Aortic esophageal fistula (AEF) is a rare but extremely life-threatening condition requiring immediate surgical treatment. The mortality rate among such patients may exceed 60 %, including after surgical treatment. Etiological and pathogenetic mechanisms of AEF are complex and various, but in most cases, they are associated with chronic aortic diseases. The second group of etiological factors of AEF includes trauma of esophagus wall by foreign bodies, malignant neoplasms of the esophagus or mediastinum. AEF may also occur as a result of surgical interventions on the aorta and esophagus. The difficulties of early diagnosis are primarily associated with non-specific clinical manifestations of AEF and the lack of unified protocol for the examination of patients with the first-time upper gastrointestinal tract bleeding. The described reasons in some cases can lead to an inaccurate diagnosis, which entails a loss of time. Among the instrumental diagnostic methods, the most informative is the combination of esophagogastroduodenoscopy and computed tomography of the chest with intravenous contrast enhancement. Each of these methods has its advantages and disadvantages, and allows to identify a number of direct and indirect signs of pathological communication between the aorta and the esophagus.
We report a rare clinical case of spontaneous rupture of the aneurysm left gastroepiploic artery with life-threatening intra-abdominal haemorrhage.Authors declare lack of the conflicts of interests.
Research Institute of emergency medicine named after N.V. Sklifosofskiy Представлен анализ результатов использования фибробронхоскопии у больных с закрытой сочетанной травмой груди. Исследование показало, что у 51,6% пациентов закрытая травма груди сопровождается множественными переломами ребер с одной или обеих сторон с наличием гидро-, пневмоторакса или их сочетанием. Это значительно затрудняет рентгенологическую диагностику внутрилегочных повреждений. Фибробронхоскопия (ФБС) является прямым методом диагностики повреждения бронхов и легких, что подтверждается совпадением данных ФБС с интраоперационными на-ходками и результатами аутопсии и влияет на выбор хирургической тактики. Однако информативность однократного эндоскопического исследования при травматических разрывах бронхов на фоне продолжающегося легочного кровоте-чения недостаточно высока. Одновременно ФБС является и лечебным мероприятием, которое позволяет в большинстве случаев добиться уменьшения интенсивности легочного кровотечения вплоть до полной его остановки.
Ключевые слова: закрытая травма груди, диагностика, фибробронхоскопия.Analysis of the results of fibrobronchoscopy in patients with concomitant closed chest trauma is presented. The study showed that in 51.6% of cases closed chest trauma is accompanied by multiple fractured ribs on one or both sides with the presence of hydro-, pneumothorax, or a combination of them. This greatly complicates radiological diagnosis of pulmonary lesions. Fibrobronchoscopy is a direct method of diagnosis of bronchi and lungs injury that is proved by conjunction of fibrobronchoscopic data with intraoperative findings and autopsy results and affects on the choice of surgical approach. However, sensitivity of single endoscopy for traumatic bronchi rupture is low because of ongoing pulmonary hemorrhage. Along with that fibrobronchoscopy is a therapeutic procedure that allows in majority of cases obtaining reduction of the intensity of pulmonary hemorrhage up to its arrest.
Rationale. Lung transplantation is the only definitive treatment in end-stage pulmonary disease. Extracorporeal membrane oxygenation (ECMO) has been used during surgery in recent years as a replacement for respiratory function; ECMO, however, has some drawbacks: the presence of an extracorporeal circuit, the need for heparinization, potential thrombogenicity that underlies the risks of developing specific complications that worsen the transplantation prognosis. In this regard, it is relevant to study the factors that make it possible to predict the need in intraoperative ECMO in order to avoid its unjustified use.Purpose. To identify predictors for intraoperative use of ECMO in lung transplantation.Material and methods. The medical records of patients who underwent lung transplantation in the Sklifosovsky Research Institute for Emergency Medicine from May 2011 to July 2017 were retrospectively reviewed. Forty nine bilateral lung transplantations were made where 15 patients (30.6%) had lung transplantation performed without ECMO, and 34 (69.4%) underwent lung transplantation and ECMO. A central veno-arterial connection was used in all patients. The study analyzed various factors of patient condition at baseline and identified the most significant of them that enabled to predict the need of ECMO use at surgery with a high degree of probability, avoiding episodes of gas exchange and hemodynamic impairments, the prolongation of surgery, and, therefore, the graft ischemia time.Results. As assessed in this study, pulmonary hypertension was the only predictor of an increased likelihood of using ECMO. The probability of connection to ECMO statistically significantly increased in the patients with systolic pulmonary artery pressure higher 50 mm Hg (p<0.05).Conclusion. The presence of pulmonary hypertension > 50 mm Hg determines the preventive use of ECMO during lung transplantation, which should reduce the number of uncontrolled emergencies during the main stages of surgical intervention; in all other cases, ECMO should be connected basing either on the pulmonary artery compression test results or when indicated.
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