[Advanced regenerative rehabilitation technologies. Successful use of autologous adipose tissue in a patient with cutaneous tracheal fistula]. / Sovremennye tekhnologii regenerativnoi reabilitatsii patsientov. Opyt uspeshnogo ispol'zovaniya autologichnoi zhirovoi tkani u patsienta s kozhno-trakheal'nym svishchom.

According to the published data, the rate of fistula formation in the postoperative period ranges from 0.3% to 29%. Currently, due to the high risk of suture failure in the postoperative period and tracheal and esophageal fistulas formation, the options for fistulas treatment by the regenerative rehabilitation methods are under consideration. The frequency of fistula healing and reduction of scar deformities after adipose tissue autografting ranges from 43% to 55%. OBJECTIVE: To develop the minimally invasive technology for postoperative fistulas treatment and describe the real-world experience of its use in terms of hospital stay reduction and patients' quality of life improvement. MATERIAL AND METHODS: Patients were selected as part of a pilot research project (Development of Personalized Approaches to Regenerative Rehabilitation for Surgical Patients, # 0394-2020-0011). Patients' quality of life was assessed using the Russian version of the EQ-5D-5L questionnaire (Russian version for Russia). This article presents a clinical example of successful repair of a cutaneous tracheal fistula by autografting of adipose tissue three months after fistula formation. RESULTS: In one month after autografting of adipose tissue, the tracheobronchial secretion through the fistula has stopped. According to the follow-up computed tomography of the neck and tracheobronchoscopy, the fistulous passage is not observed. CONCLUSION: The presence of a fistula worsens the patient's quality of life and increases the risk of secondary infection. When treating patients with tracheal fistulas of high and extremely high surgical risk, the method of autografting of adipose tissue can be a safe and effective alternative to conventional surgery. Further study of this method of regenerative rehabilitation is required.

[Optimal dates of surgery for acute calculous cholecystitis]. / Vybor optimal'nykh srokov vypolneniia operativnogo vmeshatel'stva pri ostrom kal'kuleznom kholetsistite.

OBJECTIVE: To analyze the results of surgical treatment of acute calculous cholecystitis depending on dates of surgery. MATERIAL AND METHODS: There were 123 patients with acute calculous cholecystitis in 2017. The sample enrolled 111 females (90.2%) and 12 (9.8%) males. Mean age of patients was 63.4±5.7 years. Patients were divided into 4 groups depending on dates of surgery. Group A - 18 (16.2%) patients with destructive forms of cholecystitis. These patients underwent surgery after a short preoperative preparation. Group B comprised of 32 patients (28.8%) who were operated within 72 hours. Group C enrolled 34 patients (30.7%). These patients underwent operation within 7-12 days after clinical manifestation of disease. Group D enrolled 27 patients (24.3%). Delayed surgical strategy was applied in this group. Surgical treatment was scheduled 2-3 months later. Duration of surgery, intraoperative technical features, length of hospital-stay and postoperative morbidity were studied. RESULTS: Similar outcomes were observed in groups A and B. Group B was characterized by less duration of surgery and hospital-stay. The most significant technical difficulties arose in group C. The best results were achieved in group D. CONCLUSION: Surgical treatment of acute calculous cholecystitis within 72 hours after clinical manifestation is the most preferable. However, surgical treatment should be performed in few months if medication is effective.

[EPISTAXIS DURING NASOTRACHEAL INTUBATION. ATTILA'S SYNDROME.]

BACKGROUND: Nasal bleeding is a common complication during nasotracheal intubation (NTI). This is due to the ana- tomical prerequisites and the hemostatic system failure. Using of various research methods in practice can reduce the frequency of such complications. The purpose of the study is to identify predictors of high probability of epistaxis associated with the NTI and the pecu- liarities of the anatomical mucous membrane structure of the nasal passages, and to assess significance of blood coag- ulationfailures in these cases. MATERIALS AND METHODS: 45 patients (f-25 and m-20), aged 23 to 47 years, with physical status I-IIASA were analyzed. Depending on the degree of surgical trauma manipulation during intubation were formed three groups of patients in whom the NTI was atraumatic, moderately traumatic and overly traumatic. During preoperative period all patients underwent a rhinoscopy. Intubation trauma of the trachea was assessed by visual analogue scale. The results and discussion. The study of the nasal mucosa structure showed that with atraumatic intubation (Group 1; n=9) were dominated by deep type of bedding nonplethoric nonkinking vessels (66.7% ofpatients (n=6)). During mod- erate trauma intubation (Group 2; n=24), superficial and deep vessels were found equally (50% and 50%). In patients with severe trauma during intubation (Group 3; n=13), 100% of the patients, the vessels were located superficially, 75 % were convoluted, plethoric, mucosa contact bleeding. There were no anatomical changes. CONCLUSION: The source of bleeding are superficial, plethoric, kinking vessels of the mucous membrane. Hypocoagu- lation disorders, observed in patients during reconstructive surgeries, exacerbate such bleeding and can lead to fatal complications.

[USE OF PROTECTIVE LUNG VENTILATION REGIMEN IN CARDIAC SURGERY PATIENTS.]

BACKGROUND: In cardiac surgery, protective lung ventilation and/or preventive brdnchoscopy (PB) are able to decrease lung injury effects of cardiopulmonary bypass (CPB) and mechanical ventilation. OBJECTIVES: define lung complication risks, evaluate the effect ofprotective lung ventilation (PLV) on lung functioning, and investigate the feasibility ofpreventive PB in higher pulmonary risk (PR) patients. MATERIALS AND METHODS: 66 patients participated in prospective randomized research. Allocation was based on PR and intraoperative mechanical ventilation type. PLV includedfollowing parameters: PCK PIP - up to 20 cm H20, Vt - 6 ml/ kg of PBW, PEEP - 5-10 cm H20, IE ratio - 1:1.5-1:1, EtCO2 - 35-42 mm Hg, FiO2 - 45-60%, lung ventilation during CPB, alveolar recruitment. Four groups were formed: A - higher PR plus PLV- B - higher PR plus conventional LV (CLV), C - lower PR plus PLV- D - lower PR plus CLV PIP PEEP dynamic compliance, p/f ratio and intrapulmonary shunt (Qs/Qt) were recorded. Seventeen patients of group A underwent PB. RESULTS: Advanced dynamic compliance, higher p/f ratio and lower Qs/Qt were seen in group A, in comparison with group B (p< 0.05). Lower Qs/Qt was seen in group C, in comparison with group D (p<0.05). Mucus obstruction of subsegmental bronchi was observed in 53.3% of higher PR patients. More than half ofpatients without PB sufferedfrom postoperative lung complications (70.4 vs. 34.2 7%, p

[DIAGNOSTIC AND THERAPEUTIC BRONCHOSCOPY IN PATIENTS UNDERGOING CARDIAC SURGERY IN INTRA- AND POSTOPERATIVE PERIODS].

The article presents research conducted to evaluate the use of diagnostic and therapeutic fiberoptic bronchoscopy in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis in patients in cardiac ICU. The paper presents the results of the study and comparison of invasive techniques for sampling from the respiratory tract for bacteriological analysis. We studied the bacterial profile of ICU, original content of the respiratory tract of cardiac patients in the intraoperative period and possible ways for prevention of VAP and tracheobronchitis in the postoperative period using bronchoscopy. In addition data on the effect of bronchoscopy on the respiratory and cardiovascular systems in cardiac surgical patients undergoing mechanical ventilation presented.

[THE DIAGNOSTIC AND THERAPEUTIC BRONCHOSCOPY IN CARDIAC PATIENTS UNDERGOING MECHANICAL VENTILATION IN THE POSTOPERATIVE PERIOD].

The review presents an analysis of domestic and foreign literature on the use of bronchoscopy in patients with obstructive respiratory failure in the ICU. Separately considered the issue of additional research when performing bronchoscopy and create an algorithmfor the application of diagnostic and therapeutic bronchoscopy in cardiac surgical patients undergoing mechanical ventilation.

[The results of endoscopic gastroduodenal, enteral and colorectal stenting for blastomatous stenosis: 8-year experience].

INTRODUCTION: Gastroduodenal, enteral and colorectal stenting of blastomatous stenosis is a reasonable alternative to operative treatment of unresectable tumors. Moreover in some cases it allows to gain time and to prepare the patient for radical surgery. MATERIAL AND METHODS: For the period from 2007 to 2015 in endoscopic department of acad. B.V. Petrovskiy Russian Research Center for Surgery 76 patients with piloroduodenal, enteral and colic stenoses successfully underwent self-expanding metal stents installation. There were 21 patients with malignant stenosis of the stomach and pilorobulbar area, 17 with secondary duodenal stenosis, 17 after gastrectomy and distal gastric resection; 2 with stenosing colorectal cancer, 4 patients with rectal cancer involving rectosigmoid junction, 7 with rectosigmoid junction cancer and 8 with sigmoid cancer. RESULTS: Ambulatory and hospital interventions were performed in 35.5% and 64.5% of cases respectively. Hospital-stay did not exceed 2 days. The total complication rate was 11.8% (9/76), 3 of 9 patients required surgical intervention. The attention is given to important technical aspects of intervention as well as to those clinical situations when stenting is inappropriate because of absence of favourable functional outcome. CONCLUSION: Stenting should be more actively implemented in clinical practice, especially in emergency surgical hospitals. However it requires adequate technical support of hospitals with different endoprostheses, because it provides simultaneous diagnostic survey and remedial procedure.

[Endoscopic treatment of advanced left colon cancer by stenting].

The aim of research is studying of technical capability of colorectal stenting, its clinical efficiency in permission of obstruction and an assessment of technique safety. Between October 2007 and January 2014 endoscopic stenting by self-expanding metal endoprostheses was successfully performed in 19 patients aged from 29 till 83 years with malig- nant stenoses of the left colon. Treatment was carried out in the endoscopic department of the Federal State Budgetary Institution "Petrovsky National Research Center of Surgery" under the Russian Academy of Medical Sciences. The colonic stent placement reached two intends: pre-operative decompression as the first stage of the treatment, allowing to prepare the patient safely to the surgical procedure without colostomy (6) and palliation in those cases in which the clin- ical condition is not feasible (13). In all patients stent insertion was technically successful. Common complication rate was 15.8% (3/19). Colorectal stenting in patients with bowel obstruction is absolutely justified due to allowing considerable life quality improving in inoperable patients and avoiding two-stage surgical treatment.

[Modern concept of endoscopic treatment of cicatrical esophageal anastomotic strictures].

Authors analyze their 25-year experience of endoscopic treatment of benign cicatrical strictures of esophagus and esophageal anastomotic strictures. Special attention is paid to technical aspects of bouginage of critical (diameter up to 2 mm) and substantial (3-5 mm of esophagus lumen) esophageal strictures. The advantages of the bouginage in comparison with balloon dilatation are substantiated. Basic principles of jatrogeny prevention are formulated, together with demonstration of complications, caused by too long stenting of the esophagus. The important role of planned sustaining bouginage for restenosis prevention is marked. Treatment tactics by excessive long esophagus strictures is defined.

[The treatment of the sponateneous biloma and choledocholithiasis after the liver resection on the reason of the giant hemangioma].

Patient with giant rapidly growing liver hemangioma who carried out right hemihepatectomy is reported. The feature if this case is choledocholithiasis after liver resection followed by its rare complication (spontaneous biloma) in 6 years after surgery. Minimally invasive procedures (percutaneous drainage, endoscopic papillotomy and stenting) eliminated each of bile collection and cause of biliary obstruction without surgical intervention.

[The use of self-expanding metal stents in tumors of biliopancreatoduodenal zone].

Nitinol self-expanding stents were used in treatment of 15 patients with blastomatous lesions of biliopancreatoduodenal zone. Stenting was successful in all cases, long-term results were obtained in all patients. Death occurred in 8 patients within 5,5-11 month after stent insertion. 7 patients remain under observation. In 6 patients nitinol stents remain open with no signs of occlusion from 2,5 to 15 months' observation period. Jaundice recurred in one patient after 11 month after the insertion due to stent occlusion. Thus, stenting proved to be an effective and safe method of bile flow restoration by tumor biliary tract obstruction.

[Surgical treatment of major duodenal papilla neoplasm]. / Opyt kliniki v khirurgicheskom lechenii raka bol'shogo sosochka dvenadtsatiperstnoi kishki.

Immediate and long-term results of pancreatoduodenal resections in 33 patients undergone surgery for adenocarcinoma of bile papilla from 1984 to 2003 were studied. Majority of patients had II and III stages of diseases. Correct diagnosis before surgery was made in 27 (81.8%) patients. Morphologic study revealed metastasis in 11 patients. Lethality was 9.1%, moreover last 18 pancreatoduodenal resections had no lethal outcomes. Long-term results were studied in 25 (83.3%) patients: 1-year survival was 90.4%, 3, 5 and 10 years survived 71.4, 61.2 and 51% patients respectively. Only metastatic lesion of lymph nodes and later stage of disease had negative influence on long-term results. Such factors as gender, diameter of carcinoma, lymphadenectomy and pylorus-saving variant of surgery did not influence on long-term results. It is concluded that pancreatoduodenal resection must be surgery of choice in the treatment of resected cancer of bile papilla.

[Surgical policy in patients with chronic calculous cholecystitis complicated by choledocholithiasis]. / Khirurgicheskaia taktika u bol'nykh khronicheskim kal'kuleznym kholetsistitom, oslozhnennym kholedokholitia.

Results of surgical treatment in 116 patients with chronic calculous cholecystitis complicated by choledocholithiasis were studied. Introduction in clinical practice of endoscopic papillosphincterotomy (EPST) and laparoscopic cholecystectomy changed surgical policy for benign combined lesions of gall bladder and extrahepatic bile ducts. Complex endoscopic treatment is preferable if contraindications are absent. Complex endoscopic treatment was used in 26.7% cases, combined surgical and endoscopic (trans-papillar surgeries) - in 30.2%, conventional surgical - in 33.6%. Isolated EPST and endo-biliary procedures were performed in 9.5% patients. Complex endoscopic treatment is preferable for chronic calculous cholecystitis complicated with choledocholithiasis. Combined and conventional surgical policy is indicated when appliance of endoscopic technologies is not possible.

[Intraoperative angioscopy in vascular reconstructive surgery]. / Intraoperatsionnaia angioskopiia v rekostruktivnoi sosudistoi khirurgii.

Based on the data available in the literature and their own findings, the authors analyzed the value of angioscopy in the reparative surgery of low limb vessels. Some cases of clinical application of intraoperative angioscopy are described and guidelines for the use of angioscopy as an intraoperative control of the quality of reparative surgery on low limb vessels.

[The use of angioscopy in the reconstructive surgery of vascular diseases of the lower extremities]. / Ispol'zovanie angioskopii v rekonstruktivnoi khirurgii sosudistykh zabolevanii nizhnikh konechnostei.

On the basis of the literature data and original research, the value of angioscopy in reconstructive surgery of vascular diseases of lower extremities is analyzed with a report of clinical application of intraoperative angioscopy. Practical recommendations for the use of angioscopy as a method of intraoperative control of quality of reconstructive operations on lower limbs vessels are provided.

[Endoscopic duodenobiliary drainage in the treatment of mechanical jaundice of blastomatous etiology]. / Endoskopicheskoe duodenobiliarnoe drenirovanie v lechenii mekhanicheskoi zheltukhi blastomatoznoi étiologii.

The experience of endoscopical treatment of 112 patients with blastomatous disease of extrahepatic biliary ducts was summarized. Principal method of biliary bypass was duodenobiliary drainage with the use of transpapillary endoprostheses. Endoprosthetic procedure was carried out in 79 (70.5%) patients, which gave the possibility in 14 of them after elimination of jaundice and cholangitis to perform radical operations. In 52 cases duodenobiliary drainage was used as the final palliative procedure. In 13 patients due to insufficient effect of prosthesis biliary draining procedures were used. The causes of failures in 33 (29.5%) cases were infiltrative growth of the tumor into bowel wall with stricture formation as well as high and extended lesion of hepaticocholedochus duct.

[Use of electron video-endoscopic system in the diagnostic and therapeutic endoscopy]. / Primenenie élektronnoi videoéndoskopicheskoi sistemy v diagnosticheskoi i lechebnoi éndoskopii.

Welch Allyn videoendoscopic system (USA) was used in 739 diagnostic and therapeutic investigations of 573 patients with various diseases of the gastrointestinal tract. Clinical experience has demonstrated the advantages of videoendoscope over common fibroscopes: it permits monitoring of the investigation by several specialists simultaneously, improves the training of specialists in endoscopy, permits recording and storage of endoscopic information, etc. At the same time videoendoscopes of this system are not devoid of shortcomings, i.e. the working part is too flexible, the image is frequently misrepresented during operation, this necessitating additional designing. On the whole videoendoscopic systems hold good promise in gastrointestinal endoscopy.