INTRODUCTION The main reasons for the unsatisfactory outcome of surgical treatment of patients with non-traumatic subarachnoid hemorrhage (SAH) due to ruptured cerebral aneurysms are vascular spasm (VS) and delayed cerebral ischemia. Lysis of blood clots in the subarachnoid space leads to the release of a large number of various vasoactive factors that stimulate cytotoxic, inflammatory reactions and oxidative stress, which may be one of the reasons for the development of VS and secondary ischemic brain damage.

THE AIM OF THE STUDY Study of the dynamics of oxidative stress indicators and factors of endogenous vascular regulation in patients with non-traumatic SAH due to ruptured cerebral aneurysms.

MATERIAL AND METHODS A total of 80 patients in the acute period of SAH due to ruptured cerebral aneurysms were treated and examined. The average age of the patients was 51.7 years. The control group (norm) included 25 practically healthy people, whose average age was 32.7±8.6 years. The study used the blood serum and cerebrospinal fluid of the patients. The study points were 0, 1, 3, and 7 days after the patient’s admission to the hospital. The severity of oxidative stress was assessed by the level of malonic dialdehyde (MDA) and total antioxidant activity of blood serum (TAA); vasotonic function of vascular endothelium by the content of stable metabolites of nitric oxide (NOx) and the concentration of angiotensin-converting enzyme (ACE). Biochemical studies were carried out on the biochemical analyzer “Olympus AU 2700” (Beckman Coulter, USA).

RESULTS It was revealed that patients with SAH already had pronounced oxidative stress upon admission to the hospital (increased MDA level, decreased TAA level), which led to an imbalance in the endogenous regulation of vascular tone (decreased NOx level, increased ACE concentration) and increased by the 7th day after admission to the hospital. High lactate dehydrogenase (LDH) activity was observed, the peak of which was on the 7th day of observation. Determination of LDH activity may be promising as a biomarker of ischemic brain injury and a prognostic indicator of the development of an unfavorable outcome.

CONCLUSIONS The obtained data indicate the need for a comprehensive approach to the treatment of patients with subarachnoid hemorrhage. The most relevant therapeutic goal is the removal of blood from the subarachnoid space of the brain to prevent increased oxidative stress and angiospasm.

RELEVANCE In order to objectify the diagnosis of acute appendicitis, a number of scales have been developed, the foreign practice of using which implies performing computed tomography in the case of obtaining intermediate point values corresponding to the average probability of acute appendicitis. This tactical solution, which is still difficult to implement in domestic conditions, limits the use of diagnostic scales and serves as a reason to search for other ways of using them.

AIM OF THE STUDY To evaluate the external validity of the AIRS, Ripasa, AAS and Alvarado scales on the available clinical material and upon obtaining satisfactory results, to determine the applicability of these classifiers in matters of making specific tactical decisions.

MATERIAL AND METHODS The work is based on the analysis of medical records of 293 patients hospitalized with suspected acute appendicitis at the St. Petersburg State Healthcare Institution “Elizavetinskaya Hospital” in the period from 2019 to 2022. Using information on postoperative diagnoses, the values of the AIRS, Ripasa, AAS and Alvarado scores were retrospectively calculated for each of the patients examined, followed by a comparison of the results obtained and the outcomes of hospitalization by conducting a regression analysis.

RESULTS The AIRS, Ripasa, AAS, and Alvarado scales for assessing the probability of acute appendicitis, as applied to the analyzed group of patients, demonstrated external validity due to the preservation of referral threshold values, good description of the studied binary variance (AUC greater than 0.8), and sufficiently high adjusted correlation coefficients (from 0.57 and higher). The final diagnostic accuracy for all analyzed classifiers did not differ statistically significantly and was at acceptable levels of 78.8%, 76.7%, 76.7%, and 75.7% for the AIRS, Ripasa, AAS, and Alvarado scales, respectively (p=0.115). The hypothetical choice of the upper limit of low risk as the threshold value after which all patients are subject to diagnostic laparoscopy may lead to a statistically significant decrease in the number of inpatient observations of patients with acute appendicitis without increasing the frequency of diagnostic laparoscopies in healthy patients.

CONCLUSION The use of the AIRS, Ripasa, AAS and Alvarado assessment scales is advisable both from the standpoint of diagnosing acute appendicitis and for making tactical decisions, provided that patients with intermediate scale values are shifted towards active surgical actions.

RELEVANCE Many clinical conditions are considered in a sequence of interrelated events of the continuity of the pathological process. This makes it possible to discover its patterns, specific mechanisms of occurrence and development of the disease. However, the continuum of sudden cardiac death (SCD) remains unknown.

AIM OF THE STUDY To clarify the sequence of events of the continuum of the SCD using the example of initially healthy workers of locomotive crews of the Trans-Baikal Railway.

MATERIAL AND METHODS Based on the material of a 6-year prospective observation of a natural group of 7,959 men aged 18–66 years, predictors of microalbuminuria (MAU), creatininemia (CR), reduced glomerular filtration rate (rGFR), retinopathy (RP), and SCD were determined in 22 positions. A 2×2 table, multivariate regression analysis, and survival analysis were used, and the relative risk of risk factors (RF) was estimated, which made it possible to study and construct a continuum of chronic kidney disease from pre-prepared symptomatic blocks: MAU, RP, CR, rGFR using the synthesis method based on the principle of assembling puzzles, to which the SCD block was added according to this principle.

RESULTS The formation of SCD depends on the set of risk factors in each individual case and can occur from any peripheral point of the SCD continuum (from the risk factor). The formation of SCD is determined by the proximity of the predictor to the outcome, its independent effect and (or) interaction with other risk factors. The most dangerous predictor of SCD is excessive alcohol consumption, which causes damage to the heart and (or) kidneys, closing the dysfunctional circle of re-entry cardiorenal continuum and forming cardiorenal syndrome. In the population, those most at risk of SCD are those with an initially low number of nephrons and (or) a congenital defect of the microcirculatory bed.

CONCLUSION Further study of the continuum of sudden cardiac death is needed to determine whether cardiac or renal involvement is primary and whether the risk of sudden cardiac death increases. cardiac death when each predictor is added to the continuum of sudden cardiac death, the effects of risk factor damage, their increasing power with prolonged exposure, the magnitude of tissue damage, and the probability and timing of sudden cardiac death.

BACKGROUND The article presents statistics indicating an increase in suicide risks in old age in modern society, as well as research data on various risk factors in the elderly.

AIM OF THE STUDY Based on the analysis of existing studies, develop a set of validated methods that take into account the specifics of old age and are aimed at screening clinical and psychological factors of suicide risk.

MATERIAL AND METHODS The study involved 23 elderly patients who had attempted suicide by self-poisoning and were treated in the toxicology department of the N.V. Sklifosovsky Research Institute for Emergency Medicine. The data from testing a set of methods aimed at screening clinical and psychological factors of suicide risk are presented. within the framework of a pilot study.

RESULTS The importance of such risk factors for suicide in old age as depressive symptoms, decreased level of social support and subjective experience of loneliness was confirmed. The adequacy of the developed complex to the purpose of the study was demonstrated.

CONCLUSION The pilot study allows us to make a preliminary conclusion that among the factors of depression and suicide risk in old age, the subjective experience of loneliness plays a special role. It is necessary to continue the study on an expanded sample.

INTRODUCTION Treatment of gastrointestinal bleeding in patients receiving anticoagulant and antiplatelet therapy is an extremely complex and urgent problem. The risks of recurrent bleeding in such patients are extremely high, while the effectiveness of standard methods of treating gastrointestinal bleeding in this category of patients is lower, compared to the general population. The above served as a prerequisite for this study.

MATERIAL AND METHODS In the period from 2020 to 2023, 362 patients receiving antiplatelet or anticoagulant therapy were treated for gastrointestinal bleeding at the O.I. Filatov City Clinical Hospital. All patients underwent endoscopic examination of the gastrointestinal tract, with primary endoscopic hemostasis required in 126 patients (34.8%). Endovascular embolization of the vessel — the source of bleeding. Risk factors for death, need for surgical intervention and recurrence of bleeding were analyzed. The sensitivity and specificity of the Rockall and Glasgow–Blatchford scales for assessing the risk of recurrence of bleeding and the need for surgical intervention in this category of patients were studied.

RESULTS Anticoagulant therapy was statistically significantly associated with an increased risk of death. Among the risk factors for death, COVID-19 infection, age over 75 years, and arterial hypertension were statistically significant. Endovascular hemostasis demonstrated the greatest effectiveness embolization , the frequency of recurrent bleeding in this intervention was 5.7%, versus 32.5% in endoscopic interventions. The prognostic significance of the Rockall and Glasgow– Blatchford scales according to the results of our study was insufficient.

CONCLUSION The results of the study are consistent with the data of the world literature. It is necessary to take into account the high efficiency of endovascular embolization in this category of patients when choosing a hemostasis method. Risk factors associated with a fatal outcome also do not contradict the generally accepted concept. At the same time, the feasibility and objectives of using current prognostic scales in such patients require further study.

Patients over 75 years of age receiving anticoagulant therapy, as well as patients with COVID-19, have a lower risk of death, which must be taken into account when treating such patients (p<0.01).

The appropriateness of using the Rockall and Glasgow–Blatchford prognostic scales in this category of patients is low, as evidenced by the low area under the curve (AUC) for the Rockall scale (0.6) and for the Glasgow–Blatchford scale (0.48).

RELEVANCE Despite the obvious successes of transjugular intrahepatic portosystemic shunt and orthotopic liver transplantation in some high-tech centers of the Russian Federation, the relevance of substantiating the use of selective splenorenal anastomoses in the treatment plan for portal hypertension, when hundreds of patients return to emergency surgery departments every year after conservative treatment with new episodes of bleeding, liver failure and high mortality rates, is beyond doubt.

AIM OF THE STUDY To substantiate the viability of the selective splenorenal anastomosis operation by improving the technique of performing the intraoperative vascular maneuver exposure and venous reconstruction through the use of original modern innovative approaches.

MATERIAL AND METHODS A retrospective controlled clinical study included 56 patients with intrahepatic portal hypertension with relatively preserved liver function, in whose complex treatment program for secondary prevention of bleeding, various options for selective splenorenal bypass surgery were used. In 21 patients of comparison group A, who were treated between 2006 and 2017, selective splenorenal anastomoses were performed using the traditional technique. In 35 patients of the main group B, who were treated between 2018 and 2021, the surgical technique was improved through the use of two innovative surgical techniques: intraoperative vascular maneuver exposure and venous reconstruction during the formation of a splenorenal shunt.

RESULTS Original intraoperative vascular maneuver exposure at the first stage of surgery in patients with portal hypertension provides convenient volumetricspatial relationships in the surgical wound, creates comfortable conditions for performing the main surgical technique, vascular anastomosis. The duration of surgical interventions in patients of group A was 35% longer, and the average intraoperative blood loss was 58.6% higher than in patients of group B. The difference was statistically significant. The suggested intraoperative maneuver of vascular exposure has a minimal risk of developing specific complications associated with the approach to the vessels of the left retroperitoneal space.

Seven days after the operation, patients in both groups showed a decrease in the size of the portal and splenic veins and the volume of the spleen. The blood flow velocity indices in the portal vein decreased, while those in the splenic vein increased. Turbulent blood flow was observed in the lumen of the shunts. No thrombosis of vascular conduits was detected in the early postoperative period according to Doppler ultrasound data. The observed differences were statistically insignificant.

In group A, 7 patients (33.3%) died during the study period, and in group B, 3 patients (8.6%). The differences in mortality were statistically significant. The survival rate of patients in group A was significantly lower than that of patients in group B.

CONCLUSION Changing the technique of execution through the use of modern innovative surgical techniques intraoperative vascular maneuver exposure and venous reconstruction during the formation of the splenorenal shunt allowed to improve the treatment results of patients with portal hypertension, reduce the duration of surgical interventions from 305.5±44.3 to 198.6±21.1 min (p=0.00155), average intraoperative blood loss from 930.0±198.6 to 385.1±84.7 ml (p=0.00004), reduce the incidence of complications in the early postoperative period, including postoperative pancreatitis from 19.0% to 0, anastomotic thrombosis from 28.6% to 5.7%, and mortality from 33.3% to 8.6% (p<0.05), increase the 8-week survival rate, thereby confirming the viability of the selective shunt operation splenorenal anastomosis, conditioned by the reserve for evolution built into it by the authors .

When performed in a center with technical expertise, the procedure provides long-term survival and reliable hemostasis, potentially obviating the need for liver transplantation in a significant number of appropriately selected patients with portal hypertension and relatively preserved liver function.

Severe trauma is a major medical and social problem. Severe injures is the leading cause of death in people under the age of 44. Many trauma survivors become disabled. Apart from immediate death of victims at the prehospital stage, in-hospital mortality is usually due to hemorrhagic shock, coagulopathy, systemic inflammation, both infectious and non-infectious nature, and multiple organ failure. In the last decade, a significant role of endothelial dysfunction in the development of these pathological processes has been recognized. Endothelial dysfunction refers to excessive activation of the endothelium, accompanied by multisystem manifestations. This literature review presents current data on the physiology of normal endothelium, the pathogenesis of endothelial dysfunction in trauma, its role in the development of systemic inflammation, increased vascular permeability and coagulopathy, and methods for its diagnosis and correction.

Thrombolysis is one of the effectively used methods for treating patients with acute vascular pathology. Despite the high technical success of this therapy, some problems of fibrinolytic treatment still remain unresolved. Resistance to thrombolytic agents with subsequent unsatisfactory reperfusion of the vascular bed is the most important of them. Currently, despite advances in the pharmacotherapy of drugs used in thrombolysis and improvements in the technical basis for its performance, the predictors that influence its outcome are still not clearly defined. The use of fibrinolytic drugs during thrombolysis induces activation of the procoagulative component of hemostasis in the form of increased activity of thrombin, prothrombin fragments 1.2 and the thrombin-antithrombin III complex in response to excessive fibrinolysis caused by this treatment method. This paradoxical procoagulant activation of the hemostatic system may be the cause of the lack of initial reperfusion of the vascular bed in 15–25% of cases, and from 5% to 15% of cases of early thrombotic reocclusion after initially successful thrombolysis. In parallel with the activation of the coagulation link of hemostasis against the background of this type of treatment, changes occur in the functioning of the fibrinolysis system, which directly affects the outcomes of thrombolysis. This paper provides a comprehensive overview of the spectrum of major markers of the fibrinolytic system that have been studied in the context of thrombolysis outcomes in patients with acute vascular pathology. It was concluded that it is necessary to expand the determination of laboratory blood parameters by directly determining the values of plasminogen activator inhibitor-1, thrombin-activated fibrinolysis inhibitor, α2-plasmin inhibitor in order to predict the outcome of thrombolysis.

Giant cell arteritis is a disease characterized by granulomatous inflammation of large and medium-sized arteries. The aorta and its large branches are most susceptible to pathological changes in this arteritis. The course of giant cell arteritis is often complicated by ischemia in the blood supply basin of the artery involved in the pathological process. Variants of such complications may be ischemic optic neuropathy and retinopathy, limb ischemia, and acute cerebrovascular accident. This review presents current data on the etiology and pathogenesis of giant cell arteritis, prevalence, sensitivity, and specificity of clinical and instrumental signs of this disease, as well as practical recommendations for various treatment methods during exacerbation and remission.

Echinococcosis of the liver is an important problem of hematology, which in many cases is solved only with the help of surgical methods of treatment. This is primarily due to the significant number of patients with cystic echinococcosis of the liver in endemic regions, despite the implementation of preventive measures. There are still many complicated and unsolved questions concerning differential diagnostics and choice of tactics of surgical treatment for liver echinococcosis.

The problem of surgical treatment of liver echinococcosis is far from its final solution. Depending on the size of the liver lesion area, the nature of the process, severity and type of complications, different forms of treatment for cystic echinococcosis of the liver are chosen. However, during surgical treatment, such complications as liver failure, massive intraoperative bleeding with the development of hemorrhagic shock may develop. After surgical interventions for cystic echinococcosis of the liver, morphologic changes in liver tissues and signs of liver failure do not disappear, but progress; and this negatively affects the longterm treatment outcomes. Therefore, reduction of traumatic operations, prevention of hemorrhagic complications, maximum preservation of functioning liver parenchyma is one of the most important directions of echinococcosis surgery development.

In this paper, we analyze the literature sources of PubMed, eLibrary, RINC databases, which are devoted to the comparison of the effectiveness of methods of surgical treatment for cystic echinococcosis of the liver, published for the last 5 years. The conducted analysis of modern literature testifies to the relevance of the problem of choosing the method of surgical treatment for liver echinococcosis.

In recent years, there has been intensive development of surgical hepatology, which is associated with the introduction of new technologies in the diagnosis and treatment of patients with various focal liver diseases, including cystic echinococcosis. At the same time at present, there are great differences in surgical indications for treatment of hepatic echinococcosis due to differences in the technical level and experience in conducting or mastering these techniques.

Secondary vascular spasm due to non-traumatic rupture of cerebral artery aneurysms is a formidable complication leading to serious disability of patients who face this disease, and in 30–50% of cases leads to death. Standard therapy used in intensive care units does not have tremendous success in the treatment of this pathology, which encourages scientists around the world to search for new drugs that can improve the outcome and increase the quality of life of patients. At the moment, the most promising non-surgical method of treatment is the use of nitric oxide donor drugs as part of complex therapy. In modern medicine, there are several ways to administer drugs of this group: intravenously, intra-arterially , intrathecally , intraventricularly and by inhalation . The method depends on the type of drug used. Despite the promise of using these dosage forms, there are a number of negative side effects, which, due to insufficient study, limit their widespread use in hospitals. This review contains studies examining the positive and negative aspects of the use of these drugs and the appropriateness of their use.

ABSTRACT The results of studies investigating the impact of contralateral carotid occlusion (CCO) in patients with carotid stenosis who have undergone endarterectomy or stenting vary in the literature. We aimed to determine which approach is the optimal revascularization strategy for those patients.

THE AIM OF STUDY To review the current scientific literature reflecting the outcomes of patients with CCO and to determine whether the presence of CCO plays a prognostic role in perioperative outcomes in patients undergoing carotid revascularization with endarterectomy or stenting.

MATERIAL AND METHODS Literature sources from Pubmed and MEDLINE, Scopus and Cochrane information aggregators on this topic published in Russian and English between 2003 and 2023 were selected for analysis. The terms of contralateral carotid occlusion, stenting of the single carotid artery, carotid endarterectomy, endovascular treatment for stenosis of the single carotid artery, surgery of the single carotid artery, carotid and (stent or stenting) and endarterectomy and (contralateral or bilateral) and occlusion were included in the analysis.

An observational or randomized study was considered eligible for inclusion only if it met all specified inclusion criteria: (1) carotid revascularization outcomes were compared in patients with and without CCO; (2) quantitative data on clinical outcomes of interest were provided; and (3) the study was published before September 2023. Studies that did not meet any of these criteria were not eligible for inclusion. Common exclusion criteria were carotid revascularization performed concurrently with coronary revascularization, acutely developing stroke, spontaneous carotid dissection or fibromuscular dysplasia.

RESULTS 35 literature sources were analyzed. The review article presents the world experience of surgical treatment (carotid endarterectomy and stenting of the internal carotid artery) in patients with haemodynamically significant stenosis and contralateral carotid occlusion. Some papers indicate the advantages of endovascular operations in elderly patients, others carotid endarterectomy. The accumulation of experience in treatment of this category of patients should help either in optimization or in individualization of surgical tactics.

CONCLUSION Surgical intervention in patients with haemodynamically significant stenosis of the internal carotid artery and contralateral occlusion should be differentiated and have an individual approach.

The complete closure of extensive wound defects is a serious problem of modern surgery. In a significant part of clinical cases, practicing surgeons have difficulties in the surgical treatment for extensive soft tissue wounds, especially those that have existed for a long time and have no tendency to heal. Split­ skin grafting is the operation of choice when closing chronic wounds, as it has a number of advantages over other options for skin plastic surgery. At the same time, the percentage of split­skin graft engraftment depends on the state of the recipient bed in most cases, the degree of which is determined by such mutually influencing processes as inosculation, angio­ and vasculogenesis (angiogenesis regulator), occurring simultaneously in the graft itself and the receiving wound bed. The review presents studies by domestic and foreign authors concerning new possibilities of instrumental assessment of the condition of the recipient wound bed, namely the degree of its edema. The results of scientific papers describing the relationship between the degree of swelling of the wound and the result of its plastic closure are shown. The features of modern methods of optical bioimaging are revealed when they are used in determining the amount of fluid in soft tissue wounds both in experiment and clinical practice.

ABSTRACT The article provides a historical review of the literature describing the evolution of bladder drainage and the types of urinary catheters currently in use. Complications of various drainage methods are classified and described, and measures for their prevention are proposed.

AIM OF STUDY To study bladder draining methods, their advantages and disadvantages, possible complications of each method.

OBJECTIVES To assess the indications for use of each drainage method, to focus the attention of health workers on the possibility of choosing the optimal method for bladder draining, depending on the clinical situation.

The most important factor in improving the quality of medical services at present is the continuous improvement of all aspects of the activities of a medical organization, which determines the appropriateness of using modern approaches to organizational development in medical institutions with their appropriate adaptation.

The paper presents the results of the analysis of 16 known models of organizational development, as well as the performance indicators of the Kaidzen proposal system at 19 Russian and foreign enterprises in various industries. An analysis of the authors’ long-term experience of working with small groups on standardization of treatment and diagnostic processes at the N.V. Sklifosovsky Research Institute for Emergency Medicine of the Moscow Health Department was conducted, which confirmed the assumption that medical personnel of all categories have a large number of ideas for improving the organization’s work and are willing to participate in their implementation.

The article presents the author’s model of the system of organizational development of treatment and diagnostic processes of a multidisciplinary hospital, which is based on the concept of personnel orientation and the basic principles developed by the authors.

In the part of the model detailing, a developed system of classification features is presented, which allows determining the belonging of a proposal for improvement to a certain group or class, as well as the approach proposed by the authors to sorting proposals at various stages of working with them.

The paper presents the results of testing the described approach using the example of proposals for improvement formulated by a pilot group of nurses of the operating unit of the N.V. Sklifosovsky Research Institute for Emergency Medicine of the Moscow Health Department. Conclusions are made on the possibilities of applying the presented research results for medical organizations, as well as promising areas for the development of the presented approach.

AIM OF STUDY To evaluate the effectiveness of intestinal lavage with glucose-saline solution for acute necrotic pancreatitis in children..

MATERIAL AND METHODS A retrospective analysis of the diagnosis and treatment of 48 children aged 3 to 17 years with impaired propulsive function of the intestine against the background of acute necrotic pancreatitis of moderate and severe severity was carried out. Intestinal insufficiency syndrome was diagnosed in 39 cases. In the 1st group (n=13) in I A phase in addition to standard therapy, intestinal lavage was performed during the disease phase, in the 2nd group (n=35) the standard therapy for acute necrotic pancreatitis was performed.

RESULTS Median the duration of gastrostasis in group 1 was 4 days (IQR, interquartile range: 2; 5), in group 2-6 days (IQR: 4; 7) (from 2 to 13), p=0.0181. The duration of intestinal paresis in group 1 was 2 days (IQR: 2; 4), in group 2–4 days (IQR: 3; 5), p<0.0053. The median time of onset of independent stool in group 1 was 3 days (IQR: 3; 5), in group 2 — 5.5 days (IQR: 4.3; 6), p<0.0014. Reduction in the level of C-reactive protein by day 3–4: in group 1, the median was 8.2 mg/l (IQR: 1.16; 34.6) (from 0 to 46.9), in group 2 — 31.97 mg/l (IQR: 17.71; 112.4) (from 14 to 285), p=0.028. The risk of developing purulent complications was 4-fold higher in group 2, p=0.0088. The duration of hospitalization in the 1st group was shorter, p=0.0004.

CONCLUSION Carrying out intestinal lavage in children with impaired propulsive function of the intestine against the background of acute necrotic pancreatitis significantly more quickly restores the function of the gastrointestinal tract and facilitates an earlier start of enteral feeding.

AIM OF STUDY To demonstrate the effectiveness and safety of a method for assessing the degree of external dislocation of a catheter for continuous brachial plexus block (CBPB) using a dislocation scale in clinical practice.

MATERIAL AND METHODS The study included 63 patients who underwent CBPB from the supraclavicular approach with fixation of the catheter on the skin with a patch sticker during operations for fractures of the bones of the upper limb. To analyze the size of the catheter dislocation, a method for assessing the degree of external dislocation of the catheter for CBPB was used.

RESULTS In 16 patients, the size of the external dislocation was from 0 mm to 5 mm (grade 1), which was assessed as no dislocation, in 30 patients it was more than 5 mm to 10 mm (grade 2), while there were no changes in the quality of pain relief, in 15 patients the dislocation was more than 10 mm to 15 mm (grade 3), while there was a deterioration in the quality of pain relief, it was necessary to increase the dose of the administered local anesthetic and strengthen the fixation of the catheter to the skin of the supraclavicular region with a fixation device, in 2 patients the size of the external dislocation was more than 15 mm (grade 4), which was defined as migration of the catheter beyond the brachial plexus and led to the cessation of CPBP.

CONCLUSION The physician operating the catheter for prolonged brachial plexus block, using the method of assessing the degree of external dislocation, has the opportunity to determine the likelihood of deterioration in the quality of anesthesia based on the size of the dislocation and prevent its cessation.

BACKGROUND Uterine lacerations are rare but one of the hardest and most dangerous obstetric aftereffects for life of a woman and a baby. Uterine sidewall altered by a scar after caesarean section or laparoscopic myomectomy is recognized as the leading cause of uterine rupture. In turn, histopathic laceration of the uterus during labor, associated with rupture of adjacent organs in a woman with a history of normal childbirth, seems casuistic and deserves discussion.

THE AIM OF THE STUDY To present a clinical case of non-operated uterine laceration of a multiparous woman in impetuous labor.

MATERIAL AND METHODS A multiparous woman, 35 years old, with histopathic uterine laceration, ruptures of cervix, vagina, and bladder with conization of the cervix in anamnesis in impetuous labor.

RESULTS The article describes a clinical observation of histopathic uterine laceration in labor.

CONCLUSION A favorable outcome with an organ-preserving surgery in case of histopathic uterine laceration is possible only if the diagnosis of the complication is done timely, and high-quality surgical treatment is carried out within a short space of time. The uterus after the history of cervical conization must be treated as carefully – due to its possible rupture – as the uterus altered by a scar after surgical interventions. Manual examination immediately after impetuous labor with a third-degree cervical rupture would allow for timely diagnosis of uterine laceration, prevention of blood loss and the performance of organ-preserving surgical intervention.

We present a clinical case of successful one-stage treatment of a patient with six cerebral aneurysms of one carotid basin with concomitant chronic occlusion of the contralateral internal carotid artery. The role of hemodynamics in the pathogenesis of brain aneurysms, as well as methods and stages of surgical treatment of patients with multiple aneurysms are discussed.

The article presents a clinical observation of successful treatment for retroduodenal perforation (RDP) resulting from conducted retrograde endoscopic examination, papillotomy using a combined minimally invasive treatment method, which included bilioduodenal and pancreatic stenting, endoscopic vacuum therapy (EVT), transluminal drainage. The use of the EVT system together with endoscopic stenting of the biliary and pancreatic ducts made it possible to prevent the development of fatal retroperitoneal phlegmon by actively removing purulent discharge, necrotic tissues from the area of infection, reducing ductal hypertension, which contributed to the delimitation of the process. Transluminal drainage with multiple subsequent transluminal sanation demonstrated a good result in the form of adequate draining, the possibility of performing endoscopic sanitation of the lesion, and further complete regression of the delimited fluid cavity. The use of minimally invasive methods in the treatment for retroduodenal perforation made it possible to avoid the spread and generalization of purulentseptic fatal retroperitoneal complications, and to accelerate the process of successful treatment.

ABSTRACT Axillary artery injury as a result of total shoulder artroplasty is a fairly rare complication. Isolated clinical observations are described in foreign articles, there are no reports of domestic authors about this problem. There is a need for more extensive coverage of this problem in order to prevent similar situations in the future.

THE AIM of this publication is to present a clinical case of intraoperative axillary artery injury in the process of reverse shoulder arthroplasty, and the medium­ term result of surgical treatment after replacement of the artery defect with a synthetic graft.

MATERIAL AND METHODS We present a rare clinical case of intraoperative axillary artery injury in the process of reverse shoulder arthroplasty. After the replacement of the artery defect by a team of vascular surgeons, it was decided to continue the shoulder joint replacement surgery. In the postoperative period, computed tomography angiography revealed occlusion of the restored section of the axillary artery, but the presence of collateral blood flow distal to the injury zone, the preservation of active movements in the joints of the right upper limb, and the absence of sensitivity disorders in the right hand made it possible to refrain from repeated surgical intervention. When evaluating the medium­term results 15 months after surgical treatment, a significant limitation of the function of the right upper limb was noted in the complete absence of pain syndrome.

CONCLUSION The presented clinical case demonstrates the experience of managing a patient with simultaneous reverse shoulder arthroplasty and an intraoperatively damaged section of the axillary artery with the achievement of complete absence of pain syndrome with significant restriction of function in the remote period. Bearing in mind the possible damage to the main arteries, particularly in age­related patients, and the amount of medical care required in the event of this complication, it is recommended that medical care be provided in a multidisciplinary hospital with a team of vascular surgeons.

AIM OF THE STUDY was to present a case of combined, staged surgical treatment for locally advanced cardioesophageal cancer complicated by esophageal stenosis in a comorbid patient with a significant lesion of the internal carotid artery, and to summarize the data of scientific literature on the methods for its diagnosis and treatment.

MATERIAL AND METHODS A 65-year-old patient came to the Moscow Clinical Research and Practice Center named after A.S. Loginov in August 2020 with complaints of difficulty in passing solid food through the esophagus. During the examination at the Center, Siewert II cType 3 T4bN2M0 G3 cardioesophageal junction cancer was diagnosed. Taking into account the results of comprehensive diagnostics, the patient was found to have asymptomatic stenosis of the internal carotid artery up to 75%. Step-by-step surgical treatment of the patient was performed.

DISCUSSION In the presented clinical observation for prevention of intraand postoperative ischemic complications, at the first stage the patient underwent carotid endarterectomy followed by surgical treatment for the underlying pathology. The presented observation is of interest due to the rare occurrence of such a combination of surgical interventions and the lack of consensus regarding the treatment tactics for this category of patients.

CONCLUSION Combined staged treatment of a patient with cardioesophageal cancer and internal carotid artery stenosis reduces the risk of perioperative complications and improves the prognosis of further treatment for the underlying disease.