Vishnevsky Institute of Surgery

Moscow, Russia

Vishnevsky Institute of Surgery

Moscow, Russia
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Kubyshkin V.A.,Vishnevsky Institute of Surgery | Sazhin V.P.,Ryazan State Medical University | Fedorov A.V.,Ryazan State Medical University | Krivtsov G.A.,Vishnevsky Institute of Surgery | Sazhin I.V.,Pirogov Russian Research Medical University
Khirurgiia | Year: 2017

AIM: To present treatment of 52 149 patients with ulcerative gastroduodenal bleeding (UGDB) who were treated in different regions of Central Federal District (CFD) for the period 2011-2014. It is noted that UGDB incidence per 100 thousands is increased proportionally from 32.9 to 77.8 according to population less than 20 and over 100 thousands, respectively. In hospitals of small and medium settlements the number of UGDB patients without surgery reaches 81.6 and 81.1%, the number of operated patients - 18.4 and 18.9% respectively. In hospitals of large settlements this ratio is 90.1 and 90.6%, the number of operated patients - 9.9 and 9.4%, respectively. In areas of Central Federal District the mortality rate in patients without surgery is 3.9-8.2%, in operated patients - 17.4-36.9%.RESULTS: Structured analysis of the organization of surgical care in Central Federal District revealed the relationship between outcomes and efficient use of endoscopic diagnostics and haemostasis. In municipal hospitals of Central District endoscopic technologies are insufficiently used for final elimination of ulcerative bleeding.Цель — обобщить результаты лечения 52 149 больных с язвенным гастродуоденальным кровотечением (ЯГДК) в различных регионах центрального федерального округа (ЦФО) в 2011—2014 гг. Материал и методы. Отмечено, что заболеваемость ЯГДК из расчета на 100 000 населения увеличивается пропорционально с 32,9 до 77,8 при числе проживающих в районах жителей до 20 тыс. и свыше 100 тыс. соответственно. В больницах малых и средних поселений количество неоперированных больных с ЯГДК достигает 81,6 и 81,1%, а количество оперированных — 18,4 и 18,9% соответственно. В больницах больших и крупных поселений это соотношение составляет 90,1 и 90,6%, а также 9,9 и 9,4% соответственно. В районах ЦФО летальность неоперированных больных колеблется в диапазоне от 3,9 до 8,2%, оперированных — от 17,4 до 36,9%. Результаты. Структурированный анализ организации оказания хирургической помощи в ЦФО при ЯГДК позволил установить зависимость результатов лечения больных от эффективности использования в комплексном лечении методов эндоскопической диагностики и гемостаза. В муниципальных лечебных учреждениях ЦФО для окончательной остановки язвенного кровотечения недостаточно используются возможности эндоскопических технологий.


Chililov A.M.,Vishnevsky Institute of Surgery | Akhmedov B.A.,Vishnevsky Institute of Surgery | Kozlov V.K.,Novgorod State University
Polytrauma | Year: 2016

Objective - to substantiate the possibilities of increasing efficiency of complex treatment of patients with gunshot shaft fractures of long bones of the extremities by means of implementation of the modern low invasive technologies of internal osteosynthesis and technologies of pharmacotherapy with modern immune active drugs into clinical practice of civil healthcare. Materials and methods. The prospective comparative study was based on the experience of complex treatment of 104 patients of Yemen republic who required for medical aid for treating the lower limb gunshot wounds of various severity. The gunshot injuries were characterized by shaft fractures of the long bones of the extremities and concurrent gunshot injuries to soft tissues. Men presented the main category of the patients (80.7 %). The age of the patients varied from 15 to 80, with the average age of 38.5 ± 5.7. Presence of gunshot fractures of the long bones of the extremities determined the use of various surgical techniques of single-step and staged treatment. For prevention of infectious diseases the patients with most severe fractures additionally received medicated immune-oriented therapy (besides the main pharmaceuticals of concurrent conservative treatment). Results and discussion. The patients received the complex treatment in concordance with the various techniques of staged treatment: low energy fractures were treated with the conventional techniques with the external fixation devices as a final method of fracture union, or as early as possible primary low invasive and functionally stable osteosynthesis with LCP or BIOS; high energy fractures were initially treated with the external fixation devices, which were further replaced in delayed low invasive fixation with metal plates. The main point of improving the known techniques of complex treatment was the drive to synchroneity and minimal possibility of postsurgical trauma by means of wide use of modern fixation plates, as well as preventive immune correction of posttraumatic immune dysfunction for excluding the infectious complications of gunshot fractures. As result, the efficiency of complex treatment increased: invasiveness of surgical intervention showed twofold decrease (p ≤ 0.01), as well as duration of hospital treatment (p ≤ 0.01); exclusion of recurrent osteosynthesis; sharp decrease in rate of complications resulting in disability (4-fold decrease in infectious complications and 40-fold decrease in non-infectious complications); reducing the duration of rehabilitation, significant improvement in quality of life of treated patients and achieving the fastest restoration of functioning of the injured extremity. Conclusion. The technique has been improved and the algorithm for complex treatment of gunshot shaft fractures of long bones of the extremities has been offered during arrangement of specialized medical aid for civilian persons suffered in war conflicts. The technique for treating patients with gunshot fractures of the extremities, including saving surgical preparation, early low invasive and functionally stable osteosynthesis with modern implants, and non-specific immune prevention of infectious complications, was more efficient and cost saving in comparison with the conventional treatment technique with external fixing devices and nonuse of immune active drugs as a part of conservative therapy.


Egorov V.I.,Moscow State University | Vankovich A.N.,Vishnevsky Institute of Surgery | Petrov R.V.,Moscow State University | Starostina N.S.,Moscow State University | And 3 more authors.
BioMed Research International | Year: 2014

Background. The term "paraduodenal pancreatitis" (PP) was proposed as a synonym for duodenal dystrophy (DD) and groove pancreatitis, but it is still unclear what organ PP originates from and how to treat it properly. Objective. To assess the results of different types of treatment for PP. Method. Prospective analysis of 62 cases of PP (2004-2013) with histopathology of 40 specimens was performed; clinical presentation was assessed and the results of treatment were recorded. Results. Preoperative diagnosis was correct in all the cases except one (1.9%). Patients presented with abdominal pain (100%), weight loss (76%), vomiting (30%), and jaundice (18%). CT, MRI, and endoUS were the most useful diagnostic modalities. Ten patients were treated conservatively, 24 underwent pancreaticoduodenectomies (PD), pancreatico- and cystoenterostomies (8), Nakao procedures (5), duodenum-preserving pancreatic head resections (5), and 10 pancreas-preserving duodenal resections (PPDR) without mortality. Full pain control was achieved after PPRDs in 83%, after PDs in 85%, and after PPPH resections and draining procedures in 18% of cases. Diabetes mellitus developed thrice after PD. Conclusions. PD is the main surgical option for PP treatment at present; early diagnosis makes PPDR the treatment of choice for PP; efficacy of PPDR for DD treatment provides proof that so-called PP is an entity of duodenal, but not "paraduodenal," origin. © 2014 V. I. Egorov et al.


Kondratyev E.,Vishnevsky Institute of Surgery | Karmazanovsky G.,Vishnevsky Institute of Surgery
European Journal of Radiology | Year: 2013

To evaluate the effect of hybrid iterative reconstruction on qualitative and quantitative parameters atlow dose carotid CTA.Materials and methods: 44 consecutive patients were enrolled in the study. First group (n = 22) was exam-ined under 120 kV 250 mAs, second group (n = 22) - 100 kV 250 mAs. CT images in first group werereconstructed only with the filtered back projection (FBP). CT data in second group were reconstructedboth with FBP and three levels of hybrid iterative reconstruction algorithm (iDose). We compared quan-titative and qualitative parameters among the two groups and among four different reconstructions insecond group.Results: Effective dose in 120 kV and 100 kV group was 7.18 ± 1.19 mSv and 4.14 ± 1.03 mSv, respec-tively (p < 0.0001). Mean arterial attenuation was about 25% higher in second group (236.5 ± 46 HU vs.302.6 ± 32.7 HU; p < 0.0001). Image noise at the level of humeral belt was 32.5 ± 12.5 in 100 kV group and26.3 ± 13.3 in 120 kV (p = 0.115).Average noise decreased when using 3 levels of iDose up to 23.6 ± 6.4, 17.7 ± 5.6 and 13.7 ± 5.1,respectively (p = 0.00001). Mean CNR increased to 10.38 ± 3.87, 14.5 ± 5.21 and 18.32 ± 8.61, respectively(p < 0.05).The presence of artifacts on the level of humeral belt in 120 kV group was 14%, in 100 kV - 41%(p = 0.002). The difference in visual scores between standard and low-dose protocol was significant(p = 0.008). When applying iterative reconstruction the frequency of streak artifacts decreased dramati-cally (p < 0.0001). Most studies had excellent quality with no artifacts while using highest level of iDose.Conclusion: According to the results of our study low dose CT angiography using hybrid iterative recon-struction may provide sufficient image quality and allows for significant reduction of patient dose. © 2013 Elsevier Ireland Ltd. All rights reserved.


PubMed | Vishnevsky Institute of Surgery
Type: Journal Article | Journal: World journal of gastroenterology | Year: 2015

To characterize the computed tomography (CT) findings in patients with post-inflammatory esophageal strictures (corrosive and peptic) and reveal the optimal scanning phase protocols for distinguishing post-inflammatory esophageal stricture and esophageal cancer.Sixty-five patients with esophageal strictures of different etiology were included in this study: 24 patients with 27 histopathologically confirmed corrosive strictures, 10 patients with 12 peptic strictures and 31 patients with esophageal cancer were evaluated with a two-phase dynamic contrast-enhanced MDCT. Arterial and venous phases at 10 and 35 s after the attenuation of 200 HU were obtained at the descending aorta, with a delayed phase at 6-8 min after the start of injection of contrast media. For qualitative analysis, CT scans of benign strictures were reviewed for the presence/absence of the following features: target sign, luminal mass, homogeneity of contrast medium uptake, concentric wall thickening, conically shaped suprastenotic dilatation, smooth boundaries of stenosis and smooth mucous membrane at the transition to stenosis, which were compared with a control group of 31 patients who had esophageal cancer. The quantitative analysis included densitometric parameter acquisition using regions-of-interest measurement of the zone of stenosis and normal esophageal wall and the difference between those measurements (CT) at all phases of bolus contrast enhancement. Esophageal wall thickening, length of esophageal wall thickening and size of the regional lymph nodes were also evaluated.The presence of a concentric esophageal wall, conically shaped suprastenotic dilatation, smooth upper and lower boundaries, target sign and smooth mucous membrane at the transition to stenosis were suggestive of a benign cause, with sensitivities of 92.31%, 87.17%, 94.87%, 76.92% and 82.05%, respectively, and specificities of 70.96%, 89.66%, 80.65%, 96.77% and 93.55%, respectively. The features that were most suggestive of a malignant cause were eccentric esophageal wall thickening, tuberous upper and lower boundaries of stenosis, absence of mucous membrane visualization, rupture of the mucous membrane at the upper boundary of stenosis, cup-shaped suprastenotic dilatation, luminal mass and enlarged regional lymph nodes with specificities of 92.31% 94.87%, 67.86%, 100%, 97.44%, 94.87% and 82.86%, respectively and sensitivities of 70.97%, 80.65%, 96.77%, 80.65%, 54.84%, 87.10% and 60%, respectively. The highest tumor attenuation occurred in the arterial phase (mean attenuation 74.13 17.42 HU), and the mean attenuation difference between the tumor and the normal esophageal wall (mean CT) in the arterial phase was 23.86 19.31 HU. Here, 11.5 HU of CT in the arterial phase was the cut-off value used to differentiate esophageal cancer from post-inflammatory stricture (P = 0.000). The highest attenuation of post-inflammatory strictures occurred in the delayed phase (mean attenuation 71.66 14.28 HU), and the mean CT in delayed phase was 34.03 15.94 HU. Here, 18.5 HU of CT in delayed phase was the cut-off value used to differentiate post-inflammatory stricture from esophageal cancer (P < 0.0001).The described imaging findings reveal high diagnostic significance in the differentiation of benign strictures from esophageal cancer.


PubMed | Vishnevsky Institute of Surgery
Type: | Journal: Khirurgiia | Year: 2016

to define optimal treatment of duodenal dystrophy in patients with chronic pancreatitis.515 patients with chronic pancreatitis have been treated for the period 2004-2015 in A.V.Vishnevsky Institute of Surgery. Duodenal dystrophy (DD) was diagnosed in 79 (15.3%) of them. The diagnosis was confirmed by sonography, CT, MRI and endosonography. 5 patients are under observation without surgery. 74 patients were operated after previous medical therapy during 39 months on the average. Pancreatoduodenectomy was performed in 36 patients. Organ-sparing interventions were applied in 34 cases including different duodenal resections in 20 patients and pancreatic head resections in different modifications in 14 cases. 4 patients underwent palliative surgery. Chronic pancreatitis and DD were verified by morphological analysis of specimens. Long-term results were estimated in 47 patients. Median follow-up was 49.9 months.X-ray diagnostics showed that DD was combined with chronic pancreatitis in 87.3% of cases while morphological analysis revealed 93.8%. Clinical signs of DD were caused by striated pancreatitis in 69.6% and ectopic pancreatic tissue in 30.4%. Clinical manifestations of DD did not depend on its cause and were presented by symptoms of chronic pancreatitis. Postoperative complications occurred in 25 (34.7%) patients. There were 33.5% of complications after pancreatoduodenectomy and 70% after duodenal resection. 1 patient died. Overall mortality was 1,3%. In long-term period complete regression of symptoms was observed in 66% of cases, significant improvement - in 32%, absence of the effect - in 2%.Medical therapy should be preferred for patients with DD and chronic pancreatitis. Surgery is indicated in case of persistent pain, complicated course of chronic pancreatitis and duodenal obstruction. Pancreatoduodenectomy and pancreatic head resection are preferred.


PubMed | Vishnevsky Institute of Surgery
Type: | Journal: Khirurgiia | Year: 2016

To optimize diagnostics and treatment of cystic liver tumors.The analysis included outcomes of 46 patients with liver cystic tumors.The use of abdominal Doppler-sonography (37 patients), abdominal contrast-enhanced CT (44 patients) and MRI of abdominal cavity with MR-cholangiography (24 patients) defined radiological semiotics of cystic liver diseases. The most important features of cystic tumors are intraluminal septums with blood flow (82% of patients), solid component (6.8%), daughterly cysts (11.3%), as well as biliary hypertension (39.2% of patients). Research of oncomarkers (CEA, SA 19-9, AFP) in 40 patients showed increased level of SA 19-9 only in case of cystadenocarcinoma and intraductal papillary mucinous neoplasm of biliary type. Benign and malignant cystic tumors had increased contents of oncomarkers in all cases. Surgical treatment was used in 42 patients. Extended liver resections were performed in 10 (23.8%) patients, atypical and anatomical resections (removal of less than 3 segments) - in 31 (73.8%) patients. In one case we applied cryoablation of CA in segment I of the liver in view of invasion into the wall of inferior vena cava and hepatoduodenal ligament. In 2 cases surgery was carried out laparoscopically. Also robot-assisted technique was used in 3 patients. Immunohistochemical study was performed in 22 (44.8%) patients. The diagnosis of CAC and biliary type of IPMN was confirmed in case of high expression of CK7, SK19, MUC1, S100p, SDH2, p53 antibodies. Cystadenomas were associated with moderate expression of ER, PR and p53 antibodies by stroma and CK7, SK19, CDX2, MUC1, S100p antibodies by epithelium.There are considerable difficulties of differential diagnosis of liver cystic tumors. Therefore, the use of single algorithm of diagnostics and treatment is necessary to confirm accurately the diagnosis at the perioperative stage. Cystic tumor is more likely to be assumed in women with solitary cyst in segment IV of liver. If the diagnosis is suspected or confirmed anatomical liver resection with complete tumor removal is necessary to prevent the recurrence.


PubMed | Central Hospital of FSS RF, Russian National Research Medical University, Moscow State University, Vishnevsky Institute of Surgery and Moscow City Hospital No 12
Type: | Journal: BioMed research international | Year: 2014

The term paraduodenal pancreatitis (PP) was proposed as a synonym for duodenal dystrophy (DD) and groove pancreatitis, but it is still unclear what organ PP originates from and how to treat it properly.To assess the results of different types of treatment for PP.Prospective analysis of 62 cases of PP (2004-2013) with histopathology of 40 specimens was performed; clinical presentation was assessed and the results of treatment were recorded.Preoperative diagnosis was correct in all the cases except one (1.9%). Patients presented with abdominal pain (100%), weight loss (76%), vomiting (30%), and jaundice (18%). CT, MRI, and endoUS were the most useful diagnostic modalities. Ten patients were treated conservatively, 24 underwent pancreaticoduodenectomies (PD), pancreatico- and cystoenterostomies (8), Nakao procedures (5), duodenum-preserving pancreatic head resections (5), and 10 pancreas-preserving duodenal resections (PPDR) without mortality. Full pain control was achieved after PPRDs in 83%, after PDs in 85%, and after PPPH resections and draining procedures in 18% of cases. Diabetes mellitus developed thrice after PD.PD is the main surgical option for PP treatment at present; early diagnosis makes PPDR the treatment of choice for PP; efficacy of PPDR for DD treatment provides proof that so-called PP is an entity of duodenal, but not paraduodenal, origin.


PubMed | Vishnevsky Institute of Surgery
Type: | Journal: Khirurgiia | Year: 2016

to improve the results of pancreatic resections through decrease of postoperative pancreatitis incidence.It was analyzed 207 patients who underwent pancreatic surgery for pancreatic tumor (n=137) or chronic pancreatitis (n=70). 22 risk factors of postoperative pancreatitis were analyzed in 112 patients retrospectively. In prospective study of 95 patients the efficacy of lornoxicam to prevent postoperative pancreatitis was assessed. 68 parameters of immune state were studied to estimate effect of lornoxicam.Significant factors were mellow pancreatic parenchyma, tumoral disease, pancreatic duct diameter over 3 mm, pancreatric duct index over 0.2, body mass index over 27 kg/m2. Likelihood of postoperative pancreatitis was 40%, 63%, 74.3% and 88.9% if 2, 3, 4 and 5 factors were combined respectively. Preventive use of lornoxicam reduced significantly incidence of postoperative pancreatitis (p=0.042). Incidence of pancreatic fistula and arrosive bleeding was decreased insignificantly due to small number of observations.Assessment of significant risk factors and use of medical prevention are available to decrease likelihood of postoperative pancreatitis.


PubMed | Vishnevsky Institute of Surgery
Type: Comparative Study | Journal: European journal of radiology | Year: 2013

To evaluate the effect of hybrid iterative reconstruction on qualitative and quantitative parameters at low dose carotid CTA.44 consecutive patients were enrolled in the study. First group (n=22) was examined under 120 kV 250 mAs, second group (n = 22) - 100 kV 250 mAs. CT images in first group were reconstructed only with the filtered back projection (FBP). CT data in second group were reconstructed both with FBP and three levels of hybrid iterative reconstruction algorithm (iDose). We compared quantitative and qualitative parameters among the two groups and among four different reconstructions in second group.Effective dose in 120 kV and 100 kV group was 7.18 1.19 mSv and 4.14 1.03 mSv, respectively (p<0.0001). Mean arterial attenuation was about 25% higher in second group (236.5 46 HU vs. 302.6 32.7 HU; p<0.0001). Image noise at the level of humeral belt was 32.5 12.5 in 100 kV group and 26.3 13.3 in 120 kV (p = 0.115). Average noise decreased when using 3 levels of iDose up to 23.6 6.4, 17.7 5.6 and 13.7 5.1, respectively (p = 0.00001). Mean CNR increased to 10.38 3.87, 14.5 5.21 and 18.32 8.61, respectively (p<0.05). The presence of artifacts on the level of humeral belt in 120 kV group was 14%, in 100 kV - 41% (p = 0.002). The difference in visual scores between standard and low-dose protocol was significant (p = 0.008). When applying iterative reconstruction the frequency of streak artifacts decreased dramatically (p<0.0001). Most studies had excellent quality with no artifacts while using highest level of iDose.According to the results of our study low dose CT angiography using hybrid iterative reconstruction may provide sufficient image quality and allows for significant reduction of patient dose.

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