[Improving surgical technique for tracheal resection with anastomosis]

OBJECTIVE

To present modern aspects of improving surgical techniques in tracheal resection developed in recent years.

MATERIAL AND METHODS

The authors have the most extensive experience in tracheal surgery (>2.000 patients over the past 50 years). Diagnostic capabilities, perioperative management and surgical techniques have changed over such a long period. This concerns the proposed classification of cicatricial tracheal stenosis, features of endoscopic and X-ray diagnostics, indications for various surgeries, choice of surgical approach, technique of tracheal tube mobilization and anastomosis after tracheal excision. Preventive measures for severe postoperative complications are described.

CONCLUSION

Such an extensive experience allowed the authors to develop an algorithm for the treatment of patients with tracheal stenosis. This significantly reduced the incidence of postoperative complications and mortality. Replication of such equipment is associated with technical support of hospitals and professional level of specialists consisting of endoscopist, anesthesiologist, intensive care specialist and thoracic surgeon.

Condition of the Right Heart in Patients With COVID-19‑Associated Pneumonia: Follow-Up During Hospitalization

Aim      Dynamic assessment of the right heart in patients with COVID-19-associated pneumonia of different severity during regression of the systemic inflammatory response (SIR).Material an methods    This single-center prospective study included 46 patients with the novel coronavirus infection COVID-19 and viral pneumonia according to chest multispiral computed tomography (CT). Laboratory and echocardiographic examinations of patients were performed.Results Based on the results of evaluation with the Clinical Condition Scale (CCS-COVID), patients were divided into two groups: group A, patients with a score from 6 to 9 and group B, patients with a score from 10 to 14. The study results of both groups were evaluated twice: on day 10±2.5 from the onset of symptoms (groups A10 and B10, respectively) and again on day 17±1.8 (groups A17 and B17, respectively). Patients of group B10 had more pronounced SIR (C-reactive protein, 111.38±52.5 mg / l) and a larger volume of ground-glass opacity (38.3±9.6 %). At the first stage, higher values of right ventricular global longitudinal strain (RV GLS) were detected in group B10 compared to group A10 (23.2±4.8 % vs. 19.9±3.5 %, р=0.048). During the regression of SIR intensity and the positive dynamics of CT, lower values of Е / А were observed in group B17 (1.0 [0.98; 1.2]) vs. group А17 (1.4 [1.18; 1.5, p=0.015), and е' / a' in group B17 (0.66 [0.58; 0.85]) vs. 0.95 [0.79; 1.12] in group B17 (p=0.010). Е / А and е' / a' ratios were correlated with total lactate dehydrogenase fraction (r= -0.452 and p=0.006; r= -0.334 and p=0.050, respectively).Conclusion      In patients with severe COVID-19-associated pneumonia during regression of SIR intensity, changes in the parameters that reflected RV diastolic dysfunction were observed.

[Feasibility of cardiac surgical techniques for intrathoracic tumors]

OBJECTIVE

To analyse safety and expediency of cardiac surgical technologies including cardiopulmonary bypass (CPB) in patients with locally advanced lung cancer and invasive tumors of the mediastinum.

MATERIAL AND METHODS

Cardiac surgical techniques and CPB were used in 23 patients (group 1) with locally advanced thoracic tumors between 2005 and 2015. For the same period, there were 22 patients (group 2) who underwent combined surgeries and could have had similar techniques. However, these techniques were not used for various reasons. Mediastinal malignancies and non-small cell lung cancer were diagnosed in 26 (57.8%) and 19 (42.2%) patients, respectively. Invasion of superior vena cava (n=15), aorta (n=13) and pulmonary artery (n=12) was the most common. Lesion of innominate vein (n=8), left atrium (n=6) and innominate artery (n=4) was less common. A total of 21 pneumonectomies were performed (14 in the first group and 7 in the second group). Lobectomy was less common (one patient in each group). Sublobar lung resection was performed in 10 patients (2 patients in the first group and 8 ones in the second group). All resections were total in the first group (R0) that was confirmed by routine morphological examination of resection margins of different organs and vessels. The situation was worse in the second group (R1 in 19 (86.4%) patients, R2 in 3 (13.6%) patients).

RESULTS

Total postoperative morbidity was 53.3%, mortality - 8.2%. These values are higher compared to patients undergoing surgical treatment for thoracic malignancies. Incidence of postoperative complications was higher in the first group (16 (69.6%) and 8 (36.4%), respectively). Four patients died in the first group. Sepsis (n=2), acute right ventricular failure (n=1) and acute myocardial infarction (n=1) caused death. There were no lethal outcomes in the second group. Various postoperative complications were diagnosed only in 8 (36.4%) patients. The long-term results were followed-up in 80% of patients. In the first group, 3- and 5-year survival rates were 30.5% and 25%, respectively (median 43.8 months). In the second group, these values were 25% and 2%, respectively (median 24.9 months). Long-term mortality in the second group was caused by progression of malignant process, including local recurrence, after palliative surgery (R1, R2 resection).

CONCLUSION

Higher risk of postoperative complications and mortality in patients undergoing on-pump surgery is compensated by significantly better long-term results. Further progress is associated with higher safety of CPB, as well as solving some organizational and educational problems.

[Giant traumatic diaphragmatic hernia as a complication after laparoscopic liver surgery]

Laparoscopic surgery is now one of the main options for patients with surgical diseases of abdominal cavity, pelvis and retroperitoneal space. Postoperative complications are known, and methods for their prevention after such interventions are well developed. However, there are rare complications, and their management deserves a special attention. The authors present a patient with giant traumatic hernia in long-term period after laparoscopic liver surgery. Clinical manifestations of disease are retrospectively analyzed. The authors discuss surgical aspects of treatment, i.e. choice of access, repair of diaphragmatic defect and peculiarities of postoperative period associated with non-anatomic return of abdominal organs through the diaphragmatic defect. This report will be useful for radiologists, thoracic and abdominal surgeons, anesthesiologists and intensive care specialists.

[Surgical management of tracheal anastomosis failure and risk of arterial bleeding]

OBJECTIVE

To determine the optimal algorithm for tracheal anastomotic insufficiency and prevention of arterial bleeding.

MATERIAL AND METHODS

We present 2 patients with defects of tracheal anastomosis after tracheal resection and divergence of tracheal edges. We primarily analyzed appropriate emergency care and prevention of subsequent severe complications such as arterial bleeding and respiratory insufficiency.

CONCLUSION

Tracheostomy may be preferable for complete late tracheal anastomotic insufficiency to restore breathing. However, surgery should be accompanied by prevention of arterial bleeding. Isolation of damaged area, particularly tracheostomy tube, from the mediastinum by well-vascularized tissues can prevent bleeding from major vessels (for example, innominate artery). Follow-up is unreasonable due to worsening of clinical situation, risk of hemorrhagic complications and fatal outcomes. General satisfactory clinical status of the patient is not of matter. Repeated tracheal anastomosis is justified only for early insufficiency, i.e. within 2-3 days when postoperative inflammation is mild.

[Treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia]

OBJECTIVE

To describe treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia.

MATERIAL AND METHODS

There were 91 patients with cicatricial tracheal stenosis for the period from August 2020 to April 2022 (21 months). Of these, 32 (35.2%) patients had cicatricial tracheal stenosis, tracheoesophageal fistula and previous coronavirus infection with severe acute respiratory syndrome. Incidence of iatrogenic tracheal injury following ventilation for viral pneumonia in the pandemic increased by 5 times compared to pneumonia of other genesis. Majority of patients had pneumonia CT grade 4 (12 patients) and grade 3 (8 patients). Other ones had pulmonary parenchyma lesion grade 2-3 or mixed viral-bacterial pneumonia. Isolated tracheoesophageal fistula without severe cicatricial stenosis of trachea or esophagus was diagnosed in 4 patients. In other 2 patients, tracheal stenosis was combined with tracheoesophageal fistula. Eight (25%) patients had tracheostomy at the first admission. This rate was almost half that of patients treated for cicatricial tracheal stenosis in pre-pandemic period.

RESULTS

Respiratory distress syndrome occurred in 1-7 months after discharge from COVID hospital. All patients underwent surgery. In 7 patients, we preferred palliative treatment with dilation and stenting until complete rehabilitation. In 5 patients, stent was removed after 6-9 months and these ones underwent surgery. There were 3 tracheal resections with anastomosis, and 2 patients underwent tracheoplasty. Resection was performed in 3 patients due to impossible stenting. Postoperative course in these patients was standard and did not differ from that in patients without viral pneumonia. In case of tracheoesophageal fistula, palliative interventions rarely allowed isolation of trachea. Four patients underwent surgery through cervical approach. There were difficult surgeries in 2 patients with tracheoesophageal fistula and cicatricial tracheal stenosis. One of them underwent separation of fistula and tracheal resection via cervical approach at primary admission. In another patient with thoracic fistula, we initially attempted to insert occluder. However, open surgery was required later due to dislocation of device.

CONCLUSION

Absolute number of patients with tracheal stenosis, tracheoesophageal fistula and previous COVID-19 has increased by several times compared to pre-pandemic period. This is due to greater number of patients requiring ventilation with risk of tracheal injury, non-compliance with preventive protocol for tracheal injury including anti-ischemic measures during mechanical ventilation. The last fact was exacerbated by involvement of allied physicians with insufficient experience of safe ventilation in the «red zone», immunodeficiency in these patients aggravating purulent-inflammatory process in tracheal wall. The number of patients with tracheostomy was 2 times less that was associated with peculiarity of mechanical ventilation in SARS-CoV-2. Indeed, tracheostomy was a poor prognostic sign and physicians tried to avoid this procedure. Incidence of tracheoesophageal fistula in these patients increased by 2 times compared to pre-pandemic period. In subacute period of COVID-associated pneumonia, palliative measures for cicatricial tracheal stenosis and tracheoesophageal fistula should be preferred. Radical treatment should be performed after 3-6 months. Absolute indication for circular tracheal resection with anastomosis is impossible tracheal stenting and ensuring safe breathing by endoscopic methods, as well as combination of cicatricial tracheal stenosis with tracheoesophageal fistula and resistant aspiration syndrome. Incidence of postoperative complications in patients with cicatricial tracheal stenosis and previous mechanical ventilation for COVID-19 pneumonia and patients in pre-pandemic period is similar.

[Surgery of primary tracheal tumors]

OBJECTIVE

To determine the main forms of primary tracheal cancer (PTC), to specify the indications for various surgeries in these patients depending on extent and localization of lesion.

MATERIAL AND METHODS

There were 263 PTC patients. Benign tumors were diagnosed in 68 (25.9%) patients, malignancies - in 195 (74.1%) cases. Tracheal cancer includes 3 basic morphological variants - adenocystic cancer (49.7%), carcinoid (18.7%) and squamous cell carcinoma (19.0%). Other forms of malignancies were much less common. We applied endoscopic intraluminal and open surgeries. In malignant PTC, open surgeries were performed in 165 (84.6%) out of 195 patients. Baseline palliative endoscopic treatment was performed in 30 patients. They underwent airway recanalization (with subsequent tracheal stenting in 19 patients). Endoscopic resection was preferred for benign tumors.

RESULTS

Twenty (12.1%) patients died after open surgery, and 1 (3.3%) patient died after endoscopic procedure. Most lethal outcomes occurred in early years of development of tracheal surgery. The causes of mortality were tracheal anastomotic failure in 12 patients, pneumonia in 6 patients, and arterial bleeding in 2 patients. Severe postoperative period was observed in all 3 patients after tracheal replacement with a silicone prosthesis. Long-term treatment outcomes depended on morphological structure of PTC. Favorable results were observed in patients with neuroendocrine tumor (carcinoid), worse outcomes in adenocystic cancer and unfavorable results in squamous cell carcinoma (p<0.0013). Five-year survival rates were 75%, 65.6%, and 13.3%; 10-year survival rates were 75%, 56.2%, and 13.3%, respectively. These outcomes after combined treatment of primary tracheal cancer were significantly better compared to lung cancer (p<0.05 when compared to global data).

CONCLUSION

Treatment of primary tracheal cancer should be based on classical principles of modern oncology (combined therapy, tumor resection with lymphadenectomy). Open and endoscopic interventions are justified. PTC is characterized by more favorable outcomes compared to lung cancer. It is difficult to analyze long-term results in tracheal cancer depending on various features of tumor process due to small number of observations. Accurate conclusions require multiple-center studies, preferably with international participation, which can convincingly prove certain concept.

[Long-term postoperative outcomes in patients with cicatricial tracheal stenosis depending on surgical approach]

OBJECTIVE

To analyze the long-term postoperative outcomes in patients with cicatricial tracheal stenosis and to determine the indications for various surgical strategies.

MATERIAL AND METHODS

There were 976 patients with benign cicatricial tracheal stenosis for the period 2001-2017. Tracheal stenosis occurred after mechanical ventilation and tracheostomy in 910 (93.2%) patients. Other causes were neck trauma, burns, previous surgery or tuberculosis. Idiopathic stenosis was observed in 41 (4.2%) patients. Multiple-stage reconstructive treatment was possible due to benign nature of disease. There were 2.4 operations per a patient, and 976 patients underwent 2327 procedures. Circular tracheal resection was preferred (n=396).

RESULTS

Surgical complications occurred in 107 (4.6%) cases, mortality rate - 0.3%. In long-term period, 42 patients died for various causes. In most cases (n=34, 80.9%), mortality was associated with concomitant diseases or consequences of trauma rather cicatricial tracheal stenosis or its treatment. Eight patients died from cicatricial tracheal stenosis or its treatment (7 patients after staged repair, 1 after circular tracheal resection). Four patients died due to asphyxia following T-tube obturation with a tracheobronchial secret or unjustified decannulation. For various reasons, 41 (6.2%) patients continued their treatment in other hospitals (4 patients died). Mortality rate in this group was 9.8%. Favorable long-term outcome was observed in 90.1% of patients, good and unsatisfactory results - in 7.2% and 1.8% of patients, respectively. Circular tracheal resection ensured better functional outcome.

CONCLUSION

Surgical treatment of cicatricial tracheal stenosis is associated with low incidence of postoperative complications and mortality. However, further improvement in long-term results is associated with advanced rehabilitation programs for concomitant diseases. Treatment of cicatricial tracheal stenosis should be carried out at specialized hospitals.

[Contamination of surgical wound during tracheal resection depending on the mode of mechanical ventilation]

OBJECTIVE

To analyze contamination of surgical wound during tracheal resection depending on the mode of mechanical ventilation.

MATERIAL AND METHODS

There were 976 patients. Circular tracheal resection was made in 396 of these patients.

RESULTS

Overall postoperative morbidity was 15.7%, mortality - 0.8%. Bacteriological examination of surgical wound was performed before tracheotomy and after formation of anastomosis depending on the method of mechanical ventilation. Surgical field was sterile before tracheotomy in all cases, contamination was confirmed after tracheotomy in all patients. Minimal contamination was observed in case of apneic oxygenation (100 times less than volumetric mechanical ventilation or high frequency mechanical ventilation). In all cases, several species of pathogenic microorganisms were identified. The number of species was also minimal in case of hypnotic mechanical ventilation.

CONCLUSION

Contamination does not directly affect the development of local purulent-inflammatory process. However, this factor should not be ignored and compliance with all preventive measures is required.

Cardiac damage in patients with COVID-19 coronavirus infection

The article reviews studies that confirm the relationship of a negative prognosis with the presence of risk factors for cardiovascular complications during respiratory infections, including novel coronavirus infection COVID-19. The article presents the relevant research results that provide evidence on the myocardial damage in coronavirus infection. We present a clinical case of a patient with confirmed diagnosis of COVID-19 and severe viral myocarditis, verified by histological and immunohistochemical studies.

[Tracheal resection after prolonged stenting in surgery for cicatricial stenosis]

OBJECTIVE

To analyze early and delayed results of various variants of circular tracheal resection (CTR) with anastomosis, to determine the safest approach, dates and conditions of correction, features of postoperative period in patients after previous tracheal surgery.

MATERIAL AND METHODS

There were 831 patients with cicatricial tracheal stenosis. CTR was made in 330 (39.7%) patients. Most patients had previous prolonged ICU-stay. The patients were divided into 4 groups. Group 1 consisted of 61 (18.5%) patients after previous prolonged tracheal stenting. Group 2 included 45 (13.6%) patients who underwent circular tracheal resection with a functioning tracheostomy. Tracheostomy tube served as a stent in these patients. Group 3 enrolled 32 (9.7%) patients with previous staged reconstructive plastic surgeries on cranial segment of the respiratory tract. Tracheostomy or stent were absent in 192 (58.2%) patients who underwent circular tracheal resection at the first hospitalization. These patients were enrolled into the fourth (control) group. Favorable outcomes (without complications and mortality) were achieved in 85.5% (n=282) of patients. Postoperative complications occurred in 48 (14.5%) patients. Mortality rate was 0.6% (n=2). The greatest number of complications including anastomositis and restenosis was noted in patients after CTR and previous tracheoplasty with T-tube (n=8, 25%). The most common complication in patients after tracheal resection and previous stenting was anastomositis (14.7%). Long-term results depended on postoperative complications and methods of their correction. Recurrent stenosis occurred in 5 (1.5%) patients within the period of 3 months - 8 years. CTR after previous tracheoplasty with T-tube was carried out in 4 of these patients.

CONCLUSION

Tracheal resection after preliminary stenting or tracheostomy is quite safe and technically feasible. Stenting allows postponing radical surgery for correction of concomitant diseases and closure of tracheostomy as a focus of infection within the surgical approach and further tracheal anastomosis. Tracheal resection with simultaneous closure of tracheostomy results a higher rate of postoperative complications compared with preliminary stenting.

[Tracheolaryngeal resection for cicatricle stenosis]

AIM

To determine the safest and the most effective surgical treatment of patients with cicatricle stenosis of tracheolaryngeal segment via analysis of different approaches.

MATERIAL AND METHODS

For the period 1963-2015 at Petrovsky Russian Research Center for Surgery and Sechenov First Moscow State Medical University 1128 patients with cicatricle tracheal stenosis have been treated. There were 683 men and 445 women. 684 (60.6%) patients were young and the most employable (21-50 years). All patients were divided into 2 groups depending on time of treatment: the first one included 297 patients between 1963 and 2000, the second group - 831 patients between 2001 and 2015. In group 1 tracheolaryngeal anastomosis was made in 10 (16.9%) out of 59 patients who underwent tracheal resection. Previously indication for this surgery was cicatricle stenosis of cervical trachea and larynx with upper borderline of cicatricle changes at least 2 cm from vocal folds. In group 2 these procedures were more frequent. 94 (28.5%) out of 330 patients underwent tracheolaryngeal resection. Cranial borderline of lesion was within 0.5 cm from the vocal folds (only if posterior laryngeal wall at the level of cricoid cartilage was intact). Difficult patients are those who need for double-level or redo repair and procedures with tracheostomy.

RESULTS

In the second group overall morbidity after tracheal resections followed by anastomosis was 5.6%. These complications were more common after tracheolaryngeal anastomosis (17%). There were no lethal outcomes after 94 tracheolaryngeal resections. Good long-term results were observed in 89.8% of patients after circular resection. Their quality of life was similar to that of healthy people. Preserved cicatricle tracheal segments during tracheal repair with T-shaped airway tube adversely affects quality of life in these patients in long-term period.

[Common variable immune deficiency in adults: focus on pulmonary complications]

Common variable immune deficiency is the most common form of a group of primary immunodeficiencies in adult patients. Pulmonary complications occupy leading positions. It is the development of recurrent bronchopulmonary inflammatory diseases that is considered to be one of the main causes of death and disability in patients with this disease. By presenting two clinical cases with long diagnostic delays, the authors try to attract the attention of specialists of related professions, which will minimize the development of irreversible complications in the patients.

[Long-term oucomes of tracheal transplantation: success and unsolved problems]

AIM

To analyze long-term outcomes of tracheal transplantation.

MATERIAL AND METHODS

There were 1128 patients with cicatricial tracheal stenosis who have been operated at the Petrovsky Russian Research Center for Surgery and the Sechenov First Moscow State Medical University for the period 1963-2015.

RESULTS

Operations have become safer. Postoperative morbidity and mortality reduced from 41.4% (1963-1980) to 5.6% (2001-2015) and from 21.9% (1963-1980) to 0.5% (2001-2015), respectively. Tracheal transplantation was performed in 2 cases and fundamentally different tracheal structures were applied. Donor thyreotracheal complex with restored blood supply through thyroid vessels was used in the first case (2006). Perennial experimental trials preceded clinical application of this technique. In the second case (2010) we applied scientific results of foreign colleagues (cellular technologies and methods of regenerative medicine to create artificial trachea). Patients are still alive after 12 and 8 years, respectively. Restoration of blood supply of donor trachea is possible through thyroid collaterals. This technique is successful in long-term period. Tissue-engineered trachea cannot be considered true trachea due to no all tracheal components. However, such trachea provides air-conducting, evacuation and protective functions. Tracheomalacia requires further researches as one of the main problems of tracheal transplantation.

[Circular tracheal resection for cicatrical stenosis and functioning tracheostomy]

AIM

To analyze the results of tracheal resection for cicatricial stenosis depending on the presence of tracheostomy.

MATERIAL AND METHODS

1128 patients with tracheal cicatricial stenosis were treated for the period 1963-2015. The first group consisted of 297 patients for the period 1963-2000, the second group - 831 patients for the period 2001-2015. Most of them 684 (60.6%) were young and able-bodied (age from 21 to 50 years). In the first group 139 (46.8%) out of 297 patients had functioning tracheostomy. For the period 2001-2015 tracheostomy was made in 430 (51.7%) out of 831 patients with cicatricial stenosis. Time of cannulation varied from a few weeks to 21 years.

RESULTS

Re-tracheostomy within various terms after decanulation was performed in 68 (15.8%) patients. Tracheal resection with anastomosis was performed in 59 and 330 in both groups respectively. At present time these operations are performed more often in view of their standard fashion in everyday practice. In the second group tracheal resection followed by anastomosis was observed in 110 (25.6%) out of 430 patients with tracheostomy that is 4.4 times more often than in previous years. In total 2 patients died after 330 circular tracheal resections within 2001-2015 including one patient with and one patient without tracheostomy. Mortality was 0.6%. Moreover, this value was slightly higher in patients operated with a functioning tracheostomy compared with those without it - 0.9 vs. 0.5% respectively. The causes of death were bleeding into tracheobronchial lumen and pulmonary embolism. The source of bleeding after tracheal resection was innominate artery. Overall incidence of postoperative complications was 2 times higher in tracheostomy patients compared with those without it - 22 (20%) vs. 26 (11.8%) cases respectively. Convalescence may be achieved in 89.8% patients after circular tracheal resection. Adverse long-term results are associated with postoperative complications. So their prevention and treatment will improve the outcomes.

[POSTRESUSCITATION CICATRICIAL TRACHEAL STENOSIS. CURRENT STATE OF THE PROBLEM - THE SUCCESSES, THE HOPES AND DISAPPOINTMENTS.]

BACKGROUND

Currently, the trend continues to increase the number ofpatients with cicatricial tracheal stenosis (CTS). Therefore, prevention and treatment ofthis disease remains topical. The main cause ofcicatricial tracheal stenosis is damaging the trachea during mechanical ventilation. The scheme ofprevention of this disease in Russia hasn't brought the desired results.

THE AIM

to clarify the modern etiology of cicatricial tracheal stenosis, to identify the trend in incidence rates, to determine whether there is an optimal safe alternative to tracheostomy including the use of minimally invasive techniques, to improve diagnostic and therapeutic algorithm at various stages of assistance, and also to study the results of innovative operations and new ways of maintaining gas exchange.

MATERIALS AND METHODS

1128 patients with cicatricial tracheal stenosis was treated from 1963 to 2015 in Petrovsky National Research Centre of Surgery and IMSechenov First Moscow State Medical University. Over time methods of di- agnosis, methods of anesthesia and operations have been varied. In this regard all patients were divided into two groups depending on the period of time from 1963 to 2000 (297 patients) andfrom 2001 to 2015 (831 patients). In recent decades there is a steady increase in the number of treated patients. So, if in the first group during the year operational treatment about the CTS 8,0 patients were underwent, in the second - to 55.4. Cicatricial tracheal stenosis appeared after lung mechanical ventilation at 1025 (for 90.9%) patients. They have undergone both radical one-stage treatment and multi-stage and sequential intraluminal procedures. In general there is a clear trend towards more aggressive surgical tactics. So, if in thefirst group, the tracheal resection with anastomosis was performedin 59 patients only, the second-330. Thefrequency ofpostoperative complications and mortality in the second group ofpatients was 12.9 and 0.7 %, respectively.

RESULTS

Only a reasonable combination of all treatment methods, the principle of "every patient his own version of operation" allows to minimize the risk oftreatment and to get a good lasting result. Proof of such provision may be the fact that the frequency of complications and postoperative mortality at our patients have had a tendency to decrease and currently stands at 12.9 and 0.7 %, respectively for many years. It is 2.3 and 9.6 times less, respectively, than in the periodfrom 1963 to 2000. It appears that further reduction of these indicators will be at a slower pace, afurther solution of the CTS problem will be based on the prevention of disease.

CONCLUSION

Prevention of cicatricial tracheal stenosis in the departments of reanimation and intensive care is currently inadequate. It requires fundamentally new approaches, but reform still has not brought the desired results. Diagnosis of the CTS at an early stage allows early treatment and to avoid complex and risky operations. Increasingly important, apart tracheoscopy for diagnosis of tracheomalacia purchase dynamic computed tomography and magnetic resonance - tomography. Treatment ofpatients with CTS requires a multidisciplinary approach, individual selection operations for a particular patient. The general trend of the further development of tracheal surgery is associated with an increase in the number of simultaneous resections, including at the long, two-level stenosis, as well as at relapse. The patients who had refused treatment or have elected him palliative options made possible surgery. The frequency of postoperative comnlications and mortality decreased significantiv, including after extensive and traumatic operations on the trachea.

[Surgical approaches in surgery for cicatrical tracheal stenosis]

At present time several surgical approaches are being used for cicatrical tracheal stenosis including cervicotomy, longitudinal- circumferential sternotomy and thoracotomy. Besides location of stenosis an approach is being determined by constitutional and anatomical features of patient, surgeon's and anesthesiologist's experience, well-coordinated work of operating team. If pathological process is placed in cervico-laryngeal, cervical and upper thoracic segment cervicotomy is preferable. Partial longitudinal-circumferential sternotomy is believed to be adequate in case of lesion of thoracic trachea and its bifurcation. This approach provides all types of tracheal reconstructions. Technical difficulties appear if process is localized in membranous wall of suprabifurcational part, bifurcation and primary bronchus. In these cases we recommend thoracotomy through the bed of resected the 3rd or the 4th ribs and patient's position on his front. Interventions including pulmonary tissue resection and tracheal edges convergence are possible through thoracotomy.

[Simultaneous resection of the two tracheal fragments for cicatrical stenosis]

Treatment of multifocal and extended tracheal stenosis is associated with considerable difficulties in comparison with local lesions. Resection with restoration of respiratory lumen by using of direct intertracheal anastomosis substantially entered into common clinical practice. But these interventions in patients with two-level lesion are performed rarely. Among 900 operated patients with cicatrical tracheal stenosis resection of two tracheal segments with forming of anastomoses was performed only in 5 patients. We presented an experience of single-stage resections of different segments of respiratory tract for nonneoplastic cicatrical stenosis. Indications and contraindications are defined. Technical features of resection are discussed. Our data show that such operations are possible and safe. All patients recovered. Their breath was completely restored. Risk of postoperative complications after similar operations is not higher than after one-level resection. But at present time these techniques may be used by specialists and institutions with serious experience in tracheal surgery.

[Postoperative bleeding in tracheal surgery]

AIM

Tracheal surgery became relatively safe with development of thoracic surgery, endoscopy and anesthesia. However, life-threatening vascular complications especially arrosive bleeding from great vessels play important role in the structure of postoperative complications. It is a major cause of hospital mortality after tracheal surgery.

MATERIAL AND METHODS

Since 1963 to 2013 867 patients with cicatrical tracheal stenosis were treated. Their age ranged from 8 to 77 years. Bleeding was the main cause of death after tracheal surgery. It occurs in 31 patients among whom 22 died. 9 patients are alive. There was bleeding from small cervical vessels and carotid artery in 5 and 2 patients respectively. All patients with bleeding from brachiocephalic trunk died except 2 patients who underwent complex vascular reconstructions and recurrent complications were prevented. Vascular complications occurred after both circular tracheal resection with the anastomosis (19 patients) and tracheoplasty followed by airway lumen formation on T-shaped tube (in 11 cases) or endoscopic treatment (in 1 patient). Postoperative complications were predominantly arrosive and accompanied by wound infection or severe purulent tracheobronchitis. Blood loss was relatively small in all patients and asystole was caused by blood asphyxia in died patients. Therefore, firstly respiratory tract lumen should be isolated from source of bleeding. 22 patients were urgently operated. Intraoperative death was observed in 6 cases, 7 patients died within 2-31 days. In 7 other patients cervical soft tissues, thyroid artery collaterals and carotid artery were origin of bleeding.

RESULTS

Final bleeding stop was performed with good immediate and long-term results in all cases. Final bleeding stop usually requires complex vascular reconstructions and it is difficult to predict their outcomes. It is necessary to prevent intraoperative bleeding because of unsatisfactory results of vascular complications management. So careful manipulations with vessels and their isolation from the tracheal anastomosis and tracheostomy channel with patient's own tissues are obligatory.

[Repeated tracheal resection for non-neoplastic restenosis]

Treatment of patients with recurrent cicatrical tracheal stenosis after previous circular tracheal resection is one of the most difficult problems in thoracic surgery at present time. In most cases repeated radical surgery as new resection is declined in favour of palliative treatment. It is often associated with lingering or perpetual preserving of T-shape or tracheostomy tube and respiratory tract stenting. Development of thoracic surgery last years permits to perform repeated tracheal resections with restoration of respiratory tract integrity by using of new tracheal anastomosis. For the last 4 years 6 such operations were performed with satisfactory immediate and remote results. Diagnostic algorithm before repeated surgery is similar to those before primary intervention. Special attention should be attended to state of remained parts of respiratory tract, degree and length of stenosis and tracheomalacia which may be result of divergence of edges of the primary anastomosis. Preserving of not less than 1/4 primary length of intact trachea with its satisfactory mobility is main condition for this surgery because it will permit to perform new anastomosis without high tension. Risk of postoperative complications after repeated operations is not higher than those after primary resection. But at present time these operations are in competence of small number of specialists and medical institutions with serious experience in thoracic surgery.

[Surgical stapling instruments in surgical treatment of non-neoplastic tracheoesophageal fistula]

The experience of treatment of 118 patients with non-neoplastic tracheoesophageal fistulas is presented in the article. Radical surgeries was performed in 85.6% cases, palliative operations - in 4.2% of patients. Conservative therapy was rare (12 patients). The volume of radical interventions was different. There was volume increase in case of concomitant tracheal stenosis or involvement in process adjacent organs and tissues. It is frequent situation last years. Surgical stapling instruments were used in 62 patients during surgery. Domestic (UKS-20, UKS-30, UO-40, UO-60) and import instruments were applied. Postoperative complications were diagnosed in 32.7% of patients. The most complications were determined with exacerbation of inflammation in lungs (exacerbation of purulent bronchitis, pneumonia, etc.). It was not revealed complications determined with surgical stapling instruments using for tracheal or esophageal defects removal in any patients. Relapse in long-term period was observed in 10 radically operated patients. All of them underwent tracheoplastic surgeries on the cervical and thoracic trachea except tracheoesophageal fistula separation. Clearance of the respiratory tract was formed by using of T-tube in the future. Surgical stapling instrument was used only in 2 of these patients during radical surgery. 7 patients were re-operated for tracheoesophageal fistula relapse with good result.

Rotationally resolved water dimer spectra in atmospheric air and pure water vapour in the 188–258 GHz range

Millimeter wave spectra of the water dimer under the conditions close to the atmospheric ones in pure water vapour and its mixture with air are detected and quantitatively analyzed.

[Iatrogenic trachea and esophagus injury in intensive care practice: the surgeon's view"]

From 1963 to 2011 in the Department of lung and mediastinum surgery were treated 879 patients with trachea stenosis and 107 patients with benign tracheoesopageal fistula were treated in the Department of lung and mediastinum surgery from 1963 to 2011. latrogenic trachea and the esophagus damage was caused by long-term ALV in 87% of cases. Patients were aged from 5 to 79 years. 47.2% of patients came with functioning tracheostome. 25.7% of patients had a clinically significant respiratory disorder at admission, 10.2 % of which were life-threatening. Iatrogenic damage of the trachea was identified before extubation or decannulation only in 27% of patients. In such circumstances, prevention and diagnostics of iatrogenic injuries, as well as initial care alternatives takes on special significance.

Water dimer rotationally resolved millimeter-wave spectrum observation at room temperature

Water dimers (H(2)O)(2) are believed to affect Earth's radiation balance and climate, homogeneous condensation, and atmospheric chemistry. Moreover, the pairwise interaction which binds the dimer appears to be of paramount importance for expounding a complete molecular description of the liquid and solid phases of water. However, there have been no secure, direct observations of water dimers at environmentally relevant temperatures despite decades of studies. We report the first unambiguous observation of the dimer spectrum recorded in equilibrium water vapor at room temperature.

[Surgical and endovascular treatment of lung arteriovenous malformations]

The article summarizes the experience of surgical treatment of 47 patients (1964-2012 yy) with lung arteriovenous malformations (LAVM). Men were 29, women - 18. Age varied from 6 to 49 years. 20 patients had solitary lung arteriovenous malformations, the rest 27 had multiple malformations. Before 1983 the main diagnostic means was the angiopulmonography, since that the multyspiral computed tomography has been used. Before 1980 all patients received major surgical treatment, i.e., lobectomy (n=29), pneumonectomy (n=1) and 1 explorative thoracotomy. After 1980 the endovascular embolisation under the X-ray control took the leading place among the treatment options for these patients. 11 patients had 17 embolisations; the lung resection was performed only in 3 cases. All negative outcomes (4 lethal and 8 complications) were registered before the 1980. The were no lethal outcomes after the endovascular embolisation; only 3 patients had complications. All patients demonstrated satisfactory and good outcomes, considering objective parameters and quality of life early and long after the endovascular embolisation.

[Posterior thoracotomy in ventral decubitus]

The rigidity of the chest wall, thank to its bone framework, determines the variety of operative access in thoracic surgery, both thoracoscopic and open. The posterior thoracotomy on the bed of the resected rib in ventral decubitus is traditionally but gratuitously rarely used access. The method permits comfortable access to trachea, bifurcation, main bronchi and thoracic esophagus. It can also be used in cases of foregoing thoracothomy. Authors own the experience of 111 cases with the use of posterior thoracotomy in ventral decubitus. The access proved to be preferable for the operations on the membranous part of the trachea and main bronchi, some localizations of thoracic tracheoesophageal fistula. The access suggests fast mobilization of the root of the lung without foregoing pneumolisis, which is important in cases of pleural cavity obliteration after tuberculosis or pleural empyem.

[Tracheoesophageal fistulae: the state of art]

The article summarizes the experience of treatment of 107 patients with tracheoesophageal fistula of nonneoplastic etiology. Etiology, diagnostic and treatment approaches were analyzed and compared, depending on the time period. The proportion of patients with combined pathology as tracheoesophageal fistula and cicatrical stenosis of the trachea has significantly increased recently. The main cause of fistulation was the jatrogenic tracheal injury during the mechanical lung ventilation. Basic diagnostic methods were endoscopy and computed tomography. The main objective of emergency remains isolation of the tracheobronchial tree from the gastrointestinal tract. Radical surgery can cure 97.8% of patients with minimal risk, including comorbidity. Conservative treatment and palliative surgery should be used only in case of the curative treatment failure or on the preparatory stage.

[Surgery of the diaphragm in the planned thoracic surgery]

122 patients with different diseases of the diaphragm were operated on during 1963-2011 yy. The majority of patients - 76 (62.3%) - had hernias of the weak phrenic zones. 14 (11.5%) and 17 (14.0%) patients had posttraumatic hernia and phrenic relaxation, respectively. The majority of patients had no complaints and the disease was diagnosed on the X-ray examination. Rarely, the compression syndrome, caused by the translocation of the bowel into the thoracic cavity, was registered. That clinically emerged as short breath, heaviness sensation and cardiac rhythm disorders. The worked out reconstructive operations allow to cure such patients with minimal risk.

[The transplantation of revascularized thyroid-trachea-lung complex: the experimental study]

The osteoplastic tracheobronchopathy affects the trachea, main, lobar and smaller bronchi, causing their stenosis. Nowadays the mainstay of the treatment of such patients is the cryodestruction, laser destruction and the endoscopic buginage of the trachea and bronchi. The palliative nature and low efficacy of these procedures forces to search new ways of treatment. The traditional lung transplantation or separate trachea and lung transplantation is inappropriate because of the complex affection of both trachea and bronchi. The experimental study aimed the possibility of thyreotracheolung revascularized donor complex transplantation.

[The evolution of surgical and functional operability in thoracic oncology]

The authors own the experience of 4157 operations on the reason of malignant lung tumors, of them 429 (10.3%) operations were combined. The extracorporeal membrane oxygenation is considered to be reasonable by extended thoracic resections. Surgical lung volume reduction by emphysema shows good functional results, which allows to use its principles in oncologic patients with low functional repiratory reserves. The overall multidisciplinary approach in thoracic oncology allows better treatment results and gives hope to the earlier inoperable patients.

[Surgical treatment of simple cysts of the kidney in multiphasic hospital]

The presented work is based on an analysis of survey results and surgical treatment of 418 patients with simple renal cysts during the period from 1995 to 2010. The volume of the cysts ranged from one to 2500 ml. The average volume of the operated cysts was 360.2 +/- 306.7 ml. The abilities of the multiphasic hospital, equipping it with the modern diagnostic and medical equipment, the long experience of work enabled the authors to develop the algorithm of inspection and surgical treatment of the patients with simple renal cysts and to develop practical recommendations, presenting them in logical schemes.

[Etiology, prophylaxis and treatment of extensive, multifocal cicatricial tracheal stenosis at the junction of sciences--surgery and anesthesia]

759 patients with cucatritial stenosis of trachea were treated in the Russian Scientific Center of Surgery in the period from 1963 to 2009. Extensive or multifocal stenosis was diagnosed in 172 patients. 157 patients were previously operated in other hospitals. The lesion of larynx during admission was diagnosed in 122 cases. All patients were operated in compliance with the principle of alternation methods of anesthesia and respiratory support. As a result of consistent application of the landmark reconstructive-plastic operations and resection in combination with endoscopic surgery good results were achieved. Based on the data, treatment algorithm of extended and multifocal cicatricial stenosis of the trachea was developed.

[Tracheoplasty after circular trachea resection]

One of the crucial features of the reconstructive surgery of the trachea is the choice of suturing method and materials. The authors' experience of tracheal stenoses treatment counts 759 patients, aged from 9 to 77 years. The number of administered patients, who had been operated earlier in other hospitals, has drastically increased recently. The amount of patients with long tracheal stenoses has also increased. The novel operative techniques of tracheal suture, suggested by the authors, permit better results of rehabilitation.

[Resection and aorta replacement in extended and combined operations for lung cancer]

In spite of the progress in thoracic surgery and oncology, great lethality in lung cancer patient still persists, and so the questions of not only the early diagnostics but also the development of new techniques of surgical treatment remain actual which allow radical ablation of extended tumors. In the Russian Scientific Center of Surgery named after academician B.V. Petrovsky of the Russian Academy of Medical Sciences three patients were subjected to extended combined operations of pneumonectomy with a simultaneous resection and replacement of the thoracic part of the aorta for local dissemination of lung cancer. Extracorporeal circulation was used in one patient and in two patients resection and replacement of the aorta were fulfilled on the cross-clapmed aorta under conditions of ischemia of organs and tissues below the left subclavian artery. There were no ischemic injuries of organs after operation. All the patients were directed to chemio-radiation therapy.

[Antimicrobial and antimycotic therapy in the surgery of iatrogenic esophageal and tracheal diseases]

Microbiologic analysis of tracheal and gastrostomic discharge was performed in 327 patients with iatrogenic injuries of trachea and esophagus, operated during 2003-2008. Main groups of microorganisms, colonizing the tracheobronchial tree were defined. St. epidermalis was defined in 3.9-13.3%, St. aureus - in 12.4-21.1%, Ps. small a. Cyrilliceruginosa - in 9.2-17.5% of cases. Increase of Candidae colonization was revealed (7.8-12.2%). The increase of polyresistant strains identification was typical. St. epidermalis and St. aureus demonstrated the preserving high sensitivity to vankomycin and linesolide, whereas Ps. aeruginosa showed the growth of resistance to all groups of antibiotics, but polymyxin. The common decrease of antibiotic activity requires the realization of complex antibacterial and antimycotic treatment.

Resonator spectrometer for precise broadband investigations of atmospheric absorption in discrete lines and water vapor related continuum in millimeter wave range

The instrument and methods for measuring spectral parameters of discrete atmospheric lines and water-related continuum absorption in the millimeter wave range are described. The instrument is based on measurements of the Fabry-Pérot resonance response width using fast phase continuous scanning of the frequency-synthesized radiation. The instrument allows measurement of gas absorptions at the cavity eigenfrequencies ranging from 45 to 370 GHz with the highest to date absorption variation sensitivity of 4x10(-9) cm(-1). The use of a module of two rigidly bounded maximum identical resonators differing in length by exactly a factor of two allows accurate separation of the studied gas absorption and spectrometer baseline, in particular, the absorption by water adsorbed on the resonator elements. The module is placed in a chamber with temperature controlled between -30 and +60 degrees C, which permits investigation of temperature dependence of absorption. It is shown that systematic measurement error of discrete atmospheric line parameters does not exceed the statistical one and the achieved accuracy satisfies modern demands for the atmospheric remote sensing data retrieval. Potential systematic error arising from the neglect of the effect of water adsorption on mirror surfaces is discussed. Examples of studies of water and oxygen spectral line parameters as well as continuum absorption in wet nitrogen are given.

Real Atmosphere Laboratory Measurements of the 118-GHz Oxygen Line: Shape, Shift, and Broadening of the Line

For the first time the 118-GHz line of the oxygen molecule was investigated in the laboratory under a real atmosphere. The experiment was carried out by modern resonator spectroscopy methods on the laboratory air at atmospheric pressure. The shape of the line under the real atmosphere was found to fit the Van Vleck-Weisskopf profile within experimental accuracy. The air broadening parameter value was defined as 2.14+/-0.07 MHz/Torr. The observed atmosphere oxygen line central frequency was found to be shifted down at about 150 MHz from the line center measured at low pressures, which gives a value of -0.19+/-0.08 MHz/Torr for the air shift parameter. A comparison with previous investigations is presented and reprocessing of some experimental results of other authors was carried out. Results of reprocessing agree with the findings of the present paper. Copyright 2001 Academic Press.