Vol 13, No 3 (2020)

Introduction. The number of patients with cystic formations of the pancreas has increased significantly recently. Some of the patients need open or minimally invasive surgery. The implementation of ERAS (Enhanced recovery after surgery) protocols has been proved to be effective in orthopedics, bariatric and colorectal surgery. However, safety and feasibility of implementation of accelerated rehabilitation protocols in patients with cystic formations of the pancreas who underwent resection and resection-drainage interventions have not been sufficiently studied.
The aim of the study was to assess the effectiveness and safety of implementation of the developed accelerated rehabilitation protocol in patients with cystic pancreatic formations who have undergone resection and resection-draining interventions.
Material and methods. This research is a retrospective-prospective, single-center study. The study included 110 patients with cystic formations of the pancreas of various etiologies. All patients were divided into two groups: the control group consisted of 55 patients, their perioperative management was carried out according to standard protocols, and the experimental group consisted of 55 patients, their perioperative management was carried out according to the accelerated rehabilitation protocol developed in the clinic. All patients included in the study were exposed to surgery: resection and resection-draining interventions in various modifications were performed.
Results. Patients in the studied groups were comparable by gender, age, body mass index, ASA score, preoperative albumin level. No statistically significant differences were found in the duration of the operation, intraoperative blood loss, or the frequency of blood transfusions. The overall complication rate was significantly lower in the experimental group compared with the control group (38,2% versus 58,2%, p = 0,03). Postoperative recovery of the gastrointestinal function was also faster in the experimental group. Thus, in the experimental group, the average time to the gas discharge was 2,1 ± 0,8 days; in the control group - 3,1 ± 1,1 days (p = 0,01); the average time to the first stool was 3,2 ± 1,9 and 4,2 ± 1,2 days, respectively (p <0,001). The total duration of the postoperative hospital bed per day was significantly lower in the experimental group compared with the control group (11,8 ± 7,7 vs 16,2 ± 13,2 days, respectively, p = 0,02).
Conclusions. The study demonstrated safety and effectiveness of implementation of accelerated rehabilitation protocols in patients with cystic pancreatic formations who have undergone resection and resection-draining interventions. Implementation of the protocols allows reducing the duration of the postoperative hospital bed per day, incidence rate of complications, and also accelerating the gastrointestinal function recovery.

Introduction. Non-alcoholic fatty liver disease (NAFLD) is one of the most common pathologies in obesity, at the same time the impact of bariatric operations on the course of NAFLD remains unresolved and debatable, the issue determining the relevance of this work.
The aim of the study was to assess the effect of laparoscopic sleeve gastrectomy (LSG) on the course of NAFLD and determine the criteria that affect the dynamics of NAFLD after a performed bariatric intervention.
Materials and methods. The study included clinical outcomes of 64 patients who underwent LSG between 2014 and 2017. Intraoperative liver biopsy, laboratory and instrumental investigations, the calculation of FibroTest in dynamics were performed to all patients. The frequency of postoperative complications was assessed. Follow up examinations including 58 (90.6%) patients were carried out during 2 years.
Results. Initially, 29 (45,3%) patients manifested signs of fibrosis according to METAVIR, and 19 (29,7%) patients manifested signs of non-alcoholic steatohepatitis (NASH). Elevated transaminases were registered in 14 (21,9%) patients, elevated levels of gamma-glutamyl transpeptidase (GGTP) were registered in 47 (73,4%) patients, increased total bilirubin were registered in 12 (18,8%) patients, increased alkaline phosphatase (ALP) were registered in 21 (32,8%) patients. There was an increased level of trygliceride (TG) and decreased level of high density lipoproteins (HDL) in 54 (84,4%) patients. Ultrasound investigation of the liver revealed an increased liver size in 46 (71,9%) patients, diffuse heterogeneity of the liver in 61 (95,3%), hyperechogenicity in 60 (93,8%) patients. Manifestations of liver cirrhosis were registered in 1 (1,6%) patient.
There was a significant decrease in the excess body weight in the postoperative period, and hereat, the % EBMIL (Excess Body Mass Index Loss, percentage of overweight loss) in 1 year after laparoscopic sleeve gastrectomy achieved satisfactory values and amounted to 68,30 [58,67-78,77] %. ALT, AST findings were normal in 79,7% of operated patients, cholestasis parameters - in 76,5% of operated patients, FibroTest findings - in 42,2% of cases. In 6 months after surgery there was a deterioration of the clinical and biochemical properties of non-alcoholic fatty liver disease, which was transient and regressed in one year after surgery. The mortality rate during the entire follow-up period was 0%. The effect of the surgery on the signs of non-alcoholic fatty liver disease persisted for 2 years after surgery.
Laparoscopic sleeve gastrectomy demonstrated high effectiveness in patients under 45 years old compared to the patients over 45 years old, and in patients with initial stages of fibrosis F0-F2 by METAVIR compared to patients with stages F3-F4 by METAVIR. In addition, patients with BMI higher than 40 kg/m2 achieved higher FibroTest findings after 6 months compared to subjects with BMI lower than 40 kg/m2, and in fewer cases FibroTest findings normalized in 1 year after surgery, respectively.
Conclusions. Therefore, it was noted the efficacy of laparoscopic sleeve gastrectomy in patients with obesity and non-alcoholic fatty liver disease; at the same time, it was revealed a transient worsening of the course of the disease in 6 months after surgery.

Introduction. Clinical outcomes of surgical treatment of postoperative ventral hernias are to be investigated not only in the nearest but also in the long-term postoperative period.
The aim of research was to study the effectiveness of various methods of hernioplasty and the patients' quality of life in the long-term surgical treatment of postoperative ventral hernias.
Materials and methods. The authors analyzed the results of surgical treatment of 76 patients with postoperative ventral hernias in the late postoperative period after various methods of hernioplasty during 2006-2017. The average term of follow up examination was 5.7 years. The patients’ quality of life was assessed using the SF-36 questionnaire; the anterior abdominal wall and the surgical area examination was performed in all patients; the patients were interviewed on adherence to recommendations in the postoperative period.
Results. The average physical health index (PH) was 47,27±1,05, while mental health index (MH) was 52,86±1,04. These parameters were low due to the age of the patients (60, 23±1,29 old), as well as the presence of concomitant diseases of the cardiovascular system (80,3%) and obesity (75%). Index of physical health component in sublay and corrective plastics was significantly lower than in autoplastic and onlay disposition of the prosthesis (р<0,001). However, the onlay method as well as the corrective technique and autoplasty revealed a high risk of hernia recurrence, and as a result, a decrease in physical and mental health indexes. According to the survey, it was found that more than 50% of the patients did not adhere to the recommendations for restricting physical exertion and wearing a bandage, which also contributed to the hernia recurrence. In 28% of patients reherniation or diastasis recti abdominis was detected in the surgical area. However, the patients did not notice these changes or did not believe in the success of repeated interventions.
Conclusion. Thus, the sublay technique proved to be a preferred method of various hernioplasty options. However, a search for more functional prostheses is needed to improve the quality of patients’ life. To prevent reherniation, patients are strongly recommended to adhere to the terms of wearing the bandage and restricting physical activity. Follow-up examinations of the patients should be performed by healthcare providers to timely reveal and treat recurrent postoperative ventral hernias.

ntroduction. Currently, total gastrectomy with D2 lymphadenectomy is the standard surgical treatment for proximal gastric cancer at the resectable stages (I-III). The issue of advisability of splenectomy as a component of lymphadenectomy remains a controversial one, especially when the tumor is localized in the region of the body or cardiac region of the stomach.
The aim of the study was to compare immediate and long-term outcomes, including the quality of life, between spleen preserving and spleen removing surgeries.
Methods. The study included 363 patients with gastric cancer II-III stages, localized in the upper and/or the middle third of the stomach, who underwent surgery at the Voronezh Regional Clinical Oncology Hospital and the Voronezh Clinical Hospital of the Russian Railway-Medicine in 2015-2017. All patients were conditionally divided into 2 groups for comparative retrospective analysis. All patients of the first (experimental or spleen-preserved) group (144 patients) were performed R0 total gastrectomy with D2 lymphadenectomy, including splenic hilar nodes (№ 10,11) removal without splenectomy. Patients of the second (control or splenectomy) group (219 patients) were performed R0 total gastrectomy with D2 lymphadenectomy and prophylactic splenectomy (for splenic hilar nodes removal).
Results. The average duration of the operation and the volume of blood loss did not differ in both groups. The incidence of early postoperative surgical complications was lower in the spleen-preserved group. Splenectomy was associated with more severe complications of class 4 and 5 according to the Clavien-Dindo classification.
Conclusion. Parameters of the 1- and 3-year overall survival rate did not differ in both groups. The results of the GSRS questionnaire were similar in both groups, excluding reflux-esophageal symptoms scale. The reflux scale demonstrated a statistically and clinically significant advantage of spleen preservation.

The aim of the study was to develop a model of acute destructive pancreatitis with damage to the extra-organ adipose tissue.
Materials and methods. Simulation of acute destructive pancreatitis with damage of the extra-organ adipose tissue was performed in 22 white breed boars aged 3 months. The animals were divided into groups in accordance with two series of studies, where the control (first) group included 15 animals with the pancreas and extra-organ adipose tissue remained intact. Acute destructive pancreatitis was simulated in 7 pigs of the experimental (second) group based on the proposed technique (patent for an invention No. 2668201). Ultrasound examination of the abdominal cavity and retroperitoneal region was applied to confirm the development of expected pathology in experimental animals. Intensity of blood supply was assessed using contrast radiography by injecting a contrast medium into the superior mesenteric artery. Complete blood count and biochemical assay were performed. In addition, during autopsy tissue samples were taken for histological and immunohistochemical investigations to assess changes in the internal organs.
Results. Acute destructive pancreatitis with damage to the extra-organic adipose tissue was regarded as achieved when clinical manifestations of apathy, lethargy, feed refusal were registered in animals. Biochemical blood tests revealed a significant increase in the concentration of alkaline phosphatase and alpha-amylase enzymes. Nitrogenous toxins, in particular, creatinine, were accumulated in the body of the experimental animals. Complete blood count revealed leukocytosis, the fact supporting the onset of the expected inflammatory process in the pancreas and adjacent adipose tissue. The development of necrotic and inflammatory processes in the organ was evidenced by a sharp increase in the level of amylase, creatinine and alkaline phosphatase in the blood of animals. Ultrasound examination revealed a picture of the blurring of pancreatic contours, heterogeneity of the organ structure, increased echogenicity, and enlargement of the duct. Intensification of the vascular pattern and increase in pancreatic contours were detected during the contrast examination of the abdominal vascular system. At autopsy, there were signs of enzymatic peritonitis, namely, serous-hemorrhagic exudate in the abdominal cavity and the cavity of the omental bursa, increased pneumatization of the intestinal tube with a thinning of its wall and foci of small hemorrhages. The pancreatic tissue in all cases was edematous, full-blooded, with multiple foci of fatty necrosis and purulent inflammation. Similar changes were found in the adjacent adipose tissue. At the light-optical level, vascular congestion, small foci of steatonecrosis and micro-abscesses were determined in the pancreas. Immunohistochemical studies largely evidenced the onset of acute destructive pancreatitis with damage to the extra-organ adipose tissue.
Conclusion. Thus, the proposed technique allows simulating acute destructive pancreatitis with damage to the extra-organ adipose tissue in pigs, the event frequently occurring in the clinical practice. In animals the disease is accompanied by clear clinical manifestations correlating with findings of instrumental and laboratory investigations, and autopsy results. Investigations of the pancreatic and extra-organ adipose tissue samples at the light-optical and molecular levels evidence the fact that the authors have simulated a model of acute destructive pancreatitis with involvement of the adipose tissue adjacent to the organ in the pathological process.

Introduction. Pyloroduodenal stenosis is one of the most common complications and indication for surgical treatment of peptic ulcer in 10-84% of patients. Gastric resection with Billroth-1 (B-1) or Billroth-2 (B-2) techniques is the basic surgical intervention in this pathology. However, these interventions are accompanied by a high rate of postoperative complications (7.2-35%), mortality (2-5%), and development of postresection syndromes in the long term period in 15-60% of patients.
The aim of the study was to improve the technique of gastroduodenal anastomosis creation in patients with penetrating stenosing duodenal ulcers.
Materials and methods. The authors analyzed clinical outcomes of gastric resection with a plasma scalpel (PS) using B-1 technique with single-row serous-muscular-submucosal sutures in 136 patients with penetrating stenosing duodenal ulcers. The techniques of «longitudinal dissection of the anterior wall of the duodenum» and «extraduodenization of the ulcer» were presented. B-1 technique of modified gastric resection was described in details. Clinical outcomes were assessed based on the incidence rate of complications in the early postoperative period. In 30 patients fibrogastroduodenoscopy was performed postoperatively to assess anastomotic healing.
Results. Due to the proposed techniques, it was possible to avoid intraoperative complications. Postoperative complications developed in 8.8% of patients. These included: violation of the motor-evacuation function of the stomach in 4.4% of patients, pneumonia in 2.2% of patients, suppuration of the postoperative wound in 1.5% of patients, internal bleeding in 0.7% of patients. There was no any gastroduodenoanastomosis (GDA) failure. Postoperative mortality was 0.7% of the internal bleeding. After plasma resection of the stomach using B-1 technique with single-row serous-muscular-submucosal sutures, the edges of the mucous membrane along the wound of the stomach and gastroduodenal anastomosis were visually regenerated by primary intention.
Conclusion. The presented method of gastric resection performed with plasma scalpel using B-1 technique of gastroduodenal anastomosis creation with single-row serous-muscular-submucosal sutures did not result in failure of the GDA sutures; the number of anastomositis and post-resection pancreatitis, as well as the damage to the bile ducts, was reduced. The techniques of "longitudinal dissection of the anterior wall of the duodenum" and "extraduodenization of the ulcer" reduce traumatization and simplify the operation technique.

Introduction. Currently, the possibility of effective correction of multiple organ failure and increasing the life expectancy of patients with critical heart failure using the ventricular assist devices (VAD) is absolutely evidenced. The development of alternative analogues of such devices produced within the country has been an urgent problem for many decades. The design of this machine requires the development of a protocol for carrying out complex biomedical studies on the biocompatibility and safety of the new device.
The aim of the study was to develop a protocol for testing and conducting comprehensive biomedical biocompatibility studies of a new ventricular assist device in an acute animal experiment.
Materials and methods. The study to develop a technique for implanting a left-ventricular assist device (LVAD) in an acute experiment included female mini-pigs, weighed 40-60 kg. In a series of acute experiments, 5 implantations of a disk pump as a LVAD were performed with a maximum observation period equal 6 hours.
Results. In the series of acute experiments, an implantation technique was developed and the fundamental possibility of a viscous friction pump application as a ventricular assist device was evidenced. In all experiments (n = 5), the average level of free hemoglobin did not exceed 2.6 mg%, which supports safety of performance of the viscous friction pump regarding blood erythrocytes. None of the experiments recorded episodes of pump shut-off or breakdown.
Conclusions. The series of acute experiments on mini-pigs helped reveal a number of anatomical and physiological features of this animal species that significantly complicated implementation of persistent observation. However, the developed experimental LVAD test methodology can be recommended for use in further chronic experiments on large laboratory animals (calves).

Currently, the prevalence of obesity and its extreme forms is progressively increasing throughout the world. The article presents analysis of different approaches to the surgical treatment of super and “super-super” obesity. The range of methods varies from one-stage restrictive interventions to the use of multi-component combined operations with long-term preoperative preparation. In general, the opinions of the experts seem to be different, so at the present time there are no uniform recommendations for treating patients with extreme obesity, the fact determining the need for further research

Treatment of soft tissue wound defects, especially those with a tendency to a prolonged chronic course, is a serious problem. The increase in the number of local infectious complications after surgical interventions, including orthopedic and trauma ones, requires to search for new opportunities in solving the problem of prevention and treatment of acute and chronic surgical infection. The increase in the number of multi-resistant nosocomial microflora resistant to a wide range of modern antibacterial drugs, as well as the ability of some bacterial agents to form structured biofilm colonies under certain conditions, significantly complicates the work of surgeons. Phage therapy is a promising field in the treatment of infections that is being actively developed in Western Europe, the Asian region, and the United States. Based on the experience of foreign experts, the article describes possible options of bacteriophage interaction with hydrogels, ways of fixing phage particles in hydrogel-based wound dressings, and possible effective combinations of phages with other substances.

Introduction. The incidence rate of necrotizing enterocolitis is 2.4:1000 of newborns. The number of complications reaches 51-68%, and mortality rate varies from 4 to 80%.
The aim of the study was to present current data of Russian and foreign experimental studies related to necrotizing enterocolitis in children.
Results. Currently, infants with low and very low body weight constitute the most proportion of patients with enterocolitis; the development of the disease in this cohort of patients has its distinctive features. In this regard, the issues of pathogenesis, the impact of risk factors and methods of prevention of the pathological process remain underinvestigated. Experimental models were used to study the features of the toll-interleukin 1 receptor domain containing adapter protein (TIRAP), the etiology of Toll-like receptor 4 expression, and the reasons for the increased levels of inflammatory mediators. The mechanism of intestinal-brain reciprocal communication was confirmed. The role of the bacterial flora and effectiveness of the antibacterial drug effect on this flora was also determined. Biomarkers of enterocolitis, such as an epidermal growth factor, interleukins, claudins 2, 3, 4, were detected using experimental modeling. Various options for disease prevention ranging from ischemic preconditioning to probiotics application and breastfeeding were analyzed, the latter ones having beneficial ability to form natural defenses in newborns.
Conclusions. Thus, necrotizing enterocolitis is a severe systemic disease. Experimental modeling allows analyzing the most complex, unsolved problems and introducing novel knowledge into clinical practice.

Alexander Bakulev was born in the village Nebankovskaya Vyatka province. He studied first at the parish school, and then at the Vyatka theological Seminary. In 1911 he entered the medical faculty of Saratov University. In 1918, he passed the exams for a doctor's degree ahead of schedule and remained in the hospital surgery clinic of the University. In 1926 A. N. Bakulev entered the residency at the Department of surgery of the 2nd Moscow medical Institute. In 1928 he successfully defended his thesis and was sent for a one-year internship in Germany. For the first time in the domestic practice, he proposed the introduction of radiopaque substances in the brain tissue, a method of ureteral transplantation, improved methods of x-ray examination of vessels, kidneys and ureters, developed methods of plastic esophagus (1935), surgery on the biliary tract, methods of surgical treatment of peptic ulcer, for the first time in the world surgically eliminated the fixation of the heart muscle to the heart bag with pericarditis, developed new methods of treatment of brain abscesses. A. N. Bakulev is considered a pioneer of intubation anesthesia in the USSR, the founder of thoracic and radical pulmonary surgery. He performed a successful lobectomy for chronic abscess (1938) and lung actinomycosis (1939). In 1943 A. N. Bakulev became head of the Department. During the great Patriotic war A. N. Bakulev - front, and then chief surgeon of the evacuation hospitals of Moscow, head of the surgical Department of the hospital medical and sanitary Department of the Kremlin. He successfully removed a lung from a patient with chronic suppurative process (1945), for the first time carried out a successful operation in nezaradene known to inhibit the Bayou (1948), have developed a method comissurotomy. In 1949, A. N. Bakulev was awarded the Stalin prize (1949). He was the first to impose an anastomosis between the superior Vena cava and pulmonary artery, performed surgery for aneurysm of the thoracic aorta, created a technology of heart operations in hypothermia, for the first time in the world he began to operate on children suffering from congenital heart defects. In 1955 on the initiative of A. N. Bakuleva was established Institute of thoracic surgery (now the Institute of cardiovascular surgery. A. N. Bakuleva), the first Director of which he became. Among his developments can be noted the method of electrocardio-stimulation, intended for the treatment of heart rhythm disorders, a method of plasty of coronary vessels in acute myocardial infarction. In the mid-fifties A. N. Bakulev lays the foundations of shunting operations on the vessels of the heart. In 1957 he was awarded the Lenin prize. In 1959 A. N. Bakulev performed a successful operation for valvular stenosis of the pulmonary artery. In 1958, the scientist was elected a full member of the USSR Academy of Sciences. From 1953 to 1960 – President of the USSR Academy of Sciences. A. N. Bakulev was awarded three orders of Lenin, the order of the red banner of Labor and the red Star, was awarded the highest international award of surgeons – the award "Golden scalpel". On March 31, 1967, Alexander Bakulev died suddenly from cardiac arrest and was buried at Novodevichy cemetery. In memory of Alexander Nikolaevich in 2005, a documentary film "the Key to the heart" was shot in front of the Institute of cardiovascular surgery named after A. N. Bakulev monument to the scientist, and the building – a plaque.

1. Langenbek was born in 1810 in the family of a rural pastor. At 19, he entered the medical faculty of the University of Göttingen, where he graduated with the title of doctor. In 1834, Mr .. He received a doctorate in medicine and after doing scientific practice in Belgium, France and England. In 1838, Bernhard Langenbeck received the title of Privatdocent, in 1841 he was elected extraordinary professor of the Department of Pathological Anatomy of the University of Göttingen, becoming an assistant clinic. B. Langenbek, is developing a number of surgical interventions that bring him wide popularity in the surgical world. Since 1841, B. Langenbek - head of the Department of Surgery in Kiel, then in Berlin. He is the pioneer of German scientific surgery, ensuring its rapid scientific progress in Germany.

Langenbek operates a lot on bones and joints, performs plastic surgeries, pharynx and larynx extirpation, resection of the tongue, removal of the uterus, ovariotomy, etc. Today, more than 20 surgical methods associated with the name of B. Langenbek are known, and a retractor proposed by B. Langenbek is used; hemostatic tourniquet developed by F. Esmarch and Langenbeck.

Langenbeck advocated regular postgraduate education, the establishment of a higher educational institution for military doctors, created the Red Cross Society committee in Germany, the scientific society of military doctors, founded the scientific journal Archive of Clinical Surgery, the German Society of Surgeons, whose first chairman was from 1872 to 1885 Langenbek was awarded the title of Major General and the rank of Actual Privy Councilor. September 29, 1887 Langenbek "suddenly died of a blow." On June 8, 1892, the grand opening of the Langenbeck House, which became the property of the German Society of Surgeons, took place in Berlin. Bernhard Langenbeck remains the first magnitude star among the luminaries of German surgery.