Arrosive Bleeding Research Articles

PROBLEMATIC ISSUES OF LIMB AMPUTATION IN WOUNDED WITH COMBAT TRAUMA

Among the wounded with limb injuries admitted to the Military Medical Center of the Western region during the year of Russia’s full-scale war in Ukraine, 29% had a mine-blast injury, 47% had shrapnel wounds, 8% had gunshot bullet wounds, 1.5% – thermal injuries, and14.5% – traumatic injuries. Upper limbs were injured in 22%, lower – in 32%, 15% had two limbs injured, and 31% had combined combat trauma. In all hospitalized with multi-fragment fractures, limbs were fixed with external fixation devices. 2% of patients had vascular damage. All wounded had unhealed wounds with a soft tissue defect. The average age of patients was 30 years. There were no comorbid diseases in the wounded, and concomitant diseases that did not affect the course of injury were found in 10%. Amputations of limbs were performed in 6.5%. Traumatic separation of a limb segment or its destruction with crushed bone and non-viable soft tissues, nerve damage with significant defect, soft tissue and bone defect, as well as thermal ischemia of the limb for more than 6 hours with necrosis of its soft tissues, were indications for primary limb amputation in 3% of wounded and injured, which were in the nature of primary debridement. Progressive wound infection with the development of the septic condition of the wounded despite intensive treatment, total ischemic necrosis, and recrudescent arrosive bleeding from great vessels required a secondary limb amputation in 1.5%. In 1.5% of the wounded, staged operations were performed as re-amputations. Re-amputation had to be performed in 0.6% of patients with an inappropriate limb stump level, which complicated prosthetics. To reduce the number of amputations for secondary indications, a timely diagnosis is needed of compartment syndrome and rational treatment of soft tissue wounds and gunshot fractures with surgical and medical prevention of the infectious process.

Predicting the course and outcome of acute alcoholic-alimentary pancreatitis, taking into account the genetic status of the patient according to the polymorphic loci rs11546155 and rs6119534 of the GGT7 gene

The aim of the study was to evaluate the role of the polymorphisms rs11546155 and rs6119534 of the GGT7 gene in predicting the risk of complications and outcome of AAP. The material of the study was DNA samples obtained from 471 patients with acute alcoholic-alimentary pancreatitis and 573 healthy individuals. The disease was diagnosed using clinical guidelines developed by the working group of the Russian Society of Surgeons. Statistical analysis was carried out using the Statistica 10.0 and the SNPStats programs. Results. The study found that for rs6119534 GGT7, the C/T genotype was associated with an increased risk of developing acute alimentary-alcohol pancreatitis (OR=1.94; 95% CI=1.41-2.68; P<0.0001); the T/T rs6119534 GGT7 genotype was over five times more common among patients with severe disease and was associated with an increased risk of infected pancreatic necrosis (OR=7.99; 95%CI 1.35-47.18; P=0.017). For rs11546155 GGT7, allele A was a predictor of an increased risk of developing pancreatic necrosis (OR=1.92; 95%CI 1.22-3.03; P=0.004); carriers of the A/A genotype had the highest level of leukocytes in the blood and a predisposition to the development of arrosive bleeding (OR=20.16; 95% CI 1.82-223.37; P=0.05); genotypes G/A-A/A were associated with an increased risk of infected pancreatic necrosis (OR=1.82; 95%CI 1.06-3.12; P=0.03). Conclusion. SNPs can be used as diagnostic and prognostic markers of AAP.

Enucleation of pancreatic tumors: a multiple-center study

To evaluate the immediate results of enucleation of pancreatic neuroendocrine tumors (pNETs). The results of enucleation of pancreatic neuroendocrine tumors (pNETs) were analyzed in 95 patients between 2016 and 2021. Functioning tumors (mean size 16.8 mm) were found in 70 patients, non-functioning (mean size 25 mm) - in 25 patients. Intraparenchymal tumors were found in 48 people, extraorganic lesion - in 47 patients. There were 262 patients with pNETs who underwent various surgeries between 2016 and 2021. Various resections were performed in 167 (63.8%) cases, enucleations - in 95 (36.2%) patients. Traditional surgical approach was used in 65 patients. Pancreatic fistula occurred in 21 patients (type B - 17, type C - 4), while arrosive bleeding occurred in 6 patients with unfavorable outcomes in 2 cases. Minimally invasive surgeries were performed in 30 patients. Eight patients with intraparenchymal tumors required conversion to open surgery. Type B pancreatic fistula occurred in 5 patients that led to arrosive bleeding in 2 cases (hemostasis was provided by endovascular method). Comparison of intraparenchymal and extraorgan tumors regarding the incidence of pancreatic fistula revealed odds ratio 5.26 (95% CI 1.5355; 18.0323, p=0.0041). Postoperative mortality was 2.1%. Enucleation is advisable for highly differentiated pancreatic neuroendocrine tumors up to 2 cm. Minimally invasive enucleation is indicated for extraorgan tumors. Intraparenchymal tumors significantly increase the risk of postoperative complications.

Locally advanced thyroid cancer. Issues of diagnosis and treatment

Background. From 10 to 20% of highly differentiated papillary thyroid cancer show signs of local prevalence: invasion into the surrounding fatty tissue, organs and tissues adjacent to the gland — the anterior muscles of the neck, recurrent nerve, esophagus, laryngopharynx, larynx, trachea. A tumor that has a massive spread, often with life-threatening symptoms in the form of dysphagia, stenosis of the trachea or larynx, has no alternatives to surgical treatment.Aim. Evaluation of the results of extended and extended-combined interventions for locally advanced highly differentiated thyroid cancer (immediate surgical and long-term results of treatment).Materials and methods. During the period from 2010 to 2021, 82 patients with locally advanced thyroid cancer were operated on. This cohort included patients in whom the tumor process spread not only to the neck, but also to the mediastinum: either in the region of the upper thoracic inlet, or there was a lesion of deeper parts of the mediastinum. The average age is 56.8 years. The ratio of men and women: 34 (41.5%) and 48 (58.5%), respectively. According to the prevalence of the tumor process, T4 tumors were diagnosed in 54.8% (n= 45). 37 patients had T3 (45.2%) tumors. In 57.3% (n= 47), the primary tumor was combined with the presence of a metastatic lesion in the regional lymph nodes of the neck. 34.1% (n 28) had distant metastases. In all cases it was a lesion of the lungs. Papillary thyroid cancer was verified in 89.6%. 21 patients underwent operations with resection of the larynx and trachea: in 7 cases, laryngectomy with resection of 5 to 8 rings of the trachea, in 4 cases, circular resections, in 6 cases, “shaving”, in 2 cases, “terminal” resections of the trachea with plasty of the defect of the sternum-clavicle-mastoid muscle, in 2 patients the plates of the thyroid cartilage were resected while maintaining the integrity of the organ. In 24 patients, mediastinal lymph node dissection (sternotomy) was performed; in 2 cases, mediastinal lymph node dissection was performed thoracoscopically. In 2 cases, resection of bone structures was performed — the manubrium of the sternum and sternoclavicular joints. In 33 patients, removal of the primary tumor, paratracheal, paraesophageal metastases and metastatic conglomerates from the posterior mediastinum (4 cases) was performed through the cervical approach.Results. The postoperative period in this group of patients was complicated by the development of pneumonia in 52 (63.4%) patients. Purulent mediastinitis developed in 6 (7.8%) patients, arrosive bleeding in 6% (n= 5), osteomyelitis of the sternum in 2 (2.4%) cases, gastric bleeding in 1 patient (1.5%), lymphorrhea in 2 (2.4%), parathyroid insufficiency developed in 70.7% (n 58) of observations. Postoperative mortality was 6% (n= 5).OS and disease-free survival amounted to 66.7% and 53.4%, respectively. Death from the progression of the disease occurred in all cases due to the growth of distant metastases against the background of resistance to radioactive iodine that developed during treatment or the implementation of new metastatic foci in terms of 2 to 5 years.Conclusions. This group of patients demonstrates satisfactory results of OS and disease-free survival, but requires further dynamic monitoring and evaluation of the effectiveness of drug treatment of radioiodine-resistant tumors.

Distal resection for pancreatic tumors

Aim. To study the specific features of the splenic artery architectonics and evaluate the results of distal pancreatic resection for various tumors.Materials and Methods. In the anatomical part, we examined 88 organ complexes taken from people whose death was not associated with diseases of the abdominal organs. We studied the topography of the splenic artery and the dependence of the number of its branches to the pancreas on the vessel tortuosity. The clinical part of the study presents the results of 122 distal resections performed during 2016-2021. 79 operations were carried out using the traditional method, 32 operations were robot-assisted, and 11 were performed laparoscopically.Results. The research found a relationship between the degree of the splenic artery tortuosity and the number of branches to the pancreas, which varies from three to nine. Out of the 122 operated patients, in 24 (19.7%) cases a clinically relevant (type B) pancreatic fistula that required additional treatment was formed. Intra-abdominal bleeding developed in 15 (12.3%) patients: early – in 10, late arrosive hemorrhage associated with a pancreatic fistula – in 5 cases. One (0.8%) patient died.Conclusion. It is necessary to consider the architectonics of the splenic artery during distal pancreatic resection. The frequency of pancreatic fistula formation does not depend on the method of performing the operation. Of the prognostic factors, the body mass index is statistically significant. Late arrosive bleeding develops against the background of a clinically relevant pancreatic fistula.

Experience of using stent grafts in the treatment of patients with arrosive bleeding after pancreatic surgery

Aim. To evaluate inhospital outcomes of endovascular treatment in patients who underwent endoprosthetic replacement of the culprit vessel due to arrosive bleeding after pancreatic surgery.Material and methods. In the period 2012-2021 at the A. V. Vishnevsky National Medical Research Center of Surgery, 821 operations on the pancreas due to tumors and complicated chronic pancreatitis were performed. Seventy-five (9,1%) patients developed postoperative arrosive bleeding. Stent grafts were used to stop bleeding in 14 (18,7%) of them. There were 9 men (64,3%) and 5 women (35,7%). The median age of patients was 60 years (men — 61 years, women — 59 years). Arrosive bleeding occurred after pancreaticoduodenal resection in 13 patients, while in one case — after distal pancreatic resection. In all 14 cases, postoperative bleeding was severe and classified as grade C according to the International Study Group for Pancreatic Surgery (ISGPS) classification.Results. There were following sources of bleeding: gastroduodenal artery — 4 (28,6%) patients, proximal hepatic arteries (right/left) — in 4 (28,6%) patients, proximal superior mesenteric artery — in 2 (14,3%), dorsal pancreatic artery — in 1 (7,1%), false aneurysm of proximal splenic artery — in 1 (7,1%), proximal common hepatic artery — in 2 (14,3%). In 10 (71,4%) patients, endoprosthetic replacement of the proximal segment of culprit artery was performed, while in 4 (28,6%) patients with arrosion of short gastroduodenal artery stump and false aneurysm, endoprosthesis replacement of the common hepatic artery was performed with a transition to the proper hepatic artery. The technical success of endovascular hemostasis (absence of contrast media extravasation) was achieved in 100% of cases. Three (21,4%) of 14 patients developed rebleeding from another arterial source. Inhospital mortality was 28,6% (n=4). The cause of deaths in 3 cases was the direct complications of endovascular hemostasis, while in one patient — progressive postoperative pancreatitis with the outcome in multiple organ failure.Conclusion. Endovascular hemostasis using a stent graft is an effective surgical method for the treatment of arrosive bleeding after pancreatic surgery. The intervention is associated with possible complications, the risk of which must be taken into account before the procedure. We consider arrosive bleeding from a defect in the main vessel (common/ proper/right or left hepatic arteries, superior mesenteric artery) as an indication for performing endoprosthetic replacement.

The strategy of surgical treatment of patients with tumor diseases of the pancreatoduodenal zone

Aims. To improve the results of surgical treatment of patients with tumor diseases of the pancreatoduodenal zone. Materials and methods. The cohort study included 94 patients with tumor diseases of the pancreatoduodenal zone who underwent pancreatoduodenal resection in 2014–2019. All patients belonged to the category of resectable and borderline resectable. Two groups of patients were formed. II (comparison group) — patients who received treatment in 2014–2017 (n=49). In this group of patients, the risk of developing postoperative pancreatic fistula was not calculated and the choice of the technique for the formation of pancreatoenteroanastomosis was carried out depending on the preferences of the operating surgeon. I (main group) — patients who were treated in 2018–2019 (n=45). In this group of patients, the choice of the technique for the formation of pancreatoenteroanastomosis was carried out in accordance with the developed algorithm, depending on the risk of postoperative pancreatic fistula development, and also, according to indications, a new method of reservoir terminolateral pancreatojejunostomy was used. A comparative analysis revealed the representativeness of the studied groups in terms of the main parameters (gender, age, comorbidity index, anesthetic risk, the presence of obstructive jaundice, tumor localization, stage of the disease). Results. The use of the developed algorithm led to a significant decrease in the incidence of postoperative complications from 73.4 to 37.8% (p&lt;0.01), postoperative pancreatic fistulas from 28.6 to 6.6% (p&lt;0.05), postoperative pancreatitis from 32.6 to 11.1% (p&lt;0.05) and arrosive bleeding from the intervention area from 18.3 to 2.2% (p&lt;0.05). Conclusions. The use of a differentiated algorithm for choosing the formation method made it possible to improve the immediate results of surgical treatment of patients suffering from tumor diseases of the pancreatoduodenal zone.

Hemocoagulation factors of hemorrhagic complications in acute pancreatitis

A feature of the severe condition of acute pancreatitis is the high risk of complications occurring in 50% of patients. The most dangerous are thrombohemorrhagic complications and arrosive bleeding, with late diagnosis of which mortality can reach more than 85%. The aim of the study was to determine early diagnostic criteria for the onset and development of bleeding in acute pancreatitis. The results of treatment of 82 patients with severe acute pancreatitis were analyzed. The patients were divided into the main group (with bleeding) (30 people) and the comparison group (without bleeding) (52 people). The parameters of hemocoagulation, α-amylase activity in peritoneal exudate and intra-abdominal pressure were assessed. The tPA activity and the level of TAT in the main group were of normative value and are vital for the group of individuals who are in the range of norms, as well as candidates for early markers for the diagnosis of bleeding. From the ROC analysis, the analysis determined the informativeness of the proposed indicators in the predicted bleeding. For tPA activity, the area under the ROC-curve (AUROC) became 0.942 (95% CI 0.889-0.995), the point of change is 4,5 IU/ml, for the TAT area under the ROC-curve (AUROC) it became 0.945 (95% DI 0.871-0.998), the change point is 11.5 ng/ml. We conclude that in patients with severe acute pancreatitis, a tPA activity level ≥4.5 IU/ml (sensitivity 90.2%, specificity 83.3%) and/or a TAT level ≥ 11.5 ng/ml (sensitivity 92.2%, specificity 83.3%) can be considered as a possible predictor of bleeding.

Endovascular treatment of delayed arterial bleeding after pancreatic surgery: single-center experience

To evaluate technical aspects and clinical results of transcatheter arterial embolization (TAE) for delayed postoperative arterial bleeding after pancreatic surgery. There were 821 pancreatectomies between 2012 and 2020. Delayed bleeding occurred in 106 (12.9%) patients; 74 patients were included in the study. Previous pancreatic head resection was carried out in 75.7% of cases, pancreatic body resection - in 17.6% of cases, pancreatic tail resection - in 6.8% of patients. Primary endpoint was technical success of TAE, secondary endpoints - complications after TAE, as well as recurrent bleeding after embolization. Angiography of celiac-mesenteric arterial system was performed in 74 patients (91 procedures). The most common sources of bleeding were gastroduodenal and superior mesenteric arteries (35.7%), jejunal arteries (13.1%), common hepatic artery (11.9%). Combination of embolization agents was applied for TAE (metal coils and non-calibrated PVA particles, 48.6%). In 11 (14.9%) patients, we applied stent-grafts. Technical success rate was 100%. Recurrent bleeding occurred in 13 (17.6%) patients. In-hospital mortality was 12.2% (n=9). TAE is an effective treatment procedure in patients with arrosive bleeding. This method is characterized by high technical efficiency and low in-hospital mortality, but it does not affect recurrence of bleeding.

ЭФФЕКТИВНОСТЬ СПЛЕНОРЕНАЛЬНОГО ШУНТИРОВАНИЯ В ЛЕЧЕНИИ ДОПЕЧЕНОЧНОЙ ФОРМЫ ПОРТАЛЬНОЙ ГИПЕРТЕНЗИИ У ДЕТЕЙ

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

Possibilities of applying minimally invasive technologies in the treatment of complications in patients after pancreatoduodenectomy

Several clinical observations of rare complications of pancreatoduodenectomy in the early and long-term postoperative periods are presented. The authors tell about the bile leakage (severity C), arrosive bleeding, thrombosis of the liver vessels, as well as bowel obstruction from carcinomatosis. The possibilities of modern minimally invasive technologies are demonstrated: ante- and retrograde and endovascular methods in the treatment of these complications. Pancreatoduodenectomy should be performed in multidisciplinary medical centers with extensive experience and modern equipment that allows timely correction of postoperative complications.

Splenic artery pseudoaneurysm complicated by haemorrhage into pancreatic pseudocyst: a clinical case

Background. Splenic artery pseudoaneurysm is a rare complication of acute and chronic pancreatitis caused by an arterial wall lesion with aggressive pancreatic enzymes and followed by arrosive bleeding into pseudocyst lumen and the formation of a dense fibrous capsule prone to growth.Clinical Case Description. Patient M., 61 yo, was emergently admitted to Territorial Clinical Hospital No. 2 with a preliminary diagnosis: Chronic pancreatitis, incomplete remission. Pancreatic pseudocyst. Condition after endoscopic papillosphincterotomy, pancreatic duct stenting. Gastrointestinal haemorrhage. The patient complained of moderate persistent belting upper abdominal and left subcostal pain, nausea, general weakness, black liquid stool over last five days. Pancreonecrosis in history. Pseudocyst formation in two months, endoscopic papillosphincterotomy and pancreatic stenting in hospital, the aforementioned complaints appeared past three months. Moderate anaemia (haemoglobin 73 g/L, erythrocyte count 2.8 x 1012), hyperamylasaemia (amylase 170 U/L), no other pathology in general and biochemic blood panels. The patient was rendered urgent oesophagogastroduodenoscopy for large duodenal papilla, with no evident bleeding detected. Abdominal CT angiography revealed a haemorrhagic mass connected with splenic artery lumen in the projection of pancreatic tail. The patient was transferred to an interventional radiology room for coil embolisation of splenic artery. The postoperative period was benign, and the patient discharged on day 3 after surgery for outpatient surgical patronage. Definite clinical diagnosis: Chronic pancreatitis, incomplete remission. Splenic artery pseudoaneurysm with haemorrhage into pancreatic pseudocyst. Condition after endoscopic papillosphincterotomy, pancreatic duct stenting.Conclusion. Splenic artery pseudoaneurysm with haemorrhage into pancreatic pseudocyst is reluctant to early diagnosis due to a lacking definite clinical picture and tractable only at an interdisciplinary institution disposing with a rich diagnostic toolkit and sufficiently qualified medical personnel. Endovascular treatment is overall most effective and enables a reliable aneurysm isolation from the splenic artery basin.

Endoscopic transpapillary pancreatic duct stent placement in patients with necrotizing pancreatitis

Aim . Improvement of treatment results in patients with necrotizing pancreatitis and signs of the dissociation between the distal and proximal parts of the pancreas by using endoscopic transpapillary stent placement. Material and methods . There were 25 patients with acute necrotizing pancreatitis and disconnected pancreatic duct syndrome, which have been managed by using endoscopic transpapillary stent placement throughout 2018-2020. Twenty patients have been admitted into hospital in first 24-72 hours of onset, while 5 patients – later than 72 hours. We have diagnosed necrotizing process located in the head and the neck of the pancreas and peripancreatic space in all these patients (“Model III”). Results . Positive results related to transpapillary stent placement were noted in 18 patients (72% – main group). Sixteen patients from this group were admitted into hospital in first 24–72 hours, two patients – later than 72 hours from the disease onset. Transpapillary stent placement failed in 7 (28%) patients (control group). Complications in the main group occurred in 2 patients (11,1%): in one case – the dislocation of stent into duodenum and one patient with bleeding after papillosphincterotomy, infected necrotized pancreatitis developed in 4 patients. Mortality observed in 1 case (5.5%). Complications among control group occurred in 2 patients (28.6) – arrosive bleeding, infected necrotized pancreatitis developed in 3 patients. Mortality observed in 1 case (14.3%). Conclusions . Endoscopic transpapillary stent placement is an effective minimally invasive approach in management of patients with necrotizing pancreatitis.

SURGICAL TREATMENT OF VASCULAR INJURY WITH TRAUMATIC SHOCK

Aim of study. Identify the features and offer the best tactics for the surgical treatment of vascular injuries in traumatic shock. Material and methods. The clinic has 36 patients with hemorrhagic and traumatic shock. Of them: 33 men (91.6%), women 3 (8.3%). We found, among those admitted to the clinic, 36 patients with hemorrhagic and traumatic shock. So, in 5 patients, the condition was extremely serious. The use of angiography and MSCT is of great importance for the early diagnosis of traumatic vascular damage.Results. We have performed 36 different operations for patients with shock after vascular injury: vessel ligature — 19; lateral suture — 5. Of them: at the same time imposed side seam venous vessels; сircular suture — 4; autovenous shunting — 3; prosthetics — 4: primary amputation — 1 and 7 patients with epineural suture. Along with this, severe shock, massive tissue damage and irreversible ischemia were indications for limb amputation in 1 (2,7%) patients with vascular damage. Arrosive bleeding was observed, only in one patient. In 24 (94,4%) patients, wound healing was primary, in 2 (5,5%) patients, wounds healed by secondary intention.Conclusions. The high efficiency of timely application of reconstructive- restorative operations — autovenous shunting and vascular prosthetics after stabilization of hemodynamic parameters depends on the degree of traumatic and hemorrhagic shock.

ARROSIVE BLEEDING FROM THE APPENDICULAR ARTERY IN ACUTE DESTRUCTIVE APPENDICITIS

Summary. Objective of the study: to present to the surgical community a rather rare complication of severe destructive appendicitis – arrosive bleeding and the cause of its development.&#x0D; Material and methods. Published a rare clinical case from prac-tice — the development of perforation of the appendix and arrosive bleeding from the appendicular artery in a patient with acute gangrenous appendicitis.&#x0D; Results and its discussion. The atypical course of acute appendicitis of undulating nature under the mask of acute adnexitis and antibacterial therapy has led to a prolonged delay with surgery in the surgical department. Only the appendicular abscess, which spontaneously opened into the abdominal cavity, made it possible to diagnose acute appendicitis and determine indications for emergency surgery, during which arrosive bleeding was diagnosed. The favorable outcome of the disease is due to the local purulent-necrotic process and small hemoperitoneum.&#x0D; Findings. Timely diagnosis of acute appendicitis, with the involvement of additional research methods in unclear cases, and subsequent appendectomy, are the prevention of a rather rare complication — arrosive bleeding from the appendicular artery in the development of severe complicated forms of acute destructive appendicitis.

Experience in surgical treatment of diseases of the pancreas in children

The article is devoted to the experience of surgical treatment of pathology of the pancreas at the Center for the Treatment of Developmental Anomalies and Diseases of the Hepatopancreatobiliary System in Children on the basis of the Children’s City Clinical Hospital No. 13 named after NF Filatova: annular pancreas, acute and chronic pancreatitis, tumors and cysts of the pancreas. From 2016 to 2020, more than 267 reconstructive interventions on the pancreas were performed, including longitudinal and transverse pancreatojejunoanastamosis, pancreatoduodenal resection, cystoenteroanastamosis, sectoral and total resection of the pancreas. In the postoperative period, the most severe complication in this category of patients was arrosive bleeding, which is the main cause of all deaths after surgery.

Treatment of recurrent traumatic sternomediastinitis after cardiac surgery

To assess the possibilities of omentoplasty for prevention of complications after redo sternum osteosynthesis for traumatic rupture. The study included 53 patients with recurrent sternal diastasis. Greater omentum was additionally implanted in 19 (35.8%) cases to improve healing and reduce the risk of infectious complications. In 34 patients, redo osteosynthesis was carried out using a metal wire and deployment of irrigation-aspiration system. In 19 patients, omentoplasty was additionally used to close the wound. Omentoplasty was characterized by less duration of lavage (7.4±1.5 vs. 4.2±3.3 days, p<0.0001) and no cases of arrosive bleeding (p=0.04). Omentoplasty reduces duration of treatment and risk of arrosive bleeding.

Split liver transplantation in two recipients for urgent indications: an example and logistics of interregional cooperation

Aim. To report a rare case of split liver transplantation in two urgent recipients treated in hospitals that are very far from each other. Material and methods. Partial liver grafts were obtained by controlled full-right/full-left in situ splitting. The left lobe was transplanted in a 7-year-old child with severe hepatic failure (PELD score 39) resulting, probably from an progressive intrahepatic familial cholestasis in Novosibirsk. The right lobe was used for re-transplantation in a 28-year-old patient with hepatic artery thrombosis (UNOS status 1A) after living donor right lobe liver transplantation in Moscow. Results. The course of the early post-operative period in recipient 1 was complicated by infected total pancreatonecrosis with the development of limited biliary leakage and the formation of a stricture, which required reconstructive cholangiojejunostomy 12 months after transplantation. Recipient 2 consistently underwent biliary leakage, arrosive arterial bleeding, graft artery thrombosis, all of which could become fatal. Complications were successfully eliminated by the consistent use of surgical and endovascular interventions. Conclusion. The presented observation is, firstly, an example of effective inter-center cooperation, and secondly, a demonstration of the existing problems of postmortem organ donation, which determine the need for such extreme surgery in critical situations.

Случай дистальной резекции поджелудочной железы совместно со спленэктомией при оперативном вмешательстве по поводу прорастающей в поджелудочную железу опухоли поперечной ободочной кишки

The article presents a case of successful distal resection of the pancreas together with splenectomy during surgery for a tumor of the transverse colon growing into the pancreas in an elderly patient. The main complications after pancreatic surgery are postoperative pancreatic fistulas, in which there is a risk of septic complications, arrosive bleeding, increased length of stay of patients in hospital and increased mortality [1, 12]. The novelty of the proposed invention, lies in the fact that: pancreatojejunoanastomosis is formed at a distance of 30 cm from the Treitz ligament, then enteroenteroanastomosis is formed between the adducting and diverting loops of the small intestine in the type of side – to-side two rows of sutures, the length of the anastomosis is 4 cm, at a distance of 50 cm from the Treitz ligament, to improve the passage of intestinal chime [2]. This method can be implemented in the practice of surgical hospitals.

ARROSIVE BLEEDING WITH PANCREATIC NECROSIS — TACTICAL APPROACHES

Summary. The problem of hemorrhagic complications of destructive pancreatitis is relevant.&#x0D; The aim of the study was to study the frequency and sources of hemorrhagic complications in patients with pancreatic necrosis, to evaluate the tactics of diagnosis and the effectiveness of methods to stop bleeding.&#x0D; Materials and methods. A study of the results of treatment of 40 patients with acute necrotizing pancreatitis was conducted.&#x0D; Results and its discussion. In 67.5 % of patients with acute necrotizing pancreatitis, hemorrhagic complications in the form of arrosive bleeding were observed. A method of endovascular occlusion of vessels using Gianturco spirals or stent grafts to stop arrosive bleeding in acute necrotizing pancreatitis has been introduced in the clinic. In 37.0 % of cases, repeated signs of arrosive bleeding were observed. In acute necrotizing pancreatitis complicated by arrosive bleeding, mortality was 44.4 %.&#x0D; Conclusions. The main cause of hemorrhagic complications in acute necrotic pancreatitis is acute necrotic changes, during infection of which arrosia of adjacent vessels occurs. The predominant tactic in case of bleeding from the retroperitoneal space against the background of minimally invasive treatment is clamping of drains, endovascular hemostasis using Gianturco spirals or stent grafts and the use of hemostatic soluble gauze (hemostop). Mortality in the development of arrosive bleeding in acute necrotic pancreatitis is 44.4 %.