Tactical Errors Research Articles

Causes of total hip replacement in children: part 1

Background. Total hip arthroplasty (THA) is one of the most frequently performed and effective surgical procedures in patients with hip osteoarthritis of various origin. According to a variety of large arthroplasty registries, in 10-33% of cases, the causes of end-stage hip osteoarthritis in people under the age of 25 are such orthopedic diseases of the hip as dysplasia, SCFE and Perthes disease. However, there are practically no scientific publications examining the causes of the development of end-stage hip osteoarthritis in patients under the age of 21, as well as in children, in the foreign literature and there are none at all in the domestic literature. The aim of the study is to analyze the causes of the development of end-stage hip osteoarthritis requiring total hip arthropasty in children who had suffered major orthopedic diseases of the hip. Methods. The retrospective study is based on the medical records of 500 patients (530 hip joints) aged between 10 and 18 years (15.1±1.5) who had underwent total hip replacement at the Department of Hip Pathology of the G.I. Turner National Research Medical Center for Pediatric Traumatology and Orthopedics, in the period from 2008 to 2023. The main subject of the study was the anamnesis of the course of the orthopedic disease and previous treatment. Results. After studying the medical records and archival X-rays, we have identified the main diagnostic and tactical errors in the treatment of patients with major diseases of the hip, which are specific to childhood. Additionally, according to these nosological entities we have identified the most “endemic” federal regions and subjects of the Russian Federation. Conclusions. The main causes of the development of end-stage hip osteoarthritis requiring total hip arthroplasty in patients under the age of 18 with major orthopedic diseases of the hip are: diagnostic defects, methodological choice of both conservative and surgical treatment, and iatrogenic damage to the joint components.

Причины повторных или этапных операций при мегауретере у детей и меры их профилактики.

Introduction. The second most common pathology of the ureterovesical segment, after vesicoureteral reflux (VUR), is megaureter. At the moment, it is necessary to optimize the approach to performing various types of surgical interventions in children with megaureter. The question of the timing and indications for surgery, their number and the sequence of treatment stages remains open. The aim: to analyze the causes of repeated surgical interventions for megaureter and their prevention. Materials and methods. In the pediatric uroandrology department of the N. Lopatkin Scientific Research Institute of Urology and Interventional Radiology – Branch of the National Medical Research Radiological Centre of the Ministry of Health of Russian Federation, pneumovesiscopic reimplantation of the ureter (UR) according to Cohen was performed in 26 repeated patients over 9 years. 52 interventions were recorded before pneumovesicoscopic UR. 4 (15.4%) patients were previously operated on at a research institute, 4 (15.4%) at the place of residence and then received staged treatment at the N. Lopatkin Scientific Research Institute of Urology and Interventional Radiology – Branch of the National Medical Research Radiological Centre of the Ministry of Health of Russian Federation, 18 (69.23%) patients at the place of residence. Patients underwent from 1-6 surgical interventions, the average value was 2 interventions per 1 patient. Ureteral plication was required in 7 patients. In rare cases, megaureter was combined with ureterocele, duplication of the upper urinary tract and neurogenic bladder dysfunction. Results and Discussion. We combined the reasons for repeated surgical interventions into two blocks: 1inadequate drainage of the ureter, requiring repeated manipulations, including under anesthesia; 2 – complicating factors affecting the quality of the formation of ureterocystoanastomosis, surgical errors in the reimplantation technique and tactical errors that can lead to VUR or obstruction requiring re-operation. The use of original methods: intravesical plication of the ureter, fixation of the ureter at two levels (the entry point of the ureter into the bladder and in the area of the neoostium) is used to increase the length of the submucosal tunnel and create a better anti-reflux mechanism. Conclusion. Understanding the causes of possible complications of ureteral reimplantation allows you to more carefully carry out the stages of the operation, pay attention to key points and improve the results of megaureter correction.

On the Question of Differential Diagnosis of Skin Hyperpigmentations: The Clinical Case of Notalgia Paresthetica

Introduction. Developmental disorders acquire an extensive group of diseases, including congenital forms in inheritance variants, as well as secondary acquired forms due to skin or systemic manifestations.The purpose of this publication is to demonstrate the features of the differential diagnosis of skin hyperpigmentation to identify the clinical manifestation of notalgia paresthetica.Materials and methods. A review of foreign and domestic literary sources was carried out using the search engines eLibrary.Ru, Scopus, PubMed. On the basis of the patient’s voluntary informed consent, an analysis of medical documentation was carried out, taking into account clinical and anamnestic data and the results of laboratory and instrumental examination. Results. The article presents a review of the literature, as well as a clinical case of notalgia paresthetica in a patient with degenerative-dystrophic changes in the thoracic spine.Discussion. Notalgia paresthetica belongs to a large group of cutaneous dysesthesias and is a sensory neuropathy characterized by localized unilateral itching and hyperpigmentation of the skin of the back in the zone of innervation of the cutaneous branches of the thoracic spinal nerves, affecting more often adult and elderly women. The nonspecificity of skin manifestations of notalgia paresthetica and the low awareness of doctors about this disease can lead to diagnostic and tactical errors. Skin itching of varying intensity is the main symptom of the disease, leading to an accentuation of its disease and a decrease in the quality of life of patients.Conclusion. Given the interdisciplinary nature of the pathology, the article may be of interest to neurologists, neurosurgeons, dermatovenereologists, general practitioners, general practitioners, oncologists, and endocrinologists.

A Case of Posterior Communicating Artery Aneurysm Combined With an Atypical Origin of the Ipsilateral Ophthalmic Artery

Objective: Anatomy of the ophthalmic artery (OA) is of great practical importance in surgery for anterior circulation aneurysms. In most cases, the OA arises from the supraclinoid segment of the internal carotid artery (ICA) and enters the orbit through the optic canal inferolaterally to the optic nerve. The OA arising from the anterior cerebral artery (ACA) and entering the optic canal above the optic nerve is extremely rare.Clinical case: We report a case of a 29-year-old female patient admitted to Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1 (Krasnodar, Russian Federation) with a ruptured true aneurysm of the left posterior communicating artery (PCoA) and an abnormal origin of the OA from the ACA. The disease manifested itself as ischemic stroke in the basal ganglia on the left causing diagnostic difficulties during initial hospitalization. Cerebral angiography confirmed a PCoA aneurysm and origin of the OA from the ipsilateral ACA. During surgery the neck of the aneurysm was clipped, and the aneurysm dome was opened to control the extent of clipping and remove thrombotic masses. During their removal, hemorrhage appeared from the posterior pole of the aneurysm. During the exploration it was found that the aneurysm was a dilated PCoA connecting the right ICA with the right posterior cerebral artery (PCA). A thrombosed anterior thalamoperforating artery emerged from the superior surface of the dome, and its junction with the precommunicating segment of the right PCA was detected in the region of the posterior pole of the aneurysm. The second clip was placed at the communication site between the aneurysm and the right PCA. The patient was discharged in satisfactory condition with a stable neurological status.Conclusions: The combination of abnormal anatomy of arteries at the base of the brain and cerebral aneurysms increases the risk of tactical errors and perioperative complications. Each such case requires a careful comparison of the clinical, imaging, and intraoperative findings. In the presented case of the patient with the ruptured rare PCoA aneurysm, the disease manifested atypically due to the partial thrombosis of the aneurysm and hemorrhage into the aneurysmal wall. The imaging findings revealed lacunar stroke in the thalamoperforating artery basin and an ICA aneurysm with no signs of subarachnoid hemorrhage. During the surgery the aneurysm was initially regarded as typical saccular. The opening of the dome and removal of all thrombotic masses made it possible to determine the eccentric fusiform nature of the aneurysm, perform its radical exclusion, and prevent fatal hemorrhage in the postoperative period.

Drainage methods in patients with unformed intestinal fistulas during the preparation to the surgical treatment

The aim of the study is to analyze the data of the modern foreign and domestic literature on intestinal fistulas, including high unformed small intestinal fistulas, their classification, treatment methods, drainage methods, their types and effectiveness. Research method: the search in the elibrary, CyberLeninka, PubMed and SpringerLink databases. Intestinal fistulas, often found in the surgical practice, appear due to a number of reasons (errors in the surgical technique and conservative treatment, tactical errors, the presence of severe concomitant diseases, etc.) and present a high-risk factor for death. Clinically, intestinal fistulas can differ depending on their localization, etiology, morphology, function, complications, etc., that causes certain difficulties in choosing the treatment method and reduces its success. Special attention is paid to high unformed small intestinal fistulas, which are accompanied by pronounced impairment of the body's homeostasis system, on the one hand, and the need for a multi-stage treatment, on the other hand. The treatment regimen for high unformed small intestinal fistulas includes both conservative and surgical approaches. The conservative method of treatment includes an intensive infusion therapy, control of the source of infectious complications, reduction of irretrievable losses, nutritional therapy, and a local treatment, which consists in protecting the tissues from the aggressive intestinal content and various methods of adequate drainage of the wound. The drainage methods used for intestinal fistulas differ depending on the principle of their operation, the surgical drain material, the configuration of the wound, the fistula morphology, the number of fistulas, etc. Active and vacuum methods seem to be used most frequently and efficiently in the local treatment of high unformed small intestinal fistulas. So far, according to the (very limited) modern literature, there has been a diversity in the effectiveness of the drainage treatment approaches in patients with high unformed small intestinal fistulas, thus, further studies are needed to study and evaluate their pathogenetic role and effectiveness.

Qualification of medical (medical) errors

In the article the author investigates the qualification signs of actions (inaction) of doctors (medical staff), the consequence of which is a medical error. Their content and influence at the civil law relations that arise between the doctor and the patient are established. The author emphasizes the development of a correct, well-thought-out and unified position about the legal qualification of erroneous actions of doctors (medical staff). Also in the article it is noted that possible defects of medical care are: lack of a positive result, accident, medical error, where medical error is the basis for bringing to civil liability for doctors (medical workers). It is noted that the characteristic signs of such an error are harm to the patient`s health or his death and the presence of both intentional guilt and negligence and wrongful acts (inaction) of doctors (medical workers).
 The analysis and classification of the causes (factors) of occurrence and types of medical error is carried out. The subjective and objective reasons influencing actions (inaction of doctors, medical workers are defined). It is said that the objective reasons the doctor, the medical worker cannot predict and which exclude their responsibility. It is stated that actions under the influence of objective reasons should be considered as types of accident (or incident). Subjective causes (factors) are errors made by doctors (health professionals) that unreasonably deviate from established medical standards, act carelessly, confidently or allow unreasonable risks in the absence of experience or knowledge.
 The article analyses the classification of medical errors by the causes, in particular: diagnostic errors; medical and tactical errors; technical errors; organizational errors and deontological errors. A legal assessment of a medical error as one of the possible grounds for civil liability is provided. It is substantiated that the responsibility of a doctor, medical staff depends on the presence of guilt in his actions and the qualification of the negative result of medical care.
 The article also emphasizes that doctors (medical workers) are not responsible for a medical error, but for the damage caused to the patient as a result of this error.
 Scientifically substantiated proposals and recommendations for improving the civil legislation of Ukraine in the field of medicine are formulated.

A clinical case of successful treatment of acute phlegmonous appendicitis incarcerated in a hernial sac (Amyand’s hernia)

Atypical localization of the vermiform appendix (VA) in acute appendicitis can lead to diagnostic and tactical errors in emergency abdominal surgery. The rarest and most atypical localization of the VA is within the hernial sac. This type of hernia is defined as Amyand’s hernia. The optimal scope of surgical intervention and access method (laparoscopic or open) for Amyand’s hernia have not been definitively determined. Questions remain regarding the necessity of removing an unaffected vermiform appendix, the approach to hernioplasty in destructive appendicitis, and the feasibility of using a mesh implant for hernioplasty. In cases of a sliding hernia, the destruction of the hernial sac can lead to difficulties with suturing the peritoneum, assessing the state of the strangulated testicle in men, and performing an orchidectomy. Therefore, it is imperative to establish an algorithm for the evaluation and surgical management of patients with strangulated inguinal hernias. Objective — present a clinical case of successful treatment of Amyand’s hernia with acute phlegmonous appendicitis incarcerated in a strangulated inguinal hernial sac and reactive orchoepididymitis, focusing on the selection of medical and diagnostic strategies to reduce the risk of complications. The clinical case illustrates the effective management of a patient who presented with acute phlegmonous appendicitis and purulent orchoepididymitis. These abnormalities were found to be atypically localised within the sac of a strangulated right‑sided inguinal hernia, known as Amyand’s hernia. The necessary surgical procedures included an appendectomy and an orchidectomy. Conclusions. Inflammation of the vermiform appendix in Amyand’s hernia can lead to various unpredictable purulent complications, such as acute typhlitis, purulent peritonitis, necrotizing orchoepididymitis, and Fournier’s phlegmon, necessitating extensive surgical intervention. The collective global and personal experience in treating Amyand’s hernia suggests the possibility of establishing standardised protocols for diagnosing and selecting a surgical intervention technique.

Differential diagnostic search in dermatologic practice and its effect on quality of medical care: Clinical cases

Introduction. A differential diagnostic search is a crucial method for making a final clinical diagnosis. Lack of clinical thinking leads to tactical errors, both in making a diagnosis and in choosing a therapy algorithm. The problem of iatrogeneses especially often arises at the initial stages of patient management.Case descriptions. The paper demonstrates the difficulties of verifying the diagnosis of patients with dermatological pathology on the example of clinical cases. The stages of differential diagnostic search are covered in detail. Practicing physicians stress the importance of timely correct diagnosis and, consequently, the choice of therapy. The study involved a detailed analysis of clinical cases and mistakes causing a delay in diagnosis and wrong choice of therapeutic tactics at the outpatient stage. A clinical case with designated diagnosis is presented and analyzed as an illustrative example. Special attention was given to a complex evaluation of subjective, objective and diagnostic data, the significance of analyzing the development of dermatoses.Conclusion. Careful adherence to diagnostic algorithms will avoid iatrogenic errors and thereby improve the quality of medical care and the quality of life of dermatological patients.

Use of the Scales software complex in planning the surgical treatment of patients with lumbar degenerative spondylolisthesis

The aim of the study was to develop a virtual software package that, when it is based on personalized indicators, allows planning surgical tactics and performing differentiated treatment of patients with degenerative lumbar spondylolisthesis.The results of surgical treatment of retrospective group patients were the basis for creation of a virtual complex.A virtual software package has been developed. It is an expert system for making decisions about surgical tactics for patients with lumbar degenerative spondylolisthesis. The operation of the program is based on the automated analysis of a given list of input parameters. The core of the virtual complex is represented by two configurations, one of which contains an artificial neural network. As a result of virtual processing of the patient’s individual parameters, the program gives an answer in the form of two color scales with numerical labels: a scale of differentiated choice between isolated decompression and decompression supplemented with posterior fusion; scales for a differentiated choice between laminectomy supplemented with medial facetectomy and bilateral decompression of the spinal canal from a unilateral approach. Using the developed software package, surgical treatment of 26 patients with lumbar degenerative spondylolisthesis was performed.The Scales virtual complex, based on key general somatic and clinical and radiological parameters of a patient, creates an opportunity for a surgeon to make the most balanced and informed decision on the tactics of surgical treatment of lumbar degenerative spondylolisthesis. A personalized approach, accompanied by artificial intelligence technology, is aimed at reducing the likelihood of tactical errors and long-term complications of surgical interventions. The use of color scales with digital labels makes it possible to simplify the process of preoperative planning and to create conditions for achieving a balance between the decision of the program and the individual opinion of a specialist surgeon. The result of differentiated treatment of a group of patients using a virtual system was a significant and statistically significant ( p < 0.001) improvement in the life quality of operated patients in the long-term period.

A Clinical Case of an Extrapulmonary form of Generalized Sarcoidosis 
 in the Practice of a Surgeon

The aim of the study is to present a clinical case of generalized sarcoidosis with no involvement of the lungs and intrathoracic lymph nodes.Materials of the study. The literature and data of clinical observation, surgical treatment and results of autopsy of a patient with generalized sarcoidosis were analyzed.Results. In this article the authors would like to draw attention to the case of generalized sarcoidosis with no lesions of the lungs and intrathoracic lymph nodes, which is 5% in the structure of morbidity, and present the clinical case of patient A., who was hospitalized in the surgical department of the Emergency Hospital. The patient was admitted with suspicion of urgent surgical pathology with extrapulmonary manifestations of the disease (polyserositis) and granulomatous lesions of the parietal and visceral peritoneum, extrapulmonary pleura, characteristic of sarcoidosis, and peritonitis, progression and development of a rare clinical form of this disease, neurosarcoidosis, which also amounts to no more than 10 % of all cases of this disease.Conclusions. This clinical case could draw the attention of specialists to this multisystem disease and the need for a multidisciplinary approach to treatment and diagnosis, which may be difficult due to the absence of typical manifestations of this pathology, as in the presented clinical case. The team of authors hopes that our experience will be interesting and will allow residents to avoid diagnostic and tactical errors in the management of such patients, since we have encountered a truly unusual and rare manifestation and complication of sarcoidosis in a patient, who ended up not in a specialized therapeutic or pulmonological department, but in surgical department of a multidisciplinary hospital.

A Clinical Case of an Extrapulmonary Form of Generalized Sarcoidosis 
 in the Surgical Practice

The aim of the study was to present a clinical case of generalized sarcoidosis without involvement of the lungs and intrathoracic lymph nodes.Materials and methods. The literature and data of clinical observation, surgical treatment and results of autopsy of a patient with generalized sarcoidosis were analyzed.Results. In this study, the authors draw attention to the case of generalized sarcoidosis without lesions of the lungs and intrathoracic lymph nodes, accounting for 5% in the structure of morbidity. A clinical case of patient A., who was hospitalized in the surgical department of the Emergency Hospital, is presented. The patient was admitted with suspicion of urgent surgical pathology with extrapulmonary manifestations of the disease (polyserositis) and granulomatous lesions of the parietal and visceral peritoneum, extrapulmonary pleura typical of sarcoidosis, and peritonitis, progression and development of a rare clinical form of the disease, neurosarcoidosis, which amounts to as much as 10 % of all cases of this disease.Conclusions. The clinical case demonstrates specificity of this multisystemic disease and the need for a multidisciplinary approach to treatment and diagnosis, which may be challenging due to the absence of typical manifestations of this pathology, as in the presented clinical case. The authors share their experience to help medical professionals avoid diagnostic and tactical errors in the management of such patients, since they encountered a truly untypical and rare manifestation and complication of sarcoidosis in a patient, who was admitted not in a specialized therapeutic or pulmonological department, but in surgical department of a multidisciplinary hospital.

Optimization of the Teaching of Surgical Disciplines in the Training of Family Medicine Specialists at the Undergraduate Level of Education

The quality of medical care for the population depends on the level of training of future doctors. The formation of professional competence of a general practitioner-family doctor requires a wide range of multidisciplinary knowledge. The innovative technologies, especially interactive teaching methods, are used to make the conditions of a successful educational process. A large amount of material that a general practitioner-family doctor should master encourages the introduction of innovative and integral pedagogical methods that optimize the possibilities of acquiring knowledge and the formation of special practical skills, including surgical skills. The article deals with new views of a comprehensive treatment approach of patients with acute surgical diseases, analyzed modern methods and perspective rehabilitation methodic of surgical patients during the preparing of a general practitioner–family physician at the level of underground education. On the basis of the analysis of existing educational plans and education programs of doctors in the specialty “General Practice-Family Medicine”, the evaluation of acquired theoretical knowledge, special practical skills and the recommendations on the introduction of innovative and integral methods of teaching the basics were presented. The article reveals aspects of providing specialized gastroenterological medical care to the population of Ukraine, which today has a significant medical and social importance. Over the last 5 years, the incidence of digestive system and mortality due to diseases has increased. The study of manifestation, variants of clinical course, diagnostic tactics, diagnosis are extremely relevant at the level of underground education. Knowledge of major diagnostic and tactical errors in acute surgical diseases of the stomach and duodenum is mandatory. Future general practitioners-family doctors need to know the basic clinical signs of acute surgical diseases of the hepatobiliary system and pancreas, improve the skills of taking the patient’s anamnesis (complaints, anamnesis of the disease, history of life, determination of risk factors), need to be able to make an optimal examination plan to confirm the diagnosis, establish a diagnosis, as well as to learn the algorithm of medical history records and be able to determine the period of disability of patients after surgery. During the stages of the educational process for better study effectiveness interactive, innovative methods, various approaches to diagnosis and treatment. Emergency care and rehabilitation of patients are ought to be used; solving problem situations tasks implement more effective training in surgery for the practical activity of a physician in the specialty “General Practice-Family medicine”.

ДИАГНОСТИЧЕСКИЕ И ТАКТИЧЕСКИЕ ОШИБКИ ПРИ ВЕДЕНИИ БОЛЬНЫХ С ФЕОХРОМОЦИТОМОЙ

Objective: To analyze the causes of diagnostic and tactical errors in the management of patients with pheochromocytoma (PCC) and to develop a respective treatment and diagnostic algorithm. Methods: The mistakes made during clinical and instrumental diagnostics, preoperative preparation, and treatment of 55 patients with PCC were analyzed. Among the patients, there were 38 women (69.1%), and 17 men (30.9%). The mean age of the patients was 35.9±6.2 years. In 23 (41.8%) patients, right-sided localization of the tumor was noted, in 29 (52.7%) – left-sided one, while bilateral adrenal lesion occurred in 3 (5.5%) patients. The duration of arterial hypertension (AH) ranged from 6 months to 10 years (mean 4.56±1.7 years). Results: In 52.7% of cases, patients visited a doctor after more than three years from the onset of the first symptoms of the disease. The reasons for late treatment were: an insufficient examination of patients for the symptomatic genesis of hypertension due to low awareness of primary care physicians, self-administration of antihypertensive drugs, and treatment of patients by traditional healers. Errors in the interpretation of the results of ultrasound examination and computed tomography (CT) were noted in 7.3% of cases. During preoperative preparation, tactical errors were made in 7 patients, when instead of α-blockers, antihypertensive drugs of another class were prescribed, as a result of which two of the patients developed the syndrome of "uncontrolled hemodynamics" and died. In 5.5% of cases with large size of the tumor, iatrogenic injury to the inferior vena cava (IVC) and vessels of the right kidney occurred during the operation. In a histological examination of removed pheochromocytomas, the misinterpretation rate was 3.6%, and the diagnosis was reconsidered during repeated assessment. Conclusion: In more than half of the cases, during the primary diagnosis and treatment of PCC, various errors were made due to non-targeted examination of patients, incorrect interpretation of the results of radiological methods of examination, inadequate preoperative preparation of patients, as well as the iatrogenic injuries. In order to timely identify the discussed pathology in patients with AH, it is necessary to examine them in a targeted way for PCC. The basic medications for preoperative preparation of patients should be selective α-adrenoblockers. In order to prevent iatrogenic injuries of large vessels and organs of the retroperitoneal space, a thorough preoperative study of their relations with the tumor is necessary, as well as an improvement of the practical skills of the operating doctors. Keywords: Pheochromocytoma, diagnosis, errors, adrenalectomy, iatrogeny.

Mistakes in the Organization of Specialized Care for Patients with Traumatic Amputation of Hand Segments

The aim of the study appears to focus on identifying and analyzing errors or inadequacies within the organization of specialized care for patients who have experienced traumatic amputation of hand segments. The specific goals might include understanding the flaws in the existing care structures, improving patient outcomes, and developing recommendations to enhance the quality of specialized care provided to patients who have suffered hand segment amputations.Methods. 2020 to 2022 to the clinic of the National Scientific Center for Surgery named after Syzganov, 165 patients with acute injuries of limb segments were urgently hospitalized to provide specialized surgical care, leading to decompensation of blood circulation in the hand or fingers. Results. Due to incorrect actions in 24 patients, it was not possible to replant the delivered segments (33 segments). These patients underwent stump formation.At the same time, 50-75% still allow diagnostic, technical and tactical errors in the treatment of this category of patients. The possibility of replantation and revascularization, as well as their outcome, largely depended on the timeliness and quality of first aid, compliance with the conditions for preserving the cut-off segment, the speed of transportation and other organizational factors. Conclusions. The use of modern methods of microsurgical restorative interventions with the reconstruction of injured vessels can significantly expand the possibilities of preserving and restoring completely and partially torn segments of the hand and fingers. The improvement of the results of treatment of patients with traumatic amputations and injuries of the neurovascular bundles of limb segments was significantly affected by the provision of timely specialized microsurgical care

Оптимизация хирургической тактики лечения пациентов с рецидивами варикозной болезни нижних конечностей

Aim: to justify the choice of the most optimal treatment method depending on the cause, and clinical and anatomical patterns of the varicose veins relapse. Patients and Methods: treatment results of 157 patients with varicose vein relapses were analyzed. The mean age of patients was 39,8±0,3 years. 3 years after surgery, relapse occurred in 23 (14.7%) patients, in terms of 3 to 5 years — in 95 (60.5%), after 5 years or more — in 39 (24.8%). Different treatment methods were used depending on the individual clinical and anatomical relapse form of varicose veins. Anesthesia choice depended on the type and extent of surgical intervention. Of the open access, 94 (59.9%) surgical interventions were performed, minimally invasive methods of treatment were used in 63 (40.1%) cases. The life quality was assessed at the patient's admission to the clinic and 1–2 years after the end of treatment using the CIVIQ-2 questionnaire. Results and Discussion: after the use of minimally invasive techniques, the average pain intensity on the VAS was 3.1±0.2, in patients who underwent open resurgeries — 5.4±0.3. Early postoperative complications were noted in 3 (1,9%) patients. Long-term treatment results were examined in 129 (82.2%) patients out of 157 included in the study within 12 to 24 months after discharge from the clinic. After performing open surgeries, the average value of the cosmesis index on a ten-point scale was 6.1±0.3 points, after minimally invasive interventions — 7.9±0.5. In the long-term period, the disease repeatedly recurred in 2 (1.6%) patients. It was also found that the use of the developed treatment tactics for patients with relapses of varicose veins leads to an improvement in the life quality parameters by 1,2–1,5 times. Conclusion: eliminating the causes of varicose disease relapse, minimizing the invasiveness of interventions improves immediate and long- term treatment results and the life quality of patients. The use of preoperative duplex angioscanning and modern high-tech treatment methods helps to reduce the relapse number of varicose veins associated with technical and tactical errors of surgeons. KEYWORDS: varicose vein relapses, minimally invasive interventions, open surgeries, life quality. FOR CITATION: Zubritskiy V.F., Chernookov A.I., Kuznetsov M.R. et al. Surgical tactics optimization for the treatment of patients with relapses of lower limb varicose veins. Russian Medical Inquiry. 2023;7(4):225–231 (in Russ.). DOI: 10.32364/2587-6821-2023-7-4-225-231.

Etiopathogenetic substantiation of surgical treatment of neurogenic pain syndromes

The purpose of the study was to improve classification of neurogenic (neuropathic) pain syndromes. This will make it possible to define the indications for appropriate analgesic surgery for each type of drug-resistant neurogenic pain syndrome. Incorrect management of neurogenic pain syndromes is usually associated with underestimation of pathogenetic prerequisites for its occurrence. Differentiation of compression, deafferentation and mixed neurogenic pain syndromes makes it possible to determine appropriate surgery and avoid tactical errors. Moreover, this approach allows you to save patients from unreasonable long-standing suffering. Patients with chronic pain syndromes often become disabled, sometimes in the prime of life, and isolated from society and family. Therefore, treatment of chronic pain is currently an urgent problem.

Intraneural synovial cyst of the peroneal nerve: literature review and description of a clinical case

Introduction. Intraneural synovial cyst is a rare pathological condition, which can be symptomatic due to the compression of the neighboring structures, including the peroneal nerve. The purpose of this publication is to present a clinical case of intraneural ganglion of the peroneal nerve with a critical analysis of diagnostic and tactical errors in diagnosis and treatment tactics, and literature review. We present a clinical case of a patient with an intraneural cyst of the peroneal nerve, who had 3 surgical interventions over a period of 1.5 years from the age of 13 years, followed by recurrences without restoration of muscle function. The case demonstrates underestimation of the pathogenesis of the described condition - the presence of a communicant nerve between the proximal tibiofibular joint and the peroneal nerve and proximal tibiofemoral joint as the source of synovial effusion. Awareness in relation to this pathology will improve the efficiency of diagnosis. Interdisciplinary approach of pediatric neurologists, orthopedists, neurophysiologists and radiologists can shorten the diagnostic stage and enable the earliest and most effective surgical treatment to avoid irreversible consequences due to prolonged muscle denervation.

Complicated Course of Cystous and Tumor-Like Ovarian Formations in Adolescents

The article presents the data of our own studies of patients with cystic and tumor-like formations of the ovaries in a complicated course of the disease. Difficulties in the differential diagnosis of this pathology leads to diagnostic and tactical errors, which further leads to dysfunction of the reproductive organs and irreversible consequences in the reproductive health of patients in case of untimely treatment. A comprehensive study of the features of the course of cystic and tumor-like ovarian formations, the development of diagnostic criteria, will help determine the tactics of timely treatment of this pathology, which in turn will affect the prognosis of the disease, and will also contribute to solving this problem in women of different age periods.

Treatment of postoperative unformed intestinal fistulae and general peritonitis. Diagnostic, tactical and technical errors (case report)

The authors report the case of a patient with peritoneal adhesions, intestinal obstruction, postoperative peritonitis due to entero-enteroanastomosis leak, complicated by abdominal sepsis, intestinal failure, phlegmon of the abdominal wall, bilateral polysegmentary pneumonia. Fistula-bearing part of the small intestine was resected, several debridement relaparotomies were followed by entero-enteroanastomosing. In the postoperative period, a laporostoma was brought out because of phlegmon of the anterior abdominal wall and compartment syndrome. An vacuum pack system was used to sanify the abscess. After stopping peritonitis, the abdominal cavity was sealed with mobilized skin grafts. The patient was discharged on the 41st day after admission to the hospital and on the 53rd day from the onset of the disease. The male was examined 2.5 years later, the level of his health was good, he was engaged in work. The presented case reports the stages of surgical treatment of postoperative unstable intestinal fistulae associated with diffuse peritonitis and intestinal failure in the early terms of their onset. The authors discuss diagnostic, tactical, and technical errors and analyze the reasons.

Evolution of traumatic thoracolumbar spine injurу classifications

According to some authors, traumatic injuries of the thoracolumbar region account for 2/3 to 3/4 of all vertebral fractures. The development, introduction into clinical practice and improvement of methods for treating injuries in this area are associated with attempts to classify injuries into different categories according to the most common, in the author's opinion, signs. The evolution of classifications of traumatic injuries of the spine in general and its thoracolumbar region in particular is largely due to the development of ideas about the biomechanics of injuries. The review attempts to briefly characterize the most well-known classifications. When analyzing the literature, 28 damage ranking systems were selected, reflecting in the historical aspect the change in ideas about the principles of classification, damage biomechanics and treatment tactics. When describing certain types of damage, we tried to reflect the pathomorphological characteristics of the fracture in the author's interpretation as accurately as possible, therefore, in different classifications given in this publication, the same type of damage may have slightly different signs. The information systematized in the review is primarily of historical interest, but in some cases it may be useful to the practicing clinician for a number of reasons. First, taking into account the huge amount of work carried out by the authors of the classifications on the analysis and systematization of the material, a number of publications describe rare types of fractures, and the proposed methods of treatment can still be of practical importance. Secondly, even in modern publications devoted to the study of certain features of the biomechanics or tactics of treating spinal injuries, the authors often use little-known or formally outdated injury ranking systems, since a certain classification principle may be more appropriate for the research task. Thirdly, a general analysis of the evolution of classification systems makes it possible to identify historically established both definitive and tactical errors, the understanding of which allows a more critical attitude towards generally accepted statements.