Objective. To evaluate the effect of neodymium laser application for successful decannulation in infants with a congenital and acquired tracheal stenosis and tracheostomy. Methods. 6 children were being treated in the 1^st City Clinical Hospital of Minsk in 2011-2014. All children underwent tracheostomy with a prolonged tracheal intubation and subsequent development of tracheostenosis. The children were examined using X-ray, esophagogastroscopy (PentaxEG-16K10), and bronchoscopy (Olympus MAF TYPE GM). Tracheal stenosis was treated using a medical multifunctional laser complex Multiline (“Linline Medical systems” Ltd, Belarus) equipped with a high-energy neodymium laser emitter. Children with excessive growth of granulations in thelumenof thetrachea underwent vaporization of granulations by means of a bulbous probe with a neodymium laser emitter (wavelength of 1340 nm, power: 15 W, 2 sec. exposure). In cicatricial tracheal stenosis, incisions were made with a laser scalpel (the wavelength of 1064 nm, power of 20 W). Results. Effective decannulation was observed in 5 children, including 4 children who underwent3-5 treatment sessions. In 1 child with the congenital subglottic larynx stenosis, to perform the decannulation became possible after 2 years and 24 sessions of laser recanalizationofstenosis and ablation of granulations. One child, after 9 treatment sessions, dropped out of observation, the result has not been defined. Conclusion. Tracheostomy in children promotes the formation of granulations in the tracheal lumen with the formation of stenosis, which subsequently hinders a successful decannulation. The neodymium laser application with the endoscopic access provides the visual direct approach to the focus of impact with the aim of laser-induced vaporization of soft tissues and recanalization of the trachealmass in children with short tracheal stenosis leads to successful decannulation. What this paper adds Firstly the neodymium laser for the treatment of congenital and acquired tracheal stenosis in children after tracheotomy has been used. The method has been developed for restoring the tracheal lumen by laser-inducedvaporization of excessive tracheal granulation and making scalpel incisions in the scar area. It is shown the neodymium laser application with the endoscopic access provides the visual direct approach to the focus of impact. Laser-induced vaporization of soft tissues and recanalization of the tracheal lumen in children with short tracheal stenosis leads to successful decannulation.

Objective. To clarify the topographic and anatomical feature of the perforating veins (PVs) in the proximal part of the lower extremity. Methods. 70 amputated lower extremities from the patients with severe ischemia were subjected to sectional anatomical study; 2800 patients with varicose disease underwent lower extremity sonography. Results. PVs were primarily located on the medial surface of the thigh. In the upper third of the thigh PVs drain into superficial femoral vein. It was detected that one or two PVs occur sin the lower third of the hip draining into superficial femoral vein and originating from the great saphenous vein in 73.6% cases. All PVs were accompanied by an arterial branch from the superficial femoral artery. Anatomical sectional study revealed that a nervous branch accompanied PVs in the lower third of the thigh. Two or four PVs were detected on the lateral surface of the thigh. PVs in the popliteal fossa could be referred to as “atypical” due to their rare occurence (0.4% of cases at sonography) in combination with absent typical sapheno-popliteal junction. PVs in this area were not supported by the intermuscular septa. PVs drained laterally into popliteal vein of the lower limb in 100% cases, while small saphenous vein drained into great saphenous vein in the upper third of the leg or into the intersaphenous vein. Conclusion. Perforating veins constitute perforating bundles (PV, arterial branch, nervous branch), which are predominantly located along the intermuscular septa, which create a constant and strong orientation along the direction of the great vessels. This ensures stable hemodynamics of great vessels and perforating complexes and does not allow squeezed tham togeter during physical exertion. What this paper adds For the first time it has been proved that the perforating veins of the gluteal region pass through the fascia and the thickness of the gluteus maximus muscle and enter the superior and inferior gluteal veins, being transmuscular perforating veins. For the first time it has been established that the location of the femoral perforating veins along the intermuscular septa allows preserving the hemodynamics of the perforating complexes without any squeezed in physical exertion.

In spite of a high informative value, spiral computed tomography is currently an additional optional examination and it is not included in domestic and foreign preoperative examination protocols. Purpose – assessing the feasibility of spiral computed tomography in the complex of presurgery examination of patients with ventral hernias. Materials and methods. The paper deals with analyzing the diagnostic findings of 35 patients with ventral hernias treated at Surgery Department of Municipal Non-Commercial Enterprise of Kharkiv Regional Council “Regional Clinical Hospital” during 2018–2019 period. All patients were operated on after compulsory and additional examinations according to the existing guidelines. Spiral computed tomography was an additional examination for all patients. The frequency of symptoms detected by means of computed tomography and confirmed during surgery was analyzed.  Results. Most of the signs revealed during tomography and associated with the combined abdominal pathology, were completely confirmed by laparoscopic exploration of the abdominal cavity and pelvis. Spiral computed tomography was of particular value in patients clinically diagnosed with chronic appendicitis. When assessing the ventral hernia, it was possible not only to clearly determine its content and location towards the abdominal line, but also, before surgery, to calculate the width and length of the hernia gate and the volume of the organs in hernia sac. Unlike ultrasonography, computed tomography makes it possible to thoroughly evaluate the dimensions of the hernia gate and the state of the muscular aponeurotic layer of the anterior abdominal wall. Not least important is diagnosing the combined abdominal pathology, including the oncological one, which has no clinical manifestations but still has to be exposed to surgery. Conclusions. In the complex of preoperative examination of patients with ventral hernias, spiral computed tomography provides useful information on the anatomical features of ventral hernia and the combined abdominal pathology that requires surgical intervention. These data aid in planning a favorable type of hernioplasty of ventral hernia and simultaneous surgery. Spiral computed tomography is recommended to be added to the standard protocol of presurgery examination of patients with ventral hernias.

Objective. To determine the possible triggering mechanism for the development and manifestation of acute suppurative cholangitis based on the study of the rheological, physical and chemical properties of bile. Methods. The bile of choledoch was studied inpatients (n=41) with calculous obstruction of the biliary tract, 25 of them had clinical picture of cholangitis. For comparison, 32 patients with asymptomatic choledocholithiasis were examined. Bile sampling was performed in each patient twice: the first bile intake was obtained during duodenoscopy and cannulation of the major papilla of the duodenum and endoscopic papillosphincterotomy and the second portion - during a follow-up examination three days after the endoscopic papillotomy. The biliary pH, viscosity, the amount of solids in it, the concentration of primary bile acids, microbial contamination and the intraductal pressure were studied. Results. For the first time, it has been hypothesized that a reduced concentration of bile acids in the bile causes a subsequent chain of triggering and manifestation of acute cholangitis. In the first bile intake the concentration of bile acids is three fold decreased in patients with acute cholangitis in comparison with the patients of control group, and in the second case it reliable increased but was lower than in the control group. It was a small amount of bile acids caused sedimentation of a colloidal bile solution, increased its viscosity and amount of dry sediment, caused precipitation and sludge. This chain process caused the instantaneous inclusion of concretion in sludge and acute obstruction of the choledoch. As a result of bacterial contamination, the microbial dissemination of bile increases by 10³-10⁴ times, the choledoch becomes like an abscess. Endoscopic papillosphincterotomy breaks this chain and surgical management is the definitive mode of treatment for decompression and biliary track sanitation. Conclusion. A decrease of bile acids in the content of the bile causes a chain process of sedimentation, the formation of sludge and a complete block of the choledoch, which is the primary trigger for cholangitis. What this paper adds Scientific and theoretical principles which in their essencedetermine the possible mechanism of the development of cholangitis due to choledocholithiasis have been developed. The physicochemical properties of bile play a decisive role in the triggering mechanism of cholangitis. Reduction of the synthesis of bile acids in the liver or their resorption in the intestine starts an avalanche-like process of sedimentation in the micellar solution of bile in the choledoch, sludge with the stones appears, the pH decreases, intraductal pressure rises, as a result of bacterial infection microbial contamination the microbal dissemination increases by 10³-10⁴ fold.

The articles published under CC BY NC-ND license Цель. Усовершенствовать хирургическое лечение пациентов с холангиогенными абсцессами печени при помощи внедрения миниинвазивных технологий.Материал и методы. В представленном исследовании приведены результаты лечения 49 пациентов с абсцессами печени билиарной этиологии. Среди них были 31 женщина и 18 мужчин в возрасте от 37 до 69 лет. Хирургические вмешательства по поводу печеночных абсцессов проводились одновременно с устранением первичного патологического процесса желчевыводящей системы, который стал причиной возникновения холангита, или в ближайшее время (до 3 суток) после дренирования желчевыводящих путей.Результаты. Дренирование под ультразвуковым контролем выполнено 21 пациенту с одиночными и 7 пациентам с двумя и большим количеством холангиогенных абсцессов печени. Одновременно и абсцесс печени, и желчный проток дренированы 8 пациентам в условиях рентгенологической операционной. Лапароскопические вмешательства проведены 21 пациенту.Среди пациентов, оперированных с применением миниинвазивных технологий, возникло 7 осложнений (14,3%): у 2 пациентов -желчеистечение, у 1 -правосторонний гидроторакс, у 1 -правосторонняя эмпиема плевры, у 1 -нагноение послеоперационной раны и у 2 остались конкременты в общем желчном протоке. Умер 1 пациент (2,0%) вследствие развития сепсиса при обструкции желчных путей злокачественной этиологии.Заключение. Чрескожное дренирование абсцессов печени под ультразвуковым контролем целесообразно проводить не только при одиночных абсцессах, но и при их большем количестве. Доказана возможность одновременного дренирования абсцесса печени и желчного протока. Чрескожное дренирование абсцесса печени, дренирование желчевыводящих путей и лапароскопическое хирургическое вмешательство являются взаимодополняющими составными компонентами миниинвазивного хирургического вмешательства при лечении абсцессов печени билиарного происхождения. При локализации абсцессов в краевых сегментах печени наиболее целесообразна лапароскопическая атипичная резекция печени с абсцессом.Ключевые слова: абсцесс печени, холангит, миниинвазивные процедуры, билиарное дренирование, дренирование абсцесса печени Objective. To improve surgical treatment of patients with the liver cholangiogenic abscesses of liver through the introduction of minimally invasive technologies.Methods. In the proposed study the treatment results of 49 patients with biliary liver abscesses are presented. There were 31 women and 18 men aged 37 to 69 years. Surgical interventions for hepatic abscesses were performed simultaneously with the elimination of the primary pathological process of the biliary system, which caused the occurrence of cholangitis or in the near future (up to 3 days) after biliary drainage.Results. Drainage under ultrasound guidance was performed in 21 patients with single and 7 patients with two or more cholangiogenic liver abscesses. At the same time, liver abscess and bile duct were drained in 8 patients in the x-ray operating room. Laparoscopic interventions were performed in 21...

Objective. To determine the possibility of using automatic plasmapheresis in patients with COVID-19- associated bilateral polysegmental pneumonia. Methods. The treatment of three patients with COVID-19-associated pneumonia with application of the Autopheresis-C™ automatic plasmapheresis machine (the USA) has been analyzed. The patients’ age was 47. 49 and 55 years. The patients’ case histories included factors aggravating the course of pneumonia (diabetes mellitus, chronic cardiovascular pathology with heart failure, obesity). The condition of all patients was severe. The effectiveness estimation of the given technique was carried out 6 hours after the manipulation and included a general clinical blood test, a biochemical blood test, hemodynamic parameters, and objective data. Results. After the first application of automatic plasmapheresis, all patients occurred a decrease in temperature and the level of respiratory failure, which was accompanied by an increase in hemoglobin saturation; a decrease in the severity of dyspnea was also reported, which was the reason for the changing patient position from prone to supine. All patients had a blood pressure reduction. Positive changes in the hemodynamic situation were the basis for reducing the dosage of antihypertensive drugs. Along with this, in the course of manipulation, a gradual decrease in the severity of tachycardia was noted in all patients: a reduction of heart rate was recorded. On the second day after the manipulation, the main blood parameters (leukocytosis, c-reactive protein) decreased. The observed positive effects contributed to the early transfer (by 10-15 days) of patients from the intensive care unit to the general somatic departments. Conclusion. The early inclusion of automatic plasmapheresis in the complex therapy of patients with COVID-19- associated bilateral polysegmental pneumonia leads to the stabilization of hemodynamic parameters, decline of the severity of respiratory failure, which made it possible to avoid the mechanical ventilation. What this paper adds For the first time, the clinical effectiveness of the method of automatic plasmapheresis in the framework of the complex therapy of COVID-19- associated polysegmental pneumonia is shown, which is expressed in a decrease in the manifestations of functional and metabolic disorders of vital systems for maintaining homeostasis. It was found that the inclusion of this technology in the complex therapy contributed to the stabilization of respiratory and hemodynamic parameters, which made it possible to avoid the mechanical ventilation.

Ключові слова: гострий холангіт, папілярний стеноз, аденома великого сосочка дванадцятипалої кишки, парапапілярні поліпи, парапапілярний дивертикул, парапапілярна виразка дванадцятипалої кишки. Мета роботи -удосконалити методи хірургічного лікування гострого холангіту, викликаного доброякісними утвореннями в ділянці великого дуоденального сосочка. Матеріал і методи. Проведений аналіз хірургічного лікування 83 хворих на гострий холангіт, викликаний доброякісними утвореннями в ділянці великого сосочка дванадцятипалої кишки. Серед них чоловіків було 49, жінок -34. Середній вік пацієнтів становив (49,7±6,9) років. За нозологічними формами розподіл хворих проведений таким чином: папілярний стеноз -51, аденома великого сосочка дванадцятипалої кишки -13, парапапілярні поліпи дванадцятипалої кишки -12, дивертикули дванадцятипалої кишки в ділянці великого дуоденального сосочка -5, виразкова хвороба дванадцятипалої кишки -2. Результати. Гострий холангіт при папілярному стенозі, аденомі великого сосочка дванадцятипалої кишки, парапапілярних поліпах усунений за допомогою ендоскопічних трансдуоденальних методик із видаленням безпосередньої причини виникнення гострого холангіту. Для цього застосовані ендоскопічна папілосфінктеротомія, ендоскопічна механічна літотрипсія, літоекстракція, електроексцизія поліпів та аденом. Із 83 пацієнтів, 19 (22,9%) виконано дві та більше ендоскопічних транспапілярних втручань. Найбільші труднощі виникли при канюляції великого дуоденального сосочка у пацієнтів із парапапілярними виразками та дивертикулами дванадцятипалої кишки. Двом хворим проведені лапароскопічні та ще двом пацієнтам виконані «відкриті» хірургічні втручання. Серед 83 пролікованих пацієнтів із гострим холангітом на фоні доброякісної патології великого сосочка дванадцятипалої кишки в 11 (13,3%) виникли різного роду ускладнення. Висновки. Гострий холангіт при папілярному стенозі, аденомі великого дуоденального сосочка та парапапілярні поліпи із супутнім холедохолітіазом може бути цілком пролікований виключно за допомогою ендоскопічних втручань (за необхідності -багаторазових) з невеликою кількістю ускладнень (13,3%). Лікування гострого холангіту на фоні парапапілярних виразок та дивертикулів дванадцятипалої кишки в більшості випадків потребує застосування не тільки ендоскопічних трансдуоденальних методик, а й застосування лапароскопічних біліодренуючих та відкритих резекційних хірургічних втручань.

Комунальний заклад охорони здоров'я «Обласна клінічна лікарня -центр екстреної медичної допомоги та медицини катастроф», Харків, Україна valery_vals@ukr.net