This journal is
indexed in Scopus
Year 2013 Vol. 21 No 2
S.A. SUSHKOV, YU.S. NEBYLITSIN, E.N. REUTSKAYA, A.N. RAK
DIFFICULT PATIENT. WOUND OF PYOTR IVANOVICH BAGRATION. PART III
EE “Vitebsk State Medical University”
The Republic of Belarus
The analysis of medical aid rendering to Prince P.I. Bagration wounded during Battle of Borodino has been carried out in the third part. Basing on the documents of the Patriotic War of 1812 as well as memoirs of direct participants and historians of the XIX century the events occurring after injury were restored in stages. Analysis of the military situation at the Battle of Borodino during the retreat of the Russian army up to Moscow showed that the events in the theater of military actions had a significant impact on the process of helping to Prince P.I. Bagration. Due to the unfavorable situation created in the band of the 2nd Western army at Borodino the rapid retreat of the Russian army from Mozhaisk as well as the severe state of the commander the physicians could not make a complete initial wound debridement within the first 48 hours.
The necessity of rapid evacuation of Prince P.I. Bagration from Moscow has prevented the timely implementation of secondary wound treatment at the development of phlegmon around the wound. Further progression of the infection process was followed by addition of putrid infection. Refusal of P.I. Bagration on the proposed surgical intervention led to the development of osteomyelitis, sepsis and anaerobic infection.
Expansion of the wound which P.I. Bagration permitted to perform on arrival at Simi could not change anything. On the next day to perform amputation without any slight chance of recovery was meaningless, it would only exacerbate the suffering of the commander. The cause of death was generalization of infection, accession of the anaerobic infection, prolonged severe intoxication.
Physicians who treated P.I. Bagration performed their duties scrupulously and treated the patient in accordance with the principles in that period and adapted to the evolving situation.
However unfavorable military situation in the theater of military actions and categorical denials of P.I. Bagration from operation did not allow physicians to realize all the possibilities.
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210023, Respublika Belarus, g. Vitebsk, pr. Frunze, d. 27, UO «Vitebskiy gosudarstvennyiy meditsinskiy universitet», kafedra obschey khirurgii,
Nebylitsin Yuriy Stanislavovich
Sushkov S.A. PhD, associate professor, vice-rector on scientific research work of EE “Vitebsk State Medical University.
Nebylitsin Yu.S. PhD, associate professor of the chair of general surgery of EE “Vitebsk State Medical University”
Reutskaya E.N. A 6-year student of the medical faculty of EE “Vitebsk State Medical University”.
Rak A.N. A 6-year student of the medical faculty of EE “Vitebsk State Medical University”.
V.G. BOGDAN 1 , S.G. KRYVOROT 2, T.E. VLADIMIRSKAYA 2, I.A. SHVED 2, J.M. GAIN 2
THE INFLUENCE OF ADIPOSE TISSUE-DERIVED MESENCHYMAL STEM CELLS ON COLLAGEN SYNTHESIS AT DIFFERENT WAYS OF PLASTY OF SIMULATED INCISIONAL HERNIA
EE “Belarusian State Medical University”1,
SEE “Belarusian Academy of Post-Graduate
Education” 2, Minsk,
The Republic of Belarus
Objectives. To carry out collagen biosynthesis analysis at different types of abdominal wall plasty with adipose tissue-derived mesenchymal stem cells transplantation (ATMSCs) in a simulated incisional hernia in laboratory animals.
Methods. The incisional hernia by the developed method was modeled in 140 laboratory animals (rats).
Four groups of animals depending on the type of abdominal wall plasty were formed. The plasty using a polypropylene surgical mesh with 2,5% gelatin gel and ATMSCs was carried out in the first group. One’s own tissue with 2,5% gelatin gel and ATMSCs was used in the second group; in the third group - a polypropylene surgical mesh; in the fourth group the interrupted suture was performed and 2,5% gelatin gel was additionally placed. To assess collagen formation processes the immunohistochemical tissue of the abdominal wall was studied in the dynamics with determination of the quantitative expression of biomolecular markers of collagen type I and III, as well as their relationship (I / III).
Results. It has been found out that that the transplantation of ATMSCs in the gelatin gel at the abdominal wall plasty in isolation and combined with a polypropylene surgical mesh leads to a stable high activity of collagen type I (p<0,05) in conjunction with a minimum increase (p<0,05) of the collagen type III expression both within the analyzed period and in comparison with the rates of other variants of plasty, stable elevation (p<0,05) of collagen ratio I / III type during the entire experiment.
Conclusions. The established features of collagen biosynthesis confirm the multifactorial positive impact of ATMSCs on the structural characteristics of connective tissue forming in the hernioplasty area.
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220034, Respublika Belarus', g. Minsk, ul. Azgura, d.4, UO «Belorusskii gosudarstvennyi meditsinskii universitet, voenno-polevoi fakul'tet
Bogdan Vasilii Genrikhovich
Bogdan V.G. PhD, associate professor, colonel of medical service, the deputy head of the military medical faculty of EE “BSMU” on educational and scientific affairs.
Kryvorot S.G. A researcher of CSRL of SEE “Belarusian Medical Academy of Post-Graduate Education”.
Vladimirskaya T.E. PhD, leading researcher of CSRL of SEE “Belarusian Medical Academy of Post-Graduate Education”.
Shved I.A. MD, professor, chief researcher of CSRL of SEE “Belarusian Medical Academy of Post-Graduate Education”.
Gain J.M. MD, professor, vice-rector on scientific affairs of SEE “Belarusian Medical Academy of Post-Graduate Education”.
I.V. MAIBORODIN, A.I. SHEVELA, V.A. MATVEEVA, M.N. DROVOSEKOV, M.I. BARANNICK, I.V. KUZNETSOVA
ANGIOGENESIS IN GRANULATION TISSUE AFTER IMPLANTATION OF POLYHYDROXYALKANOATE WITH MESENCHYMAL STEM CELLS
Center of Modern Medical Technology of the Institute of Chemical Biology and Fundamental Medicine of Siberian branch of RAS, Novosibirsk,
The Russian Federation
Objectives. To estimate the processes occurring in various tissues after implantation of polymeric films from polyhydroxyalkanoate (PHA) with the adsorbed autologous multipotent mesenchymal stem cells of the bone marrow origin (AMMSCBM) in experiment.
Methods. The processes occurring in the rat abdominal cavity, muscular and subcutaneous adipose tissues after implantation of PHA with the adsorbed AMMSCBM and transfected DNA of fluorescent protein GFP were studied by the methods of light microscopy.
Results. It was revealed that after implantation of PHA with AMMSCBM the increase of blood vessels number in the surrounding tissues was occurred as a result of neoangiogenesis processes. In this case AMMSCBM don’t migrate and don’t collapse in the site of administration, but form the blood vessels on account of differentiation of their structures in cells. Processes of angiogenesis in tissues around PHA in turn lead to formation of large number of blood vessels in the granulations surrounded the implanted foreign body, larger volume of granulations and thicker capsule, delimiting polymer in the future. However it is possible that formation of a thick capsule with fibrous signs after implantation of PHA with AMMSCBM is considered as the unfavorable prognostic signs indicating to high probability of various complications development afterwards. Administrated AMMSCBM are replaced eventually by their own recipient cells.
Conclusions. The implantation of PHA with AMMSCBM leads to the formation of large number of blood vessels in the granulations forming round the implanted foreign body, larger volume of granulations and thicker capsule delimiting polymer in the future.
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630090, Rossiiskaia Federatsiia, g. Novosibirsk, pr. akad. Lavrent'eva, d. 8, Institut khimicheskoi biologii i fundamental'noi meditsiny SO RAN, Tsentr novykh meditsinskikh tekhnologii, laboratoriia stvolovoi kletki,
Maiborodin Igor' Valentinovich
Maiborodin I.V. MD, professor, leading researcher of the stem cell laboratory of the Institute of Chemical Biology and Fundamental Medicine of RAS, Novosibirsk.
Shevela A.I. MD, professor, Honored Doctor of RF, deputy director of the Institute of Chemical Biology and Fundamental Medicine of RAS, Novosibirsk.
Matveeva V.A. PhD, a senior researcher of the stem cell laboratory of the Institute of Chemical Biology and Fundamental Medicine of RAS, Novosibirsk.
Drovosekov M.N. PhD, an applicant for Doctor’s degree of the stem cell laboratory of the Institute of Chemical Biology and Fundamental Medicine of RAS, Novosibirsk.
Barannik M.I. PhD, an applicant for Doctor’s degree of the stem cell laboratory of the Institute of Chemical Biology and Fundamental Medicine of RAS, Novosibirsk.
Kuznetsova I.V. PhD, a researcher of the stem cell laboratory of the Institute of Chemical Biology and Fundamental Medicine of RAS, Novosibirsk.
GENERAL AND SPECIAL SURGERY
SURGICAL TREATMENT OF EXTENSIVE AND GIANT VENTRAL INCISIONAL HERNIAS
SBEE APE “Irkutsk State Medical Academy of Post-Graduate Education”1,
NGHA “Railway Clinical Hospital at the station Irkutsk - Passenger” of JSC “Russian Railways”2,
The Russian Federation
Objectives. To evaluate effectiveness of surgical treatment of extensive and giant incisional hernias with the developed method of “the cut mesh prosthesis”.
Methods. Prospective investigation including 48 patients was conducted. Two groups were allocated. 27 patients who were subjected to plasty using the designed “the cut mesh prosthesis” method made up the main group (MG); 21 patients who underwent Shumpelik’s surgery made up the group of clinical comparison (GCC). The designed method differs from the existed ones in the way of endoprosthesis fixation in the tissues. Endoprosthesis is not sewed to the tissues but fixed by means of strips cut to its edges. Multislice computed tomography (MSCT) with hernioabdomenometry and surface electromyography (EMG) were carried out before and after the intervention. The number and character of complications were evaluated in the early postoperative period. Recurrences and life quality were analyzed in long-term period.
Results. Out of 27 main group patients early postoperative complications were revealed in 4 (14,8%) and in the group of clinical comparison (n=21) the complications developed in 6 (28,6%) of patients. At electromyography of the straight abdominal muscles in patients the electropotentials were irregular and low amplitude in both main and clinical comparison groups before the operation. One year after operation more significant restoration of the biopotentials of straight muscles was observed. No recurrences were revealed in the main group in the long-term period up to five years. Two hernia recurrences were revealed in the group of clinical comparison. While evaluating the life quality in the main group patients an increase of physical and psychological components of health was registered in contrast to the comparative group (ð<0,01).
Conclusions. The designed method of “the cut mesh prosthesis” increases effectiveness of patients’ treatment with extensive and giant incisional hernias by reducing of recurrences and reliable improvement of patients’ life quality.
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664079, Rossiiskaia Federatsiia, g. Irkutsk, m-n. Iubileinyi 100, GBOU DPO «Irkutskaia gosudarstvennaia meditsinskaia akademiia poslediplomnogo obrazovaniia», kafedra khirurgii,
Kulikov Leonid Konstantinovich
Kulikov L.M. MD, professor, a head of the surgery chair of SBEE APE “Irkutsk State Medical Academy of Post-Graduate Education”.
Buslaev O.A. A head of the surgical department of NGHA “Railway clinical hospital at the station Irkutsk-Passenger ” of JSC “Russian Railways”.
Shalashov S.V. PhD, a surgeon of the surgical department of NGHA “Railway clinical hospital at the station Irkutsk-Passenger” of JSC “Russian Railways”.
Smirnov A.A. PhD, an assistant of the surgery chair of SBEE APE “Irkutsk State Medical Academy of Post-Graduate Education”. Mikhaylov A.L. A surgeon of the surgical department of NGHA “Railway clinical hospital at the station Irkutsk-Passenger ” of JSC “Russian Railways”.
Egorov I.A. A surgeon of the surgical department of NGHA “Railway clinical hospital at the station Irkutsk- Passenger” of JSC “Russian Railways”.
Shadarov l.P. A physician of the functional diagnostics department of NGHA “Railway clinical hospital at the station Irkutsk-Passenger” of JSC “Russian Railways”.
Sobolev S.T. PhD, a physician of the functional diagnostics department of NGHA “Railway clinical hospital at the station Irkutsk- Passenger” of JSC “Russian Railways”.
Sobotovich V.F. PhD, associate professor of the surgery chair of SBEE APE “Irkutsk State Medical Academy of Post-Graduate Education”.
Privalov U.A. PhD, associate professor of the surgery chair of SBEE APE “Irkutsk State Medical Academy of Post-Graduate Education”.
S.V. ALEXANDROV 1,2
POSSIBILITIES OF ENDOSCOPIC LASER LITHOTRIPSY IN PATIENTS WITH CHOLANGIOLITHIASIS
SEE “Belarusian Medical Academy of Post-Graduate Education”1,
ME “Minsk Regional Clinical Hospital”2,
The Republic of Belarus
Objectives. To determine the wave length of laser radiation with the most marked lithotripsy effect concerning the concretions of the extrahepatic bile ducts as well as to find out the optimal parameters of laser radiation to carry out lithotripsy.
Methods. Affecting the concretions of the extrahepatic bile ducts by laser radiation of 1064, 1320 and 1440 nm wavelengths in liquid medium we have ascertained the wavelength with most expressed effect of lithotripsy. Then, changing stepwise the energy of the laser radiation impulse of 1320 and 1440 nm wavelengths we have determined the optimal values of the impulse energy to carry out lithotripsy.
Results. The largest size of the concretion could be destroyed by a single impulse of 1440 nm wavelength of laser radiation at the same parameters.
The minimal lithotripsy effect is found at 1064 nm wavelength. The optimal values of the impulse energy for the performance of extrahepatic bile duct concretions lithotripsy by 1320 nm wavelength radiation are considered to be within the limits of 0.9-1,5 J and 0,5-0,8 J for 1440 nm. Higher values of the impulse energy are considered as dangerous for application in connection with impossibility to control distinctly the process of concretion destruction and damage risk of the adjacent tissues.
Conclusions. A 1440 nm wavelength radiation has the greatest effect of lithotripsy out of three wavelengths (1064, 1320 and 1440 nm) and is considered the most safe and effective for lithotripsy performance at cholangiolithiasis. 1320 nm wavelength radiation can be also applied to destroy large concretions of the extrahepatic bile ducts at laparoscopic and videoendoscopic interventions.
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223052, Respublika Belarus', Minskaia oblast', Minskii raion, p. Lesnoi-1; UZ «Minskaia oblastnaia klinicheskaia bol'nitsa», khirurgicheskoe otdelenie ¹2,
Aleksandrov Sergei Vladimirovich
Alexandrov S.V. A head of the surgical department ¹2 of ME “Minsk regional clinical hospital”, lecturer of the surgery chair of SEE “Belarusian Medical Academy of Post-Graduate Education”.
S.N. NAVRUZOV1, M.M. MIRZAKHMEDOV2, B.S. NAVRUZOV3, M.A. AHMEDOV3
PECULIARITIES OF CLINICAL COURSE AND CHOICE OF SURGICAL TREATMENT OF HIRSCHPRUNG’S DISEASE IN ADULTS
Republican Oncological Scientific Center of the Ministry of Health of the Republic of Uzbekistan 1,
Coloproctology Scientific Center of the Republic of Uzbekistan 2, Tashkent,
Tashkent Medical Academy 3,
The Republic of Uzbekistan
Objectives. To improve diagnostics and determine the most effective ways of operative treatment in case of Hirschsprung’s disease in adults.
Methods. 82 patients with Hirschsprung’s disease (HD) undergoing examination and treatment during the period of 1990 up to 2013 yrs. in the Scientific Center of Coloproctology of the Ministry of Health of the Republic of Uzbekistan were included in the research. The age of patients varied from 15 up to 46 years. Out of 82 patients, 58 (70,7%) were males, 24 were females (29,3%). All patients underwent clinical and instrumental examination. For the comparative analysis of surgical treatment effectiveness the patients with HD were subdivided into 2 groups. The main group included 28 patients who underwent the abdominal-anal resection (BAR) of the rectum with the relegation of the proximal colon to the anal canal. The control group included 44 patients who underwent Duhamel operation. Outcomes of interventions and complications were analyzed. The long-term results of surgical treatment were evaluated using Visick score.
Results. Out of 82 surveyed patients the supraanal form of hypogangliosis was detected in 46 (56%), rectal one – in 20 (24,4%), recto-sigmoid – in 13 (15,9%), left-side one – in 2 (2,5%) and – 1 (1, 2%) subtotal form. According to Swenson biopsy data agangliosis was revealed in 36 (44%) out of 82 patients, hypogangliosis of the rectum in 46 (56%). In the main group the early postoperative complications were registered in 4 (14, 3%) patients and in the control group – in 14 (31,8%) patients. Lethal outcome was registered in 1 (2,2%) case after Duhamel operation. Late postoperative complications were revealed in 7,1% in the main group and 15% in the control group of patients.
Conclusions. The most adequate and radical way to treat HD in adults is considered to be the abdominal-anal resection of the rectum with relegation of the proximal colonic segments to the anal canal. It is aimed at the removal of hypo-or agangliosis zone and the decompensated segments of the colon and meets the requirements of radicalism.
- Bykov NI, Chepurnoi GI, Kivva AN. Vybor optimal'nogo varianta khirurgicheskogo lecheniia bolezni Girshprunga u detei [The choice of the optimal surgical treatment options of Hirschsprung's disease in children]. Det Khirurgiia. 2007;(5):10–12.
- Sansbury FH, Ellard S, Shaw-Smith C, Turnpenny P. Many patients have an identifiable genetic cause of Hirschsprung's disease. BMJ. 2012 Dec 3;345:e8199.
- Leonevskaia NM, Erdes SI, Ratnikova MA. Protokol lecheniia bolezni Girshprunga u detei [The protocol of Hirschsprung's disease treatment in children]. Ros Zhurn Gastroenterologii Gepatologii Koloproktologii. 2009;(3):57–62.
- Vorobei AV, Makhmudov AM, Vysotskii FM, Tikhon VK, Senkevich OI, Archakova LI, Novakovskaia SA. Sorokàletnii opyt lecheniia bolezni Girshprunga u vzroslykh v Belarusi [Forty years experience in the treatment of Hirschsprung's disease of adults in Belarus]. Vopr Organizatsii i Informatizatsii Zdravookhraneniia. 2010;(4):92–96.
- Vorob'ev GI, Zhuchenko AP, Achkasov SI, Biriukov OM. Bolezn' Girshprunga u vzroslykh: 25-letnii opyt kliniki [Hirschsprung's disease in adults: 25 years of experience in the clinic]. Aktual'nye vopr koloproktologii: tez dokl. Samara, RF; 2003. s. 414.
- Best KE, Glinianaia SV, Bythell M, Rankin J. Hirschsprung's disease in the North of England: prevalence, associated anomalies, and survival. Birth Defects Res A Clin Mol Teratol. 2012 Jun;94(6):477–80.
- Ergashev NSh, Khurramov FM, Khamidov BKh, Markaev AIa. Diagnostika i lechenie bolezni Girshprunga u detei [Diagnosis and treatment of Hirschsprung's disease in children]. Khirurgiia Uzbekistana. 2009;(2):36–40.
- Kapuller LL, Achkasov SI, Zhuchenko AP, Biriukov OM. Protiazhennost' zony fiziologicheskogo gipoganglioza u vzroslykh i ee znachenie v diagnostike bolezni Girshprunga [Extension of the zone of physiological hypogangliosis in adults and its importance in the diagnosis of Hirschsprung's disease]. Arkh Patologii. 2008;(1):46–49.
- Goslin B, Brown A, Robertson D. Gastroschisis, ileal atresia, and Hirschsprung's disease in a newborn: The first reported case. J Pediatr Surg. 2012 Nov;47(11):2134–36.
100060, Respublika Uzbekistan, g. Tashkent, ul. S. Azimova, d. 74, Respublikanskaia klinicheskaia bol'nitsa ¹1., Respublikanskii nauchnyi tsentr koloproktologii MZ Uzbekistana,
Mirzakhmedov Murad Mirkhaidarovich
Navruzov S.N. MD, professor, director of the Republican oncological scientific center of the Ministry of Health of the Republic of Uzbekistan.
Mirzakhmedov M.M. PhD, senior researcher of the Coloproctology Scientific center of the Republic of Uzbekistan.
Navruzov B.S. MD, associate professor of the chair of the general profile physician in surgery of Tashkent Medical Academy.
Ahmedov M.A. MD, professor of the chair of the general profile physician in surgery of Tashkent Medical Academy.
E.V. SHAYDAKOV1, V.L. BULATOV1,2, Å.À. ILYUKHIN3, I.N. SONKIN4, A.G. GRIGORYAN1
PREDICTION OF RESULTS AT ENDOVENOUS LASER ABLATION IN PATIENTS OF DIFFERENT AGE GROUPS
FSBE “SII of Experimental Medicine” of the North-west district of RAMS1,
Saint-Petersburg Institute of Bioregulation and Gerontology of the North-west district of RAMS 2,
Clinic “Medalp” 3,
Railway clinical hospital of JSC “Russian railways” 4, Saint-Petersburg
The Russian Federation
Objectives. To work out the prognostic models of results at endovenous laser ablation (EVLA) to treat varicose veins according to the combined ultimate point taking into account the patient’s age on the basis of clinical data of the retrospective cohort multicentre study (RCMS).
Methods. The research was conducted using the data of the retrospective linear cohort multicentre study on the basis of the vascular departments of three specialized clinics of Saint-Petersburg during the period from January, 2010 up to May, 2011. 257 patients with varicose veins of Ñ2 – Ñ3 classes of clinical manifestation according to ÑÅÀÐ were included in the study. The patients were subdivided into 2 cohorts: laser with the wave length of 970 nm was applied in the “H” cohort; 1470 nm and 1560 nm – in “W” cohort. The evaluation was done according to the combined ultimate point including three components: pain, ecchymosis, the presence of recanalization of the great saphenous vein (GSV) in the middle third of the thigh. The results were divided into 4 groups: the best, good, bad and the worst one. Mathematical-statistic packet of the applied programs KNIME (The Konstanz Information Miner), KNIME Desktop, version 2. 6.0 was used for calculations.
Results. The model of the results’ prediction of EVLA for different age groups was designed according to general selection and in case of lasers H and W application.
Conclusions. At W-laser application better results of EVLA are predicted in elderly and senile patients than in young patients. In case of H-laser application the result doesn’t depend on the age. Range of the linear endovenous energy density (LEED) and the diameter of veins influencing the treatment results are wider for W-laser than for H-laser in all age groups. Maximal difference of EVLA H- and W-lasers results regardless of age were revealed in the range of the vein diameters of 8-10 mm that are seen in greater frequency of obtaining the best results at W-laser application.
- Navarro L, Min RJ, Bone C. Endovenous laser: a new minimally invasive method of treatment for varicose veins-preliminary observations using an 810 nm diode laser. Dermatol Surg. 2001 Feb;27(2):117–22.
- Siribumrungwong B, Noorit P, Wilasrusmee C, Attia J, Thakkinstian A. A systematic review and meta-analysis of randomised controlled trials comparing endovenous ablation and surgical intervention in patients with varicose vein. Eur J Vasc Endovasc Surg. 2012 Aug;44(2):214–23.
- Shevchenko IuL, Stoiko IuM, Mazaishvili KV, Khlevtova TV. Mekhanizm endovenoznoi lazernoi obliteratsii: novyi vzgliad [The mechanism of endovenous laser ablation: a new look]. Flebologiia. 2011;5(1):46–50.
- Timperman PE, Sichlau M, Ryu RK. Greater energy delivery improves treatment success of endovenous laser treatment of incompetent saphenous veins. J Vasc Interv Radiol. 2004 Oct;15(10):1061–63.
- Proebstle TM, Krummenauer F, Gul D, Knop J. Nonocclusion and early reopening of the great saphenous vein after endovenous laser treatment is fluence dependent. Dermatol Surg. 2004 Feb;30(2 Pt 1):174–78.
- Min RJ, Khilnani NM. Endovenous laser ablation of varicose veins. J Cardiovasc Surg (Torino). 2005 Aug;46(4):395–405.
- Kaspar S, Siller J, Cervinkova Z, Danek T. Standardisation of parameters during endovenous laser therapy of truncal varicose veins--experimental ex-vivo study. Eur J Vasc Endovasc Surg. 2007 Aug;34(2):224–28.
- KNIME (Konstanz Information Miner). Available from: http://www.knime.org.
- Berthold MR, Cebron N, Dill F, Gabriel TR, Kotter T, Meinl T, Ohl P, Sieb C, Thiel K, Wiswedel B. KNIME: The Konstanz Information Miner. In Data Analysis, Machine Learning and Applications Proceedings of the 31st Annual Conference of the Gesellschaft fur Klassifikation. Berlin, Germany: Springer; 2007. p. 319–26.
- Shaidakov EV, Bulatov VL, Iliukhin EA, Son'kin IN, Grigorian AG, Gal'chenko MI. Optimal'nye rezhimy endovenoznoi lazernoi obliteratsii s dlinoi volny 970 nm, 1470 nm i 1560 nm: Retrospektivnoe prodol'noe kogortnoe issledovanie [Optimal conditions of endovenous laser ablation with 970 nm, 1470 nm and 1560 nm wavelength: a retrospective longitudinal cohort study]. Shaidakov EV, red. Sbornik tez 5 Saint-Petersburg Venoz foruma; 2012 Dek 7; Saint-Petersburg, RF. p. 85–86.
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- Disselhoff BC, Rem AI, Verdaasdonk RM, Kinderen DJ, Moll FL. Endovenous laser ablation: an experimental study on the mechanism of action. Phlebology. 2008 Jan;23(2):69–76.
- Sokolov AL, Liadov KV, Lutsenko MM, Lavrenko SV, Liubimova AA, Verbitskaia GO, Minaev VP. Primenenie lazernogo izlucheniia 1,56 mkm dlia endovazal'noi obliteratsii ven v lechenii varikoznoi bolezni [The use of laser radiation (1.56 micron) for endovasal ablation in the treatment of varicose veins]. Angiologiia i Sosud Khirurgiia. 2009;15(1):69–75.
- Proebstle T, Moehler T, Gul D, Herdemann S. Endovenous treatment of the great saphenous vein using a 1,320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Dermatol Surg. 2005 Dec;31(12):1678–83.
- Mordon SR, Wassmer B, Zemmouri J. Mathematical modeling of 980-nm and 1320-nm endovenous laser treatment. Lasers Surg Med. 2007 Mar;39(3):256–65.
197376, Rossiiskaia Federatsiia, g. Sankt-Peterburg, ul. Akademika Pavlova, d. 12, FGBU «NII Eksperimental'noi Meditsiny» SZO RAMN,
Bulatov Vasilii Leonidovich
Shaydakov E.V. MD, professor, deputy director of FSBE “SII of Experimental Medicine” of North-West District of RAMS, Saint-Petersburg.
Bulatov V.L. A researcher of the biogerontology laboratory of the Institute of bioregulation and gerontology of North-West District of RAMS, Saint-Petersburg.
Ilyukhin E.A. Chief physician of the clinic “Medalp”, Saint-Petersburg.
Sonkin I.N. PhD, a head of the vascular department of the railway clinical hospital JSC “Russian railways”, Saint-Petersburg.
Grigoryan A.G. Vascular surgeon of FSBE “SII of Experimental Medicine” of North-West District of RAMS, Saint-Petersburg.
I.N. IGNATOVICH1 , G.G. KONDRATENKO1 , D.D. NIKULIN2
JUSTIFICATION FOR THE OPTIMAL TREATMENT METHOD OF PATIENTS WITH DIABETIC NEUROISCHEMIC FOOT SYNDROME BASED ON COMPARISON OF LONG-TERM RESULTS OF VARIOUS METHODS APPLICATION
EE “Belarusian State Medical University”1,
ME “Minsk 11th City Clinical Hospital” 2,
The Republic of Belarus
Objectives. To justify the optimal treatment method of patients with neuroischemic form of diabetic foot syndrome having compared the long-term results (3 years) of two different application methods: conservative or surgical (the lower limb revascularization).
Methods. The data presented in the article are the completion of the research aimed to determine the optimal treatment method in patients with neuroischemic form of diabetic foot syndrome; intermediate results of this research have been published earlier.
Two groups of patients with neuroischemic form of diabetic foot syndrome were singled out to compare the treatment results: the control group and the comparison group. The patients of the control group (numbering 110) underwent only conservative treatment. The lower limb revascularization has performed to stop the critical ischemia in patients of the comparison group (numbering 48).
Results. During 3 years 65 out of 110 persons died in the control group. In 25 out of 45 staying alive patients (55,6%) we managed to save the supporting function of the foot and avoid the lower limb high amputation. During 3 years 9 out of 48 patients died (18,8%) in the comparison group. In 28 out of 39 staying alive patients (71,8%) we managed to save the supporting function of the foot and avoid the lower limb high amputation. The number of major amputations in the control group was reliably higher than in the comparison group. In the long-term results the number of ulcerous-necrotic lesions of the foot and the patients with the pain syndrome at rest condition was reliably higher in the control group. The parameters of life quality were better in the comparison group.
Conclusions. Revascularization is considered as an optimal and effective method of critical ischemia treatment and saving of the limb supporting function at neuroischemic form of diabetic foot syndrome.
- Pashkevich LA, Mokhammadi MT, Ignatovich IN, Martyniuk SN. Patomorfologiia diabeticheskoi neiropatii [Pathologic morphology of diabetic neuropathy]. ARS medica. 2010;(9):187–92.
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- Chur NN, Grishin IN, Kazlovskii AA, Kokoshko IuI. Etiologiia, patogenez, klassifikatsiia i khirurgicheskoe lechenie sindroma diabeticheskoi stopy [The etiology, pathogenesis, classification and surgical treatment of diabetic foot syndrome]. Khirurgiia Zhurn im NI Pirogova. 2003;(4):42–6.
- Malakhov IuS, Aver'ianov DA, Ivanov AV. Analiz rezul'tatov khirurgicheskogo lecheniia bol'nykh s gnoino-nekroticheskimi porazheniiami nizhnikh konechnostei ishemicheskogo geneza [Analysis of the results of surgical treatment of pyonecrotic tissue lesions of the lower limbs ischemic]. Angiologiia i Sosud Khirurgiia. 2009;(1):133–38.
- Ol'shanskii MS, Esipenko VV, Ivanov AA, Moshurov IP, Kazanskii DV. Endovaskuliarnaia korrektsiia mnogoetazhnogo porazheniia arterii pri kriticheskoi ishemii nizhnei konechnosti u bol'nogo pozhilogo vozrasta [Endovascular correction of multi-storey arterial lesions in elderly patients with critical limb ischemia]. Angiologiia i Sosud Khirurgiia. 2007;13(2):42–44.
- Ignatovich IN, Kondratenko GG, Sergeev GA, Kornievich SN, Khrapov IM. Rezul'taty lecheniia patsientov s khronicheskoi kriticheskoi ishemiei pri neiroishemicheskoi forme sindroma diabeticheskoi stopy [The results of treatment of patients with chronic critical ischemia at diabetic neuroischemic foot]. Khirurgiia Zhurn im NI Pirogova. 2011;(6):51–55.
- Ferraresi R, Centola M, Ferlini M, Da Ros R, Caravaggi C, Assaloni R, Sganzaroli A, Pomidossi G, Bonanomi C, Danzi GB. Long-term outcomes after angioplasty of isolated, below-the-knee arteries in diabetic patients with critical limb ischaemia. Eur J Vasc Endovasc Surg. 2009 Mar;37(3):336–42.
- Khamitov FF, Dibirov MD, Briskin BS i dr. Vozmozhnosti khirurgicheskoi revaskuliarizatsii pri gnoino-nekroticheskikh oslozhneniiakh sindroma diabeticheskoi stopy [The possibilities of surgical revascularization in necrotic complications of diabetic foot]. Al'm in-ta khirurgii im AV Vishnevskogo. 2009;4(2):209–10.
- De Rubertis BG, Chaer RA, Hynecek R, Benjelloun R, Karwowski J. Effect Of Diabetes On Outcome Of Percutaneous Lower Extremity Intervention. NESVS Annual Meeting: Abstracts. 2006. ð. 25.
- Gavrilenko AS, Skrylev SI. Khirurgicheskoe lechenie bol'nykh s kriticheskoi ishemiei nizhnikh konechnostei, obuslovlennoi porazheniiami arterii infraingvinal'noi lokalizatsii [Surgical treatment of patients with critical ischemia of the lower limbs due to arterial lesions of infrainguinal localization]. Angiologiia i Sosud Khirurgiia. 2008;14(3):111–17.
- Dibirov MD, Briskin BS, Khamitov FF, Proshin AV, Iakobishvili IaI. Rol' rekonstruktivnykh sosudistykh operatsii u bol'nykh diabeticheskoi angiopatiei [The role of reconstructive vascular surgery in patients with diabetic angiopathy]. Khirurgiia Zhurnal im NI Pirogova. 2009;(2):59–63.
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220116, Respublika Belarus', g. Minsk, pr-t. Dzerzhinskogo, d. 83, UO «Belorusskii gosudarstvennyi meditsinskii universitet», 1-ia kafedra khirurgicheskikh boleznei,
Ignatovich Igor' Nikolaevich
Ihnatovich I.N. PhD, associate professor of the 1st chair of surgical diseases of EE “Belarusian State Medical University”.
Kondratenko G.G. MD, professor, head of the 1st chair of surgical diseases of EE “Belarusian State Medical University”.
Nikulin D.D. A physician of the surgical department of ME “Minsk 11th city clinical hospital”.
S.V. SPIRYDONAU1, O.A. YUDINA2, A.P. SHKET1 , Y. M. CHESNOV1 , S.I. DRYK3 , A. V. ADZINTSOU1 , N.N. SHCHATSINKA1 , N.N. ZUE
VARIANTS OF CRYOPRESERVED ALLOGRAFTS PREPARATION BEFORE IMPLANTATION
Objective. To optimize a defrosting regimen of cryopreserved allografts.
Material and methods. 27 cryopreserved allografts of the aortic and pulmonary valves were included in the study. Allograft sterilization was performed in antibiotic solution, containing nutritive media, cefazolin, metronidazole and fluconazole. Cryoconservation was done using program freezer at cooling rate of 1°C per minute until -80°Ñ. Dimethylsulfoxide was used as a cryoprotectant. Three different thawing conditions were applied: 1) at 36-42°Ñ (n=10) within 15 minutes, 2) at 18-20°Ñ (n=7) within 35 minutes, 3) at 8-10°Ñ (n=10) within one hour (modification of RSPC «Ñardiology»). The removal of cryoprotectant was performed with gradual reduction of its concentration.
Results. The diameter and shape of allografts remained the same after completion of defrosting process in comparison with the primary patterns. Defrosted allografts had identically dense consistency at using various defrosting variants. The performed macroscopic evaluation permits to confirm that defrosting at 8-10°Ñ doesn’t lead to allîgraft wall ruptures.
The strength characteristics investigation during hydraulic tests revealed the absence of any differences in allografts durability after thawing in different temperature conditions. Histological evaluation of the allografts defrosted at 8-10°Ñ and at 18-20°Ñ didn’t reveal any structure changes in comparison with native valves.
Conclusions. Defrosting of cryopreserved aortic and pulmonary allografts at the temperature from 8°Ñ to 10°Ñ within 60 minutes turns up to be optimal due to providing allograft integrity, endurance and its histological structure integrity.
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220036, Respublika Belarus', g. Minsk, ul. R. Liuksemburg, d. 110, GU RNPTs «Kardiologiia», 2-e kardiokhirurgicheskoe otdelenie,
Spiridonov Sergei Viktorovich
Spirydonau S.V. PhD, cardiosurgeon of RSPC "Cardiology".
Yudina O.A. PhD, a head of the general pathology department of ME “City Pathological-anatomical bureau”.
Shket A.P. PhD, cardiologist, head of the 2nd cardiac surgery department of RSPC "Cardiology".
Chesnov Y.M. MD, cardiosurgeon of RSPC "Cardiology".
Dryk S.I. A head of the department of separation and cryoconservation of the bone marrow of ME “The 9th city clinical hospital”.
Adzintsou A. V. Cardiologist of RSPC "Cardiology".
Shchatsinka N.N. Cardiologist of RSPC "Cardiology".
Zuenok N.N. Physician of the department of separation and cryoconservation of the bone marrow of ME “The 9th city clinical hospital”.
Ostrovsky Y.P. Corresponding member of NAS, MD, professor, a head of the laboratory of cardiac surgery of SE RSPC "Cardiology", head of the cardiac surgery chair of SEE “Belarusian Medical Academy of Post-graduate Education”.
S.A. TACHYLA1, À.V. ÌàRACHKAU1, N.Î. ÌàKSUTA2 , N.V. ÀKULICH2
INFLUENCE OF VARIOUS VARIANTS OF THE MULTICOMPONENT BALANCED ANAESTHESIA ON THE LEUKOCYTE FORMULA AND PHAGOCYTIC ACTIVITY IN BLOOD OF THE PATIENTS
ME "Mogilev Regional Hospital" 1,
ME "Mogilev Regional Hospital named A.A. Kulrshov 2".
The Republic of Belarus
Objectives. To carry out comparative analysis of different variants effects of the multicomponent balanced anesthesia using isoflurane/nitrous oxide/fentanyl, sevoflurane/nitrous oxide/fentanyl and propofol/fentanyl on leukocytes: their number, composition and phagocytic activity of polymorphonuclear leukocytes.
Methods. Analysis of the number and function of leukocytes during general anesthesia at laparoscopic cholecystectomy was performed in 50 patients (3 males and 47 females, aged 51,5±12,4 years, weight 84,5±18,4 kg). At several stages of anesthesia the changes in the quantity of leukocytes, granulocytes and lymphocytes and phagocytic activity of polymorphonuclear leukocytes were determined.
Results. It has been found out that during the multicomponent balanced anesthesia with the use of sevoflurane/nitrous oxide/fentanyl and propofol/fentanyl the number of leukocytes, granulocytes and lymphocytes intraoperatively doesn’t differ from baseline and the multicomponent balanced anesthesia using isoflurane/nitrous oxide/fentanyl decreases the number of leukocytes and granulocytes during surgery. In the postoperative period leukocytosis, granulocytosis and relative lymphopenia were registered. Phagocytic activity of leukocytes decreased during general anesthesia. The intensity of fluorescence was significantly lower in the group with propofol/fentanyl application compared with group of sevoflurane/nitrous oxide/fentanyl application.
Conclusions. During anesthesia the changes of the number of leukocytes, granulocytes and lymphocytes along with stable hemodynamic parameters, oxygenation, ventilation, sufficiently deep anesthesia according to monitoring data of electroencephalography and neuromuscular block characterize an adequate level of anesthesia protection of patients against a operation trauma. In our study all three variants of the multicomponent balanced anesthesia have the ability to reduce the phagocytic index that anesthesiologist should take into account during anesthesia.
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212016, Respublika Belarus', g. Mogilev, ul. Belynitskogo-Biruli, d. 12, UZ «Mogilevskaia oblastnaia bol'nitsa», reanimatsionno-anesteziologicheskoe otdelenie,
Tochilo Sergei Anatol'evich
Tachyla S.A. An anesthesiologist-resuscitator of ME "Mogilev Regional Hospital".
Marachkau A.V. MD, a head of the anesthesiology and intensive care unit of ME "Mogilev Regional Hospital".
Maksuta N.O. A post-graduate student of the biology chair of EE "Mogilev State University named after A.A. Kuleshov”.
Akulich N.V. PhD, a head of the ecological physiology chair of EE "Mogilev State University named after A.A. Kuleshov”.
THE METHOD OF POSTPAPILLOTOMY BLEEDINGS PREVENTION
FSEI HPE "Khakassia State University named by NF Katanov", Abakan
The Russian Federation
Objectives. To decrease the incidence of postpapillotomy bleedings in patients with hemostasis system disturbances occurring in the mechanical jaundice.
Methods. The aim was achieved by the two-staged endoscopic papillosphincterotomy (EPST) with the inter-staged biliary ducts stenting. The first stage included slight dissection (up to the separation of the orifices of the common bile and main pancreatic ducts) of the major duodenal papilla and endobiliary stenting. At normalization of biochemical and coagulation parameters, the removal of the endoprosthesis and maximal EPST by cannulation method were performed. Efficacy of the method was assessed by comparing the results in two groups of patients with the mechanical jaundice. In the research group (93 patients) EPST was carried out in two stages. In the group of comparison (91 patients) generally accepted single-staged EPST was applied.
Results. Endoprosthesis displacement in the group of comparison during the first 24 hours was revealed in 5 cases (5,4%), in 3 cases (3,2%) the bile entered the duodenum freely. In these three patients the stent replacement wasn’t carried out as they were functioning. In two cases the endoprosthesis replacement was performed. In the research group the bleeding after EPST developed in 5 (5,3%) patients; in the group of comparison – in 16 (17,6%) cases. Hemostasis resistant forms of postpapillotomy bleedings in the research group were revealed in 1 (1,1%) case; in the group of comparison – in 10 (10,9%).
Conclusions. Two-staged endoscopic papillosphincterotomy with the inter-staged biliary ducts stenting in patients with the planned extensive dissection of the major duodenal papilla on the background of its marked benign stenosis or large concretions of the main bile ducts is considered to be an effective way to decrease incidence of the postpapillotomy bleedings mainly severe and resistant forms to hemostasis.
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655017, Rossiiskaia Federatsiia, Respublika Khakasiia, g. Abakan, ul. Lenina, d. 92, FGBOU VPO «Khakasskii gosudarstvennyi universitet im. N. F. Katanova», kafedra khirurgii,
Iurchenko Vladimir Vladimirovich
Yurchenko V.V. MD, professor of the chair of surgery FSBEI HPE "Khakassia State University named by NF Katanov".
A.S. KARPITSKI, G.A. JURBENKO, A.M. SHESTIUK
VIDEO LAPAROSCOPIC FUNDOPLICATION AS CORRECTION METHOD OF THE LOWER ESOPHAGEAL SPHINCTER INSUFFICIENCY
ME «Brest regional hospital»
The Republic of Belarus
In recent years gastroesophageal reflux disease is one of the most wide spread diseases of the digestive tract. Increase of the number of patients with the given pathology demands to improve the approaches to diagnose and treat this disease.
The main current trends in treatment of gastroesophageal reflux disease have been reflected in the review on the basis of published data.
It is noted that the question regarding indications for surgical treatment of the lower esophageal sphincter insufficiency as well as expediency and efficacy of operations in comparison with conservative therapy is being actively discussed up to present.
The conducted literature analysis has shown that Nissen and Toupet video laparoscopic fundoplications are considered to be the most effective and popular ones in surgical treatment of gastroesophageal reflux disease and hernias of reflux diaphragm esophageal foramen.
The analysis of publications permits to conclude that treatment choice should be always based on the peculiarities of the disease course; surgical and medicamentous procedures should not be oppose, but complement to each other.
In the case of antireflux operations performance by Nissen and Toupet the indications for surgery must be strictly defined that significantly increases the effectiveness as well as selective approach to the choice of the fundoplication depending on the ðÍ- results and manometric examination before operation.
The search and application of new more effective methods of fundoplication permit to improve the long-term results of surgical treatment of gastroesophageal reflux disease.
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224027, Respublika Belarus', g. Brest, ul. Meditsinskaia, d. 7, UZ «Brestskaia oblastnaia bol'nitsa», otdelenie torakal'noi khirurgii,
Zhurbenko Gennadii Anatol'evich
Karpitski A.S. MD, professor, a chief physician of ME “Brest regional hospital”.
Jurbenko G.A. A physician of the thoracic surgery department of ME “Brest regional hospital”.
Shestiuk A.M. A head of the transplantation department of ME “Brest regional hospital”.
NUTRITIONAL SUPPORT OF THE BODY IN CRITICAL CONDITIONS
SBEE HPE “IM Sechenov First Moscow State Medical University”
The Russian Federation
The literature analysis of pathologic changes in critical conditions and role of nutritional support in providing an organism with energetic and plastic substrates has been carried out. The hypoenergetic status is considered as the starting mechanism of «autocannibalism» processes that entail the subsequent decompensation of all systems of the body with the development of unfavorable outcomes. Nutritional support in critical conditions is of great importance. Pathological changes of metabolic processes testify to the appropriateness of combination of the preparations for enteral and parenteral nutrition together with the agents containing substrates for direct synthesis of macroergic compounds, in particular, the preparations of amber acid. It has been demonstrated that in generalized purulent peritonitis the preparations containing amber acid have a significant positive effect on processes of oxidative phosphorylation and ATP synthesis. Development of multilevel purposeful impact on links of biological oxidation will promote more effective and full-strength nutritive support of organism in the critical conditions.
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- Kosinets VA. Vliianie preparata iantarnoi kisloty «Reamberin» na funktsional'nuiu aktivnost' mitokhondrii myshechnogo sloia tonkoi kishki pri rasprostranennom gnoinom peritonite [Influence of preparation of succinic acid "Reamberine" on the functional activity of mitochondria of muscle layer of the small intestine in generalized purulent peritonitis]. Novosti khirurgii. 2007;15(4): 8–15.
119991, Rossiyskaya Federatsiya, g. Moskva, ul. Yauzskaya, d. 11, GBOU VPO «Pervyiy Moskovskiy gosudarstvennyiy meditsinskiy universitet im. I.M. Sechenova», kafedra obschey khirurgii,
Kosinets Vladimir Aleksandrovich
Kosinets V.A. PhD, an applicant for Doctor’s Degree of the General Surgery Chair of SBEE HPE “I.M. Sechenov First Moscow State Medical University”
Å.À. SHLYAKHTUNOV1, N.G. LUD1 , I.I. FEDORENKO2 , O.N. VALSHONOK2
OSTEOBLASTOCLASTOMA OF THE THIRD CARPAL BONE IN THE PATIENT WITH THE SECONDARY LYMPHEDEMA OF THE UPPER LIMB
EE "Vitebsk State Medical University ¹",
ME "Vitebsk Regional Clinical Oncology Center ²"
The Republic of Belarus
A clinical case of osteoblastoclastoma treatment of the third carpal bone of the left hand in the patient undergone a special treatment of breast cancer is presented in the article. The tumor of the hand undetected for a long period caused by the developed secondary lymphedema of the upper limb on the side of the operative intervention is considered as the peculiarity of this case. The patient has undergone the surgical treatment of osteoblastoclastoma of the third carpal bone. Tumor scraping and defect plastic replacement with a bone transplant from the eminence of the tibial bone were performed. One year after operation at the radiological control the complete accretion of bone transplants and integrity of locked plates were registered. Three years afterwards no signs of the tumor recurrence were found out. The treatment method of bone benign tumors including scraping and defect replacement by an autotransplants is considered as one of the optimal treatment ones of benign tumors of hand short tubular bones. The most acceptable donor zone for the bone transplant intake is considered to be an eminence of the tibial bone as an optimal combination of the cortical and cancellous bone substance occurs in this site, providing a complete restoration of the post-resection defect of short tubular mesopodial bones of the hand and phalanxes of fingers.
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210023, Respublika Belarus', g. Vitebsk, pr-t Frunze, d. 27, UO «Vitebskii gosudarstvennyi ordena meditsinskii universitet», kafedra onkologii s kursami LD, LT, FPK i PK,
Shliakhtunov Evgenii Aleksandrovich
Shlyakhtunov E.A. PhD, an assistant of oncology chair of EE “Vitebsk State Medical University”. Lud N.G. MD, professor, a head of oncology chair of EE “Vitebsk State Medical University”. Fedorenko I.I. A head of the general oncology department of ME “Vitebsk regional clinical onñological dispensary”. Valshonok O.N. A head of the radiological unit of ME “Vitebsk regional clinical ontological dispensary”.
TO HELP THE PRACTITIONER
COLLECTIONS IN ACUTE PANCREATITIS
ME «Mozyr City Hospital»
The Republic of Belarus
Accepted in 1992 at Atlanta Symposium of pancreatologists such terms as acute fluid collection, pancreatic necrosis, pseudocyst and pancreatic abscess are used inconsistently, without proper compliance with the classification.
Better understanding of the pathophysiology of necrotizing pancreatitis, advanced imaging techniques, accumulation of the research results made possible for the Acute Pancreatitis Working Group in 2012 to develop a new classification, dividing collections into 4 types: acute peripancreatic fluid collection, pseudocyst, acute necrotic collection and walled-off pancreatic necrosis. In contrast to the statements of Atlanta Symposium this new classification subdivides acute necrotic collection and walled-off necrosis, emphasizing that acute necrotic collection develops within the first 4 weeks of acute pancreatitis and pancreatic walled-off necrosis develops later. Each type of collections can be sterile or infected. Acute peripancreatic fluid collections develop at the early stage of the disease and most of them can resolve spontaneously. If acute peripancreatic fluid collection exists longer than 4 weeks, it should be called a pseudocyst. Interventions required only in the case of infected collection, otherwise conservative treatment is indicated. Disturbance of the duct integrity supports the existence of all types of collections and affects on the outcome of drainage procedures. Optimal time to perform a surgical intervention is considered within 3-4 weeks after completion of necrosis demarcation. Minimally invasive interventions such as laparoscopic, percutaneous and endoscopic retroperitoneal are considered as an equivalent to open necrosectomy.
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247760, Respublika Belarus', g. Mozyr', ul. Kotlovtsa, d. 14 a, UZ «Mozyrskaia gorodskaia bol'nitsa»,
Khokha Vladimir Mikhailovich
Khokha V.M. Deputy of chief physician on surgery of ME “Mozyr city hospital”.