Tactics Of Surgical Treatment Research Articles

On the issue of surgical treatment of highly differentiated thyroid cancer. Case reports

The article discusses the modern surgical tactics of treatment of differentiated thyroid cancer, with an emphasis on organ-preserving operations. The clinical cases in which preoperative diagnostics was not able to reveal the extent of tumor spread are presented. Non-radical surgical tactics in such situations inevitably leads to repeated surgery that is performed against the background of ongoing cancer progression, in which case the patient may be at a higher risk of recurrence than s/he would be with a timely radical operation and therefore may require further treatment.

Возможности оптической когерентной томографии переднего отрезка в режиме ангио (AS-OCTA) в диагностике и тактике хирургического лечения заболеваний роговицы

Purpose. To describe three clinical cases of corneal vascularization of different etiologies, to evaluate the possibilities of the method of optical coherence tomography of anterior segment in the mode of angiography (AS-OCTA) in diagnostic and selection of treatment strategies of corneal diseases, as well as to provide diagnostic protocol. Material and methods. For the first time AS-OCTА was performed at the S. Fyodorov Eye Microsurgery (Moscow). The presented clinical cases included three patients with different pathologies of the anterior segment of the eye: postherpetic neovascularization, superficial epithelial fibroplasia and limbal stem cell deficiency syndrome (LSCD). The scan was performed on an Avanti xR optical coherence tomography device (Optovue Inc. Fremont, California, USA) in the «OCT» and «Angio OCT» modes using the AngioVue program and the SSADA algorithm. Results. In the presented clinical cases, the use of AS-OCTA makes possible to accurately assess the depth, area and architectonics of the vessels, and helps to determine the tactics of surgical treatment and type of keratoplasty. However, the disadvantages of this technique include the complexity and long time required for its implementation, as well as the appearance of a large number of artifacts even with minimal eye movement of patients. At the same time, in the presence of a qualified operator and with proper compliance with the patient, it is possible to obtain valuable diagnostic data. Conclusion. Our study is the first in the Russian Federation to demonstrate the use of anterior segment OCT angiography to visualize the corneal vasculature and provide a protocol for performing it on an Avanti xR optical coherence tomograph. In this preliminary study of patients with corneal neovascularization, we regard the results obtained using AS-OCTA as promising for non-invasive vascular imaging, in particular, before and after the treatment of various conditions with corneal neovascularization. Key words: cornea, neovascularization, limbal stem cell deficiency, anterior segment optical coherence tomography, angiography, corneal limbal vasculature

Combined operations in outpatient laser treatment of chronic hemorrhoids of stage 2–3

Introduction. When performing laser coagulation of hemorrhoids, there is a demand for the elimination of simultaneous diseases, but their laser treatment is under study and implementation in the practice of coloproctologists.Aim. To study the features of transmucous laser thermal ablation of chronic hemorrhoids of stage 2–3 with simultaneous elimination of other anal canal diseases in outpatient settings.Materials and methods. Transmucous ablation of hemorrhoids of 2–3 degrees was performed in 104 (27.5%) people in combination with laser removal of chronic anal fissures in 82 (75%) patients, intra-sphincter fistulas in 10 (9.6%) and other anal canal pathology in 18 (17.4%) patients. The median age of patients was 43 years, 48 men (46.2%), 56 women (53.8%).Results. Surgical tactics of laser treatment of simultaneous and underlying pathology allowed one-step elimination of both diseases in all 100% of patients. The duration of combined operations was 20.0 min. (15; 20) the pain intensity was 2.5 points (2; 3). Intraoperative blood loss was minimal. Pain in the postoperative period persisted for 5 days. After surgery, bleeding occurred in 2 (1.9%) patients. During the year, a recurrence of hemorrhoids occurred in 2 (1.9%), anal fissure in 10 (12.2%), condyloma in 2 out of 3 operated.Discussion. The obtained characteristics of combined operations showed that all their signs corresponded to minimally invasive interventions, both operations, the main and combined, were low-traumatic, performed under local anesthesia and had one access and a common operating field.Conclusion. Combined pathology of the anorectal region is observed in a quarter of patients with chronic hemorrhoids. In 100%, it was eliminated by simultaneous operations that were minimally invasive, which allowed them to be performed on an outpatient basis under local anesthesia.

Iatrogenic damage to the vascular-nerve bundle and lymphatic collectors of the femoral triangle during phlebectomy

The rapid development of innovative medical technologies, the expansion of indications for surgical treatment, a significant increase in the number of operations performed for varicose veins entails a steady increase in the frequency of iatrogenic damage to the vascular-nerve bundle and lymphatic collectors of the lower limb. This can lead to severe complications requiring surgery, social and economic consequences associated with the need forlong-term outpatient and inpatient treatment, social security costs and a marked decrease in quality oflife. Reports on the occurrence of this pathology in the medical literature are few and, as a rule, describe extremely rare clinical cases. Timely diagnosis of complications, tactics of surgical treatment of patients with iatrogenic injuries in the surgical treatment of varicose veins and possible options for correcting emerging complications continue to cause discussion and remain one of the discussed problems of modern angiosurgery. The article provides a review of the literature devoted to the analysis of possible causes of iatrogenesis in varicose vein surgery: damage to the neurovascular bundle and lymphatic vessels of the femoral triangle, femoral vein, great saphenous vein, femoral artery, concomitant damage to the artery and vein, lymph nodes and basins, saphenous nerve during phlebectomy. The issues of diagnosis and options for correcting the complications that have arisen. The problem of mistakes and complications in the vein surgery should be resolved through comprehensive training of phlebologists, including compulsory teaching of vascular surgery skills, as well as supplying special equipment and instruments to the clinics.

Topical issues of surgical treatment of pelvic floor dysfunction. A literature review

This article presents a review of the current literature on the problem of omission and prolapse of the internal genitalia in women. Patients diagnosed with pelvic organ prolapse need pelvic floor plastic surgery. Currently, in spite of the extensive experience in managing this category of patients, there is still no single and unambiguous approach to the choice of surgical treatment tactics.
 This review describes the latest information on the etiopathogenesis of pelvic floor supporting apparatus lesions, namely, systemic connective tissue dysplasia as the main development factor. Prospective development of genetic and immunohistochemical marker diagnosis is the key to individual selection of treatment options for this multidisciplinary problem. The results of interventions are characterized by extreme variability in terms of both effectiveness and the frequency of intra- and postoperative complications. The treatment of rare forms of prolapse after surgery for rectal cancer also raises many questions. The current multitude of types of surgical interventions for genital prolapse and variants of pelvic floor defect closure is constantly being modified. To date, there is no universal treatment option, and all available techniques have both advantages and disadvantages, as well as limited application due to the risk of somatic complications, high recurrence rate, and the need for expensive equipment and a highly qualified surgeon.
 New research is needed, taking into account the current knowledge about the cellular and molecular mechanism of the lesion of the pelvic floor supporting apparatus. All of this will improve the methods of correction of pelvic organ prolapse in both typical and rare forms caused by iatrogenic factors. As a result, this may lead to an improvement in the quality of life of such patients.

Biological and physical mechanisms of cerebral aneurysms formation, growth and rupture

According to various researchers, the prevalence of unruptured cerebral aneurysms (CAs) in the general population varies from 2 to 5 %. In the vast majority of cases, CAs do not have clinical and neurological manifestations and are discovered incidentally during routine neuroimaging studies. CAs can cause intracranial hemorrhage. As a rule, hemorrhages of this type occur in patients aged 40–60 years. It has been established that about 10–15 % of patients die from an aneurysmal hemorrhage before they receive specialized medical care. Recurrent aneurysmal intracranial hemorrhage is the main cause of high mortality and disability in this group of patients. The search for literature sources in the scientific databases PubMed/Medline, EMBASE, Cochrane Library and eLibrary demonstrated the existence of numerous studies devoted to the study of molecular biology and biophysical mechanisms of formation, growth and rupture of CAs. Combining the results of these studies was the motivation for writing this literature review. The paper reflects in detail the role of inflammation and molecular genetic factors in the growth and rupture of the CAs, and presents the biophysical factors of the rupture of the CAs. The authors pay special attention to the shape, size and coefficient of the CAs as the most important geometric risk factors for the formation and rupture of the CAs. This review presents current data on mathematical modeling of various types of CAs with an assessment of the risk of rupture of the latter, which has found its application in wide clinical practice. The authors also attempted to describe the hemodynamic features in various types of CAs. In turn, the type of blood flow in the CAs cavity largely depends on the size and shape of the latter and the geometry of the carrier artery, which is the basis for preoperative planning and the choice of tactics for surgical treatment of patients with unruptured CAs.

Prophylaxis of postoperative hypoparathyroidism in thyroid surgery.

There are a number of thyroid gland diseases that require surgical treatment. Therefore, it is important to improve the surgical approaches and treatment tactics in patients that need such surgery. To provide an algorithm to prevent parathyroid gland damage during surgery. This work was based on treatment results of 226 patients with different thyroid diseases. All patients received extrafascial surgical interventions using modern methodological approaches. For prevention of postoperative hypoparathyroidism, we used the "stress-test", 5-aminolevulenic acid, and a method of double visual-instrumental registration of photosensitizer-induced fluorescence of parathyroid glands. Transient hypoparathyroidism was registered in four (1.8%) cases after surgery. Permanent hypocalcemia in patients was not recorded. Autotransplantation of parathyroid gland was required only in one case (0.44%). A deficiency or low level of vitamin D was detected in 35% of the cases, and in the majority of those cases, it was due to secondary hyperparathyroidism. The deficiency was corrected with the administration of vitamin D in all cases. In 10.17% (23 patients) of cases, there was no proper visual glow effect after administration of 5-aminolevulinic acid (5-ALA), which required proceeding to the second part of the proposed method (a helium-neon laser and registration of fluorescence using a laser spectrum analyzer). The proposed methodological approach allows prevention of persistent hypoparathyroidism and reduces the frequency of transient hypoparathyroidism and other complications in surgical treatment of patients with various thyroid gland diseases.

Surgical treatment of the perihilar cholangiocarcinoma with portal vein invasion

Background. Perichilar cholangiocarcinoma is a rare type of malignant neoplasm and is 3-7 cases per 100,000 population. Surgical method is the only radical method of treatment, allowing to improve long-term survival results. One of the important and characteristic features of perihilar cholangiocarcinoma is tumor invasion to the area of the portal vein bifurcation, which occurs in 30–45% of cases. Portal vein invasion is the one of the main causes of perihilar cholangiocarcinoma irresectability. However, innovative surgical technologies allow resection of the liver with resection and reconstruction of the portal vein with acceptable mortality.
 The aim. The aim of our study was to asses results of surgical treatment of perihilar cholangiocarcinoma with (Group 1) and without (Group 2) portal vein invasion.
 Materials and methods. From 2003 to January 2023 in the Department of Surgery and Liver Transplantation of the Ukrainian National Institute of Surgery and Transplantation, 208 patients with perihilar cholangiocarcinoma underwent major extended liver resections. We compared 93 (46%) patients who received extended liver resection with portal vein resection (Group 1) with 115 (54%) patients who underwent liver resections without vascular reconstructions (Group 2). The average Ca 19–9 in the group 1 was 288 (8 – 1000) U/ml, in the group 2 –262 (10 – 612) U/ml. The level of total bilirubin in patients of the group 1 was 312 (43 – 621) mcmol/l, in the group 2 – 267 (10 – 612) mcmol/l. In view of this, in the preoperative period, 190 (91,3%) patients underwent decompression of the bile ducts, using percutaneous transhepatic cholangiostomy (PTBD) or retrograde endobiliary stenting. For patients with small remnant liver volume less than 40 %, in 80(38,5%) cases we did preoperative PVE of a resected part of the liver. In 9 cases we made simultaneous PVE and PTBD. When choosing the volume of surgical intervention, we proceeded from the tumor type of Bismuth-Corlette classification, invasion into the portal vessels and the depth of the liver lesion. The portal vein reconstruction was in all cases performed in an “end-to-end”. In all cases we made extended lymphadenectomy.
 Results. All complications were classified according to the Dindo-Clavien classification. Postoperative mortality in the main group was 11.5%. The overall 1, 3, 5-year survival in the group 1 was 96%, 68,3%, 57,4%, respectively. 1, 3, 5-year survival rate in the comparison group 2 was 98,4%, 76,7%, 47,3%, respectively.
 Conclusions. Aggressive tactics of surgical treatment of perihilar cholangiocarcinoma provides maximum radicality, allows to increase resectability in case of tumor invasion of the portal vein with acceptable mortality and long-term survival.

Modern treatment management strategy for inflammatory bowel diseases

MODERN TREATMENT MANAGEMENT STRATEGY FOR INFLAMMATORY BOWEL DISEASES Olexander I. Poida1, Volodymyr M. Melnyk1, Mykola D. Kucher1, Tetiana G. Kravchenko1, Myroslav I. Kryvoruk2 1 O. O. Bogomolets National Medical University, Taras Shevchenko Boulevard, 13, Kyiv 01601, Ukraine 2 UNCE (Utility non-commercial enterprise) «Kyiv City Clinical Hospital №18», Taras Shevchenko Boulevard, 13, Kyiv 01601, Ukraine Introduction. Enrichment of knowledge in etiology and pathogenesis, improvement of existing and development of new methods and technologies, strategies and tactics for IBD will contribute to improving the results of their diagnosis and treatment. The aims. To improve the treatment results of patients with IBD by developing and implementing modern treatment management strategies for their diagnosis and treatment. Material and methods: The modern diagnostic and treatment management of IBD has been developed and put into practice. It provides for the improvement of diagnosis and differential diagnosis of diseases, justification and selection of the optimal personalized method of treatment, depending on the characteristics of the clinical course, the severity of the patient's condition, and the existing risk of complications. Results. From 2013 to 2022, 1340 patients, 732 (54.6 %) men and 608 (45.4 %) women with IBD were treated at the Coloproctology Center of Ukraine. There were 812 (60.6 %) patients with ulcerative colitis and 528 (39.4 %) with CD. Conservative therapy received 1107 (82.6 %) patients, and surgical treatment – 233 (17.4 %). Postoperative complications occurred in 37 (15.9 %) patients, and deaths – were in 5 (2.1 %). All patients in the conservative treatment group had positive therapeutic dynamics, and improvement of morphological changes in the intestinal mucosa according to the control colonoscopy and biopsy. Positive functional results and life quality improvement were obtained in most patients after surgical treatment. Conclusion. 1. Conservative treatment involves the use of modern and highly effective drugs that can modify the course of IBD and thus prevent complications. 2. The choice of surgical strategy and treatment tactics is reasonable in the presence of a high risk of adverse course of UC and CD, as well as the development of complications that pose a threat to the patient's life. 3. Implementation of the proven treatment management for inflammatory bowel disease allowed: to increase to 82.6 % the number of patients who are indicated conservative therapy and reduce the risk of recurrence of these diseases; to decrease the number of surgical interventions to 17.4 %, increase the performance of surgical interventions according to relative indications to 62.5 %, even before the occurrence of severe complications of diseases; reduce the incidence of postoperative complications to 15.9 %, postoperative mortality to 2.1 %, and improve functional outcomes and quality of life of operated patients. Keywords: bowel, inflammatory diseases, diagnosis, treatment.

Long-term results of revascularization of the lower extremities in patients with critical ischemia and diabetes mellitus with localization of the occlusive-stenotic process in the femoral artery

Aim: to determine the most preferable tactics of surgical treatment of patients with critical ischemia of the lower extremities of atherosclerotic genesis and diabetes mellitus based on a comparison of the results of revascularizing interventions. Methods: The study involved 82 patients who were treated in the department of vascular surgery due to critical ischemia of the lower extremities as a result of atherosclerotic occlusive-stenotic lesion of the femoral arterial segment against the background of diabetes mellitus. After the diagnostic stage and preoperative preparation, the patients were divided into two groups depending on the nature of the intervention performed: endovasal revascularization or femoropopliteal autovenous bypass grafting above the knee joint gap. In the postoperative period, dynamic observation of patients was continued with a predominant assessment of the clinical status. Results: Clinically, circulatory decompensation requiring repeated intervention or amputation was observed in 9 (30 %) patients from the first group and in 13 (25 %) patients from the second. High amputation was performed in 2 (6.6 %) study participants from the endovasal revascularization group and 3 (5.7 %) from the open surgery group. Over the entire observation period, 2 (6.7 %) and 4 (7.8 %) patients died in the groups under consideration, respectively. No statistically significant differences were obtained for any of the studied parameters, however, repeated interventions were significantly more frequently performed in patients undergoing endovascular revascularization. Conclusion: When analyzing the advantages and disadvantages of endovascular and open surgery in patients with diabetes mellitus and critical ischemia, the first should be preferred due to the possibility of repeated repetition throughout the patients life. Particular attention should be paid to conservative therapy and assessment of clinical status in the late postoperative period.

Optimal Surgical Treatment Tactics in Patients with Synchronous Metastatic Colorectal Cancer

Aim: The aim of the study is to choose the optimal tactics of surgical treatment in patients with colorectal cancer (CRC) with synchronous intra-abdominal metastases. Materials and methods: The study included 74 patients with CRC with synchronous intra-abdominal metastases (peritoneal carcinomatosis and/or liver metastases), which were divided into 3 groups: I group (25 patients)-Intestinal stoma + neoadjuvant chemotherapy + Cytoreductive Surgery (CRS) + Adjuvant Chemotherapy (ACT); II group (18 patients)-Colon/rectal resection + ACT + CRS + ACT; III group (31 patients)-CRS + ACT. Results: The best oncological results were obtained in III group (median overall survival 46 months vs 27m. in I group and 31m. in II group). In contrast, a higher incidence of postoperative complications was observed also in this group (29%). There is no significant difference in overall survival (p>0.05 according to Log-Rank test) and the rate of postoperative complications between all groups of patients. The mean length of hospital stay was shorter in III group-9.8 days (p<0.01). Conclusions: All three options could be selected for the treatment of synchronous metastatic CRC. Therefore, the main goal remains the achievement of complete cytoreduction. So, it is necessary to focus on its possibility when choosing the sequence of stages of treatment in such patients. However, if it is possible to achieve complete cytoreduction and in the setting of the oncological center it is recommended cytoreductive surgery as the first step followed by adjuvant chemotherapy as the best treatment tactics for patients with synchronous metastatic CRC.

The Choice of Tactics for Surgical Treatment of Acute De Bakey Type I Aortic Dissection in a Multidisciplinary Surgical Hospital

BACKGROUND Acute proximal aortic dissection (Stanford type A) remains the most common fatal pathology of the thoracic aorta. Despite the improvement of surgical technologies, hospital mortality after emergency surgical interventions is 17–25%, in complicated cases it can reach 80–90%.AIM OF STUDY Description of the perioperative treatment tactics adopted at the N.V. Sklifosovsky Research Institute for Emergency Medicine as well as the evolution of approaches that make it possible to obtain satisfactory hospital and long-term results in the treatment of aortic dissection.MATERIAL AND METHODS the study included 278 patients operated on from 2015 to 2021 in the acute stage of aortic dissection (less than 48 hours from the moment of manifestation of the disease). The operated patients were divided into two groups, depending on the presence of complicated forms: group A, 102 patients with uncomplicated course of the disease; group B, 176 patients with complicated course of the disease. Additionally, patients were divided depending on the level of distal reconstruction performed: group I, 83 patients, surgery was limited to prosthetics of the ascending aorta, without removing the clamp; group II, 137 patients who underwent hemi-arch surgery; group III, 58 patients, with distal reconstruction involving the aortic arch.RESULTS Total hospital mortality was 28.1%: 25.3% in group I, 29.1% in group II, 29.3% in group III. In the group of uncomplicated dissection, postoperative mortality was 18.6%, while in the group of complicated dissection it was 33.5%.CONCLUSION An integrated multidisciplinary approach with the formation of an “aortic team”, an individual approach to surgery, depending on the anatomy of the dissection and the clinical status of the patient, will improve the results of the treatment of acute aortic dissection, as the most severe and multiple organ pathology of the aorta.FINDING 1. Hospital mortality of complicated forms of dissection remains significantly higher — 33.5% versus 18.5% of uncomplicated course. 2. The most optimal method of distal reconstruction in patients with the peracute stage of dissection is an open anastomosis with the aorta using the “hemi-arch” technique. 3. If it is necessary to extend the surgical intervention on the aortic arch, a distal anastomosis in areas 0, 1, 2 with the possibility of a subsequent endovascular stage is the priority.

Surgical Rehabilitation of a Posttraumatic Iris Cyst, Cataract and Astigmatism Patient

Injuries cause serious disturbance of the form and function of the organ of vision due to the damage and accompanying or remote complications and therefore have a high proportion to the structure of low vision, blindness and disability. One of the complications of penetrating wounds of the eye is iris cysts. Iris cyst can increase and cause pupillary block, secondary glaucoma, uveitis, corneal dystrophy, and therefore it requires surgical intervention. The goal of surgical treatment of an iris cyst is to ensure complete removal of the cyst.Objective: to estimate the clinical and functional results of treatment in a posttraumatic iris cyst, posterior subcapsular cataract and myopic astigmatism patient.Patient and methods. Patient B., 49 years old with posttraumatic retention iris cyst, posterior subcapsular cataract, compound myopic high astigmatism was examined. To determine the tactics of surgical treatment of the patient, a complex of General ophthalmology was performed (visometry, IOP measurement, autorefractometry, biomicroscopy, ophthalmoscopy), as well as special (B-scanning, optical coherence tomography of the retina) research methods. The follow-up period was 1 year.Results and discussion. To improve visual functions and prevent the development of secondary glaucoma, the patient was offered surgery — excision of the iris cyst and cataract phacoemulsification with toric intraocular lens. Simultaneous carrying out of two stages of the operation reduced the risks of postoperative complications and shorten the rehabilitation period.Conclusion. Positive optical and therapeutic effects were achieved as a result of the surgical treatment 44 years after an open eye injury: the eye is calm, the iris cyst is not detected, visual acuity has increased. The postoperative period showed the saving the stable and high visual and functional result with no recurrence of the iris cyst.

Differentiated tactics of surgical treatment of intervertebral disc herniation complicated by spinal canal stenosis

Objective: to conduct a retrospective analysis and evaluate the results of various methods of surgical treatment of patients with intervertebral disc herniation (IDH), which is complicated by spinal canal stenosis (SCS) of the lumbar spine.Materials and methods: 80 patients (36 (45%) men and 44 (55%) women) with a diagnosis of IDH complicated by SCS took part in the study. The average age of patients is under 50 years. All patients were operated on in the neurosurgery department of Zaporizhzhya Regional Clinical Hospital between 2016 and 2020. Patients were divided into two groups depending on the area of ​​the spinal canal and the method of surgical treatment. Group A (n=20) – relative SCS, area of the spinal canal – 75‒100 mm2, the presence of IDH >6 mm (according to magnetic resonance imaging). These patients underwent a standard microdiscectomy. Group B (n=60) ‒ absolute SCS, spinal canal area <75 mm2, the presence of IDH <6 mm (according to magnetic resonance imaging). This category of patients underwent surgery with wide decompression of the spinal canal and stabilization of the spinal motion segment using the method of interbody and transpedicular fixation of the corresponding spinal motion segment. The postoperative follow-up period is up to 6 months. A visual analogue scale was used to assess the pain syndrome in the lower limb and back and the degree of its reduction in the postoperative period. The impact of surgical treatment on the quality of life of patients with IDH complicated by SCS was assessed using the Oswestry Disability Index questionnaire (ODI).Results. Before the operation in group B, an inversely proportional dependence of the pain syndrome level on the visual analogue scale on the age of the patients (p<0.05) and the duration of the disease (p<0.05) was recorded. No such dependence was found in group A. In both groups, a significant decrease in pain syndrome was noted at the end of the first day after surgery, with a further gradual decrease until the end of the observation period. When comparing groups at the end of the first day after surgery, after 3 and 6 months, no statistically significant differences were found (p>0.05). In both groups, a significant decrease in the Oswestry index was registered immediately after surgery and its further decrease until the end of the follow-up period. When comparing the groups at the end of the first day after the operation, after 3 and 6 months, no statistically significant differences were found (p>0.05), but preoperative Oswestry index was significantly higher in group B, (р=0.04 according to the Mann‒Whitney test).Conclusions. In group A, the treatment effectiveness of patients reached 80‒85%, in the observation period on the 3 and 6 months. In group B, the treatment effectiveness of patients was also high and amounted to 75‒80%, in the observation period on the 3 and 6 months. Thus, taking into account the high variability of clinical and morphological changes in patients with IDH complicated by SCS, it is optimal to use differentiated surgical treatment tactics.

Moving on to surgical stage of glaucoma treatment

Making a decision about the need for surgical intervention in glaucoma patients is not easy, and the rationale for it involves a balanced approach based on numerous objective, as well as, unfortunately, subjective factors. Therapeutic approaches in modern glaucomatology have temporarily, and as it seems, for quite some time, have shifted towards active observational therapeutic strategy, which brought negative results expressed in deteriorating outcomes of surgical treatment. At the same time, it is obvious that not all indications for surgical treatment have the same "weight", which also determines the need for a differentiated approach. The discussion about the decisionmaking time for transition to surgical tactics of glaucoma treatment has been repeatedly discussed, is being discussed, and will continue to be discussed in the professional circles, with new arguments arising due to clarification of the pathophysiology of glaucomatous optic neuropathy, active use of interdisciplinary approaches, emergence of new tools, devices and technologies, coupled with improvement of surgical skills, increase in the life expectancy of the population, as well as the need for rational assessment of socio-economic resources of the state and the individual. This review describes the generalized experience and the authors' own point of view on this problem.

Posterolateral Rotational Knee Instability: Evolution and Current Trends in Surgical Treatment

Background. Diagnostics and treatment of patients with chronic posterior and posterolateral instability of the knee is one of the most understudied problems of modern orthopedics. This is due to rather low frequency of this pathology, as well as to complex anatomy of tendoligamentous structures of the posterolateral part of the knee joint. Steadily increasing number of foreign publications dedicated to this topic say that there is no common approach to the tactics of surgical treatment of patients of this category at the moment.
 Aim of review to evaluate the main trends of surgical treatment of this pathology according to the stage of involvement of various anatomical structures responsible for posterolateral rotational instability in the pathologic process.
 Results. Despite a large number of methods of surgical treatment of posterolateral corner injuries, when analyzing modern publications, several main trends concerning posterolateral instability of the knee joint can be identified. In case of type 1 posterolateral instability, an isolated arthroscopic posterior cruciate ligament plasty is the most optimal. As for types 3 and 4, today such anatomical techniques as Larson and LaPrade have completely replaced the methods of non-anatomical reconstruction of the posterolateral corner. In addition, a large number of publications have recently appeared concerning arthroscopic techniques of these surgeries. The most important problem concerns the extent and the methods of surgical intervention in case of type 2 instability. Authors of the article consider that an arthroscopic posterior cruciate ligament plasty combined with popliteal tendon plasty is the most optimal for such category of patients.
 Conclusion. The actual problem is the question of the method of surgical treatment in case of type 2 instability. The optimal technique for such patients is arthroscopic posterior cruciate ligament plasty combined with popliteal tendon plasty.

Options in Tendon Transfers for Anterior-Superior Rotator Cuff Tears: Review

Background. Irreparable anterior-superior rotator cuff tears can cause significant shoulder dysfunction due to the failure of normal biomechanics of the joint, because of the loss of compressive effect of the rotator cuff on the humeral head. Muscle-tendon transfers are an alternative to standard surgical treatment options: debridement of injured tendons, arthroscopic anchor suture, and reverse shoulder arthroplasty. Currently, several options of muscle-tendon transfers are described in the foreign literature, and there is an active discussion over the results of the already proposed techniques, and their improvements, while these techniques are practically not covered in the domestic literature.
 The aim to describe modern surgical technique options of the muscle-tendon transfers for the treatment of patients with anterior-superior rotator cuff tears based on a review of foreign literature sources.
 Methods. The search for publications from 1988 to 2022 was carried out in the PubMed/MEDLINE and Google Scholar databases.
 Results. Nowadays, the most common muscle-tendon transfers options for patients with anterior-superior rotator cuff tears are the sternocostal portion of the of pectoralis major tendon transfer and the latissimus dorsi tendon transfer. A review of foreign literature showed that muscle-tendon transfers are a well-described alternative to standard methods of treating profile patients with a predictable result.
 Conclusion. Currently, there is no consensus on clear indications for certain types of muscle-tendon transfers in case of anterior-superior rotator cuff tears, there is a lack of data on long-term results. This determines the need of study of the long-term clinical results of use of these methods and develop an algorithm for choosing the tactics of surgical treatment of relevant patients.

Criss-cross heart: a clinical case of a rare congenital heart defect in a newborn

Introduction. Criss-cross syndrome is a rare congenital heart disease with an incidence of 8 cases per 1 million newborns. The purpose of the work is to demonstrate a rare CHD, a criss-cross heart diagnosed postnatally. The purpose of the work was to demonstrate a rare CHD, a criss-cross heart diagnosed postnatally. Materials and methods. A clinical observation of a newborn child with a rare congenital heart defect is presented. Medical documents with the results of clinical examination (physical examination) and instrumental examinations (X-ray examination, echocardiography, computed tomography) were used for analysis. Results. A child with a rare congenital heart defect (CHD) – criss-cross heart with discordant atrioventricular connections, transposition of the great vessels and preductal aortic coarctation was monitored from the time of delivery until surgical treatment. This malformation was diagnosed postnatally, based on the characteristic clinical symptoms of the detailed segmental analysis of the ultrasound picture of the heart, which is presented as illustrations. Timely diagnosis allowed the choice of adequate medication and surgical tactics of treatment, and the diagnosis was confirmed by computed tomography. Discussion. It is important for the clinician to remember that rare congenital heart diseases cannot always be diagnosed antenatally, and with the results of screening indicating the presence of more common malformations, the real postnatal heart picture may differ significantly. An additional difficulty is the differential diagnosis of the described malformation due to the rare anomalous mutual arrangement of the anatomical structures. Conclusion. Detailed segmental analysis during echocardiography immediately after birth reveals the main diagnostic marker of criss-cross syndrome – inability to simultaneously visualize all four heart chambers and both atrioventricular valves from a four-chamber position.

LONG-TERM RESULTS OF SURGICAL TREATMENT OF PATIENTS WITH PROXIMAL HUMERUS FRACTURE

The aim of the study – evaluation of the surgical treatment effectiveness of fractures inthe proximal metaepiphysis of the humerus, the analysis and generalization of the surgerylong-term results of the surgical intervention.Materials and methods. The study has examined and analyzed the results of surgicaltreatment of the proximal humerus fractures in 76 patients who were treated in thetraumatology department of the regional municipal institution «Chernivtsi EmergencyHospital» in the period from 2015-2020. The average age of patients was 52 years old.The results of treatment were evaluated clinically, radiologically and by questionnaire(according to the QuickDASH scale) for 1 year after osteosynthesis. In order toeliminate the influence of individual, age and gender factors, the results of treatmentof the injured limb were compared with the function of a healthy limb of the patient.The QuickDASH scale (brief scale for assessing the inability to use the upper limb)consists of 11 questions that are offered to the patient. The answer to each questionis rated from 0 (best result) to 5 (worst). Using a special formula, the total result iscalculated, which can range from 0 (no violations) to 100 (complete inability to usethe limb). The QuickDASH scale is a brief version of the DASH scale that retains therepresentativeness of the full version.Results. It has been established that the choice of different methods of surgicalinterventions for fractures of the proximal humerus requires consideration of variousfactors, including the patient’s age, type of fracture, the presence of comorbidities,osteoporosis and the patient’s social needs. It has been shown that the long-termconsequences of surgical interventions may also be due to those factors. A methodfor ensuring stable fixation of fragments, which involves holding the spokes throughthree points: acromion-bone fragment- distal metaepiphysis of the humerus, has beenproposed and described.Conclusions. The tactics of surgical treatment of patients with the proximal humerusfractures depends on many factors, including: type of fracture, age of the patient, thepresence of comorbidities, the presence of osteoporosis and social needs of the patient.Closed reposition under the control of EOA (Electron- optical X-ray image amplifier) andfixation with needles allows to improve the results of treatment and reduce the duration ofdisability. Long-term results of treatment of patients with the proximal humerus fractureshave shown that closed reposition and fixation of fractures with needles leads to bettertreatment results compared to bone osteosynthesis.

Possibilities of Ultrasound Examination in the Assessment of Age-Related Changes in the Soft Tissues of the Face and Neck: A Review

Purpose. The ultrasound imaging of the soft tissues of the face and neck in the vertical position of the patient and determining the degree of participation of each of them in the age-related changes in the contours of the face and neck. Methods. In this review, we discuss the ultrasound anatomy of the soft tissues of the face and neck, the importance of ultrasound for planning surgical treatment, and the results of clinical studies that report ultrasound imaging of the soft tissues of the cervicofacial region. Results. Ultrasound imaging allows for the determination of the causes of age-related changes in the contours of the soft tissues of the cervicofacial region as well as determining the further tactics of surgical treatment. Ultrasound results help the plastic surgeon at all stages of treatment including intraoperative evaluation of the effectiveness of correction. Conclusions. A review of the literature has shown the need for wider use of ultrasound in aesthetic surgery as an important diagnostic procedure that should be performed with the upright position of the patient that allows for an objective assessment of the degree of participation of each of the tissues (skin, adipose tissue, muscles, submandibular salivary glands, etc.) in the formation of age-related changes in the face and neck.