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Acute appendicitis in adults. Clinical guidelines.

Objective: To develop the adapted scale for analysis of necessary septal myectomy (SME) in aortic valve replacement (AVR) for severe aortic stenosis.

Material and methods: A retrospective and prospective analysis included 180 patients with severe aortic stenosis and interventricular septal hypertrophy ≥1.5 cm who underwent surgery between 2012 and 2024. Age of patients was 64 (61; 67.3) years. There were 96 (53.3%) men and 84 (46.7%) women. Heart failure NYHA class III was observed in 98 patients (54.4%), class II in 54 (30.0%) patients. The AVR+SME group included 100 patients, and the AVR group included 80 patients. Both groups did not differ in preoperative clinical and echocardiography characteristics.

Results: Logistic regression was performed to identify significant predictors. Multivariate analysis provided logistic function including 3 predictors: IVST / PWT, indexed LV myocardial mass and aortic annulus diameter. Regression model included significant factors obtained at the first stage of analysis. The obtained prognostic model was significant (p<0.01). Sensitivity was 77.0%, specificity - 83.8%. IVST/ PWT and indexed LV myocardial mass increase the probability of concomitant SME, while aortic annulus diameter has inverse relationship. The cut-off point for indexed LV myocardial mass is 167.5 g, for IVST/ PWT - 1.15, for aortic annulus diameter - 23.5 mm. Further analysis was performed by assigning a score to each predictor. The total score in two groups was determined. Thus, total score > 83.5 indicates advisability of SME in aortic valve replacement.

Conclusion: The new scale for predicting the need for SME in AVR will improve postoperative results.

We present successful surgical treatment of a patient with chronic kidney disease (CKD) and hyperparathyroidism undergoing renal replacement therapy. At baseline, parathyroidectomy via cervical access was performed for parathyroid adenomas. After 6 years, clinical and laboratory relapse of disease required thoracoscopic resection of atypically located anterior mediastinal adenoma. This case demonstrates that this disease is one of the most difficult in modern medicine requiring a special approach in diagnosis and treatment. Patients with CKD and hyperparathyroidism need for follow-up, control of total and ionized serum calcium, inorganic phosphorus and parathormone, osteodensitometry, ultrasound and scintigraphy of thyroid and parathyroid glands, and, if necessary, CT or MRI of the neck and chest organs.

Objective: To create a formalized method for predicting papillary thyroid cancer recurrence after hemithyroidectomy based on preoperative data.

Material and methods: At this stage of the study, we selected 101 patients with papillary thyroid cancer who underwent surgical treatment in 2017-2023. Recurrence was observed in in 47 patients. Fifty-four patients had no recurrence within 5 years after surgical treatment, i.e. these patients underwent surgery in 2017-2018. To find prediction rules, we used original classification method based on searching for subsets of variables and piecewise linear rules separating classes in pairs with subsequent voting of such rules to make a decision.

Results: The exam was carried out using a training sample (101 cases) and sliding control method (10 tests on 10 random cases). On the training sample, sensitivity of predictive algorithm was 91%, specificity 78% and error rate 13%. The aggregated result of 10 trials using sliding control method revealed sensitivity of predictive algorithm 86%, specificity 75% and error rate 15%. This result is close to overall sample and confirms the effectiveness of this method for predicting recurrence.

Conclusion: The pilot experiments revealed the patterns in data for potential prediction of recurrence based on preoperative indicators. Further study of this problem may be valuable for decision-making and adjustments in the management of patients with papillary thyroid cancer.

The number of elderly and senile patients who are in need of surgical care delivery is growing steadily year over year. This category of patients is characterized by comorbidity, polypragmasy and high prevalence of geriatric syndromes including loss of autonomy, malnutrition and cognitive impairments that increase the risk of developing perioperative complications. Management of these patients at all stages requires a comprehensive multidisciplinary approach. Nevertheless, there is no uniform understanding of solution of this problem at present. Determination of consensus on certain issues using the Delphi method will allow to gather and unite expert opinions. In this regard, the working group formulated the main points of management of elderly and senile patients before, during and after surgical treatment and conducted a cross-sectional analysis of experts' opinions.

Objective: To analyze morphological changes in wall of functioning and non-functioning small intestine in patients with preventive ileostomy and to determine histological predictors of water-electrolyte disorders.

Material and methods: We prospectively analyzed 57 patients >18 years old who underwent rectal resection with preventive ileostomy between January 2022 and November 2023. Anthropometric data included gender, age, body mass index, ECOG and ASA classes. Complications associated with large losses through ileostomy were water-electrolyte disorders, dehydration and acute renal failure with repeated hospitalization. Morphological analysis implied intraoperative full-layer biopsy of small intestine on anterior abdominal wall (ileostomy). Intraoperative biopsy of efferent and afferent loops was also carried out. Tissue samples were examined by light microscopy. We analyzed mean height of mucous membrane villi and depth of crypts, as well as their ratio. Fibrosis and swelling of submucosa were evaluated too. The results were analyzed in the SPSS Statistics 20 software.

Results: Mean height of intestinal villi <465 microns (p=0.028), ratio of their height to crypt depth <4.38 (p=0.034) and submucosal fibrosis (p=0.031) significantly affected malabsorption and readmission of patients. The risk of readmission was 11.5 and 5.5 times higher in univariate analysis. Multivariate analysis revealed in-hospital dehydration with resumption of infusion therapy as a predictor of readmission (p=0.046).

Conclusion: Ileostomy is a certain stress for the patient's body. Not every patient is able for adaptation. One of the adaptation mechanisms is hypertrophy of mucous membrane villi involved in digestion. This mechanism is less pronounced in patients with repeated hospitalizations. Preoperative morphological examination of ileum mucosa may be an additional objective predictor of possible complications of preventive ileostomy.

Objective: To evaluate the quality of recommendations provided by ChatGPT regarding inguinal hernia repair.

Material and methods: ChatGPT was asked 5 questions about surgical management of inguinal hernias. The chat-bot was assigned the role of expert in herniology and requested to search only specialized medical databases and provide information about references and evidence. Herniology experts and surgeons (non-experts) rated the quality of recommendations generated by ChatGPT using 4-point scale (from 0 to 3 points). Statistical correlations were explored between participants' ratings and their stance regarding artificial intelligence.

Results: Experts scored the quality of ChatGPT responses lower than non-experts (2 (1-2) vs. 2 (2-3), p<0.001). The chat-bot failed to provide valid references and actual evidence, as well as falsified half of references. Respondents were optimistic about the future of neural networks for clinical decision-making support. Most of them were against restricting their use in healthcare.

Conclusion: We would not recommend non-specialized large language models as a single or primary source of information for clinical decision making or virtual searching assistant.

We present this clinical case as a demonstration of difficulties in differential diagnosis of pulmonary coccidioidomycosis. Differential diagnostics of peripheral pulmonary lesion performed using bronchoscopy with BAL and TBCB and video-assisted thoracic surgery (VATS) biopsy. Diagnostic specimens were tested using microbiological (luminescent microscopy, culture for M. tuberculosis (BACTEC MGIT960 and Lowenstein-Jensen Medium), RT-PCR, cytological and morphological (hematoxylin-eosin, Ziehl-Neelsen, PAS, Grocott methenamine silver (GMS) stainings) examinations. A diagnosis was verified correctly In Russia the country is not endemic for coccidioidomycosis and patient was treated accordingly. Diagnostics of peripheral pulmonary lesions requires of multidisciplinary approaches. Morphological examination, based on detection of only granulomatous inflammation in lung biopsy cannot be used for finally DS and requires microbiological confirmation for TB or other infections, and dynamic monitoring of the patient with concordance their anamnesis vitae and morbi.

We demonstrate robot-assisted treatment of a patient with benign pancreatic insulinoma. A 31-year-old patient suffered from attacks of weakness, numbness of the fingertips and «turbidity of consciousness» for 2 years. These symptoms occurred on an empty stomach and regressed after eating. We found pancreatic insulinoma. The patient underwent robotic enucleation of pancreatic tumor. Surgery time was 145 min. Postoperative period proceeded without complications. Hyperglycemia up to 10.5 mmol/l on the first postoperative day was followed by normalization after 4 days. The patient was discharged in 6 days after surgery. Minimally invasive robotic enucleation of insulinoma minimizes surgical trauma and provides precise resection of tumor. The key aspect of safe enucleation is localization of tumor at a distance of at least 2 mm from the pancreatic duct.

We present gallbladder rupture following trauma. A 9-year-old boy admitted in 1.5 hours after injury. Considering clinical and ultrasound data, we diagnosed traumatic damage to the spleen and hemoperitoneum, biliary dyskinesia, cholestasis, sludge. Hemostatic therapy was carried out. After 3 days, signs of peritonitis appeared. Follow-up ultrasound revealed gallbladder enlargement with heterogeneous content, fluid in all parts of abdominal cavity. Intraoperatively, the gallbladder was enveloped in omentum soaked in bile. After mobilization of the gallbladder, we found longitudinal linear tear up to 3 cm clogged with omentum. Cholecystectomy was performed. Thus, we present a patient with combined injury and damage to the spleen. However, gallbladder wall thickening and heterogeneous content were interpreted as concomitant pathology. Delayed manifestation of peritonitis was due to gallbladder enveloped in omentum. The last one soaked in bile partially entered the gallbladder through perforation and prevented bile leakage into abdominal cavity. Timely diagnosis of gallbladder damage presents certain difficulties, especially in case of combined injury. Ultrasound signs of traumatic gallbladder rupture in this case were wall thickening, heterogeneous content and gradual gallbladder enlargement. It is necessary to analyze all organs at the damage site including computed tomography in patients with combined trauma.