Introduction According to domestic and foreign authors, the leading cause of death in victims with polytrauma is blood loss. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is one of the new promising ways to manage bleeding in patients in a state of traumatic shock. There are a large number of publications in the world scientific literature indicating the high effectiveness of this technology in the treatment of bleeding. However, in the Russian Federation, this method has not yet entered into everyday practice, and scientific research on this matter is scarce. AIM Based on literature data and analysis of our own sample, to justify the need to use REBOA technology for the treatment of victims with polytrauma.

Material and methods A retrospective analysis of the medical records of patients with polytrauma admitted to the N.V. Sklifosovsky Research Institute for Emergency Medicine in 2021 was carried out. Data from medical records and the Results of forensic medical examinations were studied. The main sample included victims with polytrauma (Injury Severity Score, ISS, of more than 17 points) delivered from the scene of the incident in a state of traumatic shock (systolic blood pressure, SBP, of less than 90 mm Hg) and a verified source of bleeding. To assess the potential survival of victims, we used the Trauma Score and Injury Severity Score (TRISS) scale.

Results Of the 92 patients with polytrauma, 19 patients (20.6%) had indications for REBOA. The most common sources of bleeding were injuries to the pelvic ring, 14 (73.7%), abdomen, 11 (57.9%), and chest, 7 (36.8%). In 6 victims (31.5%), there were combined abdomen and pelvic injuries as the area of blood loss. The mean age of the victims was 48.8±19.9 years, the mean ISS value was 39.4±20.1. On admission, the mean SBP was 62.4±31.5 mm Hg, and heart rate — 91.8±43.3 beats/min. In 8 victims (42.1%), norepinephrine was administered immediately upon hospitalization at an average dose of 837.5±537.0 ng/kg/min. As a result of their injuries, 15 patients (78.9%) died, and 4 were discharged from the hospital. According to the Conclusions of forensic experts, the leading cause of death was blood loss in 11 (61.1%), severe traumatic brain injury (TBI) in 4 (22.2%), and infectious complications in 3 cases (16.7%).The TRISS was calculated for each patient. In order to identify the most potentially viable patients with indications for REBOA, we excluded 5 patients with severe TBI (the mean TRISS was 20.9±11.1%), and 5 patients with the TRISS of less than 50% (the mean TRISS was 10.0±14.1%), the latter died from hemorrhagic shock. Among the remaining 9 patients with higher TRISS values, 5 (26.3%) who died had the mean TRISS of 80.5±15.8%, comparable to the mean TRISS of 83.3±2.4% in the 4 survivors.

Conclusion 1. According to foreign and domestic publications, the technology of resuscitation endovascular balloon occlusion of the aorta (REBOA) is effective for stopping internal bleeding in patients with polytrauma. 2. When analyzing our own sample of patients, it was proven that 20.6% of patients with polytrauma had indications for the use of REBOA. Most of them (78.9%) died. The main cause of death was hemorrhagic shock. 3. About a quarter of patients (26.3%) with indications for REBOA had a potentially high chance of survival. In the future, the use of this technology may reduce the number of deaths.

Relevance Klebsiella pneumoniae is one of the main pathogens of nosocomial infections. Hospital strains of this pathogen are characterized by a high frequency of resistance to many antibiotics, including carbapenems. The main mechanism for the formation of resistance to carbapenems is the production of carbapenemases by bacteria. To date, K. pneumoniae is considered one of the main “distributors” of clinically important antibiotic resistance genes.

Aim of the study To study the frequency of occurrence of the most common carbapenemase genes in multiresistant K.pneumoniae strains isolated from patients of intensive care units in an emergency hospital.

Material and methods 4708 samples of various types of clinical material from patients of 5 intensive care units of the N.V. Sklifosovsky Research Institute for Emergency Medicine were analyzed. Microbiological studies were carried out using standard generally accepted methods. For the purposes of this study, unique sequential K.pneumoniae strains resistant to imipenem and/or meropenem were selected. DNA isolation was carried out using the RIBO-prep kit (Russia). Carbapenemase genes were detected by real-time PCR using the kits of reagents “AmpliSens MDR-MBL-FL” and “AmpliSens MDR-KPC/OXA-48-FL” on a “Rotor Gene” device (Corbett Research, Australia).

Results Etiologically significant microorganisms were detected in 64.7% of the studied samples. K. pneumoniae was isolated in a quarter of the samples. 194 unique carbapenem-resistant strains of K.pneumoniae were selected. Of these, 11.3% of the genes of the studied carbapenemases were not detected. In 38.1% of strains, 1 carbapenemase was detected, in 29.9% — two and in 20.6% — three or more. Among the strains with one carbapenemase gene, OXA-48 (19.1%) and CATTLE (13.4%) producers prevailed. Strains producing only NDM betalactamase were found in 5.7% of cases. Isolated allocation of VIM and IMP was not detected. In 34%, metallobectalamases were isolated in combination with serine carbapenemases. The production of serine carbapenemases alone was detected in 48.5% of the strains. Depending on the specialization of the intensive care unit, there are differences in the frequency of detection of serine and metallobetalactamases in strains of carbapenem-resistant Klebsiella.

Conclusion K. pneumoniae is the causative agent of nosocomial infections in 25% of cases. In 11.3% of carbapenem-resistant strains, the production of KPC, OXA-48, NDM, VIM and IMP genes was not detected. When developing algorithms for antibacterial therapy, it is necessary to take into account that from 25.7% to 60.6% of K. pneumoniae strains in different intensive care units are the producers of metallobetalactamases.

Aim of study To study the effect of local phage therapy alone and in combination with systemic antibiotic therapy on the dynamics of microflora colonizing the skin of the periwound area during surgical treatment of infected burn wounds.

Material and methods Scientific hypothesis: the use of local phage therapy in monotherapy in the treatment of burn wound infections reduces the risk of colonization of the skin of the periwound area by bacteria of the ESKAPE group. The experimental study analyzed the results of microbiological studies of washings from the skin surface of 40 animals with infected burn wounds, in the course of phage therapy in monotherapy and in combination with systemic antibiotic therapy.

Results In the group of animals receiving phage therapy alone, the proportion of ESKAPE group bacteria colonizing the skin of the periwound area at the time of completion of the course of antimicrobial therapy was 9%, while in the group receiving phage therapy in combination with systemic antibiotic therapy it was 43% (p=0.011).

Conclusion The use of local phage therapy in single mode during the surgical treatment of infected burn wounds reduces the risk of colonization of the skin of the peri-wound area by pathogens of the ESKAPE group. At the same time, systemic antibiotic therapy causes an imbalance of resident and transient skin microbiota in the periwound area and an increase in the frequency of its colonization by pathogens of the ESKAPE group.

Abstract The problems of preventing postmanipulation pancreatitis (PMP) remain the subject of debate and a lot of research from leading scientific clinics around the world. The article is devoted to the assessment of prevention methods of PMP in patients with lesion of the pancreaticobiliary zone who underwent transpapillary interventions. Aim of the study Evaluation of the effectiveness of the author’s method of preventing PMP.

Material and methods A prospective two-center randomized study included 545 patients treated in the Department of Liver Surgery and General Surgery in 2020–2022, who underwent ERCP and endoscopic papillosphincterotomy. There were 146 (26.8%) male patients, and 399 (73.2%) female patients, aged from 18 to 92 years, the mean age 62.7±7.4 years. Patients were divided into 3 groups according to the method of preventing PMP: in the 1st group, standard drug premedication was supplemented with two postbulbar blocks with a solution of lidocaine 0.5% 10 ml before and after the intervention (RF Patent No. 2779221, 09/05/2022), in the 2nd group standard premedication was combined with placebo was used, and in the comparison group 3 no submucosal injections were performed. The monitoring of clinical manifestations of PMP and the level of amylase was carried out every 12 hours until the parameters normalized. Statistical processing was carried out using program STATISTICA 6.1 for Windows.

Results The frequency of mild pancreatitis, corresponding to the criteria for PMP, did not exceed 18% in groups 1 and 3 (p=0.3408), but was lower with pseudo postbulbar block, 9% (χ2=2.83, р=0.0926), the difference was not statistically significant. The incidence of severe pancreatitis was significantly lower in group 1 with double postbulbar block where there were no cases of pancreatic necrosis among 143 patients (χ2=6.19, р=0.0129). The mortality did not differ significantly among groups (χ²=0.15, р=0.7004). The duration of the hospital period had significant differences between groups (Student’s t-test 1.973, p=0.001). The hospital period with double postbulbar block turned out to be significantly shorter.

Conclusion 1. Double postbulbar blockade significantly reduces the risk of developing severe postmanipulation pancreatitis, regardless of existing risk factors. 2. Double postbulbar block significantly reduces the duration of the hospital period after endoscopic papillosphincterotomy. 3. Pseudo postbulbar block using saline requires further evaluation as a possible way to prevent mild pancreatitis.

Relevance Abdominal aortic aneurysm is a common disease, manifested by an expansion of the abdominal aorta of more than 3 cm and accompanied by the development of serious complications with high mortality. There are symptomatic aneurysms, asymptomatic aneurysms and ruptured aneurysms. The timing of surgical intervention for symptomatic aneurysms still causes some controversy.

Aim of study To determine the tactics and timing of surgery in patients with symptomatic abdominal aortic aneurysms.

Material and methods The medical histories of 188 patients with symptomatic abdominal aortic aneurysms admitted to the Department of Vascular Surgery of N.V. Sklifosovsky Research Institute for Emergency Medicine. There were 152 men (80.8%) and 36 women (19.2%). The average age of those admitted was 69.8±2.5 years (from 53 to 84 years).

Results All patients were divided into three groups, depending on the time of operation from the moment of admission: those operated in the first 24 hours (n=27); those operated from 24 to 72 hours from the moment of admission (n=20) and those operated later than 72 hours (n=136). The mortality by group was 14.8% in the first group, 20.0% in the second group, 7.3%in the third group.

Conclusions Patients with symptomatic abdominal aortic aneurysm should be admitted to the intensive care unit for evaluation and preparation for delayed surgery. In cases where hospitalization in the intensive care unit is impossible or pain persists, the patient should be operated on urgently. When the pain syndrome is relieved and blood pressure is normalized, the patient can be further examined and operated on in a delayed manner.

Relevance Treatment of complicated forms of acute destructive appendicitis continues to be an urgent problem in emergency abdominal surgery. Aim of study Improving the results of surgical treatment of patients with appendiceal peritonitis with laparoscopic appendectomy.

Material and methods A retrospective analysis of the treatment of 150 patients with acute appendicitis complicated by local and diffuse peritonitis aged from 17 to 69 years was carried out. There were 77 (51.3%) women and 73 (48.7%) men. Depending on the treatment tactics used, two groups of patients were divided. In the main group (64 patients), the leading treatment method was laparoscopic appendectomy. In the comparison group (86 patients), traditional approaches were used, including open appendectomy with the McBurney approach in 72 patients (83.7%) and laparotomy for diffuse peritonitis in 14 (16.4%).

Results The analysis of the surgical techniques used showed that in the main group, wound postoperative complications developed in 9 patients (14.1%). In the comparison group, postoperative complications developed in 32 patients (37.2%). For local non­limited peritonitis, the total duration of hospitalization after laparoscopic appendectomy performed in 49 patients was 6.7±1.4 days, and 8.6±2.1 days (p<0.05) in 72 patients who underwent open appendectomy. The duration of hospitalization was 8.2±2.7 days in case of diffuse peritonitis after laparoscopic appendectomy, sanitation and drainage of the abdominal cavity (15 cases), and 12.4±1.3 days (p<0.05) in 14 patients after laparotomy, appendectomy, sanitation and drainage of the abdominal cavity, intubation of the small intestine.

Conclusion Laparoscopic appendectomy may be the operation of choice for complicated forms of acute appendicitis according to developed indications. It should be performed by a surgeon experienced in endosurgical operations. To increase the efficiency of washing the abdominal cavity in case of diffuse peritonitis, it is recommended to use hardware sanitation. The capabilities of laparoscopic appendectomy make it possible to adequately perform the required amount of surgical treatment, minimize surgical trauma, and significantly reduce the rate of postoperative complications and the duration of hospital treatment compared to open appendectomy.

Introduction Perioperative cognitive impairment occurs in both pregnant and non-pregnant women. Prediction, early detection and effective treatment of these disorders are important for the well-being of women and their offspring.

Aim of study To evaluate the effect of anesthesia and surgery on the level of anxiety, depression, short-term memory, and concentration in pregnant and nonpregnant women.

Material and methods The observational prospective study included 120 patients who were divided into two equal groups — pregnant (n=60) and nonpregnant (n=60) women. A comparative analysis of testing psychosomatic reactions and cognitive functions using the MoCa test, Benton and Wechsler tests, selfassessment questionnaire, Hospital Anxiety and Depression Scale (HADS) was carried out. The relative risk and odds ratio of developing anxiety and depression were calculated.

Results Anxiety indicators in pregnant women before surgery reached subclinical values of 7.5 (8.4; 6.6), and in non-pregnant women – the norm: 6.5 (7.3; 5.7) (p<0.001); Results of depression in pregnant women after surgery were 7.3 (8.5; 6.1), in non-pregnant women — the norm: 6.3 (7; 5.5) (p<0.001). The odds of developing short-term memory impairment in pregnant women before surgery was 3.1 times higher than in non-pregnant women, odds ratio 3.1 (95% CI [1.3–7.4]). In the pregnant group, short-term memory scores before surgery were 5 (5.8; 4.2), and after surgery they decreased to 3.8 (4.7; 2.9) (p<0.001). There was a decrease in concentration of attention in pregnant women: before surgery 6.2 (6.8; 5.6), and after surgery — 5 (5.8; 4.2) (p<0.001). The relative risk (RR) of developing depression in pregnant women after surgery was 6.1 times RR=6.1 (95% CI 2.4; 15.8), sensitivity Se (%)=0.9, specificity Sp (%)=0.5. The relative risk (RR) of developing short-term memory impairment after surgery was 1.1 times RR=1.1 (95% CI 1; 1.2), sensitivity Se (%)=0.5, specificity Sp (%)=0, 8. The relative risk (RR) of developing problems with concentration after surgery was 8.3 times RR=8.3 (95% CI 3.9; 18.3), sensitivity Se (%)=0.8, specificity Sp (%)=0.7.

Conclusions The Results obtained allow us to conclude that before surgery, pregnant women experience a subclinical version of anxiety, against the background of which the chances of developing problems with short-term memory and concentration increase. After surgery, pregnant women experience a subclinical version of depression, along with it there is also impairment of intelligence, short-term memory and concentration. The initial impairment of memory and attention requires the selection of anesthesia in a group of pregnant women.

Relevance In recent years, local hemostatic agents have become widespread, as their application at the incision area of the major duodenal papilla can stop or prevent bleeding. Aim of study To study the efficacy of topical application of incomplete silver salt of polyacrylic acid (PAAg) (Haemoblock) for the prevention and treatment of bleeding from the papillosphincterotomy area.

Material and methods The prospective study included 211 patients who were hospitalized at the Regional Clinical Hospital in Ryazan from 2020 to 2023. In the main group of patients, for the purpose of hemostasis and prevention of bleeding, the area of the dissected major duodenal papilla was irrigated with 20 ml of an aqueous solution of PAAg. In the control group, irrigation was carried out with 20 ml of 0.9% sodium chloride. The main group included 111 patients (44 men, 67 women, mean age 55.09±20.97), the control group included 100 patients (43 men, 57 women, average age 53.85±20.34).

Results In the main group of patients, bleeding from the MDP incision was observed in 83 cases after papillosphincterotomy, and in 82 cases in the control group. After irrigation with an aqueous solution of PAAg, bleeding from the MDP incision was arrested within 120 seconds in the main group in 70 patients, and in 51 patients in the control group, after irrigation with 0.9% sodium chloride solution. Within 300 seconds from the initiation of irrigation, hemostasis occurred in 12 of the 13 remaining patients in the main group with ongoing bleeding and in 27 of 31 patients in the control group. In two patients in the control group, bleeding was managed in 300 seconds without additional methods of endoscopic hemostasis. The use of additional methods of endoscopic hemostasis due to ongoing bleeding in the main group was required in one patient; the incision area was injected with an adrenaline solution. In the control group, additional endoscopic hemostasis was performed on two patients: in one case, injection with an adrenaline solution, in the other, diathermocoagulation of the incision area of MDP. In the early postoperative period, delayed bleeding was detected in 3 patients of the main group, which was significantly lower than the same indicator in the control group (7 observations).

Conclusions Local application of PAAg for the treatment of early bleeding in papillosphicterotomy showed a significantly faster onset of hemostasis.

Aim of study To analyze clinical, laboratory, instrumental and microbiological data in patients with diagnosed liver abscesses who had previously had a new coronavirus infection.

Material and methods An analysis of the work carried out with 13 patients who received treatment at the surgical clinic of the Botkin Hospital in the emergency surgical department No. 76 from September 2021 to October 2022 for liver abscesses and previous COVID-19 is presented.

Results All presented patients were comprehensively examined. Surgical intervention was performed — transcutaneous drainage of liver abscesses under ultrasound guidance. Positive changes were revealed in the course of complex therapy, including antibacterial (based on the Results of a microbiological study with determination of the sensitivity of the flora to antibacterial drugs), anti-inflammatory, and daily sanitation of the abscess cavity. All patients were discharged for outpatient follow-up treatment in stable, satisfactory condition. Nine patients (69.2%) were discharged with drain under the supervision of clinic doctors. In 5 patients (30.8%) with regression of the abscess cavity, drainage from the abscess cavity was removed before discharge.

Conclusion Patients with previous COVID-19 may develop liver abscesses. It is important to conduct thorough diagnostic measures in patients who present with fever and (or) abdominal pain after a coronavirus infection. Further prospective studies are needed, including morphological assessment of liver changes (upon autopsy in case of death).

Relevance Traumatic brain injury (TBI) remains one of the leading causes of morbidity and mortality worldwide. Despite advances in treatment based on understanding of the mechanisms of brain injury after TBI, there is a clear need for new therapeutic strategies. Remote ischemic postconditioning (RIPostC) can be considered as a non-pharmacological technique to reduce secondary brain damage and improve clinical outcomes in patients with TBI.

Aim of study Raising awareness of emergency physicians, neurosurgeons, neurologists, neurophysiologists about the possible use of the concept of RIPostC in patients with TBI.

Material and methods To achieve this goal, the Results of clinical and experimental studies of the use of RIPostC after TBI were analyzed. Literature search was carried out in electronic search systems PubMed (https://pubmed.ncbi.nlm.nih.gov), eLibrary (https://elibrary.ru) using the keywords: “traumatic brain injury”, “remote ischemic conditioning”. A systematic search and selection of publications was performed in January–February 2023. The results of the review included patients with an established diagnosis of traumatic brain injury, followed by the use of RIPostC and animals with experimental modeling of TBI in various ways, followed by RIPostC.

Conclusion The totality of data suggests that the use of the concept of RIPostC as a non-invasive protective technique in the provision of emergency care for patients with TBI may contribute to limiting secondary brain damage. However, the underlying neuroprotective processes are quite complex and need further study. Establishing the relationship of humoral, neurogenic and inflammatory reactions in response to the use of RIPostC in TBI will contribute to understanding the mechanisms of emerging neuroprotection, help ease the course of the disease and improve the clinical outcome.

Introduction Currently, bronchial lavage (BL) is widely used in clinical practice for the treatment of severe bronchopulmonary lesion in adults. However, indications and contraindications for this procedure are not fully defined. In addition, it was not possible to find in the literature a classification of either BL in general or used for therapeutic purposes in particular, which significantly complicates the standardization of procedures for its use in various diseases.

Aim of study To determine possible classification characteristics, as well as indications, contraindications for therapeutic BL in adults and possible complications that may arise, based on the analysis of literature data.

Results Therapeutic BL can be carried out both as planned and for health reasons. Indications for planned BL are purulent bronchitis, pneumonia, purulentdestructive infiltration, as well as chronic lung diseases: bronchiectasis, interstitial lesions. In turn, the indication for emergency therapeutic BL is progressive acute or chronic respiratory failure, developing due to bronchial obstruction. Such conditions may include massive pulmonary hemorrhage, acute obstruction of the bronchi with mucus and pus, postoperative atelectasis and hypoventilation of the lungs, aspiration of gastric contents, severe bronchial asthma, purulent destruction of the lungs, acute respiratory distress syndrome, thermochemical lesions of the respiratory tract. Contraindications to therapeutic BL can be both absolute and relative. Absolute contraindications are intolerance to drugs used for local anesthesia; decompensated heart and (or) pulmonary failure; acute cerebrovascular accident; various types of arrhythmias; stenosis of the larynx and (or) trachea II–III degree; neuropsychiatric diseases; pain syndrome in the abdominal cavity; extremely serious condition of the patient, when clarification of the diagnosis can no longer affect treatment tactics. Relative contraindications include acute respiratory disease of the upper respiratory tract; coronary artery disease; severe diabetes mellitus; pregnancy (second half); chronic alcoholism; grade III enlargement of the thyroid gland. It should be noted that most of the absolute contraindications are conditional and are not taken into account when performing BL according to vital indications with appropriate medical and technical support. Classification of BL used for medicinal purposes can be carried out according to the following criteria: method of sanitation; access used; level of sanitation; sanitized area; volume and composition of the lavage solution. It is noteworthy that the methods of carrying out procedures for various conditions and diseases still remain unregulated. An exception is the final stage of the therapeutic BL procedure in the case of the use of surfactant preparations, which standardization is regulated by approved standard operating procedures. It should also be noted that bronchial lavage for therapeutic purposes is justified from a pathoanatomical and pathophysiological point of view, but is accompanied by serious, albeit temporary, changes in the lungs, which can be partially avoided by improving the lavage technique.

Conclusion All of the above indicates that in order to solve existing problems, it is necessary to conduct systematic research in this direction with the involvement of all interested specialists.

Abstract Tracheal rupture is an urgent life-threatening complication that relates to complex and poorly understood areas of trauma surgery. The article presents a review of modern world and domestic literature on instrumental tracheal ruptures, the Relevance of early diagnosis and various treatment methods. Based on an analysis of modern literature data, the article describes the issues of conservative and surgical treatment methods, as well as an assessment of their results. The problem of the diagnostic algorithm and the choice of conservative, surgical treatment has not been solved and remains relevant. The issues of treating patients with a defect in the membranous wall of the trachea in intensive care and in need of artificial ventilation in clinical practice remain unresolved. All of the above indicates the Relevance of the study.

Aim of the study To present data from domestic and foreign literature on the diagnosis and treatment of instrumental tracheal ruptures.

Material and methods A review of the literature was carried out for the period from 1993 to 2024 in Russian and English, available on the databases Pubmed, Medline, UpTodate, Scopus, E-library, on topics such as post-intubation tracheal rupture, iatrogenic tracheal rupture, diagnosis and treatment of instrumental tracheal ruptures, closed tracheal injury.

Results The concept of the classification system, risk factors, etiopathogenesis is outlined. Information is provided on the diagnostic significance of computed tomography and tracheobronchoscopy. Close attention is paid to the methods and choice of treatment tactics, the principles of intraoperative tactics, and the strategy of conservative treatment. A comparative assessment of treatment Results and their complications with a conservative or surgical treatment approach is given.

Conclusion Thus, an analysis of domestic and foreign literature indicates that the issues of diagnosis and treatment of iatrogenic tracheal injuries remain largely unresolved. There is no generally accepted algorithm for instrumental diagnosis of tracheal ruptures. There are no uniform approaches to determining indications and contraindications for conservative and surgical treatment of tracheal injuries. There are diametrically opposed opinions regarding the choice of treatment tactics. These contradictions create significant difficulties in assessing the Results of treatment of this complex category of patients.

Relevance The number of amputations performed on patients with diabetic foot syndrome is increasing all over the world. Almost half of these operations are the so-called “minor amputations” carried out within the foot. The high recurrence rate of neuropathic ulcers, impaired biomechanics, and a decrease in the quality of life of patients after these surgeries encourage the study of this problem and the search for possible treatment options due to the capabilities of surgical treatment for post-amputation foot deformities.

Aim of study To evaluate the nature of surgical interventions for post-amputation foot deformities in patients with diabetic neuropathy.

Material and methods The literature search was carried out in the databases of medical publications PubMed, CyberLeninka, Google Scholar, Scopus, Medline, eLIBRARY among articles in English and Russian. The search was performed using the following terms: transmetatarsal resection, diabetic foot syndrome, transmetatarsal amputation, minor amputation.

Results Surgical treatment methods for deformities after amputation of part of the forefoot are widely presented in the world literature and are more studied. The possibilities of correcting foot deformities that occurred after amputation of the entire anterior section (from transmetatarsal amputation to the level of the Chopart`s joint) are less covered, this direction and methods have been studied to a lesser extent.

Conclusions Surgical methods for the correction of post-amputation foot deformities have firmly entered the wide international practice. Their effectiveness is confirmed by studies with a high level of evidence. Nevertheless, a wider, academic research of the problem of orthopedic status in patients with this pathology and the corresponding methods of surgical treatment is required.

Relevance In modern realities, medical workers, primarily representatives of surgical specialties, are increasingly faced with the need to have legal literacy, since medical activities associated with surgical practice are associated with high legal risks.

Aim of study Studying the legal training of surgeons in the Republic of Tatarstan based on the experience of participating in criminal proceedings in cases related to improper provision of medical care.

Material and methods During the period from May 15 to May 31, 2021, an anonymous survey of 124 surgeons from various medical organizations of the Republic of Tatarstan was conducted. The questionnaire consisted of 13 multiple-choice questions with an additional field for comments. The participation in the survey was voluntary, and the questions were devoted to the experience of participation in criminal proceedings in “medical” cases and the need for legal training in this matter.

Results Among those surveyed, 51.5% of respondents at least once during the years of their career gave explanations to law enforcement agencies regarding the unfavorable outcome of medical care, and 38.7% were directly involved in a criminal case. According to 52.2% of respondents, the most common reason for complaints to law enforcement agencies is the inadequacy/bad manners of patients. The vast majority of doctors surveyed are guided in their activities by currently existing procedures, orders, standards and clinical recommendations. However, more than 37% of doctors have no idea how to act in the event of a criminal case being initiated due to an unfavorable outcome of medical care, and for 71.0%, medico-legal training is “highly relevant”.

Conclusion The problem of criminal liability for improper provision of medical care for surgeons in the Republic of Tatarstan is extremely relevant. There is an urgent need to develop interdisciplinary formats for interaction between the medical, forensic and legal communities in order to improve the legal literacy of medical workers and reduce criminal risks in surgical practice.

Aim of study To evaluate the safety and efficacy of percutaneous transhepatic cholangiostomy (PTC) as a first-line intervention in the treatment of patients with acute cholangitis (AC) Grade II–III (TG 13/18).

Material and methods The results of treatment of 42 patients with AC Grade II–III, who underwent PTC, were analyzed. The criteria for non-inclusion were the presence in patients of destructive cholecystitis and (or) acute pancreatitis, AC due to proximal block of the bile ducts, regardless of etiology, as well as the presence of cholangiogenic liver abscesses. Literature data were used as reference results of the use of endoscopic techniques. AC was diagnosed and its severity was determined in accordance with the diagnostic criteria TG 13/18. The control points of the study were the frequency of post-manipulation complications associated with PTC, as well as the immediate efficacy of cholangiostomy, assessed by the dynamics of Grade-status within 24 and 48 hours.

Results In all 42 patients, PTC was technically successful. Major complications that might require a change in treatment tactics (significant hemobilia, bile peritonitis, bleeding into the abdominal cavity) were not observed. Two complications occurred: subcapsular hematoma (2.4%) and right-sided pleurisy (2.4%). When assessing the dynamics of Grade status, its significant decrease was found in the group of patients with initial Grade III after 24 hours (from 16 to 9 hours) and 48 hours (from 9 to 4 hours). In patients with initial Grade II status, in three cases it worsened to Grade III, which still persisted in one patient even in 48 hours. There was no in-hospital mortality in the examined patients.

Conclusion Antegrade endobiliary intervention for acute cholangitis involves performing real-time monitored biliary decompression. Experience with the use of percutaneous interventions does not confirm the high risk and frequency of post-manipulation complications in comparison with endoscopic retrogradeprocedures. It seems obvious that there is a need for and the possibility of choosing both retrograde and antegrade methods of emergency biliary decompression in the arsenal of treatment for patients with acute cholangitis.

Background Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is a critical care treatment option for patients with refractory cardiogenic shock. This method of temporary support of the cardiorespiratory system gives us and the patient time to restore organ function or is a «bridge» to other methods of treatment. Nevertheless, the issue of identifying the optimal time for VA ECMO implantation in patients with acute myocardial infarction complicated by refractory cardiogenic shock remains relevant.

Aim To evaluate the efficiency of extracorporeal membrane oxygenation in various clinical situations in patients with acute myocardial infarction complicated by refractory cardiogenic shock and post-infarction damage to the valves of the heart.

Material and method We present 3 patients with acute coronary syndrome complicated by refractory cardiogenic shock, of different age groups and comorbidities, who underwent veno-arterial extracorporeal oxygenation in various SCAI shock stages, and mechanical complications associated with acute myocardial infarction.

Results In all the cases, stabilization of hemodynamics and heart function was achieved, and there were no hypoxic disorders of organs. In one case, a hemorrhagic complication associated with the VA ECMO procedure was noted. In one case, VA ECMO was performed as an intermediate stage for the correction of post-infarction mitral valve injury.

Conclusion These clinical cases demonstrate the efficiency of the timely start of VA ECMO before the development of organ dysfunction, which allows restoring myocardial function, and helps maintain hemodynamic normalization before the cardiac surgical stage of treatment.

The article presents a case of using the trunk of the great saphenous vein from a living related donor in elective surgery for the main arteries of the lower leg. The possibility of using a vein from a relative in special clinical situations is shown. High risks of repeated interventions aimed at relieving early and late complications of vascular reconstructions remain an urgent problem in angiosurgery. Very often, operations are performed in the presence of extensive necrosis and trophic ulcers (stage IV according to the Fontaine-Pokrovsky classification). The gold standard for choosing a shunt during reconstructive operations on the infrainguinal arteries was and remains an autovenous conduit from the great saphenous vein (C, D type of arterial bed lesion according to TASC II). During repeated reconstructions in the absence of a suitable autovein and with the distal position of the peripheral anastomosis, it is not always possible to use a synthetic prosthesis as a reliable alternative. Unsatisfactory Results of using such materials dictate the need to choose a suitable graft. The problem of using allografts requires further in-depth study. In this regard, the case of using a donor vein as a material for reconstruction is given. It was concluded that it is possible to effectively use allovein from a related donor in a patient after previously performed reconstructive interventions and in the absence of autologous material for bypass surgery.

Background Spotted hemlock (Conium maculatum) is one of the most poisonous plants. Hemlock poisoning is extremely rare, but can lead to serious consequences, including death.

Material and methods A clinical observation of a 50-year-old patient with a diagnosis of hemlock poisoning is presented.

Conclusion The clinical observation of acute hemlock poisoning presented by us does not exclude its direct cardiotoxic effect and requires further research in this direction, which will allow optimizing the treatment of this group of patients.

The problem of iatrogenic damage to the extrahepatic bile ducts during cholecystectomy remains relevant. Insufficient experience of the surgical team, limited knowledge of the topographic anatomy of the subhepatic space, especially in conditions of perivesical inflammatory infiltrate, poorly timed access conversion are some of the main reasons.

The results of treatment of these patients depend on the timing of recognition of the injury, the type of the injury, the characteristics of reintervention, and timely reconstructive surgery performed in a specialized center. Up to 30 % of damage occurs due to combined injury to the extrahepatic bile ducts and afferent vessels of the liver, which aggravates the course of the disease.

We report a clinical case of a female patient. The fragment of the hepaticocholedochus was excised during a planned cholecystectomy. In the same clinic, the primary reconstructive operation was performed (drainage of the hepaticocholedochus using a Kehr’s drain). Afterwards, an external fistula of the common hepatic duct was formed. The reconstructive operation was performed 4 days after the initial operation, in a specialized department of the regional clinical hospital. Relaparotomy was performed. In a dense inflammatory infiltrate during mobilization of the suspected hepaticocholedochus, a Kehr’s drain was identified, which distal branch was not located in the lumen of the bile duct. Thrombosis of the right hepatic artery was diagnosed. The Kehr’s drain was removed, the lobar ducts were identified to their confluence, and the confluence was preserved. The distal stump was sutured. Next, arteriotomy and thrombectomy were performed, and adequate retrograde and antegrade blood flow was recoverd. A hepaticoenteroanastomosis has been formed. The patient was discharged with recovery. When examined after 2 months, the condition was satisfactory. Timely diagnosis of thrombosis of the right hepatic artery, adequate revascularization and biliary reconstruction made it possible to avoid liver necrosis and achieve a good treatment outcome.

The article presents a clinical case of adrenal dysfunction in a patient with severe community­acquired pneumonia requiring extracorporeal membrane oxygenation. We discuss the lack of diagnostic criteria for adrenal dysfunction in critical conditions; the tactics of hydrocortisone treatment: initiation of use, its duration, dose titration and withdrawal conditions.

Abstract A clinical observation of the successful treatment of an HIV-infected patient with esophageal-pleural fistula and pleural empyema after diverticulectomy is presented, where the key tactical decision was the use of transluminal vacuum therapy together with adequate drainage of the pleural cavity and correct drug therapy. When analyzing the available literature, no publications concerning the treatment of HIV-infected patients with the discussed esophageal pathology were found.

Aim of study To discuss the Results of treatment of postoperative esophageal-pleural fistula using transluminal vacuum therapy in a patient with HIV infection.