[Thoracic endometriosis and catamenial pneumothorax].

It was analyzed own experience of diagnosis and treatment of catamenial (menstrual) pneumothorax and thoracic endometriosis and literature review. It is shown that catamenial pneumothorax has specific clinical and instrumental signs allowing to establish the diagnosis before surgery. It was proposed surgical treatment including the removal of trans diaphragmatic way of pneumothorax development, removal of thoracic endometriosis and the establishment of reliable pleurodesis. It was demonstrated that this volume of surgery can be successfully implemented by using of thoracoscopic access. Relapse prevention includes hormonal therapy for the 6 months after surgery under the supervision of an obstetrician-gynecologist.

[Videothoracoscopic treatment of postoperative bleedings and its' complications by thoracic traumas].

35 patients, operated on the thoracic trauma (ISS - 9±3), had videothoracoscopy on the reason of the continued bleeding (n=6), clotted hemothorax (n=27) or pleura empyem (n=2). The best results were obtained in case of the clotted hemothorax thoracoscopic evacuation within 3 days after bleeding. Even the late use of videothoracoscopic procedures for the treatment of postoperative complications shortens the hospital stay in comparison with the traditional methods. The video-assisted thoracoscopic surgery is an accurate and safe method for the postoperative bleeding complications in hemodynamically stable patients.

[The surgical treatment of the pleural empyem].

The treatment results of the 286 patients with pleural empyem after thoracic injuries (n=107) and closed trauma of the pleural cavity (n=179) were retrospectively analyzed. The frequency of pleural empyem was 1.39% by injuries and 1.34% by the closed thoracic trauma. 15 (14%) patients of the first group developed the bronchopleural fistula, whereas the complication was observed in 32 (17.9%) patients of the second group. The adequate pleural drainage with intrapleural enzyme therapy in acute inflammation period allowed recovery in 78% and 71.9% of patients, respectively. Early videothoracoscopic sanation of the pleural cavity shortened the recovery time in more then 1.5 times. The chronization of the empyem was more often observed after the closed thoracic trauma - 14.5% rather than 6.5% after the open thoracic injury. The lethality rate by pleural empyem was 14% after the open injuries and 15.6% after the closed trauma.

[Thoracic ultrasound in penetrating chest trauma: the tactics management].

The thoracic ultrasound for the detection of hemothorax and hemopericardium was performed in 655 patients with penetrating thoracic trauma. Ultrasound findings were compared with the results of surgical exploration. Sensitivity and specificity of ultrasound in detection of hemothorax was 72.1 and 90.1%; in detection of hemopericardium - 70.6 and 73.7%, respectively. The results of the US diagnostics depended on patients' position (supine or when seated) and on time interval between the examination and surgery. The isolated US investigation in supine position leads to the increase of false negative results. We consider that in hemodynamically stable patients the doutbtfull US data in detection of hemopericardium is the indication to videothoracoscopy. The lower-chest injuries with the US signs of hemothorax are considered to be the indication for VATS except for the obvious left-side thoracoabdominal injuries.

[The preoperative thoracic X-ray for tactical decisions for the thoracic injuries treatment].

Data of 379 patients with penetrating thoracic wounds were analyzed. The pathologic changes on X-ray of the thoracic cavity were registered 239 (63,1%) patients: the hemothorax was diagnosed in 44,3%, pneumothorax - in 26,8% and hemopneumothorax - in 28,9%. 154 patients had videothoracoscopic surgery and 225 patients were operated on using traditional open methods. Operative findings were compared with X-ray data. The sensitivity of plain chest radiography in diagnostics of hemothorax was 52,1%, the specificity - 92,1%. Mistakes of interpreting X-ray data in diagnosing of low-volume hemo- or pneumothorax were defined. The computed tomography of the thorax proved to be the most precise means of intrapleural injuries diagnostics. The optimal algorithm of preoperative thoracic X-ray was suggested.

[Septic complications of penetrating thoracic injuries].

224 cases of septic complications after penetrating thoracic injuries were analyzed. Pleura empyem was observed in 105 of 7572 patients (overall number of the injured), lung abscess - in 22 cases, pericarditis was diagnosed in 108 patients, costal and sternal osteomyelitis - in 26 and mediastinitis - in 21 patients. Overall frequency of septic complication was 2,96%. Main reasons of septic complications were: massive blood loss, initial contamination, thoracotomy through the initially infected wound, long -lasting and coagulated hemothorax and late diagnosis and hospitalization. Staphylococcus aureus was the most frequent microbe detected - 29,4%. Lethality rate was 9,8% (22 patients). Adequate drainage of the wound allowed rehabilitation of the majority of patients. Cases with costal osteomyelitis required major surgical dissection in 73,1%.

[Traumatic gunshot wounds of neck, thorax and abdomen].

Basing on the largest experience in the country, authors characterize the dynamics of growth, localizaton and severity of wounds from traumatic (nonlethal) weapon. Every third victim with neck wound had deep neck structures damage. Open wounds of thorax and abdomen, though performed from traumatic weapon, pose a certain life threat.

[Shock score and surgical tactics for thoracic injury treatment].

Results of surgical treatment of 216 patients with thoracic injuries were retrospectively analyzed. 111 (51,4%) were operated on with the use of open technologies, whereas the rest 105 (48,6%) patients were treated with the use of videothoracoscopy. Patients were divided into 2 groups according to the shock score value. Was demonstrated, that videothoracoscopic operation was reasonable by shock score value less then 1,5. In patients with the shock score value more then 1,5, open surgery was more appropriate. Success of videothoracoscopic injury repair is stipulated also by detailed preoperative diagnostics, detecting the extent of the injury of the thorax and wounds of other regions, requiring urgent treatment.

[Thoracoskopy in diagnosis and treatment of lung injuries].

The thoracoscopy was used at 150 patients with penetrating wounds of thorax. Severity of injury according to ISS scale was 9.02+/-1.1 scores, RTS criteria - 7.84+/-0.0 scores, and TRISS - 99.8+/-0.1%. Lung injuries were diagnosed at 71 (47.3%) patients. Features of various wounds of lung and methods of closure have been analyzed. Bleeding, air intake and intrapulmonary hematoma were the indications for hermetic closure of wound canal. Coagulation of lung wound was performed at 24 (33.8%) patients, closure with endosurgical techniques - 30 (42.2%); the wounds have not been closured at 8 (11.3%) patients. Conversion to thoracotomy was necessary at 5 (7%) patients with deep wounds of lung. The thoracoscopic surgical procedure has been completely performed at 58 (81.7%) patients. The better postoperative results were achieved after endosurgical closure of lung wounds. Computed tomography is perspective method of preoperative diagnosis of lung injury severity.

[Thoracoscopy in the treatment of intrapleural bleeding due to injury of chest wall vessels].

Thoracoscopy was used in the treatment of 141 patients with penetrating wounds of chest. Injuries of chest wall vessels were diagnosed at 68 (48.2%) patients. Rate of thoracoscopy conversion due to bleeding from chest wall wounds was 4.3%. Thoracoscopy is effective at injuries of intercostals arteries and their muscular branches, but injuries of internal thoracic artery require conversion into thoracotomy at 50% cases. It is revealed that expediency of thoracoscopy is in direct proportion to time from injury point and is inversely to hemothorax volume.

[Video-thoracoscopy in the treatment of patients with penetrating wound of the thorax].

Thoracoscopic surgical procedures were used in the treatment of 79 patients with penetrating wound of the thorax complicated by hemothorax. Small hemothorax was diagnosed in 72.1% patients; 56.1% had injuries of thoracic organs, 26.3% -- injuries of diaphragm. Thoracoscopic hemostasis and correction of intrathoracic injuries were performed in 84,6% patients. Conversion to video-assisted minimally-invasive thoracotomy (because of injuries of the diaphragm as a rule) occurred in 15,8% patients, conversion to typical thoracotomy -- in 3.5%. In medium hemothorax (16.4% patients) injuries of thoracic organs and anatomic structures were diagnosed in 76.9% cases. Hemostasis and correction of intrathoracic injuries through thoracoscopic approach were performed in 43.8% patients, conversion to typical thoracotomy was necessary in 7% cases. Big hemothorax was diagnosed in 11.4% patients, 55.6% of them had injuries of thoracic organs and anatomic structures. Complete thoracoscopic procedure was performed in 44.4% cases; 33.3 patients required conversion to thoracotomy. Thoracoscopy is an effective method of surgical treatment of thoracic injuries in patients who don't require urgent thoracotomy. This procedure permits repair of intrathoracic injuries in 73.4% cases. Postoperative complications were seen in 15% cases, postoperative lethality was 1.4%.

[Thoracoscopy in surgery of thoracic wounds]. / Rol' torakoskopii v khirurgii ranenii grudi.

One hundred and sixty-eight thoracoscopic operations were performed in patients with closed (47.5%) and open (52.5%) trauma of the chest. Thoracoabdominal injuries were diagnosed in 23.9% patients. Thoracoscopic surgeries were performed in 79.8% patients, surgeries from the mini-approach - in 17.3%. Injuries uncorrectable by endosurgically were diagnosed during thoracoscopy in 2.9% patients. Indications for urgent thoracoscopy in thoracic injuries are the following: 1) middle and small hemothorax or hemopneumothorax; 2) suspicion for heart wound; 3) suspicion for diaphragm injury; 4) tense pneumothorax. Surgical policy and technique of endosurgeries in open thoracic trauma are optimized. Up-to-date surgical policy based on thoracoscopy permitted us to improve results of surgical treatment: to reduce lethality by 4.7%, number of complications - 2.9 times and completely avoid unjustified 'diagnostic' thoracotomies. Mini-invasive surgical methods promoted early rehabilitation of patients with trauma of the chest.

[Vertical gastroplasty as a treatment method in morbid obesity]. / Vertikal'naia gastroplastika kak metod lecheniia morbidnogo ozhireniia.

Since November 1992 in the RRCS. RAMS 38 patients aged 16-61 years (mean body mass 149.9 kg) for obesity of 3-4 grade underwent operation of vertical gastroplasty (VGP) by E. Mason's method. In 78.9% of patients uncomplicated course of early postoperative period was observed. One patient died due to thromboembolism of pulmonary artery. Two patients underwent regastroplasty due to tearing away of the staples of vertical mechanical suture and restoration of body mass (BM). Up to now stabilization of BM was detected in 19 patients. In this group mean values of surplus BM lowering made up 54.1% and maximal--60.1%. Positive influence of performed operations on the course of majority of the concomitant diseases in the absence of serious metabolic after-effects was observed. Initial results of operations seemed to be favourable, but for final conclusions about the effectiveness of VGP in far off period the accumulation of the experience and prolongation of follow-up period together with standardization of operation procedure are necessary.

[Results of use of sandostatin in pancreatoduodenal resections]. / Rezul'taty ispol'zovaniia sandostatina pri pankreatodyodenal'nykh rezektsiiakh.

From February 1995 to July 1996 pancreato-duodenal resection has been performed in 12 patients in RCS (7 men and 5 women, mean age 53.6 years). The operation was indicated in malignant tumors of the pancreatic head, big duodenal papilla, distal part of common bile tract (9 patients); benign diseases of pancreas (3 patients). Sandostatin (0.3 mg/day for 4-7 days) was used in all cases to prevent postoperative pancreatitis and pancreato-jejuno-anastomosis incompetence. The levels of alphfa-amylase, blood glucose, leucocytes were monitored, as well as the duration of pancreato-jejuno-anastomosis drainage use, rate and seriousness of postoperative complications and duration of in-patient treatment. The results were compared to a control group, consisting of 6 men and 6 women (mean age 53.8 years) with malignant tumours of big duodenal papilla, head of the pancreas, common bile tract. The use of Sandostatin has decreased the level of alphfa-amylase in the first postoperative day to 292.8 +/- 152.2 u/l vs. 594.9 +/- 368.79 in a control group (p > 0.05), duration of the drainage use: 6.1 +/- 1.5 days vs. 12.9 +/- 7.2 days (p < 0.05). The number and rate of severity of postoperative complications were significantly less: 58.3% vs. 100%. The frequency of pancreato-jejuno-anastomosis incompetence has decreased 3 times; the rate of abdominal cavity abscesses has decreased by 30%, the number of bile tract complications has decreased too (1 vs. 2). The rates of postoperative mortality were 8.3% in both groups. The use of Sandostatin made it possible to decrease the frequency and severity of postoperative complications and decrease the duration of in-patient treatment.

[Basic principles of surgical policy in complicated chronic pancreatitis]. / Osnovnye printsipy khirurgicheskoí taktiki pri oslozhnennom khronicheskom pankreatite.

The paper presents some experience with surgical treatment of 183 patients with complicated forms of chronic pancreatitis. The type of a surgical intervention depended on the pattern of pancreatic morphological changes. Operations of internal drainage of the pancreas in 103 patients with ductal hypertension provide the largest percentage (92.4%) of good and satisfactory results. Resectional methods of surgical treatment for chronic pancreatitis (n = 36) without signs of intraductal hypertension and with the prevalence of predominant lesions in some portions of the gland yield 80% good and satisfactory results. The incidence of postoperative complications following pancreatic resections is higher than those after drainages (16.2 versus 11.6%). The paper gives a concept of combined operations on the pancreas and bile ducts in chronic pancreatitis complicated by stricture of the distal common bile duct, revealed in 24.4% of cases.

[Diagnosis and treatment of neoplastic diseases of extrahepatic bile ducts and major duodenal papilla]. / Diagnostika i lechenie opukholevykh porazhenii vnepechenochnykh zhelchnykh protokov i bolshogo sosochka dvenadtsatiperstnoi kishki.

Fifty-three operations were conducted on 48 patients for tumors of the extrahepatic bile ducts and the major duodenal papilla. Early diagnosis of this pathological condition is very difficult, which affects directly the results of treatment; 18% of patients underwent radical operations. Modern diagnostic methods--computer tomography, ultrasonic examination, and endoscopic retrograde pancreatocholangiography made it possible to detect neoplastic diseases in all of the examined patients. Radical surgical treatment is expedient in distal localization of the neoplastic process and in the absence of metastases. Endoscopic and puncture methods of decompression of the bile ducts are indicated in diffuse forms of the disease.

[Long-term results in surgical treatment of chronic pancreatitis]. / Otdalënnye rezultaty khirurgicheskogo lecheniia khronicheskogo pancreatita.

The work analyses 141 patients who were operated on for primary chronic pancreatitis which was caused by alcohol abuse in 84.4% of cases. The patients were divided into 2 subgroups according to the damage to the pancreas: 1--with dilatation of the pancreatic duct (49.6%), 2--without dilatation of the pancreatic duct (50.4%). Internal drainage of the duct system and their associated cysts was the main method of management of patients of the first group (52 patients). Patients of the second group were subjected to various resections of the pancreas (24) and occlusion of the ducts with a polymeric composition (19). In 38 cases the operation on the pancreas was complemented by operations on the biliary tract, stomach, and duodenum. Various postoperative complications were encountered in 27 (19.1%) patients, mortality was 5.7%. The results were most favorable after operations for internal drainage, resection of the organ, and external drainage of the cysts. Irrespective of the type of the operation, progressive fibrous degenerative changes of the gland with a statistically significant (p < 0.05) reduction of its size was noted in the late-term period. The method of occlusion of the duct system was marked by the greatest number of poor results. Strict argumentation of the indications for the use of each type of operation makes it possible to obtain good and satisfactory late-term results in 85.6% of cases.