SURGICAL TREATMENT OF COMPLICATED GASTRIC CANCER IN YOUNG AND MIDDLE-AGED PATIENTS.

The high frequency of complicated forms of gastric cancer in young and middle-aged patients is associated with faster and more biologically aggressive tumor growth, as well as with a delay in diagnosis. The study aimed to evaluate the efficacy, safety, and technical feasibility of surgical interventions for complicated forms of gastric cancer in young and middle-aged patients. We studied 98 patients with complicated forms of gastric cancer from IIB to stage IV according to the TNM8 classification with a predominant lesion of the antrum and body of the stomach. We performed open, laparoscopic, or robot-assisted surgeries of various scopes (R0 or R1), mostly gastrectomy and subtotal distal resection of the stomach. We compared the clinical manifestations of the disease, the time of surgery, intraoperative blood loss, postoperative complications, survival, and quality of life in 2 groups of patients divided by age: 19 young patients (mean age 39.4±4.4 years) and 79 middle-aged patients (mean age 53.9±5.8 years). Clinical manifestations of gastric cancer were more pronounced in young patients. The number of postoperative complications in patients of Group 2 was significantly higher (7.8% to 5.26%) compared to Group 1 (p<0.05). Rehabilitation in patients who underwent laparoscopic surgery was significantly (p<0.05) faster than with the traditional method. The overall survival of young patients with IIB-IV stages of gastric cancer was 0.8 months less, and among patients with III-IV stages it was 2.4 months less than in the group of middle-aged patients and did not depend on the surgery scope. There were no statistically significant differences between the groups in terms of intraoperative blood loss, duration of surgery and hospital stay. Increased surgery duration of in middle-aged patients significantly correlated with the number of postoperative complications. Extended surgeries do not significantly increase the number of lethal, life-threatening complications. Combined surgeries in the R0 scope in patients with advanced gastric cancer (including with carcinomatosis) improved the quality of life of patients yet did not increase in overall survival, which determines the reasonable limits of surgical aggression.

[ARRHYTHMIAS IN PATIENTS OPERATED ON FOR HIATAL HERNIA].

The purpose of this publication is to identify the prevalence of arrhythmia as one of the manifestations of gastrocardial syndrome in patients with hernias of the esophageal orifice of the diaphragm and reflux esophagitis. To evaluate the results of antireflux surgery in the dynamics of arrhythmia regression. Materials and methods: the study included 101 patients with hiatal hernias who were undergoing inpatient examination and treatment. Arrhythmia was detected in 35 (34.6%) of 101 patients with hernias of the esophageal orifice of the diaphragm. Arrhythmias are characteristic of cardiofundal (40%), subtotal (66.6%) and total (100.0%) hernias of the esophageal orifice of the diaphragm, were recorded at a younger age, were dependent on the duration of the underlying disease. Clinical manifestations of arrhythmia depended on the degree of shortening of the esophagus, most often arrhythmias occurred with shortening of the esophagus of the II degree in cardiofundal hernias (68.7%), subtotal (60.0%) and total (100.0%). As a result of antireflux surgery, clinical manifestations of arrhythmia regressed in 19 (54.3%), in 26 (74.2%) patients, electrocardiogram and Holter monitoring indicators decreased or were absent altogether. In conclusion, it should be emphasized that arrhythmias on the background of hernia of the esophageal orifice of the diaphragm, associated with anatomotopographic and physiological features, are a frequent clinical situation characterized by the mutually aggravating effect of both diseases on each other. An instrumental study of the state of the cardiovascular system in the pathology of the upper gastrointestinal tract showed that there is an improvement in the indicators of cardiac arrhythmias associated with the underlying disease, the correction of which is possible only with surgical treatment of the underlying disease.

[Management of surgical complications following prolonged warfarin therapy in a general surgical hospital]. / Lechenie khirurgicheskikh oslozhnenii prolongirovannoi terapiei varfarinom v obshchekhirurgicheskom statsionare.

OBJECTIVE: To analyze an effectiveness of algorithm for complex treatment of patients with surgical complications of prolonged warfarin therapy in a general surgical hospital. MATERIAL AND METHODS: The study included 138 patients with surgical complications of prolonged warfarin therapy. All patients received warfarin for at least 6 months (49.5% of patients - over 5 years). Warfarin therapy was indicated for deep vein thrombosis in 54 patients and various cardiac diseases in 84 patients. Examination included clinical and instrumental survey, laboratory tests and coagulation tests - thromboelastography (TEG) and thrombodynamics test (TT). RESULTS: Recurrent VTEC occurred in 24 out of 138 patients, hemorrhagic complications - in 114 patients. Therapeutic management was applied in 111 patients, 27 ones underwent surgery (emergency treatment - 25 patients, after two days - 2 patients). Ten patients underwent endoscopic hemostasis, two patients - ultrasound-assisted percutaneous drainage of hematoma. Recurrent VTECs were caused by inadequate laboratory control and violations of warfarin therapy. Most of these patients underwent therapeutic management (only 3 patients required surgery for life-threatening flotation in great veins). Treatment of 114 patients with hemorrhagic complications of prolonged warfarin therapy depended on features of bleeding and severity of warfarin-induced coagulopathy. Depending on these factors, warfarin was discontinued and intravenous administration of vitamin K / FFP / prothrombin complex concentrate was applied. This approach ensured successful therapeutic measures in 90 patients of this group. Twenty-four patients underwent surgery after correction of hemostatic disorders. TT was characterized by high efficiency in analysis of thrombotic predisposition and prediction of the risk of VTEC. TEG was valuable for assessment of warfarin-induced coagulopathy and treatment of patients with hemorrhagic complications of prolonged warfarin therapy. CONCLUSION: The developed clinical and diagnostic algorithm for management of hemorrhagic complications of prolonged warfarin therapy ensures positive clinical results even in a general surgical hospital.

[Optical sonography in differential diagnosis of thyroid nodes]. / Optosonografiya v differentsial'noi diagnostike uzlovykh obrazovanii shchitovidnoi zhelezy.

OBJECTIVE: To develop a non-invasive method for differential diagnosis of thyroid nodes. MATERIAL AND METHODS: Optical sonography was made in 623 patients with thyroid nodes including 374 women (60%) and 249 men (40%) aged 19-79 years (mean 64±15 years). All patients underwent ultrasound-assisted fine-needle aspiration biopsy. Cytological examination revealed cystic colloidal goiter (CCG) in 317 (51%) cases, follicular adenoma (FA) - in 197 (31.5%) cases, thyroid cancer - in 109 (17.5%) cases. All patients underwent surgery. Histological examination verified cystic colloidal goiter in 354 (56.8%) cases, follicular adenoma - 75 (12.0%) cases, thyroid cancer - 194 (31.2%) cases. Follicular cancer was diagnosed in 120 cases, papillary cancer - 70 cases, undifferentiated cancer - 4 cases. RESULTS AND CONCLUSION: Sensitivity, specificity and accuracy of optical ultrasonography in differential diagnosis of thyroid nodules were estimated. Sensitivity of ultrasonography in the diagnosis of thyroid malignancies was 0.75, specificity 0.62, accuracy 0.67. Sensitivity of ultrasonography in the diagnosis of thyroid adenoma was 0.85, specificity 0.62, accuracy 0.73. Sensitivity of optical sonography in the diagnosis of CCH was 0.62, specificity 0.61, accuracy 0.7. Optical sonography ensures differentiation of CCH and follicular adenoma, CCH and thyroid cancer, follicular adenoma and thyroid cancer. Sensitivity, specificity and accuracy of ultrasonography in differential diagnosis of FA and thyroid cancer are 0.85, 0.62, 0.73 and 0.8, 0.71, 0.7, respectively.

[Ultrasound assessment of vocal cords function after thyroid surgery]. / Pervyi opyt otsenki funktsii golosovykh sviazok ul'trazvukovym metodom issledovaniia u bol'nykh posle operatsii na shchitovidnoi zheleze.

OBJECTIVE: To analyze vocal cords function after thyroid surgery by using of ultrasound examination. MATERIAL AND METHODS: Assessment of voice quality according to GRBAS scale, ultrasound examination of vocal cords and indirect laryngoscopy were performed in 57 patients after thyroid surgery. RESULTS: Postoperative indirect laryngoscopy and ultrasound revealed normal mobility of vocal cords in all patients. However, 98.3% of patients subjectively noted deterioration of voice quality due to hoarseness and fatiguein early and long-term period, respectively. Complete restoration of vocal function occurred after 6 months postoperatively. Impaired voice quality is probably due to edema of vocal cords after intubation that is manifested by unclear contours during ultrasound. Ultrasound is useful to diagnose shortening and displacement of paretic vocal cords. CONCLUSION: Ultrasound of vocal cords could be alternative to indirect laryngoscopy for postoperative assessment of vocal cords function in patients after thyroid surgery.

[Transoral approach to thyroid gland in the experiment]. / Transoral'nyi dostup k shchitovidnoi zheleze v eksperimente (s kommentariem P.S. Vetsheva).

AIM: To develop minimally invasive and safe endoscopic access to thyroid gland. MATERIAL AND METHODS: Transoral pre-mandibular video-assisted gas-free access to thyroid gland was developed in experimental study that included 19 human cadavers. Stereometric modeling defined the evaluation criteria including the form of basal arch of lower jaw and its height. There was no conflict of instruments in working chamber under platysma. Additional trocar was deployed to resolve the conflict between working parts of instruments during thyroid gland mobilization. The angle of operative action between the instruments is close to 90°. Trocar hole is used for drainage. RESULTS: The access provides good visualization of recurrent laryngeal nerve, upper and lower thyroid arteries and parathyroid gland. It is less traumatic compared with other extra-cervical accesses to thyroid glands.

[Risk of hypocalcemia after thyroid surgery].

AIM: To reveal calcium metabolism disorders that frequently occur after thyroid surgery. MATERIAL AND METHODS: The study included 202 patients who underwent thyroid surgery for different diseases and had normal calcium level in peripheral blood at baseline. RESULTS: Based on laboratory data postoperative hypocalcemia was diagnosed in 57 (28.8%) patients. It was not always accompanied by clinical symptoms. Clinical picture depended on degree of hypocalcemia. Symptoms was diagnosed more frequently if calcium concentration was less than 2.1 mmol/l. Clinical manifestations were absent in 64.9% of cases on background of hypocalcemia. Incidence of hypocalcemia was higher after thyroidectomy compared to organ-preserving surgery. Symptoms of hypocalcemia occurred after thyroidectomy only. Casual parathyroidectomy does not always cause hypocalcemia. Only in 14% of patients with hypocalcemia excised parathyroid was identified in specimen. At the same time 7.6% of patients with postoperative normocalcaemia also had excised parathyroids in specimens. Symptoms of hypocalcemia does not always occur at 1 day after surgery. They can appear later, for example at 5 days postoperatively and depend on severity of hypocalcemia. Thyroidectomy has high risk of postoperative hypocalcemia with clinical symptoms (19.6%) that is transient in 15.5% of cases and permanent in 4.1% of patients.

[Ultrasonic method of study and puncture biopsy in diagnosing thyroid nodules]. / Ul'trazvukovye metody issledovaniia i punktsionnaia biopsiia v diagnostike uzlovykh obrazovanii shchitovidnoi zhelezy.

Results of diagnosis of thyroid nodes in 404 patients are analyzed. Ultrasonic examination and US-assisted puncture biopsy were carried out before operations. Their results were compared with ones of morphologic study performed after surgery. Solitary nodes were diagnosed in 171 (42.3%) patients, multiple--in 233 (57.7%). The most specific ultrasonic symptoms of different forms of thyroid nodes were revealed. Thyroid cancer is imaged as hypoechogenic node with clear and unclear contour, heterogeneous structure, multiple zones of hyperechogenicity and calcification. Adenomas are presented as isoechogenic homogenic nodes with clear border and cystic cavities. Colloid nodes picture is the same. Rathen often different morphologic forms of nodes are similar, thus ultrasonic examination permits to detect morphologic structure of nodes hypothetically only. Sensitivity of puncture biopsy for goiter, adenomas and cancer was 87.1, 92.9 and 69.7% respectively. Cancer was not diagnosed before surgery in 30.3% cases when colloid goiter or adenomas were suspected. In these cases small cancer was located amidst colloid nodes and didn't differ by ultrasonic symptoms. Diagnosis of malignant tumor in nodular goiter was highly precise. Morphologic form of cancer was verified cytologically in majority of cases.