Bulletin of the Russian Military Medical Academy

BACKGROUND: Gunshot wounds to the abdomen are among the most severe and very common injuries in both wartime and peacetime. Despite the widespread use of personal armor protection, there is a trend toward increasing proportion of gunshot wounds to the abdomen in the overall structure of combat trauma, reaching 9%–13% in modern armed conflicts.

AIM: This study aimed to evaluate the efficacy and safety of the most crucial tactical approaches for providing surgical care for gunshot wounds to the abdomen in a Level-3 Military Medical Organization, considering injury patterns and the features of the traumatic disease course.

METHODS: Injury characteristics and main clinical indicators were studied in 207 patients with gunshot wounds to the abdomen admitted through the stages of medical evacuation to a Level-3 Military Medical Organization. The structure of surgical interventions performed at this stage was analyzed. An assessment of the immediate outcomes of surgical treatment was conducted.

RESULTS: Primary operations were performed on 35 (17%) patients. Repeated interventions as part of the damage control strategy were performed on 143 (69%) wounded patients. No indications for surgical treatment at the Level-3 Military Medical Organization stage were present in 29 (14%) wounded patients. Multiorgan injuries, combined with the reduced scope of operations performed at the previous evacuation stage, necessitated the implementation of a wide range of surgical procedures. In most cases, these were performed within time frames most favorable from the standpoint of the traumatic disease course, which made it possible not only to fully implement the damage control strategy but also to perform reconstructive interventions in more than 37% of patients with extensive intestinal tract injuries, as well as to eliminate laparostomy in 28.7% of the wounded patients. The frequency of postoperative complications at the Level-3 Military Medical Organization was 14.3%, and hospital mortality was 2.4%.

CONCLUSION: Level-3 military medical organizations are key to coordinating and implementing treatment programs for combat abdominal trauma, as this stage possesses the personnel and logistical resources to provide the necessary surgical care within the most favorable timeframe regarding the course of traumatic disease. The main tactical directions in implementing the treatment program are damage control and infection focus management, as well as correction of deficiencies from previous interventions. Additionally, for some wounded patients, it is advisable to perform reconstructive interventions on the intestinal tract and eliminate laparostomy at Level-3 military medical organizations.

BACKGROUND: Despite 30 years of using video-assisted technologies to provide surgical care for wounded patients with penetrating gunshot chest wounds, the capabilities, effectiveness, and safety of modern high-tech video thoracoscopic treatment methods at the stages of specialized medical care remain debatable for a number of reasons. Available publications in accessible medical sources consist mainly of isolated clinical observations.

AIM: This study aimed to demonstrate and analyze the experience of performing video thoracoscopic surgical interventions for penetrating gunshot chest wounds in a level 3 military medical organization during a modern armed conflict.

METHODS: The results of surgical treatment of penetrating gunshot chest wounds in a level 3 military medical organization were analyzed. The sample consisted of 25 men aged 19 to 56 (mean 36 ± 10) years.

RESULTS: The duration of surgical interventions ranged from 30 to 125 (median 70 [45; 100]) minutes. Intraoperative blood loss volume did not exceed 50 mL. The volume of lysed blood and clots aspirated from the pleural cavities was 400 [100; 800] mL. The size of extracted foreign bodies ranged from 6 to 26 (mean 16 ± 5.8) mm. In the postoperative period, the exudate was serosanguineous in all cases, with a mean volume of 120 [80; 150] mL. No intraoperative complications were recorded. Nineteen (76%) patients were evacuated by air ambulance to a level 4 military medical organization on the day following video thoracoscopy. The further evacuation and clinical course were tracked for 17 (89.5%) wounded patients.

CONCLUSION: The study findings demonstrate the feasibility of providing specialized medical care at a level 3 military medical organization, as well as the safety and high effectiveness of early video thoracoscopic surgical interventions for eliminating life-threatening consequences and preventing complications in wounded patients with penetrating gunshot chest wounds.

BACKGROUND: The classification of gunshot wounds to the spine and spinal cord was developed during the Great Patriotic War. Since then, the nature of gunshot wounds has changed, differing from wounds of past wars by even greater diversity, severity, extensiveness of tissue damage along the periphery of the wound channel, and the combined and complex nature of the injury. Therefore, a need has arisen to create a modern classification of gunshot wounds to the spine and spinal cord.

AIM: This study aimed to improve the basic classification of gunshot wounds to the spine and spinal cord for formulating a detailed clinical diagnosis that reflects the severity and nature of the wound.

METHODS: Data from the examination and treatment of two groups of wounded patients were analyzed. The first (control) group consisted of 23 wounded patients with gunshot wounds to the spine and spinal cord who underwent treatment in an army specialized hospital (1980–1982). The second (main) group included 45 wounded patients who underwent treatment at the clinics of neurosurgery and military field surgery of the S.M. Kirov Military Medical Academy (2022–2024). The wounded patients in the second group were divided into two subgroups: the first with combined anterior, anterolateral, and lateral wounds of the anterior surface of the neck, chest, abdomen, and pelvic organs with spinal injury; and the second with combined and isolated wounds of the posterior spinal structures and spinal cord.

RESULTS: A clinical-anatomical classification of gunshot wounds to the spine and spinal cord was developed.

CONCLUSION: The developed clinical-anatomical classification of gunshot wounds to the spine and spinal cord will allow for a more precise determination of the nature of combined gunshot injuries to the spine and spinal cord, formulate an extended diagnosis, conduct targeted medical triage of incoming wounded patients, determine the priority of surgical care, and define the prognosis and outcome of these injuries.

BACKGROUND: Nitric oxide is a universal regulator of metabolic processes in the immune system, stimulating antiviral and antibacterial defense mechanisms, and providing a cytoprotective effect. However, information on the rehabilitative potential of nitric oxide in polytrauma remains limited.

AIM: This study aimed to evaluate the efficacy and safety of inhaled nitric oxide as an adjunct to standard respiratory rehabilitation in patients with lung contusion and polytrauma.

METHODS: An open-label, single-center, prospective, randomized, active-controlled clinical trial was included 89 adult patients with lung contusion and polytrauma. In the control group, 46 patients received standard therapy. In the main group, 43 patients additionally received nitric oxide via a face mask at a low dose (30 ppm) for 20 minutes twice daily.

RESULTS: By day 4 of observation, the main group showed improvement in blood oxygen saturation parameters (95.6% [95% CI: 94.5–96.7] vs 91.6% [95% CI: 90.2–93]), and a decrease in arterial blood lactate concentration (2.66 mmol/L [95% CI: 2.04–3.28] vs 4.12 mmol/L [95% CI: 3.3–4.9]) compared with day 1.

CONCLUSION: Low-dose nitric oxide is highly effective and safe in respiratory rehabilitation for patients with lung contusion and polytrauma, substantially improving the outcomes of standard treatment for these patients.

BACKGROUND: Long-term exposure to occupational stress in deep-sea equipment operators leads to microcirculation adaptation disorders and increases the risk of developing cardiovascular diseases.

AIM: This study aimed to evaluate changes in blood erythropoietin levels, microcirculation parameters, and exhaled nitric oxide concentration in deep-sea equipment operators under simulated occupational conditions.

METHODS: A non-randomized, single-center, prospective cohort study of 55 healthy male deep-sea equipment operators aged 29–51 years was conducted. All subjects had their blood erythropoietin concentration, microcirculation parameters, and exhaled nitric oxide concentration measured at various time intervals.

RESULTS: On the 20th day of isolation in the study complex under simulated deep-sea equipment conditions, a significant (p = 0.013) decrease in erythropoietin level was observed in the subjects’ venous blood. A significant (p = 0.036) change in this parameter was also identified between the 10th and 20th days of the study. The integral microcirculation index did not change significantly throughout the study, indicating stable regulation of microcirculation mechanisms under prolonged isolation. Analysis of the amplitude-frequency spectrum of perfusion oscillations revealed a decrease in passive (respiratory and cardiac) and myogenic components of the microcirculation regulation mechanism, which is associated with physical inactivity during prolonged confinement and indicates a limitation of the influence of cardio-respiratory rhythms on microcirculation. During prolonged isolation in deep-sea equipment, the endothelial components of microcirculation regulation experience strain, and their contribution to managing the state of the microcirculatory bed and, accordingly, maintaining hemostasis is significantly enhanced.

CONCLUSION: The study involving healthy men experiencing prolonged isolation as deep-sea equipment operators demonstrated that a comprehensive assessment of microcirculation parameters, nitric oxide, and erythropoietin enables the identification of mechanisms underlying endothelial dysfunction and adaptive changes in the tissue blood flow regulation system.

The intestine is one of the most important target organs of stress caused by hemorrhagic shock, traumatic shock, burns, and severe injuries to bones and soft tissues. This review examines the microbial endoecology of the gastrointestinal tract in wounded patients with polytrauma. Severe intestinal injury plays a major role in the development of infectious complications and multiple organ failure in wounded patients with polytrauma. Such complications result from interactions between impaired gastrointestinal motility, damage to the intestinal epithelium, the immune system, and the gastrointestinal microbiota. The formation of gastrointestinal endoecology depends on the influx of microorganisms into the system, the reproduction rate of individual representatives, and their elimination into the environment. The gut microbiome can be disrupted under the influence of the intestinal environment in critically injured patients. Three hypotheses are highlighted—bacterial translocation, lymphocyte-derived bacteremia, and in situ virulence—that explain the role of the gastrointestinal biota-tissue complex in the pathogenesis of sepsis and multiple organ failure in critically injured patients. Early diagnosis and stratification of patients with biotissue complex disruption of the intestine in systemic response to injury may improve outcomes through the timely initiation of appropriate specific treatment.

Familial hypercholesterolemia is an inherited disorder of lipoprotein metabolism characterized by persistently elevated in low-density lipoprotein cholesterol levels, which substantially increases the risk of cardiovascular disease. Current diagnostic approaches include clinical criteria (family history and elevated cholesterol levels) and genetic testing, enabling earlier and more accurate identification of familial hypercholesterolemia in the early stages of the disease. There are various forms of inheritance patterns of familial hypercholesterolemia, including heterozygous and homozygous types, each with distinct genetic causes and risks of developing cardiovascular complications. The main diagnostic methods for familial hypercholesterolemia include: classical laboratory tests (lipid profile, complete blood count, blood biochemistry including glucose, creatinine, urea, total bilirubin, alanine aminotransferase, aspartate aminotransferase, and creatine phosphokinase), instrumental examinations (computed tomography and coronary angiography, duplex scanning of the extracranial brachiocephalic arteries, computed tomography for calcium score, and echocardiography), and genetic methods (polymerase chain reaction [PCR], expression of regulatory micro microRNAs, and DNA melting curve analysis). Screening programs, including cascade and targeted approaches, are key to early diagnosis and intervention, substantially improving the prognosis for patients with familial hypercholesterolemia. For example, implementing PCR testing in familial hypercholesterolemia screening enables assessment of the genetic mutation spectrum and refines the choice of lipid-lowering therapy. All this minimizes adverse reactions, as targeted therapy rapidly reduces cholesterol and low-density lipoprotein cholesterol to target levels, thereby preventing associated diseases and improving the patient's quality of life.

BACKGROUND: Gunshot wounds to the extraperitoneal portion of the rectum represent one of the most complex injury types in modern armed conflicts. The complexity is determined both by the severity of such wounds and by the high variability of approaches to treating this category of casualties at stages of medical evacuation.

AIM: This study aimed to achieve expert consensus on controversial issues in multistage surgical treatment of patients with extraperitoneal rectal wounds using the Delphi method.

METHODS: A cross-sectional study using the Delphi method was conducted. The expert group consisted of 29 specialists. At the first stage of the study, the working group formulated 24 questions on the tactics of multistage surgical treatment for patients with extraperitoneal rectal wounds. At the second stage, an anonymous survey was conducted using an online questionnaire without indicating the experts' personal data. Based on the summarization and analysis of the responses, 22 statements were compiled. At the third stage, anonymous expert voting was conducted. The threshold for achieving consensus on each statement was set at a total proportion of “Agree” and “Partially agree” responses of at least 80%.

RESULTS: All involved specialists completed the entire study cycle. At the third stage, consensus was achieved by the experts for each of the formulated statements.

CONCLUSION: The study achieved consensus among experts on the most problematic and pressing issues of multistage surgical treatment for patients with extraperitoneal rectal wounds. This result creates prerequisites for developing a personalized tactical approach to the operative treatment of this category of wounded patients at various stages of medical evacuation.