[Diagnostic and conservative treatment nuances in patients with obstructive jaundice: in the wake of Russian consensus].

The research was performed at the Loginov Moscow Clinical Scientific Center. It is based on Russian obstructive jaundice (OJ) consensus results, considered at the 45th annual Central Research Institute of Gastroenterology Scientific session Oncological issues in the gastroenterologist practice (1 March 2019). The article objective is to note the diagnostic and conservative treatment current issues in patients with OJ. The increase in the number of patients with OJ of different etiology provides problem actuality. In a large number of cases, medical treatment is delayed due to inadequate diagnostic and management, while correct patients routing today can be provided regardless of medical institution level. In this article the examination steps and conservative treatment role in patients with biliary obstruction management are presented.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]. / Rossiiskii konsensus po aktual'nym voprosam diagnostiki i lecheniya sindroma mekhanicheskoi zheltukhi.

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

[Complications after cardiac injuries].

An analysis of 293 victims with cardiac and pericardium injuries was made. Cardiac complications could appear suddenly and be registered on any stage of treatment process. They differentiated by character and duration of wound process. Pericarditis took place in 288 patients. The syndrome of system inflammation reaction was noted in 47.9% of patients, a sepsis (sometimes severe sepsis) was in 14.3%. Complications in postoperative period were determined by posthypoxic and hemic hypoxia, coagulopathy. They were manifested by myocardial ischemia and thromboembolic complications. An acute myocardial infarction took place in 29 (9.8%) cases and rhythm and conductivity abnormalities were in 23 (7.8%) patients. The circulatory failure with clinical picture of pulmonary edema was developed in 12 (4.1%) cases. The lethality consisted of 44 (15%) patients.

[Modern methods of low-invasive treatment of the stricture and damage of the pancreatic duct, pancreatolithiasis].

The authors analyzed the experience of diagnostics and treatment of 49 patients. It was shown, that low-invasive methods of treatment (the endoscopic lithoextraction, stenting, surgical drainage) should be the priority means in treatment of pancreatolithiasis, strictures and cases of the pancreatic duct damage. The lethality consisted of 2.04% in these interventions.

[Injuries of the duodenum].

Results of surgical treatment of 69 patients with injuries of the duodenum were analyzed. The most frequent causes of the injury were stab-incised wound of the abdomen (43 patients), gunshot wounds (2 patients), closed injury of the abdomen. Postoperative complications developed in 18 (26%) cases. Lethality was 20.3% (14 patients died). Injuries caused by the closed trauma were considerably more severe than those caused by wounds of the duodenum; lethality was 37.5% and 11.1% respectively. The authors discuss questions of the special diagnostics and surgical strategy for open and closed injuries of the duodenum. Causes of the development of unfavorable outcomes were pyo-septic complications associated with progressing retroperitoneal phlegmons, peritonitis, development of traumatic pancreatitis, incompetent sutures of the duodenum with a formed duodenal fistula. Therefore, the effective prophylactics of incompetent sutures of the duodenum is its decompression with aspiration of the duodenal contents as well as decreased secretion by means of drainage of the bile excreting ducts and medicamental suppression of synthesis of the digestion enzymes of the pancreas and duodenum using Octreatid which allowed considerable decrease of the number of postoperative complications.

[Choledocholithiasis in nonstandard situations: possibilities of combined methods of minimally invasive intervention].

The possibilities of minimally invasive combined interventions were shown in treatment of 49 patients with choledocholithiasis in nonstandard situations. The worked out and used minimally invasive combined operations allow ablation of concrements from bile ducts in patients who had undergone such operations as Billroth-II gastric resection and extirpation of the stomach and when cannulation of the major duodenal papilla is not possible. The authors have extended the possible application of minimally invasive methods of lithoextraction in patients with choledocholithiasis in nonstandard situations.

[The possibilities of combined methods of minimally invasive interventions in treatment of benign diseases and lesions of the bile ducts].

The authors have shown the possibilities of minimally invasive operations under ultrasonic, endoscopic and radiological control in treatment of patients with lesions and strictures of the bile ducts. The experience is based on an analysis of operations on 68 patients. In most patients the patency of ducts was restored without using open traditional operations due to the developed and used combined minimally invasive operations.

[Postnecrotic cysts of the pancreas: possible ways of minimally invasive external and internal drainage].

The authors have shown a possibility of minimally invasive interventional surgery in treatment of postnecrotic cysts of the pancreas and their complications. The most optimal accesses for drainage of the cavities located inside the body and the pancreas head are determined. The use of the methods of internal drainage of the cyst cavity connected with the main pancreatic duct allowed avoidance of open operations. The results of antegrade percutaneous or transcavital as well as retrograde endoscopic restoration of the patency of the main pancreatic duct in treatment of the pancreatic cysts connected with the duct system are shown.

[Endoscopic treatment of children with esophagus stenoses of different etiology].

Nowadays not only diagnostic but also therapeutic interventions are widely used in pediatric endoscopy. The authors analyze 25 cases of esophageal stenosis of different genesis (caustic, peptic, anastomotic and congenital esophageal obstructions) in children aged from 1.6 to 15 years. The endoscopic treatment was successfully performed by mechanical dilators with a guidewire and balloon dilator in all patients. The age less than 2 years, previous complications, subtotal stenosis can not be considered absolute contraindication for endoscopic treatment.

[Operative treatment and diagnostics of Zenker diverticulum using modern endoscopic technique].

The authors present results of examination and treatment of 272 patients with Zenker diverticulums of different localization. Features and problems in fibroesophagoscopy in patients with Zenker diverticulum are discussed. Surgical interventions with endoscopic assistance were fulfilled in 37 patients with diverticulum. A new way of endoscopic management of Zenker diverticulum using preparation "Disport" and the method of endoscopic incision of cricofaringeal muscle are proposed. Good clinical results of the treatment were obtained.

[On the question of heart injuries].

The work is devoted to an analysis of hospitalized patients to the specialized department of injuries of the chest and abdomen of the Mariinskaja hospital at the period from 1993 through 2010. The diagnosis of injury of the pericardium and heart had 280 patients, during the operative treatment heart injuries were detected in 156 (55.71%) patients. Penetration to the heart chambers was found in 132 (84.61%) of them, with perforating and multiple injuries there were 24 (15.39%) patients. Operations were performed during 20 minutes after admission on 65 (28.9%), and during the following two hours on 160 (71.1%) patients. Expectant management and conservative treatment were used in treatment of 34 patients (12.14%), three patients were admitted in the state of apparent death and died during 15 minutes. The lethality of 41 patients was 26.28%. mainly it was those who were operated at the period from 80 to 100 minutes from the moment of injury. The success of treatment depends on the early hospitalization, correct diagnosis and emergent surgery.

[Acute gastroduodenal bleedings against the background of diabetes mellitus].

The authors have analyzed results of treatment of 60 patients with acute gastroduodenal bleedings against the background of diabetes mellitus. The main methods of diagnosis are the endoscopic and laboratory methods. In 60% of the patients the source of bleeding was acute erosion-ulcerous lesions, in 40% -chronic ulcers. Choice of the method of treatment depended on the source of bleeding, the degree of carbohydrate metabolism, the spectrum of concomitant pathology. Endoscopic hemostasis is the method of choice in treatment of acute and chronic ulcers of high risk of relapses in somatically burdend patients.

[Gastroduodenal bleedings as a problem of emergency surgery].

An analysis of 3938 observations gave data on the frequency of different causes of gastrointestinal bleedings, specific features of performing endoscopies during making diagnosis, endoscopic signs of gastrointestinal bleedings, possible technical diagnostic and tactical errors, methods of endoscopic hemostasis. Modern national and foreign digital endoscopes are assessed.

[Surgical treatment of injuries of the large vessels].

The authors present an experience with treatment of 99 patients with primary wounds of main vessels. The age of the patients was from 42 through 83 yeas. In 85 patients there were stab wounds, 9 patients had gunshot wounds, in 5 patients injuries of the main vessels were results of blunt trauma. Eleven patients were admitted in the condition of shock of I degree, 27--II degree and 46--III degree, 15 patients were in the terminal state. Wounds of the aorta were diagnosed in 10 patients, 4 patients died. Injury of the superior vena cava was found in 4 wounded patients, nobody died. Postcava was injured in 11 patients, 6 patients died. Wounds of the portal vein were diagnosed in 8 patients, 7 of them died. Operations were fulfilled on 19 patients with wounds of the neck and injuries of the large vessels. One patient died. Injuries of the large vessels of the upper and lower extremities took place in 15 patients. Nobody died.

[Endoscopy in diagnosis and treatment of complicated esophageal anastomoses].

The authors describe an experience with treatment of 115 patients with complicated course after esophagogastroanastomoses and esophagojejunoanastomoses using endoscopic techniques. The diagnostic manipulations and algorithm of treatment of patients with early and late complications in the area of nutritional anastomoses were developed. Thanks to high tech minimally invasive interventions (bougienage, balloon dilatation, stenting, endoscopic hemostasis, dissection of scar strictures) traumatic reoperations could be avoided.

[Minimally invasive surgery of abscesses of the retroperitoneal space].

The article presents an experience with treatment of abscesses of the retroperitoneal space in 28 patients using interventions under ultrasonic control. All the patients underwent draining operations. Determination was made of optimal terms of operative treatment under the ultrasonic control depending on the character of pathological fluid accumulation; of rational approaches to the abscess cavity to support the safest passing the needle through the retroperitoneal space tissues. An algorithm of management of the patients at the stages of both stationary and ambulatory treatment was developed. An analysis of causes of the approach conversion after minimally invasive draining operations was made. Draining operations under USI control in most cases of retroperitoneal abscesses allowed sanitation of purulent cavities without open operations.

[Endoprosthesis of self-expanding metallic stents in stenosing diseases of the esophagus].

The article deals with the questions of treatment of diseases developing with constriction of the esophagus lumen using modern minimally invasive techniques. The authors set the tasks to improve treatment of patients with dysphagia using endoscopic stenting. Original solutions of complex problems are presented arising in treatment of such group of patients. A detailed analysis of complications is given and the scheme of the causes of their appearance which is thought to be actual.

[Treatment of cardia achalasia].

Results of endoscopic, ultrasonic and operative treatment of 78 patients aged from 19 through 82 years were analyzed. Endoscopic balloon cardiodilatation was used in 68 patients, in 10 of them it was supplemented with an injection of botulinum toxin in the esophagus wall and operative treatment (6 patients) that resulted in obtaining good and satisfactory results in most patients.