialis muscle. Thanks to this method, it was possible to remove the atypically located parathyroid gland from the cervicotomy access and to discharge the patient within the standard terms for a given volume of surgery.

Background. Sporadic multiple gland disease in primary hyperparathyroidism occurs in 7 to 33 % of cases. The absence of specific risk factors, low sensitivity of imaging methods, and low efficiency of bilateral neck exploration and intraoperative monitoring of parathyroid hormone indicate the complexity of the diagnosis and treatment of this disease’s form. Aim of the research. To analyze the results of surgical treatment of multiple lesions of the parathyroid gland in primary and secondary hyperparathyroidism. Methods. There was retrospective study, which included 100 observations of surgical treatment for primary and secondary hyperparathyroidism in the thoracic department of Irkutsk Regional Clinical Hospital from May 2018 to September 2019. The main point was to identify the frequency of surgical treatment outcomes in patients with multiple parathyroid lesions. As part of the study, potential predictors of multiple gland disease in primary hyperparathyroidism were analyzed. Results. Multiple gland disease in primary hyperparathyroidism occurs in 29 % of cases and causes persistence of the disease (p ≤ 0.01). Signs of multiple gland disease in primary hyperparathyroidism include the level of ionized calcium, parathyroid hormone (p ≤ 0.05), creatinine level and glomerular filtration rate (p ≤ 0.01). A negative result of intraoperative monitoring correlates with persistence of primary hyperparathyroidism in multiple lesions (χ2, p ≤ 0.05). Selective parathyroidectomy is associated with persistence of hyperparathyroidism in multiple lesions (χ2, p ≤ 0.05), while total parathyroidectomy is associated with remission of the disease (χ2, p ≤ 0.05). We did not find a statistically significant relationship between the results of surgical treatment for morphology of the parathyroid glands (χ2, p > 0.1). Conclusion. Multiple gland disease is the main cause of persistence of primary hyperparathyroidism. This form of the disease corresponds to lower levels of calcium, parathyroid hormone, and kidney function. Persistence factors have been established: removal of less than four parathyroid glands and a negative result of intraoperative monitoring of parathyroid hormone. Bilateral neck exploration does not reduce the incidence of disease persistence.

The study was to report a case of surgical treatment of multinodular cervicothoracic goiter complicated by compression syndrome of the neck (compression of the trachea, esophagus) with severe comorbid pathology.

Российская ФедерацияЦель.Исследовать уровень FGF23 до и после хирургического лечения вторичного гиперпаратиреоза и в группах сравнения у пациентов, получающих гемодиализ, разделенных по уровню паратиреоидного гормона, и у практически здоровых людей

The analysis of the results of surgical treatment of hyperparathyroidism in 63 patients on dialysis replacement renal therapy is presented. A total of 63 primary and 4 secondary (for recurrence) surgical interventions were performed including 12 (17.9 %) - subtotal parathyroidectomy, 8 (11.9 %) - total parathyroidectomy with autotransplantation (type I), 43 (64.2 %) - total parathyroidectomy with removal of the central cellular tissue of the neck, the superior mediastinum and upper horns of the thymus gland with autotransplantation (type II); 3 (4.5 %) - secondary total parathyroidectomy type II and 1 (1.5 %) - secondary parathyroid adenomectomy. With the use of intraoperative monitoring of intact parathyroid hormone, 15 (22.4 %) operations were performed. In the postoperative period from 1 to 134 months, the patients had a decrease in blood levels of calcium, phosphorus and intact parathyroid hormone. Postoperative hypoparathyroidism was detected in 38 cases (56.7 %) of 67 observations: in 5 cases after subtotal parathyroidectomy, 5 - after total parathyroidectomy type I, and 28 - after total parathyroidectomy type II. The permissible level of parathyroid hormone was reached in 13 (19.4 %) cases: 1 - after subtotal parathyroidectomy, 11 - after total parathyroidectomy type II and 1 - after parathyroid adenomectomy. Persistence and relapse of the disease were revealed in 16 observations: 6 - after subtotal parathyroidectomy, 3 - after total parathyroidectomy type I and 7 - after total parathyroidectomy type II. When using intraoperative monitoring of intact parathyroid hormone, there are: 1 observation with the development of the persistence of the disease, 3 - with the permissible level of parathyroid hormone and in 13 cases - with the development of hypoparathyroidism. Based on the results of a comparative analysis of the results of surgical intervention, depending on the type of operation, total type II parathyroidectomy is justified for the prevention of the development of persistence and recurrent HTT (p = 0.01).

The narrowing of the lumen of the trachea due to cicatricial stenoses of the trachea is one of the urgent problems of the modern surgery. The processes taking place in the trachea and lungs lead to a change in the state of the immune system. Assessment of the dynamics of indices of nonspecific resistance is one of the methods for assessing the severity of the course of the disease. We studied the indices of nonspecific resistance of the organism in narrowing the lumen of the trachea in an experiment in the early postoperative period. The study was carried out on the basis of the scientific department of experimental surgery with the vivarium of Irkutsk Scientific Centre of Surgery and Traumatology, on 24 white male Wistar rats with a body weight of 300–350 g. We simulated narrowing the lumen of the trachea by placing a silicone tube in the lumen of the trachea for 14 days. The parameters of phagocytosis, the state of phagocytic activity of blood neutrophils, spontaneous NBT-test, induced NBT- test were studied. The animals were withdrawn from the experiment on the 3rd, 7th and 14th day. We revealed that as a result of narrowing of the lumen of the trachea with the original procedure, the nonspecific resistance of the organism was violated with inhibition of the phagocytic activity of leukocytes. There was inhibition of phagocytic activity of leukocytes and depletion of the functional reserve of leukocytes.

Objective – to present the experience of restoration of chest structure in the patients with polytrauma with use of the device SRKCH-22. Materials and methods . The presented experience is based on a retrospective analysis of treatment of 40 patients with chest structure disarrangement. The patients underwent intrapleural osteosynthesis using the stapling instrument for ribs, clavicles and the lower jaw (SRKCH-22). Results . The main results of using this method of chest structure restoration were early activation of the patients, the feasibility of performing operation in any surgery unit during providing emergency care, the absence of infectious complications and low postoperative mortality (2.5 %). Conclusion . The efficiency of the method is associated with early patient activation on the background of chest structure restoration, effective pain relief and normalization of respiratory function in the patients with polytrauma.

Background. In our country some aspects of thyroid and parathyroid surgery are still discussed. Aim. To present our experience in surgical treatment of benign diseases of the thyroid and parathyroid glands. Materials and methods. A retrospective analysis of the results of surgical treatment of 1511 patients with thyroid and parathyroid disease was performed. Results. Thyroidectomy was performed in 73.6 % of cases with thyroid diseases. The frequency of postoperative complications: laryngeal paresis - 1.37 %, hypoparathyroidism - 0.84 %, hemorrhagic complications - 1.2 %. Selective parathyroidectomy was performed in 99 % of cases with primary hyperparathyroidism. Persistent hypoparathyroidism and laryngeal paresis have not been identified. Total parathyroidectomy with central neck dissection, upper mediastinum and upper horn of the thymus gland was performed in 66.3 % of cases with secondary hyperparathyroidism. Persistent laryngeal paresis was established in 3.3 % of cases, hemorrhagic complications - in 3.3 %. Conclusions. Constant analysis of our own results gives us reasons for our own attitude to the controversial issues of thyroid and parathyroid surgery. Presently, we prefer thyroidectomy in the treatment of diffuse toxic goiter and multinodular goiter, hemithyroidectomy - for the single-node goiter. In the surgical treatment of primary and uremic hyperparathyroidism, we consider mandatory the use of intraoperative monitoring of intact parathyroid hormone. When performing total parathyroidectomy, we perform the autotransplantation of the fragment of the parathyroid gland.

Cicatricial tracheal stenosis is an urgent matter in thoracic surgery and otolaryngology. The main causes of cicatricial stenosis of the trachea is orotracheal intubation, tracheostomy and neck injuries with damage to the trachea. One of the factors that complicate this disease course is addition of nosocomial infection. We conducted a retrospective study of medical records of 33 patients treated in the thoracic surgery department of Irkutsk Regional Clinical Hospital diagnosed with cicatricial stenosis of trachea for the period from 2011 to 2013. 75 % of patients with cicatricial stenosis of trachea were men of working age up to 50 years old. We evaluated the results of bacteriological examination of detachable tracheobronchial tree. The bacteriological examination of the patients with cicatricial stenosis of trachea often exhibited hospital microflora in the form of Pseudomonas aeruginosa, Streptococcus viridans, Staphylococcus aureus. Associations of microorganisms represent this microflora in 84.4 %. During the antibiotic sensitivity examination, the low effectiveness of commonly used antimicrobials was revealed. The choices in treatment of the patients with cicatricial stenosis of trachea are: colistin, polimeksin, imipenem, meropenem, vancomycin, sulperazon. These results indicate that microbiological monitoring is necessary to detect major pathogens and their antibiotic resistance level at cicatricial stenosis of the trachea.

Surgical treatment of secondary hyperparathyroidism (HPT) in patients having renal replacement therapy (RRT) is a current problem. The aim of our study was to optimize the treatment of secondary HPT based on the comparative analysis of effectiveness of the surgeries with different extents. We conducted a retrospective analysis of the results of surgical treatment of uremic HPT in 34 patients. 36 surgeries were performed including 34primary (16subtotal parathyroidecomies (PTE), 13total parathyroidecomies (total PTEI), 5total parathyroidecomies with central neck dissection and resection of superior mediastinum and superior thymus horns (total PTEII)) and 2repeated surgeries (total PTEII and parathyroidadenomectomy). Gross examination of 134 surgical specimens revealed dyssynchronous pathological changes in parathyroid glands (PTG), normal PTG structure was found in 2cases. Recurrent HPT was found in 3 cases, persistent HPT – in 9cases, hypoparathyroidism – in 5cases after subtotal PTE and in 9 cases after total PTE with autotransplantation (p=0,267). Target values of parathyroid hormone were registered in 8patients, including 4 patients after subtotal PTE and 4 patients after total PTE (p>0,95). Morbidity was similar in all types of surgeries (p>0,5). Analysis of morbidity determined that simultaneous surgery of thyroid gland increased the risk of laryngeal paralysis (р=0,028). The decrease in occurrence of secondary HPT persistence (with the source accessible for removal through cervical approach) at total PTE based on the removal of parathyroid glands of all localizations accessible through cervical approach (including thyroid gland lobes with diagnosed ectopia, central cervical fat pad, superior mediastinum and superior thymus horns) was registered (NNT=4).

The objective of the present study was to analyze the current literature concerning mechanisms underlying the development of tracheal stenosis, new methods for the treatment and prevention of this condition. The main cause behind the formation of cicatrical stenosis of trachea is believed to be long-term artificial lung ventilation whereas the principal factors responsible for the injury to the tracheal wall include the impact of the cuff and the free end of the endotracheal tube, reflux of duodenal and gastric contents, concomitant infection, and the involvement of the autoimmune component. These pathogenic factors produce morphological changes in all layers of the tracheal wall with the formation of the granulation tissue the appearance of which serves as a forerunner of irreversible changes leading to tracheal stenosis. The biomedical technologies including auto- and allo-transplantation, tissue engineering, gene and cell-based therapy are considered to be the most promising methods for the treatment and prevention of this condition likely to improve the outcome of the management of cicatrical tracheal stenosis.

The primary interventions for trachea in the thoracic surgery units are performed for the treatment of cicatricial stenosis of the trachea. Circular resection of the trachea is one of the treatment procedures in this pathology. The benefit of this method as compared to the others is that the resection with tracheo-tracheal anastomosis allows a one-stage recovery of patient with this pathology. The first successful resection of the trachea was performed in the late 19th century, and since then this surgery technique is constantly being improved. Several methods of suture placing in anastomosis surgery are proposed, different suture materials are used, special devices are developed to facilitate the anastomosis performing. There are several tactics depending on the presence or absence of tracheostome in the patient. Different methods are worked out to approximate the trachea ends with different diameters. Prevention of anastomosis leakage is achieved by strengthening the anastomosis area to reduce the suture tension. In addition, there are studies dealing with the improvement of trachea regeneration by physiotherapy impact on the anastomosis area. Laser therapy and hyperbaric oxygenation are also put forward for use. Nevertheless, a number of items remain to be solved: indications for circular resection of the trachea are not clearly formulated, the size of trachea fragment to be resect is the subject of active discussion.

The objective of the present study was to analyze the current literature concerning mechanisms underlying the development of tracheal stenosis, new methods for the treatment and prevention of this condition. The main cause behind the formation of cicatrical stenosis of trachea is believed to be long-term artificial lung ventilation whereas the principal factors responsible for the injury to the tracheal wall include the impact of the cuff and the free end of the endotracheal tube, reflux of duodenal and gastric contents, concomitant infection, and the involvement of the autoimmune component. These pathogenic factors produce morphological changes in all layers of the tracheal wall with the formation of the granulation tissue the appearance of which serves as a forerunner of irreversible changes leading to tracheal stenosis. The biomedical technologies including auto- and allo-transplantation, tissue engineering, gene and cell-based therapy are considered to be the most promising methods for the treatment and prevention of this condition likely to improve the outcome of the management of cicatrical tracheal stenosis.Цель работы - анализ современной литературы о механизмах формирования стенозов трахеи и новых способах лечения и профилактики. Основной причиной формирования рубцового стеноза трахеи считают длительную искусственную вентиляцию легких, а среди основных причин, приводящих к возникновению повреждения стенки трахеи, - воздействие манжеты и свободного конца интубационной трубки, рефлюкс дуоденального и желудочного содержимого, присоединение инфекции, аутоиммунного компонента. Патогенные факторы приводят к морфологическим изменениям во всех слоях трахеи с формированием грануляционной ткани, появление которой является предвестником необратимых изменений и, по мнению авторов, приводит к стенозу трахеи. Наиболее перспективными методами лечения и профилактики считаются биомедицинские технологии с применением ауто- и аллотрансплантации, тканевой инженерии, клеточной и генной терапии, направленные на улучшение результатов лечения рубцовых стенозов трахеи.