Khirurgiya最新文献

Objective: To compare the results of robot-assisted (RA) and laparoscopic (LA) technologies in abdominal surgery in Russian surgical practice.

Material and methods: A systematic review and meta-analysis were conducted in accordance with methodological recommendations of the Russian Ministry of Health and the Cochrane guidelines. Considering heterogeneity of primary study designs, we did not determine the overall effect of meta-analysis. Differences were presented for each study. The review continues the 2021 study and updates data using similar inclusion criteria and approaches to meta-analysis.

Results: The number of studies devoted to abdominal robotic surgery has increased since 2020. Controlled non-randomized trials comprised 96%. Predominant area of research was oncological coloproctology. Duration of robotic surgeries varied from 113 to 665 min, laparoscopic surgeries - from 91 to 427 min. Differences in favor of shorter laparoscopic surgery were significant in half of the studies. The incidence of intraoperative complications in robotic interventions varied from 0% to 13%, in laparoscopic interventions - from 0% to 30%. There was a tendency to less blood loss in robotic interventions. Comparison of inpatient treatment, postoperative complications (0-56% after robotic interventions, 1-70.6% after laparoscopic surgeries) and mortality (0-8.7% after robotic surgery and 0-11.8% after laparoscopic interventions) did not reveal significant differences.

Conclusion: At the modern stage of robotic surgery in the Russian Federation, differences between robotic and traditional laparoscopic interventions are not significant in abdominal surgery. Further researches with higher methodological quality are needed due to low evidence base.

Objective: To identify key clinical, laboratory, and instrumental predictors and develop a prognostic scale for acute mesenteric ischemia (AMI) to optimize early diagnosis.

Material and methods: A prospective, cross-sectional, single-center study was performed between 2016 and 2024. Inclusion criteria: age ≥ 18 years, suspected or diagnosed AMI during surgery or autopsy.

Results: Prognostic scale is based on relative contribution of predictors. The model demonstrates very good discriminatory ability with AUC 0.832.

Conclusion: Thus, the proposed diagnostic algorithm brings us closer to solving the problem of patient selection for in-depth radiological diagnosis in resource-limited emergency hospitals. Implementation of this algorithm in clinical practice will standardize diagnostic process for acute mesenteric ischemia, reduce the time to diagnosis, and initiate timely treatment. This is critical for improving the outcomes of this life-threatening condition.

Objective: To optimize diagnosis and treatment methods for recurrent TEF based on analysis of extensive clinical experience; to propose preventive strategies reducing postoperative complications.

Material and methods: Treatment outcomes were analyzed in 115 patients with TEF between 2004 and 2023. Of these, 40 (34.8%) ones underwent redo surgeries after previous failed fistula closure. There were 69 surgical interventions including third-time surgeries in 7 patients with repeated recurrences. TEF associated with tracheal cicatricial stenosis (TCS) in 29 (48.3%) cases necessitated concomitant surgical approaches. Treatment method was determined by characteristics of previous interventions and clinical situation.

Results: No mortality was recorded. The most common postoperative complications were purulent-inflammatory processes. Key risk factors for recurrence were TEF associated with TCS and persistent tracheostomy after tracheoplasty with T-tube. Redo surgical interventions, 3-fold attempts of fistula closure, led to complete recovery in some cases.

Conclusion: The study confirms feasibility of radical treatment for recurrent TEF, even in case of significant anatomical and functional alterations. Original strategies for prevention of recurrence and refined surgical indications enhance treatment efficacy. These data can be used to improve clinical guidelines aimed at reducing recurrence rates and achieving better long-term outcomes.

Objective: To improve surgical treatment of abdominal trauma using endoscopic surgical methods.

Material and methods: The study enrolled 87 patients with abdominal organ injuries. All patients were divided into two groups depending on surgical approach: group 1 - traditional surgical treatment, group 2 - advanced strategy based on endoscopic surgical methods.

Conclusion: Endoscopic technologies for abdominal trauma reduce the incidence of open diagnostic surgeries, postoperative morbidity and length of hospital-stay.

Objective: To analyze different methods for autologous transplantation of stromal-vascular fraction of adipose tissue combined with skin grafting with split-thickness skin graft 1:6 in patients with extensive deep burns.

Material and methods: Open comparative controlled prospective study was devoted to results of autologous skin grafting with split-thickness skin graft 1:6 and autologous cells of stromal-vascular fraction of adipose tissue. Patients were divided into 4 groups depending on transplantation method: injection, aerosol, combined (aerosol+injection) and comparison group (standard skin grafting with split-thickness perforated transplants).

There were 43 cases. Inclusion criteria: age 18-65 years, total area of skin burn 10-60% of body surface area, deep burn 10-45% of body surface area. Autologous skin grafting was performed on 10-15% of body surface area. Clinical, laboratory, cytological and histological methods were used to evaluate postoperative outcomes.

Results: Combined (injection+aerosol) transplantation method was followed by significantly earlier engraftment (by 5 days, 9.9 ±0.7 days in the main group and 14.5±0.88 days in the control group, Student's t test 3.518) and reduction of postoperative complications to 6% (in the control group 27%).

Conclusion: Analysis of biotechnological methods for surgical treatment of patients with extensive deep burns showed the effectiveness of combined (aerosol+injection) transplantation and skin grafting with split-thickness skin graft. This approach reduced skin recovery time and incidence of postoperative complications.

Objective: To evaluate the methodology of Trial Sequential Analysis as a tool for developing and critically appraising of clinical guidelines on the model of midline ventral hernias.

Material and methods: Systematic searching for international guidelines on the management of ventral hernias was conducted in the PubMed, EMBASE, Scopus, Web of Science, CINAHL, and Cochrane Library databases up to May 01, 2023. Searching depth was 5 years. Quality of systematic reviews was assessed using a Critical Appraisal Sheet from the Oxford Center for Evidence-Based Medicine. TSA was performed using Copenhagen Trial Unit (Centre for Clinical Intervention Research, Denmark) software. We analyzed sensitivity of models using relative risk reduction rates.

Results: We analyzed 3 international guidelines on the management of primary and incisional ventral hernias: the International Endohernia Society (IEHS, 2019), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES, 2016), and the European Hernia Society (EHS, 2023). Systematic reviews in all guidelines had high quality. The IEHS (2019) and SAGES (2016) guidelines synthesized evidence without meta-analytical processing, whereas the EHS (2023) guideline incorporated meta-analysis. Our supplementary TSA calculations demonstrated that EHS (2023) guideline evidence base is sufficiently powered to identify diabetes mellitus and surgical site infection as key risk factors of incisional hernia following midline laparotomy. Alloplastic mesh appeared to be a preventive factor against hernia recurrence compared with suture repair. Nonetheless, optimal mesh placement technique remains inconclusive.

Conclusion: To ensure necessary evidence base for updated guidelines on midline ventral hernias, further protocol studies are needed, including international collaboration. An alternative option for achieving a larger sample size, but with lower evidence base, could be research of surgical registries.

Tuberculous spondylitis and psoas abscess secondary to mycotic thoracoabdominal aortic aneurysm are extremely rare. This life-threatening condition requires surgical treatment after diagnosis. Treatment of these patients involves specific antibacterial therapy combined with total resection of infected tissues and vascular reconstruction. At the same time, the most optimal surgical tactics in these patients is unclear. We present a 65-year-old male patient with tuberculous ostitis of L2-L4 vertebrae and right-sided psoas abscess secondary to 6-month-old ruptured mycotic thoracoabdominal aortic aneurysm. The main complaint at admission was severe lumbar pain. For diagnostic purposes, the patient underwent removal of right-sided retroperitoneal lesion with subsequent histological examination of tissues. Typical signs of tuberculosis infection required anti-tuberculosis chemotherapy. A month later, the patient underwent endovascular aortic repair due to infrarenal aortic enlargement and saccular protrusion of aortic wall within its bifurcation. Pain syndrome decreased after surgery. Postoperative CT revealed shrinkage of paraaortic hematoma and reduction of infrarenal aortic diameter. After 6 months, CT angiography confirmed pulsatile blood flow through the stented visceral arteries without endoleaks. Destruction zones of L2-L4 vertebrae decreased. This case demonstrates the possibility of endovascular treatment of a patient with ruptured mycotic thoracoabdominal aortic aneurysm with secondary tuberculous spondylitis and psoas abscess. This technique seems to be an acceptable alternative to open aortic repair in elderly comorbid patients.

Objective: Investigation of the causes of differences between current and recommended therapeutic and diagnostic tactics for colon diverticulitis (CD).

Material and methods: An anonymous online survey was conducted from 01.2023 for 60 days. The participants received an information letter and a link to an online questionnaire. Demographic indicators, the level of self-esteem, sources of motivation in decision-making, diagnostic and therapeutic tactics were studied. The respondent's probability of choosing a specific treatment tactic was estimated in scores from 0 to 10.

Results: 377 respondents from the Russian Federation participated: 56 (14.9%) coloproctologists (CP), 299 (79.4%) general surgeons (GS), 22 who did not specify a specialty. The majority (46/56, 82.1%) of CP rate their knowledge of the problem as excellent and good, among GS the corresponding proportion is 199 (66.5%) (p=0.02). When making decisions, respondents were most often guided by professional experience (Me 8, Q₁-Q₃ 6-10), methods adopted in the clinic (Me 8, Q₁-Q₃ 5-10) and Russian guidelines (Me 9, Q₁-Q₃ 7-10). A weak relationship was found between reliance on personal experience and the level of self-esteem (r=0.188, p<0.001), as well as the number of colorectal resections performed per year (r=0.242, p<0.001) and between reliance on national recommendations and the level of knowledge on the diagnosis and treatment of CD (r=0.223, p<0.001). Nineteen (5%) respondents for Hinchey IA and 91 (24%) respondents for Hinchey IB-II choose colon resection. In Hinchey III, non-operating specialists choose tactics that are inconsistent with the guidelines (lavage) (p<0.001). For Hinchey IV 35 (9.3%) respondents also offered non-radical treatment options. There is no consensus on issues not covered by guidelines.

Conclusion: There is low adherence to the existing recommendations that leads to significant differences in the approaches practiced by respondents from different cohorts. Further research is needed to fill in the gaps found and update the guidelines accordingly.

Objective: To describe the concept of comprehensive left ventricular outflow tract reconstruction based on eliminating all obstructive mechanisms.

Material and methods: The authors analyzed own experience of left ventricular outflow tract reconstruction in patients with hypertrophic cardiomyopathy (over 400 surgeries).

Results: Complex left ventricular outflow tract reconstruction involves resection of interventricular septum and correction of papillary muscles, chordae tendineae and accessory muscle bundles. The described approach demonstrates high efficacy and safety and can be considered a modern standard.

Conclusion: A personalized approach based on precise myectomy allows for optimal hemodynamic outcomes with minimal risk of complications.

Objective: To evaluate safety and efficacy of jejunum segment interposition after proximal gastric resection.

Material and methods: There were 80 jejunum segment interpositions after proximal gastric resection in 2012-2023. Primary subtotal proximal gastric resection was performed in 70 (87.5%) patients, resection of esophagogastrostomy in 9 (11.2%), gastric bypass surgery - in 1 (1.3%). The indications for surgery were cancer in 66 (82.5%) patients, recurrence of cancer in esophagogastrostomy - 2 (2.5%), postgastrectomy diseases - 12 (15.0%). Mean age of patients was 62 years. There were 51 (63.8%) men and 29 (36.2%) women.

Results: In early postoperative period, 8 (10.0%) patients developed complications. Failure of esophagojejunostomy occurred in 5 (6.3%) cases, subdiaphragmatic abscess - in 1 (1.3%) patient. Another (1.3%) patient had jejunum insert necrosis that required its extirpation and direct esophagogastrostomy. One (1.3%) patient died from non-occlusive mesenteric ischemia with intestinal necrosis on the 3^rd day after surgery. There were no long-term specific complications related to jejunum segment. Reflux esophagitis was recorded in 2 (3.6%) out of 56 patients.

Conclusion: Jejunum segment interposition after proximal gastric resection is a relatively safe technique preventing severe reflux esophagitis.