[Sclerotherapy as an alternative to surgery for recurrent nodular goiter]. / Skleroterapiya kak al'ternativa operatsii pri lechenii bol'nykh s retsidivnym uzlovym zobom.

OBJECTIVE: To evaluate the results of treatment of recurrent nodular goiter using sclerotherapy with polidocanol. MATERIAL AND METHODS: A comparative analysis of sclerotherapy (30 patients) and conventional surgical treatment (17 patients) of recurrent goiter was performed. RESULTS: Sclerotherapy ensures reduction of nodes (linear dimensions of nodes decreased by 14.2±1.1 mm after 3 courses), correction of endocrine imbalance in patients with functional autonomy and relief of initial signs of cervical organ compression in all patients with recurrent goiter. Sclerotherapy is associated with less pain syndrome and no need for inpatient treatment. However, the most significant advantage is reduced risk of complications. Hypoparathyroidism and laryngeal paresis developed in 53 and 24% of patients after conventional surgery while these events were not observed after sclerotherapy. CONCLUSION: Sclerotherapy with polidocanol is a perspective alternative to conventional surgery for recurrent nodular goiter.

[DIC-syndrome-related mortality in acute necrotic pancreatitis]. / DVS-sindrom pri pankreonekroze.

AIM: To improve the results of acute necrotic pancreatitis management via an analysis of changes in the main causes of mortality in patients with this disease over the last decade. MATERIAL AND METHODS: We have analyzed medical records of patients with acute necrotic pancreatitis followed by lethal outcome for the period 2015-2016. In all cases autopsy was performed in order to determine morbidity and mortality. Complications of pancreatic necrosis significant for tanatogenesis, treatment and prevention strategy were compared with those for 2005-2006. RESULTS: It was shown that not only significantly decreased mortality in acute necrotic pancreatitis but also important changes in its structure occurred for the last ten years. At present time DIC-syndrome and its organ complications are the most significant causes of death. CONCLUSION: Prevention of DIC-syndrome and its complications is necessary to improve the outcomes. Endothelial protectors' administration in early period, timely diagnosis and adequate treatment of DIC-syndrome are advisable.

[Efficiency of combined methods of hemorroid treatment using hal-rar and laser destruction]. / Éffektivnost' kombinirovannoi metodiki lecheniia gemorroia s ispol'zovaniem HAL-RAR i lazernoi destruktsii uzlov.

AIM: To develop the combined method of treatment of hemorrhoids with arterial ligation under Doppler control and laser destruction of internal and external hemorrhoids. MATERIAL AND METHODS: The study included 100 patients with chronic hemorrhoids stage II and III. Combined method of HAL-laser was used in study group, HAL RAR-technique in control group 1 and closed hemorrhoidectomy with linear stapler in control group 2. Сomparative evaluation of results in both groups was performed. RESULTS: Combined method overcomes the drawbacks of traditional surgical treatment and limitations in external components elimination which are inherent for HAL-RAR. Moreover, it has a higher efficiency in treating of hemorrhoids stage II-III compared with HAL-RAR and is equally safe and well tolerable for patients. This method does not increase the risk of recurrence, reduces incidence of complications and time of disability.

[Systemic disorders management in patients with acute pancreatic necrosis]. / Vozmozhnosti korrektsii sistemnykh narushenii pri lechenii bol'nykh ostrym nekroticheskim pankreatitom.

AIM: To study the effectiveness of sulodexide for systemic disorders correction in patients with acute pancreatic necrosis. MATERIAL AND METHODS: The study included 60 patients with acute pancreatic necrosis who were divided into main and control groups by 30  patients. Their age varied from 27 to 79. Standard combined therapy with prevention of disseminated intravascular coagulation and thrombotic complications was recommended in all patients. In the control group enoxaparin therapy in prophylactic doses (4,000 IU (40 mg) per day) was used. Mean duration of treatment was 6±0.9 days. Sulodexide was used in the main group. Sulodexide was administered since the 1st hospital day 600 LE per day intravenously for 5-10 days. The duration of treatment was determined according to clinical course and «capillary leak¼ that was measured by serum proteins loss. Mean duration was 8.8±0.3 days. RESULTS: Hospital-stay was significantly lower in study group than in control group for about 5±2.2 days (p<0.03). Overall mortality was lower by 10%. In both groups unfavorable outcomes were caused by severe multiple organ failure. There were no deaths in case of SOFA score less than 6. In the main group mortality of patients with severe multiple organ failure was 2.4 times lower than in the control group (14% vs. 33%). CONCLUSION: Correction of microcirculation and tissue perfusion improves the severity of systemic manifestations of acute destructive pancreatitis. Mortality and hospital-stay were decreased due to reduced incidence, severity and duration of multiple organ failure and frequency of complications.

[Prevention of paracolostomic hernia]. / Profilaktika parakolostomicheskoi gryzhi.

AIM: To improve the prevention of paracolostomic hernias. MATERIAL AND METHODS: We studied the prevention of paracolostomic hernia using mesh allograft. The study involved 73 patients with low-ampullary rectal cancer. Open or laparoscopic abdominoperineal extirpation of rectum was performed in all observations. 21 patients underwent prophylactic Sugarbaker's repair of paracolostomic area. We used the modifications of this surgical stage for transabdominal and retroperitoneal stoma. RESULTS: There were no postoperative complications associated with the use of allograft. The hernia occurred in one case (4.8%) of prevention group and in 14 (26.9%) patients of control group. CONCLUSION: The first results of composite allograft application to prevent paracolostomic hernias are encouraging. The absence of specific complications and favorable long-term results allow to continue the investigation.

[Transanal endoscopic microsurgery].

AIM: To analyze the immediate and remote results of transanal endoscopic microsurgical intervantions and its role in treatment of rectal tumors. MATERIAL AND METHODS: The results of transanal endoscopic microsurgery in 56 patients with rectal tumors were studied. Adenoma and adenocarcinoma were observed in 45 (80%) and 11 (20%) patients respectively. Mean height of tumor lower edge placement was 8.6 ± 0.3 cm from anus, mean diameter - 3.7 ± 0.3 cm. All patients underwent full-layer resection of rectum. RESULTS: Postoperative complications were observed in 4 (7%) patients. There were no deaths. Transanal endoscopic microsurgery is modern, adequate and effective treatment of benign and early forms of malignant rectal tumors. It is associated with lower incidence of complications and recurrence under condition of careful selection of patients. Based on obtained results we recommend surgeons to apply this technique only in case of tumor placement below 10-11 cm from anus and tumor's diameter up to 3-4 cm to minimize risk of complications and recurrences. Full-layer resection of rectum is recommended in all cases of operations for benign tumors because of there is high risk of latent malignancy.

[Endovascular laser obliteration in treatment of patients with varicose veins with trophic disorders].

The authors studied efficacy and safety of endovasal laser obliteration (EVLO) in treatment for varicose veins in patients with trophic disorders, carrying out comparative analysis of the outcomes of treatment of 95 patients subjected to EVLO (Study Group) or combined phlebectomy (Control Group). It was shown that EVLO is accompanied by less traumatic lesion of tissues during interventions, thus leading to more rapid relief of oedemas of lower limbs and reduction of trophic skin disorders. In patients with open trophic ulcers with an area of more than 10 cm2 healing occurred averagely one month faster than in those after phlebectomy. Hence, EVLO may be recommended as a preferable technique in treatment of varicose veins in patients with trophic disorders. However, if the diameter of the venous trunk exceeds 1 cm there is a probability of its recanalization even in the remote period after the intervention.

[Endoscopic retrograde cholangiopancreaticography for the treatment of necrotic pancreatitis].

40 patients with the acute necrotic pancreatitis and verified biliary hypertension were included in the study. During the endoscopic retrograde cholangiopancreaticography we avoided the main pancreatic duct contrast enhancement. The canulation during papillosphincterotomy (PST) was not used if the concrement was infringed in the ampulla. The use of these methods led to fast relief of the biliary hypertension and truthworthy positive dynamics of the disease course. The negative consequences were usually limited to transitory amilasemia and the pancreonecrosis progression was registered in only 4±4% cases. In comparison with cholecystostomy, the ERCP with PST showed better prognosis considering the frequency of septic complications and terms of hospital stay. The statistical analysis proved the the ERCP with PST are preferable to cholecystostomy in cases of pancreonecrosis with choledochlithiasis and biliary hypertension and the overall severity of pancreonecrosis is not higher than 11 by the physiological condition scale.

[The miniinvasive treatment of the aseptic fluid collections by the acute necrotizing pancreatitis].

The study aimed to state the indications to punctures and draining of the aseptic fluid collections by the acute necrotizing pancreatitis. Data of 82 patients were analyzed. The miniinvasive treatment proved to be preferable to the conservative treatment only in cases of the internal organs compression. Punctures and draining didn't provide the decrease of septic complications and pseudocyst formation. Poor result of miniinvasive procedures predict the high risk of pseudocyst formation.

[Sclerotherapy for the treatment of thyroid functional anatomy].

Comparative efficacy of ethanol and ethoxysclerol in sclerotherapy was studied among 37 patients with thyroid functional autonomy. It is shown that ethoxysclerol exceeds ethanol in efficiency of treatment, doesn't lead to depressed function of treated thyroid lobe and is better tolerated. Thereby ethoxysclerol should be always used as a sclerosant in patients with hormonal disturbances and multiple "hot" nodules.

[Laparoscopic abdominal drainage by sterile destructive pancreatitis].

90 patients with acute pancreatitis were observed, in 60 of them laparoscopic drainage was performed. The procedure by sterile pancreatonecrosis is indicated only in presence of extent amount of exudate in abdominal cavity. Duration of draining the abdominal cavity should be strictly limited because of the high risk of septic complications. Contraindications for the abdominal drainage by acute necrotic pancreatitis are not only adhesions in the abdomen and shock state of the patient at the moment of procedure necessity, but also unstable hemodynamics in anamnesis and even by the arterial pressure downtrend.

[The ways of improvement of pancratonecrosis treatment].

The data of 220 patients with acute necrotic pancreatitis are analyzed. The lethality comprised 25%. The main reasons of treatment failure are late beginning of the intensive treatment in consequence of diagnostic mistakes, absence of preventive measures and adequate antibacterial therapy of pneumonia in patients on artificial lung ventilation, lack of necessary treatment in patients with disseminated intravascular clotting syndrome. Therefore, a wide introduction of clinical tests for early diagnosis and prognose the severity of the disease, are indispensable. The prognose-aligned preventive treatment is essential, which should include effective prophylaxis of the life-threatening complications. The invasive diagnostic and treatment procedures in early period of the disease can seriously deteriorate the patient's state and should be performed only if absolutely indicated.

[Gall bladder drainage at acute pancreatitis].

Determination of indications and contra-indications to cholecystostomy in patients with acute necrotic pancreatitis was the aim of this study. 102 patients were examined. Presence of caput pancreatis enlargement, infiltration and limited fluid accumulation, gall bladder enlargement and increase in bilirubin level was evaluated. Evidence of biliary hypertension was evaluated according to bile amount flowing out of the cholecystostoma. Findings allowed to draw the following conclusions. Increase in conjugated bilirubin, dilatation of bile ducts, gall bladder enlargement over 120 mm lengthwise are the indications to cholecystostoma surgery at acute necrotic pancreatitis. Gall bladder drainage in other cases is not reasonable. Cholecystostoma surgery should be carried out at the latest 3 days from the moment of admission to hospital preferably by laparoscopic method. Presence of initial hypotension is the contra-indication to gall bladder drainage even in case of total normalization of hemodynamics.

[Prediction of multiple organ failure due to sepsis at the patients with purulo-necrotic diseases of soft tissues].

Microcirculatory disorders at sepsis lead to severe tissue perfusion injury and multiple organ dysfunction. Level of decrease of albumin serum concentration may be used as marker of microcirculatory disorders. One hundred and forty patients with purulo-necrotic diseases of soft tissues were examined. It was demonstrated that intensity of systemic inflammatory reaction (SIR) and old age of patients are the independent risk factors of severe sepsis; multiple organ failure is associated with significant decrease of albumin serum concentration with slight symptoms of SIR. Numeric criteria of risk assessment and 3 risk category of sepsis and multiple organ failure are formulated.

[Serum albumin in systemic inflammatory reaction syndrome].

A group of patients with pyoinflammatory surgical disease, which showed a strong correlation between the serum concentration of albumin and the number of signs of a systemic inflammatory reaction (SIR), was examined. It was found that the more number of such signs the patient had, the less blood concentration of albumin was: the linear correlation coefficient averaged -0.78 (p < 0.01) in the group. In the natural development of the disease, the larger number of signs of SIR (negative changes) is followed by decreased albumin concentrations and their reduction (positive changes) leads to an increase and even complete restoration of albumin concentrations. With a fatal outcome, there is a much greater drop in the serum concentration of albumin, which is inconsistent with the magnitude of criteria of SIR. The possible reasons for a reduction in blood albumin concentration and for ineffective correction of hypoalbuminemia in sepsis are discussed.

[Extracorporeal detoxication in patients with destructive pancreatitis].

Criteria of severity of endogenous intoxication in patients with destructive pancreatitis in enzymatic toxemia are discussed. It is demonstrated that the level of middle mass molecules and integral index of affection of the pancreas, abdominal cavity and retroperitoneal space are objective criteria of endogenous intoxication and can be used for determination of indications for extracorporeal detoxication and for assessment of treatment efficacy. Prescription of extracorporeal detoxication according to these criteria in an early period of the disease before multiple organ failure development promotes faster management of endotoxemia, prophylaxis of septic complications, decreases lethality and period of treatment of patients with destructive pancreatitis.

[Albumin redistribution between blood and peritoneal exudate in abdominal diseases].

Albumin concentrations were measured in blood serum (As) and in peritoneal exudate (Ae) of patients with peritonitis and acute pancreatitis. As and Ae registration during several days revealed strong negative correlation between an index, Ae/As, and serum albumin As in 51% of the patients. The absolute value of the linear correlation coefficient, r, exceeds 0.7 in each of these patients. Moreover, pooled data in this group of patients showed that integral correlation coefficient was very high, r approximately equal to 0.94 at p < 0.01. In other words, the higher ratio Albumin in exudate/Albumin in serum, the lower albumin concentration is in serum. Other patients had either lesser coefficient of the negative correlation, between -0.3 and -0.7 (14% of all patients) or very low negative or even positive correlation of the index, Ae/As, and serum concentration As (35% of all patients). Probable albumin redistribution between blood, peritoneal exudate and tissue pool in relation to ratio exudate Albumin/serum Albumin is discussed.

[Treatment of patients with pancreonecrosis]. / Lechenie bol'nykh pankreonekrozom.

Results of treatment of patients with necrotic acute pancreatitis taking into account a risk of an unfavorable course of the disease are analyzed. The risk is determined according to the level of albumin measured with fluorescent test. This approach to choice of policy of treatment which doesn't correspond to clinical picture and treatment may be regarded as preventive permits to improve results of treatment in all variants of the disease. Decreased number of severe complications, lethality and time of hospitalization in necrotic pancreatitis an demonstrated.

[Informative value of the parameter "effective concentration of albumin" in diffuse peritonitis: data from a multi-center study]. / Informativnost' pokazatelia "éffektivnaia kontsentratsiia al'bumina" pri rasprostranennom peritonite: dannye mnogotsentrovogo issledovaniia.

The paper represents data on new potentialities in evaluating a severity of patients with total peritonitis (TP). They are based on the fluorescence analysis of the physical-and-chemical properties of blood albumin. The findings are a result of a multi-center research undertaken by clinics of Moscow and Moscow Region. The properties of albumin-molecule binding sites were investigated by the fluorescence test. The parameter, measured in the test, was named "effective albumin concentration". The study protocol comprised the data of clinical examinations, scales SAPS and MPI as well as laboratory findings and EAC. The subsequent analysis denoted that a combination of 2 parameters, i.e. EAC and serum urea concentration routinely measured, is highly informative in evaluating the TP severity and correlates well with the survival rate in the discussed pathology. The study results could be a basis for an early individual prognostication of TP course made on the 1st postoperative day.