Absolute Indication Research Articles

Профилактика эпиретинального фиброзирования в послеоперационном периоде при хирургическом лечении пролиферативной диабетической ретинопатии

Purpose. To improve the surgical technique for correcting the retinal central zone to prevent epiretinal fibrosis in the postoperative period in patients with proliferative diabetic retinopathy. Material and methods. The study included 104 patients (104 eyes) with proliferative diabetic retinopathy without signs of epiretinal fibrosis in macular area. All patients were divided into 4 groups: group 1 (n = 27) – vitrectomy with silicone oil tamponade; group 2 (n = 28) – vitrectomy with internal limiting membrane peeling and silicone oil tamponade; in groups 3 (n = 25) and 4 (n = 24) a similar volume of vitreoretinal intervention was performed with gas-air tamponade of the vitreal cavity. 3 months after primary vitrectomy, 61 patients (61 eyes) underwent additional vitreoretinal interventions due to the presence of epiretinal fibrosis with tangential traction syndrome and/or silicone oil tamponade of the vitreal cavity. The observation period was 6 months. Results. At postoperative period, in patients without internal limiting membrane peeling against the background of vitreal cavity tamponade with silicone oil, risk of epiretinal fibrosis increased by 2.7 times (p = 0.036 compared with data before treatment) and by 1.8 times (p = 0.048) against the background of gas-air tamponade. The presence of epiretinal fibrosis with tangential traction syndrome and/or silicone oil tamponade of the vitreal cavity after primary vitrectomy is an absolute indication for additional vitreoretinal interventions. The highest morphological and functional results were due to the absence of epiretinal fibrosis, due to the removed internal limiting membrane, which would serve as a substrate (platform) for cell proliferation on its surface. Conclusion. Optimal surgical technique performed during vitreoretinal intervention for proliferative diabetic retinopathy is internal limiting membrane peeling and use gas-air tamponade of the vitreal cavity, which provides effective prevention of epiretinal fibrosis in retinal central zone and improvement of morphological and functional parameters of patients' eyes. Keywords: proliferative diabetic retinopathy, vitreoretinal intervention, internal limiting membrane peeling, epiretinal fibrosis, tangential traction syndrome, vitreous cavity tamponade

Clinical features of hypertrophic cardiomyopathy depending on the hereditary factor

The objective was to study the clinical features of symptomatic hypertrophic cardiomyopathy (HCM) depending on the form (familial / non-familial), the age of onset and the presence of arterial hypertension (AH).Methods and materials. During 6 years, we examined 250 HCM patients, 100 patients with symptomatic HCM aged from 18 to 86 years were included in the study. Results. Patients with the clinical manifestations onset at a young age more often had a familial form of the disease, an autosomal dominant type of inheritance, an asymmetric HCM with reverse curve interventricular septal morphology. On the contrary, patients with the clinical manifestations onset at the age of ≥45 years had non-familial form of the disease and asymmetric HCM with basal interventricular septal hypertrophy. The young HCM patients with associated AH more often were obese, had CHF of III–IV functional class (NYHA), larger anteroposterior left atrial diameter than patients without AH and more often needed interventricular septal reduction. HCM patients and associated AH with the disease onset at the age of ≥45 years significantly more often had angina syndrome. Absolute indications for interventricular septal reduction in HCM patients with the disease onset ≥45 years of age were determined only for HCM patients and associated AH. At the same time, 50 % of HCM+AH patients both at a young age and in the older group, had obesity. Conclusions. The interventricular septal morphology differs significantly depending on the age of clinical manifestations onset. Co-existing AH and obesity are predictors of the progressive HCM course and an increase in the proportion of patients with absolute indications for interventricular septal reductions regardless of the age of clinical manifestations onset.

Laparoscopic Hepatectomy for Giant Hepatic Hemangioma Using the Involved Intrahepatic Anatomic Markers Approach

BackgroundHepatic hemangioma has been one of the absolute indications of laparoscopic hepatectomy (LH).1 However, the risk of catastrophic intraoperative bleeding and the difficulty to control it make the laparoscopic treatment of giant hepatic hemangioma (GHH) a technical challenge for hepatobiliary surgeons.2 Herein, we presented a video of LH for GHH using the involved intrahepatic anatomic markers approach. MethodsA 22-year-old female was referred for treatment of an intractable GHH (18 cm), which involved the left hepatic pedicle, left hepatic vein (LHV), and middle hepatic vein (MHV), resulting in the invisibility of the above intrahepatic anatomic markers on CT. The procedure was performed according to the following steps: (1) dissecting and ligating the left hepatic artery (LHA) and left portal vein (LPV) via intrafascial approach, respectively; (2) cutting the accessory LHA; (3) transecting parenchymal along the demarcation line in a caudal-to-cranial direction and exposing the involved caudal middle hepatic vein (MHV); (4) isolating and transecting the involved left hepatic duct; (5) preserving the integrity of involved MHV; (6) isolating and transecting the left hepatic vein (LHV) and splenic vein (SV); (7) mincing and extracting the specimen. This study was approved by the West China Hospital Ethics Committee and was conducted in accordance with the ethical guidelines of the Declaration of Helsinki. All treatments were performed after obtaining written informed consent from the patients. ResultsThe operative time was 286 min, and blood loss during operation was 160 ml. This procedure ensured the integrity of MHV and maximized the residual functional hepatic volume. The histopathologic examination confirmed the hepatic cavernous hemangioma. The patient had an uneventful postoperative recovery and was discharged on the fifth day after operation. ConclusionLH using the involved intrahepatic anatomic markers approach is feasible and effective for intractable GHH. Its advantages lie in decreasing the risk of disastrous hemorrhage or open conversion rate while maximizing the postoperative functional hepatic reserve.3

Replantation of solitary kidney in a patient with giant primary retroperitoneal sarcoma

Background. Surgery for non-organ malignant retroperitoneal tumors poses a serious challenge. Long-term asymptomatic course of the disease leads to a delayed diagnosis, when tumors can reach massive size with potential involvement of adjacent organs and critical structures. In most cases, nephrectomy is often required during resection of retroperitoneal sarcomas. Recently, there has been growing interest in nephronsaving surgery for large retroperitoneal tumors.Description of the clinical case. A 70-year-old patient was admitted to Irkutsk Regional Cancer Center with right-sided giant primary retroperitoneal tumor and grade 1 hydronephrosis of solitary right kidney. The patient underwent extended resection of primary retroperitoneal tumor with right-sided hemicolectomy and nephradrenalectomy. Extracorporeal resection of the solitary kidney was then performed. After obtaining negative kidney smears (imprints), the kidney was replanted in the pool of right iliac vessels. No complications were observed in the postoperative period. Histopathology examination revealed was welldifferentiated liposarcoma. On follow-up examination 38 months after surgery, there were no signs of local tumor recurrence, and renal function was satisfactory.Conclusion. Extracorporeal resection of the kidney with heterotopic replantation is an effective nephron-saving method in surgery for primary retroperitoneal sarcomas. The patient’s solitary kidney with primary retroperitoneal sarcoma is an absolute indication for kidney’s saving, including the use of transplant technologies.

Combined modality treatment of operable breast cancer using intraoperative radiotherapy

Objective of the study: To review worldwide literature data on the efficacy of combined modality treatment including intraoperative radiation therapy (IORT) in patients with operable breast cancer (BC). Material and Мethods. Of 110 publications (2000–2021) available from Scopus, Pubmed, Elibrary and other databases, using the key “breast cancer”, “local recurrence”, “intraoperative radiotherapy” and “radiation technique”, 45 were included in the literature review. Results. Radiotherapy is of paramount importance in the organpreserving treatment of breast cancer, as numerous randomised studies have shown that the use of postoperative radiotherapy dramatically reduces the number of locoregional recurrences. The use of IORT as an effective method of relapse prevention compared to standard postoperative adjuvant radiotherapy is an important trend in radiation oncology.Conclusion. The use of IORT in combination treatment modality for operable breast cancer should be differentiated and based on clinical and morphological prognostic factors. Different molecular subtypes of breast cancer are characterized by significant differences in pathogenesis and response to therapy. Further studies on the effectiveness of IORT are required to identify a group of patients with absolute indications for the use of IORT.

Hyperbaric Oxygen Therapy in Orthopaedics: An Adjunct Therapy with an Emerging Role.

Hyperbaric oxygen therapy (HBOT) has emerged as an adjunct treatment modality in various orthopedic and rheumatological conditions. Undersea and Hyperbaric Medical Society (UHMS) defined the minimum number of HBOT cycles, dose, and frequency for various diseases. UHMS laid the 14 absolute indications for HBOT. This article deals with the mechanism of actions of HBOT and evidence of various musculoskeletal disorders where HBOT was utilized to accelerate the healing process of the diseases. The review literature search was conducted by using PubMed, SCOPUS, and other database of medical journals for identifying, reviewing, and evaluating the published clinical trial data, research study, and review articles for the use of HBOT in musculoskeletal disorders. Various clinical researchers documented cellular and biochemical advantages of HBOT which possess allodynic effects, anti-inflammatory, and prooxygenatory effects in patients with musculoskeletal conditions. Studies on the usage of HBOT in avascular necrosis and wound healing provide a platform for exploring the plausible uses of HBOT in other musculoskeletal conditions. Literature evidence states the complications associated with HBOT therapy. The existing HBOT protocols have to be optimized for various musculoskeletal disorders. Large scale blinded RCTs have to be performed for demonstrating the level of evidence in the usage of HBOT in various musculoskeletal clinical scenarios.

Endoscopic submucosal dissection in early gastric cancer with papillary histological type.

412 Background: Gastric papillary adenocarcinoma has been regarded as differentiated-type adenocarcinomas along with well- or moderately-differentiated tubular adenocarcinomas in current endoscopic submucosal dissection (ESD) indication. We aimed to investigate lymph node metastasis (LNM) and to verify the safety of ESD in patients with papillary early gastric carcinoma (P-EGC). Methods: 4,264 patients with early gastric cancer (EGC) underwent curative gastrectomy between October 2000 and December 2017 at National Cancer Center, Korea. Among them, 45 patients were pathologically confirmed with P-EGC. We compared clinicopathological factors among differentiated-type EGC except P-EGC (n=2,106), undifferentiated-type EGC (n=2,113), and P-EGC. Logistic regression model was used to investigate risk factors of LNM. Results: P-EGCs were frequently located in lower third of the stomach (71.1%, P < 0.001), and about half of them (46.7%, P < 0.001) had elevated morphology. Mucosal cancer of P-EGC (37.9%) was significantly lower than differentiated-type (48.8%) and undifferentiated-type EGC (22.2%, P < 0.001). Angiolymphatic invasion and LNM occurred most frequently in P-EGC (46.9% and 20.0%, respectively) compared to differentiated-type (18.9% and 9.2%, respectively) and undifferentiated-type EGCs (10.9% and 11.7%, respectively; P < 0.001 and P = 0.004, respectively). P-EGC that was not mixed with other pathological type tended to have increased risk of LNM referent to differentiated EGC. (Odd ratio [OR] 2.53, 95% confidence interval [CI], 0.99-6.50). Among 45 patients with P-EGC, 13 patients met the current ESD indication; 3 patients corresponded to absolute indication and 10 patients did expanded indication. One patient had LNM and met expanded criteria with submucosal invasion less than 500 μm. In multivariate analysis, OR for LNM meeting expanded indication of P-EGC was 40.67 (95% CI, 2.54-702.76) referent to that of absolute indication compared to LNM meeting expanded indication of non-papillary EGC (10.28, 95% CI, 1.37-77.04). Conclusions: When ESD was applied to P-EGC, it should be carefully performed because of high rate of submucosal invasion and high risk of LNM even in with submucosal invasion less than 500 μm.

Diagnostic, Structured Classification and Therapeutic Approach in Cystic Pancreatic Lesions: Systematic Findings with Regard to the European Guidelines.

Due to the increasing use of cross-sectional imaging techniques and new technical possibilities, the number of incidentally detected cystic lesions of the pancreas is rapidly increasing in everyday radiological routines. Precise and rapid classification, including targeted therapeutic considerations, is of essential importance. The new European guideline should also support this. This review article provides information on the spectrum of cystic pancreatic lesions, their appearance, and a comparison of morphologic and histologic characteristics. This is done in the context of current literature and clinical value. The recommendations of the European guidelines include statements on conservative management as well as relative and absolute indications for surgery in cystic lesions of the pancreas. The guidelines suggest surgical resection for mucinous cystic neoplasm (MCN) ≥ 40 mm; furthermore, for symptomatic MCN or imaging signs of malignancy, this is recommended independent of its size (grade IB recommendation). For main duct IPMNs (intraductal papillary mucinous neoplasms), surgical therapy is always recommended; for branch duct IPMNs, a number of different risk criteria are applicable to evaluate absolute or relative indications for surgery. Based on imaging characteristics of the most common cystic pancreatic lesions, a precise diagnostic classification of the tumor, as well as guidance for further treatment, is possible through radiology.

Endoscopic Resection of Undifferentiated Early Gastric Cancer

Endoscopic resection (ER) is widely performed for early gastric cancer (EGC) with a negligible risk of lymph node metastasis (LNM) in Eastern Asian countries. In particular, endoscopic submucosal dissection (ESD) leads to a high en bloc resection rate, enabling accurate pathological evaluation. As undifferentiated EGC (UD-EGC) is known to result in a higher incidence of LNM and infiltrative growth than differentiated EGC (D-EGC), the indications for ER are limited compared with those for D-EGC. Previously, clinical staging as intramucosal UD-EGC ≤2 cm, without ulceration, was presented as 'weakly recommended' or 'expanded indications' for ER in the guidelines of the United States, Europe, Korea, and Japan. Based on promising long-term outcomes from a prospective multicenter study by the Japan Clinical Oncology Group (JCOG) 1009/1010, the status of this indication has expanded and is now considered 'absolute indications' in the latest Japanese guidelines published in 2021. In this study, which comprised 275 patients with UD-EGC (cT1a, ≤2 cm, without ulceration) treated with ESD, the 5-year overall survival (OS) was 99.3% (95% confidence interval, 97.1%-99.8%), which was higher than the threshold 5-year OS (89.9%). Currently, the levels of evidence grades and recommendations for ER of UD-EGC differ among Japan, Korea, and Western countries. Therefore, a further discussion is warranted to generalize the indications for ER of UD-EGC in countries besides Japan.

Avaliação das informações sobre indicações absolutas e relativas de cesarianas disponíveis em sites populares

Abstract Objectives: to evaluate the reliability of information available on popular websites, in other words, websites aimed lay pregnant women, about absolute and relative indications for cesarean sections. Methods: this was a descriptive/comparative study based on the popular websites most likely to be visited by lay pregnant women and that contained information about indications for absolute and relative cesarean sections. Cohen’s Kappa index of agreement was used to analyze the reliability degree on the indications for cesarean sections presented on the websites and the scientific evidence. Results: there was a higher prevalence (62.63%) of information on the indications for cesarean sections that did not mention whether the indication was absolute or relative, and of these indications, 40.74% were not indications for cesarean sections. Low agreement was also observed among websites and the scientific evidence when the website mentioned the indication for cesarean section was absolute or relative. Conclusion: this study showed that the reliability of the information on absolute and relative indications for cesarean sections available in popular websites is questionable.

Acromioclavicular Joint Problem in Athletes

Introduction: Acromioclavicular (AC) joint separations account for 12% of all shoulder injuries. People doing high-energy physical activities such as athletes are at risk for AC joint separation. The mechanism of injury could be direct or indirect. Direct mechanism involves a direct blow to the AC and coracoclavicular (CC) ligaments. Indirect mechanism happens when the injury force hits the AC joint indirectly, involving axial compression, as seen in a fall with an extended arm, where caput humeri is pressed against the acromion. The purpose of this paper is to elaborate on AC joint problems in athletes by reviewing literatures. Review: Patients with AC joint injury will exert complaints of pain and be unwilling to lift the affected arm, implying mobility function impairment. Signs such as skin abrasions and bruises can be found during inspection. A prominent distal clavicle is a pathognomonic sign of dislocation of the AC joint. A well-known classification for AC joint separations, Rockwood classification, divides the separations into six types. The classification helps determine different managements and prognoses for each of the AC joint separation types. Athletes should be treated in consideration of their position in the sports season. For athletes in season, pain should be treated as the priority. Absolute indications for surgical management are then identified to help determine the athlete’s return-to-play capability. For out-of-season athletes with AC injury, look for absolute or relative indications for operative management. If there is no indication, plan for rehabilitation. But if there are some indications, either absolute or relative, plan for surgery immediately. Complaints of pain and functional disabilities such as motion should be carefully assessed and managed. To determine suitable management, the injury should be classified properly. Type I and II injuries are treated with nonsurgical management. For type IV and VI injuries, surgical intervention is needed. AC joint separation Rockwood type III and V both had complete AC and CC ligament tear but repair is adequate for acute type III AC injury while reconstruction is needed for type V AC injury. Conclusion: AC joint separations should be treated as joints, not as bones where compressions are applied therefore limiting movements. Repair and reconstruction indications should be properly assessed on patients to ensure functions returned to their pre-injury state which is important for athletes’ return to sports.

Evaluation on the information about absolute and relative indications of cesarean sections available on popular websites

Resumo Objetivos: avaliar a confiabilidade das informações disponíveis em sites populares, ou seja, sites voltados para gestantes leigas, sobre indicações absolutas e relativas de cesarianas. Métodos: estudo descritivo/comparativo, baseado nos sites populares mais prováveis de serem visitados por gestantes leigas e que traziam informações sobre as indicações de cesarianas absolutas e relativas. Para analisar o grau de confiabilidade das indicações de cesarianas apresentadas pelos sites e a evidência cientifica, foi realizado o índice de concordância de Kappa de Cohen. Resultados: houve maior prevalência (62,63%) de informações de indicações de cesarianas que não mencionavam se a indicação apresentada era absoluta ou relativa, sendo que destas, 40,74% não eram indicações de cesarianas. Observou-se, concordância baixa entre os sites e a evidência cientifica quando o site mencionava que a indicação de cesariana era absoluta ou relativa. Conclusão: este estudo demonstrou que a confiabilidade das informações acerca das indicações absolutas e relativas de cesarianas disponíveis em sites populares é questionável

Analysis of the Caesarean Section Rate in Armenia for the Period 2016-2021 Based on the Results of a Single Center Study

Background: The caesarean section rate is an important factor that characterizes the effectiveness of the obstetric service. The large variability of the initial state of women in labor and the variety of indications for surgery does not allow us to identify the main determinants. We attempted to determine and analyzed the first data on the structure and frequency of caesarean section in Armenia in the hospital of the Erebоuni multidisciplinary clinic before the introduction of the M. Robson scale. Methodology: We conducted a retrospective study of the history of childbirth in 38,111 patients registered at the Erebouni Medical Center for the period 2016-2021. The materials of the study were case histories, hospitalization materials and annual reports. Results: According to the obtained data, 80.5% of caesarean section operations were performed as planned. Only 14% of pregnant women were delivered by caesarean section according to absolute indications, the frequency of that in this maternity hospital increased from 36.77% to 44.95% over the analyzed period Conclusion: Thorough psychoprophylactic preparation of pregnant women for childbirth, including those with a scar on the uterus after a previous cesarean section, can ensure a steady desire of women in labor for vaginal delivery, full mobilization of their own capabilities, and more trusting cooperation with medical staff.

Morphologic evaluation of megakaryocytes in immune thrombocytopenia patients older than 80 years.

In immune thrombocytopenia (ITP), which is a common acquired bleeding disorder, cytotoxic T-cell-mediated cellular immune response against both circulating platelets and bone marrow megakaryocytes are the most important mechanisms in the pathogenesis. In our study, we evaluated the features of 33 patients with ITP, over 80 years of age. The median age of the patients was 90, 15 patients were female (45.4%). The mean platelet count of the patients was 39×109/L and the mean mean platelet volume was 10,33fL. Twelve patients had a target thrombocyte count greater than 30×109/L, while 20 patients had a target platelet count of 75×109/L or greater with an absolute indication of antiaggregation. In the environmental spread, 18 dysplasia findings were observed. Morphologic observations suggesting dysplasia including micromegakaryocytes and a non-dysplastic but dysmegakaryopoietic finding, multiple segmented nuclei may be related to the degree of thrombocytopenia and response to treatment. Likewise, nondysplastic features including immature forms, emperipolesis, bare nucleus, hypolobulation, and hypersegmented nucleus were related to the degree of thrombocytopenia.

Алгофобия пункции верхнечелюстной пазухи, все ли мы знаем о ней?

Introduction. Performing a puncture of the maxillary sinus at the stages of diagnosis and treatment of rhinosinusitis remains relevant. The emerging algophobia, according to other patients, or their own previously experienced pain forces patients to abandon this manipulation. In this context, properly performed, with good anesthesia, maxillary sinus puncture is painless and easily tolerated by patients. Objective. To increase the effectiveness of the treatment of maxillary sinusitis by improving the anesthetic support during the puncture of the maxillary sinus based on the study of various types of analgesia near the located anatomical zones. Patients and methods. A total of 152 patients took part in the prospective study, of which: according to absolute indications, 50 patients with acute exacerbation of chronic sinusitis underwent maxillary sinus puncture under application anesthesia, 50 patients with chronic periodontitis underwent extraction of the tooth of the upper jaw under infiltration anesthesia, and 52 patients with chronic diseases of the upper gastrointestinal tract underwent esophagogastrodoudenoscopy (EGD) under topical anesthesia. To objectify and determine the intensity of pain, a visual analogue scale, the McGill questionnaire, Wong–Baker and Brief Pain scales were used. Results. Pain sensations of patients from the puncture of the maxillary sinus averaged 1.27 points, in the first control group, 0.18 points; in the second control group, 1.79 points. The subjective assessment of pain during tooth extraction was significantly lower and significantly different from those during puncture and EGD. Subjective assessments during puncture and EGD did not significantly differ from each other. Values for all groups ranged between «no pain» and «almost no pain.» Conclusion. Subject to the technique and time of anesthesia, puncture of the maxillary sinus is well tolerated by patients of different age groups, and pain, according to the questionnaires, does not go beyond “almost does not hurt.”

Arthroscopic Bony Bankart Repair Technique: A Technical Note

Introduction: Labrum is a static stabilitator of the glenohumeral joint. Tear to this fibrocartilaginous structure could cause shoulder instability. Lately, anterior detachment of labrum is known as a contributor to recurrent anterior instability. Anterior labrum detachments are the classic Bankart lesion. Bankart lesion involving avulsion fracture is known as bony Bankart lesion. Management for this lesion is done operatively by doing antomical repair to return rigidity to its original state. Bankart repairs were originally done openly with coracoid osteotomy and subscapularis tenotomy. Currently, arthroscopic Bankart repair is often used as the preferred surgical management. Variations of portal placements, suture placements, suture technique and other components of Bankart repair can be found today, giving options for surgeons to achieve optimal results. Surgical Technique: In athletes, bony Bankart lesion, as an intraarticular lesion with displaced labrum and avulsion causing instability, is an absolute indication for surgical intervention to ensure function return. Nonoperative treatments have been reported on small bony Bankart lesions, but outcome on follow-up showed 25% recurrent instability. We performed arthroscopic bony Brankart repair by implementing labral repair, intraosesus tunneling and double-row suture bridge techniques. First, landmarks of incisions and portals were made. Incisions for visualisation were then done. Anterior portal and posterior portal were established before identifying bony Bankart lesion. A 5 o’ clock, trans subscapularis portal was then created. We released the bony Bankart and curatage the margin. A 6 o’clock stitch was anchored through rigid suture passage (drilled bone tunnel) in 5 o’clock direction. A 4.30 o’clock stitch was anchored in a 4 o’clock suture passage. The last stitch was a 3 o’clock stitch anchored through a 3 o’clock passage. Soft tissue release was conducted until subscapularis fibers were exposed. In the remodelling process, we performed overcorrection repair. Modifications done to the Bankart repair in this paper were done to achieve excellent post-op anterior stabilization.

Treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia

To describe treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia. There were 91 patients with cicatricial tracheal stenosis for the period from August 2020 to April 2022 (21 months). Of these, 32 (35.2%) patients had cicatricial tracheal stenosis, tracheoesophageal fistula and previous coronavirus infection with severe acute respiratory syndrome. Incidence of iatrogenic tracheal injury following ventilation for viral pneumonia in the pandemic increased by 5 times compared to pneumonia of other genesis. Majority of patients had pneumonia CT grade 4 (12 patients) and grade 3 (8 patients). Other ones had pulmonary parenchyma lesion grade 2-3 or mixed viral-bacterial pneumonia. Isolated tracheoesophageal fistula without severe cicatricial stenosis of trachea or esophagus was diagnosed in 4 patients. In other 2 patients, tracheal stenosis was combined with tracheoesophageal fistula. Eight (25%) patients had tracheostomy at the first admission. This rate was almost half that of patients treated for cicatricial tracheal stenosis in pre-pandemic period. Respiratory distress syndrome occurred in 1-7 months after discharge from COVID hospital. All patients underwent surgery. In 7 patients, we preferred palliative treatment with dilation and stenting until complete rehabilitation. In 5 patients, stent was removed after 6-9 months and these ones underwent surgery. There were 3 tracheal resections with anastomosis, and 2 patients underwent tracheoplasty. Resection was performed in 3 patients due to impossible stenting. Postoperative course in these patients was standard and did not differ from that in patients without viral pneumonia. In case of tracheoesophageal fistula, palliative interventions rarely allowed isolation of trachea. Four patients underwent surgery through cervical approach. There were difficult surgeries in 2 patients with tracheoesophageal fistula and cicatricial tracheal stenosis. One of them underwent separation of fistula and tracheal resection via cervical approach at primary admission. In another patient with thoracic fistula, we initially attempted to insert occluder. However, open surgery was required later due to dislocation of device. Absolute number of patients with tracheal stenosis, tracheoesophageal fistula and previous COVID-19 has increased by several times compared to pre-pandemic period. This is due to greater number of patients requiring ventilation with risk of tracheal injury, non-compliance with preventive protocol for tracheal injury including anti-ischemic measures during mechanical ventilation. The last fact was exacerbated by involvement of allied physicians with insufficient experience of safe ventilation in the «red zone», immunodeficiency in these patients aggravating purulent-inflammatory process in tracheal wall. The number of patients with tracheostomy was 2 times less that was associated with peculiarity of mechanical ventilation in SARS-CoV-2. Indeed, tracheostomy was a poor prognostic sign and physicians tried to avoid this procedure. Incidence of tracheoesophageal fistula in these patients increased by 2 times compared to pre-pandemic period. In subacute period of COVID-associated pneumonia, palliative measures for cicatricial tracheal stenosis and tracheoesophageal fistula should be preferred. Radical treatment should be performed after 3-6 months. Absolute indication for circular tracheal resection with anastomosis is impossible tracheal stenting and ensuring safe breathing by endoscopic methods, as well as combination of cicatricial tracheal stenosis with tracheoesophageal fistula and resistant aspiration syndrome. Incidence of postoperative complications in patients with cicatricial tracheal stenosis and previous mechanical ventilation for COVID-19 pneumonia and patients in pre-pandemic period is similar.

Intraluminal endoscopy for biliary duodenal obstruction

Cholelithiasis complicated by cholecystoduodenal fistula and small bowel biliary obstruction is an absolute indication for surgical treatment. Modern possibilities of intraluminal endoscopy (electrohydraulic lithotripsy) made it possible to avoid intra-abdominal access (laparotomy, laparoscopy) and postoperative complications. Finally, rapid rehabilitation was noted.

The ultrasound estimation of extravascular lung water in volume controlled versus pressure controlled ventilation after one lung ventilation in Thoracoscopic surgery. A-comparative study

ABSTRACT Background Thoracoscopic surgeries are an absolute indication of one lung ventilation OLV, the choice of using volume-controlled ventilation (VCV) or pressure controlled ventilation (PCV) remains controversial. Respiratory complications are major cause of postoperative morbidity which is associated with increased extravascular lung water (EVLW). Assessment of (EVLW) helps in early detection and treatment of respiratory complications. Lung ultrasound (LUS) has been suggested as reliable method of assessment of EVLW. This study was designed to figure out whether there was any difference in OLV by either PCV or VCV on EVLW water in the ventilated lung using LUS score and arterial oxygenation. Methodology 50 patients were randomly assigned into two groups; Group V: received VCV (Vt 7 ml/kg ideal body weight) Group P: received PCV (To achieve Vt 7 ml/kg ideal body weight, Pmax 30 cmh2o) Results We found that both techniques PCV and VCV showed no statistically significant differences as regards the ultrasound score at different timings of measurement; (T0) before induction of anesthesia, (T5) immediately at the end of operation after extubation, and (T6) 2 hours after ICU admission. Where P values were 0.525, 0.309, and 0.597 consecutively, we also found there were no statistically significant differences between the two groups regarding hemodynamics, arterial blood gases, ventilatory parameters. Conclusion We concluded that when utilizing VCV & PCV in OLV in thoracospic surgeries there was no statistically significant difference regarding EVLW score measured by LUS in the ventilated lung.

Neonatal diabetes mellitus and polycystic ovaries in a child with severe insulin resistance caused by a variant in the INSR gene. Description of the clinical case

Rare severe insulin resistance syndromes such as Donohue syndrome, RabsonMendenhall syndrome, and type A insulin resistance are caused by mutations in the insulin receptor (INSR) gene. Donohue and RabsonMendenhall syndromes are caused by biallelic mutations in the - and / or -subunits of INSR, are characterized by a severe course with severe clinical symptoms and an unfavorable prognosis. The difficulty of managing and treating these patients is associated with a low incidence, lack of practice in managing such patients, as well as a lack of experience in surgical interventions in these patients.
 All insulin resistance syndromes are characterized by a significant increase in the level of insulin in the blood plasma in the absence of obesity, progressive diabetes mellitus and an excess of androgens. Polycystic ovary syndrome or stromal hyperthecosis develops in adult patients with syndromic forms of insulin resistance.
 We present a rare clinical case of a complicated course of Donohue syndrome, diagnosed in a 2-month-old patient. A feature of this clinical case was the giant growing multifollicular ovaries, which became an absolute indication for organ resection surgery.
 The experience of treatment and observation of this patient reflects the importance of early verification of the diagnosis, timely appointment of adequate therapy, allows you to objectively assess the effectiveness of the treatment, helps in choosing medical tactics and predicting the course and outcome of the disease.