Bulletin of Pirogov National Medical & Surgical Center
Peer-reviewed journal "Bulletin of Pirogov National Medical & Surgical Center"
Национальный медико-хирургический Центр им. Н.И. Пирогова
Authors who publish with this journal agree to the following terms: Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal. Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
ENDOVASCULAR REVASCULARIZATION OF THE HEART IN COMBINATION WITH STIMULATION OF EXTRACARDIAL NEOANGIOGENESIS (YURLEON TECHNIQUE) DIFFUSE CORONARY ATHEROSCLEROSIS
In modern cardiac surgery practice, there is a significant increase in the number of patients with diffuse multivessel coronary artery disease, which is due to a combination of factors, including the widespread introduction of endovascular revascularization methods, prolonged drug therapy and the expansion of surgical indications. To optimize the treatment of this category of patients, in 2007, Academician Yu.L. Shevchenko proposed an innovative method for stimulating extracardial neoangiogenesis (“YurLeon”), which has received widespread clinical application. Aim. To evaluate the clinical efficacy of hybrid myocardial revascularization using the «YurLeon» and percutaneous coronary intervention in patients with coronary artery disease with diffuse coronary artery disease. Materials and methods. The study included 77 patients with diffuse coronary artery disease who were treated at the St. George Thoracic and Cardiovascular Surgery Clinic at the N.I. Pirogov National Medical and Surgical Center. 64.9% of them were men (n = 50), the median age was 72.00 years (68.00–75.00). Group I (n = 37) – patients who underwent hybrid revascularization (PCI+YurLeon); group II (n = 40) – control (isolated PCI). Clinical data, EchoCG, gated-SPECT, coronary angiography, and quality of life assessment (SAQ-7 questionnaire) were evaluated. Results. The results of a 12-month follow-up demonstrated a significant improvement in the left ventricular ejection fraction from 49% to 58% (p<0.001), a decrease in the volume of hibernated myocardium by 44.4% (from 18% to 10%), (p<0.001) and an improvement in the functional class of angina pectoris in the PCI+YurLeon group. In 67.6% of patients in this group, functional class I–II angina pectoris was achieved. There was a significant improvement in the quality of life in group I patients (p<0.001) Conclusion. The results of the study confirm the prospects of hybrid myocardial revascularization (PCI+YurLeon) in the treatment of patients with diffuse coronary artery disease, while the developed algorithms for patient selection and stratification according to expected effectiveness make it possible to optimize the use of this technique in clinical practice.
ACUTE CORONARY SYNDROME EARLY AFTER SURGICAL MYOCARDIAL REVASCULARIZATION: A SINGLE-CENTER STUDY AND PROPENSITY SCORE MATCHING ANALYSIS
Rationale. Acute coronary syndrome (ACS) is a life-threatening complication that can occur in the perioperative period of coronary artery bypass grafting (CABG). Objective: to analyze the causes, recognition capabilities, risk factors, immediate treatment results and hospitalization outcomes in patients with perioperative ACS that developed after CABG. Methods. The main study group included 45 patients with ACS (group I) who underwent percutaneous coronary intervention (PCI) at the Pirogov Center in 2016–2025 after CABG and emergency coronary bypass angiography (CAG). Using the propensite score matching (PSM) from the control sample (sample size – 1000 patients after CABG without ACS), 45 patients after CABG without ACS (group II) were included in the control group. The average follow-up period for patients in both groups was 10 [7; 13] days. The primary endpoint of the study was death. Secondary endpoints were endovascular revascularization, resternotomy, bleeding, acute cerebrovascular accident (ACVA), and myocardial infarction (MI). Results. The death rate was 8 (17.8%, group I) versus 1 (2.2%, group II), OR 0.105, 95% CI 0.013–0.880, p = 0.030, resternotomy – 7 (15.6%, group I) versus 2 (4.4%, group II), OR 0.252, 95% CI 0.049–1.290, p = 0.157. Endovascular revascularization was performed in 38 (84.4%) patients of the main group, 12 (26.7%) patients of group I had a verified diagnosis of MI. Risk factors for the development of ACS after CABG: lack of arterial revascularization (OR 4.528; 95% CI 1.373–14.933, p = 0.013), incomplete revascularization (OR 4.385; 95% CI 1.254–15.332, p = 0.021). Conclusion. Perioperative ACS in the early period of CABG is a formidable complication and determines a statistically significantly higher frequency of fatal outcomes compared to patients without this complication. Isolated autovenous revascularization and incomplete myocardial revascularization are predictors of ACS, increasing the likelihood of its development by 4 times.
USE OF PROVISIONAL STENTING TECHNIQUE IN BIFURCATION LESIONS OF CORONARY ARTERIES: RESULTS OF A SURVEY OF ENDOVASCULAR SURGEONS
Objective. To analyze the current state of application of the provisional stenting technique for bifurcation lesions of the coronary arteries by different specialists in various medical organizations in Russia. Materials and methods. The data required for analysis and statistical processing were obtained by developing a formalized questionnaire (20 questions, some of which with the ability to select several answers at the same time - multiple choice), which was published in three Russian Internet communities dedicated to endovascular surgery (“Angiopicture”, “Rentgenhirurg Club” and “Endovascular School”). Participation was anonymous. The survey lasted 14 days (from June 23, 2024 to August 6, 2024). The results of the study were collected using the Google Forms online service and processed using the Google Sheets service. Multiple-choice answers were processed as absolute numbers and presented as a percentage of the total number of answers to a specific question. Results and discussion. The total number of respondents who took part in the survey was 86, whose average age was 35 years. Practical activity is represented by work in medical organizations of various levels, but most of the responses were received from 3rd level MO (48.8%). The professional experience of most respondents in the specialty does not exceed 15 years (80.2%). The following results were revealed based on the study: Slightly less than half of the respondents (43%) equally assess the possibility of using provisional stenting on a planned and emergency basis. When choosing this technique, 58.1% of respondents rely on their professional experience in treating bifurcation lesions of the coronary arteries. The vast majority of endovascular surgeons perform sequential insertion of coronary guidewires into the main branch and then into the side branch using two coronary guidewires. (73.3%). When performing provisional stenting, the preferred technique is the classical one, with sequential “POT-kissing-POT” dilations (34.9%). The most common criterion for performing SB dilation after MV stenting is significant impairment of blood flow through the SB (TIMI <3) – 81.4%. When switching to a two-stent technique, surgeons give great preference to the following techniques: “CULLOTE” (75.6%) and “T/TAP” (64%). The reasons for using the provisional stenting technique are: good results in the early and late postoperative periods (82.6%), ease of implementation (83.7%), and the possibility of switching to a two-stent technique (66.3%). Conclusion. To date, there is no unified approach to provisional stenting for bifurcation coronary artery disease. The results of this survey revealed disagreements among specialists regarding the indications and sequence for selecting and performing provisional stenting. Finding the optimal method for performing provisional stenting is a critically important clinical task aimed at reducing perioperative complications and improving long-term treatment outcomes.
RESULTS OF SURGICAL TREATMENT OF INFRARENAL ABDOMINAL AORTIC ANEURYSMS WITH AND WITHOUT OCCLUSIVE-STENOTIC LESIONS OF THE ILIO-FEMORAL SEGMENT
Purpose of the study: To compare the results of open surgical treatment of infrarenal aortic aneurysms with and without steno-occlusive lesions of the ilio-femoral segment. Materials and methods: The analysis of the results of open surgical treatment of infrarenal aortic aneurysms was performed in 125 patients. The patients were divided into two groups: group 1 – aneurysm with occlusive-stenotic lesion of the ilio-femoral segment (n = 59), group 2 – aneurysm without hemodynamically significant lesion of the ilio-femoral segment (n = 66). All patients underwent resection of the abdominal aortic aneurysm with aorto-iliac or aorto-femoral bifurcation prosthetics. Results: In-hospital mortality in group 1 was higher, 10% compared to 3% in group 2, but no statistically significant differences were found (p = 0.1). The main cause of mortality was the highest level of myocardial infarction (62%). The occurrence of cardiovascular complications was significantly more common in group 1 and amounted to 29% compared to 7% in group 2 (p = 0.002). The incidence of thrombosis of the prosthesis branches and lower limb arteries was 17% in group 1 compared to 4.5% in group 2 (p = 0.02). The time of clamping the aorta and lower limb arteries in group 1 was longer due to the need for arterial reconstruction (p = 0.03). Conclusion: 1. Larger diameter (>70 mm) of abdominal aortic aneurysms (AAA) without hemodynamic lesion to the ilio-femoral segment (IFS) is associated with late diagnosis and associated with the asymptomatic nature of the disease and more often requires access via TFLT. 2. Smaller diameter (<50 mm) of AAA in patients with steno-occlusive lesion to the ILS is associated with early patient referral due to clinical presentation of chronic arterial insufficiency of the lower extremities. 3. Open surgical treatment of patients with AAA and occlusive-stenotic lesion to the ILS is accompanied by a high risk of cardiovascular complications and postoperative mortality compared to AAA without atherosclerotic lesion to the ILS.
RESULTS OF THE USE OF VENOUS HOMOGRAPHS FOR THE FORMATION OF PERMANENT VASCULAR ACCESS FOR HEMODIALYSIS
Background: Chronic kidney disease is widespread (10-13% of the world’s population), irreversible, progressive, and associated with an increased risk of cardiovascular disease. Every year, there are 10-12% more patients with end-stage renal failure. They are shown renal replacement therapy by conducting programmed hemodialysis through permanent vascular access. Aims: to evaluate the results of the use of freshly prepared venous homographs in the formation of permanent vascular access in patients with stage V chronic kidney disease, in comparison with the use of synthetic prostheses. Materials and methods: A retrospective study included 40 patients with stage V CKD who underwent PSA formation with a synthetic prosthesis (SSP) and venous femoral vein homograft. Depending on the material used, 2 groups were formed: group 1 – SSP was used (n = 22), group 2 – femoral vein homograph was used (n = 18). Homograft was used in patients after SSP thrombosis and/or with paraprosthetic access infection. In patients after the formation of PSD (synthetic conduit and venous homograph) in the postoperative period, the following were assessed: primary patency after 1.5 months, 3 months, 6 months, 9 months and 12 months after the formation of access, complications during puncture and needle extraction, and the level of recirculation 12 months after the formation of access. The frequency of formation of aneurysms of biological conduits has been studied. The total follow-up period for patients after the formation of PSD (synthetic conduit and venous homograph) was 1 year. Results: The patency of permanent vascular access after 12 months in the first group was 86%, the patency of permanent vascular access after 12 months in the second group was 94%. There was no statistically significant difference in the patency of permanent vascular access between the groups (P = 0.82). During puncture and needle extraction, no bleeding was observed from the homograph during hemodialysis during the follow-up period. There was no significant level of recycling in both groups by the end of the study (14±5.1% in the group of synthetic vascular prostheses (SSP) and 16±4.2% in the group of homographs). No aneurysmal transformation of homographs was detected during the 12 months of follow-up. Conclusions: The formation of PSD by venous homograft can be considered an acceptable alternative to synthetic conduit.
RESULTS OF CYANOACRYLATE ADHESIVE СLOSURE OF VARICOSE VEIN
Objective. To evaluate the immediate and medium-term results of cyanoacrylate adhesive closure (CАС) in the treatment of patients with varicose veins at one medical center setting. Material and methods. The study was performed at the “Venosan” Phlebological Center (Zheleznodorozhny city, Moscow region). The inclusion criteria were: CEAP classes C2-C6, junctional incompetence and axial reflux lasting more than 0.5 sec, the diameter of the trunk of the saphenous vein ≥ 5 mm and the presence of varicose tributaries. All patients underwent VenaSeal procedure. In all cases, an isolated truncal ablation was performed without intervention on side bracnches excluding the use of compression stockings. Intraoperative pain was assessed using a standard Visual Analog Scale (VAS). The effectiveness of the treatment was assessed by its anatomical success in target vein occlusion, the safety of the procedure was characterized by the absence of complications. Occlusion rate was assessed by Kaplan-Mayer method and patients’ quality of life was measured by AVVQ. Results. Between 2021 and 2024, CAC was performed in 11 patients (20 lower extremities and 23 venous trunks) – 9 women (82%) and 2 men (18%). Their mean age was 59.2±15.4 years. The distribution of patients according to CEAP was: C2 – 6 (54%); C3 – 1 (9%), C4 – 4 (36%) and C6 – 1 (9%). The mean diametre of the GSV was 10.1±3.6 mm, the diametres of the SSV and the AASV were 9.8±3.5 mm and 8.5±0.7 mm respectively. The control duplex ultrasound was performed on the 3rd day, 1st and 3rd months after the intervention. Vein occlusion on the 30th day was achieved in all 100% of patients. Recanalization of the target veins during the follow-up period was noted in 1 patient (4% of all treated veins). In 1 (9%) patient, one truncal vein was ablated, in 7 (63%) – two and in 2 (18%) patients – three trunks were ablated simultaneously. The mean intervention time comprised 55.9± 9.7 minutes. Intraoperative VAS in 93% of patients was less than 3 points. Migration of glue with its propagation into the deep vein was detected in 1 patient (4%), the formation of soft tissue granuloma was noted in 1 patient (4% of all treated veins). Phlebitic skin reaction was registered within 7 to 21 days after the intervention in 2 (18%) patients. There were no cases of paresthesia, deep or superficial vein thrombosis, nor PE in our patients. Сonclusion. CAC has shown high efficacy and safety in our group of patients with occlusion rate of up to 90% in 3 year period.
DIAGNOSIS AND TREATMENT OF COAGULATED HEMOTHORAX AFTER A GUNSHOT INJURY TO THE CHEST AT THE STAGE OF SPECIALIZED CARE
Relevance: Coagulated hemothorax is the most common complication of penetrating gunshot wounds to the chest, requiring surgical treatment in most patients. Materials and methods: From 2023 to 2024, videothoracoscopy was performed on 43 victims with complications of penetrating gunshot wounds to the chest. Coagulated hemothorax was detected in 39 patients (90.7%). Results: Spiral computed tomography with Hounsfield lesion density testing has the highest diagnostic capabilities for this pathology (specificity – 93% and sensitivity – 100%). It was established that the main cause of this complication was incorrect installation and inadequate function of pleural drainage. Coagulated hemothorax developed after pleural drainage and primary surgical treatment in 33 victims (76.7%), after atypical thoracotomy – in 4 wounded (10.3%) and in 2 patients (5.1%) after typical thoracotomy. The average interval between surgeries was 7.4±6 days. Conclusion. The best results of treating clotted hemothorax after penetrating gunshot wounds to the chest were achieved with its earliest possible detection in cases of video-assisted thoracoscopic evacuation in the range of 3–7 days. Performing sanation videothoracoscopy at a later date (more than 7 days) was associated with an increase in the volume of surgical intervention (lung decortication, induction of chemical pleurodesis), which significantly increased the duration of treatment of the wounded at the stage of specialized medical care by 2 times.
EFFICIENCY OF NON-OPIOID ANALGESICS IN PATIENTS WITH TRAUMATIC LIMB AMPUTATIONS IN THE EARLY POSTOPERATIVE PERIOD
Justification: This work is the integration of safer and more effective drugs into clinical practice to optimize pain relief and reduce the risks associated with the use of traditional opioid analgesics. Objective: to evaluate the effectiveness of pain relief in the early postoperative period using non-opioid analgesics (ibuprofen, tafalgin, nefopam) in patients with mine-blast wounds (MBW) accompanied by traumatic amputations of the limbs. Methods: The study included 45 patients randomly assigned to three groups depending on the analgesic used: ibuprofen, tafalgin or nefopam. Results: In all groups, there was a significant decrease in the need for additional postoperative analgesia, including opioid drugs. Nefopam provided the most pronounced analgesic effect, reducing pain intensity on the VAS scale more than ibuprofen and tafalgin. However, its use was accompanied by a higher frequency of side effects (dizziness, tachycardia, hypertension). Ibuprofen demonstrated an optimal combination of analgesic efficacy and safety, with a minimal frequency of side effects. Conclusion: Nefopam has a pronounced analgesic effect in the early postoperative period in patients with MVR, but is associated with an increased frequency of side effects. Ibuprofen showed a high level of safety and sufficient efficacy, which makes it a preferred component of multimodal analgesia for this category of patients.
TREATMENT OF PATIENTS WITH CHRONIC ARTERIAL INSUFFICIENCY AND TROPHIC ULCERS OF THE LOWER EXTREMITIES BY USING INNOVATIVE, COMBINED TREATMENT AND PROPHYLACTIC COMPLEXES
Background: Diseases of the arteries of the lower extremities are a serious problem for public health. A significant increase in the incidence of chronic obliterating diseases of the arteries of the lower extremities indicates the need to revise and optimize existing treatment methods. Objective: To improve the treatment results for patients with chronic arterial insufficiency in the presence of a trophic tissue defect, reduce the recovery and healing time of trophic ulcers, and improve the quality of life of patients. Materials and methods: A study was conducted that included 71 patients aged 40 to 70 years, of both sexes, who underwent surgical treatment for mesh-occlusive lesions of the femoralpopliteal-tibial arterial segments with CAN IV (according to Fontaine-Pokrovsky). After randomly dividing into two equal groups, a one-stage surgical intervention was performed in the study group of 34 people using the author’s technique with reconstruction of the vascular component and closure of trophic ulcers. In the control group, 37 patients received standard treatment. Results: The main criteria for assessing the effectiveness of the treatment in both groups were the following: regression of ischemia to CAN I – CAN IIa; the number of anesthetic interventions in the first group; the rate and quality of healing of trophic defects. The median healing time in the main group was 13 (Q1-Q3 12.00–15.00) days, and in the control group – 16 (Q1-Q3 15.00–17.00). The median length of hospital stay in the control group was 15 (Q1-Q3 14.00–16.00) days with further transfer to the purulent surgery departments or to the outpatient stage to prepare wounds for surgical treatment. In the study group, the median hospitalization period was 10 (Q1-Q3 8.00–11.00) days. The results confirm the effectiveness of the applied combined surgical approach in the treatment of this category of patients. Conclusion: In the postoperative period, in patients who underwent surgical treatment for steno-occlusive lesions of the femoral-popliteal-tibial arterial segments with stage IV CAD (according to Fontaine-Pokrovsky), namely those who underwent combined surgery, focusing on the indicators of the absence of infectious complications in the postoperative period, the timing of the onset of healing of trophic ulcers, passed with fewer complications, less severe pain syndrome. A significant reduction in the duration of patient treatment, i.e. the stage of providing medical care in hospitals, was also confirmed. During the outpatient observation period, it was revealed that the timing and rate of healing in Group I were also more favorable. In patients of Group I who underwent combined surgery, more favorable treatment results were observed. This was manifested in the absence of infectious complications after surgery and a faster onset of healing of trophic ulcers. In addition, a significant reduction in the overall duration of inpatient treatment for these patients was noted. Positive dynamics were maintained at the outpatient stage, where patients of group I demonstrated shorter periods and a high rate of wound healing. These results confirm the effectiveness of the combined surgical approach used in the treatment of this category of patients.
MODIFIED METHOD OF ALLOPLASTY OF THE RECTOVAGINAL SEPTUM IN PATIENTS WITH LOWER RECTOCELE GRADE 2–3
Summary: Surgical treatment of women suffering from rectocele of 2–3 degrees is a pressing issue. Such patients suffer from severe defecation disorders and are concentrated in proctology departments. For rectocele correction, local tissue plastic surgery is most often used, which involves removing excess vaginal mucosa and suturing portions of the levator muscles. The disadvantage of this method is the high relapse rate. The use of mesh implants significantly reduces the relapse rate, but their installation is associated with the risk of infection, contact erosions of the vaginal mucosa progression and the formation of fistulas that can disable patients. Aims: The method for plastic surgery of the rectovaginal septum developing with a mesh implant protected from contact with the vaginal mucosa and evaluation of its applicability in patients with lower rectocele of 2–3 degrees. Materials and methods: In the Proctology Department of the State Autonomous Healthcare Institution of the Sverdlovsk Region “Regional Clinical Hospital No. 1”, 78 patients with grade 2–3 lower rectocele were treated. The first group consisted of 38 patients who underwent standard technology of rectovaginal septum plastic surgery with local tissues. The second group consisted of 40 women who were treated using a modified technique. The clinical picture before and after surgery, the duration of the intervention, the frequency and severity of postoperative complications, and the dynamics of clinical manifestations after 3 months were assessed. Results: Women in both groups suffered from severe defecation disorders requiring manual assistance. The duration of the operation in the first group was 60 [49; 68] minutes and in the second – 65 [50; 70] minutes (p = 0.226). The patients of the first group had 9 complications of the postoperative period of class II and IIIb according to the Clavien-Dindo classification, the women of the second group had 3 complications related to class II and IIIa, while the average severity of complications was lighter than in the first. The decrease in the severity of complications in patients of the second group is probably due to the unloading of the stitched levators by the implant, preventing the cutting of the sutures applied to them, the formation of seromas and hematomas. On examination after 3 months, 92.2% of women of the first group did not have an anatomical defect in the rectovaginal septum, and 3 patients had a relapse of the disease. 97.4% of women showed an improvement in defecation and only one patient was forced to return to manual assistance. At the same time, after 3 months, 95% of patients of the second group did not have a rectocele. All women of the second group defecate without the use of manual assistance. Conclusions: The modified alloplasty method is applicable and effective in 95% of patients with lower rectocele, is easily tolerated and contributes to a more comfortable course of the early postoperative period. Sutured levators in front of the mesh implant protect it from contact with the vaginal mucosa, which reduces the risk of bedsores and vaginal fistulas.
PERSONALIZED APPROACH TO THE PROGNOSIS AND PREVENTION OF INTRA-ABDOMINAL ADHESIONS AFTER APPENDECTOMY
Rationale: The incidence of acute appendicitis is 708 cases per 10000 population. Postoperative complications after open appendectomy were 2.35 to 10%, after laparoscopic appendectomy from 4.9% to 6.2%. Abdominal interventions are accompanied by the development of intra-abdominal adhesions in 14.0% of patients, after repeated interventions – in 90.0-96.0% of the operated patients. Purpose: To determine the efficacy of anti-adhesion therapy after appendectomy. Materials and methods: 60 patients with acute appendicitis who underwent open appendectomy. Men – 19 (31.7%), women – 41 (68.3%). The control group consisted of 30 (50%) patients who did not undergo prevention of intra-abdominal adhesions in the postoperative period, and another 30 (50%) patients who received anti-adhesion therapy (main group). To calculate the risk of intra-abdominal adhesions after ppendectomy, we have developed an “Assistant program for determining the effectiveness of the treatment method and preventing the development of postoperative intra-abdominal adhesions”. Results: By the method of rating testing, it was established that the highest risk of developing postoperative intra-abdominal adhesions is present in patients who do not receive a set of anti-adhesion measures. Anti-adhesion therapy in patients after appendectomy reduces the risk of intra-abdominal adhesions by 1.97 times, improves the quality of life of operated patients. Conclusion: When performing abdominal operations, it is necessary to form groups of patients with a tendency to the formation of intra-abdominal adhesions, for whom anti-adhesion therapy is indicated in order to reduce the risk of developing an adhesive process in the abdominal cavity.
MONITORING OF LABORATORY PARAMETERS AND INTRAABDOMINAL PRESSURE IN EARLY DIAGNOSIS OF POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH GYNECOLOGICAL PERITONITIS
Aim. Identification of early postoperative complications in patients with gynecological peritonitis by monitoring laboratory parameters and intra-abdominal pressure. Material and methods. This study analyzed the results of complex diagnostics and treatment of 94 patients with gynecological peritonitis. All patients underwent emergency surgical interventions, which varied in their scope and method of implementation. For detailed monitoring of the postoperative course of the disease and timely identification of possible complications, the study cohort was stratified into two observation groups. The first group included 72 patients (76.6%) who did not experience any complications in the early postoperative period, while the second group consisted of 22 patients (23.4%) who developed intra-abdominal, systemic and wound complications of varying severity. Results. To assess the dynamics of the postoperative period, changes in laboratory parameters and the level of intra-abdominal pressure were monitored before the operation, as well as on the 1st, 3rd and 5th day after surgery. Intergroup analysis of clinical parameters did not reveal statistically significant differences when comparing the indicators both before surgery and during the first 24 hours of the postoperative period. The conducted assessment of the dynamics of the studied parameters between cohorts of patients with and without complications demonstrated comparable results at all observation points of the specified time interval. On the 3rd day after the intervention, significant differences were found in most parameters (p<0.001), with the exception of pyruvate, fibrinogen and intra-abdominal pressure levels. By the 5th day after the operation, the differences were statistically significant (p<0.001) for all studied parameters. The most pronounced differences were observed in the following parameters: C-reactive protein – 145.90 [141.75; 149.30] mg/l in the group with complications versus 14.40 [12.47; 16.73] mg/l in the group without complications; procalcitonin – 8.60 [5.80; 11.78] ng/ml versus 1.60 [1.27; 1.92] ng/ml; IL-6 – 148.80 [145.54; 155.68] pg/ml versus 30.00 [27.63; 34.52] pg/ml; and IAP level – 17.8 (0.41) mmHg versus 8.9 (0.29) mmHg. Conclusion. Thus, the analysis of the dynamics of changes in the levels of laboratory markers of blood serum and intra-abdominal pressure justifies the inclusion of CRP, procalcitonin, IL-6 and intra-abdominal pressure in the group of predictors. Their combined use allows us to assume the development of early postoperative complications as early as 3 days after surgery, which helps to choose the optimal treatment tactics.
INTRAPERITONEAL HYPERTENSION IS AN INTEGRAL INDICATOR OF THE PROGRESSION OF PERITONITIS WITH THE DEVELOPMENT OF ABDOMINAL COMPARTMENT SYNDROME
The aim is to study the prognostic value of IBD in patients with advanced purulent peritonitis as a predictor of the development of postoperative complications and abdominal compartment syndrome. Materials and methods. A study was conducted with the participation of 130 patients treated at the State Clinical Hospital in Vladimir from 2019–2024 with a clinical picture of widespread peritonitis. There were 72 men (55%) and 58 women (44%). The average age of the patients was 56.2±11.3 years. The degree of organ dysfunction was determined by the SOFA scale. The Mannheim Peritonitis Index (MIP) and the APACHEII scale were used to assess the prognosis and severity of peritonitis. IAP monitoring was performed in 100% of the observations. Surgical interventions were performed in 125 (96%) cases. Results: Based on the etiology of peritonitis, 4 groups were formed. Group 1 (n-41) (31.5%) patients with acute gangrenous-perforated appendicitis and widespread purulent peritonitis. The indicators of the integral scales ARASNE-II, SOFA, MIP, plasma lactate, C-reactive blood protein reflected the relationship between the severity of the course of intraperitoneal infection and the increase in IBD. Group 2 (n-15) (11%) is represented by patients with destructive pancreatitis. In 8 (6.1%) cases, pancreatic necrosis was alcoholic, in 7 (5.3%) biliary pancreatitis. The results of the study of IBD in this category of patients showed the relationship of an increase in IBD with an increase in PH on the ARASNE-II and SOFA scales, while the phenomena of a systemic inflammatory reaction increased up to the development of septic shock. Group 3 (n-53) (40%) patients with perforation of the diverticulum of the colon complicated by widespread peritonitis. Laparostomy was performed in 7 (5.3%) cases in patients with advanced fecal peritonitis. The lowest rates of IBD were in patients who underwent nasointestinal intubation of the small intestine with a Miller-Abbott probe. And in the groups of patients whose management took place with the formation of laparostomy and the use of negative pressure VAC systems, the development of compartment syndrome was not noted. Group 4 – (n-21) (16%) patients with acute adhesive small bowel obstruction. There were no fatalities. The level of IBD III and IV art. on the fifth day after surgery, was noted in 4 (3%) cases. This condition was a sign of the development of abdominal compartment syndrome. Conclusion: Abdominal compartment syndrome is the clinical and morphological essence of peritonitis in the toxic and terminal phases of its development. Intraoperative and postoperative decompression of the stomach and intestines with intra-intestinal lavage, the use of “open” abdominal tactics, careful control over the volume and nature of infusion therapy, early application of extracorporeal detoxification methods are integral ways to prevent the development of this formidable complication of peritonitis, which should always be performed in patients of this category, regardless of etiological causes and trigger points secondary widespread peritonitis.
CONSERVATIVE TREATMENT OF PELVIC BONE FRACTURES IN PATIENTS OVER 65 YEARS OLD
Due to the general increase in life expectancy of the population, the number of elderly and senile people suffering from osteoporosis is increasing in the world. Pelvic bone fractures that occur against the background of osteoporotic changes in the bones of the skeleton are distinguished by a number of characteristic features and are associated with a high mortality rate. If in the young population the main cause of these fractures are high-energy injuries resulting from road accidents and falls from a great height, then in elderly patients with concomitant osteoporosis, pelvic fractures can occur as a result of a fall from their own height. Fragility of bone tissue, the presence of a large number of chronic diseases and impaired adaptive capacity of the body in elderly patients complicates surgical fixation of pelvic ring fractures using various metal structures, which forces clinicians to adhere to conservative treatment tactics. Aims: to study the medium-term and long-term results of conservative treatment of pelvic bone injuries in patients over 65 years of age. Materials and methods. During the period from 2021 to 2024, a total of 30 patients (mean age 72±6.21 years) over 65 years old with pelvic bone fractures were treated at the A.K. Yeramishantsev City Clinical Hospital. The distribution of pelvic bone fractures according to the AO/OTA classification was as follows: type A in 6 (20%) patients, type B in 18 (60%), acetabular fracture in 6 (20%) patients. Results and conclusions. The mid-term treatment results after 6 months were assessed in 30 (100%) patients (in 6 they were excellent, in 16 – good, in 6 – satisfactory, in 2 – poor). The remote treatment results after 12 months were assessed in 24 (80%) patients (in 6 of them they were excellent, in 12 – good, in 4 – satisfactory, in 2 – poor). After 2 years, 16 (53%) patients were assessed (4 had excellent results, 8 had good results, 2 had satisfactory results, and 2 had poor results). 26 (86%) patients restored their previous activity level. Mortality was 0%. The analysis of pelvic fracture treatment results showed that in elderly patients with a comorbid history, it is preferable to adhere to conservative treatment tactics.
USE OF MEMBRANE-STABILIZED LIPOTRANSFER IN LOWER EXTREMITY WOUND CLOSURE
Autotransplantation of adipose tissue becomes a promising method in the treatment of deep wounds with muscle damage and exposure of neurovascular structures, especially against the background of chronic ischemia and venous insufficiency. The necessity of the regenerative approach was the reason for the present study. Aims. To investigate the effectiveness of primary closure of deep wounds of the lower limbs using the modified autograft of the own adipose tissue obtained from the distant donor zones in order to accelerate the reparative processes, to prevent the formation of pathological scars and to achieve the optimal aesthetic result. Materials and methods. We compared 2 adipose tissue samples placed in solutions with different chemical content for each group (0.9% NaCl solution, 15% dimethyloxobutylphosphonyl dimethylate solution), with exposure for 5 hours and evaluation of ionic composition by electron microscopy in low vacuum and energy dispersive X-ray spectral analysis (EDX) with evaluation of potential cell viability. A clinical case is described in which autotransplantation of adipose tissue was performed in a patient with a gaping wound of the lower limb after primary surgical treatment of the wound surface under intravenous sedation and local anesthesia on the 3rd day. Results. The viability of fat cells can be improved by modifying the microenvironment with artificial solutions. The effectiveness of the surgical method was confirmed in practice – on the 7th day there was a complete closure of the wound defect with the formation of a stable skin cover. The subsequent restoration of the skin cover was carried out by secondary tension on the base represented by the transplanted fat tissue (“subcutaneous base” – according to the modern anatomical terminology). Conclusion. Autotransplantation of adipose tissue is an effective technique for primary closure of deep soft tissue defects characterized by a high level of safety and a favorable potential for further recovery. Clinical observations confirm the prospectivity of this approach with the further possibility of improving the effectiveness of the method.
AN INTEGRATIVE APPROACH IN A SURGICAL INPATIENT SETTING: DERMATOVENEREOLOGY AND UROGYNECOLOGY
Background: Urogenital chlamydia is one of the most prevalent sexually transmitted infections, often asymptomatic and associated with infertility and pregnancy loss. Treating chlamydial cervicitis in women with cicatricial cervical deformity is particularly challenging, as structural abnormalities promote chronic infection and reduce the effectiveness of standard antibiotic therapy. Aims: To improve treatment outcomes for chlamydial infections of the lower genital tract in women with cicatricial cervical deformity through a combined approach that includes reconstructive surgery. Materials and methods: This single-center, nonrandomized, prospective study enrolled 91 women aged 18 to 45 years with laboratory-confirmed urogenital Chlamydia trachomatis infection. Participants were allocated into three groups: group A (n = 30) included women with cicatricial cervical deformity who underwent reconstructive surgery (Eltsov-Strelkov technique) combined with antibiotic therapy (doxycycline, 100 mg twice daily for 21 days); group B (n = 31) consisted of women with cicatricial cervical deformity who received antibiotic therapy alone; group C (n = 30, control) comprised women with normal cervical canal architecture treated with doxycycline only. Recurrence of chlamydial infection was assessed clinically and by polymerase chain reaction (PCR) at 1- and 12-months posttreatment. Results: At 1 month posttreatment, the efficacy of doxycycline monotherapy in women with cicatricial cervical deformity (group B) was 83.3%, compared with 96.7% in patients with normal cervical anatomy (group C). The combined approach in group A achieved a 96.8% success rate. At 12 months, a significant decrease in treatment efficacy was observed in group B, dropping to 76.7% (p<.05), while the outcomes in group A remained stable (96.8%) and were comparable to those in the control group (96.7%). Conclusions: Combining reconstructive surgery with antibiotic therapy significantly improves treatment outcomes for urogenital chlamydia in women with cicatricial cervical deformity by reducing recurrence and enhancing local immune responses.
METHOD FOR DETERMINING THE PROBABILITY OF DETECTION OF IGA ANTIBODIES TO DEAMIDATED GLIADIN PEPTIDES IN PATIENTS WITH IGA NEPHROPATHY
Backgraund: IgA nephropathy (IgA-N) is one of the leading causes of terminal renal failure requiring renal replacement therapy. The etiopathogenesis of the disease is not fully understood. Some studies suggest an association with diseases and conditions that are accompanied by inflammation and increased permeability of the intestinal wall. A number of studies indicate a high prevalence of certain antibodies (AB) in the blood specific and sensitive for celiac disease in IgA-N patients. These IgA AB are thought to influence the activity and risks of glomerular disease progression. Aims: to develop a tool (predictive model) to determine the probability of detecting of IgA AB to deamidated gliadin peptides (IgA DGP AB) in IgA-N patients serum. Materials and methods: the study included 105 patients aged 18 to 64 years with morphologically confirmed IgA-N. The median duration of the disease before nephrobiopsy was 17 (6–48) months. Distribution by sex: men – 92 (87.6%), women – 13 (12.4%). All patients underwent a complex clinical examination. Results: on the basis of the obtained data a prognostic model for determining the probability of detecting IgA DGP AB in IgA-N patients serum depending on proteinuria, systolic blood pressure and total IgA was constructed by the method of binary logistic regression. The regression model obtained has high statistical significance (the area under the ROC curve was 0.860; 95% CI: 0.744 to 0.976; p<0.001). The sensitivity and specificity of the model were 82.4% and 83.1%, respectively. Conclusions: the developed predictive model for determining the probability of detecting IgA DGP AB in IgA-N patients serum, which has high sensitivity and specificity, may reduce the cost of diagnostic measures in selecting patients for AB testing; improve risk assessment of IgA-N progression; and create new opportunities for personalized clinical approach and optimization of treatment strategies, which in turn may lead to improved renal outcomes for IgA-N patients.
SYPHILIS IN BLOOD DONORS FROM TATARSTAN AND JAPAN
We determined the frequency of donor rejection due to the detection of syphilis markers in blood donors of the Republic of Tatarstan (RT) and compared the results with the data of Japanese colleagues. We studied the results of the examination of donors of the Republican Blood Center (Kazan) in 2015–2024 and the incidence of syphilis in the RT in 2015-2024. In Japan, the quantitative indicators of donation differ from those in the RT: a) the proportion of female donors is 4.6% higher, b) the proportion of repeat donors is 7.2% higher (p<0.001). The incidence of syphilis per 100 thousand blood donations in the RT is 10.9 times higher than in Japan. At the same time, in the RT, repeat donors are rejected 24.7% less often due to laboratory markers of syphilis (p<0.001). During the observation period, the average annual incidence of syphilis in the RT was 13.8 cases per 100,000 population, which is 7 times lower than the syphilis detection rate per 100,000 donations. While the incidence rate in the population has been steadily declining since 2015, among donors this indicator increased sharply in 2018–2020 (151%, 153%, and 122%, respectively). Donors are rejected after a positive laboratory test result, which is not a clinical diagnosis of syphilis and does not exclude the possibility of a false positive result. It is concluded that the high level of positive results of laboratory markers of syphilis in donors (mainly primary) of blood in the RT encourages an active fight against syphilis in the population as a whole, an increase in the specificity of laboratory tests, and infection safety measures for blood transfusion therapy.
СELIAC TRUNK COMPRESSION SYNDROME IN CLINICAL PRACTICE
Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome (MALS), is a rare condition caused by extrinsic compression of the celiac trunk by diaphragmatic anatomical structures. This review consolidates current concepts regarding the etiology, pathophysiology, clinical manifestations, diagnostic approaches, and treatment strategies for CACS. The discussion includes anatomical variability, the roles of vascular and neurogenic mechanisms in the development of pain, and comparative data on the efficacy of various surgical approaches. Special attention is paid to imaging modalities and clinical outcomes following celiac trunk decompression. The review highlights the importance of an individualized patient management strategy and the need for multidisciplinary collaboration.
METHODS OF MEASURING INTRA-ABDOMINAL HYPERTENSION IN ABDOMINAL SURGICAL PATHOLOGY
The literature review presents a topical issue in surgery and intensive care – modern methods of measuring and monitoring intra-abdominal pressure, which are key prognostic and dynamic methods for diagnosing “abdominal catastrophe”, as well as resolving the issue of relaparotomy, laparostomy, especially in difficult-to-diagnose types of gunshot and postoperative peritonitis. Despite numerous studies conducted over the past decade, many issues in the treatment of patients with severe intra-abdominal hypertension still remain unresolved. Recommendations, protocols for examination and treatment of patients with this pathology are constantly changing and adjusted as new information becomes available. To systematize the existing literature data on the diagnosis of intra-abdominal hypertension, this literature review is presented, which analyzes the data of publications, meta-analyses, clinical guidelines for the past ten years related to this topical issue. The review covers the issues of determining and diagnosing intra-abdominal pressure, abdominal compartment syndrome, and considers and analyzes the algorithm and methods of treating intra-abdominal hypertension, the critical value of which indicates the absolute need for surgical abdominal decompression followed by temporary closure of the abdominal cavity. Intra-abdominal hypertension combined with dysfunction of at least one organ is considered an urgent indication for surgical correction in order to prevent the development of compartment syndrome and fatal complications. Methods for detecting intra-abdominal hypertension indicators are among the main “reliably working” means of objectification and diagnosis of problems with the abdominal organs, the interpretation of which directly affects the treatment tactics of patients. Thus, methods for measuring and monitoring intra-abdominal hypertension allow timely prevention of the number of complications and optimization of surgical strategy, which is especially important in military field surgery, when there is an acute shortage of laboratory and instrumental methods for examining patients.
COMBINED TREATMENT OF GASTRIC CANCER USING MINIMALLY INVASIVE TECHNOLOGIES
Gastric cancer treatment is one of the most complex and evolving fields in oncology and surgery. Although surgery remains the primary treatment option, global research indicates that a multimodal approach, including perioperative chemotherapy, significantly improves long-term outcomes for patients with locally advanced gastric cancer. However, the choice of the optimal surgical technique remains a matter of debate. Modern trends in gastric cancer surgery emphasize the use of minimally invasive techniques. Studies suggest that minimally invasive surgery reduces surgical trauma, leading to less blood loss, fewer wound complications, faster postoperative recovery, and an earlier start of chemotherapy. Laparoscopic surgery has already become the standard approach for early-stage gastric cancer. However, the role of robot-assisted techniques in gastric cancer treatment has yet to be fully defined. This study aims to explore the advantages and limitations of robotic surgery in gastric cancer treatment as part of a multidisciplinary therapeutic strategy, based on a systematic review of global literature.
THE PITFALLS OF DIRECT ORAL ANTICOAGULANTS
Anticoagulant drugs have undergone drastic changes in recent decades. The introduction of direct oral anticoagulants into clinical practice has led to their widespread use for long-term oral anticoagulant therapy. There is less control over therapy, and medications are prescribed by doctors of many specialties. This monitoring system for patients receiving direct oral anticoagulants is suboptimal. And the lack of antidotes for apixaban and rivaroxaban exacerbate the problem.
THE ROLE OF ANTI-VEGF THERAPY IN THE TREATMENT OF AGE-RELATED MACULAR DEGENERATION: A COMPARATIVE ANALYSIS OF DRUG EFFICACY
Rationale: The article examines modern aspects of anti-VEGF therapy as the primary treatment method for the neovascular form of age-related macular degeneration (AMD). The pathophysiological mechanisms of disease development, including the role of vascular endothelial growth factor in pathological neovascularization, are described. Objective: To conduct a comparative analysis of the efficacy and safety of anti-VEGF drugs used in the treatment of neovascular AMD, considering their pharmacological characteristics, administration regimens, and potential adverse effects. Methods: A review of scientific literature was conducted, analyzing studies indexed in international bibliographic databases, including PubMed, Scopus, Web of Science, and the Cochrane Library, from 2019 to the present. The selection included original clinical studies (randomized controlled trials, cohort studies, systematic reviews, and meta-analyses) that assess the efficacy and safety of anti-VEGF drugs in patients with neovascular AMD. Results: A comparative analysis of anti-VEGF drugs, including Ranibizumab, Aflibercept, Bevacizumab, Faricimab, and Brolucizumab, was performed. Differences in mechanisms of action, duration of therapeutic effects, injection frequency, and safety profiles were noted. Various dosing regimens optimizing injection frequency were reviewed. Potential risks of anti-VEGF therapy, including intraocular inflammation, retinal vasculitis (most commonly associated with Brolucizumab), and systemic adverse effects, were identified. Conclusion: Anti-VEGF therapy remains the primary treatment method for neovascular AMD, ensuring disease stabilization and preservation of visual function. Modern drugs demonstrate high efficacy but differ in pharmacokinetic properties and safety profiles, necessitating an individualized approach to therapy.
NUTRITIONAL SUPPORT FOR PATIENTS WITH PULMONARY TUBERCULOSIS: ANALYSIS OF THE ENTERAL NUTRITION MARKET
The relevance of the work is due to the need to resolve frequently occurring malnutrition in patients with pulmonary tuberculosis through nutritional support. The objectives of the study included studying the importance of nutritional support in patients with pulmonary tuberculosis, as well as analyzing enteral nutrition mixtures available on the market, determining their component composition and the feasibility of using a certain type of mixture for this category of patients. The work used the methods of semantic analysis and “text mining” to summarize the data of scientific publications posted in the scientometric databases Pubmed, Web of Science, eLIBRARY on nutritional support for patients with pulmonary tuberculosis. Based on the results of the literature review, enteral nutrition mixtures with a high protein component are recommended for patients with pulmonary tuberculosis, aimed at stopping protein-energy deficiency. The presented review substantiates the importance of nutritional support in severe forms of pulmonary tuberculosis, describes the high-protein mixtures for enteral nutrition available on the market, and presents the domestic mixture GASTROAUXILLIUM, developed on the basis of the Scientific and Production Center for Healthy Nutrition Technologies of the Saratov State Medical University named after V. I. Razumovsky, which surpasses the existing imported analogs in component composition and production technology.
FEATURES OF PALLIATIVE CARE ORGANIZATION IN MULTIDISCIPLINARY HEALTHCARE FACILITIES: THE ROLE OF THE MULTIDISCIPLINARY TEAM
Rationale: Palliative care (PC) is an essential component of the healthcare system aimed at improving the quality of life for patients with incurable diseases and their families. In modern conditions, the integration of PC into multidisciplinary healthcare facilities faces various organizational and resource limitations. The multidisciplinary team (MDT) plays a critical role in enhancing the effectiveness of PC. Objective: To analyze the features of PC organization in multidisciplinary healthcare facilities with a focus on the role of MDTs and to evaluate prospective directions for the development of this system. Methods: The study was conducted using an analytical review of peer-reviewed scientific publications, international guidelines, and official statistical reports. Data on PC integration models (embedded palliative care departments, consultative services, and outpatient programs) and studies on the effectiveness of the multidisciplinary approach were considered. Results: The analysis demonstrated the high effectiveness of the multidisciplinary approach, as evidenced by reduced hospitalization rates, improved symptom control, and enhanced quality of life for patients. Key limitations were identified, including a shortage of qualified personnel, insufficient funding, legal and cultural barriers. Particular attention was paid to the need for the implementation of educational programs, optimization of funding, and integration of various PC models to improve service accessibility. Conclusion: The integration of PC into multidisciplinary healthcare facilities requires a comprehensive approach involving MDTs. Further research in pediatric PC and the development of specialized programs to overcome organizational and cultural barriers are necessary. Implementing these measures will improve the accessibility and efficiency of PC, reduce the burden on the healthcare system, and enhance the quality of life for patients and their families
MODERN CONCEPTS OF PHANTOM PAIN AND ITS TREATMENT METHODS
The number of limb amputations is increasing every year in the world. The reason for this may be a limb injury, infection, acute ischemia, a complication of diabetes mellitus, or a malignant tumor. On average, in more than half of cases, patients develop phantom sensations, which can be painless and painful. The feeling of touch, itching, and pressure can be painless. Painful sensations are electric shock, burning, stabbing or throbbing pain. Some patients describe phantom pain as an «electric shock», others as a «burning sensation», and others as «insects crawling inside». Phantom pain was described in the 16th century by Ambroise Pare and since then this term has been constantly present in the medical literature. Unfortunately, for such a long time, the exact pathogenesis of the disease has not been established and methods for the prevention and treatment of phantom pain have not been developed. This review describes the current view of the mechanism of phantom pain syndrome, and also examines the main therapy used in the treatment of phantom pain at the present stage, both before and after amputation.
SURGICAL MANAGEMENT OF AN EXTRACRANIAL INTERNAL CAROTID ARTERY ANEURYSM
Aneurysms of the extracranial internal carotid artery are rare, but pose a serious threat due to the high risk of ischemic stroke and associated neurological complications. This article describes a clinical case of a patient with connective tissue dysplasia who was diagnosed with a saccular aneurysm of the left internal carotid artery. Resection of the aneurysm with the formation of an end-to-end anastomosis without the use of a vascular prosthesis was performed. No complications were noted in the postoperative period. A follow-up examination after 6 months confirmed the patency of the reconstructed vessels. Timely diagnosis and surgical treatment are crucial for the prevention of neurological complications and mortality.
BLOOD TRANSFUSION IN CASE OF APPARENT SIGNS OF INCOMPATIBILITY IN A PATIENT WITH COMPLICATED SIGMOID COLON CANCER: A CLINICAL CASE
The article presents a clinical observation of a patient with sigmoid colon cancer and anemia requiring transfusion support with donor erythrocytes. The patient was found to have anti-erythrocyte antibodies that agglutinated with 3 screening and 11 identification panel erythrocytes. Agglutination was also detected in the autocontrol and with 18 samples of phenotype-compatible donor erythrocytes. The above information allowed us to assume the presence of autologous antibodies to common erythrocyte antigens with low hemolytic activity in the patient. Due to the increasing clinical signs of anemic hypoxia, a decision was made to transfuse the least incompatible blood. Based on the results of automated immunohematological testing, 3 such samples of erythrocyte leukodepleted suspension in an additional PAGGSM solution were selected. After conducting a biological test, a venous blood sample was collected and centrifuged. No visual signs of hemolysis were detected. The patient was discharged in a satisfactory condition. To detect alloantibodies in patients with polyagglutination, it is optimal to include in clinical guidelines methods of adsorption of autoantibodies by autologous or allogeneic erythrocytes. Transfusion of partially phenotype-compatible blood (ABO, D, C, E, c, e, k) is advisable to prevent patient death from anemia. It is recommended to transfuse one dose of maximally compatible leukodepleted erythrocyte suspension in PAGGSM, slowly and with invasive hemolysis monitoring at the end of the biological compatibility test.
MULTISTAGE SURGICAL TREATMENT IN A PATIENT WITH AN INGESTED TISH BONE
There is demonstrated the clinical monitoring of the successful treatment of the 46-year-old patient ingested a small sharp fish bone of the rectum, complicated with the progressive perineum abscess, that required a multistage treatment- opening the abscess, wound necroectomy, sigmoid colostomy formation in connection with the progressing of purulent process, followed by sigmoid colostomy closure in a planned manner after 4 months.
TUBERCULOUS PERITONITIS ON THE BACKGROUND OF HIV INFECTION
Justification of the study. Tuberculous peritonitis is a fairly rare pathology. This disease is a complication caused by a specific lesion of the lymph nodes of the abdominal cavity, intestines, genitals, and spine, spreading through contact. The purpose of the study. To present a clinical case of a patient with tuberculous peritonitis who developed against the background of infection caused by the human immunodeficiency virus. Methods. The article presents a clinical case of a patient operated on for tuberculous peritonitis that developed against the background of infection caused by the human immunodeficiency virus, diagnostic features, and the course of the disease. Results. The result of successful treatment of tuberculous peritonitis, which developed against the background of infection caused by the human immunodeficiency virus, is presented. As a result, after diagnostic laparoscopy, resection of 20 cm of the ileum with end-to-end anastomosis, sanitation, and drainage of the abdominal cavity were performed. The postoperative course was uncomplicated, the sutures were removed on the 12th day.
COMPREHENSIVE STEP-BY-STEP TRAINING OF PATIENTS WITH HIP STUMP WALKING ON A PROSTHESIS
Introduction. After the prosthetic device has been manufactured, the most important task for doctors who rehabilitate a patient with a hip stump is to restore its lost biomechanical function by teaching the patient to walk on the prosthesis. From a biomechanical perspective, walking with a prosthesis is significantly more complex and energy-consuming than walking with crutches. Therefore, the process of teaching patients with a hip stump to walk using a prosthesis is complex, highly demanding, and requires the collaboration of multiple specialists. The aim of this clinical lecture is to familiarize a wide range of doctors from various specialties involved in the rehabilitation of the injured person with modern approaches to the step-by-step training of patients with a hip stump to walk using a prosthesis. Main part. In the main part of this clinical lecture, the stages of teaching patients with a hip stump to walk using a prosthesis are analyzed in detail. Significant attention is given to presenting the various techniques used in these stages. The role of each specialist in the interdisciplinary team involved in teaching patients with a hip stump to walk using a prosthesis is outlined. Conclusion. It is noted that if a patient does not start walking on a prosthesis as soon as possible after hip stump formation, a flexion-adduction contracture of the hip joint on the affected limb will quickly form. This will prevent the patient from walking even with the most advanced prosthesis and is extremely challenging to correct. As a result, the patient may rely on crutches or a wheelchair for the rest of their life, often experiencing significant psychological challenges. In the case of residual limb diseases that prevent the patient from walking on a prosthesis, it is necessary to refer the patient to the appropriate specialists in a timely manner. Otherwise, if the patient stops using the prosthesis, a flexion-adduction contracture of the hip joint on the affected limb-which is difficult to treat-will quickly develop, and the patient may never regain the ability to walk with a prosthesis.
EVGENY MIKHAILOVICH TAREEV, AN OUTSTANDING RUSSIAN THERAPIST, SCIENTIST AND TEACHER (ON THE OCCASION OF HIS 130th BIRTHDAY)
The biography of the outstanding Russian therapist E.M. Tareev, his treasure trove in the development of national healthcare, medical science and education, is presented.