Introduction. Treatment of respiratory failure in pneumonia caused by coronavirus infection (COVID-19) is still an unsolved problem that requires a comprehensive approach and the development of new methods that expand the range of possibilities of modern therapy. There is evidence that the heated oxygenhelium mixture has a positive effect on gas exchange in the infiltration zone by improving both ventilation and diffusion.
AIM of study. To evaluate the effectiveness of the inclusion of a heated oxygen-helium mixture HELIOX (70% Helium/ 30% Oxygen) in the complex intensive care of respiratory failure of pneumonia caused by SARS-CoV-2 infection.
Material and methods. The study included 60 patients with confirmed viral pneumonia caused by COVID-19. The patients were randomized into two groups: group 1 (n=30) — patients who were treated with the standard COVID-19 treatment protocol with the heated oxygen-helium mixture HELIOX, and group 2 (control) (n=30) — patients who received standard therapy. Lethality was studied for 28 days, the time in days until a steady increase in SpO2>96% was achieved when breathing atmospheric air; the time until the patient is transferred from the intensive care unit (ICU) to the general department.
Results. Inhalation of the HELIOX mixture (70% Helium / 30% Oxygen) resulted in a faster recovery of the hemoglobin oxygen saturation index (SpO2). Starting from day 3, these differences became statistically significant. The time in days from inclusion in the study to a persistent increase in the degree of oxygen saturation of hemoglobin (SpO2>96%) when breathing atmospheric air in the group with inhalation of the HELIOX mixture was less — 8 (7; 10), compared to 10 (8;13) in the control group (p=0.006). In the group with inhaled HELIOX mixture, the median treatment time in the ICU was 8 (7; 9.5) days vs 13 (8; 17) days (p<0.001) in the comparison group.
Conclusions. Inhalation of the HELIOX mixture (70% Helium / 30% Oxygen) led to a faster recovery of the hemoglobin oxygen saturation index SpO2, which contributed to reduction in the duration of oxygen therapy and a decrease in mortality.

Unified management plan and treatment strategy for COVID-19 patients are yet to be discovered. Many trials on COVID-19 interventions have been registered or are ongoing. In this article the results of large-scale clinical trials on COVID-19 treatment are presented, the potential mechanism of action of some drugs is discussed, the features of the main pharmacological and non-pharmacological therapeutic options for COVID-19 patients are described.

Relevance. Rhabdomyolysis is one of the complications of the new coronavirus infection COVID-19, which may cause acute kidney injury (AKI). The reason for the development of rhabdomyolysis in our observation in a patient after suffering COVID-19 in the long-term period was an increased muscle load.
Aim of study. Presentation of a case of rhabdomyolysis with AKI in a patient after COVID-19 in the long-term period.
Material and methods. In clinical observation, a 25-year-old patient L. is presented, who was being treated in the Department for the Treatment of Acute Endotoxicosis of the N.V. Sklifosovsky Research Institute for Emergency Medicine. In 2020, he developed COVID-19, complicated by rhabdomyolysis and AKI in the long term period.
Results. Examination revealed an increase in creatinine phosphokinase (CPK) — 106,000.0 U/L, alanine aminotransferase (ALT) — 553.0 U/L, aspartate aminotransferase (AST) — 1582.0 U/L, lactate dehydrogenase (LDH) — 2809.0 U/L, levels of serum creatinine 164 μmol/L and myoglobin — 201 ng/ml. Virological research: IgM — 0.27 units per ml; IgG — 7.28 units per ml. 3 Three-phase scintigraphy with 99mTc-pyrfotech revealed signs of necrotic changes in the muscles of the upper half of the back, muscles of the chest (mainly on the right), muscles of the shoulder and upper half of the forearm on both sides. Kidneys: decreased perfusion of the right kidney (relative to the left), moderate slowdown of urodynamics at the level of the calyx-pelvis complex on both sides.
Conclusions. The reason for the development of rhabdomyolysis in the long-term period in the patient after suffering from COVID-19 was an increased muscle load. Targeted research and medical history can help identify signs of rhabdomyolysis. The use of the radionuclide diagnostic method makes it possible to identify areas of soft tissue damage with a one-step assessment of renal function in rhabdomyolysis in the acute period of the disease, as well as to evaluate the effectiveness of treatment with dynamic observation. When rhabdomyolysis is confirmed, it is necessary to carry out detoxification and infusion therapy, to monitor renal function in order to detect acute kidney injury, and in case of deterioration of renal function and intoxication, renal replacement therapy is indicated.

 Pregnant women occupy a special place in the incidence structure of the new coronavirus infection COVID -19. Taking into account the likelihood of a more severe course of acute respiratory syndrome (ARDS) in this group, it is worth remembering the possibility of timely use of veno-venous extracorporeal membrane oxygenation (IV ECMO) in order to correct life-threatening hypoxia. At the Lapino Clinical Hospital, a cesarean section was successfully performed in a 37-year-old female patient at 20–21 weeks of gestation against the background of IV ECMO with further decannulation  and discharge from the hospital. 

We report a clinical case of treatment of a complicated postoperative course in a patient who underwent pancreatoduodenal resection associated with coronavirus infection. Prevention and treatment of such complications have been suggested.
Pancreatoduodenal resection (PDR) is indicated for malignant tumors of the pancreatic head, duodenum or its large papilla, distal common bile duct, as well as in chronic pancreatitis with a predominant lesion of the pancreatic head with severe pain syndrome.
The given clinical observation describes an example of treatment of a patient who developed a series of thromboembolic complications in the early stages after PDR performed for a neuroendocrine tumor of the pancreatic head. The oncology disease, extensive surgery such as PDR, and the postoperative period itself are risk factors for the development of various thromboembolic complications. According to the literature, the incidence of thromboembolic complications after PDR is 3–3.3%.
The reason for the atypical course of the postoperative period when performing pancreatoduodenal resection in patients with tumor of the pancreas may be conditions that are not directly related to either the pathology of the pancreas or the features of the surgical intervention. When analyzing the patient’s condition, one should take into account the conditions of treatment. In such situations, proper detection of COVID-19 and adequate correction of therapy can fundamentally change the outcome of the disease.

A case of successful emergency carotid endarterectomy (CEE) in the acute period of ischemic stroke (within an hour after the onset of symptoms) in a patient with acute occlusive thrombosis of the internal carotid artery in the course of moderate-severe COVID-19 with a positive result of the polymerase chain reaction of the nasopharyngeal smear for SARS-CoV-2. The diameter of the ischemic focus in the brain according to multispiral computed tomography did not exceed 2.5 cm. The course of ischemic stroke was characterized by mild neurological deficit (score 5 according to National Institute of Health Stroke Scale). It was demonstrated that the severity of the patient’s condition was associated with bilateral, polysegmental, viral penvmonia with 65% damage to the lung tissue, a decrease in SpO2 to 93%. Laboratory noted coagulopathy with an increase in D-dimer (2837.0 ng/ml), prothrombin according to Quick (155.3%), fibrinogen (14.5 g/l) and signs of a “cytokine storm” with leukocytosis (28.4 10E9/l), an increase in C-reactive protein (183.5 mg/l), ferritin (632.8 ng/ml), interleukin-6 (176.9 pg/ml). The patient underwent glomus-sparing eversional CEE. The intervention was performed under local anesthesia due to the high risk of developing pulmonary barotrauma when using mechanical ventilation. To prevent the development of acute hematoma, a double active drainage was used into the paravasal space and subcutaneous fatty tissue (SFT). In case of thrombosis of one of the drainages, the second could serve as a spare. Also, upon receipt of hemorrhagic discharge from the drainage located in the SFT, the patient would not need to be transported to the operating room. Removal of skin sutures with revision and stitching of the bleeding source could be performed under local anesthesia in a dressing room. The postoperative period was uneventful, with complete regression of neurological symptoms. Used anticoagulant (heparin 5 thousand units 4 times a day s/c) and antiplatelet therapy (acetylsalicylic acid 125 mg at lunch). The patient was discharged from the hospital on the 12th day after CEE in satisfactory condition.

Introduction. This article is devoted to the discussion of a life-threatening condition - basilar artery thrombosis (BAT). The article presents the results of a comparative analysis of two groups of patients with angiographically confirmed BAT: with and without reperfusion therapy.

Relevance. Basilar artery thrombosis is a life-threatening condition in which mortality can reach 95%, and severe neurological deficits and dependence in everyday life on others (modified Ran-kin Scale (mRS), score 4–5) are observed in 65% of surviving patients. Ischemic stroke (IS) due to BAT is diagnosed in 1–4% of patients with acute cerebrovascular event (ACVE). Currently, reperfusion therapy (RT) in the form of systemic thrombolytic therapy (sTLT) with rt-PA and/or thrombectomy (TE) is the only effective and safe method for treating patients with IS. In randomized trials, it was found that RT, whether it is sTLT, TE or a combination of these techniques, despite the best degree of functional recovery in patients by day 90 from the onset of the disease, does not lead to a statistically significant decrease in mortality. Nevertheless, the results of 10 prospective studies of the use of endovascular treatment in patients with IS in the posterior circulation system indicate that this type of therapy leads to a decrease in 90-day mortality from 95% to 16–47% in case of successful recanalization (mTICI (modified Thrombolysis in Cerebral Infarction), 2–b–3).

Aim of study. To assess the safety and efficacy of TE in patients with BAT.

Material and methods. This study included 15 patients with IS, admitted within the 6-hour therapeutic window, and confirmed BAT by CT and/or MRangiography. The baseline level of wakefulness was assessed using the Glasgow Coma Scale (GCS), and the severity of neurological deficit was assessed by the National Institutes of Health Stroke Scale (NIHSS).

Results. Basilar artery thrombectomy was performed in 7 patients (endovascular treatment group), 8 patients received no endovascular treatment (standard therapy group). Good clinical outcomes by day 90 from the onset of the disease (mRS, score 0–2) were observed in 57.1% of patients in the endovascular treatment group and in 12.5% of patients in the standard therapy group. However, these differences were not statistically significant (p>0.05). There were also no differences between the two groups in functional outcomes and Rivermead mobility index (RMI) by day 90 from the onset of the disease (Barthel Index of Activities of Daily Living (BI) score 97±5.0 and 100, RMI score 14.0±0.0 and 15 in the endovascular treatment group and standard therapy group, respectively). Mortality by day 90 in the endovascular treatment group was 42.9% (3 patients), in the standard therapy group — 87.5% (7 patients). In the subgroup of patients with GCS score at admission no more than score 8, there was a statistically significant strong two-way negative correlation between TE performance and mortality (r=-1.0; p=0.000), as well as a positive correlation between TE and a Rankine score by day 90 (r=0.956; p=0.003). Mortality was statistically significantly lower in the endovascular treatment group compared to the standard therapy group (0% versus 100%, respectively, p=0.025). Clinical outcomes of the disease by day 90 were statistically significantly better in the endovascular treatment group: mRS, score 0–2 in 100% of cases versus 0% in the standard treatment group (p=0.028).

Conclusion. Currently, the only effective treatment for basilar artery thrombosis is thrombectomy. The possibility of performing thromboectomy in these cases should be considered in all patients, regardless of the severity of the stroke and the decrease in the level of wakefulness, since endovascular treatment in this case is a life-saving procedure. The symptom of a hyperdense basilar artery can be used as a diagnostic tool for suspected basilar artery thrombosis, but should not rule out angiography. In our series of observations, the mortality rate in patients who underwent thrombectomy was 42.9%. Good functional outcomes (mRS, score 0–2) and the absence mobility limitation (RMI, score 14) were observed in 57.1% of patients by day 90 after thrombectomy.

Aim. To evaluate the efficiency of cardioprotective therapy using intravenous metoprolol in combination with a high dose of atorvastatin in the prevention of myocardial remodeling (MR) and heart failure (HF) in patients with acute ST-segment elevation myocardial infarction (STEMI).
Material AND methods. A prospective study included 100 STEMI patients who underwent primary percutaneous intervention (PCI). Depending on the regimens of drug cardioprotection, three groups of patients were formed: the first (2014–2015) — 34 patients who received 80 mg atorvastatin as a part of the basic therapy on the first day of STEMI, then 20–40 mg/day for 30 days. The second group (2017–2018) — 34 patients who received atorvastatin 80 mg/day for a month from the onset of STEMI. The third group (2018–2019) — 32 patients who received intravenous metoprolol tartrate (5–15 mg) and atorvastatin 80 mg/day before PCI for a month from the onset of STEMI. On days 1 and 2 of STEMI and one month later, patients were assessed for serum levels of cardiac biomarkers; on the 1st, 7th days and one month later, echocardiographic studies (EchoCG) were performed. At the end of the observation, clinical and imaging outcomes (MR and HF) were assessed, which were compared with the dynamics of biomarkers between the groups of patients.
Results. The combined use of atorvastatin 80 mg/day for a month from the onset of STEMI and a single intravenous injection of metoprolol tartrate (5–15 mg) in the acute phase of STEMI before PCI showed the most significant effects in the prevention of the development of structural and functional myocardial disorders and clinically severe heart failure, and also caused the minimal serum activity of cardiomarkers in the third group of patients in comparison with the first and second groups of patients without this drug combination. Also, correlations between biomarkers and echocardiography indicators were established in the third group of patients who received cardioprotective therapy.
Conclusion. The combined use of high-dose atorvastatin for a month with a single intravenous injection of metoprolol tartrate in acute STEMI before PCI prevents the formation of MR and clinically significant HF in the post-infarction period. Comprehensive dynamic assessment of cardiac biomarkers and echocardiography parameters within a month after post-STEMI is a highly informative tools for monitoring the efficiency of cardioprotective therapy.

 Today, algorithms have been developed for actions after excluding hernia incarceration directly during the patient’s hospitalization, but there are no clear recommendations for how to proceed: to offer surgery in this hospitalization or  to recommend planned surgical treatment. To answer this question, it is necessary to assume the probability of repeated incarceration. To solve this  problem, we have suggested high, medium and low risk of incarceration of  inguinal or femoral hernia and determine the optimal timing of surgery. 

Background. The syndrome of systemic inflammatory response, which underlies the damaging effect of factors of infectious and non-infectious genesis, may cause multiple organ failure. The degree of its severity is determined, among other things, by the activation of neutrophils. The paper highlights new mechanisms of the anti-inflammatory action of the inhalation anesthetic xenon, mediated by a decrease in the ability of neutrophils to pro-inflammatory response.
Aim of study. To evaluate the effect of xenon on the activation of human neutrophils under ex vivo conditions.
Material AND methods. We studied the effect of xenon inhalation on reduction of the ability of neutrophils to be activated proinflammatory by reduced expression of adhesion molecules CD11b and CD66b on the surface of neutrophils and on the phosphorylation of proinflammatory kinases: ERK 1/2 and kinase — p38 in neutrophils of healthy volunteers.
Results. The use of xenon at a dose of 30 vol. % within 60 minutes in healthy volunteers statistically significantly reduces the ability of neutrophils to proinflammatory activation. The addition of lipopolysaccharide (LPS) to the incubation medium of neutrophils causes their pronounced activation, statistically significantly increasing the phosphorylation of key proinflammatory neutrophil kinases ERK1/2 and kinase p38. Inhalation of xenon in volunteers (30% within 60 minutes) has a pronounced anti-inflammatory effect on LPS-stimulated neutrophils, decreasing their activation by inhibiting pro-inflammatory kinase ERK1/2 and pro-inflammatory MAP kinase p38.
Conclusion. The actual study, performed on isolated neutrophils from volunteers who underwent xenon inhalation, revealed the anti-inflammatory properties of the inert gas xenon, which, in our opinion, may have a direct relationship to the identification of the mechanism of its neuroprotective properties. Thus, the research results available today suggest that xenon has a pronounced pleiotropic mechanism of brain protection. This is a partial blockade of NMDA receptors, and phosphorylation of the enzyme glycogen synthase-3β, and limitation of the inflammatory activation of neutrophils.
Findings. Inhalation of xenon in volunteers (30% within 60 minutes) has a pronounced anti-inflammatory effect on neutrophils stimulated by lipopolysaccharides, decreasing their activation by inhibiting proinflammatory ERK 1/2 kinase and proinflammatory MAP kinase p38, as well as reducing the expression of markers of activation and degranulation CD11b and CD66b on the surface of neutrophils. Stimulation by lipopolysaccharides statistically significantly reduces spontaneous apoptosis of neutrophils, while xenon increases the ability of neutrophils to apoptosis, which is likely to contribute to the resolution of inflammation.

Aim of study. To determine the optimal tactics of surgical treatment of patients with combined stenosis of the carotid and coronary arteries by comparing the results of the simultaneous and staged approach according to the literature.

Material and methods. A systematic literature search was performed in the PubMed and MEDLINE databases to compare the results of simultaneous and staged interventions for combined stenosis of the carotid and coronary arteries. The following keywords were used as a search query: (“combined coronary and carotid artery stenosis and simultaneous”), (“combined coronary and carotid artery stenosis and staged”), (“combined coronary and carotid artery stenosis and cost”). We compared the results of simultaneous (interventions on the vessels of both systems are performed simultaneously) and staged operations (interventions are performed alternately, with a time interval from 2 to 160 days). References from included studies were also manually reviewed. The search was conducted by two independent experts (S.L., S.N.), and any disagreement was resolved by the clinical expert (A.A.).

Results. A literature search identified 198 potentially relevant studies. A total of 13 studies met the inclusion criteria, of which 5 included two interventions. This systematic analysis includes the results of treatment of 43,758 patients with combined stenosis of the carotid and coronary arteries, who underwent staged or simultaneous revascularization of the vessels of the carotid and coronary flow. Perioperative neurological complications in the group of staged operations were observed somewhat more often than in the group of simultaneous interventions (3.2% versus 4.22%; p=0.8), myocardial infarction was observed with a frequency of 1.5% in the group of simultaneous interventions, and 2.5% (p=0.5) in the group of staged interventions. The mortality rate after simultaneous and staged interventions was 3.9% and 3.6%, respectively, with a fairly high spread in the study groups (p=0.5). Data analysis showed that simultaneous interventions did not affect the incidence of neurological, cardiac complications, and deaths (OR (odds ratio) 1.02; 95% CI (confidence interval) — 0.98–1.14, p = 0, 69; OR — 1.26; 95% CI — 0.66-2.41; p=0.48; and OR — 0.97; 95% CI — 0.67-1.38; p=0.85 — respectively).

Conclusion. 1. The cumulative incidence of neurological and cardiac complications and mortality in staged tactics, according to observational studies included in this systematic review, is 4.2%; 2.6% and 3.6%, respectively (p>0.05). 2. The cumulative incidence of neurological and cardiac complications and mortality with simultaneous tactics according to observational studies included in this systematic review is 3.3%; 1.5% and 3.9%, respectively (p>0.05). 3. Given the relatively low risk of developing myocardial infarction (OR — 1.26; 95% CI — 0.66–2.41; I2 — 94%), the low risk of developing neurological complications (OR 1.02; 95% CI — 0,98–1.14; I2=75%), and deaths (OR — 0.97; 95% CI — 0.67–1.38; I2 — 76%) — (p>0.05), with simultaneous interventions, it can be concluded that simultaneous interventions may be the method of choice for surgical treatment for combined stenosis of the carotid and coronary arteries.

 The conducted analysis of Russian and foreign literature sources showed that the problem of diagnostics and treatment of polytrauma in elderly and senile patients is still relevant. The main discussion point is the high  mortality rate in this group of patients. Although at this level of the  medicine’s evolution, an active approach to the treatment offered to such patients is applicable, the mortality rate in this group of patients remains much higher than in the group of patients under 65. The priority here is to study the difficulties of diagnosing injuries in elderly and senile patients with  polytrauma. Also, a fundamental issue is the development of an effective algorithm for the surgical treatment of injuries, taking into  consideration age­related changes, the presence of concomitant pathology and an increased risk of complications in patients of this age group.  

Introduction. The article is devoted to an actual problem — blunt trauma of the abdomen and organs of the retro­peritoneal space.
Aim of study. Specify the indications for non­operative management of patients with blunt trauma of the solid organs of the abdominal cavity, retroperitoneal space, with retroperitoneal hemorrhage and measures for this treatment option.
Material and methods. The analysis of literature sources of Russian and foreign authors is carried out and the indications, methods and necessity of non­operative management of patients with blunt trauma of solid organs of the abdominal cavity and retroperitoneal space, retroperitoneal hemorrhages are substantiated.
Conclusion. Non­operative management of patients with blunt trauma of solid organs of the abdominal cavity and retroperitoneal space, retroperitoneal hemorrhages is possible only in large specialized centers with a wide range of diagnostic and therapeutic capabilities.

Introduction. Epileptic seizures are an important problem that significantly worsens the quality of patients’ life with both newly diagnosed and recurrent brain gliomas.
Review. The analysis of domestic and foreign literature showed that low-grade gliomas, this symptom occurs on average in 76%, with high-grade gliomas – in 21% of patients. Despite the maximum allowable tumor resection, it is likely that epileptic seizures persist in 18-64% of patients, and in 5% of patients they first appear in the postoperative period. From 15 to 50% of epileptic seizures in cerebral gliomas are drug-resistant. In patients undergoing chemotherapy, it is better to use new antiepileptic drugs because their cross-effects are minimal.
Conclusion. There is no generally accepted algorithm for prescribing and discontinuing antiepileptic drugs in patients with symptomatic epileptic seizures with cerebral gliomas. Further research is needed to determine the optimal combination and dosage regimen of antiepileptic drugs, especially during chemotherapy.

Introduction. The regional vascular centers (RVC) network was created throughout Russia to manage cardiovascular diseases. On the basis of N.V. Sklifosovsky Research Institute for Emergency Medicine in Moscow, a center was created, which received the status of the head RVC. A comprehensive analysis of its work has not yet been carried out.
Aim of study. To assess the main performance indicators and development directions of the head RVC based on the analysis of data for 2012–2019.
Results. Analysis of the data obtained showed that by 2019 the flow of patient admissions increased 2.3-fold. At the same time, the use of the hospital bed fund does not exceed 100%, and the use of the intensive care bed fund has increased to 123%. A significant proportion of patients come with not field-specific diagnosis. The mortality, which is the main indicator of the quality of treatment in patients treated at the RVC, remained within 2.33–3%, which turned out to be 3 times lower in similar patients treated in other departments of the Institute.
Discussion. Against the background of a constant increase in the number of hospitalizations, resusci-tation provision turned out to be insufficient when the number of hospital beds corre-sponded to the flow of admissions. The general lack of intensive care beds in the center and the lack of specialized intensive care for the department of vascular surgery forces the use of other intensive care units of the Institute. The admission of patients with other (not specific for RVC) diagnosis to the vascular center reduces the volume of highly specialized care for specialized patients.
Conclusion. The analysis of the performance indicators of the head regional vascular center on the basis of N.V. Sklifosovsky Research Institute for Emergency Medicine, identified the need to expand the resuscitation bed fund in the existing departments of the center and organize specialized resuscitation for patients of the vascular surgery department. Also, the lack of intensive care beds is aggravated by a large flow of non-core admissions. Their reduction with the existing structure will provide significant savings in resources and will increase the number of treated profile patients and improve the quality of highly specialized care.

Background. Mirizzi syndrome (MS) is a relatively rare complication of cholelithiasis, which occurs in a wide range from 0.2 to 5% according to different authors. Today, the surgical treatment of MS remains a challenge.
Aim of study. To determine the possibilities of laparoscopic interventions in the surgical correction of various types of MS.
Material AND methods. The work is based on a prospective analysis of cases of laparoscopic treatment of 19 patients with MS who were treated in the emergency surgery departments of the Republican Scientific Center for Emergency Medical Care in 2017–2019. This is 22.9% of all admitted patients (83) with MS during this period. Type 1 MS was diagnosed in 3 patients (15.7%), type 2 was diagnosed in 16 patients (84.2%).
Results. In all cases of type 1 MS, laparoscopic cholecystectomy was performed. A new method for the correction of type 2 MS by forming a sleeve from the gallbladder wall was suggested, which was performed in 10 patients with good results. In the postoperative period, no nonspecific complications were observed in patients undergoing laparoscopic interventions. One patient had residual choledocholithiasis, which was managed by day 5 after the surgery with endoscopic retrograde cholangiopancreatography and endoscopic papillosphincterotomy and the removal of the calculus from the common bile duct. The average duration of stay of patients in a hospital bed was 10.8 days. Fatal outcome was observed in 1 case (5.3%).
Conclusion. 1. The inclusion of endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and magnetic resonance imaging cholangiography in the diagnostic scheme improves the accuracy and quality of recognition of Mirizzi syndrome and allows the indications for the use of video laparoscopy to be evaluated. 2. Indication for laparocopic treatment of type 2 Mirizzi syndrome is the presence of a single calculus in the supraduodenal part of the common bile duct, which makes it possible to reduce the number of conversion to laparotomy. 3. In cases of type 1 Mirizzi syndrome, the operation of choice is laparoscopic cholecystectomy. 4. The operation of choice in patients with type 2 Mirizzi syndrome is laparoscopic subtotal cholecystectomy, fistula plasty with a gallbladder flap on the Kehr’s T-tube drain with the formation of a “cystic duct”-type sleeve.

Unfortunately, suppuration of a postoperative wound remains the most frequent complication of surgical intervention. If suppuration is located superficially, within the subcutaneous fat, it can be successfully managed with minimal functional losses. The clinical course is significantly complicated if the focus of infection is located under the skin, in the thickness of the muscles, in the fracture zone. In the case of suppuration in the area of osteosynthesis, the complication may become critical.
Such a complication is a serious condition that requires multi-stage complex and sometimes multidisciplinary treatment.
The conditions for a successful outcome in this pathology are the minimum period from the moment of suppuration, active surgical tactics, stability of the implant, and good vascularization of the surrounding soft tissues.
Active surgical tactics involves the opening and sanitation of purulent foci, leaks, recesses. Staged necrectomies are inevitable companions of surgical treatment and can cause the formation of defects in the skin, subcutaneous tissue, and muscles.
The resulting soft tissue defect leads to exposure of the bone and plate. Removal of the metal fixator becomes inevitable.
Only the closure of the defect with a complex of tissues based on free vascularized composite grafts can radically solve the problem.
The article presents two clinical observations of deep wound infection after bone osteosynthesis, where autotransplantation of a vascularized flap was used. The use of this technique made it possible to achieve suppression of infection, wound healing by primary intention, to create conditions for consolidation of the fracture, restoration of function and preservation of the limb as a whole.

Introduction. Aortic valve replacement in cardiopulmonary bypass with suture fixation of the prosthesis is the “gold standard” in cardiac surgery. Currently, the frequency of use of heart valve bioprostheses is increasing in older patients. Despite all the advantages of using heart valve bioprostheses, this type of prosthesis has a major drawback - it is not durable. In most cases, the reason for the dysfunction of prostheses in the late postoperative period is early calcification of the prosthesis valves or their rupture due to degeneration. With the development of new “gentle” techniques for replacing heart valves, transcatheter aortic valve implantation was introduced into clinical practice. The use of transcatheter aortic valve implantation (TAVI) “valve in valve” for reoperations in older patients is of great interest, since in recent years the procedure has been widely used in clinical practice and shows promising data in patients with high surgical risk.
Aim of study. Show first experience of using a technique «valve in valve» at N.V. Sklifosovsky Research Institute for Emergency Medicine.
Material and methods. The results of surgical treatment of a patient with aortic valve bioprosthesis dysfunction using the TAVI “valve in valve” technique are presented.
Results. The use of the TAVI “valve in valve” method made it possible to perform reprosthetics of the aortic valve (AV) from a transfemoral approach, not to increase the volume of intervention during reoperation, to avoid trauma to the structures of the heart and nearby tissues when accessing the AV in a patient with a high surgical risk.
Conclusion. The use of the TAVI “valve in valve” method in cardiac surgery makes it possible to achieve good immediate and long-term results when it is necessary to replace the AV in patients with a high surgical risk.

Aim of study. Presentation of our own first clinical experience of venous reconstruction in portosystemic bypass surgery with the use of autologous vascular prostheses of the falciform ligament of the liver in the splenorenal position in a patient with portal hypertension syndrome in the outcome of liver cirrhosis of viral etiology.
Material and methods. Clinical observation of a patient born in 1978 with a diagnosis of cirrhosis of the liver of viral etiology (HCV) Child-Pugh A (6). MELD 10 points. Inactive phase. Intrahepatic portal hypertension syndrome. Esophageal varices grade III according to A. G. Scherzinger, gastric varices type I (GOV1) according to Sarin. Condition after repeated recurrent esophageal-gastric bleeding. Due to the high risk of another bleeding, as a secondary prevention of esophageal-gastric bleeding, partial splenorenal anastomosis of “H” - type was performed with the use of an autologous vascular prosthesis of the falciform ligament of the liver in the splenorenal position.
Results. A flap measuring 60.0x20.0 mm was cut from the falciform ligament of the patient’s liver. From the latter, after adjusting the size of the graft to the individual needs of the patient, an autologous conduit was formed. It was used as an insert in the formation of an “H” - type splenorenal anastomosis with the imposition of two end-to-side anastomoses between the splenic vein and one end of the conduit and between the left renal vein and the other end of the conduit. The patency of the anastomosis was checked using intraoperative sonography. In a satisfactory condition, the patient was discharged for outpatient follow-up treatment at the place of residence. At the moment of writing the article, the follow-up period was 8 months. The bleeding did not recur. No varicose veins were found in the esophagus and stomach during control endoscopic examinations. The patency of the splenorenal shunt was confirmed by ultrasound dopplerography.
Conclusion. The first clinical experience of venous reconstruction with portosystemic bypass surgery using as a possible replacement of autologous vascular prostheses of the falciform ligament of the liver in the splenorenal position in a patient with portal hypertension syndrome in the outcome of cirrhosis of the liver of viral etiology gives hope for the possibility of further successful testing of this method of splenorenal bypass surgery to reduce the risk of bleeding from varicose veins.

 This article reports the first experience of the N.V. Sklifosovsky Research Institute for Emergency Medicine in reperfusion therapy for ischemic stroke in a patient taking oral anticoagulant. 

The article reports an example of the simultaneous use of brachial plexus block and combined two-segment spinal-epidural anesthesia with fixation of an epidural catheter in the subcutaneous canal in an 81-year-old patient after receiving a household injury - closed fracture of the olecranon of the right ulna with displacement of fragments and closed transtrochanteric fracture with a fracture of the right femur fragments. After preoperative preparation and examination, the patient underwent two consecutive surgical interventions within a day: open reduction of comminuted transtrochanteric fracture of the right hip, dynamic femoral screw osteosynthesis and open reduction of fracture of the right olecranon, Weber’s osteosynthesis. Surgical interventions were carried out under regional anesthesia: block of the brachial plexus via supraclavicular access and combined two-segment spinal-epidural anesthesia with a method developed in our clinic for fixing an epidural catheter in the subcutaneous canal using a modified spinal needle. After the operation, the patient underwent postoperative pain relief in the form of epidural analgesia for 72 hours. The postoperative period passed without complications. On the 13th day, the patient was discharged for outpatient treatment by a traumatologist. The use of local anesthesia in the form of two methods of regional anesthesia during two consecutive surgical interventions, in an elderly patient with a high anesthetic risk, followed by long-term postoperative anesthesia in the form of epidural analgesia with a reliable method of epidural catheter fixation in the subcutaneous canal without the use of narcotic analgesics, contributed to the successful carrying out two surgical interventions at once, early activation of the patient, absence of complications in the postoperative period. Reliable catheter fixation is very important for the quality of epidural analgesia. Dislocation of catheters by more than 2 cm can lead to migration of catheters from the epidural space, changing the course of anesthesia, deteriorating its quality, or even interrupting it altogether. The new method of catheter fixation in the subcutaneous canal developed by us made it possible to prevent catheter dislocation.

Summary. The analysis of the historical development of the state system of training in the field of clinical toxicology showed that the opening of the first specialized departments (centers) served as an impulse for the adoption in the future of appropriate organizational decisions and regulatory documents that led to the creation of the country’s first department of clinical toxicology. In addition, this became possible after the emergence of qualified personnel of clinical toxicologists, as well as scientific and practical areas, primarily general resuscitation and toxicological chemistry, and the achievements of fundamental sciences, new pharmacological and technical means of detoxification of the body, on which basis educational materials of the proper level were formed.
An important role for the creation of the Department of Clinical Toxicology was played by the publication by E.A. Luzhnikov, the country’s first textbook on clinical toxicology. The results of the activities of Academician E.A. Luzhnikov in the organization of training in the field of clinical toxicology also contributed to the acquisition of a comprehensive level of knowledge and the expansion of teaching in this direction.
However, today, clinical toxicology has not become a basic specialty in the vast majority of medical institutions of higher education, including Moscow, which, in our opinion, hinders the process of training the required number of practical, scientific, and teaching personnel in this area.
The choice of clinical bases for training is of fundamental importance, of which multidisciplinary research emergency hospitals or emergency hospitals are optimal.
Along with the proven form of teaching in the form of field cycles, further reflection requires the place of distance learning as another approach to expanding the audience of listeners. It is also absolutely necessary to support the teaching process within the framework of continuous professional education, including cooperation with scientific and practical medical societies.
The most important component of the learning process is the accumulation of scientific experience in the specialty, to which a decisive contribution is made by the creation of scientific schools on the bases of toxicological subdivisions. Additional opportunities are also provided by the modern formation of the scientific specialty “Toxicology”, which makes it possible to achieve the most qualified examination of the results of scientific research.
Conclusion.The development of the state educational system in the field of clinical toxicology in Russia is closely related to its formation as an independent scientific and practical direction in medicine, which has high social significance, and the adoption of the experience gained in the course of educational activities.