The OBJECTIVE was to improve the treatment of victims with liver injury in blunt abdominal trauma by using minimally invasive methods of diagnosis and treatment. METHODS AND MATERIALS. We analyzed the treatment results of 76 patients with blunt liver injuries using traditional treatment and 78 patients who were treated with the developed new algorithm. In the second group, patients with ultrasound signs of liver injuries and stable hemodynamics (BP>90 mm Hg) underwent MSCT with intravenous contrast. In the absence of ongoing bleeding signs, conservative treatment was carried out; if they were detected, angiography with selective angioembolization was performed. RESULTS. There were no statistically significant differences in gender, age, mechanism and severity of injury (according to the ISS, Tsibin, VPH-P scales) and severity of the condition (VPH-SP) between the patients of the groups. More than half (52.3 %) of the victims of the main group were treated without abdominal surgery. By using the proposed algorithm in patients with stable hemodynamics, laparocentesis gave way to less traumatic and more accurate methods of diagnosing intra-abdominal bleedings. All laparotomies in the main group were performed for other abdominal injuries. In the victims of both groups, video laparoscopy was diagnostic in nature. One patient of the main group with liver injury of IV degree according to the AAST scale with ongoing intraparenchymatous and intraperitoneal bleeding underwent endovascular hemostasis. CONCLUSION. The use of non-operative and minimally invasive treatment of hemodynamically stable patients with liver ruptures in isolated and combined blunt abdominal trauma allowed to reduce the number of the performed diagnostic video laparoscopies by 24 %, laparotomies by 29 %, and completely abandon laparocentesis as a diagnostic method, reduce mortality rate by 4.6% and the duration of inpatient treatment of surviving patients for 4 days.

Hepatic artery thrombosis (HAT) following liver transplantation (LT) is a severe life-threatening complication that can lead to graft loss and mortality after LT. According to different reports, HAT incidence ranges from 2% to 9%. Modern endovascular and radiosurgical techniques allow for minimally invasive liver graft revascularization. Nonetheless, a major consequence of even a successful revascularization is ischemic cholangiopathy, which can lead to ischemic biliary strictures and anastomotic leak. The paper presents a clinical case of long-term complex treatment of combined complications of LT using minimally invasive endovascular and endoscopic techniques.

Background. Almost half of the patients with ankle fractures have fracture of the posterior malleolus. Conclusions of the existing studies are contradictory and do not provide a decisive answer to the question of the need for fixation of the posterior tibial fragment. Aim of the study — to compare the radiologic and functional outcomes of osteosynthesis of the posterior tibial fragment in unstable ankle fractures using closed reduction and minimally invasive technique and direct open reduction using posterolateral and posteromedial surgical approaches. Methods. Prospective multicenter study enrolled 132 patients with complex ankle and posterior malleolus fractures. They were divided into three groups depending on the technique of fixation of posterior tibia. Functional and radiologic results of treatment were assessed at 12, 24, and 48 weeks after osteosynthesis. The AOFAS and Neer scales were used. Results. Bone union occurred in all patients at an average of 8.3±0.8 weeks after surgery. Analysis of postoperative CT scans showed that the use of posterior approaches provided statistically significantly more precise reduction of the fragments of posterior tibia. Functional results of patients of the second (posterolateral approach) and third (posteromedial approach) groups at 24 and 48 weeks of follow-up were statistically significantly superior to those of the first group. The median AOFAS score at 48 weeks of follow-up was 86 for group 2 patients and 90 — for group 3. The median scores on the Neer scale were 88 and 94 points respectively. Conclusion. Posterior approaches in the surgical treatment of patients with complex ankle and posterior malleolus fractures allow for more precise fragment open reduction compared to closed one. These patients also show better mid-term functional outcomes.

Aim: Studying, statistical processing and classification of complications that arose after breast augmentation with silicone gel implants. Material and methods. Complex clinic-radiological examination of 590 women after a breast augmentation with silicone gel implants was performed. Various complications after breast augmentation were diagnosed in 223 (37.8%) cases. Radiology examination included X-ray mammography, ultrasound and magnetic resonance imaging (X-ray, US and MRI). Results. The analysis of the data obtained allowed us to divide all the identified complications of breast augmentation into 3 groups depending on the etiology and pathogenesis of their occurrence. Conclusion. The proposed classification of complications of breast augmentation using silicone gel implants, based on their etiology and pathogenesis, will allow to choose the optimal treatment method predicting its efficiency.

ФГБОУ ВО Санкт-Петербургский государственный университет, Санкт-Петербург; 3 malleolus simultaneously via the same approach reduces intraoperative soft tissue trauma.In modern traumatology open reduction and internal fixation of posterior malleolus is performed regardless of the fragment size.This is due to the fact that the displacement of intra-articular fragments is a factor typically leading to worse functional outcomes and can be eliminated by the surgeon.Posteromedial and posterolateral approaches provide good visualization of distal posterior tibia.Notably execution of these approaches is technically possible and is not associated with high risk of injury to vascular-nervous bundle and other anatomic structures.

The article presents the experience of treating wounded K., 29 years old, who, as a result of the suicide bombing of a homemade shell-free explosive device in a moving car of the St. Petersburg Metro 03.04.2017 received a severe mine-explosive combined wound to the head, chest and limbs with a fragmented blind skull. The trauma was accompanied by brain damage, a fracture of the cranial vault bones, lungs contusion, and fragmented fracture of the right tibia bones. The patient underwent sequential bifrontal decompressive craniotomy, external fixation of the right shin bones fractures, blocked intramedullary osteosynthesis of the latter, dura mater plasty, cranioplasty with a titanium plate after its computer modeling. The complex treatment allowed the patient to be discharged from the hospital after 4 months in a satisfactory condition.

Introduction . In megacities, the use of organs obtained from those who died as a result of sudden out-of-hospital cardiac arrest (OHCA) for transplantation is one of the promising ways of addressing the problem of organ donor shortage. In St. Petersburg, the model of transition from life support via extracorporeal membrane oxygenation (ECMO) of patients after OHCA to ECMO life support for organs of potential donors was tested for the first time. Materials and methods . In order to implement the program, round-the-clock ECMO and transplantation teams were organized at the inpatient emergency ward of Pavlov First St. Petersburg State Medical University. Interaction with the St. Petersburg City Emergency Station, St. Petersburg was established. The protocol of work with potential donors brought to the hospital after a sudden circulatory arrest was developed, approved by the ethics committee, and implemented in clinical practice. This was the first in Russia and in international practice. Between 2017 and 2020, 67 patients with sudden OHCA were brought to the inpatient emergency ward. In 4 (5.97%) cases, advanced cardiovascular life support was successful, and 11 (16.42%) patients became effective donors. Mortality among this group of patients without subsequent postmortem donation was 77.61% (52 patients). Results . Liver transplantation from non-heart-beating donors (NHBDs) whose blood circulation was restored by ECMO (ECMO NHBD) was performed in 5 recipients who were in severe condition against the background of liver failure. In 1 (20%) case, there was severe liver allograft dysfunction for 33 days with subsequent complete restoration of function. Kidney transplantation was performed in 22 patients. Immediate graft function occurred in 10 (45.45%), while delayed function occurred in 12 (54.55%) patients. Kidney graft survival was 86.4%, kidney graft recipient survival was 95.5%, liver graft recipient survival was 80%, and the follow-up period was 24.1 ± 7.15 months. Conclusion . The use of ECMO to save the lives of patients with sudden OHCA can be implemented in conditions of a high degree of organization and synchronization of the work of the city emergency medical station and the emergency department of a multidisciplinary hospital. If cardiopulmonary resuscitation with ECMO (ECMO CPR) fails, it is possible to launch the ECMO NHBD donor program. Long-term outcomes of liver and kidney transplantation from ECMO NHBD are consistent with those using organs from brain-dead donors. Widespread implementation of the new organ donation model will increase the availability of transplant care.

ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ МНОЖЕСТВЕННЫХ ПЕРЕЛОМОВ РЕБЕРБеленький И.Г. 1 , Майоров Б.А. 2,3, Исаев М.В. 4 , Тулупов А

Представлен случай успешной эндоваскулярной механической тромбэктомии, выполненной первичным ретроградным дистальным доступом у пациентки с внутристентовым подострым тромбозом бедренноподколенного сегмента. Обоснован выбор тактики и описаны особенности эндоваскулярной реваскуляризации.

The Objective was to assess and improve the treatment results of victims with spleen injury in blunt abdominal trauma by using high-tech minimally invasive methods of diagnosis and treatment.Methods and materials. The article analyzed the results of treatment of 86 patients with isolated and combined blunt spleen injuries who received conventional surgery, and 52 similar patients who were treated in accordance with the new algorithm. This algorithm included conventional splenectomy for unstable hemodynamics and non-operative and minimally invasive management for stable hemodynamics after MSCT. In the absence of CT signs of ongoing bleeding, non-operative management was performed, if ongoing bleeding signs were detected, angiography with selective angioembolization was performed.Results. In both groups, most of the victims with blunt spleen injury were admitted to the trauma center after traffic accidents and catatraumas. There were no statistically significant differences in the injury severity (ISS, Tsibin scales), and the condition severity (VPH-SP). The tactics of non-operative and minimally invasive management was applied in 31 patients of the prospective group with stable hemodynamics. Non-operative management was performed on 16 patients of the prospective group. Four patients of this group underwent angiography and selective embolization of the branches of the splenic artery. In the retrospective group, there was a greater number of local complications compared to the prospective group (p=0.006). The decrease in the number of visceral and generalized complications was statistically insignificant (p>0.05). In the retrospective group, 21 victims died. Of these, 12 patients died from severe combined trauma and massive blood loss during the first 24 hours. In the prospective group, the total number of deaths was 10 patients. Of these, 6 died from polytrauma with acute massive blood loss, 1 – from severe traumatic brain injury, 1 – from PE, 2 – from sepsis. In the prospective group, among the patients with stable hemodynamics who had conservative treatment of abdominal trauma, 2 deaths were observed in the long-term period due to severe traumatic brain injury and PE.Conclusion. Organ-preserving management was carried out in 26 of 52 (50 %) patients, the number of performed diagnostic laparocenteses was reduced by 50.6 %, laparoscopies – by 16.5 %, laparotomies – by 60.7 %, the duration of inpatient treatment of surviving patients was more than for 7 days, mortality – by 5.2 %.

ВОЗМОЖНОСТИ МАГНИТНО-РЕЗОНАНСНОЙ ТОМОГРАФИИ В ДИАГНОСТИКЕ ПОВРЕЖДЕНИЙ СПИННОГО МОЗГА У ПОСТРАДАВШИХ С ТРАВМОЙ ШЕЙНОГО ОТДЕЛА ПОЗВОНОЧНИКАТихова К

A case of acute oral poisoning by 1.4-butanediol, complicated by the development of severe hypoxia in a 34-year-old patient actively engaged in bodybuilding, is presented. The psychoactive substance was used by the patient to increase sexual activity and physical stamina. The duration of systematic daily intake was 4 months. The toxicogenic stage of acute poisoning was caused by a single dose of 50 ml of undiluted 13% 1.4-butanediol together with ethanol, manifested by convulsive syndrome, depression of consciousness to the level of coma II, acute respiratory failure with aspiration syndrome, respiratory acidosis (pH 7.22; partial pressure carbon dioxide 61.2 mm Hg), lactic acidosis up to 7 mmol / L, hyperammonemia up to 240 μmol / L, cerebral edema (decrease in white matter density to 21.6 ± 1.7 HU units), loss of vascular tone resistance (pareso arterioles) and a significant increase in cerebral blood flow rate to 115 ± 20.1 ml / 100 g per minute, increasing the volume of extracellular fluid (+ 130% of the proper volumes). Intensive therapy was complex, including infusion and detoxification therapy, correction of acid-base disorders, hypoxic disorders by using a substrate antihypoxant (Cytoflavin) in a daily dosage of 0.57 ml / kg body weight daily, for 9 days. The article discusses the toxicokinetics and toxicodynamics of 1.4-butanediol, radiation diagnostics and the clinical picture of acute poisoning, the features of its course, and pathogenetic approaches to therapy.

A three-compartment heart - a severe congenital defect, can develop after genetic mutation or teratogenic influence on fetus at early stages of embryogenesis. According to the literary data, the survival of such patients without surgery is 6-7 %. This publication demonstrates clinical case of the patient who has single ventricle of the heart and lived up to 56 without surgery.

The article deals with the results of radiological and clinical laboratory testing of 108 victims treated in «St. Petersburg research Institute of emergency care named after I. I. Dzhanelidze», in the period from 2015 to 2017, with associated trauma of the spine. The patients developed suppurative-inflammatory diseases and their complications. CT diagnosis of purulent-inflammatory diseases of the spine combined injury. In addition, the article presents literature data about the use of radiologic methods of examination (x-ray, computed tomography, magnetic resonance imaging) purulent-inflammatory diseases of the spine and their complications.

Наблюдения из практики 74 Частота разрывов трахеи при закрытой травме груди составляет от 0,5 до 0,9 %, а главных и долевых бронхов -от 2 до 5 % [1-3].Летальность при данной патологии достигает 50 % [1], что связано с высокоэнергетическим воздействием травмирующей силы сразу на несколько частей тела пострадавшего, тяжестью торакальных и внеторакальных повреждений, быстрым возникновением жизнеугрожающих состояний и т. д.Все это делает проблему быстрой диагностики и неотложного хирургического лечения таких повреждений особенно актуальной.Приводим наше клиническое наблюдение.Пострадавший З., 25 лет (водитель мотороллера), в тяжелом состоянии доставлен в противошоковую операционную нашего института 09.05.2014 г. через 35 мин после лобового столкновения с препятствием на высокой скорости.Сознание отсутствует, клокочущее дыхание с частотой около 40 в мин, выраженная эмфизема мягких тканей шеи и верхней половины груди с обеих сторон.После проведения спиральной компьютерной томографии (СКТ) и фибробронхоскопии установлен диагноз: «Тяжелая сочетанная травма головы, груди и позвоночника.Закрытая черепно-мозговая травма.Ушиб головного мозга легкой степени.Закрытый двойной перелом нижней челюсти в области 31-32 зубов и угла.Закрытая травма груди.Разрыв бифуркации трахеи.Эмфизема средостения, мягких тканей шеи и грудной стенки (рис.1).Множественные ушибы и ссадины грудной стенки.

Aim. To study the possibility of using minimally invasive interventions for pancreatic pseudocysts complicated by perforation and diffuse enzymatic peritonitis. Material and Methods. We analyzed the results of treatment of 298 patients with pancreatic pseudocysts inclyding 119 cases of pancreatic pseudocysts complicated by perforation and diffuse enzymatic peritonitis. To determine the most effective surgical method in treatment of pancreatic pseudocysts complicated by perforation and diffuse enzymatic peritonitis combination of minimally invasive procedures (laparocentesis, laparoscopy) for the relief of enzymatic peritonitis followed by ultrasound-assisted pseudocysts drainage and traditional laparotomy with external drainage of pancreatic pseudocyst were compared. Results. In order to optimize the diagnostic search 57 diagnostic features (clinical, laboratory, instrumental) recorded in 119 patients were selected. After correlation analysis features having moderate or strong association with the occurrence of pancreatic pseudocyst complicated by perforation were selected. Diagnostic scale was developed based on these symptoms. Effectiveness of different methods of surgical treatment of pancreatic pseudocysts complicated by perforation and diffuse enzymatic peritonitis was evaluated according to incidence of sepsis and mortality rate. The use of minimally invasive techniques has reduced the incidence of sepsis from 18.8% to 5.9%, mortality from 9.4% to 2.9%. Conclusion. Diagnostic scale consisting of 5 signs that allows to verify pancreatic pseudocyst perforation with the probability near 95.8% was developed. Method of choice for treatment of enzymatic peritonitis is remedial laparoscopy (laparocentesis). External drainage of pancreatic pseudocysts is advisable to carry out under ultrasound guidance. Remedial laparotomy is indicated if minimally invasive approach is ineffective.

Aim. To develop more effective methods of surgical treatment of patients with purulent-necrotic parapancreatitis. Material and Methods. Treatment of 819 patients with purulentnecrotic parapancreatitis was analyzed. The volume of pancreatic necrosis and extent of purulent-necrotic parapancreatitis were determined according to multispiral computed tomographic angiography or magnetic resonance imaging, as well as during surgery or autopsy. Different surgical methods were compared depending on time and type of surgery. Effectiveness was estimated according to incidence of complications, severe sepsis and mortality rate. Conclusion. Minimally invasive drainage under x-ray guidance with step-by-step replacement of drains to larger diameter followed by aspiration and/or instrumental necrosectomy is preferable in treatment of purulent-necrotic parapancreatitis. Laparotomy with necrosectomy are ad-visable if minimally invasive procedures are ineffective.