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Pacific Medical Journal

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No 1 (2018)
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REVIEWS

5-10 489
Abstract
This literature review describes the main stages of formation a new method named transanal total mesorectal excision, his benefits and disadvantages. Based on the world literature data, we can say that transanal total mesorectal excision is a new promising method of the surgical treatment of rectal cancer allows increasing the quality of mesorectal excision. It is very important for the oncologic safety of surgery. However further studies are needed to establish the role of transanal total mesorectal excision in the surgical treatment of rectal cancer.
11-15 327
Abstract
The role of gene polymorphism in the development of destructive forms of acute pancreatitis was analyzed. Based on the review of literature data, it has been established that the most promising for the prevention of destructive pancreatitis is the determination of mutations in the secretory trypsin inhibitor gene SP1NK1. The literature data indicate that the mutations of the cationic trypsinogen gene and the gene of the transmembrane regulatory protein of cystic fibrosis can only be important in conjunction with other markers. Patients with combined mutations have the highest risk of developing destructive pancreatitis.

ORIGINAL RESEARCHES

15-18 448
Abstract
Objective. Aim is to evaluate the effectiveness of antibiotic therapy used in acute hematogenous osteomyelitis (AHO) in children. Methods. From 2013 to 2016 years 64 patients with AHO were treated in the Department of Purulent Surgery of the Stavropol Regional Clinical Hospital, Russia. The children were divided into two groups: 1st group received monotherapy (Daptomy-cin) with the subsequent transition to oral administration of Clindamycin; 2nd group received standard antibacterial therapy (combination of Ceftriaxone and Amikacin with the subsequent transition to Cefotaxime). Clinical indices, laboratory parameters (leukocytes, ESR, CRP), pain syndrome (FPS-R) were assessed. Results. The duration of antibacterial therapy in 1st group was 15.3±1.2 days. In 2nd group the duration of therapy was 22.1±2.8 days. Normalization of leukocytes and ESR in children from 1st group was on day 7, in contrast to group 2 where this index was normalized in 14 postoperative days. The long-lasting pain syndrome is associated with a large number of different injections in children of group 2, whereas in children of group 1, the pain syndrome was not on the 7th day after the operation. Conclusions. The use of modern treatment approaches, including Daptomycin monotherapy followed by step-wise antibacterial therapy, reduced the treatment time for children with AHO and improved their quality of life.
19-25 385
Abstract
Objective. The study objective is a retrospective comparative analysis of the surgical treatment results of patients with medial fractures of the femoral neck. Methods. We analyzed the surgical management of 655 patients aged 32-94 with medial fractures of the femoral neck. The total and single-pole hip replacements, the osteosynthesis of the femoral neck with cannulated screws, with the system DHS, and the Targon were carried out. Results. There was no significant difference in the number of somatic and wound complications in patients after total and subtotal arthroplasty. Also, there were no specific complications associated with the use of bone cement. After total and subtotal arthroplasty, the mortality during the year was 0.6 and 3.6 %, respectively. Conclusions. Other things being equal, the choice of the surgical treatment method of medial femoral neck fractures should be based on the nature of the damage, the quality of the bone, the age of the patient, its somatic status, mental state and the expected prognosis of life expectancy. Osteosynthesis can be successful in elderly patients with type I and II hip fractures in the Garden. In young people the indications can be expanded in the case of surgery in the first 24-48 hours after the injury. In other situations, osteosynthesis can only be regarded as a palliative operation.
25-29 497
Abstract
Objective. In relation to the development of endoscopic surgery there emerged a need to study and improve the technique of laparoscopic decompression of the celiac trunk, as well as the determination of indications and contraindications to this operation. Methods. There were assessed the results of laparoscopic decompression of the celiac trunk in 21 patients. To confirm a diagnosis we used a method of duplex scanning and data of computed angiography. Results. Complications in intraoperative as well as in early postoperative period were not registered. According to the duplex scanning the moderate amount of narrowing of the celiac trunk before the surgery was 72.5 %, in early postoperative period it was 42.5 %o, and in a separate period it was 33 %o. Conclusions. Laparoscopic decompression of the celiac trunk requires high qualification of a surgeon being an effective treatment method for a group of carefully selected patients, and the performance of laparoscopic ultrasound investigation becomes an integral part of an operation both for topical diagnostics of arterial structures and for assessment the adequacy of the intervention.
30-33 288
Abstract
Objective. We analyzed the cytological picture of the vagina and its relation to morphologic changes of the endometrium in women with vegetative-vascular manifestations of climacteric syndrome. Methods. 140 women aged 45-52 y.o. were examined: 40 conditionally healthy with a normal rhythm of menstruation, 60 women with vegetative-vascular manifestations of climacteric syndrome with the episodes of menstrual disorders, and 40 women with the climacteric syndrome without menstruation during a year. In the blood serum, the content of follicle-stimulating (FSH) and luteinizing (LH) hormones as well as estradiol, progesterone and testosterone was determined. Colpositologic examination, needle-biopsy and scrapings of the endometrium were performed. Results. It was found that the type of vaginal smear was influenced not only by the level of the hormones of the ovaries, but by the ratio of LH and FSH. This is most clearly seen in menstruating women with climacteric syndrome. Attention was drawn to the connection of non-atypical endometrial hyperplasia in healthy women and the proliferative type of vaginal smear. Conclusions. With the help of the colpocytological study in women with climacteric syndrome, pathological proliferation of the vaginal epithelium can be revealed, which can indirectly indicate endometrial hyperplasia. The most informative in the sense of the onset of proliferative processes in the female genital organs can be called a cytological picture of the vagina, the level of estrogens and the ratio of gonadotropic hormones - LH / FSH.
34-37 367
Abstract
Objective. To improve the results of surgical treatment of occlusal lesions of subclavian arteries with spinal-subclavian steal syndrome and combined stenosis of carotid arteries. Methods. 90 patients aged 37-86 years (69 men and 21 women) with a lesion of the first segment of the subclavian arteries were examined in the department of vascular surgery of the Amur Regional Clinical Hospital, from 2010 to 2016. Lesion of the left subclavian artery was detected in 79 (87.8 %), and of the right one - in 11 (12.2 %) patients. Syndrome of vertebral-subclavian stealing was diagnosed in 87 cases (96.6 %), 42 patients (46.6 %) had concomitant stenosis of the internal carotid artery. Results. A total of 72 patients were operated, including 34 patients with concomitant stenosis of the carotid arteries. Depending on the strategy of surgical treatment, all patients are divided into two groups with comparable clinical characteristics. The first included 28 people surgical treatment was performed based on the developed algorithm, the second (control) group included 44 people. In 52 cases stenting of the subclavian artery was performed, in 20 - carotid-subclavian shunting, and in 8 one-stage ipsilateral carotid endarterectomy and carotid-subclavian shunting were performed. Preliminary carotid endarterectomy was performed in 11 patients, carotid endarterectomy was performed in the second stage in 15 patients. The frequency of perfusion complications was lower in the main group. Conclusions. The developed algorithm of revascularization with occlusive lesion of subclavian arteries and combined stenosis of carotid arteries allows to reduce the number of perfusion complications.
38-40 290
Abstract
Objective. The high effectiveness of endoscopic treatment methods of colorectal cancer has been proven to be superior to conventional access. Methods. The experience of treatment of 299 patients with colorectal cancer at the Institute of Surgery of PSMU for 20142017 is summarized. The results of 224 minimally invasive laparoscopic interventions are presented. Results. 26 complications were noted in the postoperative period: necrosis of the colon (1), anastomosis failure (7), bleeding (2), stricture of anastomosis (5), parostomic dermatitis (3), parastomatic hernia (3). Conclusions. Laparoscopic access is most effective in tumors up to 3 cm in the maximum measurement in patients with a body mass index of less than 30. Laparoscopically assisted interventions have advantages in patients with tumors greater than 3 cm in the largest measurement and in locally occluded formations. The use of a robotic complex is most justified in resections of the rectum.
41-43 339
Abstract
Objective. Preoperative biopsy before endoscopic resection of epithelial colorectal tumors is recommended. Some papers show variance between biopsy results and total morphological examination. The aim of the study was to evaluate sensitivity, specificity and diagnostic accuracy of routine preoperative biopsy and also positive and negative predictive value. Methods. 86 patients with 101 epithelial colorectal tumors were included. Biopsy was taken from any tumors before endoscopic resection. The results of morphological examination for biopsy specimens and resected tumors have been analyzed and compared Results. The average polyp size was 2,3 сm. Total match was in 43 cases (42.6 %). In 17.8 % of cases dysplasia grade was misdiagnosed, in 88 % was underestimated by biopsy. 27 % of tumors were misdiagnosed serrated adenomas. 14 tumors were adenocarcinomas, misdiagnosed by biopsy. Sensitivity, specificity and diagnostic accuracy for serrated adenomas diagnosis was 30, 98.3, and 71.2 %; for dysplasia staging - 70.3, 95.7, and 82,1 %; for early cancer diagnosis - 16.6, 100, and 85,1 % respectively. Conclusions. The data shows that preoperative biopsy has a low level of sensitivity, specificity and diagnostic accuracy for some cases.
44-47 337
Abstract
Objective. The problem of reducing mobility and mortality from breast cancer (BC) is continuing to be an acute issue of women's health. The possibility of early diagnosis is particularly relevant for citizens of the Primorsky Krai where about a third of primary patients are identified in late stage. However, there is no information on the regional spectra of BC risk-associated mutations. Methods. We examined 107 women with breast cancer, aged between 23 and 79 years, without and with a family history. The search for the mutations was performed on six regions of the BRCA1 gene by polymerase chain reaction and sequencing. Results. We identified five risk-associated polymorphisms: insertion of 5382insC (rs80357906), missenses of Q356R (rs1799950) and C61G (T300G, rs28897672), deletions 3819del5 (rs80357609) and 4154delA (rs80357711). Conclusions. The results of the study show that two mutations predominate in the spectrum of high-risk BRCA1 mutations among breast cancer patients such as 5382insC (46 %) and Q356R (42 %)
47-51 310
Abstract
Objective. Stdy objective is to assess effectiveness of the breast cancer diagnostic in Kabarovsk territory. Methods. Statistical analysis of morbidity was carried out, and prognosis was made based on the data of official medical documentation of Regional Clinical Centre of Oncology, Khabarovsk. Results. The level of regional morbidity corresponded to the average of Russian one. During 2003-2015 the absolute number of patients increased by 22.9 %, this diagnosis was determined to 6548 patients, and the level of case detection during the planned preventive examination increased from 13.4 % in 2003 to 36.9 % in 2015. About 1/3 of patients has the cancer of III-IV stage. Conclusions. The steady trend of increasing the incidence of breast cancer over the period from 2003 to 2015, the presence of unresolved problems within the prognosis, gives grounds to expect an increase in the incidence of breast cancer in the foreseeable time period, which is explained by the integrating effect of a complex of various factors. There is a trend towards an increase in the frequency of diagnosis of breast cancer at the I-II stage, but progress here is rather slow due to the lack of a mammo-graphic screening system in the Khabarovsk territory.
51-56 346
Abstract
Objective. Explore and analyze the probability of occurrence of pathological fractures with degenerative-dystrophic diseases of the skeleton, determine the impact of new original designs of implants and implants with loads in the area of proximal femur, assess the strength characteristics of bone-implant prophylactic used for proximal femur using the original designs of implants and implants. Methods. Develop and propose original designs reinforcement implants and implants to which the patents of the Russian Federation and the method of their application. In the bone were virtually introduced original designs of implants in 8 different versions, mathematical modeling, using models of reinforced systems bone-implant proximal femur by laser scanning. Implemented testing various options post-mortem samples stiffening bones and artificial bones mannequin to complete destruction of bone-implant system. Results. Through mathematical modeling established that when loaded on proximal femur, causing distortion in the cranial and caudal cervical parts voltage increases, which results in a fracture at critical points. When this line fracture has direction from the periphery, where there is the maximum voltage inside. Bench test results indicate that the horizontal load on the head along the axis of the diaphysis of the femur neck reinforced strength increased to 93 %, and for vertical up to 152 % depending on the combinations of input implants. Conclusions. Implants when used for proximal femur should be located closer to longer-term cortical layer and further away from the central axis of the femur: the voltage of the external load strain partially redistributed in item reinforcement. All options studied reinforcement increases the strength of bone-implant system as when vertical and horizontal load, with the best effect demonstrated system with the greatest area of contact (screw-corkscrew).

METHODS

57-59 395
Abstract
Objective. The study objective is a comparative assessment of the effectiveness of the fine-needle aspiration biopsy and excisional biopsy under the control of the electronic radial echoendoscope in pancreas disorders. Methods. We analyzed the results of the diagnostics of 30 pancreas tumors in 28 patients aged 29-76 after the fine-needle aspiration biopsy and core needle biopsy. Results. According the results of postsurgical morphological examination, and according to catamnesis data, the diagnostics accuracy (95 % confidence interval) after the aspiration biopsy fell within the range of 84-100 %o, and after the excisional biopsy it was within the range of 38.2-75.2 %o. Conclusions. The obtained data confirmed the high sensibility and the singularity of fine-needle aspiration pancreas biopsy. Its advantage is a high safety caused by the low risk of complications. The method of getting the biopsy material using the fine-needle forceps under the control of the electronic radial echoendoscope has lower sensibility and its effectiveness requires further analysis
59-61 312
Abstract
From July 2014 to July 2017, 498 surgical interventions for the heart were performed at the Cardiosurgery and Vascular Surgery Center of the MC of the FEFU using transsternal access. Infectious complications associated with the sternotoma wound were recorded in 6 (1.2 %), including sternomediastinitis - in 4 people (0.8 %o) over 60 years old. Two patients with sternomediastinitis were treated with the classical open method and two patients with vacuum aspiration in a constant mode with a pressure of -70 mm Hg. Art. With vacuum therapy, the normalization of leukocyte and C-reactive protein levels in the blood occurred on average in 10 days, and in patients treated with the open method, these indicators reached the norm on the 17th and 20th days, respectively. The complete sanitation of the wound (negative result of bacterial swab test) with vacuum aspiration was recorded on the 15th, and with the classical method of treatment -on the 20th day. With vacuum aspiration, the average length of stay in the hospital was 60, and with open treatment, 75 days.
62-63 353
Abstract
The loss of tonus and the loss of elastic properties of the diaphragm leads to a disruption in the function of respiration, the cardiovascular system and the gastrointestinal tract. During the period from 2013 to 2015, eight plasmas of the diaphragm were performed regarding its relaxation: three patients underwent surgical treatment through thoracotomy, five with thoracoscopic access. Duplication plastic of the diaphragm was performed using the Surgipro synthetic grid endoprosthesis. The obtained results testify the effectiveness of the thoracoscopic access for large thoracic operations of a high degree of complexity.
64-66 372
Abstract
The problems of morbidity and surgical treatment of kidney cancer with a low level of introduction of nephronsparing surgery (NSS). To objectify the parameters of the risk of complications and safety of the NSS, resectability of the tumor in kidney cancer, the use of the R.E.N.A.L. nephrometry scoring system. The reasons for the inadequate use of NSS in the case of the analysis of clinical cases, unjustified nephrectomy, NSS of a moderate level of complications were studied. The measures on perfection of nephron-sparing surgery treatment of patients with kidney cancer, improvement of oncological and functional results of treatment of localized kidney cancer are suggested.
67-70 351
Abstract
Objective. To assess the effect of combined surgical treatment with the simultaneous use of histochrom along the sinus trabeculectomy and at the early post-surgery period within the magnetic therapy in patients with primary open-angle glaucoma. Methods. The study includes 64 patients aged 38-87 y.o. (50 men and 14 women) with primary open-angle glaucoma in the developed stage (27 cases), and in the advanced stage (37 cases), with moderate or high eye pressure. The 1st (initial) group included 36 people who underwent the combined treatment: the sinus trabeculectomy with the use of the medicine 'Histochrom' within the magnetic therapy during the surgery and the early post-surgery period. The 2nd (control) group included 28 people who underwent the sinus trabeculectomy routinely. Results. There were noted in the initial group: the increase of maximal velocity of the blood flow in the ophthalmic artery after 3 and 6 months of care maintaining the normal value of the resistance index; statistically significant improvement in the minimal and maximal blood flow velocity in the posterior short ciliary arteries at all stages of care with a maximum value at 6 months and normalization of the resistance index in the month of. Conclusions. The comparative analysis showed the statistically significant increase of the maximal velocity of the blood flow in the ophthalmic artery and in posterior short ciliary arteries in the initial group compared with the control one.
70-71 285
Abstract
Since 2014, 143 laparoscopic operations for kidney tumors in patients aged 31 to 82 (79 men and 64 women) have been performed at the FEFU Medical Center. 50 resections of the kidneys, 89 nephrodrenalectomies with lymphodissection and 4 nephrenelectomies with resection of the bladder were performed. 108 interventions are performed laparoscopically with manual assistance, the rest was performed laparoscopically. Four postoperative complications (intra-abdominal hemorrhage, transient hypocorticism, severe renal failure and suppuration of the operating wound) and one fatal outcome due to acute gastric ulcer with massive blood loss were recorded.
72-74 318
Abstract
Objective. In case of traumatic spleen injury, splenectomy is often performed. Authors in such a situation tried to adhere to the organ-preserving and conservative approach presenting in this work an algorithm for managing such patients. Methods. Data on 36 cases of spleen damage with closed abdominal trauma in children 2-14 years old, who were admitted to the Regional Children's Clinical Hospital No. 1 in 2008-2017 are presented. Results. The most informative and constant laboratory index of spleen damage with closed abdominal injury was leukocytosis registered in 94.3 % of cases. Conservative treatment was started by 29 patients and was successful in 28 cases, laparoscopy was performed for 5 children, and there were no conversions in this group. Three laparotomies were performed: resection of the superior pole of the spleen and two splenectomies (one with autotransplantation of the splenic tissue into the large omentum). Mortality was 2.8 % - a child died with organ rupture following the acute leucosis. Conclusions. Conservative treatment in case of hemodynamic stability in patients with spleen injuries should be a method of choice. Failures of conservative treatment do not lead to mortality increase. In case of laparotomy the preference should be given to organ-saving methods - resection of an organ and splenography.
75-78 352
Abstract
Objective. The aim of the study was to determine the location of laser thermotherapy in the treatment of infant hemangiomas of the head and neck, and to find the optimal treatment technology for this disease. Methods. We observed 1466 children aged 9 days to 6 years with infant hemangiomas of the head and neck. An infrared diode laser with a wavelength of 0.97 μm, propranolol with an individual dose selection and a combination of these methods were used during the treatment. Local hemodynamics of infant hemangiomas was studied by ultrasound, as well as using thermal imaging, optical spectroscopy and percutaneous measurement of oxygen tension. Results. With intensive local hemodynamics monotherapy with in infant hemangiomas was insufficient. Combination of propranolol and laser thermotherapy was more effective. Conclusions. Combined therapy of infant hemangiomas allowed a two-fold reduction in the duration of use of propranolol and a three-fold reduction in the frequency of repeated sessions of laser thermotherapy. Overall, excellent and good results were obtained in 97.5 % of patients. Satisfactory results with the formation of cosmetic defects requiring further therapy were caused by delayed treatment after the already occurring complications, especially ulcers.

PUBLIC HEALTH ORGANIZATION

78-84 333
Abstract
Objective. Over the past decades, the country has not improved the basic indicators of medical care for cancer patients, which determines the relevance of the problem and the appropriateness of a multifaceted approach to its solution, with a comprehensive analysis of a number of information bases, including data on the territorial and temporal features of oncological pathology that are the basis for studying the epidemiology of malignant neoplasms of the large intestine (colon) in a particular area. The purpose of this study was a scientific assessment of the main indicators of morbidity and mortality from colon cancer in a single region of the Russian Federation. Methods. In the process of work, morbidity and mortality indicators, reporting forms of statistical recording of cancer patients and reglamuting documents of higher organizations were used. The data of twenty-year observations on the dynamics of changes in the numerical values of the parameters of the studied pathology were processed. Results. The basic indicators of provision of medical care to the population with cancer of the colon in the Amur region, where there is a constant increase of morbidity and mortality from this disease. It is revealed that maximum number of cases falls in older age groups. In dynamics tracked the number of patients with the initial manifestations of the disease, with a slight decrease in their advanced stages of the disease. Increased activity of identifying patients with a significant reduction in mortality in the first year since diagnosis. Against the background of a number of positive aspects in the Oncology service noted a significant increase in mortality. Indicate the quality of the service activities the index of reliability of the accounting of this category of patients that is traditionally comparable to other regions of the country. The results of the study recommended by the authors for use in the practice of Oncology service region in the development priorities targeted health, social and economic programs. Conclusions. Despite the great work of scientific institutions and bodies of practical health care of the Amur region, aimed at reducing morbidity and mortality from malignant neoplasms, their level is still high with a trend annual increase of statistical indicators.
85-88 345
Abstract
The growing intensity of modern transport communications entails an increase in the severity of multiple and combined injuries in road traffic accidents. The combined skeletal deteriorations during a road traffic accident are accompanied by a number of specific complications, high disability and lethality. The most significant medical and social problems in the system of medical management here are explained by errors in the diagnosis in the acute period of trauma. The severity of the general condition of the patient often conceals the symptoms of local injuries, which entails untimely surgical treatment and rehabilitation. A range of early and late complications in victims of road accidents caused by an underestimation of soft tissue injuries and a violation of continuity in the links of the treatment process: emergency medical care - a reception department - resuscitation - a hospital - a polyclinic - a rehabilitation center. The modern level of the society development predetermined the effectiveness of instruments of medical and social adaptation of patients with polytrauma. Involvement of the service of emergency commissioners allows optimizing medical and psychological rehabilitation and social-welfare reintegration of victims in road traffic accidents.
89-92 333
Abstract
Objective. Nowadays in conditions of independent sailing the use of high-tech methods to render emergency medical care is sporadic. Methods. The treatment of patients with acute surgical diseases and abdominal injuries from crews of surface ships and submarines (n=236) treated on board (236 people) and in a coastal hospital (2,510 people) was analyzed. Results. The most frequent pathology in conditions of independent sailing was acute appendicitis. Moreover, in more than 50 % of cases on ships were carried out "vain" appendectomy for a simple appendicitis. In the hospital, the proportion of such interventions was 22 %. 47.1 % of patients escaped the "vain" appendectomy using laparoscopy. Conclusions. The main reason for "vain" appendectomy is the lack of the necessary competencies for a specialist in performing a diagnostic search in an extreme situation. Obligatory training of surgeons should be considered as a method of laparoscopy, taking into account various variants of its application in combination with various variants of anesthesia.
93-94 377
Abstract
The Russian Society of Surgeons suggests enhancing the surgical care in territorial entities of Russia, in cities and regions with low population density and with the absence of necessary number of doctors and equipment - and delivering surgical care of the first level in outpatient clinics and day inpatient facilities. However it is necessary to keep areas and part of surgical staff and use them as a day inpatient facility or as centers of outpatient surgery. In outpatient and day inpatient facility conditions it is necessary to perform operations and surgical treatment that do not require twenty-four-hour care and treatment. Having the indications, patients should be referred to a medical organization that provides specialized surgical care in intermunicipal surgical hospitals. Surgical care to general population of the second level should be provided in medical organizations of specialized surgical care. The surgical treatment of the third level should be provided in medical organizations delivering hightech surgical care.

PRACTICE OBSERVATIONS

95-96 310
Abstract
The observation of concomitant acute phlegmonous appendicitis and invagination of Meckel's diverticulum with an ectopic pancreas and a thin-intestinal invagination in a boy of 12 years is described. Authors suppose that this case shows the necessity of investigation of the ileum in appendectomy even in the presence of undoubted changes in the appendix.
96-98 300
Abstract
The case study of the massive thromboembolism of the branches of pulmonary artery in a woman aged 31 y.o. the next day after the cesarean section in gestational age of 36-37 weeks. Despite the high risk of the fatal case the conservative treatment effect was achieved. The informativity of multispiral computed tomography in the diagnosis of pulmonary embolism is emphasized.

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ISSN 1609-1175 (Print)