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In memory of academician V.G. Savchenko, who made an invaluable contribution to the development of the program bone marrow transplants both in Russia and in the Samara region.

The paper is devoted to determining the frequency, features of the clinical course and technique of safe thyroidectomy in patients with retrosternal goiter. Materials and methods. We analyzed the treatment of 26 patients with retrosternal goiter. All patients underwent the neck-approach thyroidectomy with the identification of the recurrent laryngeal nerve during surgery. Results. It was found that patients with Graves’ disease did not have retrosternal goiter, with mixed toxic goiter the frequency was 13.7%, with nodular euthyroid goiter – 26.1%. In 11.5% of patients with retrosternal goiter, the diagnosis was made by chest x-ray, in 76.9% - by ultrasound imaging, in 19.2% - by CT imaging. Of the 26 patients, 1 (3.8%) was hospitalized urgently due to respiratory failure and compression syndrome, and 25 (96.2%) were admitted as planned. Operations in 25 (96.2%) were performed under endotracheal, in 1(3.8%) – under mask anesthesia. Intraoperatively, it was found that the location of the recurrent laryngeal nerve changed in the case of chest goiter that required special care when mobilizing the posterior surface of the thyroid gland from the trachea in the zone of the lower thyroid artery and in Berry ligament. Technical manipulations aimed at preventing damage to the recurrent laryngeal nerve at different stages of thyroidectomy are proposed. Conclusion. The results of operations in patients with substernal goiter show that if it is carefully performed and the recurrent laryngeal nerve is preserved, the postoperative period does not differ from that in the usual location of the thyroid gland and even relieves, since the compression syndrome is eliminated.

Objectives - to improve the surgical treatment results in patients with injuries of the esophagus after the elimination of deformation of a vertebral column with metal devices. Material and methods. From 2001 to 2018 we treated 17 patients with esophageal injury appeared as a result of cervical vertebras fixation with metal devices - in 12 patients to correct their instability due to the traumatic compression fractures and in 5 patients having the herniated discs with the spinal channel compression. 12 patients underwent the urgent operation, 5 patients - the delayed or planned one. Three mechanisms of esophageal injury were defined: 5 patients had the first type of injury, 8 - the second type, 4 - the third type. The patients were operated on after the diagnosis confirmation. The operation was aimed at the removal of the metal device from the collum and the closure of the esophagus wall defect. Tactics of treatment of the esophageal injuries depended on the alterations in its paries, the size of the defect, the nature of the trauma and the mediastinitis prevalence. In 8 patients the primary suture of the esophagus was applied. In 9 patients with decubituses of the esophagus and the large size of the defect we applied the partial suturing of the defect and the transesophageal drainage of the fistula and mediastinum, strengthening the injured zone with a muscle on the pedicle. Results. First intention healing was achieved in 5 patients of the 8 ones who underwent the esophagus wall suturing without a fistula transesophageal drainage. The partial suture incompetence occurred in 3 cases and it required the transesophageal drainage through the defect in the esophagus wall. The external tubular esophageal fistula formed in 12 patients. After the drainage removal the fistula closed in 10 cases. One of the 17 patients died of the multiple organ failure and sepsis. Conclusion. Injuries of the esophagus caused by the metal devices fixing the unstable vertebras have the clinical features depending on the installation time. The suturing of the esophageal defect and the suture strengthening m. sternocleidomastoideus on the pedicle supplemented by a through lumenal transesophageal drainage have advantage in comparison with the esophageal wall suturing without drainage.

Objectives - to improve the treatment results in patients with a closed chest injury complicated by the flail chest through the evaluation of the pathomorphological changes in the fracture sites on the background of their stabilization. Material and methods. The study is based on the autopsy protocols of 402 victims, whose primary cause of death was a closed chest injury with multiple rib fractures. In total 289 histological specimens were studied, including 82 samples taken from the rib fractures zones of the persons with a flail chest died in different periods after the injury. Depending on the time passed from the injury till death, there were identified 5 groups of patients. So It was possible to reveal the consistency of the evolution of morphological changes in the zone of rib fractures on the 1st, 2nd, 5th, 14th, and 21st day after the injury, with preserved breathing without stabilizing the rib cage. Results. We found out that on the 1st, 2nd, 5th day there were no morphologically significant changes in the fracture zone, aimed at its stabilization. With breathing preserved for more than 5 days, there was a delay in the primary callus formation and enhanced bone resorption in the fracture site. Osteoblasts activation, which manifests the proliferation of cellular elements in fragmentary rib fractures, occurred 7-9 days later than in a single fracture. It was conditioned by the persistent "floating" of the rib fragments which impacted the newly formed trabeculae of bone and forced them to rearrange twice during the bony callus formation. The increased time of the rib fractures repair aggravated the lung injury, contributed to the development of pneumonia and purulent-septic complications detected posthumously which, in their turn, were the primary cause of deaths. Conclusion. In 17.4% of victims with severe chest injury and flail chest the death is conditionally preventable. The crucial requirement of the effective treatment of patients with the thoracic trauma and flail chest is the usage of various methods of the thoracic cage stabilization.

Objectives - to improve treatment results in patients with ventral hernia and the concurrent surgical diseases by means of the designed surgery tactics. Material and methods. The treatment of 834 patients with ventral hernia, aged from 18 up to 82 years, was analyzed. The group consisted of 196 men (23.5%) and 638 women (76.5%). According to the European Hernia Society (EHS) classification of postoperative ventral hernias the gate types were distributed in patients as follows: W1 - in 132 patients (15.8%), W2 - in 397 (47.6%), W3 - in 305 (36.6%), in 243 (29.1%) cases the hernias were recurrent. 394 (47.2%) patients had 597 simultaneous interventions. The treatment tactics for the patients with hernias and associated diseases was defined according to the designed classification. For the abdominal wall repair the 2 variants of the "tension-free" mesh repair technique were used. Results. Forced simultaneous interventions were performed in 34 patients when the intestinal loops adherent to the scar were situated in the hernia sac. In 27 cases the postoperative ventral hernia was combined to the intestinal fistulas, located out of the hernia area. 12 patients underwent herniolaparotomy conditioned by the intra-abdominal intestinal fistulas closure and small hernias size. To prevent the compartment syndrome in 3 patients with splanchnoptosis the right part of the colon was resected. 103 patients had the planned simultaneous operations including the laparoscopic cholecystectomy in 19 cases, 114 patients underwent the panniculectomy. The preventional appendectomy was performed in patients with the recurrent large hernias. In 140 cases the omentum resection was done due to the signs of the chronical strangulation and omentitis. Postoperative pulmonary artery thromboembolia was the death cause for 3 (0.4%) patients. Only 8 (0.9%) patients suffered the partial hernia recurrence. Conclusion. In patients with hernias the simultaneous operations are conditioned by the pathogenesis and do not affect the severity and frequency of wound complications in the postoperative period. A condition for the simultaneous interventions in patients with hernias is the necessary implementation of the combined techniques of the ventral tension-free mesh hernioplasty.

Introduction Severe chest injury with associated trauma to the rib cage, hemothorax, contusion of the lung, heart, ruptures of the mediastinal vessels,diaphragm is an important cause of morbidity and mortality in patients with polytrauma. Methods An algorithm for the examination and treatment of patients with severe chest trauma was developed, and new methods of treatment protected by 5 patents proposed. Results We report outcomes of 29 patients with multiple floating fractures of the rib cage which were stabilized, reduced and repaired with devices and frames developed by the authors. Discussion Less traumatic methods of costosternal stabilization of multiple chest injury have shown to be effective in stabilization of patients’ condition, improvement of pain, respiratory function properly maintaining the reduced bone.

To analyze clinical course and develop surgical technique for thoracoabdominal hernia in patients after previous sterno-mediastinitis.There were 7 (20%) patients aged 53-69 years with thoracoabdominal hernia after previous cardiac surgery followed by postoperative sterno-mediastinitis. Thoracoomentoplasty was used for treatment of this complication. There were 2 males and 5 females.All patients underwent surgery aimed at translocation of the organs from mediastinum to abdominal cavity, restoring normal anatomical location of stomach, transverse colon and large omentum, stabilizing the thorax and closing the defects in the diaphragm and anterior abdominal wall.Surgical indications are justified by stomach and transverse colon dysfunction due to their displacement to the mediastinum with threat of strangulation, cardiac compression by hernial sac, as well as chest instability. Combined approach allows to achieve recovery in all patients.Цель исследования - выявить особенности клинического течения и разработать технику оперативного лечения больных торакоабдоминальными грыжами после перенесенного стерномедиастинита. Материал и методы. Обобщен опыт лечения 7 пациентов (2 мужчин, 5 женщин) в возрасте от 53 до 69 лет с торакоабдоминальными грыжами, образовавшимися в результате осложнений после операций, выполненных через стернотомный доступ по поводу ишемической болезни и пороков сердца, которым для купирования стерномедиастинита применяли торакооментопластику. Результаты. Всем пациентам выделили из средостения и переместили в живот желудок, поперечную ободочную кишку и большой сальник, стабилизировали грудную клетку, устранили и закрыли дефекты в диафрагме и в передней брюшной стенке. Выводы. Показания к операции обусловлены нарушениями функции желудка и поперечной ободочной кишки из-за их смещения в средостение с угрозой ущемления органов в грыжевом мешке, постоянного давления содержимого грыжевого мешка на сердце, а также развития нестабильности грудной клетки. Применение комбинированного подхода позволяет добиться выздоровления у всех больных.

To evaluate the features and choice of surgical strategy in patients with gastrointestinal fistula based on classification of their types.There were 398 patients with gastrointestinal fistula. Fistula type 1 was found in 126 (31.7%) cases, type 2 - 38 (9.6%) cases, type 3 - 73 (18.3%) cases, type 4 - 26 (6.5%) patients, type 5 - 135 (33.9%) cases. One-stage and two-stage treatment was applied in patients with fistula type 1, two-stage treatment only - for fistula type 2. In patients with fistula type 3, treatment strategy depended on timing of fistula formation, its level and amount of intestinal chymus loss. In case of fistula type 4, radical treatment is difficult. However, surgery is safer when adhesions between intestinal loops are not yet dense enough. Indeed, dissection is associated with less risk of their damage. Reconstructive procedures were applied for fistula type 5 depending on its localization.The causes of gastrointestinal fistula were complications after surgery for acute ileus in 73 patients (17 ones died), blunt abdominal trauma in 81 (8), open abdominal trauma with cold weapons in 39 (6) and firearms in 11 cases (2), mesenteric thrombosis in 33 patients (8), pancreatic necrosis in 25 cases (9), abdominal hernia in 15 cases (4), acute appendicitis in 40 patients (3), colonic diverticulosis in 24 patients (1), urological diseases in 5 cases, colon perforation by a foreign body in 3 cases, colonoscopy in 5 patients, Hirschsprung's disease in 2 patients, Crohn's disease in 11 cases (3), colon polyps in 4 patients, intestinal tuberculosis in 1 case (1), small bowel resection for obesity in 1 patient and gynecological diseases in 25 patients (2). Fistulas type 1 and 4 were followed by the highest postoperative mortality since these interventions are associated with the most severe changes in abdominal cavity. Low mortality was observed in patients with fistula type 5, no abdominal inflammation and normalized intestinal passage. The overall mortality in patients with gastrointestinal fistulas was 16.1%.Treatment strategy in patients with gastrointestinal fistula primarily depends on the type of fistula that requires emergency, urgent, delayed or reconstructive surgery. Staged approach in patients with gastrointestinal fistulas can improve treatment outcomes.Наиболее часто свищи желудочно-кишечного трата (ЖКТ) формируются на фоне спаечной болезни брюшной полости и острой спаечной кишечной непроходимости. Поэтому операции при них технически сложны и относятся к вмешательствам высокой степени сложности. Систематизация свищей ЖКТ на основе разделения их по этиологии, патогенезу и морфологическим признакам имеет важное значение, но не всегда отвечает требованиям клинических ситуаций. Дополнение классификаций вариантами возможных осложнений при образовании свища ЖКТ позволяет определить тактику лечения и выбор способа операции у больных.Оценка тактики и выбора способа хирургического лечения пациентов со свищами ЖКТ, основанная на их классификации в зависимости от их типа.Работа основана на результатах лечения 398 больных со свищами ЖКТ. Свищи 1-го типа были у 126 (31,7%) больных, 2-го — у 38 (9,6%), 3-го — у 73 (18,3%), 4-го — у 26 (6,5%), 5-го — у 135 (33,9%). При лечении больных со свищами 1-го типа придерживались одноэтапной и двухэтапной тактики лечения. При свищах 2-го типа использовали только двухэтапную тактику лечения. При свищах 3-го типа тактика зависела от сроков образования свища, его уровня и объема потерь кишечного химуса. При свищах 4-го типа радикальное лечение затруднено, но безопаснее выполнять операцию в период, когда сращения между петлями кишечника еще недостаточно плотные, что снижает риск их десерозации и, следовательно, повреждения. Для закрытия свищей 5-го типа выполняли реконструктивно-восстановительные операции, объем которых зависел от уровня расположения свища.Причинами образования свищей ЖКТ были осложнения, развившиеся после операций по поводу острой кишечной непроходимости у 73 (умерли 17) пациентов, закрытой травмы живота у 81 (8), открытой травмы живота холодным оружием у 39 (6) и огнестрельным оружием у 11 (2), мезентериального тромбоза у 33 (8), панкреонекроза у 25 (9), грыжи живота у 15 (4), острого аппендицита у 40 (3), дивертикулеза ободочной кишки у 24 (1), урологических заболеваний у 5, перфорации ободочной кишки инородным телом у 3, при фиброколоноскопии у 5, болезни Гиршпрунга у 2, болезни Крона у 11 (3), полипов толстой кишки у 4, туберкулеза кишечника у 1 (1), резекции тонкой кишки по поводу ожирения у 1, гинекологических заболеваний у 25 (2). Максимальные показатели летальности зафиксированы при свищах 1-го и 4-го типов, так как в этих случаях хирургические вмешательства приходится выполнять при наиболее тяжелых патологических изменениях в брюшной полости. Низкая летальность отмечена у пациентов с 5-м типом свищей, при котором операции выполняют в условиях стихшего воспаления в брюшной полости и разрешившейся острой кишечной непроходимости. Общая летальность у пациентов со свищами ЖКТ при соблюдении предложенной тактики и способов лечения составила 16,1%.Тактика лечения больных со свищами ЖКТ в первую очередь зависит от типа свища, требующего выполнения экстренной, срочной, отсроченной или реконструктивно-восстановительной операции. Соблюдение принципа этапности у больных со свищами ЖКТ позволяет улучшить результаты их лечения.

To evaluate clinical efficacy of combined anterior prosthetic hernia repair in treatment of large and giant ventral hernias.Patients with large and giant hernias have been analyzed. In the main group (n=675) combined methods of hernia gates repair were applied, in control group (n=257) - stretching repair including prosthesis deployment. Surgeons (n=22) were interviewed for learning curve, safety, limitations and reliability of combined methods.Combined method of hernia repair in patients with large and giant hernias reduces overall postoperative morbidity (p0.001), wound complications (p0.05) and incidence of recurrent hernia (p0.001). Questionnaire data showed the possibility of learning for the method by the most of surgeons to treat these patients. As a result, some practical recommendations are presented for successful procedures and satisfactory results of treatment.Цель исследования - провести оценку клинической эффективности передней протезирующей герниопластики комбинированным способом при лечении пациентов с большими и гигантскими грыжами. Материал и методы. Проведен анализ результатов лечения больных с огромными и гигантскими грыжами. В основной группе (n=675) были применены варианты комбинированного способа пластики грыжевых ворот, а в группе сравнения (n=257) - натяжные способы пластики, в том числе с использованием протеза. Среди хирургов (n=22) проведено анкетирование, содержащее вопросы о простоте освоения, безопасности, ограничении и надежности использования комбинированных способов. Получены данные, свидетельствующие, что применение комбинированного способа пластики грыжевых ворот у больных с большими и гигантскими грыжами способствует снижению общих послеоперационных осложнений (р0,001), раневых осложнений (р0,05) и рецидива грыжи (р0,001). Результаты анкетирования показали возможность освоения способа большинством хирургов при лечении данной категории больных. На основании чего изложен ряд практических рекомендаций, позволяющих успешно выполнять его приемы и достичь удовлетворительных результатов лечения.