Cecal volvulus (CV) is one of the rare forms of strangulated intestinal obstruction, which accounts for 20–40 % of all colonic volvuluses and 1.0–1.5 % of all cases of intestinal obstruction in adult patients, mainly females aged from 40 to 62 years old (female to male gender ratio 4:1). One of the complications of cecal volvulus is a violation of the blood supply to the intestinal wall (23.8–44.2 %), which leads to necrosis in 36.7 % of cases, to perforation of the intestinal wall 23 % of cases, and to the development of peritonitis in 41.6–43 % of cases. If there is doubt about the viability of the ischemic intestine, the choice of the extent of surgical intervention was always determined in favor of its resection. The emergence of laparoscopic technologies in the arsenal of modern surgery makes it possible to assess the viability of the organ in the dynamics of its conduction, to choose the optimal tactics for treating the patient in the delayed period, which in some cases helps refrain from unnecessary resection operations, to preserve the organ and achieve a favorable outcome in patients diagnosed with cecal volvulus.

Cecal volvulus (CV) is one of the rare forms of strangulated intestinal obstruction, which accounts for 20–40 % of all colonic volvuluses and 1.0–1.5 % of all cases of intestinal obstruction in adult patients, mainly females aged from 40 to 62 years old (female to male gender ratio 4:1). One of the complications of cecal volvulus is a violation of the blood supply to the intestinal wall (23.8–44.2 %), which leads to necrosis in 36.7 % of cases, to perforation of the intestinal wall 23 % of cases, and to the development of peritonitis in 41.6–43 % of cases. If there is doubt about the viability of the ischemic intestine, the choice of the extent of surgical intervention was always determined in favor of its resection. The emergence of laparoscopic technologies in the arsenal of modern surgery makes it possible to assess the viability of the organ in the dynamics of its conduction, to choose the optimal tactics for treating the patient in the delayed period, which in some cases helps refrain from unnecessary resection operations, to preserve the organ and achieve a favorable outcome in patients diagnosed with cecal volvulus.

BACKGROUND. Theoretical data convincingly support the use of extracorporeal hemocorrection (ECHC) methods in the treatment of sepsis. However, a large number of researchers have still not been able to convincingly prove the advantage of ECHC methods; there is no unanimity of opinion. We tried to analyze our own experience in using ECHC methods in the treatment of abdominal sepsis over the past 3 years. AIM OF STUDY. To analyze the use of ECHC methods in the early stages of treatment of abdominal sepsis, to determine whether their use had an advantage for survival. STUDY DESIGN. Prospective cohort. DESCRIPTION OF THE METHOD. In 50 cases (group 1), ECHC was performed early after surgery. The median time from admission to the intensive care unit after surgery to the start of ECHC was 25.3 (17.7; 36.5) hours. When determining the ECHC modality, we were guided by the individual approach and clinical experience of the ECHC specialist. Apheresis methods alone were performed in 8 % of patients (4/50), a combination of apheresis methods and renal replacement therapy was performed in 40 % (20/50), renal replacement therapy (RRT) methods were performed in 98 % (46/50), plasmapheresis/plasma exchange/selective plasma filtration were performed in 30 % (15/50), selective hemosorption of cytokines was performed in 4 % (2/50), selective hemosorption lipopolysaccharides was performed in 24 % (12/50). We analyzed outcomes, assessments of the severity of functional disorders and sepsis-associated organ dysfunction according to the APACHE scales II and SOFA and their dynamics, probabilities of outcomes depending on the scores on the indices (logistic regression); life times, cumulative survival rate (Kaplan-Meier method). SAMPLE CHARACTERISTICS. There were 113 patients after emergency laparotomy due to widespread peritonitis, abdominal sepsis, aged from 23 to 90 years. 67 men, 46 women. In 50 cases of observation (group 1), ECHC was performed in the early stages ; in 63 cases, methods of active hemocorrection were not used (group 2). In group 1 there were 35 patients with septic shock and 15 patients with stable hemodynamics (subgroup 1/shock and subgroup 1/sepsis). In group 2 there were 20 patients with shock and 43 with stable hemodynamics (subgroup 2/shock and subgroup 2/sepsis). RESEARCH RESULTS ECHC. Methods allowed survival of patients with more severe APACHE scores II and SOFA: in survivors in subgroup 1/shock Me 29 (24; 31) versus 23 (14; 26) in the subgroup 2/shock and 8 (4; 10) versus 4 (2; 6) points, p=0.048 and p = 0.010; with stable hemodynamics in survivors in subgroup 1/sepsis Me 20 (17; 22) versus 15 (11; 19) in subgroup 2/sepsis, p=0.016. ECHC changed the survival threshold in favor of more severe patients from 29 to 33 points; reduced the likelihood of an unfavorable outcome 1.2-fold for each point on the APACHE scale II and 1,276 times over the entire range of estimates; prolonged survival time in hemodynamically unstable patients at a significance level of p = 0.083, shifting the first quartile of survival from 1 to 12 days, the median from 12 to 20, the third quartile from 27 to 45 days. When performing ECHC, the cumulative survival rate was higher throughout the entire hospital observation period: 0.886 (95 % CI 0.780–0.939) in 2 days versus 0.700 (95 % CI 0.499–0.802); 0.800 (95 % CI 0.667–0.868) in 10 days versus 0.545 (95 % CI 0.325–0.658); 0.653 (95 % CI 0.494–0.734) in 14 days versus 0.416 (95 % CI 1.185–0.533). Overall mortality from all causes was 35.4 % (40/113), 67.3 (37/55) with shock, 5.2 % (3/58) with stable hemodynamics. The maximum risk of an unfavorable outcome occurred in the early stages: 30 % (12/40) of all deaths occurred in the first 4 days after surgery, 20 % (8/40) in the first 24 hours. In shock patients, 10-day mortality was lower when performing ECHC: 20.0 % (7/35) versus 45.0 % (9/20), p = 0.050, 1st stage. Fisher’s test, P = 0.38 insufficient. Hospital mortality in the shock subgroups was equal, all the advantages of ECHC achieved in the early stages were lost; although in most late outcomes the peritonitis was relieved; which was confirmed during the section. CONCLUSIONS. The power of the study was sufficient to identify statistically significant advantages of extracorporeal hemocorrection in the treatment of abdominal sepsis based on APACHE index estimates II and SOFA. For the Kaplan–Meier method, differences were obtained for shock patients at a significance level of 0.083; the number of observations must be doubled to detect statistically significant differences. The final results of hospital mortality require additional in-depth analysis, since in the later stages many deaths were not associated with abdominal sepsis and occurred with already resolved peritonitis. It is necessary to understand to what extent they were associated with experienced sepsis, and to what extent with comorbid pathology; whether there was an association with methods of extracorporeal hemocorrection.

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.

RELEVANCE Treatment of patients with complicated abdominal infections (AI) is still a difficult task, as evidenced by high mortality rates. THE AIM OF THE STUDY is to analyze the results of microbiological investigations of patients with advanced diffuse peritonitis who were treated in the surgical department of the emergency hospital. MATERIAL AND METHODS In this study, the main pathogens of advanced peritonitis were identified in 69 patients (the average age of patients was 64±17 years). The cause of peritonitis in the absolute majority of cases (94%) was a perforation of the gastrointestinal tract. A study of various types of clinical material was carried out: blood — 143 samples, urine — 125 samples, bronchoalveolar lavage — 119 samples and 130 samples of wound discharge. 260 strains of microorganisms were isolated. RESULTS The predominance of the Enterobacteriacea species (K. pneumoniae and E. coli), non-fermenting bacteria (Acinetobacter spp.) as well as the increasing role of Enterococcus spp. and Staphylococcus spp. (S. aureus and CNS) were found. Multidrug-resistant strains dominated among the identified pathogens. CONCLUSION The obtained data on the structure of pathogens of complicated abdominal infection confirm global trends. In order to develop new treatment methods for complicated AI, one of the possible solutions may be the use of human microbial ecology approaches.

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.

Purpose. To identify and evaluate the effectiveness of sonographic signs of intestinal ischemia in patients with strangulated small bowel obstruction.Materials and methods. For the period 2017–2019, 115 patients with SIO were treated at the N.V. Sklifosovsky Federal Research Institute of Emergency Medicine. There were 64 women (55.6%) and 51 men (44.4%). The mean age was 62 ± 15 years. In all patients, the diagnosis was verified intraoperatively. All patients underwent ultrasound examination of the abdominal cavity in B-mode with the assessment of blood flow of the intestinal wall in the mode of CDI. Patients were divided on the basis of intraoperative data into 2 groups. The first group: 63 (54.8%) patients with signs of ischemia of the strangulated loop of the intestine. The second group consisted of 21 (18.1%) patients in whom intestinal necrosis was detected. The comparison group included 31 (26.7%) patients with adhesive small bowel obstruction without intestinal strangulation.Results. The most informative signs of ischemia of the strangulated intestine of the loop are infiltrative changes of its mesentery. In the second and third groups 9 (14.3%) and 12 (57.1%) participants, respectively, showed severity of intestinal ischemia, compared with 1 participant (3.2%) in the first group. The next informative criterion is the thickening of more than 0.4 cm and edema of the intestinal wall. In the second and third groups 30 (47.6%) and 14 (66.6%), in the comparison group 4 (12.9%), akinesis of the strangulated loop and paresis of the entire small intestine also directly correlated with intestinal ischemia. The absence of differentiation of intestinal wall layers occurs in (23.8%), the absence of blood flow in the intestinal wall in the CDI mode (19%), gas inclusions in the intestinal wall (4.3%).Conclusion. The assessment of sonographic symptoms allows to diagnose the presence of ischemic changes in the intestinal wall and perform surgery before the development of necrosis in the early period. In cases of late admission of the patient to the hospital, with the onset of intestinal necrosis and the associated erased clinical picture, ultrasound allows to establish indications for surgery before the development of peritonitis.

A 93-year-old patient underwent endoscopic treatment of perforated duodenal ulcer after previous laparoscopic suturing complicated by failure of sutured defect. A self-expanding nitinol stent with partial polyurethane coating was used. Positive effect of the treatment was noted. Further study of this method and its clinical introduction in case of favorable results can significantly reduce the incidence of complications and mortality in patients with perforated gastroduodenal ulcers.

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.

Seat belt syndrome is a triad of symptoms: body belt marks (hemorrhages, ecchymosis, abrasions on the abdominal wall), intra-abdominal trauma and spinal fractures in the thoracic and lumbar spine. The abdominal mark of a safety belt implies a complex diagnostic algorithm to exclude injury to the intraabdominal organs and the abdominal wall. The clinical picture of damage is not specific, which leads to errors in diagnosis or delays at the beginning of the examination protocol. A dynamic examination of the patient (ultrasound, CT, X-ray) is necessary. The damage to the abdominal wall with a seat belt, which entailed the development of septic complications, require long-term general and local treatment, additional diagnostic methods and surgical interventions.

Seat belt syndrome is a triad of symptoms: body belt marks (hemorrhages, ecchymosis, abrasions on the abdominal wall), intra-abdominal trauma and spinal fractures in the thoracic and lumbar spine. The abdominal mark of a safety belt implies a complex diagnostic algorithm to exclude injury to the intraabdominal organs and the abdominal wall. The clinical picture of damage is not specific, which leads to errors in diagnosis or delays at the beginning of the examination protocol. A dynamic examination of the patient (ultrasound, CT, X-ray) is necessary. The damage to the abdominal wall with a seat belt, which entailed the development of septic complications, require long-term general and local treatment, additional diagnostic methods and surgical interventions.

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.

AIM:To develop medical algorithms for reduction of morbidity and mortality in rare forms of mechanical intestinal obstruction.MATERIAL AND METHODS:17 patients with mechanical intestinal obstruction have been operated in Sklifosovsky Research Institute for Emergency Care for the period 2010 - 2016. There were 13 women and 4 men aged 56 (44,5-74,5) years on the average. Phytobezoar was detected in 7 patients (41.2%), tumor in 7 patients (41.2%) and gallstone ileus in 3 patients (17.6%).RESULTS:There were no complications in group 1. In group 2 postoperative complications occurred in 3 patients: gastrocnemius vein thrombosis followed by successful medication (Clavien-Dindo type II), abdominal abscess drained under ultrasonic control (Clavien-Dindo type IIIa) and 1 (8.3%) death (Clavien-Dindo type V). Postoperative mortality in group 2 was 8.3%.CONCLUSION:Despite small sample size and no statistically reliable results the advantages of minimally invasive access are obvious. However, further trials are required to ensure the reliability of the results.

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.

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 combined method of hernioplasty with the use of biologic and sunthetic implants has been worked out. 12 patients have been operated on: the "open" technique was used in 5 patients, the rest 7 have been operated on laparoscopically. The use of dura mater as an implant for hernioplasty allows avoiding tissue tension by muscle sheath plasty. By the combined use of the synthetic implant and dura mater plate, the latter assumes the mechanical load, preventing the hernia recurrence. Besides, the dura mater plate isolates the synthetic implant from the abdominal cavity and subcutaneous fat. No postoperative complications or lethal outcomes were registered.