INTRODUCTION. Splenic injuries in abdominal trauma is one of the most common injuries in abdominal surgery. The damage to this organ occurs in 22.3–30%. This is the second most common injury among damages to parenchymal organs.

AIM OF STUDY. To study the immediate results of treatment and to determine the factors that influence the choice of tactics for open injuries of the spleen.

MATERIALS AND METHODS. The study included 75 patients with abdominal wound and damaged spleen. In 54 (72%) patients, stab and slash wounds were revealed, in 21 (28%) patients there were gunshot wounds (bullet or fragment). All patients were divided into two groups: Group A included 44 (58.6%) of patients, where the time gap between the time of injury and the surgery did not exceed 1 hour, and Group B, which included 31 (41.3 %) of cases, where the time gap between the moment of injury and surgical intervention exceeded 1 hour.

RESULTS. As a result of the study, it was found that organ-preserving operations for open injuries of the spleen were possible in 33.3% of cases. The choice of surgical tactics for injuries of this organ depended on the type of damage to the organ: in case of gunshot wounds of the spleen, the organ-preserving operation was not possible at all, but this operation was performed for stab/slash wounds in 33.3% of cases. The development of complications and deaths directly depended on the journey time: in the case of that time gap up to one hour, complications developed in 27.3% of cases, and the mortality rate was 15.9%. If the time of journey exceeded 1 hour, the number of complications increased to 77.4%, and mortality rate grew up to 51.6%. According to our data, the number of complications and deaths depended more on the time of admission than on the type of operation performed. In addition, it is necessary to note one more factor that affected the lethal outcome and this was the type of the wound. Therefore, as a result of the study, it was found that mortality in the group with gunshot wounds amounted to 17 out of 21 (80.95%), and for stab/slash wounds it was 6 out of 54 (11.1%). It was found that the journey time and the type of operation performed operation affected the level of D-dimer in patients with splenic injuries. So, the level of D-dimer was 566±0.3 ng/ml in the group of the wounded, delivered within an hour after trauma, and 643±0.2 ng/ml in the group where the journey time exceeded an hour.

CONCLUSIONS. 1. Performing organ-preserving operations with open injuries of the spleen is possible in 46.3% of cases and only for stab and slash wounds. Organ-preserving operations cannot be performed for gunshot wounds.

2. The number of complications and deaths is more dependent on the journey time to the hospital than on the type of operation performed. If a patient is admitted within an hour after trauma, the complication rate is 27.3%, and mortality rate is 15.9%. If the journey time exceeds one hour, the complication rate is 77.4% and the mortality rate is 51.6%.

3. In patients splenic inguries, the journey time and the type of the operation performed affect the level of the D-dimer, which may affect the course of the immediate postoperative period.

ABSTRACT. Laparoscopic simultaneous surgery (LSS) in patients with multisystem abdominal organs lesion is accompanied by ports’ re-installation for subsequent surgical intervention. Preserved trocar wounds (PTWs) pass carbon dioxide from the abdominal cavity, increasing its consumption and causing depressurization of the carboxyperitoneum. The incidence of extraperitoneal insufflation during laparoscopy varies from 0.43 to 2% (I.V. Vartanova et al., 2016). The presence of many methods of sealing PTWs indicates their inefficiency.

AIM OF STUDY. To develop an easy-to-use, more reliable and effective way of sealing PTWs.

RESULTS. As a result, a comparative evaluation of known methods of sealing PTWs, we have developed an easy-to-use, more reliable and effective way of sealing PTWs «Method for sealing punctures of the abdominal wall after removing the trocar during a laparoscopic surgery» (patent RF for the invention № 2621121).

DISCUSSION. This method was performed in 55 patients, in all cases it provided reliable PTWs tightness, allowed maintaining stable carboxyperitoneum during laparoscopic interventions, without increasing carbon dioxide consumption, which reduced the cost of LSS and prevented the development of both intraand postoperative complications. The uniqueness of this method is that PTW is sealed from the side of the abdominal cavity, preventing carbon dioxide from penetrating into either the preperitoneal or subcutaneous tissue.

CONCLUSION. An increase in the number of patients with combined surgical pathology necessitates the use of the developed method for sealing punctures when moving trocars and neutralizing sub- and postoperative complications. In addition, this method allows to reduce carbon dioxide consumption.

Abstract Steadily growing flow of patients and a constant increase in the requirements for the quality of medical care more and more often lead to the need to reorganize the work of various departments of medical hospitals. However, such actions are very costly and do not always give the desired result. One of the effective methods of preliminary planning, as well as predicting the results of proposed transformations, is the method of simulation modeling of medical and diagnostic processes based on a specially created model. In this article we describe the original data on the operation of the admission and diagnostics department (ADD) of N.V. Sklifosovsky Institute, which served as one of the grounds for its reorganization, as well as the creation of a simulation model of ADD, reconstructed on the principles of a patient-oriented approach. We considered all stages of the model construction in detail and thereby justified its structure and the qualitative and quantitative parameters which formed the basis therein. The temporal and numerical results of modeling the flow of patients through the ADD, as well as the flow of changes in the parameters of the model to the throughput of the ADD are presented. Thus, specific examples show how problem areas of the existing diagnostic and treatment process can be identified, and what options are available for its optimization and modernization. In addition, suggestions are made for further improvement of the created model and options for its use, for example, for the study of various contingencies and emergencies, mass revenues, etc.

RELEVANCE. The dependency results of draining operations on the efficcacy of drainig of ductal system of the pancreas and adequate outflow of the pancreatic juce through anastomosis are undoubtful, therefore the development of new techniques of longitudinal pancreatojejunostomy (LPJ) extending area of anastomosis is an actual challenge.

AIM OF STUDY. To compare the immediate and long-term results of longitudinal pancreatojejunostomy with the expansion of the area of anastomosis in patients with chronic pancreatitis.

MATERIAL AND METHODS. We analysed immediate and long-term results of LPJ in 58 patients with chronic pancreatitis with impaired patency of the major pancreatic duct (MPD) without the head enlargement.

RESULTS. All patients were divided into two groups: comparison group ( n=26, operated up to 2008 ) and main group (n=32, operated stumps during the MPD diastasis and posterior pancreatic surface (n=3) into anastomosis, with resection of the anterior pancreatic surface in the form of triangular fragments (n=11), with circulation of the small intestine loop during the recovery phase (n=19). The original LPJ in the study group of patients did not lengthened the surgery (160 [135, 185]) and intraoperative blood loss (265 [175, 340]). In the main group of patients there was no postoperative complications and fatal outcomes, but the average duration postoperative hospital treatment (18 [16; 20.5]) exceeded some data of foreign and domestic authors. Pain within 5 years after surgery in patients of the main group exceeded 26.6% and the appearance of diarrheal syndrome with dependance from reception of enzyme preparations was twice lower than in patients og the comparison group. According to questionnaire EORTC QLQ-C30, 5 years after surgery statistically significant differences between groups in terms of scales CF, NV, DY (p=0.03, 0.02, 0.006 respectively), indicating the advantage of intervention performed in the mail group.

CONCLUSIONS. 1. An indication for longitudinal pancreatojejunostomy in chronic pancreatitis is impaired patency of the main pancreatic duct in the absence of an increase and inflammatory mass in the pancreatic head.

2. The width of the main pancreatic duct is less than 5 mm and the presence of diastasis between its proximal and distal stumps with the posterior surface of the pancreas preserved, is not a reason for refusing longitudinal pancreatic jujunostomy in favor of the resection method.

3. The expansion of pancreatojejunal anastomosis when performing longitudinal pancreatojejunostomy can improve the immediate and longterm results of surgical treatment for chronic pancreatitis.

ABSTRACT. The diagnostic standard for airway burn in inhalation trauma is bronchoscopy. Determining the severity of a burn of the respiratory tract within first 24 hours is difficult due to the multiple foci of fixed soot, therefore, this procedure is possible only after its removal. Optimization of the standard method of sanitation bronchoscopy in case of airway burn by removing soot with endoscopic forceps and brushes significantly increase the efficacy of primary endoscopic diagnosis, which amounts to 74.9%. The most common mistakes in diagnosing the severity of mucosal damage are associated with a burn of the 1st degree.

THE RELEVANCE is determined by the significant frequency of iatrogenic injuries of the radial nerve during internal osteosynthesis of the humerus, long-lasting functional disorders, a large number of unsatisfactory results, as well as the lack of a unified approach to diagnosis and treatment.

MATERIAL AND METHODS. The causes of iatrogenic damage to the radial nerve were studied in 22 patients who underwent internal fixation during fractures of the humeral diaphysis. The ultrasound examination was used to visualize the radial nerve. In 13 patients (59.1%), a pathogenetic treatment was used, including medication, physical and mechanical therapy.

RESULTS AND DISCUSSION. In plate osteosynthesis, a greater number of iatrogenic damage to the radial nerve was observed than during osteosynthesis with screws. The ultrasound method had high diagnostic values to determine the continuity of the nerve trunk and identify conflicts with solid structures. The use of pathogenetic therapy of neuropathy led to a more rapid clinical recovery of limb function.

CONCLUSION. To prevent iatrogenic injuries and avoid gross manipulations, the access with sufficient visualization of the radial nerve is necessary in plate osteosynthesis and distal blocking outside the projection of the radial nerve is necessary in intramedullary osteosynthesis. Indications for early revision after iatrogenic damage are neurotmesis and a nerve conflict with bone fragments or an implant.

MATERIALS AND METHODS. We observed 164 patients from 2013 to 2019 (mean age 39.8 ± 5.1 years) who underwent anatomical antegrade ACLR ВТВ autograft . Group 1 (43 people, 31.1%) and Group 2 (48 patients, 29.3%) included patients with isolated medial GA of 2-3 degree and/or varus deformity of at least 5º. Group 3 (73 people or 44.5%) included patients with normal articular cartilage and the correct axis of the limb. In Group 1, ACLR was supplemented with an “open wedge” HVTO. The assessment was carried out according to Lysholm Knee Scoring Scale, 2000 IKDC, KOOS.

RESULTS. The simultaneous performance of HVTO and ACLR shows good clinical and radiological results in 93% in the first year, and three years after surgery keeps it in 88.4%. The results of treatment of patients of Group 1 turned out to be significantly better in comparison with Group 2 (p<0.01). In Group 1, the anteroposterior and rotational hypermobility of the knee joint was 16.3%, less commonly we observed pain, synovitis, atrophy of the muscles of the thigh and contracture (p <0.01), some dysfunctions (C according 2000 IKDC scale) were determined in 11.6% (p<0.05), and significant impairment of the knee joint function (D according to 2000 IKDC scale) were not observed (p<0.001). In the first 5 years after surgery, a much larger number of patients of the 1st group were able to fully return to their work, domestic and sports activities, compared with Group 2 (p<0.05).

CONCLUSION. The combined ACLR and HVTO allow reliable technology in the treatment of anterior instability in patients with GA (p< 0.05%). This approach is effective in young active middle-aged patients, with anterior instability of the knee joint and varus GA or prerequisites for its development, as well as with revision ACLR, posterior tibial plateau tilt of more than 12º. Performing HVTO simultaneously with ACLR is not practical for patients with valgus deviation of the lower leg, failure of the posterolateral capsular ligamentous complex, or changes in the external joint.

ABSTRACT. Shoulder dislocations are among the most common injuries and occupy the first place among all dislocations of limbs. Currently, the conventional approach to the treatment and diagnosis of this pathology is preserved. The closed reduction is performed under local anesthesia, the limb is immobilized with a bandage sling. There is no single opinion on the period of immobilization. Common indications for surgical treatment are unreduced, habitual and open shoulder dislocations. The preference is given to operations with the restoration of anatomy, while at the end of the last century, techniques were often used to limit the amplitude of movements in the shoulder joint. Currently unphysiological reconstruction methods are not favourable, since they violate the normal biomechanics of the shoulder joint and do not directly affect the pathological substrate of damage. Outcomes after arthroscopic options for operations are not inferior to those after open interventions. This article provides an overview of clinical and radiological methods for examining patients and treatment options for this pathology.

ABSTRACT. An increase in the number of patients with severe brain damage of various etiologies determines the need to improve neuroprotection technologies. The review is devoted to modern views on the mechanisms of brain protection, as well as the basic processes underlying damage to neurons. The article discusses the results of the most important experimental studies in this area using inert xenon gas. The authors analyzed a number of works highlighting neurotective properties of the xenon inhalation anesthetic in studies performed in vitro and in vivo. The main mechanisms of neuronal death depending on the type of damage are shown, the points of application of the protective effect of xenon on the brain and the prospects for further research in this area are demonstrated in the article.

ABSTRACT. Defining molecules with high prognostic value for predicting the course and outcomes of life-threatening sepsis, severe injuries, vascular accidents remains an urgent problem in emergency medicine. One of the promising candidate biomarkers of emergency states and critical illness is the content of extracellular DNA (exDNA) in blood plasma. The purpose of this review is to identify the prospects for the introduction of cfDNA in clinical medicine and the severities arose along this way. The levels and altered dynamics of the concentration of circulating DNA fragments, including the organ-specific fraction of exDNA seem informative today for assessing the degree of damage to the organ of interest, the probability of a complicated course and the prognosis of outcomes of emergency/critical illness in Intensive Care Unit (ICU) patients. Sources of exDNA circulating in the bloodstream may include the nuclei of dying cells from organs and tissues, damaged mitochondria, the pool of which should be remodeled with mitophagy, as well as microorganisms. Similarly to pathogen-associated molecules (PAMP) represented by fragments of bacterial and viral DNA, native DNA molecules associated with damage (DAMP) bind to toll-like receptors (TLR9) and intracellular DNA sensors (cGAS-STING, NLRP3), initiating the inflammatory processes in tissues and hemostatic disorders. These processes represent natural adaptive responses protecting against microbes, as well as disadaptation responses potentiating cell damage in organs. The increasing expression of genes encoding proinflammatory signaling pathways associated with NF-kB transcription factor and interferon-regulating factors (IRF), in turn, contribute to production of cytokines and other factors enhancing the stress-responses that alter the functional activity of cells in various organs. The available literature data suggest that the quantitative determining plasma exDNA, which serves as PAMP and DAMP to significantly contribute to pathogenesis of emergency states and critical illness, might aid in predicting the outcome and justifying the in-time personalization of treatment of emergency and post-emergency patients.

ABSTRACT. The attention of neurologists, neurosurgeons, intensive care physicians has been attracted recently by the new PICS (Post Intensive Care Syndrome) symptom complex (PIC) or PIC syndrome — Post Intensive Care Syndrome. One of the most severe options for PIT syndrome is critical illness polymyoneuropathy (CIP). Polyneuropathy (Critical illness polyneuropathies, or CIP) and myopathy (Critical illness myopathies, or CIM) are common complications of critical care. Several syndromes of muscle weakness are combined under the term «Intensive care unit-acquired weakness» or ICUAW. Respiratory neuropathy is a special case of PMCS, where respiratory failure is associated with damage to the neuromuscular apparatus of external respiration. The clinical consequence of respiratory neuropathy is an unsuccessful weaning from ventilator and a long stay of patients in ICU. This systematic review of the literature is an analysis of publications devoted to the main pathogenetic mechanisms of the development of CIP and respiratory neuropathy, diagnostic methods, new therapeutic approaches to the treatment of ICU patients with respiratory neuropathy. The special attention is given to the problem of acute muscle wasting, diagnosis and correction of proteinenergy metabolism disorders in patients with respiratory neuropathy.

Abstract. The article presents the organization of specialized medical care to patients with crush syndrome, acute liver and kidney failure (ALKF), and endotoxic shock, who suffered in the earthquake in Armenia, delivered via air ambulance to N.V. Sklifosovsky Research Institute. In the present report we defined characteristics of medical supplies, qualified and specialized treatment of patients with combined trauma.

ABSTRACT. We report a case of treatment of a 60-year-old female patient D. with a metastatic fracture of the upper and middle third of the left humerus. We made a radical removal of the metastasis, which was complicated by pathological fracture of the left humerus. To replace the removed tumor defect we performed metal and polymer endoprosthetic replacement of the left humeral diaphysis using a locking screw system and bone cement (methyl methacrylate). For accelerated recovery and rehabilitation we applied adaptogenic immunomodulator «Vitavis» (Altai elixir) and neutral anolyte (NA). After the removal of the tumor, postoperative wound was treated with neutral anolyte (NA). Dressings also contained neutral anolyte (NA). These drugs were successfully combined with postoperative basic therapy. The patient was discharged from the hospital on the 4th day after surgery. The functional results of the left upper limb are satisfactory.

ABSTRACT. A 53-year-old male patient had extensive traumatic damage to the right lower limb in a car accident that happened 17 years ago, which subsequently led to a large amputation at the hip level. Later, adduction contracture in the right hip joint with a complex regional pain syndrome developed. Due to the ineffectiveness of various methods of conservative treatment, it was decided to perform right-sided lumbar sympathectomy. Ten days later, the patient was discharged for outpatient treatment. The result of the operation was a complete relief of pain syndrome both in the early postoperative and in the long-term periods of time. Despite the large number of types of conservative therapy in modern clinical practice, none of them is perfect. Doctors decide to operate less often, trying to minimize the intervention. However, therapeutic effects are not always possible as monotherapy, often requiring additional treatments. Due to the wide development and distribution of medical products, doctors often neglect or forget about such a method as lumbar sympathectomy. Therefore, the problem of complex regional pain syndrome remains relevant today.

ABSTRACT. The rupture of the left ventricle free wall is one of the most dangerous complications of myocardial infarction. Due to the widespread availability of echocardiography method, the detection of this fatal complication and the number of lives saved after surgery grew. The survival of patients depends on early diagnosis, stabilization of the patient’s condition, promptness and tactics of surgical intervention. We report a case of successful closure of a rupture of the left ventricle free wall on the 15th day after myocardial infarction.

RELEVANCE. The increasing availability of invasive methods for assessing the coronary vessels contributes to the growth in the diagnosis of myocardial damage in intact coronary arteries. One of the least studied diseases that mimic the course of myocardial infarction is Takotsubo syndrome, which quite often remains undiagnosed in real clinical practice. The medical and economic significance of this disease is determined by the high risk of developing life-threatening complications and the need to provide emergency specialized medical care.

AIM OF STUDY. The paper presents an analytical review of scientific medical literature from the perspective of illustrating modern concepts of the most common risk factors, etiopathogenesis, diagnosis and treatment of Takotsubo syndrome. A clinical observation of a patient with verified secondary Takotsubo syndrome against a malignant neoplasm of the kidney is also presented.

CONCLUSIONS. For a detailed understanding of the potential mechanisms for the development of Takotsubo syndrome, determining the most informative methods for its diagnosis, developing effective strategies for providing medical care and criteria for long-term prognosis, further large-scale studies are needed. Raising the level of awareness of doctors about Takotsubo syndrome, in turn, will allow timely detection of this disease, which will improve the prognosis for patients and minimize the economic costs of treatment. The exclusion of the possibility of overdiagnosis will also help determine the true prevalence of this disease.

ABSTRACT. This article discusses the clinical cases of rare and difficult to diagnose brain damage — osmotic demyelinating syndrome (ODS). ODS is a lifethreatening condition, manifested by acute demyelination of the headbrain on the background of water-electrolyte disturbances,usually associated with fast management of hyponatremia. Within the framework of ODS, central pontine myelinolysis (CPM) and extra-pontine myelinolysis (EPM) are observed, which are accompanied by acute demyelination in the pons and white matter of the cerebral hemispheres, respectively. In 60%, CPM combine with EPM. The main reason for the development of ODS is a violation of water-electrolyte metabolism associated with alcohol abuse, chronic hepatic and/or renal failure, diabetes mellitus, Sheehan syndrome, polydipsia, condition after the removal of pituitary adenoma, bulimia, immunodeficiency syndrome. Today, the diagnosis of ODS is based on magnetic resonance imaging of the brain. The article indicates the main causes of the disease, clinical features, methods of diagnosis and treatment, as well as the outcomes of the disease.

AIM OF STUDY: to improve the results of surgical treatment of patients with endocrine ophthalmopathy complicated by optical neuropathy. For this, medial orbitotomy and decompression of the optic nerve were performed for a patient with endocrine ophthalmopathy, CAS<3, OD=18 mm, OS=23 mm and visual acuity OD=1.0 OS=0.2, using transorbital transconjunctival endoscopic access. The first step was a retro caruncular incision. After that, we defined an access to the medial wall of the orbit with its subsequent resection. Then, we performed ethmoidectomy and approach to the optic nerve canal. Upon completion of bone decompression, we opened periorbitis.

RESULTS. The postoperative period was uneventful. In the early postoperative period, regression of exophthalmos was observed OD=18 mm, OS=20 mm, improvement in visual acuity OD=1.0 OS=0.5 . No complications were recorded. A satisfactory result was obtained.

CONCLUSION. Transorbital endoscopic medial orbitotomy and optic decompression can be effectively used in the treatment of patients with endocrine ophthalmopathy complicated by optic neuropathy, refractory to conservative therapy. The technique is promising and requires further randomized studies.