[Results of 300 pancreatic duct stenting in acute pancreatitis]

OBJECTIVE

To analyze the results of pancreatic duct stenting in moderate and severe forms of pancreatitis.

MATERIAL AND METHODS

Pancreatic duct stenting in 300 patients with acute pancreatitis was analyzed. Examination and treatment were carried out in accordance with national clinical guidelines for acute pancreatitis (2015).

RESULTS

Pancreatic duct stenting was performed in 300 patients with moderate and severe forms of pancreatitis (according to APACHE II) in the first 8-72 hours after the onset of the disease. Plastic stent sizes range from 4 to 7 cm in length and 5 to 7 Fr in diameter. Infection with pancreonecrosis occurred in 22 (7.3%) of 300 patients in the main group, and 20% of 150 patients in the control group. Mortality was 16 (5.3%) in the main group, and 24 (16%) - in the control group.

CONCLUSIONS

Pancreatic stenting reduced infection by 3, 2 times, and mortality by 4 times. The dosage of Octreotide was personalized depending on the severity of the disease according to APACHE II.

[New possibilities in antibacterial treatment of intra-abdominal infections caused by multiresistant microflora]

AIM

To determine the place of new drugs with activity against multidrug resistant strains of microorganisms in the treatment of complicated intraabdominal infections.

MATERIAL AND METHODS

The incidence and distribution of pathogens isolated from intra-abdominal specimens in patients with intra-abdominal infections are analyzed.

RESULTS

The current situation on the growth of resistant strains among pathogens causing intra-abdominal infections is rewied. New combined drugs for the treatment of multidrug resistant infections - ceftolozane/tazobactam and ceftazidim/avibactam plus metronidazole, has been suggested. Their potential role in empiric and targeted antibacterial treatment of complicated intraabdominal infections is defined.

CONCLUSION

Taking into consideration local monitoring data and risk factors of multi resistant strains Ceftolozane/tazobactam in combination with metronidazole can be used in empiric regime of treatment. Due to the high activity on carbapenem resistant strains of Klebsiella pneumonia and the lack of alternatives, it is advisable to use Ceftazidim/avibactam for the targeted therapy.

[Compression anastomoses with nikelid-titanium rings in peritonitis]

AIM

To introduce into clinical practice compression anastomosis with nikelid-titanium rings (NTR) with shape memory in advanced peritonitis patients who need for intestinal resections.

MATERIAL AND METHODS

Seventy-six procedures of interintestinal anastomoses with NTR (Günter-Ziganshin implant) have been analyzed for the period 2011-2017. Interventions were carried out for widespread peritonitis. In all cases a unified technique of anastomosis was used by applying an implant in the form of a 'clerical clip'. There were following procedures: gastroenterostomy resection for its failure - 5; small intestine resection followed by interntestinal anastomosis - 36; ileotransverso- or colocolostomy - 35.

RESULTS

Mean time of enteroenterostomy was 2.6±0.98 min. If elective re-laparomy was supposed, laparostomy was formed followed by sanation within 48 hours. In 55% of patients 3-5-fold elective sanations were performed. Adequacy of compression anastomoses was assessed clinically according to the nature of drainage output and visually during redo surgery. There were 11 (14.5%) deaths: 9 (12%) patients had APACHE-II score over 20. Macro- and microscopic analysis of intestinal specimens and interintestinal anastomoses with nikelid-titanium rings showed complete impermeability and no visual defects. Microscopically neutrophilic leukocyte infiltration and increased number of fibroblasts were observed as the evidence of regenerative processes activation. Implant rejection time was 7.8±1.4 days.

CONCLUSION

The use of compression anastomoses in case of advanced peritonitis reduces the risk of anastomosis failure to 3% and decreases time of surgery that reduces intraoperative aggression and improves outcomes in patients with prognostically unfavorable outcomes.

[Radiofrequency ablation in comprehensive surgical treatment of patients with varicose veins of lower limbs]

Analysed herein are the results of using radiofrequency ablation (RFA) in comprehensive surgical treatment of patients presenting with varicose veins of the lower extremities. The study included a series of ninety-eight 28-to-60-year-old patients (with a total of 105 operations performed) suffering from varicose veins of the lower limbs. Of these, there were 10 men (10.3%) and 88 women (89.7%). Venous disease of clinical class C2 according to the CEAP classification was diagnosed in 80 patients, that of class C3 in 17, and that of class C4a in 1 patient. The procedure of RFA was performed by means of the VNUS device model RF62. The impact was exerted in an automatic mode, maintaining the catheter's temperature at 120° C during a 20-second treatment cycle for each 7 cm of the vein's length. In all cases, each 7-cm-long venous segment to be treated was acted upon 4 times. Forty-five patients after RFA underwent ultrasonographic monitoring performed first on POD 7 and then at 3, 6, 12 and 24 months. Recanalization of the trunk of the great saphenous vein (GSV) was registered in 3 (2.8%) cases at terms up to 3 months after the operation. In 2 cases recanalization turned out to be provoked by an incompetent perforant vein in the lower third of the femur. Seven (6.6%) patients with a large diameter of the great saphenous vein were found to develop post-closure hyperpigmentation which resolved spontaneously 8 months later. The remaining patients, with strict adherence to the indications for RFA, demonstrated complete obliteration of the vessel treated, with no recanalization observed ultrasonographically 10-12 months after the procedure. An additional experimental study with a morphological analysis confirmed appropriateness of carrying out four 20-second treatment cycles of RFA in each segment of the vein. A conclusion was made that RFA used in comprehensive surgical treatment for varicose veins of the lower limbs makes it possible to attain good therapeutic and cosmetic results that persist over time, if conducted in compliance with the mentioned fundamentally essential peculiarities of performing the procedure.

[Principles «cliff» pancreatic necrosis in a first-aid hospital]

INTRODUCTION

Pancreatic necrosis - acute surgical disease accompanying high rates of mortality and complications.

MATERIAL AND METHODS

The analysis of the treatment of 256 patients with pancreatic necrosis moderate and severe degrees. In the control group was conducted basic therapy, the main (n=158), which further were administered high doses of octreotide and endoscopic stenting of the main pancreatic duct to decrease the intraductal pressure, prevention and treatment of internal pancreatic fistula.

RESULTS AND DISCUSSION

In the main group in contrast to the control is marked by a more rapid decline in the level of amylase, lipase and leukocyte index of intoxication. The infection occurred in the basic - 11%, control 20% died in the study group - 3%, control - 9%.

[Role of correction of the syndrome of intestinal failure and abdominal hypertension in the prevention of infection of pancreatic necrosis]

The number of patients with acute pancreatitis and pancreatic necrosis has been steadily increasing. Mortality in infected pancreatic necrosis remains high.

AIM

To develop measures to prevent infection of pancreatic necrosis by timely correction of intra-abdominal hypertension and the syndrome of intestinal failure.

MATERIAL AND METHODS

Developed a package of measures, consisting of early intestinal lavage and enterosorption, intravenous highdoses of octreotide, epidural blockade, adequate detox and the start of effective antimicrobial therapy. Comparative evaluation of clinical, laboratory and instrumental data in the primary (n=50) and control (n=50) groups.

RESULTS

In the main group pancreatogenic sepsis occurred in 10%, control 18%. Mortality, respectively, was 8 and 16%.

[Analysis of the clinical application of epidermal growth factor ("Heberprot-P") and bioplastic material ("Collost") in treatment of skin and soft tissues defects in patients with diabetic foot syndrome]

RELEVANCE

Currently, there is increasing the number of diabetic foot patients with tissues defects. The local treatment of this pathology against the backdrop of diabetic angiopathy and polyneuropathy is a topical issue.

AIM

Treatment of wound defects in patients with neuroischemic form of diabetic foot syndrome; study of the effectiveness of collagen implants and gene-therapy technologies in wound closure.

MATERIAL AND METHODS

The comparative study was conducted for analyzing clinical effects of "Heberprot-P" and bioplastic material "Collost" on wound healing process in patients with verified diagnosis "diabetic foot syndrome" on the base of City Clinical Hospital №81(Moscow) and "Diabetic Foot" center (Kazan).

RESULTS

The article shows the availability, methodology, results of combination treatment of wound defects of lower limbs in DFS patients with gen-therapy methods and bioplastic materials based on native type I collagen.

CONCLUSION

The use of bioplastic materials based on native type I collagen for treatment of tissue defects in patients with diabetic foot is preferably than the use of epidermal growth factor.

[Clinical and instrumental diagnosis of concomitant venous dysfunction of the brain and extremities]

OBJECTIVE

to compare the frequency, preferential localization, severity of disturbances of venous circulation in the brain and limbs.

MATERIAL AND METHODS

Authors examined 140 people during 2009-2014: 20 apparently healthy people without clinical manifestations of extra-intracerebral venous insufficiency; 70 patients with clinical and instrumental signs of venous encephalopathy; 50 patients with varicose disease. History and clinical status were studied for all patients. In addition to physical methods, dynamic teletermography and triplex study of head, neck and extremity vessels were used.

RESULTS AND CONCLUSION

-A higher, than previously estimated, frequency of concomitant venous dysfunction of the brain and other locations was identified. It has been shown that venous insufficiency is a systemic pathology that affects venous circulation of the brain and extremities.

[Metabolic therapy with Actovegin in case of ischemic syndrome of limbs]

Actovegin was used in complex conservative and surgical treatment of lower limb chronic ischemia and diabetic foot syndrome in 200 patients. In 120 patients Actovegin was used in combination with reconstructive operations, angioplasty and stenting for preparation for surgery. In 80 patients Actovegin was used as independent method of treatment. In severe cases the medicine was injected intravenously 1000-2000 mg №10-15, and in mild degrees (IIA-IIB) - 400-800 mg intramuscularly with conversion on the tablet form in the future. Clinical picture, dopplerographic and microcirculatory data evidence about absolute safety, efficiency and comparative cheapness of the parenteral and enteral forms of Actovegine.

[Modern aspects of surgical treatment of combined gallstone disease and multifocal atherosclerosis aorta and its branches]

Lipidic metabolism infringements in the organism according with pathology of hepatocyts generates plural associated diseases. On prevalence and weight of metabolic damages the first place occupy cholelithiasis and atherosclerosis. Results of treatment of 752 patients with an atherosclerosis and cholelithiasis after surgical intervention was analysed. Basing on studying pathophysiological shifts at simultaneous cholelithiasis and atherosclerosis the algorithm of examination and tactics of the surgical treatment (simultaneouse or stage operations) are optimised, criteria for application of miniaccesses operations are specified.

[The prophylaxis and treatment of renal dysfunction by pancreatogenic endotoxicosis]

The treatment of 386 patients with the acute pancreatitis of various etiology was analyzed. Renal dysfunction was revealed in 243 (63%) of them. The prognostic factors of renal dysfunction were carried out. The timely application of the treatment scheme, including early extracorporal detoxification, permit the significant improvement of the treatment results of the acute pancreatitis.

[Cholelitiasis and age: tactic of surgical treatment]

We examined the resultants of treatment of 268 old patients. RESULTATES: The global demographic transition to an older population effects developing as well as developed coutries. Cganges in mitochondria with age, in body composition, in biliary tract gives to start for many diseases such as cholelitiasis. It has recommended the special surgic tactict of treatment such situations.

[Prevention and treatment of hepatorenal syndrome by acute intestinal obstruction]

Results of treatment were analyzed in 358 patients with acute bowel obstruction resulted from a variety of causes. Algorithm for control of liver and renal function disturbances in dynamics was estimated basing on the markers for hepatorenal failure. It is shown that differentiated approach to extracorporal detoxification combined with enterosorbtion and complex therapy allows preventing hepatorenal failure and decreasing lethality and terms of hospitalization.

[Outcomes of reconstructive operations in gerontological patients with diabetic foot syndrome]

The authors share herein their experience in treating a total of two hundred and forty-six patients presenting with an ischaemic form of diabetic foot syndrome on the background of secondary to occlusion ofmajor arteries. The patients'average age amounted to 74 years. According to the findings of ultrasonographic angioscanning and radiopaque aorto- arteriography, 62.3 % of the patients were diagnosed as having bilateral lesions of the arterial bed and only 37.7 % of the patients had lesions of the major vessels on one side. Reconstructive operations on the aortoiliac-femoral zone were performed in sixty-nine (28 %) patients, distal reconstruction in one hundred and twenty-seven (52 %) patients, multi-storey reconstructions in eighteen (7 %), and prolundoplasty in thirty-two (13 %) patients. Direct revascularization of lower extremities made it possible to save the supporting foot in 89 % of the patients undergoing proximal reconstructions and in 83 % of the patients subjected to distal reconstructions, as well as to decrease the rate of high amputations to 11 %.

[Distal reconstructions under critical lower limb ischemia in elderly patients]

Performong reconstructive operations on arteriae is the only way to avoid limb amputation in patients with critical limb ischemia. Whereas reconstructive manipulations on distal arteriae, especially in patients older then 75 years, are often entailed by thrombotic complications. High peripheric vessel resistance is considered to be the crucial factor of the bypass thrombosis. The conducted study demonstrated the efficacy of the use of vena saphena magna collateral tributaries as bypass unload collectors. Femoral distal autovenous in situ reconstruction decreases vessel resistance. Due to the arterial reconstruction with bypass unload using unligated autovenous tributaries the cumulative bypass patency was 75,1% a year after the procedure. 5-year cumulative bypass patency was 53,8%. 5 - year lethality was 28,6%.

[Correction of protein-energy metabolism in hepatorenal failure in surgical patients]

Infringements of a protein-energetic metabolism in hepatorenal complications are an actual problem in urgent surgery. 358 patients with a acute surgical pathology of intestines were analyzed, in 27.4% of patients infringements of functions of a liver and kidneys were revealed, necessity for normalization of the protein-energetic metabolism was noted in 47-70% of cases. As a result the scheme for protein-energetic metabolism correction was specified in depending of a kind of intestinal impassability and a degree of severity of surgical disease. The early correction of a protein-energetic metabolism in complex with the extracorporeal support methods of a detoxication has provided the expressed positive clinical effect.

[Role of reconstructive vascular surgery in patients with diabetic angiopathy]

Treatment results were analyzed in 1244 patients with diabetic angiopathy. 882 of them had necrotic suppurative affection of feet. Distal affection predominated among patients with neuroischemic form of diabetic foot syndrome. Combined affection of popliteofemoral and tibial-foot segments was revealed in 46.3% of observations. Stenosis of ileofemoral arterial segment was discovered in 40 (4.9%) patients, occlusion--in 27 (3.3%) patients. Reconstructive operations on aorta and great vessels were carried out to 520 patients; among them: aorto-femoral bifurcational bypass--to 38 patients, proximal popliteofemoral bypass--to 191 patients, distal popliteofemoral bypass--to 195 patients, tibiofemoral bypass--to 96 patients. Thrombosis in reconstruction region was observed in 41% of patients after popliteofemoral bypass including 16% in short-term period and 25% after a year. Low frequency of large amputations amounting 20.4% and low lethality (3.2%) indicated that bypass operations are highly effective in this group of patients.

[Hepato-renal syndrome and problem of protein-energy metabolism correction during urgent surgery of the abdominal organs]

Early connecting of hardware detoxification methods allow more efficient use of amino acid preparations for action. The use of efferent technology provides a full correction of protein and energy metabolism in the immediate surgical patients with complicated diseases of the abdominal cavity. This will reduce bed-day in patient and surgical mortality.

[Distal reconstructions with the autovein in situ for critical ischemia of lower extremities in elderly and senile patients]

The work was devoted to the problem of early and late thromboses of transplants at femoro-popliteal-tibial shunting. One of the main causes of frequent thromboses of the shunts was soundly shown to be high peripheral vascular resistance. The investigation has shown efficiency of using collaterals of the large subcutaneous vein as collectors of unloading the shunt in order to decrease the peripheral vascular resistance in femorodistal reconstruction with the autovein in the in situ position. In a year the cumulative passability of the shunt in the main group patients treated by the method of unloading the shunt with the help of non-ligated autovein collaterals made up 75.1% compared to 69.3% in patients of the group of comparison, and within 5 years 53.8% and 45.2% respectively. The index of safety of the extremity in a year was 81.5% in the main group patients, and 73.2% in control group patients, in 5 years 64% and 46.5% that demonstrated advantages of the method of leaving the functioning tributaries of the large subcutaneous vein intact after reconstruction.

[Diagnostic and management algorithm of acute pancreatitis]

The analysis of diagnostics and treatment of 602 patients with destructive pancreatitis has shown that definition of etiological and pathogenetic forms of pancreatitis defines strategy of treatment. In this way, patients with biliary pancreatitis require emergency operative treatment with use of endoscopic interventions without dependence from a stage of disease. To patients with alcoholic or alimentary pancreatitis in the stage of enzymatic toxemia conservative treatment should be spent only, until shock and/or delirium won't be reduced. Endoscopic retrograde cholangiopancreatography + endoscopic papillosphincterotomy with concrement removal from common bile duct--is the operation of choice in case of acute biliary pancreatitis at the first stage. Laparoscopic cholecystectomy is the operation of choice at the second stage of disease. At destructive pancreatitis of other origin in a stage of the infection or necrotic suppurative inflammation use of open and closed small invasive methods of intervention is most proved. Given tactics of treatment has allowed to lower severity of clinical course, frequency of complications and lethality.

[Purulent and necrotic complications of diabetic foot syndrome and their reflection in ICD-10 and standards of insurance medicine]

Treatment of 1046 patients with complicated forms of diabetic foot is analyzed. New classification of purulent and necrotic complication of diabetic foot is described. Current medical-economic standards for diabetic foot complicated forms are subjected to criticism. A new concept of the medical-economic standard is discussed.

[Clinical course, diagnosis and treatment of cholelithic intestinal obstruction]

Forty-seven cases of intestinal obstruction due to gall-stones are analyzed. All the patients underwent surgery including enterolithotomy with two-layer intestinal closure (40), passage of stone into cecum (3), intestinal resection due to wall necrosis (3). Two patients died due to intestinal perforation with retroperitoneal phlegmon and multiple organ failure. It is concluded that clinical symptoms of cholelithic intestinal obstruction are wave-like. Intestinal X-ray and ultrasonic examinations are the most informative for final diagnosis.

[Improvement of the quality of life of elderly patients with syndrome of "diabetic foot"]

The immediate and long-term results of treatment of 198 gerontological patients with the "diabetic foot" syndrome were analyzed from the standpoint of quality of life. The main group consists of 125 patients who underwent reconstructive operations. The control group includes 73 patients who underwent primary amputation. Reconstructive operations could save extremity in 87% of patients, amputation on the femur was made in 14 (11.2%), shank -in 2, amputation at the level of foot and toes in 67 (53.6%). Lethality after the primary amputation in the nearest period was 22% (16 patients). Overall survival within 5 years in the main group was 87.2%, lethality 12.2%; survival in the control group was 35.6%, lethality--64.4%. So, the reconstructive operations can considerably improve quality of life of gerontological patients in the nearest and long-term periods.

[Results of diabetic foot surgical treatment in gerontological patients]

The experience in surgical treatment of 1200 patients with an ischemic form of diabetic foot syndrome is analyzed. Surgical reconstruction of the major arteries was performed in 338 (28%) patients including reconstructive surgeries on the aorto-iliac-femoral segment--70 (21%), distal reconstructions--246 (73%), extra-anatomic reconstructions--22 (6%) patients. In distal reconstructions autovein in situ was used in 94, reversed autovein--in 82, and PTFE grafts--in 70 patients. Good results were achieved in 235 (69%), satisfactory--in 57 (17%) patients. Early thrombosis was revealed in 46 (14%) patients, femoral amputation was performed in 36 (10.6%) patients, 5 (1.4%) patients died.

[Autovenous bypass in situ in distal occlusions of the arteries]

In patients with bad distal bed and blood flow along the bypass two functioning venous collaterals were left with the diameter less than 1 mm, with the blood flow volume 100-150 ml/min one collateral was left, if the volume was 150-200 ml/min it was not necessary to make an arterio-venous output. One-two functioning collaterals left did not influence the volume and linear velocity of blood flow along the bypass and the parameters of hemodynamics. 78 patients (91%) were discharged with the functioning bypasses and decreased ischemia. A year later thrombosis of the bypass was noted in 6 (14%) of 43 follow-up patients, stepwise liquidation of one or two collaterals was fulfilled in 5 patients due to a more than 1 mm dilatation. Prognostically the blood flow in the zone of a distal anastomosis less than 100 ml/min is thought to be most critical.

[Treatment of pyonecrotic complications in diabetic macroangiopathy]

Results of treatment of 104 patients aged from 47 to 82 years with stage IV talocrural ischemia (by A.V. Pokrovsky) due to diabetic macroangiopathy were analyzed. Significant depression of immune status was revealed: number of T- and B-lymphocytes decreased by 40-50%, phagocytosis--by 65-75%, number of immunoglobulins--by 25-30%. The majority of the patients had endotoxicosis, hypercoagulation and hyperlipidemia; the correction of it by hemosorption and plasmapheresis was performed depending on the disease stage. 90 patients underwent surgery. Reconstruction in aorto-ileo-femoral zone was performed in 57 patients (in 34--with good results), in femoro-popliteo-femoral zone--in 33 patients (in 19--with good results). The "Gore-Tex" grafts were the plastic material for reconstruction, but autovein in situ was also used in femoro-popliteal zone.

[Surgical treatment of middle-aged and elderly patients with chronic ischemia and distal occlusions]

Operative treatment for critical ischemia was performed on 346 elderly and senile patients. An assessment of the distal bed and outflow pathways has shown the conditions for the reconstruction of the vessels to be unfavorable in 257 (74%) patients. Femoro-proximal-popliteal shunts were made in 82 patients with good effect in 74 of them. Femoro-distal-popliteal and tibial shunts were made in 62 patients with good effect in 52. In 12 patients out of 20 with the isolated plasty of the profound femoral artery better blood flow and arrest of pains in rest were noted. Lumbar sympathectomy was performed in 142 (41%) patients, in 46 of them it was combined with continuous intraarterial infusion and in 20 patients--in combination with the rotor osteotrepanation on the femur and shin. Good results after sympathectomy were noted in 102 patients.

[Status of lymphatic vessels, lymph flow and lymph toxicity in patients with obliterating arterial diseases of the lower extremities]

The condition of the lymph vessels, the lymph flow, and the toxicity of peripheral lymph were studied in 46 patients with obliterating diseases of the arteries of the lower limbs. The results of the study showed the severity of the destructive changes in the peripheral lymphatic system to be directly dependent on the severity of the arterial ischemia of the limb. Block of the lymphatic system, deceleration of the lymph flow, and changes in the lymph vessels themselves lead to deterioration of the tissue drainage function and intensification of regional endotoxicosis. In view of which correction of the peripheral lymphatic system should be included in the complex of measures for the treatment of patients with obliterating diseases of the lower limb arteries.