OBJECTIVE:To demonstrate the results of endovascular intervention in patients with acute arterial mesenteric ischemia, while observing the indications developed in the clinic. MATERIAL AND METHODS:In total, endovascular approach in the treatment of acute mesenteric ischemia were used in 49 patients in the clinic. In compliance with the developed indications and criteria, endovascular intestinal revascularization was performed in 27 patients. Various endovascular intervention techniques were used (aspiration, balloon dilation, artery stenting and their combinations). Extracorporeal filtration techniques were used as a treatment for reperfusion syndrome after intestinal revascularization in 10 patients. RESULTS:Angiographic success in the form of complete restoration of the main blood flow in the basin of the superior mesenteric artery and its large branches was obtained in 85% of cases. Intestinal viability was preserved in 15 (56%) patients. After successful endovascular surgery, intestinal necrosis was diagnosed on laparoscopy in the remaining 12 (44%) patients, which required extensive (n=2) or non-extensive (n=10) resection. Postoperative mortality was 48% (13 patients). CONCLUSION:Endovascular surgery in acute mesenteric ischemia is an effective method of intestinal revascularization. To optimize the indications for these interventions, it is necessary to gain experience and conduct large-scale studies.

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.

Background. Traumatic brain injury (TBI) remains a big problem of modern neurosurgery, accompanied by high rates of disability and lethality. Venous thromboembolism (VTE) including venous thrombosis and pulmonary embolism (PE) plays a significant role in the structure of mortality in this pathology. Regimens and schemes of pharmacological prevention of VTE in TBI as well as corresponding preventative measures are not yet determined completely.Aim. To identify the frequency of VTE in patients with isolated moderate and severe TBI, and to evaluate the results of prevention and treatment of these complications in patients of this category.Materials and methods. Over a 3‑year period (from 2020 to 2023) 73 patients with isolated moderate and severe TBI (51 men and 22 women, mean age 61.0 ± 13.0 years) were treated in the V. M. Buyanov City Clinical Hospital. Of these, 31 patients received only conservative therapy, and 42 patients underwent surgery (craniotomy with hematoma removal, closed external hematoma drainage, and installation of intracranial pressure sensor). Ultrasound examination of the lower limb veins was performed at patient admission, then every 7 days until discharge from the hospital. Pharmacological prevention of VTE using low molecular weight heparin in non‑surgical patients was started after 1–2 days if computed tomography of the brain 24 h after admission showed no negative hematoma dynamics. Surgical patients were prescribed preventive medications 24 h after surgery if computed tomography confirmed intracranial hemostasis.Results. Venous thrombosis was detected in 22 (30.1 %) of 73 patients. PE complicated the underlying disease in 1 (1.4 %) case and was non‑fatal. There was no fatal PE in the study group. An increase of the initial intracranial hematoma volume occurred in 3 (4.1 %) patients, in 2 (2.8 %) patients the recurrence of hemorrhage occurred before the beginning of heparin administration, and in 1 (1.4 %) case against the background of therapeutic doses of anticoagulants prescribed for venous thrombosis. In the majority of cases (82.0 %; 18 of 22 patients) thromboses were localized in deep veins of the lower leg and were asymptomatic. Intrahospital mortality was 23.3 % (17 patients), all lethal outcomes were due to the course of traumatic brain disease.Conclusion. VTE is a frequent complication of TBI with intracranial hemorrhage. Regular ultrasound diagnostics makes it possible to diagnose asymptomatic distal venous thrombosis in a timely manner and to prescribe therapeutic doses of low molecular weight heparin in time which in turn allows to avoid fatal PE. Currently, there are no clear domestic recommendations for the prevention and, most importantly, for the treatment of these complications in patients with isolated moderate and severe TBI, which requires further active study of this problem.

AIM OF STUDY. To compare the results of carotid endarterectomy performed at different times (1st, 2nd and 3rd week) of the acute period of ischemic stroke.MATERIAL AND METHODS. In the acute period of ischemic stroke (1–21 days), 92 patients with symptomatic stenosis of the internal carotid artery of 50% or more were operated on using carotid endarterectomy . There were 66 men and 26 women. The average age was 65.7±8.4 years. All patients were divided into three groups depending on the timing of the operation: Group 1, where the operation was performed on the 1st week of stroke (n=48); Group 2, where the operation was performed on the 2nd week after stroke (n=28); Group 3, where carotid endarterectomy was performed on the 3rd week after stroke (n=16). In-hospital endpoints of the study in each group were ipsilateral ischemic stroke, any other stroke (contralateral ischemic or hemorrhagic), myocardial infarction, wound hemorrhagic complications requiring repeated operation and surgical hemostasis, death, and major adverse cardiovascular events (stroke + myocardial infarction + fatal outcome).RESULTS. There were no postoperative ipsilateral ischemic strokes, myocardial infarctions, or deaths in the study group (92 patients). In the overall group of patients (n = 92), the incidence of any postoperative stroke was 2.2% (2 patients): one hemorrhagic stroke on the side of carotid endarterectomy (group 3) and one contralateral ischemic stroke on the first postoperative day in a patient with bilateral critical stenosis of the internal carotid artery (group 1). Postoperative wound hematoma, which required revision and bleeding arrest in the early postoperative period, developed in one (1.1%) patient in Group 1. The overall incidence of major adverse cardiovascular events was 2.2% or 2 patients. In all three groups, a statistically significant and positive effect in regression of the initial neurological deficit was obtained at discharge. In patients operated in the first week after stroke, the neurological deficit at discharge according to the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale was the lowest. In general, 31.3%, 17.9% and 12.5% of patients in groups 1, 2 and 3 were discharged without neurological deficit (0 points according to the NIHSS scale), respectively.CONCLUSIONS. Carotid endarterectomy performed in the acute period of ischemic stroke is a safe surgical intervention in the prevention of recurrent ipsilateral ischemic events. The most positive neurological dynamics and the least neurological deficit at discharge were achieved after operations performed in the first week of ischemic stroke.

Primary hyperthyroidism is a common endocrine pathology, with parathyroid adenoma being the most frequent cause of this condition. A number of patients have deep-seated mediastinal adenomas which poses certain challenges in diagnostics and impose serious limitations for performing a surgery using a traditional transcervical approach. Nonetheless, the combination of modern tools of topical diagnostic investigations along with mini-invasive surgical methods allow to perform a radical operation in this group of patients with reduced injury rate. In this article we present a clinical case of surgical treatment of a 65-Year-Old female patient with primary hyperthyroidism caused by retrosternal parathyroid adenoma located in the aortic-pulmonal window. Preliminary diagnosis was based on Chest Computed Tomography (CCT scan) and technetium-99mTC scintigraphy. Considering complex anatomical and topographical location of the tumour it was decided to perform a thoracoscopic parathyroidectomy. The postoperative period was uneventful, with the laboratory values of parathormone being within reference range after the surgery. On the third day after the operation the patient was discharged. Further follow-up has not shown any signs of relapse.

BACKGROUND:One of the causes of acute intestinal ischemia and necrosis is mesenteric venous thrombosis or its larger-scale and prognostically less favorable variant, i. e., portomesenteric thrombosis. Despite the fact that the main method of treatment for mesenteric venous thrombosis is anticoagulant therapy, the necessity to perform the operation of intestinal resection for mesenteric venous thrombosis remains high, accounting for 17-91%, with the pathology-related mortality amounting to 41%. OBJECTIVE:This study was aimed at analyzing possibilities of diagnostic methods and the use of various strategies in treatment of patients with massive mesenteric and portomesenteric venous thrombosis. PATIENTS AND METHODS:The work was based on therapeutic outcomes in a total of 25 patients with mesenteric venous thrombosis. Of these, 19 patients underwent conservative treatment and 6 patients were subjected to resection of the necrotized intestine. The patients' age ranged from 33 to 92 years (mean 63±11 years). There were 15 (60%) men and 10 (40%) women. The diagnosis of mesenteric venous thrombosis was verified by means of the following instrumental diagnostic methods: laparoscopy (n=10), laparotomy (n=6), and computed tomography of the abdominal cavity with intravenous contrast enhancement (n=9). RESULTS AND DISCUSSION:Amongst all patients admitted to our clinic with acute intestinal ischemia over a 12-year period, mesenteric venous thrombosis accounted for 7.7%. The need for small bowel resection appeared in 6 patients, with 5 of them requiring further programmed relaparotomy and formation of an anastomosis. All those 6 patients had presented with a clinical picture of peritonitis. The remaining 19 patients received anticoagulant therapy alone. 7 of the 25 patients with mesenteric venous thrombosis died, with the overall in-hospital mortality thus amounting to 28%. The mortality rate in the group of operated-on patients and in the group of conservative treatment amounted to 50% and 21%, respectively (p=0.169). The volume and spread of venous thrombosis in the portomesenteric venous system also significantly influenced the lethality rate. Amongst 14 patients having developed thrombosis only in the system of the superior mesenteric vein, mortality was 21%. In those with massive portomesenteric venous thrombosis (11 patients), mortality was 36% (p=0.409). CONCLUSION:Intravenous contrast-enhanced computed tomography and diagnostic laparoscopy should be recognized as the main methods of making the diagnosis of mesenteric venous thrombosis. Anticoagulant therapy may prevent the development of intestinal venous gangrene and improve therapeutic outcomes in patients with mesenteric venous thrombosis.

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.

Objective. The aim of this study is to assess the safety of the use of regional anesthesia for performing carotid endarterectomy (CEA) in patients in the acute phase of ischemic stroke.Material and methods. The study included 66 patients in the acute phase of ischemic stroke (atherothrom-botic subtype according to the TOAST classification) who underwent carotid endarterectomy. The inclusion criteria for the study were as follows: acute phase of atherothrombotic ischemic stroke (first 28 days), ipsilateral symptomatic ≥ 50% stenosis of the internal carotid artery, 1-4 points neurological deficit according to the modified Rankin Scale (mRS), 1-13 points neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), size of the cerebral ischemic lesion ≤ 4 cm. This single-center prospective cohort study compared two anesthetic approaches, regional anesthesia (RA, 46 patients) and general anesthesia (GA, 20 patients). The RA techniques included ultrasound-guided superficial and deep cervical plexus blocks on the side of the surgery.Results. The study found no significant differences in the baseline patient characteristics, surgery techniques and clinical outcomes between the groups. There were no neurological or cardiovascular toxic reactions to the local anesthetics. Conversions from RA to GA were not performed. In the RA group, recurrent ipsilateral ischemic strokes, myocardial infarctions, wound hemorrhagic complications and lethal outcomes did not occur.Conclusion. This pilot study has demonstrated the safety of RA for performing CEA in patients in the acute phase of ischemic stroke. RA provides adequate neuromonitoring and timely intraoperative recognition of «new» ischemic complications. To compare the efficacy of RA and GA for performing CEA in patients with acute ischemic stroke, large randomized controlled trials are needed.

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.

The authors report endovascular treatment of acute thromboembolic occlusion of superior mesenteric artery in a 75-year-old patient whose postoperative period was complicated by massive reperfusion and translocation syndrome. Contrast-enhanced CT in 12 hours after successful thrombectomy from superior mesenteric artery revealed CT signs of irreversible bowel lesion, i.e. gas in hepatic veins, intestinal wall and mesenteric veins, bowel wall thinning. In addition, CT revealed extremely rare sign of severe acute mesenteric ischemia (gas in superior mesenteric artery and celiac axis). We found no description of gas in celiac axis following acute mesenteric ischemia in available literature.

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.

This review article presents an analysis of the world literature devoted to treating patients with tandem stenosis of the intra- and extra-cranial parts of the internal carotid artery. We indicate the frequency of tandem lesion occurrence and describe the applied instrumental methods of its diagnosis. The review demonstrates the results of tandem stenosis surgical treatment in both early and more modern studies and describes the possibilities of endovascular correction of extra- and intra-cranial stenosis of the internal carotid artery. The authors emphasise the lack of large-scale studies — including randomised studies — regarding combined, tandem carotid stenosis and the need for further studies.Received 30 March 2021. Revised 8 May 2021. Accepted 11 May 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflicts of interests.Contribution of the authors: The authors contributed equally to this article.

The manuscript is devoted to world experience of carotid endarterectomy and carotid artery stenting in advanced age patients. Some authors report the advantages of endovascular surgery in elderly patients while the others prefer carotid endarterectomy. Senile patients (75-80 years old) with asymptomatic internal carotid artery stenosis is one of the most difficult group for the management. This is due to a more complex assessment of perioperative surgical risk, high incidence of complicated atherosclerotic plaques in carotid arteries and dubious benefits of surgery considering short life expectancy and severe comorbidities. Accumulation of experience in the management of advanced age patients should be valuable for either optimizing or individualizing surgical strategy.

OBJECTIVE:To evaluate the effectiveness and safety of various heparin therapy regimens for venous thromboembolic complications in patients with acute cerebral circulatory disorders of the hemorrhagic type.MATERIAL AND METHODS:In a prospective single-center study, treatment results of 62 patients with hypertensive brain hematoma were analyzed. All patients were divided into two comparable groups: the group of «very early» prophylactic heparin therapy or the first 48 hours from the moment of the disease (n=35) and the group of «early» prophylactic heparin therapy, or later than 48 hours from the moment of the intracerebral hematoma development (n=27). The end points of the study were: venous thrombosis, pulmonary embolism (fatal and non-fatal), recurrent intracerebral hemorrhage, other clinically significant hemorrhagic complications, and intrahospital mortality.RESULTS:In the group of «very early» and «early» prophylactic heparin therapy, the results were as follows: venous thrombosis 22.9% vs. 29.6% (p=0.36), total rate of PE 2.9% vs. 11.1% (p=0.03), nonfatal PE 0% vs. 7.4% (p=0.007), fatal PE 2.9% vs. 3.7% (p=0.76), recurrent intracerebral hemorrhage and other hemorrhagic complications 0% in both groups, intrahospital mortality was 54.3% versus 48.1% (p=0.54).CONCLUSION:The earliest administration of direct anticoagulants in prophylactic doses in patients with hemorrhagic stroke leads to the decrease in the frequency of venous thrombosis and thromboembolic complications, without being accompanied by the development of repeated intracranial and other hemorrhagic events.

The paper presents the latest data on applications of various types of endovascular interventions on the superior mesenteric artery. Efficiency of a number of devices for reperfusion therapy with acute mesenteric ischemia is described.The results of works with the largest samples of patients (frequency of laparotomy, intestinal resection and lethality), timing of endovascular surgery and comparative results of open and endovascular operations in the basin of the superior mesenteric artery are also discussed.

OBJECTIVE:To evaluate the results of endovascular treatment of patients with ischemic stroke caused by acute tandem occlusion of the internal carotid and middle cerebral arteries (ICA and MCA).MATERIAL AND METHODS:Endovascular intervention was performed in 8 patients with tandem occlusion of ICA and MCA. The neurological deficit on admission was 17.4±5.6 NIHSS points and the average ASPECTS score was 9.5±0.8. The time from the onset of neurological symptoms to reperfusion was 224±68 min. Thrombolytic therapy was initiated before brain revascularization and continued intraoperatively in 4 out of 8 patients. ICA stenting after aspiration thrombectomy was required in 6 patients. Both antegrade (n=4) and retrograde (n=2) methods of brain revascularization were used.RESULTS:The rate of detection of tandem lesion in patients with ischemic stroke who underwent endovascular treatment was 5.4%. Technical success in restoring blood flow in the ICA basin at extra-and intra-cranial levels (mTICI 2b/3) was achieved in 7 (87.5%) patients. Intracranial hemorrhagic complications that affected the outcome of the disease were clinically significant in 25% of patients (n=2). The mortality rate was 37.5% (n=3). A satisfactory clinical result (a deficit of 0-2 mRS scores) was achieved at discharge in one of 5 surviving patients.CONCLUSION:Further studies of choosing the optimal surgical tactics for tandem occlusion of ICA and MCA, taking into account its effectiveness and safety, are need.

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.

Aim The purpose of this study was to analyse the world literature dedicated to the problem concerning treatment of a combination of internal carotid artery stenosis at the extracranial level and an arterial aneurysm of the brain, as well as to demonstrate own results of surgical treatment of patients presenting with this concomitant pathology of the carotid basin. Patients and methods From 2013 to 2019, a clinical course of combined pathology of the basin of the internal carotid artery (an intracranial aneurysm and stenosis of the internal carotid artery at the extracranial level) was revealed in 35 of 1638 examined patients. There were ten men and 25 women, with a mean age of 66±7 years. In all the 35 patients, intracranial aneurysms appeared to be asymptomatic and were revealed during diagnosis of an atherosclerotic lesion of the internal carotid artery. Fifteen (43%) of the 35 patients were operated on. A two-stage surgical approach was used in 2 patients with ipsilateral location of the cerebral aneurysm and stenosis of the internal carotid artery: the first stage consisted in clipping of the arterial aneurysm, with stage 2 being carotid endarterectomy. A vascular stage alone (carotid endarterectomy or stenting of the internal carotid artery) was carried out in 9 patients, with a neurosurgical stage alone (clipping of the aneurysm) in 4 patients. Results The incidence of internal carotid artery stenosis with an arterial cerebral aneurysm, according to our findings, amounted to 2.1%. In the group of surgical treatment, in 1 case (6.7%) after stenting of the symptomatic stenosis of the internal carotid artery a female patient with an ipsilateral asymptomatic aneurysm of the middle cerebral artery intraoperatively developed 'minor' ischaemic stroke. Neither perioperative aneurysmal ruptures nor lethal outcomes were observed in the group of patients subjected to surgical interventions. Conclusion An individual tactical approach to patients presenting with a combination of a cerebral aneurysm and internal carotid artery stenosis at the extracranial level made it possible at this stage of the work to avoid both intracranial haemorrhagic complications and lethal outcomes. The frequency of perioperative ischaemic cerebral events amounted to 6.7%. Further collection of the clinical material is needed to work out an optimal surgical policy in a combined lesion of the extra- and intracranial basin of the internal carotid artery.