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Objective: To identify the risk factors of external intestinal fistulas in patients with severe acute pancreatitis (SAP) and pancreatic necrosis.

Material and methods: A retrospective and prospective study included 537 patients (354 (65.9%) men and 183 (34.1%) women) with SAP. Mean age was 51.2±18.5 years. To assess the effectiveness of intensive therapy, patients were divided into 2 groups. The control group (n=207) included patients who underwent examination and treatment according to the national guidelines «Acute pancreatitis», 2020). In the main group (n=330), examination and treatment were supplemented with original protocol.

Results. p: Atients with intestinal failure score< 5 had no purulent-septic complications and multiple organ failure. Among patients with 6-9 scores, purulent-septic complications were observed in 11.7% of cases, multiple organ failure - 14.8% of cases. Among patients with 10-12 scores, the incidence of purulent-septic complications was 24.6%, multiple organ failure - 30% of cases. Thus, intestinal failure score > 10 is an important prognostic criterion of purulent-septic complications and multiple organ failure. In addition, external intestinal fistulas occurred in 8.5% of patients with intestinal failure score > 10.

Conclusion. p: Rogression of intestinal failure correlates with purulent-septic complications and external intestinal fistulas in patients with SAP and pancreatic necrosis. Original diagnostic algorithm is valuable for early detection of functional gastrointestinal disorders, severity and localization of these changes. Original scoring system makes it possible to predict the risk of purulent-septic complications and multiple organ failure on the first day after admission. Moreover, timely therapy improves treatment outcomes in patients with SAP. In our study, the incidence of purulent-septic complications including external intestinal fistulas decreased from 10% to 7% in the main group.

Objective: To evaluate the diagnostic capability of intraoperative fluorescence lymphography (FLG) in detecting of sentinel lymph nodes (SLN) and lymph outflow pathways in patients with biliary cancer (BC).

Material and methods: From April 2023 till March 2024, ten liver resections for BC were performed using FLG. We carried out the standard lymph node dissection with additional removal of lymph nodes (LN) that have accumulated indocyanine green (ICG). The lymphatic outflow pathways in all patients and frequency of SLN invasion were evaluated.

Results: Ten patients were included: five patients had been diagnosed with intrahepatic cholangiocarcinoma (IHCC), two - with perichilar tumor (PT), the last three ones had gallbladder cancer (GBC). SLN No. 1 were detected in eight patients, the accumulation of ICG was detected in the following groups of LN: No. 8 (n=2), No. 13 (n=1), No. 12b (n=2), cystic lymph node (n=2), and No. 7 (n=1). SLN No. 2 was detected in seven patients. In three cases LN No. 13 were stained, in one - LN No. 12a, in another - LN No. 8. In two patients, staining of vesicular LN was noted. The combined morphological assessment of SLN No. 1 and SLN No. 2 made it possible to predict the presence of LN metastases in all patients (100%, n=3). Fluorescence of third-order LN was detected in four patients. In one case, the staining of LN No. 13 was noted. Another patient revealed accumulation of ICG in LN No. 3. In two cases, at the third stage, fluorescence of LN No. 7 was noted, while metastatic invasion of LN No. 7 was detected in one patient with IHCC.

Conclusion: Using FLG, it was possible to determine an alternative lymph flow outpath to LN No. 7 in three patients. The method allowed to identify and remove metastatic LN No. 7 in one case. 100% sensitivity was shown in the determination of SLN in BC in a small group of patients. It is advisable to study the sensitivity of the method in large-scale studies.

Circulatory arrest is the main method used in surgical interventions for prosthetics of the proximal aorta. However, recently, facts have been discovered that prove the benefits of avoiding circulatory arrest during planned and emergency surgical interventions. We present a clinical case of planned prosthetics of the ascending section and the aortic arch with a Intergard Woven 28 mm multibranch prosthesis without circulatory arrest in conditions of mild hypothermia. The patient was extubated 5 hours after the operation, and was discharged home in satisfactory condition on the 7th day. The rejection of circulatory arrest made it possible to reduce the duration of surgery, the duration of hospitalization and complications associated with hypoperfusion of organs and tissues that occur during cooling of patients.

Septal myectomy is the gold standard for patients with obstructive hypertrophic cardiomyopathy. Nevertheless, some patients develop postoperative recurrence of left ventricular outflow tract obstruction and clinical symptoms of heart failure. Such ones require redo surgery if optimal medical therapy is ineffective.

Objective: To analyze treatment outcomes in children with anorectal injury.

Material and methods: There were 31 children aged 1-18 years with traumatic injuries of the rectum and anus. Diagnostic measures included analysis of anamnesis, examination, rectal examination, bladder catheterization, X-ray methods including CT and MRI.

Results: Over the past 30 years, combined trauma has occurred in 346 children. Of these, 217 children died at the scene, 12 - in hospitals. Injuries of more than 3 areas were observed in 184 children. Injuries of the rectum and anus were diagnosed in 31 children. In 9 children, anorectal injury was the result of traffic accidents. All ones had TBI, thoracoabdominal trauma, bone fractures of extremities and pelvis. Four people died at the scene. In 10 children, anorectal injury was associated with damage by foreign bodies including falling from height (n=2) and sledding (n=2). In one child, damage to the rectum and large intestine was associated with injection of compressed air into the rectum under pressure. Thermal trauma of the perineum with anorectal injury occurred in 3 young children. Two girls younger 6 years old had anorectal injury due to rape. In 6 children, damage to the rectum occurred after pelvic surgery (n=4) and injury of sphincter in patients with rectal atresia (n=2). The author presents 3 own cases.

Conclusion: Traumatic anorectal injuries are severe lesions in childhood. The primary objective in patients with combined trauma and anorectal injury is to save the child's life through diagnosis and treatment of life-threatening syndromes. Diagnosis and treatment should be carried out after exclusion of all probable causes taking into account the need for emergency care. Surgical treatment was favorable in all children.

Metastatic breast cancer is the most common malignancy and urgent problem due to high mortality. This fact emphasizes the need for development of innovative surgical approaches. Innovative approaches, including 3D modeling, provide unique opportunities for accurate reconstruction of the sternum. This method promises significant progress in individualized treatment with higher effectiveness and survival. We present resection of sternum body with anterior segments of ribs II-III and bone replacement with individual titanium implant in a patient with metastatic breast cancer.

Tracheal bifurcation stenting for cicatricial stenosis is a complex problem due to individual anatomical features in each patient. Unlike malignant stenosis with acceptable metal self-expanding stents, tracheal bifurcation stenting with standard linear silicone stents for cicatricial stenosis is a technically complex task. In such cases, 3D printing is perspective for manufacturing of personalized endoprostheses. The article presents treatment of a patient using individual silicone bifurcation endoprosthesis manufactured with 3D printing technologies. Safe implantation, improvement of breathing quality and service life of such stents are demonstrated. Long-term results confirmed their effectiveness and safety.

Objective: To study the incidence and risk factors of regional lymph node metastases in patients with early primary operable prognostically unfavorable breast cancer.

Material and methods: The study included 200 patients with early (stage I and IIA) prognostically unfavorable molecular biological type of breast cancer between 2015 and 2019. Patients were divided equally into two groups: group 1 - oncoplastic breast resection or mastectomy with regional lymph node dissection at the first stage; group 2 - sentinel lymph node biopsy with urgent cytological examination was performed instead of regional lymph node dissection, and lymph node dissection was performed only in case of verified metastasis.

Results: There were regional lymph node metastases in 15 (7.5%) patients. Of these, 10 (66.7%) ones had luminal B, Her2/neu-positive type of breast cancer, 3 (20%) and 2 (13.3%) patients - triple negative and Her2/neu-positive breast cancer, respectively. Metastatic regional lymph node lesion was common in luminal B, Her2/neu-positive type (14.7%), in Her2/neu-positive type - 3.6%, in triple negative type - 3.8%. Analysis of relationship between the incidence of regional lymph node lesion on primary tumor dimension, malignancy grade, BRCA1, BRCA2 and CHEK2 gene mutations, as well as lymphovascular invasion in tumor found no significant differences.

Conclusion: Luminal B, Her2/neu-positive breast cancer has the highest aggressiveness regarding regional metastasis (14.7%) among prognostically unfavorable types of breast cancer in stage I-IIA patients.

Objective: To improve the treatment strategy in patients with severe combined abdominal trauma using minimally invasive technique (REBOA).

Material and methods: We present a patient with severe combined abdominal trauma (traffic accident) who underwent REBOA.

Results: The patient admitted to the intensive care unit in 65 min after traffic accident. Examination including eFAST and CT was performed within 25 min. The REBOA took 7 minutes. After that, the patient was transferred to the operating theatre under ongoing intensive therapy. The patient underwent emergency surgery: angiography, embolization of splenic arteries, fixation of anterior semicircle of the pelvis and right iliac wing with external fixation device, surgical treatment of wounds of the right shoulder and left forearm, open fractures of the patellae on both sides, plaster immobilization, external fixation of the right humerus and left forearm using the Ilizarov apparatus A prerequisite for successful treatment is «Damage-control» tactics (total surgery time was 102 min). After that, further treatment was continued in the intensive care unit. Intraoperative and early postoperative transfusion therapy was performed (packed red blood cells 1268 ml, fresh frozen plasma 1475 ml, platelets 420 ml). ICU-stay was 16 days, hospital-stay - 32 days.

Conclusion: Minimally invasive REBOA technology is important in the treatment of patients with severe combined abdominal trauma. Further accumulation of experience with subsequent analysis and evaluation of results is necessary.

Objective: To describe the causes and mechanisms of postoperative mortality in abdominal surgery.

Material and methods: The primary endpoints were mechanism and cause of death within 30 days after surgery. Mortality-associated factors were examined in Cox proportional hazards model with mixed effects.

Results: Analysis included 550 patients (335 (60.9%) men and 215 (39.1%) women) who underwent abdominal surgery in level II hospitals; 59 (10.7%) out of 550 patients died within 30 days after surgery. Mean age of patients was 53 years. In respiratory diseases, acute respiratory failure associated with damage to lung parenchyma should be noted. Among cardiovascular diseases, the following mechanisms should be distinguished: distributive (e.g., intestinal ischemia, anastomotic insufficiency, sepsis), hypovolemic (blood loss), obstructive (PE), cardiogenic (acute heart failure, arrhythmia, myocardial infarction). The most common causes of death were gastrointestinal perforations (7 patients), upper gastrointestinal bleeding (2 patients), PE (3 patients), and intestinal gangrene (2 patients). Among 59 patients, 6 (10.2%) died within 24 hours, 21 (35.6%) - within the period from 24 hours to 7 days, 12 (20.3%) - within 8-14 days, 20 (33.9%) - later than 14 days after surgery. Forty-seven (79.7%) out of 59 patients died in hospital and 12 (20.3%) patients died outside the hospital.

Conclusion: Circulatory failure accounts for majority of deaths after abdominal surgery. Differences in time to death highlight the risk of death throughout perioperative period and after discharge. We propose to stratify the causes of death to primary and secondary ones (due to the main disease independent on postoperative outcomes and due to postoperative complication).