Gestational thrombocytopenia (GT) is the most common type of thrombocytopenia during pregnancy. Unlike other types of thrombocytopenia, it is not accompanied by dysfunction of the cellular component of hemostasis. Currently, a quantitative decrease in platelets in GT is a contraindication to neuraxial blockades (NAB), which significantly reduces the quality of care in childbirth.

The aim of the study is to determine the possibility of safe use of neuraxial blockades in gestational thrombocytopenia. A retrospective prospective study involved 70 patients who were performed delivery, depending on obstetric indications, either conservatively or surgically. The patients were divided into two groups. The main group (group No. 1) included 35 patients with gestational thrombocytopenia. The comparison group (group No. 2) consisted of 35 patients with a platelet content above 150×10⁹/l. A comparative intergroup analysis of indicators of a general blood test, coagulogram, thromboelastography with a test for functional fibrinogen before childbirth and 2 days after delivery. The change in platelet content and its effect on the coagulation status of patients during pregnancy were retrospectively analyzed. A comparative assessment of the volume of blood loss during childbirth and the early postpartum period and the risk of complications of neuraxial blockade in patients with and without gestational thrombocytopenia was carried out.

It was found that during gestational thrombocytopenia in the perinatal period, there is no decrease in coagulation potential, assessed by the results of coagulography and thromboelastography at a platelet level above 49×10⁹/l. The investigated indicators of hemostasis did not have significant intergroup differences during pregnancy and childbirth. In the group of patients with gestational thrombocytopenia, the volume of blood loss during labor and the postpartum period did not differ from the group without thrombocytopenia, regardless of the method of delivery. The median blood loss after vaginal delivery in group 1 was 225 ml, in group 2 – 250 ml, with abdominal delivery – 572 ml and 386 ml – respectively. In this study, no complications of neuraxial blockade were observed in any of the groups.

The results obtained suggest that in patients with gestational thrombocytopenia, even with a significant decrease in platelet content, it is possible to perform neuraxial blockades during labor, taking into account the clinical picture and the absence of coagulation disorders confirmed by thromboelastography.

ABSTRACT Nowadays surgical treatment of patients with traumatic intracranial hematoma (TICH) and injuries of the brain is a very actual problem in neurosurgery.

The purpose of this work was to assess of the feasibility and safety of minimally invasive endoscopic removal of TICH.

MATERIAL AND METHODS In the period of 2010–2019, 2734 operations were performed on patients with traumatic brain injury in the Sklifosovsky Research Institute. There were 334 patients with TICH and the CC/BC foci, that made 12.2% of all patients. The median of hematoma volume, that did not cause a loss of consciousness was 48 cm2, and in most of the patients the hematoma volume ranged 30–35 cm2. Local fibrinolysis of TICH was performed in 14 patients with the hematoma volume of 30–50 cm2 without brain dislocation and not causing the consciousness depression more severe than sopor.

Endoscopic removal of TICH was performed in 4 men at mean age of 54.8 years within 18–36 hours after trauma. Three patients had depression of consciousness to obtundation (14 by Glasgow Outcome Scale (GCS)), and one patient was in clear consciousness. The volume of the dense part of the contusion foci in the pole-basal regions of the frontal and temporal lobes was 24–40 cm3.

RESULTS Among patients with TICH operated on by using the traditional technique, postoperative lethality was 13%, good outcomes were seen in 41%, and 46% had neurological disorders of varying severity. While treating the patients with TICH by using the local fibrinolysis method, 1 patient died after surgery, a good outcome was seen in 8 of 14 patients, and neurological disorders persisted in 3 patients in the postoperative period.

Radicality of surgery in patients operated on by using endoscopic technique averaged 76% ranging from 41% to 91%. There were no complications during surgery nor in post-operative period. Patients were discharged from hospital after 8-21 days.

AIM OF STUDY To identify risk factors for adverse outcomes of surgical treatment of patients with HS.

MATERIAL AND METHODS A retrospective analysis of the results of surgical treatment of 500 patients operated on at the N.V. Sklifosovsky Institute from 1997 to 2020 for hypertensive intracerebral hematomas. The mean age of the patients was 53.1±12.2 years. There were 335 (67%) men and 165 (33%) women.

The level of consciousness before the operation was clear in 176 (35.2%), stupor (11–14 score, GCS) — in 258 (53.6%), sopor (score 9–10, GCS) — in 38 (7.6 %), moderate coma (7–8 score, GCS) — in 10 (2%) patients, deep coma (score 6) — in 7 (1.4%) patients. ICHs were lobar in 218 (43.6%) patients, lateral in 212 (42.4%) patients, thalamic in 10 (2%) patients, mixed in 10 (2%) patients, cerebellar in 50 (10% ) patients. The average volume of ICH was 46.5±25.1 cm3, supratentorial ICH – 49.6±24.5 cm3 (from 4 to 147 cm3), subtentorial — 18.7±6.4 cm3 (from 5 to 36 cm3). The average duration of the surgical intervention was 3.3±2.6 days. The following types of operations were performed: open removal of the ICH in 271 (54.2%) patients, puncture aspiration and local fibrinolysis of the ICH in 98 (19.6%) cases, endoscopic aspiration of the ICG in 131 (26.2%) patients.

RESULTS The risk factors for lethal outcome in HT surgery are the age of patients older than 50 years (χ²=13.9, p<0.04), the volume of cerebral hemispheres more than 50 cm³ (χ²=7.8, p<0.01), the total volume of ICH and perifocal edema more than 100 cm3 (χ²=9.1, p<0.01), transverse dislocation of the median structures of the brain more than 5 mm (χ²=32.2, p<0.0001), axial dislocation of the brain (χ²=16 ,1, p<0.02), BP before surgery higher than 160 mm Hg (χ²=21.9, p<0.002), presence of IVH (χ²=36.9, p<0.00001), AOH (χ²=28.0, p<0.0001), surgery time — the first day after hemorrhage (χ²=64.4, p<0.00001), residual volume of ICH after surgery more than 15 cm³ (χ²=4.0, p<0.05) and recurrence of ICH (χ²=33.1, p<0.00001). The outcomes correlate with the severity of the patient’s condition before surgery (R=0.38, p<0.00001), and the risk factor for death is the depression of consciousness to deep stupor and below (χ²=97.2, p<0.00001).

CONCLUSION Assessment of risk factors can help clarify the prognosis of the outcomes of surgical treatment and optimize the treatment tactics of patients.

RELEVANCE Early enteral nutrition is an essential element of intensive care for acute pancreatitis. Its intolerance is manifested by high gastric residual volumes, pain syndrome, bloating, diarrhea, nausea and vomiting. The relevance of our study is determined by the lack of information on how the routes of nutrient delivery affect its tolerability considering the gradual «as­per­protocol» increase in nutrition volumes for patients with moderately severe acute pancreatitis.

THE AIM OF THE STUDY Was to identify the key factors that determine intolerance to early nasogastric and nasojejunal enteral feeding in ICU patients with the early phase of moderately severe acute pancreatitis.

MATERIAL AND METHODS We conducted an open randomized controlled trial. Out of 64 patients with predicted severe course of acute pancreatitis, we identified a cohort with moderately severe acute pancreatitis, in which 17 (51.5%) patients received early enteral nutrition through a nasogastric tube, and 16 (48.5%) via an endoscopically placed nasojejunal tube. The criteria for nutrition intolerance were as follows: nasogastric tube discharge of more than 500±100 ml at a time or more than 500 ml/day in comparison with the enterally administered during this period, increased pain, bloating, diarrhea, nausea and vomiting. Using the method of logistic regression, indicators with prognostic significance were determined. The null hypothesis was rejected at p<0.05.

RESULTS Regardless of the nutrition route, the progression of multiple organ failure increases the incidence of high gastric residual volumes (SOFA — OR (odds ratio) — 1.337, 95% CI (confidence interval) 1.001–1.787; p = 0.049). Pain syndrome is less common on the day of surgery (OR 0.258, 95% CI 0.110–0.606; p=0.002). Nasojejunal feeding was associated with a lower incidence of nausea and vomiting (OR 0.168, 95% CI 0.06–0.473; p=0.001), but with more diarrhea (OR 6.411, 95% CI 1.274–32.262; p=0.024).

CONCLUSION The progression of multiple organ failure increases the incidence of high gastric residual volumes. The pain syndrome is less pronounced on the day of surgery and more intense in case of nasogastric nutrition. Postpyloric nutrition reduces the incidence of nausea and vomiting, but increases diarrhea.

INTRODUCTION The cause of heart failure in patients with coronary artery disease after anterior myocardial infarction may be dilatation of the cavity of the left ventricle (LV) with subsequent unfavorable course of the disease. In the case of early reperfusion, which prevents transmural myocardial necrosis, the damaged segment more often becomes akinetic than dyskinetic. Surgical remodeling of the left ventricle (SRLV) is aimed at reducing the volume and restoring its elliptical shape by eliminating scars in the akinetic and/or dyskinetic segments.

AIM OF STUDY To evaluate the survival of patients with chronic heart failure (CHF) who had anterior wall myocardial infarction in the early and late periods after surgical remodeling of the left ventricle, in combination with coronary bypass grafting and/or interventions on the mitral valve.

MATERIAL AND METHODS The study included 99 patients with coronary artery disease (CAD) who had myocardial infarction of the anterior LV wall and with severe heart failure, who underwent surgical LV remodeling in the period from 2002 to 2020. The analysis of early and long-term results was carried out. The risk factors influencing lethality were determined.

The mean age of the patients was 56.0±10.2 years (from 23 to 81 years). The vast majority of patients (90%) were men. LV ventriculoplasty was combined with coronary bypass grafting in 97 (98%) patients, with mitral valve repair in 2 (2%) patients, with mitral valve replacement in 2 (2%) patients.

RESULTS In the early postoperative period, all patients showed an improvement in global LV systolic function. The ejection fraction (EF) of the left ventricle increased from the average preoperative average value of 34.2±3.7% to 43±4.2% in the postoperative period (р<0,001). Left ventricular end systolic volume index (LVESV) decreased from 71.4±15.3 ml/m² to 43.8±9.6 ml/m², respectively (р<0,001). In the early postoperative period, 5 (5%) patients used the following means of mechanical hemodynamic support: intra-aortic balloon pump (IABP), non-implantable device for temporary support of the left ventricle (LVAD) and extracorporeal membrane oxygenation (ECMO). The 30-day mortality rate after LVESV was 6%. Prior to surgery, all patients had NYHA functional class (FC) III or IV. In the postoperative period, all patients experienced regression of heart failure symptoms and improved exercise tolerance. NYHA functional class improved to I and II in 100% of cases. Using univariate analysis, it was possible to determine that EF ≤30%, LVESV ≥80 ml/m² and pulmonary artery pressure (PAP) >60 mm Hg. were risk factors for hospital mortality. The overall fifteen-year survival rate was 59.8±0.13%. The absence of readmission to the hospital due to recurrent angina pectoris, mitral valve dysfunction and progression of heart failure (HF) was 72% among surviving patients.

CONCLUSION Surgical remodeling reduces the volume of the dilated left ventricle and restores its elliptical shape in patients with CAD after anterior myocardial infarction. The results of our study demonstrate an improvement in LV systolic function in all patients in the early postoperative period and low mortality, an acceptable fifteen-year survival rate, and a low readmission rate due to the progression of chronic heart failure (CHF).

ABSTRACT In this article the most relevant methods of subclavian vein catheterization were considered in order to find the optimal technique that can be used in routine clinical practice by pediatric intensive care physicians.

OBJECTIVE To compare the efficiency and safety of subclavian vein catheterization by supraclavicular access under ultrasound control and subclavian access by anatomical landmarks in children.

RESULTS The number of attempts for successful catheterization was statistically lower in ultrasound-control group compared to the anatomical landmarks group (1.2±0.4 vs. 2.6±1.3, p<0.0001); in the anatomical landmarks group such complications as catheter malposition (14% vs. 0), arterial puncture (5% vs. 1%) and pneumothorax (10% vs. 0) were observed more often than in the ultrasound group.

CONCLUSIONS We recommend catheterization of the subclavian vein by supraclavicular access under ultrasound control to be commonly used in clinical practice due to its high efficiency and safety.

RATIONALE Acute exogenous poisonings represent a serious medical problem due to the prevalence, severity of the course and high lethality. In their pathogenesis, an important place is given to oxidative stress (OS). Among modern methods of treatment of acute poisoning, the attention is drawn to approaches aimed at normalizing homeostatic indicators by cleansing the enteric environment, restoration of its barrier function.

PURPOSE OF THE STUDY Assess the impact of the enteral correction program (ECP) on the parameters of lipid peroxidation (LPO) and antioxidant systems in acute exogenous poisoning.

MATERIAL AND METHODS 119 patients who underwent treatment at the N.V. Sklifosovsky Research Institute for Emergency Medicine, of which 45 were with severe acute poisoning with psychopharmacological agents (PPPA) and 74 with poisoning with corrosive substances (PCS). The two study groups consisted of 40 patients with PCS and 23 patients with PPPA, whose standard therapy was supplemented with ECP. The ECP included making intestinal lavage on admission, the introduction of glucosed saline enteral solution in the following days; and for patients with PCS the treatment also included enteral nutrition and Pektovit.

The comparison groups included 56 people (34 with PCS and 22 with PPPA) comparable to the patients of the study groups by sex, age, the type and severity of poisoning poisoning treated with standard therapy The severity of OS was assessed by the KMDA/TAA index which was calculated by means of measuring the concentration of malonic dialdehyde (as an LPO parameter) and total antioxidant activity in the blood plasma of the patients. Serum levels of nitric oxide stable metabolites were also measured.

The analysis of the results was performed with the regard to patient’s age.

RESULTS In patients of working age, regardless of the toxicant type, LPO activation occurred, which was expressed with an increased KMDA/TAA by 1.4–1.8 times compared to the norm. Using ECP at the study stages contributed to maintaining this balance level between pro- and antioxidants. In patients of comparison groups there was an increase in the LPO system imbalance, while KMDA/TAA exceeded the norm by 2.2–2.4 times that was statistically signifi cantly different from the parameters in the study groups.

Older patients showed decreased levels of LPO products, the total antioxidant activity compared to the normal for the age, and, as a result, a decrease in KMDA/TAA by 1.3–1.5 times in PCS and by 2–2.4 times in PPPA. This is due to the low adaptive potential of this category of patients. In this age group, ECP contributed to a moderate activation of LPO, which provided the trend towards normalization of OS parameters.

CONCLUSIONS The use of the enterable correction program has a positive impact on the dynamics of oxidative stress parameters, ensuring the maintenance of oxidative processes at the level required for an adequate protective reaction of the body to chemical injury.

AIM OF STUDY Was to compare the dynamics of engraftment of skin micrographs in a burn wound when using protectors from an allodermal graft and from a hydrogel coating.

MATERIAL AND METHODS The experimental study was conducted on 18 rats with a scab formed 3 days after modeling a deep burn with an area of 20% of the body surface. Partial fascial necrectomy was performed: two rounded sections of the sling with a diameter of 25 mm were excised. 6 automicrographs of skin 4x4 mm, 0.3 mm thick, were applied to each surface freed from the scab. In each animal, micrographs on one of the wounds were covered with a hydrogel protector, on the other with an allodermotransplant from another animal of the group. A secondary aseptic dressing was applied to the protectors. On the 5th and 20th days after the operation, the state of micrographs was studied: blood circulation — according to laser Doppler flowmetry, microstructure in vivo — using optical coherence tomography, microstructure ex vivo — according to histological examination of biopsies.

ReSUlTS Differences in the rate of restoration of blood circulation of micrographs in the early stages of the postoperative period were found. In the first 5 days, the perfusion of micrographs under an allodermal protector exceeded the indicator in micrographs under a hydrogel coating by 44 [21; 51] % (p=0.031) due to the contribution of endothelial and neurogenic mechanisms of blood flow modulation. Starting from day 10, the differences in perfusion were levelled, but there were signs of more active endothelial regulation of blood flow under the skin (p=0.028). Histologically, the appearance of full-blooded capillaries was revealed earlier in micrographs under the alloderm than when using a hydrogel protector. By 20 days, under the condition of regular change of hydrogel coatings, the area of wound healing under the studied coatings did not significantly differ. However, the structure of the integumentary tissue under the alloderm according to the optical coherence tomography data was closer to normal skin than when using a hydrogel protector.

CONClUSIONS From the point of view of the physiology of the wound process, alloderm is the preferred option of an autograft protector in comparison with a hydrogel coating, which is probably due to the paracrine biological activity of the alloderm. However, hydrogel coatings can provide a comparable level of efficiency, provided they are regularly changed and, potentially, given the properties of cytokine activity.

Disorders of cerebrospinal fluid (CSF) secretion, dynamics and absorption are common in different illnesses and injuries of the central nervous system (CNS). Nowadays magnetic-resonance tomography (MRI) is the leading research method of CSF dynamics. There are some MRI techniques for both qualitative and quantitative evaluation of CSF dynamic. The assessment of CSF movement is needed to define treatment strategy for patients with different types of hydrocephalus. In this review we have summarized the information about physic basement, area of application of modern MRI techniques. The main attention was paid to modern views on hydrocephalus pathogenesis, pathological CSF flow dynamics in CNS disorders and traumatic brain injury.

Transcranial magnetic stimulation (TMS) is a relatively new diagnostic and therapeutic method. Its widespread introduction into neurosurgical practice began in 2009. The method is used for non-invasive detection of eloquent brain areas. The combination with tractography facilitates the projection of pathways. The review summarizes the main results of TMS in the planning of neurosurgical interventions. We described the principle of method, analyzed its benefi ts and shortcomings, compared it with direct cortical stimulation which is a “gold standart” in detection of eloquent brain centers.

The number of patients with chronic kidney disease (CKD) and end-stage renal disease is steadily growing. With the failure of kidney function, the risk of developing acute myocardial infarction (AMI) with severe coronary artery stenosis and hospital mortality is growing. Case management of CKD and AMI is a complicated task. This review reflects the distinctive features of the course of AMI in hemodialysis patients, patients with kidney transplantation, their diagnosis and treatment.

RATIONALE Hollow organ perforation is an urgent problem in abdominal surgery. According to the literature, the incidence of perforation is from 0.37% to 2.3% of cases among various acute surgical pathologies of the abdominal organs. The greatest attention in the literature is paid to the problem of perforated gastroduodenal ulcers. At the same time, a much smaller number of publications, both Russia and foreign, are devoted to other, more rare types of perforations. This situation is most likely explained by the low prevalence of other types of perforations, which, in turn, does not make them a less urgent problem in emergency surgery, which requires a modern approach to the treatment of this group of patients.

PURPOSE OF THE STUDY Analysis of domestic and foreign literature on the diagnosis and treatment of rare types of benign intestinal perforations.

MATERIAL AND METHODS A literature review was performed for the period from 1994 to 2020 in Russian and in English, available on Pubmed, Medline, Springer, Scopus, E-library, on topics such as perforated diverticula of the small intestine, perforation of Meckel’s diverticulum, perforated ulcers of the small intestine, perforation of the intestine by a foreign body. RESUltS With all the variety of surgical techniques for various types of perforation of the gastrointestinal tract, currently in the literature there are no specific criteria for choosing a particular method of intervention with regard to the cause, level, and duration of perforation.

CONCLUSION The lack of unified approaches in the diagnosis and treatment of patients with rare GIT perforations dictates the need for a more in-depth study of this issue in order to apply and optimize the technique of videolaparoscopic approach, develop a treatment and diagnostic algorithm for patients with suspected perforations of the gastrointestinal tract using the video laparoscopic method.

INTRODUCTION In connection with the increase in the number of cases of combined and multiple injuries among the population, a proportional increase in the number of cases of diaphragm injury is also observed. In this case, shock is observed, damage to the organs of the chest and abdomen prevails in the absence of strictly specifi c clinical symptoms of diaphragm rupture, which leads to a large percentage of medical and diagnostic errors and complications. The described diffi culties in diagnosing cases of diaphragm injury dictate the need to develop a standardized approach to the management of this category of patients.

AIM OF STUDY Refi nement of the treatment and diagnostic approach to the management of patients with concomitant blunt trauma and diaphragm injury from the view of modern diagnostic and surgical technologies.

MATERIAL AND METHODS The literature review presents materials of domestic and foreign publications for the period from January 2015 to December 2020, obtained from electronic databases of medical literature PubMed, Cochrane Library, Scopus, eLibrary using the primary search strategy for the following search queries: diaphragm damage, diaphragm rupture, multisystem injury of the chest and abdomen, tactics of multi-stage surgical treatment, closed abdominal trauma, treatment and diagnostic algorithm, thoracoscopy, thoracotomy, laparoscopy, laparotomy (total 308 publications), with subsequent exclusion of experimental studies, non-full-text articles, publications not in Russian or English, manuscripts on open trauma and post-traumatic diaphragmatic hernia older than 30 days old from the moment of injury. The data extraction method was performed by two researchers independently of each other. The analysis was made of multicenter studies, systematic reviews, large case series, original articles (14 retrospective selective studies from 1994 to 2018; a total of 928 patients with closed diaphragmatic injury) and one meta-analysis (2023 patients).

RESULTS The treatment and diagnostic algorithm for multisystem closed diaphragmatic injury has been standardized based on the hemodynamic status of the patient, the indications for minimally invasive and open interventions in this category of patients have been clarifi ed, and a description of the staged surgical treatment has been given.

CONCLUSION Timely diagnosis, minimally invasive interventions in the treatment of diaphragmatic injuries, as well as their stage-by-stage organization in conditions of severe polytrauma contribute to a decrease in mortality.

The perforative acute appendicitis with the development of diffuse peritonitis increases the incidence of postoperative complications to 47%, and mortality to 3%. Mortality in the case of the development of diffuse purulent peritonitis makes 4.5-58%, and it can exceed 70% in severe forms of diffuse peritonitis with the development of infectious-toxic shock and multiple organ failure. National Clinical Guidelines for acute appendicitis with diffuse peritonitis allow for appendectomy from both the median and laparoscopic access in the absence of general contraindications to the creation of pneumoperitoneum. However, despite the proven advantages of laparoscopic appendectomy, there are opponents of its use in diffuse forms of appendicular peritonitis. An increased number of postoperative abscesses with a minimally invasive approach has been reported in literature; however, recent randomized studies refute this fact. There is also evidence that the laparoscopic method for appendicular peritonitis often leads to a lengthening of the operation time and higher operating costs, but at the same time there is a decrease in postoperative pain syndrome, a reduction in the length of inpatient treatment and early social and labor rehabilitation, which leads to an overall decrease in hospital costs. Thus, to date, there is no generally accepted opinion about the advisability of laparoscopic access for appendicular peritonitis. At the moment, the presence of diffuse peritonitis is the most common intraoperative reason for refusing a minimally invasive surgical treatment. However, there is a tendency to trying to standardize indications and contraindications, which was the objective of our literature review.

This article provides data from the current Russian (National guidelines for the management of patients with diseases of the brachiocephalic arteries of 2013; Recommendations “Blockage and stenosis of the carotid artery” of the Ministry of Health of the Russian Federation, 2016) and foreign (European Society of Cardiology / European Society of Vascular Surgeons for Diagnosis and Treatment Peripheral Artery Diseases 2017; Recommendations for myocardial revascularization of the European Society of Cardiology and the European Association of Cardio-Thoracic Surgeons 2018) recommendations regarding the choice of a revascularization strategy for combined coronary and carotid artery disease. Conclusions are drawn about the unresolved issue. A literature review of the largest series of Russian articles by one institution devoted to this topic was carried out. Hospital and long-term outcomes have been demonstrated, as well as predictors of complications for various revascularization strategies. The stages of creation and the results of approbation of a new computer program for risk stratifi cation, which makes it possible to determine the mathematical probability of the development of unfavorable cardiovascular events during the implementation of various surgical tactics, taking into account the individual characteristics of the patient. A conclusion was made about the effectiveness of this development.

INTRODUCTION Critical lower limb ischemia is a widespread disease that occurs due to atherosclerotic lesions of the arteries with progressive narrowing of their lumen. Clinically critical ischemia is manifested by pain at rest, resistant to narcotic analgesics, and/or ulcerative necrotic process on the legs. In the absence of treatment, patients undergo amputation of the lower limb. Almost all patients die 10 years after amputation of the lower limb at the level of the thigh. Currently, there are following methods of treatment of critical ischemia: conservative therapy, direct revascularization, lumbar sympathectomy and neurostimulation.

AIM OF STUDY To present the data of modern scientifi c literature on the use of lumbar sympathectomy and epidural spinal cord stimulation in the treatment of critical lower limb ischemia.

MATERIAL AND METHODS This review presents the latest data obtained as a result of studying domestic and foreign literature on the treatment of critical lower limb ischemia with lumbar sympathectomy and epidural spinal cord stimulation. Currently, lumbar sympathectomy is performed by surgical (open, mini-access and endoscopic) and percutaneous (chemical or radiofrequency) methods. Percutaneous access is becoming widespread due to its minimally invasiveness, maximum accessibility, ease of performance and low cost. Epidural spinal cord stimulation is performed for resistant pain syndrome. The mechanism of action of spinal stimulation is to block the transmission of nerve impulses at the level of the gelatinous substance of the posterior horns of the spinal cord during stimulation of afferent fi bers of a larger diameter (type A-alpha and A-beta fi bers).

CONCLUSION Spinal neurostimulation and lumbar sympathectomy are promising methods of treatment for critical lower limb ischemia in case of impossibility of direct revascularization. Lumbar sympathectomy can reduce the intensity of pain and improve the quality of life of patients. According to a number of studies, epidural spinal cord stimulation signifi cantly reduces the likelihood of amputation of the lower limb, and also reduces the intensity of pain in patients refractory to conservative therapy, as well as in those who are not indicated for direct revascularization of the arteries of the lower extremities. More large-scale studies are needed to determine the indications for the above methods.

The issues of medical evacuation by ambulance transport are still widely discussed by specialists. The authors of the article analyzed, using a clinical case as an example, the capabilities of the aviation medical brigade in the conditions of the city of Moscow, as well as the interaction of all emergency services of the metropolis in an emergency situation.

IM OF STUDY To show the possibilities of antegrade X-ray surgical techniques in the treatment of iatrogenic bile duct injuries after videolaparoscopic cholecystectomy.

MATERIAL AND METHODS The study included 24 patients with “minor” and 20 patients with “major” (according to Strasberg) iatrogenic injuries of the extrahepatic biliary tract. Antegrade endobiliary intervention was performed in 26 patients, including the “bridge-procedure” variant preceding the reconstructive surgery. Endobiliary drains were maintained during the reconstructive surgery and in the early postoperative period to control the viability of the anastomosis.

When a stricture of the biliodigestive anastomosis (BDA) was detected, balloon dilatation of the anastomotic area was performed. In the subgroup of “minor” injuries, external drainage of the subhepatic biloma in 18 people were supplemented with endoscopic papillotomy in 12 cases.

RESULTS In all patients with “minor” injuries of the biliary tree, X-ray surgical techniques were effective. In 11 patients with “major” bile duct injuries, cholangiostomy drainage was gradually transformed into external-internal drainage. In 2 trauma cases of classes D and E temporary antegrade stenting of the duct injury area with a coated self-expanding endobiliary stent was performed. The follow-up period after removal of the antegrade frame drainage ranged from 8 months to 14 years. There were no stricture or failure of BDA.

CONCLUSION Short-term external biliary drainage, including the use of rendezvous techniques, may be suffi cient to eliminate the failure of the cystic duct stump. Cholangiostomy drainage, temporary endobiliary stent allow preparing the patient for reconstructive intervention. Drainage marking of the damaged area facilitates the verifi cation of tubular structures in the reconstruction area. Preservation of drainage after reconstructive intervention is the prevention of failure of the biliodigestive anastomosis in the early postoperative period, the development of its stricture in the long term.

We planned to develop a tension-free hernioplasty method for giant and large postoperative ventral hernias. Twenty-three patients with complicated postoperative ventral hernias were operated on using the method. Ultrasound, computed tomography, and plain radiography of the abdominal organs were performed for diagnosis.

We have developed a tension-free hernioplasty method, where we placed a mesh implant between the fl aps of the hernial sac in order to isolate it from the abdominal organs and subcutaneous fat. When applying this method, positive results were obtained (this method is absolutely tension-free plasty of the anterior abdominal wall, since own tissues are not put together; the location of the mesh implant made it possible to signifi cantly reduce or almost completely avoid local complications, such as seroma, suppuration of the postoperative wound, fi stula formation.

This method can signifi cantly reduce the percentage of local complications and completely avoid compartment syndrome in the early postoperative period. In all patients operated on by the method, no relapses were observed during the follow-up period (3 years).

Radiation proctitis is a complication of radiation therapy used in the treatment of pelvic malignant tumors. The leading clinical symptom of this kind of late radiation complications is recurrent rectal bleeding, leading to the development of anemia. Despite the availability of modern drugs, conservative treatment methods remain ineffective, and minimally invasive endoscopic technologies are not applicable in all cases and can lead to the development of complications in the form of ulcers and fi stulas. About 20 years ago, the world scientifi c community recommended hyperbaric oxygenation (HBO) as a method of treating late radiation damage to the rectum. However, this technique has not been widely used.  We have presented the experience of treating the successful use of HBO in the treatment of a 50-year-old patient with chronic radiation proctitis complicated by recurrent rectal bleeding. Conservative and endoscopic methods of treatment in this patient were ineffective. This clinical observation demonstrates that HBO is an effective method of treating rectal bleeding associated with radiation proctitis.

Patient A., 65 years old, male. He was admitted to the City Alexandrovskaya Hospital with complaints of fever within 5 days to 39.0°C, dry cough, shortness of breath during exertion, pain in the right fl ank of the abdomen and right lumbar region for 7 days. Three days earlier, the patient had received a positive polymerase chain reaction test for the presence of SARS-CoV-2. Examination of the patient revealed a hemorrhagic rash on both legs. The patient was consulted by a dermatovenerologist, acute infectious hemorrhagic vasculitis, bullous form, was diagnosed.

According to multispiral computed tomography with angiography (MSCT AG) of the abdominal organs: the psoas major muscle on the right was thickened, its structure was determined by the accumulation of the contents of hemorrhagic density with signs of partial lysis in the marginal zone, with a total size of 52x48x148 mm. No data available for aortic aneurysm / dissection. The patient denied the presence of injuries, taking anticoagulant drugs. The psoas major muscle hematoma was regarded as spontaneous hematoma against the background of coagulopathy caused by COVID-19.

According to the MSCT data of the chest organs, it was visualized: polysegmental lesion in both lungs, numerous areas of compaction of the lung tissue were determined by the type of ground glass, with zones of consolidation and reticular changes in the structure. The degree of damage to the lung tissue was 55%.

In view of the fact that the patient had data for the presence of a hematoma of the psoas major muscle on the right, as well as hemorrhagic vasculitis, anticoagulant therapy was contraindicated. Laboratory tests revealed an increase in the level of procalcitonin up to 12.8 ng/ml, C-reactive protein up to 135.1 mg/l, leukocytes up to 13.46 10^9/l, ferritin up to 532.2 ng/ml, D-dimer up to 1145 ng/ml. A multidisciplinary council (infectious disease specialist, general surgeon, therapist, pulmonologist, vascular surgeon, dermatovenerologist, septologist) decided to revise and drain the hematoma of the psoas major muscle on the right, as a likely source of sepsis (increased procalcitonin). Under intravenous anesthesia, the hematoma was opened posteriorly peritoneally, evacuated (about 300 ml in volume), 2 drains were installed. On the 10th day after the operation, a control MSCT was performed, according to which the hematoma of the right psoas muscle decreased in size by half. A decision was made to remove the drains.

On the 13th day after admission to the hospital, the patient developed pain in the right forearm, hand, left leg and foot. Performed MSCT revealed hypertension of the arteries of the upper extremities and arteries of the lower extremities: thrombosis of the distal third of the brachial, ulnar and radial arteries; thrombosis of the superfi cial femoral artery (PFA) on the left. An anticoagulant therapy was started (heparin 7500 IU intravenously in a stream with subsequent transfer to continuous intravenous administration using an infusion pump with an initial rate of 1000 IU per hour, under the control of APTT with an indicator reaching 1.5–2.5 times higher than the norm), disaggregant therapy (acetylsalicylic acid 100 mg once a day), analgesic therapy (ketorol 1.0 ml/m). An emergency simultaneous operation was performed: thrombectomy from the brachial, radial, and ulnar arteries on the right under local anesthesia (transverse arteriotomy of the brachial artery, Fogarty catheters 3F, 5F) with satisfactory antegrade and retrograde blood fl ow; plus under spinal anesthesia, an attempt was made to thrombectomy, Fogarty 5 catheter passed freely, a weak retrograde blood fl ow was obtained, but after 3 minutes, repeated thrombosis of the PBA developed). That followed by femoral-popliteal prosthetics (above the knee joint gap) with a synthetic prosthesis “Ekofl on” with obtaining a satisfactory pulsation distally.

On the 21st day after the operation, the patient was discharged from the institution in a satisfactory condition.

The purpose of this work was to study the history of the development of traumatology-orthopedics at the N.V. Sklifosovsky Research Institute for Emergency Medicine.

Traumatology as an independent discipline began to form at the N.V. Sklifosovsky Research Institute for Emergency Medicine during the reign of Professor S.S. Yudin (chief surgeon since 1928), who invited the famous Argentinean traumatologist-orthopedist Professor Lelio Zeno to work at the institute.

In 1932, the trauma department of the N.V. Sklifosovsky Research Institute for Emergency Medicine was headed by Professor V.V. Gorinevskaya. She organized a 100-bed trauma clinic for the treatment of injuries to the head, spine, limbs, chest and abdominal cavity. She is rightfully considered one of the founders of trauma science in the USSR.

With the development of traumatology and orthopedics as an independent specialty in 1961, two clinics were formed at the institute. The first trauma clinic was run by Dr. med. sciences professor I.I. Sokolov. The second clinic was headed by Dr. med. Sci. P.N. Petrov.

In 1971, Dr. med. Professor, Honored Scientist of the Russian Federation, Academician of the Russian Academy of Medical and Technical Sciences of the Russian Federation V.P. Okhotsky was appointed the head of the traumatological service of the institute and the chief traumatologist of Moscow (from 1971 to 2001). With his active participation in Moscow, the reorganization of outpatient care was completed, work was widely launched on the medical aspects of the prevention of road traffic injuries and the introduction into practice of the most rational methods of diagnosis and treatment of patients with injuries of the musculoskeletal system. In the N.V. Sklifosovsky Research Institute for Emergency Medicine A.G. Suvalyan introduced the method of intramedullary osteosynthesis of long tubular bones (humerus, femur and tibia). Under the guidance of prof. V.P. Okhotsky the dissertation researches of A.G. Suvalyan, M.A. Suvalyan and S.S. Myakota were carried out. The expediency of early surgical intervention on the extremities in case of combined traumatic brain injury and multiple trauma of the extremities has also been proven, new functional methods of treatment of diaphyseal fractures of the shoulder, lower leg, spine and intra-articular injuries have been developed.

In close scientific cooperation with scientists from other clinics of the institute, a comprehensive method of treating open injuries of the limbs has been developed (dissertation researches of I.F. Byalik, I.Yu. Klyukvin, O.P. Filippov, M.V. Zvezdina, R.S. Titov). Much scientific work has been carried out to improve the diagnosis and treatment of intra-articular injuries of the knee joint (dissertation researches by M.A. Malygina, O.P. Filippov, A.Yu. Vasa).

From 2001 to 2016 the head of the department of emergency traumatology of the musculoskeletal system was a student of prof. V.P. Okhotsky – Dr. med. sciences, Professor, Academician of the Academy of Medical and Technical Sciences of the Russian Federation I.Yu. Klyukvin. Since 2016 the department is headed by Dr. med. sciences Alexey M. Fine.

The scientific developments of the employees of the Department of Emergency Traumatology have a practical orientation. Every year, the department’s employees successfully perform more than 2500 surgical interventions using advanced low-traumatic techniques, making extensive use of the achievements of biotechnology.