[Prospects for development of laparoscopic surgery in the Central Federal District of the Russian Federation]

OBJECTIVE

To analyze the achievements of laparoscopic surgery in the Central Federal District of Russia and outline perspective trends for further application.

MATERIAL AND METHODS

The study included adult patients with abdominal surgical diseases hospitalized in general surgical departments of the Central Federal District between 2014 and 2021. We analyzed the prevalence of elective and emergency laparoscopic surgeries. Incidence and results of laparoscopic interventions between 2018 and 2021 were estimated considering primary statistical data presented in the annual collections of the Chief Surgeon of the Ministry of Health of Russia «Surgical care in the Russian Federation».

RESULTS

The absolute number of laparoscopic surgeries in the Central Federal District increased from 23.686 to 80.489 (by 3.4 times) between 2014 and 2021. The annual number of elective laparoscopic surgeries exceeded the number of emergency ones up to 2019. In 2020-2021, this situation changed in favor of emergency abdominal procedures. Laparoscopic surgeries are the most common for in acute cholecystitis (71.06-81.10% of all laparoscopic interventions annually) and acute appendicitis (46.85-55.60%). In 2020 and 2021, the absolute number of laparoscopic appendectomies exceeded the number of laparoscopic cholecystectomies. These values are lower for perforated ulcers (15.44-20.39%) and acute pancreatitis (32.40-36.71%). Laparoscopic operations are rare for acute intestinal obstruction, strangulated hernia and ulcerative gastroduodenal bleeding. In elective surgery, high availability of laparoscopic surgeries was noted in patients with cholelithiasis (89.40-93.78%), hiatal hernia (62.12-77.27%) and adrenal gland diseases (64.23-87.25%). The most intensive increment of availability (by 2.4 times) was noted for inguinal hernia from minimum level (10.98%) in 2018 to 26.00% in 2021. Mortality after some laparoscopic operations decreased in comparison with laparotomy by 12-45 times (2018-2021). However, this aspect and results of laparoscopic surgeries in case of delayed hospitalization require additional study.

CONCLUSION

Analysis of laparoscopic surgery showed the timeliness of beginning and development of this direction In Russia. The prospect of further development of laparoscopic surgery for abdominal diseases is determined by modern trends. These are increase in the number of laparoscopic operations for acute appendicitis, acute cholecystitis and perforated ulcers, as well as higher number of early (after admission) operations.

[Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]

OBJECTIVE

To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications.

MATERIAL AND METHODS

We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021.

RESULTS

There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses.

CONCLUSION

We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.

[Results of treatment with oral anticoagulants in patients with lower limb deep vein thrombosis]

Analysed herein is the incidence rate of decompensated forms of venous insufficiency in patients who endured lower limb deep vein thrombosis and were prescribed either warfarin, rivaroxaban in therapeutic doses or rivaroxaban in a preventive dose. The study enrolled a total of 129 patients presenting with thrombotic lesions of deep veins of the lower limbs. The patients were divided into three groups depending on the anticoagulant therapy prescribed. Patients of the first and second groups for 6 months received warfarin and rivaroxaban, respectively, in therapeutic doses, and group three patients continued taking rivaroxaban in a therapeutic dose for a long time. RESULTS: Eighteen (36%) patients from the first group and two (4.5%) patients from the second group discontinued taking the anticoagulant before the scheduled date. Relapses of venous thromboembolic complications were observed in 11 (22%) group one patients and in 7 (15.9%) group two patients, with no relapses observed in the third group. Negative dynamics of the ultrasonographic picture was observed in two groups: 16% of group one patients and 9.1% of group two patients were found to develop signs of damage of previously unaltered veins or occlusion of a previously patent vein after endured thrombosis without clinical manifestation. Trophic disorders were observed in a third of patients of the first group and in one patient of the second group by the fourth year of follow up. None of the third group patients developed trophic ulcers. Statistically significant differences in the examined groups were obtained for such parameters as adherence to treatment and the degree of severity of venous insufficiency, in favour of rivaroxaban, with quality of recanalization being significantly better in the third group. A conclusion was drawn that prolonged preventive administration of new oral anticoagulants did not lead to the development of decompensated forms of venous insufficiency.

[Prevalence of thrombophilic conditions and genetic carrier status in neuroischaemic form of diabetic foot]

BACKGROUND

Diabetes mellitus a commonly encountered pathology in the whole world and has a tendency towards steady growth of morbidity and development of vascular complications. The presence of haemostatic disorders and genetic susceptibility to thrombosis in patients with diabetes mellitus increases the risk for the development of thrombotic complications.

AIM

The purpose of the study was to determine the incidence rate of thrombophilic conditions (TC) and thrombosis-associated gene carrier status (TAGCS) in patients suffering from neuroischaemic form of diabetic foot.

PATIENTS AND METHODS

The study enrolled a total of 38 patients undergoing treatment at the Department of Vascular Surgery for critical ischaemia of lower limbs combined with diabetes mellitus during the period from 2016 to 2018. There were 29 (76.3%) men and 9 (23.7%) women. The mean age amounted to 58.9±7.3 years. The diagnosis of TC and TAGCS was made based on the study for the presence of the markers of antiphospholipid syndrome, level of homocysteine and antithrombin III, proteins C and S, as well as comprehensive genetic study in order to reveal gene polymorphisms (prothrombin, Leiden mutation, MTHFR gene, MTR gene and others). Based on the obtained findings we calculated the incidence rate of TC and TAGCS, as well as their combinations in the examined patients.

RESULTS

In the studied group of patients we revealed various incidence of TC and TAGCS, and, most importantly, that of a combination of these conditions. All cases of thrombophilias were combined with TAGCS. Hyperhomocysteinemia was most commonly combined with the MTRR 66 A>G gene mutation, the presence of lupus anticoagulant - with PAI-1 675 5G>4G, whereas thrombophilic conditions - with MTRR 66 A>G and PAI-I - 675 5G>4G. Two patients were found to be carriers of the factor V Leiden mutation.

CONCLUSION

The examined patients were diagnosed as having TC or TAGCS, as well as their combinations in one form or another, thus increasing the risk for the development of thromboses and embolisms in such patients.

[Contemporary data on efficacy of anticoagulant therapy in recanalization of deep veins]

The article is a literature review containing a detailed description of anticoagulant therapy variants, their efficacy in recanalization of deep veins, as well as patients' compliance to treatment. Russian specialists have demonstrated that the processes of active re-organization of thrombotic masses, in some cases leading to complete clearing of the vessel's lumen from a thrombus, may be observed at terms from 3 to 6 months, with a failure to occur within the above period reportedly followed by formation of irreversible cicatricial-sclerotic alterations in the veins. That is why adequate anticoagulant therapy should be initiated promptly in order to prevent the development of irreversible alterations and a decompensated form of chronic venous insufficiency. The process of recanalization of the venous segments involved appears to primarily depend on efficacy of anticoagulant therapy. Of special attention is a class of novel oral anticoagulants characterised by high clinical efficacy, prolonged and relatively safe administration, as well as thrombolytic activity. The use of anticoagulant therapy, as well as adherence of patients to treatment make it possible to significantly decrease the frequency of a decompensated form of venous insufficiency and the need for reconstruction of the major veins.

[Pathogenesis and prevention of secondary thromboses and thromboembolic complications in patients with endured lower limb deep vein thrombosis]

The study was aimed at revealing the role of thrombophilic states in the pathogenesis of deep vein thrombosis and determining efficacy of pathogenetic prevention of venous thromboembolic complications. The study included a total of 84 patients presenting with lower limb deep vein thrombosis. The patients were subdivided into two groups. The patients of the Study Group (n=44) were examined for thrombophilic states, revealing of which was followed by prescribing specific lifelong therapy aimed at correction of the alterations revealed. The Control Group patients (n=40) received a carefully selected therapeutic dose of warfarin (until the value of the International Normalized Ratio was within the therapeutic range from 2 to 3) and were given recommendations on taking this agent for 6 months followed by discontinuation. The Study Group patients demonstrated less relapses of deep vein thromboses as compared with the Control Group patients. The symptoms of chronic venous insufficiency in the Study Group were also less pronounced. These results are in accord with the findings of ultrasonographic duplex scanning in the remote period after endured thrombosis. A conclusion was drawn on the necessity of carrying out further studies aimed at altering the recommended therapeutic regimen for patients in the remote period after sustained deep vein thrombosis.