Acute appendicitis in adults. Clinical guidelines.

Aims : assessment of the safety of early closure of temporary ileostomy in patients with rectal cancer after the total end partial mesorectal excision. Materials and methods : participants: patients of our clinical centers were examined with CT-proctography or rectoscopy to check whether bowel anastomoses were intact on 8-th day after the primary surgery. Patients with intact anastomoses who fulfilled the inclusion criteria were randomized to 2 groups: the first group, (n=37) with early closure of ileostomy (day 8-13 after stoma formation) and the second group (n=39) with deferred closure (after 12 weeks). It was expected that early closure would be a safe procedure. Results : 76 participants were randomized; results of their treatment were analyzed. Time boards of reconstructive surgery do not result in terms of postoperative complications (8.1% in 1-st group versus 7.7% in control, p=0,08, not significant). However duration of reconstructive surgery in the group with the early closure of ileostomy was shorter (Tm in 1-st group = 51 min (28-127) versus 70 min (30-135) in second group, duration of surgery in intervention group was shorter in 1,37 times that one in control group (95% CI 1,28-1,46, p=0,02)). Conclusion : early closure of ileostomy in patients after surgery for rectal cancer is feasible and doesn’t result in an increase the number of postoperative complications; it may be considered as an alternative to deferred closure. However, this problem should be studied in greater depth to evaluate both complications associated with ileostomy and the quality of the life.

Цель: улучшение результатов хирургического лечения больных острым холециститом за счет широкого внедрения ранних лапароскопических операций, сокращения показаний к консервативному лечению и декомпрессионным пункционным методам. Материал и методы. В работе обобщен опыт лечения 3140 пациентов с острым холециститом, которым была выполнена лапароскопическая холецистэктомия. Автор придерживается активной хирургической тактики – лапароскопическая операция в первые 2–15 ч после госпитализации при отсутствии абсолютных противопоказаний к пневмоперитонеуму. Результаты. Рассмотрены технические особенности лапароскопических операций при различных формах острого холецистита. Обсуждаются причины неудовлетворительных результатов хирургического лечения заболевания – поздняя госпитализация и применение малоэффективной консервативной терапии. Отражены негативные последствия многоэтапных методов лечения острого холецистита. Определен алгоритм раннего радикального хирургического вмешательства. Характер воспалительных изменений стенки желчного пузыря и перивезикальных тканей, а также спаечный процесс в брюшной полости не влияли на принятие решения о сроках проведения операции и выборе метода. Заключение. Радикальное хирургическое вмешательство в лапароскопическом варианте у подавляющего большинства пациентов с деструктивным холециститом в максимально короткие сроки от начала приступа или поступления в стационар следует рассматривать как операцию выбора, сопровождающуюся минимальным числом осложнений.

: laparoscopic antireflux surgery are becoming more frequent tool in the treatment of gastroesophageal reflux disease (GERD). In this case, according to the literature, symptoms of dysphagia in the postoperative period arise again in 3-30% of patients, which leads to the fact that 3-6% of them are operated repeatedly. The aim of research : assessment mechanisms for recurrence of GERD and the ability to perform adequate surgical correction after primary antireflux surgery. Materials and methods : the team of authors during the period from 1993 to 2018 operated on 2,678 patients for GERD and hernia of the esophageal aperture of the diaphragm (GVAP). 127 (4.74%) patients underwent surgery for recurrent form of the disease, 46 from their initial operation is performed in other clinics. Results : the median follow-up of re-operated patients was 63 months (12 to 139 months). A satisfactory functional result was achieved in 76.4% of the reopened patients.

This work is based on analysis of publications devoted to the problem of surgical approach to treatment of acute pancreatitis over the last 30 years. The main aim of this review is to identify the key steps of evolution of surgical approach to treatment of infected pancreatic necrosis and also to determine the most promising approach among existing methods. The analysis of the most modern clinical recommendations adopted in different countries of the world, as well as the search for such problems, the solution of which will be the main task of world medical science in the near future, is carried out. It has been established that medical communities of different countries give preference to minimally invasive methods of debridement: percutaneous and transluminal endoscopic drainage. According to the most advanced recommendations, the method of choice for surgical treatment of infected pancreatic necrosis is transluminal endoscopic drainage, with inefficiency – percutaneous puncture drainage. The main idea that defines the search vector for treatment methods for the disease is the recognition of the fact that all surgical approaches are aimed at achieving one goal – removing the maximum possible volume of necrotic masses with minimal damage to surrounding tissues. Only a method that satisfies both requirements can be recognized as leading.

AIM:To evaluate safety of early closure of ileostomy in patients with rectal cancer after primary surgery.MATERIAL AND METHODS:The trial included patients from several medical centers without signs of anastomotic leakage. CT-proctography or rectoscopy were performed in 8 days after primary surgery to confirm integrity of the anastomoses. Exclusion criteria were factors affecting normal tissue regeneration (diabetes mellitus, steroid drugs prescription, etc.). Patients with intact anastomoses and no exclusion criteria were randomized into 2 groups: group 1 (n=31) with early closure of ileostomy (in 8-13 days after surgery) and group 2 (n=34) with delayed closure (after 12 weeks). All data were analyzed.RESULTS:Postoperative morbidity was similar in both groups (6.45% vs. 5.88%, p=0.08). However, less duration of reconstructive surgery was noted in group 1 (50 (27-126) min vs. 71 min (31-134). This value was 1.42 times less in the main group (95% CI 1.30-1.52; p=0.02).CONCLUSION:Early closure of ileostomy in patients after surgery for rectal cancer is feasible and does not result increased postoperative morbidity. This approach may be considered as an alternative to delayed closure. However, further researches devoted to analysis of ileostomy-associated complications and quality of life are necessary.

AIM:To assess mechanisms of recurrent gastroesophageal reflux disease and the ability to perform adequate surgical correction after previous surgery.MATERIAL AND METHODS:The authors from various surgical centers have operated 2678 patients with gastroesophageal reflux disease and hiatal hernia for the period 1993-2018. 127 (4.74%) patients underwent redo surgery for recurrent disease, 46 of them were previously operated in other clinics.RESULTS:Median follow-up after redo surgery was 63 months (12-139). Satisfactory functional result was achieved in 76.4% of patients.

Elaparoscopic fundoplication has gained rapid surgery and is the gold standard in the treatment of hiatal hernia and gastroesophageal reflux disease. However, with the invention of robot-assisted laparoscopic technologies, disputes over this or that minimally invasive technology have not subsided. Methods. A group of authors from 2015 to 2019 y.e. 363 surgical treatments was performed for the treatment of hiatal hernia and gastroesophageal reflux disease. Patients were stratified on laparoscopic fundoplication or robot-assisted laparoscopic fundoplication. Intraoperative and postoperative results were evaluated. Results. All 363 patients completed Nissen fundoplication: laparoscopic fundoplication - 291 (80.17%) patients, robot-assisted laparoscopic fundoplication - 72 (19.83%) patients. Intraoperative and postoperative results are comparable with each other. Complications of Clavien-Dindo Classification >3 were observed in 3 patients in the laparoscopic fundoplication group. The follow-up period for patients of the laparoscopic fundoplication group ranged from 1 to 53 months (median - 19 months), for patients of the robot-assisted laparoscopic fundoplication group ranged from 1 to 41 months (median - 13 months). Conclusion. The observed values demonstrate that robot-assisted laparoscopic fundoplication is comparable to laparoscopic fundoplication in terms of a workable result.

ХИРУРГИЯ 3, 2017 В классическом обзоре 1949 г. H. Blegen привел данные анализа распространенности situs inversus, собрал полный для своего времени обзор литературы, предположил возможную этиологию и проанализировал ошибки абдоминальных хирургов при выполнении хирургических вмешательств на органах брюшной полости, предположил возможные причины относительных неудач оперативного лечения [12]. В работе H. Blegen (1949 г.) при анализе результатов обращений в разные ведущие клиники США 802 486 пациентов, прошедших по разным причинам общий медицинский осмотр, и 503 930 рентгенографий был выявлен 121 случай situs inversus. Таким образом, распространенность аномалии в его наблюдении составила 1:6587. В результате 117 000 аутопсий было выявлено 20 бывших пациентов с situs inversus, частота распространенности 1:6164 [6, 12]. Хотя Аристотель [34] впервые описал эту аномалию у животных, у человека феномен впервые был выявлен только в XVII веке и описан последовательно Fabricius (1600 г.) [37], Servicus (1615 г.) [37] и Riolan (1650 г.) [27]. C. Beck [11] утверждал, что одним из наиболее ранних достоверных описаний случаев была аномалия, выявленная у Марии Медичи, королевы Франции (1575—1642 г.). По данным А.М. Шулутко (2000 г.) впервые аномалия situs inversus viscerum прижизненно была диагностирована врачом Kuchenmeister в 1824 г. [1, 10, 33]. По данным H. Blegen, Kuchenmeister в 1864 г. подчеркнул важность перкуссии и аускультации для установления диагноза. В 1897 г. Vehemeyer впервые диагностировал эту аномалию по результатам рентгенографии [12]. С этого момента рост частоты выявленных аномалий, в том числе situs inversus, постоянно увеличивался, так что к 1938 г. было описано прижизненно (Larson) более 475 случаев situs inversus [12, 37]. Еще в XIX веке Д.Н. Зернов [3] констатировал развитие situs inversus y одного из двух близнецов [3]. Российский ученый А.К. Зиверт в публикации 1902 г. на русском языке «Случай врожденной бронхоэктазии у пациента с обратным расположением внутренностей», а в 1904 г. уже на немецком первым описал основные признаки синдрома (сочетание бронхоэктазов с situs inversus) [9]. В 1933 г. Ман Картагенер (Manes Kartagener) дал повторно подробное описание такого состояния (в современном клиническом представлении это нарушение функции ворсинок с нарушением мукоцилиарного клиренса, ранний, врожденный, хронический ринит, бронхит, синусит, отит, а также мужское бесплодие). Ман Картагенер получил научное признание после публикации в 1935 г. диссертации, посвященной этиологии бронхоэктазов [36]. В 50-х годах продолжалась дискуссия о наследственной этиологии situs inversus, ведь, как выяснилось позднее, обратное расположение внутренних органов, хотя и является наиболее характерным признаком синдрома Картагенера, встречается менее чем у половины таких больных. В настоящий момент незавершенный поворот кишечника принято считать аномалией, ассоциирующейся преимущественно с наследуемым аутосомно-рецессивным состоянием — первичной цилиарной дискинезией. В результате развития генетики и биохимии за последние 5 лет происходит стремительный рост числа публикаций, уточняющих этиологию цилиопатий: изучено более двадцати генов, ответственных за развитие синдрома Зиверта—Картагенера [24]. Таким образом, учитывая, что большинство пациентов с situs inversus за всю жизнь не имеют хирургических заболеваний, есть высокая вероятность, что при относительно невысокой распространенности аномалии (0,01—0,005% популяции) обычный практикующий хирург может не встретить подобного пациента в течение всей своей профессиональной деятельности. При анализе более 10 тыс. компьютерных томографий, выполненном А.И. Прониным в ГКБ No52 в 2012—2015 гг., был выявлен единственный случай situs inversus totalis и еще 3 клинических наблюдения декстракардии разной степени выраженности. В случае выявления показаний к оперативному лечению требуется нестандартное индивидуальное планирование операции. В обзоре литературы H. Blegen провел анализ публикаций, посвященных 144 пациентам с situs inversus, которым было выполнено 158 хирургических операций. Среди них 99 операций по поводу аппендицита, 24 в связи с заболеваниями желчного пузыря, 5 операций на желудке, 8 лапаротомий по поводу заболеваний органов таза, 2 нефропексии, 11 операций на толстой и тонкой doi: 10.17116/hirurgia2017397-101

Objective. To evaluate technical and morphological aspects of laparoscopic left lateral liver segment explantation for transplantation. Material and Methods. In Privolzhsky Federal Medical Center of FMBA of Russia 3 series (14 interventions) of laparoscopic left lateral liver sector resection were performed. Operations were performed in compliance with the principles of donor liver resection. In each series different variants of tools and hardware systems were applied. Indications were benign neoplasms of II-III segments including focal nodular hyperplasia in 12 cases and hemangioma in 2 cases. Severity of liver parenchyma damage was assessed in excised specimen. Results. Postoperative complications were not observed, patients were discharged in terms from 3 to 6 days. The average hospital stay was 3.8 days. Morphological study of histological preparations of liver tissue revealed different severity of cholestasis and steatohepatosis, fibrosis, mixed inflammatory infiltration (lymphocytes, polymorphonuclear leukocytes). Identified changes were chronic. Signs of acute ischemic damage of liver parenhima were not found. Conclusion. Laparoscopic liver resection (left lateral sector) for subsequent transplantation is technically feasible with the accumulation of experience of laparoscopic procedures.

Спаечный процесс является естественным следствием абсолютного большинства оперативных вмешательств на органах брюшной полости, возникающим с вероятностью 95% [79]. До 30% пациентов, перенесших операции по рассечению спаек, нуждаются в повторных вмешательствах по причине рецидива спаечного процесса, а смертность от последствий спаечной болезни в виде острой тонкокишечной непроходимости достигает 30% [33, 36, 81]. Несмотря на актуальность проблемы внутрибрюшных спаек и сопутствующих им осложнений, далеко не все хирурги предпринимают меры для их предотвращения. Последствия спаечного процесса экономически высокозатратны для здравоохранения. Уровень затрат на лечение осложнений, вызванных спайками, только в США составляет около 1,3 млрд. долларов в год, а число ежегодных госпитализаций для выполнения адгезиолизиса превышает 303 тыс. [90]. Игнорирование этой проблемы или отказ от поиска новых методов, направленных на предотвращение спаек, для современного здравоохранения уже неприемлем. Несмотря на разнообразные попытки хирургов уменьшить образование спаек, ни один из существующих в настоящее время подходов не позволяет получить удовлетворяющий целям конечный результат. Решение проблемы спайкообразования требует согласованных усилий всех специалистов медицинской науки и хирургии.

Background. The urgency of the problem with training specialists in laparoscopic techniques is due to the wide introduction of minimally invasive technologies into surgical practice. Previously untrained, a surgeon runs considerable difficulties with the coordination of movements and the use of tools, which may lead to both the longer life of surgical aids and damage to the viscera and vascular structures in a patient. Many factors influence the level of manual skills in the audience at the beginning of training, which further affect its duration and hence cost.Objective. To evaluate the effect of initial level of basic manual skills for the duration of the study.Materials and methods. The investigation enrolled 255 listeners: medical students, interns, residents, and practicing surgeons. Manual skills as single successive performance of exercises 1 (peg transfers) and 2 (cutting a circle) in an endotrainer box were tested before training. The correlation of the results of testing for the rate of formation of basic laparoscopic skills was then analyzed.Results. According to the results of the testing, only 20 % of the physicians showed a result of less than 110 s and were ready for being further taught in intracorporeal suturing techniques. The authors consider that all students and interns/residents and most physicians must start their training in laparoscopic technique from a series of basic exercises. The analysis revealed a correlation between the results of doing exercises 1 and 2 and the number of their repetitions to achieve the needed level (r = 0.66).Conclusion. The single performance of peg transfers and cutting a circle exercises before training could objectively measure the performance of laparoscopic skills, define an individual plan, and optimize the costs of the training.

Intracorporeal suture (ICS) is regarded today as a mandatory element, which the surgeon must possess before the development of laparoscopic surgery in the operating room. At the Department of Surgery No. 1 MSMSU proposed a simulation method of effective teaching ICS on box simulators. The testing method was attended by 255 students: students of medical universities, interns, residents, and practicing surgeons. Only 20 % of doctors have shown the necessary level of knowledge of manual skills to start learning the art of ICS. All students, interns, residents, and 80 % of physicians had to start training with basic exercises unit. During testing, the proposed method of separate training of ICS has demonstrated high performance, availability, and economic benefits.

Objective: to make the language adaptation and testing of an EORTC QLQ PRT-23 module, a method to assess quality of life, which has been elaborated in conjunction with the European organization for research and treatment of cancer quality of life questionnaire group (EORTC QLQ group), in clinical practice. Subjects and methods. An initiative study of the language adaptation of the EORTC QLQ PRT-23 module was completed. The elaborated questionnaire was tested in clinical practice. The criteria for including patients (n = 176) in the study were successful radical antitumor therapy; at least three months’ duration of small pelvic radiotherapy (RT); clinical Stage 0–IV according to the Radiation Therapy Oncology Group (RTOG) and EORTC; and endoscopically verified signs of developed radiation-induced rectitis (Stages 0–IV after M.S. Bardychev); no recurrence of the underlying disease throughout the follow-up; patient compliance; availability of a patient to be followed. Results. The range of performed RT in the patients included in the study protocol was as follows: 61 (34.6 %) patients had a total focal dose of RT, which was not higher than the tolerance values for the rectal mucosa (from 60 to 70 Gy); 115 (65.4 %) patients had a radiation dose range of 70 to 80 Gy. At least 3 months passed from the completion of the given RT to the study inclusion. With the EORTC QLQ PRT-23 module, the differences between RTOG/EORTC 0 and RTOG/EORTC II–IV groups were as follows: p0–II < 0.02, p0–III < 0.0001, and p0–IV < 0.0006. When the EORTC QLQ С-30 and QLQ PRT-23 in RTOG/EORTC III group (n = 7) and the RTOG/EORTC 0 group, this was p0–III < 0.002.Assessment of the QLQ С-30 and QLQ PRT-23 modules and comparison of patients with RTOG/EORTC Stages I, II, and IV and those with RTOG/EORTC stage 0 revealed no statistically significant group difference: p0–I < 0.81, p0–II < 0.07, and p0–IV < 0.07, respectively. The use of the QLQ PRT-23 module only yielded significantly different results between the patients without chronic radiation-induced rectitis (Stage 0) and those with the endoscopic manifestations of Stages III and IV radiation-induced rectitis (p0–III < 0.0006; p0–IV < 0.0004). The values of the EORTC QLQ С-30 and QLQ PRT-23 questionnaires were statistically significantly different in the patients with endoscopically verified radiation-induced rectitis and in those without this condition (p0–I < 0.03; p0–II < 0.02; p0–III < 0.0016; p0–IV < 0.00009). Conclusion. The EORTC QLQ С-30 and QLQ PRT-23 questionnaires may be used in the patients with chronic radiation-induced rectitis for assessment of the quality-of-life index, for determination of the integral values over time (before, during, and after treatment), for informed involvement of a patient during treatment, for estimation of patient satisfaction with the therapy performed. The EORTC QLQ С-30 questionnaire supplemented by the QLQ PRT-23 module is a subjective method. Our study provided support for the fact that the QLQ С-30 and QLQ PRT-23 questionnaires for staging chronic radiation-induced rectitis must be used in combination with any third questionnaire.