Endovascular Occlusion of Giant Posttraumatic Pseudo-Aneurysm of Superior Mesenteric Artery Connected to Mesenteric Arteriovenous Fistula.

The aim of the study was to show the capabilities of endovascular occlusion of giant posttraumatic pseudo-aneurysm of superior mesenteric artery (SMA) connected to a mesenteric arteriovenous fistula (AVF) under the conditions of portal hypertension and life-threatening esophageal variceal bleeding. MATERIALS AND METHODS: A 27-old male patient underwent endovascular occlusion; the patient being hospitalized with a clinical picture of gastrointestinal bleeding. The examinations: ultrasound, esophagogastroduodenoscopy, multispiral computed tomography with angiography - revealed the source of bleeding to be esophageal varices against the background of portal hypertension caused by massive arteriovenous shunt, its source being AVF with an aneurysmal component (32×35 mm in size) between SMA and superior mesenteric vein (SMV) dilated up to 50 mm in diameter. Patient's past medical history recorded that 4.5 years ago the patient had undergone the resection of a small intestine area due to a penetrating stab wound in the abdominal cavity. Taking into consideration an extremely high operative intervention risk due to the condition severity related to blood loss, portal hypertension, and ascites, it was decided to embolize AVF with a vascular occluder - Amplatzer Vascular Plug II (USA), 14×10 mm in size. RESULTS: A unique endovascular intervention - transcatheter occlusion of pseudo-aneurysm and AVF separation - was performed in life-threatening esophageal variceal bleeding under the condition of a giant post-traumatic aneurysm of SMA and mesenteric AVF. Due to an extremely large-sized SMV and an arterial pseudo-aneurysm, first ever we used the technique applied for transcatheter occlusion of a cardiac septum defect.Occluder implantation enabled to completely close the communication of aneurysmatic AVF with SMV, and occlude the aneurysm cavity. During an immediate postoperative period portal hypertension was arrested. No recurrent bleedings occurred within 4 postoperative months.

[Perforative appendicitis in the left-sided false diaphragmal hernia]. / Perforativnyi appenditsit v levostoronnei lozhnoi diafragmal'noi gryzhe.

Abnormal localization of the appendix in hernial sac occurs in 2-4% of cases. Appendix is often found in inguinal and femoral hernias. Localization of the appendix in diaphragmatic hernia is described as a casuistic case. Case report of successful surgical treatment of a patient with perforated appendicitis in the left diaphragmatic hernia is presented.

[Blunt abdominal trauma with intestinal damage]. / Zakrytaia travma zhivota s povrezhdeniem kishechnika, izolirovannaia i sochetannaia.

The last decades are characterized by advanced incidence of injuries with the share of abdominal injuries 1.5-18%. Blunt abdominal trauma is characterized by high incidence of complications and mortality due to severity of injury of internal organs and difficult diagnosis. The article presents 3 case reports of isolated and combined abdominal trauma followed by intestinal injury. Patients were treated at the department of emergency surgical gastroenterology of Sklifosovsky Research Institute for Emergency Care in for the period from August 2017 to February 2018.

[Ileocecal intussusceptions]. / Ileotsekal'naia invaginatsiia kishechnika.

AIM: To present treatment of patients with ileocecal intussusception. MATERIAL AND METHODS: There were 3 patients with ileocecal intussusception for the period from June 2016 to August 2017. CONCLUSION: Abdominal sonography is main diagnostic method for intestinal intussusception. X-ray examination including contrast-enhanced irrigography gives more complete information about suspected intussusception. It is necessary to differentiate intestinal intussusception from other diseases accompanied by abdominal pain, vomiting, bloody discharge from rectum, abdominal neoplasm. Minimally invasive laparoscopic approach is advisable for diagnosis and treatment of intestinal intussusception.

[Endovascular and surgical treatment of a patient with traumatic rupture of the aorta and hepatic artery].

Traumatic rupture of the aorta is the second most common cause of death in closed chest injury. The latest findings of autopsy showed that 80% of lethal outcomes in aortic injury occur in the prehospital period. Taking into consideration the incidence and high rate of death prior to the diagnosis stage, aortic rupture in closed thoracic injury is an important problem. Due to the characteristic mechanism of the development (during sharp deceleration of the body) this type of traumatic lesion of the aorta became known as "deceleration syndrome". The most vulnerable to tension aortic portion is its neck where the mobile part of the thoracic aorta is connected to the fixed arch in the place of the arterial ligament attachment. Open surgical intervention in patients with severe closed chest injury (often concomitant injury) is associated with high mortality and complications. Currently endovascular prosthetic repair of the aorta is a method of choice at the primary stage of treatment of patients with aortic injury. In this article we present a rare case report of concomitant lesion of large vessels (the descending aortic portion and proper hepatic artery) in a patient with severe concomitant injury, as well as peculiarities of diagnosis and combined treatment (endovascular prosthetic repair of the aorta and hepatic artery with an aotovein).

[The difficulties of diagnosis and treatment of non-occlusive mesenteric circulatory disorders].

AIM: To review one of actual problems of emergency surgery - diagnosis and treatment of patients with non-occlusive mesenteric circulatory disorders. MATERIAL AND METHODS: The article presents the clinical observations showing the ambiguity of clinical picture, features and challenges of diagnosis, treatment of disease and opportunities for positive outcomes. Diagnostic methods are x-ray, abdominal ultrasonography according to which acute abdominal ischemia may be assumed. However, in all unclear cases diagnostic videolaparoscopy is mandatory to determine further tactics. Unfortunately diagnostic videolaparoscopy is not always interpreted comprehensively and not a definitive method of diagnosis. Wide surgical access is usually necessary for non-occlusal acute violation of mesenteric circulation and volume of surgery varies from segmental to subtotal intestinal and colic resection with obligatory enteral intubation and decompression. Thus, complex pre- and postoperative treatment is required.

[Emergency fiberoptic bronchoscopy for diagnostics and treatment of lung atelectasis].

The article deals with results of fiberoptic bronchoscopy using during treating of patients suffering atelectasis. According to the research atelectasis is likely to advance in the first three days after serious patients have been admitted to the intensive therapy unit or after operative treatment. Left-sided atelectasis is half as widespread again the right-sided one. The research highlights the effectiveness of atelectasis X-ray diagnosis. Fiberoptic bronchoscopy in almost all the cases allowed diagnosing the degree of tracheobronchial tree obstruction and its causes. Single suction fiberoptic bronchoscopy leads to normalization and encouraged positive dynamics in 76% of all the cases (57 patients). Repeated endoscopic sanation in the first two days was necessary for 25 patients (25.3%) with unresolved or reoccurring atelectasis. The effectiveness of second research was to 84%. It's important to add that mostly patients with serious chest injury were subjected to unresolved or reoccurring atelectasis. And mainly in these cases blood was seen through the tracheobronchial tree lumen.

[Gastric and intestinal scintigraphy in the complex diagnosis of small bowel obstruction].

An algorithm has been developed for radiation diagnosis of small bowel obstruction, which involves abdominal X-ray and ultrasound studies at the first stage and radionuclide evaluation of gastrointestinal transit, by using 100-150 ml of aqueous 99mTc-technefite or 99mTc-bromeside solution in a dose of 50-100 MBq (radiation load 0.7-1.4 MeV) per os. The sensitivity, specificity, and diagnostic efficiency of the whole radiation diagnostic complex and each procedure separately were determined by the results of examination in 180 patients with suspected small bowel obstruction, of whom 104 patients were operated on, but obstruction ceased during medical treatment. Inclusion of the radionuclide technique into the diagnostic complex involving plain radiography and ultrasonography was shown to enhance diagnostic efficiency up to 97-98%.

[Treatment of intestinal insufficiency syndrome in patients with peritonitis]. / Lechenie sindroma kishechnoi nedostatochnosti u bol'nykh s peritonitom.

Results of the treatment of 90 patients with generalized peritonitis and syndrome of intestinal insufficiency were analyzed. In the study group (45 patients) enteral administration of 1% pectin solution and glutamin solution (15-30 g/day) were included in combined therapy. Clinical and laboratory control, radiation monitoring and bacteriological studies carried out for evaluation of efficacy of therapy established. A decrease of endogenous intoxication and time of repair of functional activity of the gastrointestinal tract, immunomodulation, normalization of microbiocenosis of the small intestine. This therapy diminishes the number of complications and lethality.

[Choice of surgery scope in occlusive obstruction of the colon]. / Vybor ob''ema operativnogo vmeshatel'stva pri obturatsionnoi neprokhodimosti obodochnoi kishki.

From 1980 five hundred and seventy-three patients underwent surgery for occlusive obstruction of the colon (OOC). Radical surgeries (left-sided hemicolonectomy, Hartman's surgery, subtotal colonectomy) were performed in 440 (77%) patients, 133 (23%) patients underwent palliative surgeries. One hundred and sixty-one patients of radically operated underwent one-stage surgeries (93 right-sided hemicolonectomies and 68 subtotal colonectomies). Postoperative lethality after radical surgeries was 16.5%. Postoperative lethality, time of hospital stay, rate of postoperative complications after Haptman's surgery and subtotal colintcyomy don't differ, but patients after subtotal colonectomy don't require reconstruction surgery.

[Toxicity of mushrooms Paxillus involutus and Paxillus atrotomentosus]. / K voprosu o toksichnosti gribov vida svinushka tonkaia i tolstaia.

Thirty-eight patients with mushroom (Paxillus involutus and Paxillus atrotomentosus) poisoning were treated. Slight poisoning (acute gastroenteritis) was diagnosed in 17 patients, medium-severe in 13, severe in 6, and extremely severe in 2 patients. Changes in the LPO-AOD system correlated with the severity of hepatorenal involvement. The treatment included hepatotropic therapy; patients with acute renal failure were treated by hemodialysis. Paxillus mushrooms induced functional evacuatory disorders in the small intestine. Eleven patients with adhesions in the abdominal cavity developed ileus. Two patients died: a man aged 26 years after eating fried (not boiled) mushrooms and a woman aged 76 years with ileus with symptoms of multiple organ dysfunction. The rest patients were discharged from hospital in satisfactory condition. Clinical course of poisoning with Paxillus mushrooms is discussed.

[X-ray diagnostic features of giant bleeding ulcers in stomach and duodenum]. / Rentgenologicheskie osobennosti diagnostiki gigantskikh krovotochashchikh iazv zheludka i dvenadtsatiperstnoi kishki.

The study was based on the analysis of clinical, X-ray, and morphological examinations made in 64 patients with giant gastric and duodenal ulcers. All the patients were admitted for gastroduodenal hemorrhage. Among the examinees, there were 28 patients with giant ulcer of the stomach and 26 with that of the duodenum. The authors present the methods of X-ray examinations and the X-ray symptomatology of giant ulcers of the stomach and duodenum. Gastroscopic and X-ray examinations were comparatively analyzed. The paper gives evidence that the X-ray examination has many advantages in estimating the size and ratio of ulcers to the adjacent organs and tissues. The paper outlines giant duodenal ulcers. The authors identify two groups of patients with giant ulcers of the duodenal bulb, which differ in its size and the extent of deformity. One of valid signs of the penetration of giant ulcers is not only their size, but their depth and fixation to the adjacent organs and tissues.

[Use of ultravist to examine the gastrointestinal tract in patients with emergency abdominal pathology]. / Ispolzovanie ultravista dlia issledovaniia ZhKT u bolnykh s ékstrennoi abdominalnoi patologiei.

The paper deals with the results of using the nonionic water soluble contrast agents ultravist 300 and ultravist 370 (Schoring, Germany) to examine the gastrointestinal tract (GIT) in 21 patients with acute abdominal abnormality. GIT contrasting was made in 9 patients in the early postoperative period and in 12 patients on their admission to the Institute. The examinations revealed the high contrast rate of the above agent when administered into the stomach and upper small intestine, which excluded failure of gastroenteroanastomic sutures and the sutured gastric wall in 2 patients, established, in terms of gastric displacement and deformity, left-sided subdiaphragmatic abscess, and in terms of transposition of a portion of the gastric fornix into the pleural cavity, rupture of the left diaphragm, and to exclude diaphragmatic rupture with closed abdominal injury. The revealed important quality of ultravist within a short time (1-2 hours) to contrast the small intestine and enter the colon enabled differential diagnosis to be made between complete and partial small intestinal ileus and between early comissural small intestinal ileus and postoperative intestinal paresis. Ultravist contrast studies allowed the authors to avoid an emergency operative intervention and to follow up the resolution of ileus during medical therapy.

[X-ray diagnosis features of acute bleeding ulcers of the stomach and duodenum]. / Osobennosti rentgenodiagnostiki ostro krovotochashchikh iazv zheludka i dvenadtsatisperstnoi kishki.

The paper is based on the analysis of clinical, X-ray, and morphological studies in 74 patients with massive gastrointestinal hemorrhage who were treated at the hospitals of the N.V. Sklifosofsky Research Institute of Emergency Care, in 1991-1994. Among the examinees, there were 28 with medio-gastric ulcer and 44 with parapyloric ulcers. In 2 patients bleeding occurred with the anastomosis ulcers of the stomach operated on. The paper presents the specific features of X-ray studies of patients with bleeding gastroduodenal ulcers. X-ray studies should be twice performed in these patients. The first study is conducted if gastroscopic findings are unclear, the repeated one is carried out while assessing changes in disease regression. The emergency gastroscopic and subsequent X-ray studies have demonstrated that acute ulcers may be at various sites and multiple. X-ray diagnosis of bleeding ulcers is determined by their sites and the nature of an ulcerous process. The X-ray diagnosis of chronic callous gastric ulcers accompanied by hemorrhage was based on the detection of two direct symptoms of a "niche" on the gastric outlines and configuration and an inflammatory mound on the gastric outline and configuration. That of chronic bleeding ulcers of the duodenal bulb is based not only on searches for the basic symptom of peptic ulcer -"niche", but other signs of the disease-the deformed organ, and the magnitude of a periprocess. Gastroduodenoscopy is applied not only for the primary diagnosis of a hemorrhagic source, but a therapeutical technique. However, the use of endoscopy alone in patients with gastroduodenal hemorrhage did not give a comprehensive idea of the magnitude of ulcerous changes, organ-specific deformity, and a periprocess.

[X-ray characteristics of acute intestinal obstruction in middle-aged and elderly patients]. / Rentgenologicheskie osobennosti ostroi kishechnoi neprokhodimosti u lits pozhilogo i starcheskogo vozrasta.

The authors presented clinical and x-ray findings of 188 patients with mechanical intestinal obstruction (92 of them were middle-aged and advanced in years and 96 were under 60). A combined program of x-ray examination included 3 stages: panoramic polypositional roentgenography of the chest and abdominal cavity, dynamic x-ray control over the state of the abdominal cavity, and contrast study of the G.I. tract. A distinctive feature of the x-ray symptomatology of intestinal obstruction in middle-aged and old patients was the absence of classical x-ray symptoms in some cases during panoramic roentgenography of the abdominal cavity. In patients over 60, x-ray symptomatology was characterized by marked colon distension and intestinal distension of various degree in 77.1%