CYSTIC PULMONARY HAMARTOMA MANIFESTING AS SPONTANEOUS PNEUMOTHORAX

Cystic hamartoma refers to rare benign lung tumors. The literature describes 17 cases of this disease. The tumor may look like multiple bilateral cysts or a solitary single-chamber or multi-chamber cyst of a large size, which makes it difficult to diagnose. The disease can be complicated by spontaneous pneumothorax. The cyst itself often looks like a pneumothorax. An observation of a 52-year-old man complaining of chest pain and shortness of breath is presents. On the x-ray, the left lung is compressed with air, which is regarded as a spontaneous pneumothorax. Two-day drainage did not give any results. The video-assisted thoracoscopic surgery technique was performed and a large air cyst was detected. A conversion to a thoracotomy was made. A cyst of 20×15 cm size originated from the lower lobe, the lung was in atelectasis. Cyst resection and lung decortication were performed. Histological examination of the cyst wall revealed a hamartoma of the lung. The postoperative period was uneventful. Differential diagnosis of cystic hamartoma is conducting with lymphangioleiomyomatosis, air cysts, extrapulmonary sequestration, echinococcal cysts, and lung cancer. Indications for surgery are the following: chest pain, shortness of breath, pneumothorax, and hemoptysis. In a unilateral process, a cyst resection or lobectomy have to be performed. Cystic pulmonary hamartoma should be included in the differential diagnostic range in patients with recurrent spontaneous pneumothorax, hemoptysis, single and multiple lung cysts. It is impossible to determine the diagnosis without a biopsy and histological examination.

DEMOGRAPHIC DIFFERENCES IN PATIENTS WITH ABDOMINAL AORTIC ANEURYSM IN DIFFERENT COUNTRIES: GERMANY, TAJIKISTAN AND RUSSIAN FEDERATION

Objective. To compare the demographics, comorbidities and risk factors in patients with abdominal aortic aneurysm (AAA) treated in three different communities; Germany, Tajikistan and Russian Federation. Methods. A retrospective comparative study including patients with an infrarenal AAA who were treated with either endovascular aneurysm repair (EVAR) or open repair (2011-2015) in Cologne, Dushanbe and Ryazan was done. A total number of 711 patients, 499 from Cologne, 46 from Dushanbe and 166 from Ryazan were included in the study. Demographic data including age, gender, body mass index (BMI), comorbidities (diabetes, coronary artery disease (CAD)), hypertension, cerebrovascular disease, chronic obstructive pulmonary disease (COPD, smoking), actual treatment as well as the diameter of the abdominal aorta were collected, retrospectively. Results. There was no statistically significant difference in AAA prevalence with respect to gender between the study centers. Similarly, the BMI did not differ significantly between these 3 centers. Though, the patients from Cologne were older than those from Dushanbe and Ryazan. Moreover, the number of patients treated due to ruptured aneurysm was significantly lower in Cologne in comparison to the other two centers (P<0.05). The AAA-diameter of patients in Ryazan and Dushanbe was greater than that found in Cologne. Regarding the actual medication that patients were presented with, antiplatelet-aggregation medication, statin and beta blockers were used significantly more often in Cologne. Patients from Tajikistan had COPD more often than patients from the other centers. Conclusion. The prevalence of comorbidities, risk factors as well as medication in patients with infrarenal abdominal aortic aneurysm is different in the various geographical regions. What this paper adds The study demonstrates that the prevalence of comorbidities, risk factors as well as medication in patients with infrarenal abdominal aortic aneurysm is different in the various geographical regions. These differences have been firstly demonstrated in patients from the Russian Federation and Tajikistan.

PURULENT SEPTIC COMPLICATIONS OF ACUTE PANCREATITIS AND THEIR PATHOGENETIC RELATIONSHIP WITH HELICOBACTER PYLORI

Objective. To study of the role of Helicobacter pylori as an etiological factor of acute pancreatitis and a marker of the development of its purulent-septic complications. Мethods. The study was conducted in the period of 2015-2020; patients with acute pancreatitis (n=124) were divided into 2 groups: the main group (66 patients with moderate severity and severe course) and the comparison group (58 patients with a mild form). All patients underwent a screening study of Helicobacter pylori in feces and serological blood test to detect antibodies, namely immunoglobulin M to Helicobacter pylori (determination of the phase of the disease - acute or chronic). In 39 (31.5%) patients of the main group, a bacteriological study of biological and biopsyspecimensof antral mucous membrane were taken and examined histologically for organisms. The selection of antibiotics for treatment was carried out taking into account the infection of patients with Helicobacter pylori and was performed using the author’s method, the effectiveness of treatment was controlled microbiologically. Results. The positive result of the express test was in 66 (100%) patients of the main group and in 39 (67.2%) patients in the comparison group. During serological examination, a positive result was obtained: 24 hours after hospitalization - in 8 (13.8%) patients in the comparison group, in 23 (34.8%) patients in the main group; after 7 days - in 9 (15.5%) patients and 42 (63.3%) patients, respectively. Helicobacter pylori is sensitive to the majority of antibiotics used to treat purulent-septic complications of acute pancreatitis; after finishing the course of antibiotic therapy, eradication was achieved in 37 (94.9%) patients of the main group. Conclusion. Positive results of a serological study of Нelicobacter pylori after 7 days from the moment of hospitalization were more common in patients of the main group (63.3%) in relation to the comparison group (15.5%) (χ²=28.9, p<0.001), which gives grounds to consider bacteria, as one of the markers of the development of purulent-septic complications of acute pancreatitis. What this paper adds The role of Helicobacter pylori (HP) in the pathogenesis of acute pancreatitis has been studied for the first time and its value as a marker for septic complications development of acute pancreatitis is shown. It allowed optimizing the etiotropic antibiotic therapy for this disease.

ASSESMENT OF ANTI-NOCICEPTIVE ACTIONS OF ADIPOSE-DERIVED MESEMCHYMAL STEM CELLS IN EXPERIMENTAL PERIPHERAL NEUROPATHIC PAIN

Objective. To estimate an anti-nociceptive and regenerative potential of adipose-derived mesenchymal stem cells in experimental post-traumatic neuropathy in rats. Methods. Neuropathic pain was induced by axotomy technique in rat left hind paw (Wistar rats (n=113)). The respective group of subjects received ADMSCs dose of 1×10⁶ cells/kg and 2×10⁶ cells/kg into the site of sciatic nerve injury at 2 regimens: single (7^th day post-surgery) and twice (7^th and 14^th day post-surgery). Nociceptive responses, as well as histological changes of sciatic nerve and perineural tissue were assessed in dynamics. Results. Sciatic nerve axotomy led to a significant increase of mechanical nociceptive sensitivity of ipsilateral hind paw by 7^th day, as well as to fibrotic changes of peri- and epineural areas of damaged nerve fibers and to denervation of surrounding muscle tissue and fascia. Local administration of ADMSCs effectively abolished mechanical hyperalgesia by 14^th day after first injection at all regimens tested. Among tested regimens, the most pronounced anti-nociceptive and regenerative effects were induced by single injection of ADMSCs (1×10⁶ cells/kg). As the dose and frequency of ADMSCs administration elevated, their reparative and anti-inflammatory properties reduced. Conclusion. Obtained results testify anti-nociceptive potential of ADMSCs and feasibility of its further investigation on the experimental models of neuropathy. What this paper adds For the first time the impact of different regimen of allogenic adipose-derived mesenchymal stem cells (ADMSCs) transplantation on nociceptive sensitivity and microstructure changes of sciatic nerve in rats with peripheral neuropathy has been studied. Allogenic transplantation of mesenchymal stem cells at a dose of 1×10⁶ cells/kg has been found out to exhibit the most powerful anti-nociceptive and regenerative effects with a single local injection confirmed by algometry and histological study.

THE EFFECTIVENESS OF SPLENORENAL SHUNT IN TREATMENT OF PREHEPATIC PORTAL HYPERTENSION IN CHILDREN

Objective. To evaluate the results of treatment of prehepatic portal hypertension (PPH) in children by method of side-to-side splenorenal bypass. Methods. A retrospective, monocentric analysis of 114 patients with prehepatic portal hypertension was carried out in the period from 2000 to 2018. The age of the patients was from 6 months up to 18 years, the average age 10,1±3,8 years (M±σ). All patients underwent side-to-side splenorenal shunt. In the postoperative period, on the 7^th day, ultrasound examination of the abdominal organs with Doppler sonography (US) was performed to assess the volume of the spleen, the rate of portohepatic perfusion, the rate of blood flow along the side-to-side splenorenal shunt, as well as to assess its diameter. Control US was performed after the 1^st, 3^rd, 6^th, 12^th months; to assess the regression of esophageal and gastric varicose veins, the control esophagogastroduodenoscopy (EYD) was performed after 3^rd , 6^th, 12^th months and then once a year. Subsequently, the control examination of the patients was carried out once a year. The follow-up was 2-18 years. Results. Out of 114 patients who underwent side - to - side splenorenal shunt, 5 (4,4%) patients had recurrent bleeding from the esophageal variceal vein at the follow-up period (2-18 years). One patient had intra-abdominal arrosive bleeding from side-to-side splenorenal shunt provoked by severe postoperative pancreatitis. The average diameter of the shunt was 12±1.9 mm. The spleen volume decreased by 39.7±10.3%. Portohepatic perfusion reduced by 39% in comparison with the indicators before surgery. The blood flow rate along the side -to-side splenorenal shunt was 2403±557.3 ml/min. in 95,4% of patients the regression of variceal vein was noted. Hypersplenism syndrome was arrested in 73.6% of children. Conclusion. Side -to- side splenorenal shunt is considered to be an effective method of portal decompression with the effectiveness inpreventingboth esophageal and gastricvariceal veins bleeding in 95,4% of patients. What this paper adds The results of treatment of the prehepatic portal hypertension by method of side-to-side splenorenal shunt have been firstly analyzed, and the effect of this variant of portosystemic shunt on portohepatic perfusion has been assessed. It has been established that this option of shunt is effective for the portal system decompression and occupies an intermediate position between selective and total variant of portosystemic shunt.

EFFECTIVE CORRECTION OF THE COMMON ATRIOVENTRICULAR CANAL WITH TETRALOGY OF FALLOT AND HYPOPLASIA OF THE RIGHT VENTRICLE IN A CHILD

The paper presents a description of a case of successful one and a half ventricular correction of a complex congenital cardiac anomalies, including the common atrioventricular canal, tetralogy of Fallot, and hypoplasia of the right ventricle in a child (2 year and 4 months). Ararecongenitalanomalycharacterized by acombinationof intracardiac defects, required an innovative surgical approach, the exclusivity of this clinical case has determined. The surgical strategy of complete atrioventricular canal defect is determined by a number of factors. One of the most important is balance between right and left ventricular outputs. The balanced type with adequate development of the ventricles involves the biventricular repair performance. Unbalancedatrioventricular canal defects includea hypoplastic ventricle. Reconstructive surgeryfor onehypoplasticventricle is oriented towards the degree of hypoplasia. In particular, a mild right ventricular hypoplasia allows perfoming biventricular radical operation while a severe degree suggests univentricular repair. In case of borderline, moderate degree of hypoplastic right ventricle the one and half ventricle repair can be carried out. Another important point is the presence of concomitant pulmonic stenosis required the choice of optimal method and material for reconstruction which is not always obvious and often it is the subject of debates. This report presents a description of the diagnostic stages with an emphasis on determining the type of balance of the common atrioventricular canal, the degree of hypoplasia of the right ventricle, the approach to choosing the optimal method for correcting the defect in general and the material for reconstructing the outflow pathway from the right ventricle in particular, as well as the subsequent successful correction of congenital multicomponent cardiac abnormalities in a young patient.

ANTEROLATERAL LIGAMENT AS ROTATION STABILISER OF KNEE- JOINT. THE ROLE OF MRT AND ULTRASONOGRAPHY IN UNDERSTANDING ITS ANATOMY AND IN SELECTING SURGICAL TREATMENT STRATEGY FOR ITS INJURIES

Objective. To assess the variability of the anterolateral ligament according to MRT and ultrasonography data and to coordinate it with surgical treatment strategy for its injuries. Methods. The anterolateral ligament was analyzed on 100 series of MRI images of knee joints without traumatic pathology on Philips Achieva 1.5 T tomograph using the standard research protocol in three mutually perpendicular planes and 150 series of MRT images of knee joints with injuries and without injuries of the anterolateral ligament obtained on different tomographs from 0.2 to 3 Tesla. The quality of visualization of anterolateral ligament separate portions, the number of layers, and the contact with the joint capsule were evaluated. Both knee joints were analyzed by ultrasonography in 30 patients with anterior cruciate ligament injuries of one of the knee-joint and in 30 patients with intact knee-joints. Results. During the studies in the identification of anterolateral ligament with magnetic resonance tomography (MRT 1.5T)it was revealed at least partially in 92% of cases (in 68% as a two-layer structure; in 24% as a single-layer structure; in 14% as a thickening of the capsule or in 10% as a separate extracapsular structure), ultrasound examination - in 100% (the structure was not determined, however, in 26.67% of patients without clinically pronounced pathology of the knee-joint and significant trauma in anamnesis ultrasound scan revealed a violation of the integrity of the cortical layer at the tibial attachment site), Conclusion. According to MRT and ultrasonography data, the anterolateral ligament is a constant structure of the knee-joint, but very variable in its anatomical parameters, which in some cases may be poorly visualized on MRT, may have a two-layer structure, may be located either extracapsular or as a thickening of the knee-joint capsule. The variability of its anatomical structure makes it impossible to make the theoretical substantiation of the advantages of one separate method of its restoration, but, on the contrary, justifies a differentiated approach to the selection of optimal surgical treatment. What this paper adds With the help of current research methods, the normal anatomical parameters and anatomical variants of the anterolateral ligament of the knee joint have been clarified and detailed. It is necessary to emphasize the importance of a differentiated approach to choosethe optimal methods of surgical treatment for its injuries.

THE PREVALENCE OF GENETIC POLYMORPHISMS FOR REGULATION OF VASCULAR TONE, PLATELET RECEPTORS, VASCULAR WALL REMODELING AND PROTHROMBOTIC FACTORS IN DIABETIC FOOT SYNDROME

Objective. To analyze the frequency of occurrence of eNOS 786C>T, END1 Lys198Ash, ITGB3 1565T>C (Leu33Pro), F5 1691G>A, F2 20210G>A, MMP9 8202A>G, MTHFRA 1298 C,VEGFA 634C>G gene polymorphisms in diabetic foot syndrome. Methods. The study included patients (n=198) with uncomplicated diabetes mellitus and patients (n=199) with the development of diabetic foot syndrome. Genotyping of the studied gene polymorphisms was performed by the polymerase chain reaction method. Results. In patients with uncomplicated diabetes mellitus and in patients with diabetic foot, no significant differences were found in the frequency of occurrence of polymorphisms 786C>T of the eNOS3 gene, Lys198Ash of the END1 gene, 1691G>A of the F5 gene, 20210G>A of the F2 gene, 8202A>G of the MMP9 gene, 634C> G of the VEGFA gene and their allelic variants. Associative relationship between the polymorphisms of the NOS 786C>T, END1 Lys198Ash, F5 1691G>A, F2 20210G>A, MMP9 8202A>G, VEGFA 634C>G genes and the development of diabetic foot syndrome was not found. With the development of a diabetic foot, a heterozygous variant of the 1565TС polymorphism of the ITGB3 gene was more common than in uncomplicated diabetes mellitus (37.7% and 28.3%, respectively (χ²=6.243, p=0.045)). The risk of developing a diabetic foot with the carriage of this polymorphism is 1.5 times higher than with other variants of gene polymorphism ((OR=1.534 (95% Cl 1.006 - 2.338), p<0.05). Polymorphism 1298 AS of the MTHFR gene was more often detected in the group of patients with uncomplicated diabetes mellitus than in the group with the development of diabetic foot (45.4% and 29.1%), (χ²=11.55, p=0.004). Conclusion. The development of diabetic foot syndrome is associated with the carriage of the heterozygous 1565TС polymorphism of the ITGB3 gene, in which the likelihood of developing this complication increases 1.5 fold. In diabetes mellitus without complications, a more frequent carriage of the heterozygous polymorphism 1298 AC of the MTHFR gene was revealed, which may have a protective effect against the development of diabetic foot syndrome. What this paper adds The frequency of occurrence of genetic polymorphisms for regulating vascular tone, platelet receptors, vascular wall remodeling and prothrombotic factors and their allelic variants in diabetic foot syndrome was studied. It was found that the frequency of heterozygous 1565TС polymorphism of the ITGB3 gene in the development of diabetic foot is 1.3 fold higher than in the uncomplicated course of the disease. It was revealed that the fregnency of this variant of the ITGB3 gene polymorphism is associated with the risk of developing this complication of diabetes mellitus. In the presence of the heterozygous 1565TС polymorphism of the ITGB3 gene, the risk of developing diabetic foot syndrome increases by 1.5 fold than with the carriage of other variants of the T1565С polymorphism of the ITGB3 gene. It was found that in the uncomplicated course of the disease, the heterozygous genotype 1298 AC of the MTHFR gene occurs 1.6 fold more often than in the development of diabetic foot syndrome.

PROGNOSIS FOR SECONDARY PERITONITIS OUTCOME

Objectives. To develop a new system for predicting the outcome of secondary peritonitis and analyze its accuracy in comparison with the most common analogous systems. Methods. The study is based on the analysis of treatment results in patients (n=352) with secondary peritonitis. At admission sepsis was diagnosed in 15 (4.3%) patients, septic shock - in 4 (1.1%) persons. There were the following main causes of death in the mortality structure: purulent intoxication and/or sepsis - 51 cases (87.9%), cancer intoxication - 4 (6.9%) cases, acute cardiovascular failure - 3 cases (5.2%). The efficacy of the Mantheim Peritoneal Index (MPI), WSES prognostic score, APACHE-II scale, gSOFA score and Peritonitis Prediction System (PPS) developed by the authors were analyzed. The likelihood of the effect of 85 clinical and laboratory parameters on the outcome of patients with secondary peritonitis using nonparametric methods of statistical research (Fisher’s test, Mann-Whitney test, Chi-square with Yates correction) have been analyzed. Criteria predictively associated with lethal outcome (p <0.05) were selected, they were included in the PPS scale. To compare the predictive value of peritonitis prediction systems, ROC analysis was used with the construction of ROC curves for each of the systems. Results. The most important criteria in predicting fatal outcome are the patient’s age, the presence of malignant tumor, the exudate nature, sepsis (septic shock), and also polyorganic insufficiency which is not associated with developed peritonitis. To assess the prognostic value of peritonitis prediction systems, ROC curve analysis was used. The greatest accuracy in terms of predicting mortality in patients with generalized secondary peritonitis is possessed by PPS (AUC 0.942), minimal - APACHEII (AUC 0.840). Conclusion. APACHEII, MPI, WSESSSS and PPS systems can be considered as reliable in predicting mortality in patients with peritonitis. The greatest accuracy in predicting fatal outcome in patients with generalized secondary peritonitis had PPS (94%). What this paper adds An original system for predicting the outcome of peritonitis (PPS) has been developed. It was found that the criteria of the patient’s age, the presence of a malignant neoplasm, the nature of the exudate, sepsis (septic shock), as well as polyorganic insufficiency not associated with the developed peritonitis are of the greatest importance in predicting the death outcome. When conducting a comparative assessment with the most common similar systems (MPI, WSES SSS, APACHE-II), it was found that the most accurate in terms of predicting mortality in a patient with generalized secondary peritonitis is the PPS (AUC 0.942), the minimum - APACHEII (AUC 0.840).

APPLICATION OF INTESTINAL AUTOTRANSPLANTATION IN TREATMENT OF SURGICAL DISEASES OF THE ABDOMINAL CAVITY

This review is devoted to the relevance of the problem and the assessment of potential surgical indications, surgical methods and clinical results in the intestinal autotransplantation. Radical resection of theneoplasmisperformed. Currently, the main indications for performing intestinal autotransplantation are considered neoplasms of the pancreas, mesenteric and retroperitoneal space with the involvement of the superior mesenteric vessels in the process. Preliminary results demonstrate that radical resection can be effective in carefully selected patients. Although perioperative morbidity and mortality are relatively high, the literature describes some cases with long patient survival, especially when performing radical resection of a benign tumor or a tumor of potentiallow malignant. However, early tumor recurrence remains a serious problem in patients with a high-grade tumor, especially with pancreatic ductal adenocarcinoma (PDAC). It should be noted that when using intestinal autotransplantation, it is possible to perform a radical resection of the organ in patients with separate neoplasms in the abdominal cavity and the involvement of the main mesenteric vessels in the process. However, this aggressive method is associated with significant operational risk and should be only performed in specialized centers. The additional combination therapies have to be developed to optimize the clinical outcome and prolong the survival of patients with pancreatic cancer.