Vol 3, No 4 (2018)

Articles
DYNAMICS OF MORPHOLOGICAL CHANGES IN FRACTURE SITES IN VICTIMS WITH THORACIC TRAUMA AND FLAIL CHEST
Belokonev V.I., Pushkin S.Y., Ardashkin A.P., Ushakov N.G., Kameev I.R.
Abstract
Objectives - to improve the treatment results in patients with a closed chest injury complicated by the flail chest through the evaluation of the pathomorphological changes in the fracture sites on the background of their stabilization. Material and methods. The study is based on the autopsy protocols of 402 victims, whose primary cause of death was a closed chest injury with multiple rib fractures. In total 289 histological specimens were studied, including 82 samples taken from the rib fractures zones of the persons with a flail chest died in different periods after the injury. Depending on the time passed from the injury till death, there were identified 5 groups of patients. So It was possible to reveal the consistency of the evolution of morphological changes in the zone of rib fractures on the 1st, 2nd, 5th, 14th, and 21st day after the injury, with preserved breathing without stabilizing the rib cage. Results. We found out that on the 1st, 2nd, 5th day there were no morphologically significant changes in the fracture zone, aimed at its stabilization. With breathing preserved for more than 5 days, there was a delay in the primary callus formation and enhanced bone resorption in the fracture site. Osteoblasts activation, which manifests the proliferation of cellular elements in fragmentary rib fractures, occurred 7-9 days later than in a single fracture. It was conditioned by the persistent "floating" of the rib fragments which impacted the newly formed trabeculae of bone and forced them to rearrange twice during the bony callus formation. The increased time of the rib fractures repair aggravated the lung injury, contributed to the development of pneumonia and purulent-septic complications detected posthumously which, in their turn, were the primary cause of deaths. Conclusion. In 17.4% of victims with severe chest injury and flail chest the death is conditionally preventable. The crucial requirement of the effective treatment of patients with the thoracic trauma and flail chest is the usage of various methods of the thoracic cage stabilization.
Science and Innovations in Medicine. 2018;3(4):6-12
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MODERN ALGORITHMS OF THORACIC CAGE STABILIZATION IN PATIENTS WITH MULTIPLE RIB FRACTURES AND FLAIL CHEST
Benyan A.S., Korymasov E.A., Borkovskiy A.Y.
Abstract
Objectives - to improve the treatment results in patients with multiple rib fractures and flail chest via the development and implementation of modern therapeutic and tactical algorithms. Material and methods. A non-randomized prospective study has been carried out to evaluate the results of treatment in 198 patients with multiple rib fractures and flail chest in the period of 2011-2017. Three clinical types were identified: 1) patients with multiple rib fractures with disordered thoracic cage structure - 77 (38.9%); 2) patients with flail chest - 71 (35.9%); 3) patients with multiple rib fractures without disordered thoracic cage structure - 50 (25.2%). There were developed and applied the diagnostic and treatment algorithms depending on the severity of injures of sternocostal frame and intrapleural organs, the presence and severity of associated injuries and background diseases, the conditions of medical aid. Results. The treatment tactics of all patients was based on the differentiated, staged and combined use of various methods of stabilizing the thoracic cage including the advanced types of medical care. Surgical stabilization methods were used in 162 patients, in 26 of them a combination of surgical techniques was applied, in 20 - the internal pneumatic stabilization, in 42 - the conservative treatment was performed. The retrospective analysis and the obtained results compared to the results of the equivalent historical group allowed us to state the decrease of mechanical ventilation time from 11.0 ± 3.9 to 5.1 ± 3.2 days (t = 1.17; p> 0.05), the length of stay in the ICU from 11.5 ± 5.4 to 6.8 ± 3.7 days (t = 0.72; p> 0.05), the complications frequency from 36.5% to 15.9% and mortality rate from 22.3% to 8.7%. Conclusion. Modern diagnostic and treatment algorithms in patients with multiple rib fractures and flail chest are based on stage-by-stage application, succession and combination of various methods of the thoracic cage stabilization throughout the medical assistance process. The algorithms, allowing to stabilize the thorax and to improve the condition of the patients in general, make it possible to realize the full potential of modern thoracic surgery.
Science and Innovations in Medicine. 2018;3(4):13-19
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LIVER HYDATIDOSIS: OPTIMIZATION OF SURGICAL TREATMENT METHODS
Ivanov S.A., Kenarskaya M.V., Panfilov K.A.
Abstract
Objectives - optimization of hepatic echinococcosis treatment schemes based on the data analysis of the immediate and long-term results. Material and methods. The study included 373 clinical cases of patients with liver echinococcosis who received treatment in 2005-2018 in Samara Regional Clinical Hospital n. a. V.D. Seredavin. 342 patients underwent a traditional operation, the surgical puncture was performed in 31 patient. Starting from 2003 all patients received the antirelapse chemotherapy with albendazole according to the WHO's recommendations in the postoperative period. Results. The treatment tactics in patients with liver hydatidosis was defined according to the parasite's developmental stage, its localization, and the size of liver cyst. The traditional surgery was successful after one operation in more than 93% of cases, postoperative mortality was 1.46%, the number of postoperative complications - 12.5%, the number of relapses in 5 year follow-up period was 6.8%. In 31 patients we used the puncture surgery treatment of hepatic echinococcosis PAIR and PEVAC-methods. Conclusion. Modern approach to hepatic echinococcosis treatment should provide differentiated
Science and Innovations in Medicine. 2018;3(4):20-26
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ENDOVENOUS LAZER COAGULATION: LONG-TERM RESULT - CRITERION OF TRUTH
Shalashov A.G., Kazantsev A.V.
Abstract
Objectives - to study the long-term results of endovenous laser coagulation in patients with varicose veins of the lower extremities. Material and methods. The study included 241 patients with varicose disease of the lower limbs veins, who underwent surgical treatment using the method of endovenous laser coagulation. Results. The technical success of the operation was achieved in all cases, which was confirmed by color duplex scanning. There were no intraoperative complications. Long-term outcome was studied in 174 (72.2%) patients in the period up to 5 years. During the follow-up period the GSV occlusion signs were detected in 168 (96.4%) patients, partial recanalization of the GSV was registered in 6 (3.5%) patients.
Science and Innovations in Medicine. 2018;3(4):27-30
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ENTERAL INSUFFICIENCY TREATMENT IN PATIENTS WITH GENERALIZED PERITONITIS
Kenarskaya M.V., Ivanov S.A., Korymasov E.A.
Abstract
Objectives - to improve the treatment results in patients with generalized peritonitis complicated by the enteral insufficiency syndrome. Material and methods. In the period of 2016 -2018 there were 45 patients with a widespread peritonitis admitted to Samara regional clinical hospital named after V.D. Seredavin for treatment. The patients were divided into a control and a main group. The patients of the main group received the intestinal intubation with a specially designed catheter, the intestinal lavage during surgery and in the early postoperative period, the enterosorption, enteral nutrition and bowel decontamination; and in the absence of contraindications - the enteral oxygen therapy. Dynamics of the enteral insufficiency syndrome (EIS) development in both groups were evaluated according to the defined criteria, including laboratory and clinical indicators. Each criterion could weight from 1 to 3 points, their amount reflected the degree of enteral insufficiency. Results. In the main group of patients the small intestinal function was notably restored till the beginning of the third day, what coincided with the transition of the third degree of enteral insufficiency in the second. In patients of the control group the restoration of intestinal function was starting in period of fifth and sixth day after the operation, but the 3d degree of enteral insufficiency remained for 12 hours. Conclusion. The intestinal treatment in combination with the standard therapy allowed to reduce the degree of EIS in the beginning of treatment. This helped to improve the treatment results in general.
Science and Innovations in Medicine. 2018;3(4):31-35
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PROLONGED AIR LEAK AFTER LUNG RESECTION
Korymasov E.A., Benyan A.S.
Abstract
Objectives - to analyze the causes of postoperative air leak and to propose a therapeutic and diagnostic algorithm for this complication. Material and methods. The study includes the analysis of the prolonged air leak causes after various lung resections, the classification of the causes according to their affiliation, the designed definitions of basic concepts. Results. The most common causes of prolonged air leakage are the incompetence of the lung resection line, the undetected (unresolved) cause of pneumothorax, the inadequate drainage system function. Various tactical approaches to this problem were described. Depending on the effectiveness of the auxiliary techniques, the indications for repeated operations were determined. Conclusion. Knowledge of the causes of postoperative prolonged pathological air leak is the basis for the optimal management of patients after lung resection.
Science and Innovations in Medicine. 2018;3(4):36-40
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OBLITERATING ATHEROSCLEROSIS OF THE LOWER EXTREMITIES: COURSE PROGNOSIS AND TREATMENT
Kazantsev A.V.
Abstract
Objectives - to develop a course prognosis method for obliterating atherosclerosis of femoropopliteal and tibial localization. Material and methods. We studied a group of patients with obliterating atherosclerosis of femoropopliteal and tibial localization. The subjects for analysis were significant prognostic clinical, hemodynamic, hemostasiological, immunological characteristics, markers of endothelial dysfunction, changes in lipid profile. Results. As a result of multivariate analysis the pathogenetically substantiated prediction system with the disease index calculation was developed. The obliterative atherosclerosis course with index less than 13 points is assessed as non progressive, with index 13 points and more - as progressive.
Science and Innovations in Medicine. 2018;3(4):41-45
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INNOVATIVE METHOD OF PERICARDIAL FENESTRATION ASSOCIATED WITH UNDERLYING CHRONIC RECURRENT PERICARDITIS: CASE REPORT
Medvedchikov-Ardiya M.A., Benyan A.S., Mukhambetaliev S.A.
Abstract
Objectives - to illustrate the clinical follow-up of a patient with chronic recurrent pericarditis subjected to a pericardial fenestration performed in a new manner, with subxiphoidal pericardiotomy, pericardioscopy followed by trans-pericardial thoracoscopy. Material and methods. A 69-year-old woman with chronic recurrent pericarditis and the threat of cardiac tamponade was subjected to subxiphoidal pericardiotomy, pericardioscopy and subsequent transpericardial thoracoscopy forming the pericardial window and junctions with pleural and abdominal cavity. Results. The first special aspect of the presented case is the combination of access types and the usage of non-standard access to the pleural cavity; the second one is the combined formation of fistulae between the pericardial cavity and two other cavities - the left pleural and abdominal. The positive outcome of this operation was the bidirectional drainage of pericardial exudate, as well as the minimal postoperative pain syndrome due to the absence of transthoracic access. Conclusion. The positive clinical result in the early postoperative period and during the long term followup period, the absence of complications allows for the safety of the technique and the possibility of performing such surgical operations in patients with acute and chronic exudative pericarditis and the threat of cardiac tamponade.
Science and Innovations in Medicine. 2018;3(4):46-49
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ESOPHAGEAL INJURY CAUSED BY THE SPINE DEFORMITY CORRECTION USING VARIOUS TECHNIQUES OF SPINAL FIXATION
Pushkin S.Y., Belokonev V.I., Abashkin N.Y., Shcherbakov D.A., Ayrapetova M.P.
Abstract
Objectives - to improve the surgical treatment results in patients with injuries of the esophagus after the elimination of deformation of a vertebral column with metal devices. Material and methods. From 2001 to 2018 we treated 17 patients with esophageal injury appeared as a result of cervical vertebras fixation with metal devices - in 12 patients to correct their instability due to the traumatic compression fractures and in 5 patients having the herniated discs with the spinal channel compression. 12 patients underwent the urgent operation, 5 patients - the delayed or planned one. Three mechanisms of esophageal injury were defined: 5 patients had the first type of injury, 8 - the second type, 4 - the third type. The patients were operated on after the diagnosis confirmation. The operation was aimed at the removal of the metal device from the collum and the closure of the esophagus wall defect. Tactics of treatment of the esophageal injuries depended on the alterations in its paries, the size of the defect, the nature of the trauma and the mediastinitis prevalence. In 8 patients the primary suture of the esophagus was applied. In 9 patients with decubituses of the esophagus and the large size of the defect we applied the partial suturing of the defect and the transesophageal drainage of the fistula and mediastinum, strengthening the injured zone with a muscle on the pedicle. Results. First intention healing was achieved in 5 patients of the 8 ones who underwent the esophagus wall suturing without a fistula transesophageal drainage. The partial suture incompetence occurred in 3 cases and it required the transesophageal drainage through the defect in the esophagus wall. The external tubular esophageal fistula formed in 12 patients. After the drainage removal the fistula closed in 10 cases. One of the 17 patients died of the multiple organ failure and sepsis. Conclusion. Injuries of the esophagus caused by the metal devices fixing the unstable vertebras have the clinical features depending on the installation time. The suturing of the esophageal defect and the suture strengthening m. sternocleidomastoideus on the pedicle supplemented by a through lumenal transesophageal drainage have advantage in comparison with the esophageal wall suturing without drainage.
Science and Innovations in Medicine. 2018;3(4):50-53
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SIMULTANEOUS OPERATIONS TACTICS IN PATIENTS WITH VENTRAL HERNIAS
Fedorin A.I., Belokonev V.I., Pushkin S.Y., Kovaleva Z.V., Pushkina D.S.
Abstract
Objectives - to improve treatment results in patients with ventral hernia and the concurrent surgical diseases by means of the designed surgery tactics. Material and methods. The treatment of 834 patients with ventral hernia, aged from 18 up to 82 years, was analyzed. The group consisted of 196 men (23.5%) and 638 women (76.5%). According to the European Hernia Society (EHS) classification of postoperative ventral hernias the gate types were distributed in patients as follows: W1 - in 132 patients (15.8%), W2 - in 397 (47.6%), W3 - in 305 (36.6%), in 243 (29.1%) cases the hernias were recurrent. 394 (47.2%) patients had 597 simultaneous interventions. The treatment tactics for the patients with hernias and associated diseases was defined according to the designed classification. For the abdominal wall repair the 2 variants of the "tension-free" mesh repair technique were used. Results. Forced simultaneous interventions were performed in 34 patients when the intestinal loops adherent to the scar were situated in the hernia sac. In 27 cases the postoperative ventral hernia was combined to the intestinal fistulas, located out of the hernia area. 12 patients underwent herniolaparotomy conditioned by the intra-abdominal intestinal fistulas closure and small hernias size. To prevent the compartment syndrome in 3 patients with splanchnoptosis the right part of the colon was resected. 103 patients had the planned simultaneous operations including the laparoscopic cholecystectomy in 19 cases, 114 patients underwent the panniculectomy. The preventional appendectomy was performed in patients with the recurrent large hernias. In 140 cases the omentum resection was done due to the signs of the chronical strangulation and omentitis. Postoperative pulmonary artery thromboembolia was the death cause for 3 (0.4%) patients. Only 8 (0.9%) patients suffered the partial hernia recurrence. Conclusion. In patients with hernias the simultaneous operations are conditioned by the pathogenesis and do not affect the severity and frequency of wound complications in the postoperative period. A condition for the simultaneous interventions in patients with hernias is the necessary implementation of the combined techniques of the ventral tension-free mesh hernioplasty.
Science and Innovations in Medicine. 2018;3(4):54-58
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PREMEDICATION AS A FIBROBRONCHOSCOPY SAFETY FACTOR
Shteiner M.L.
Abstract
Review article surveys premedication as one of the safety methods in flexible endoscopy. The traditional premedication provided technical convenience of bronchoscopy by sedation and secretion drying. This approach had become less justified since bronchoscopy was widely used in patients with severe somatic pathology. This new condition forced the usage of inhalation broncholytics (M-cholinolytics : and e2-agonists) which mainly have tracheobronchial impact and minimal systemic action, and parenteral gluco-corticosteroids with powerful broncholytic and definite cardioprotective effect. Parenteral ad-ministration of theophylline may be used in premedication with some restrictions.
Science and Innovations in Medicine. 2018;3(4):59-62
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TACTICS OF PRENATAL CARE OF A YOUNG PATIENT WITH INHERITED LONG QT SYNDROME AND IMPLANTED CARDIOVERTER-DEFIBRILLATOR
Tatarsky R.B., Lebedeva V.K., Lubimtseva T.A., Gureev S.V., Lebedev D.S., Garkina S.V.
Abstract
Ase report. This clinical case illustrates the example of prenatal care of a young woman with verified long QT syndrome (LQTS) type 2 with implanted cardioverter-defibrillator (ICD). In the course of pregnancy she had physiological sinus tachycardia, though the life-threatening ventricular arrhythmias and ICD shocks were not registered. On the 38th week of pregnancy the woman underwent the planned caesarean delivery (due to obstetrics indications) with live child. In the post-partum period she continued to experience recurrent VF episodes terminated after the adequate ICD shocks. Life-threatening arrhythmias were triggered by group PVC registered in the settings of persistent bradycardia. At the moment the number of the adequate ICD shocks reduced supported by betablocker therapy, the patient remains on continued standard monitoring. Discussion. Numerous cases of favourable course and even benefits in clinical and functional status during pregnancy in patients with LQTS are reported. This fact can be conditioned by the positive influence of physiological hemodynamical changes and hypersympathicotonia during pregnancy especially on the bradydependent arrhytmias. Conclusion. Pregnancy in patients with inherited LQTS and implanted ICDs is not always contraindicated and treatment tactics depends on certain clinical situation. Algorithms of pharmacological and shock therapy during pregnancy in women with ICD are corrected individually.
Science and Innovations in Medicine. 2018;3(4):63-67
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EVALUATION AND CHARACTERISTICS OF POPULATION AGEING
Sirotko M.L.
Abstract
Objectives - to make an assessment of the actual situation in the population ageing process and to define its tendency. Material and methods. The classification characteristics are defined based on the calculation on the elderly people ratio to the total number of people. The structure of the international ranking is presented. The modern approach such as a prospective age was the basis of the ageing evaluation. The point of analysis was the ageing tendency in the Samara region population in the 20th century, observing its range and structure marks, the degree according to the ageing index. Results. The prognostic ageing values of the 2010 year for the period till 2031were corrected. The escalation of the eldest population group in the nearest future was decisively proved. The further interdisciplinary problem management was stated to be focused on, as the elderly people are crucially dependent on the just-in-time and full-range healthcare services supported by the social adaptation.
Science and Innovations in Medicine. 2018;3(4):68-72
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