Khirurgiya最新文献

The literature review is devoted to transcatheter pulmonary valve replacement. The authors summarize the indications, clinical data and current capabilities of transcatheter pulmonary valve replacement. The authors also overviewed modern valves for transcatheter pulmonary artery replacement. Effectiveness of transcatheter pulmonary valve implantation has been substantiated. Various studies comparing the outcomes of different valve systems for endovascular implantation were analyzed. The authors concluded the prospects for transcatheter pulmonary valve implantation.

Surgery for mediastinal tumors is still one of the most difficult in modern medicine. This is due to vital organs and various nature of tumors in this area. Teratomas are relatively rare among mediastinal tumors. However, they have certain features that is important for treatment strategy and management of possible complications. This can complicate diagnostic algorithm, exclude transthoracic biopsy and contribute to active surgical approach even for benign process. Oncogenesis of teratoma has its own characteristics. Tissues of different organs are always present in this tumor. Among these, pancreatic tissue inclusions are rare. A few data in the world literature on the treatment of such patients do not allow to develop a universally accepted algorithm of diagnosis and treatment. The authors present two patients with mediastinal teratoma. The second patient had teratoma with pancreatic tissue. The authors discuss the diagnostic algorithm for similar cases. A special attention is paid to description of possible complications throughout long-term follow-up period. Surgical aspects including the choice of access and local spread of process (adhesions in the area of surgical interest) are considered. The report on the treatment of two patients with rare mediastinal tumors containing pancreatic tissue will be useful for primary care physicians, thoracic surgeons, oncologists and morphologists.

Objective: To determine the optimal treatment strategy for patients with asymptomatic carotid stenosis.

Material and methods: The authors reviewed clinical guidelines for the management of patients with asymptomatic carotid stenosis 60-99%, as well as medical studies and meta-analyses comparing carotid endarterectomy and optimal drug therapy in asymptomatic patients between 1993 and 2023.

Results: The choice of treatment strategy for patients with asymptomatic carotid artery stenosis is still a controversial issue. There were several large randomized clinical trials comparing carotid endarterectomy with optimal medical therapy in asymptomatic patients at the end of the 20^th century. However, drug therapy has undergone significant changes calling into question the relevance of previous results. This review highlights the evolution of management of patients with asymptomatic carotid stenosis and also presents modern approaches to the treatment of these patients.

Conclusion: Patients younger 75 years old gain an advantage from carotid endarterectomy with small perioperative risk compared to optimal drug therapy and yearly risk of cerebral embolism. Patients with asymptomatic carotid stenosis 80-99% are candidates for carotid endarterectomy due to higher risk of acute cerebrovascular accident at least until more data are available. The choice of the best tactics for a particular patient should be made individually depending on own experience and patient's adherence to therapy and lifestyle correction. The results of the ACTRIS (2025) and CREST-2 (2026) studies are expected to clarify this issue.

Objective: To review the first robotic hernia repairs performed at the Ilyinsky Hospital, evolution of this technology, learning curve and early outcomes.

Material and methods: There were 17 procedures at the Ilyinskaya Hospital between 2021 and 2023 (13 men and 4 women). Mean age was 60 years, body mass index 28 kg/m². ASA grade 1 was observed in 1 patient, grade 2 - 14 ones, grade 3 - 2 patients. Ventral, inguinal and umbilical hernias were diagnosed in 7, 8 and 2 cases, respectively. Ventral hernias required IPOM+ procedure in 3 cases, eTEP-RS procedure in 2 cases and eTEP-RS-TAR procedure in 2 cases. Patients with inguinal hernia underwent transabdominal preperitoneal hernia repair. In case of umbilical hernia, TARUP procedure was performed in 1 case and vTAPP procedure in 1 case.

Results: Mean surgery time was 2 hours 38 min (min 1 hour 35 min, max 10 hours 11 min). There was one intraoperative complication (bleeding from epigastric artery). The follow-up period ranged from 3 months to 3 years. There were no recurrent hernias. Postoperative complications were noted in 2 cases. One patient was diagnosed with epididymitis after TAPP, 1 patient - with seroma after eTEP-RS procedure. All complications were relieved by conservative treatment. Bleeding from a. epigastrica inferior was diagnosed after removal of the trocar at the end of surgery. This event required suturing.

Conclusion: Robotic hernia repair appears to be technically feasible and safe. This approach provides favorable results regarding quality of life and recurrence rate.

Objective: To analyze the causes and surgical treatment of hiatal hernia after esophagectomy, technical features of surgery and methods of prevention.

Material and methods: We retrospectively analyzed the incidence of postoperative hiatal hernias after esophagectomy in patients with esophageal cancer between 2018 and 2023. Structure of hernias, surgical options and postoperative results were assessed.

Results: We analyzed 161 patients after Ivor Lewis (n=101) and McKeown (n=60) esophagectomies (open surge surgeries - 43.5%, thoraco- and laparoscopic procedures - 23%, hybrid procedures - 33.5%). The incidence of postoperative hiatal hernia was 3.7%. Hernia occurred within 1-15 months. There were 5 men and 1 woman (mean age 65 years). In all cases, partial or complete dissection of the left diaphragmatic crura was performed. The incidence of hernia after minimally invasive surgery was 4.4%, after open surgery - 2.9%. Two (33.3%) patients underwent urgent surgery for ileus within 2 months after primary esophageal surgery. Three (50%) patients underwent elective surgery. One (16.6%) patient is currently followed-up. The complication was asymptomatic in 2 (33.3%) patients. One (16.6%) patient died after emergency surgery in a COVID hospital due to strangulated hernia and progressive respiratory failure. Mean follow-up period was 16 months. No recurrent hernias were diagnosed.

Conclusion: Hiatal hernias occur 2 times more often after minimally invasive esophagectomies. Active surgical strategy is necessary for symptomatic hernias due to high risk of strangulation and emergency interventions. The incidence of this complication is lower without wide diaphragmotomy, transection of the left diaphragmatic crus and high abdominal pressure during laparoscopic stage.

Introduction: In some cases, percutaneous nephrostomy (PNS) and trocar epicystostomy (TCS), which require adequate anesthesia, are used to restore the passage of urine. The choice of method, namely general or local anesthesia, depends on many factors, including the risks and complications of anesthetic care and should be made individually.

Objective: To analyze the efficacy and safety of local anesthesia using articaine in PNS and TCS.

Materials and methods: The study included 85 patients aged 40-60 years who had undergone PNS or TCS. Positive allergic background, significant comorbidity, severe obesity, cicatrical changes in the area of operation were the exclusion criteria. Patients were divided into two groups depending on the type of anesthetic for local anesthesia. Specifically, 2% Articaine-Binergia - 2 ml diluted in 10 ml of 0.9% saline solution was used in the first group of 48 (40 PNS and 8 TCS) humans, and 2% Lidocaine - 2 ml in the same dilution was used in the second group of 37 (30 PNS and 7 TCS) subjects.

Results: The articaine group has been considerably superior to the lidocaine one on all indicators in the clinical evaluation of anesthesia's efficacy in scores. A better safety profile has been noted by symptoms of allergic reaction, tissue neurotoxicity, formation of hematomas and infiltration of the injection site in the analysis of adverse events (complications) in the articaine group.

Conclusions: The conducted study on the use of Articaine-Binergia in urological interventions requiring local anesthesia, in particular such as PNS and TCS, showed that Articaine-Binergia exceeded lidocaine in analgesic effect and safety profile, and, importantly, saving in anesthetic's use due to the lower total volume of administration has been noted.

The issue of emergency care for traumatic bleeding is of particular relevance in modern medicine due to widespread military conflicts. This characterizes the need to summarize available data on hemostatic agents in combat conditions. This review of available literature is devoted to systemic and local hemostatic agents, as well as devices for temporary bleeding arrest. The most promising local hemostatic agents are chitosan-based products. Systemic hemostatic agents are represented by various forms and require further clinical trials. Modern tourniquets significantly reduce the mortality rate in extreme conditions and significantly exceed their historical counterparts in convenience and efficiency.

This review is devoted to internationally accepted diagnostic algorithms for complicated chronic pancreatitis (CP). In addition, the authors discuss interventional radiological and endoscopic diagnostic and therapeutic procedures, as well as their role in surgical approaches for this disease. Chronic pancreatitis is often diagnosed with severe symptoms following severe course of disease and complications. Imaging techniques, such as ultrasound, endoscopic ultrasound, CT, MRI/MR cholangiocreatography (MRCP), secretin-stimulated MRCP, are valuable to assess the pancreas in patients with initial manifestations of CP. Modern treatment of complicated CP includes transpapillary or transmural drainage of false cysts, shock wave lithotripsy and stenting for pancreatic duct strictures and/or stones, stenting for biliary hypertension, endovascular interventions for vascular complications and radical surgical treatment. Endoscopic methods are preferable regarding better short-term quality of life. Early surgical intervention (within 3 years after clinical manifestation) is effective to eliminate or significantly reduce pain and pancreatic insufficiency. Multidisciplinary team including surgeons, endoscopists and interventional radiologists should determine the most optimal diagnostic and treatment approach individually for each patient.

Degradable ureteral stent not requiring redo procedure for removal is an important issue in modern urology. This device could solve the problem of «forgotten stent» often leading to long-term complications. The authors describe the prototype of biodegradable ureteral stent based on poly(L-lactide-co-ε-caprolactone) and present the first results of its testing. Characteristics of synthesized polymer meet the requirements in medicine. Tests of rod-shaped stent prototypes showed that material has sufficient strength and elasticity. Analysis of stent degradation in artificial urine environment at 37 ºC showed that it retains strength for at least 2 weeks. No suppression of cell growth confirms no cellular toxicity. New material based on poly(L-lactide-co-ε-caprolactone) is promising for development of experimental samples of biodegradable ureteral stents and further in vivo testing.

Objective: To evaluate actual myocardial energy requirements using indirect calorimetry, oxygen delivery (DO₂), oxygen extraction ratio (O₂ER), cardiac output (CO) and their components, as well as to study the impact of positive inotropic agent (dobutamine) on myocardial metabolism in early postoperative period after cardiac surgery.

Material and methods: We measured the main metabolic parameters using indirect calorimetry in 20 patients after on-pump cardiac surgery with cardioplegia. To evaluate the impact of metabolic load on CO, VO₂ and DO₂, we administered dobutamine 3 µg/kg/min at the second phase of the study. Basal metabolic parameters were recorded together with CO and arterial and venous blood gas composition.

Results: Under dobutamine infusion, VO₂I and VCO₂ significantly increased by 10%, DO₂I increased by 27%, and O₂ER decreased by 10%. Aerobic metabolism increased from 1902.3±380.6 to 2130.9±423.1 kcal/day. The predicted energy expenditure values (Harris-Benedict equation) were significantly lower (1759.7±255.6 kcal/day). Cardiac index increased by 26%, stroke volume - by 10%, heart rate - by 21%. Central venous pressure, left ventricular end-diastolic volume and ejection fraction were the same. VO₂I obtained through indirect calorimetry were higher than those measured using the reverse Fick method. At the first phase, these values were 138.6±28.9 and 72.8±27.6 ml/min/m², at the second phase - 155.4±28.2 and 68.1±27.1 ml/min/m², respectively.

Conclusion: Energy expenditure exceeded the predicted values. This was accompanied by elevated VO₂ and DO₂ with moderate decrease of O₂ER in postoperative period. VO₂ values assessed by indirect calorimetry and reverse Fick method represent two distinct physiological parameters, and they are not interchangeable. Further studies are required to assess this technology in critically ill patients.