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Repeated endovascular interventions and surgical bypass operations for diseases of the lower limb arteries, with progression of the underlying disease, increased stage of chronic ischemia of the lower extremities, and ultimately the development of critical ischemia of the lower extremities, lead to a situation where there are no patent vessels, either native or shunts, through which revascularization procedures can be effectively performed. The way out of this clinical impasse is to develop and actively use new approaches for performing endovascular interventions. Our study presents the currently available "new" approaches and evaluates their safety and effectiveness.

Objective: To demonstrate variable anatomy of inferior mesenteric vein and importance of preoperative vascular examination and imaging.

Material and methods: We present a middle-aged patient with extremely rare variant of inferior mesenteric vein anatomy.

Results: Surgical procedure was followed by uneventful postoperative period. The patient was followed-up. There were no signs of recurrence.

Conclusion: Analysis of imaging is important for preoperative management and minimizing the risk of intraoperative complications associated with variable anatomy.

Objective: To research the features of endoscopic treatment of choledocholithiasis and biliary strictures in patients with surgically altered anatomy of the upper gastrointestinal tract.

Material and methods: A single-center retrospective study included 19 consecutive patients. Early outcomes including: the success of intubation of the afferent limb, the success of selective cannulation of the biliary ducts, the effectiveness of the performed operations; the frequency of complications; factors related to these indicators.

Results: 3 (15.7%) patients failed intubation of the afferent limb. In 16 (84.2%) patients, endoscopic treatment was an effective final treatment method - regression of obstructive jaundice was achieved and cholangitis was stopped. 9 (69.2%) of 13 patients with choledocholithiasis, complete one-stage stone extraction was performed; 4 (30.8%) patients staged treatment was performed, during which 3 patients underwent cholangioscopy procedure with lithotripsy (laser and electrohydraulic). 3 patients with benign strictures underwent staged endoscopic treatment - multiple procedures to upsize and number of stents. In 1 (6.3%) 85-year-old patient with choledocholithiasis complicated by cholangitis and abscesses, surgery and complex therapy did not avoid a fatal outcome. There were no other complications.

Conclusion: Endoscopic treatment of choledocholithiasis and biliary strictures in patients with surgically altered anatomy is a more difficult task. In a significant proportion of patients endoscopic treatment is effective. The success of the endoscopic treatment is due to the equipment of the hospital and the skills of physicians. It may be advisable to concentrate this technique in a centres with skill and expertise.

Objective: To evaluate the efficacy and safety of robot-assisted (RATS) and video-assisted thoracoscopic (VTS) minimally invasive surgeries for anterior mediastinal neoplasms.

Material and methods: The study involved 74 patients who underwent surgeries for anterior mediastinal neoplasms between 2020 and 2023. Patients were divided into two groups: group 1 (RATS, 33 patients) and group 2 (VTS, 41 patients). The following parameters were evaluated: surgery time, incidence of postoperative complications, pain syndrome and recovery time.

Results: Duration of RATS was significantly shorter (mean 120 min) compared to VTS (140 min) (p< 0.05). Postoperative pain was also lower in the RATS group (4.5 vs. 6.0 points) (p< 0.05). The incidence of complications was lower in the same group that contributed to earlier recovery.

Conclusion: Robot-assisted surgeries are preferable for anterior mediastinal tumors. The advantages of RATS include shorter surgery time, lower pain and complication rate. Thus, this approach is more advisable in high-risk patients.

Objective: To evaluate universal intestinal suture in rehabilitation of patients with single-row anastomoses after elective upper gastrointestinal tract surgery.

Material and methods: A single-center study included 142 patients over 8-year period. There were 72 (50.7%) pancreaticoduodenectomies and 70 (49.3%) gastric resections and gastrectomies. The rehabilitation program included single-layer anastomoses using universal intestinal suture, intestinal drainage for decompression and enteral nutrition, therapeutic and diagnostic endoscopy to stimulate motor evacuation function, patency of anastomoses and assessment of anastomositis.

Results: Intestinal drainage for decompression and enteral nutrition was used for 6 (4; 7) days after surgery. Intraluminal endoscopy was performed after 9 (7; 11) days. In patients with anastomositis grade 0 (26.5%) and 1 (62.4%), we observed minimal inflammation along intestinal suture line (mean hospital-stay 16 (13; 20) days). In patients with anastomositis grade 2 (8.5%) and 3 (2.6%), we observed surface erosions and ulcers in the anastomosis zone (mean postoperative hospital-stay 20 (16; 27) days). Postoperative complications unrelated to anastomoses were diagnosed in 17.6% of cases; 12% of patients underwent redo surgery. Mortality rate was 2.8%.

Conclusion: Universal intestinal suture in rehabilitation of patients with single-layer anastomoses contributed to uncomplicated healing of anastomoses in 88.9% of patients with anastomositis grade 0-1 and reduced the incidence of anastomositis grade 2-3 to 11.1%, as well as hospital-stay after elective upper gastrointestinal tract surgery.

Objective: To identify prognostic factors and role of preoperative therapy for resectable intrahepatic cholangiocarcinoma (IHCC).

Material and methods: We analyzed the results of surgical and combined treatment of IHCC between 1999 and 2023. Immediate and long-term outcomes were evaluated depending on negative prognostic factors and additional therapy.

Results: The study included 195 patients. Postoperative complications grade ≥III were observed in 35 (17.9%) case. Mortality rate was 3.1% (n=6). Thirty-eight patients (19.5%) underwent treatment before surgery, 109 (55.9%) ones - after surgery. The median overall survival was 31 months, 5-year overall survival - 32.0%. The following factors worsened overall survival: node size ≥8 cm (HR 1.45; 95% CI 0.97-2.17), invasion (HR 1.63; 95% CI 1.07-2.47), multiple lesion (HR 1.51; 95% CI 1.00-2.28). R1 resection worsened disease-free survival (HR 1.88; 95% CI 1.14-3.10). Lymph node metastases decreased overall (HR 1.96; 95% CI 1.27- 3.04) and disease-free survival (HR 2.37; 95% CI 1.63-3.44). Two and more negative factors worsened overall (p=0.0013) and disease-free survival (p=0.0005). Absence of adjuvant therapy worsened overall (HR 2.12; 95% CI 1.41-3.20) and disease-free survival (HR 1.42; 95% CI 0.99-2.04). There was a trend towards higher overall (p=0.088) and progression-free survival (p=0.029) in case of preoperative therapy (n=195). In unfavorable prognosis group, preoperative therapy (n=33) was superior to standard treatment (resection+capecitabine after surgery, n=26). There was a trend towards higher overall survival (p=0.066) and significantly better progression-free survival (17 vs 13 months, p=0.018).

Conclusion: Negative prognostic factors for resectable IHCC are lesion size ≥8 cm, intrahepatic and regional metastases, invasion into neighboring structures, R1 resection. Combination of negative factors worsened prognosis. Adjuvant therapy improved postoperative outcomes. Preoperative therapy may be advisable in case of negative factors and high risk of R1 resection.

Objective: To analyze long-term structural and functional changes of connective tissue in patients with recurrent hernias after repair with implants.

Material and methods: Excisional biopsies from the hernia recurrence sites were performed in 60 patients who had previously undergone hernia repair with implants. In 37 (62%) patients, polypropylene mesh of the unidentified manufacturer was previously implanted. Eight (13%) patients underwent PROLENE polypropylene mesh implantation, 4 (5%) patients - Ultrapro partially absorbable lightweight mesh composed of approximately equal parts of non-absorbable polypropylene fibers and absorbable poliglecaprone fibers, 4 (7%) patients - polyethylene terephthalate meshes of the unidentified manufacturer, 8 (13%) patients - PROCEED™ surgical mesh with absorbable anti-adhesive coating.

Results: There were chronic inflammation foci at the site of recurrence in 1-5 years after implantation. Macrophages and mast cells were in active functional state. After 6-10 years, implant-induced fibrosis with areas of hyalinosis around the implant developed. There were fractures, cracks and other defects on threads of unidentified polypropylene implant and Prolene endoprosthesis. After 19 years, fragments of polyethylene terephthalate endoprosthesis were surrounded by giant cell granulations with tissue hyalinosis at the site of recurrence.

Conclusion: Polypropylene and polyethylene terephthalate endoprostheses were subject to destruction over time (after 7 years in our study). Any implant causes persistent inflammation many years later. Desynchronization of inflammation and regeneration phases can lead to excessive connective tissue with its subsequent fibrous transformation and implant deformation in long-term period (up to 19 years).

Objective: To assess the effectiveness of local treatment of venous trophic ulcers in gerontological patients.

Material and methods: We analyzed treatment venous trophic ulcers in 4 groups of elderly and senile patients. All patients received conservative therapy. In the 1^st group (n-74), local injection of 0.1% polyhexanide-betaine gel throughout 7-10 days was followed by liposomal antioxidant-phospholipid complex «Flamena». In the 2^nd group (n-69), immune correction with «Imunofan» was carried out along with local therapy. In the 3^rd group (n-69), local treatment was combined with pulsed high-intensity optical irradiation of the wound. In the 4^th group (n-69), local treatment was combined with immune correction and pulsed high-intensity optical irradiation. Cytological analysis was performed to estimate effectiveness of treatment. Statistical analysis was performed using nonparametric Friedman and Mann-Whitney tests.

Results: The number of leukocytes, lymphocytes and macrophages increased by the 7^th day of treatment. Activation of inflammation was more pronounced in groups 2, 3 and 4 (p< 0.0083). By the 15^th day, leukocyte count decreased. The number of macrophages and lymphocytes remains high; the number of fibroblasts increases. Cytograms were mainly inflammatory and inflammatory-regenerative. By the 22^nd day, cytograms corresponded to regenerative-inflammatory and regenerative types with the lowest number of neutrophils, moderate number of lymphocytes, macrophages and fibroblasts.

Conclusion: Complex local treatment of venous trophic ulcers with local immunomodulatory therapy and pulsed high-intensity optical irradiation contributes to conversion of chronic inflammation to acute one with initiation of reparation processes and tissue regeneration.

Objective: To investigate late complications after pancreatoduodenectomy (PD) as a part of multivisceral surgeries (MVS) and the impact of these interventions on the quality of life.

Material and methods: Analysis of complications in long-term postoperative period included 776 patients (233 cases of MVS with PD (main group) and 543 cases of standard PD (comparison group)). Analysis of the quality of life included 58 patients from the main group and 67 patients from the comparison group. The quality of life was studied using the Russian-language versions of the EORTC QLQ-C30 and EORTC QLQ-PAN26 questionnaires.

Results. t: Here were no significant between-group differences in the incidence of long-term postoperative complications (26.2% versus 20.1%, p=0.059). Diabetes mellitus occurred in 26 (15.9%) and 57 (10.8%) patients, respectively (p=0.08). Malnutrition (10.3% versus 3%, p<0.001), cholangitis (7.3% versus 2.5%, p=0.003) and edema/ascites (7.3% versus 0.8%, p<0.001) were significantly more common in the main group. According to the EORTC QLQ-C30 scores in the main group, general health (58 (58 - 58) versus 66 (58 - 66), p<0.001, weak clinical significance) and physical functions (79.5 (73 - 89) versus 86 (73 - 93), p=0.04, weak clinical significance) were significantly worse, and weakness was more pronounced (22 (22 - 33) versus 11 (11 - 22), p<0.001, moderate clinical significance). According to the EORTC QLQ-PAN26 scores, weight loss (24.5 (16-33) versus 16 (0-16), p<0.001, weak clinical significance), weakness in arms and legs (16 (16-16) versus 0 (0-16), p<0.001, moderate clinical significance) and dry mouth (8 (0-16) versus 0 (0-16), p=0.004, weak clinical significance) were more common in the main group.

Conclusion: MVS with PD is significantly more often accompanied by cholangitis and symptoms of alimentary failure in long-term period. This determines the worst quality of life after MVS with PD.

Objective. t: O assess severity of catabolism in patients with pancreatic necrosis complicated by external duodenal fistulas considering CT data of lumbar muscle density.

Material and methods: A retrospective non-randomized pilot study included 11 patients (7 men (63.6%) and 4 women (36.4%)) diagnosed with severe acute pancreatitis and pancreatic necrosis. Late phase of disease was complicated by external duodenal fistulas in all patients. Mean age of patients ranged from 34 to 88 years (49 (34; 88) years). All patients were retrospectively assessed for lumbar muscle density at the level of the third lumbar vertebra using CT data (HUAC). Study stages: stage 1 - 24 hours after admission; stage 2 - 1.5±0.52 days after external duodenal fistula; stage 3 - 19.4±6.68 days after external duodenal fistula. The following parameters were retrospectively assessed in all patients: RPHU, RPA, LPHU, LPA. After that, mean lumbar muscle density (HUAC) was calculated. To assess prognostic significance of parameters, patients were divided depending on outcomes: group of survivors included 8 patients (n=8; 72.7%) aged 34-62 years; group of deceased included 3 patients (n=3; 27.3%) aged 63-88 years.

Results: At the first stage (HUAC 1), values were was 34.69±8.44 (95% CI 26.89-42.50) HU and 31.35±6.76 (95% CI 14.57-48.14) HU, respectively (p=0.565). At the second stage (HUAC 2), mean values were 34.61±7.61 (95% CI 27.57-41.65) HU and 22.04±3.32 (95% CI 13.79-30.30) HU, respectively (p=0.028). Significant differences could indicate important changes in physiological state. At the third stage (HUAC 3), mean values were 37.14±7.21 (95% CI 30.47-43.80) HU and 19.44±3.51 (95% CI 10.71-28.16) HU, respectively (p=0.004).

Conclusion: Despite the obvious importance of traditional methods for diagnosing nutritional deficiency, it is necessary to expand the list of perspective and more sensitive methods for prevention of nutritional disorders in patients with external duodenal fistulas. The proposed method for assessing the density of lumbar muscles has an important prognostic value and allows assessing the severity of catabolism upon admission and in follow-up period.