Ambulatornaya khirurgiya = Ambulatory Surgery (Russia)
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Discussion on the issue of primacy of the lower extremities varicosity and knee osteoarthritis
Comments on the published case report of surgical treatment of arteriovenous malformation of the index finger of the hand
Medical ward: Strategies for responding to patient grievances
Fixed-dose ruscus extract combination and its place in current clinical guidelines for the treatment of chronic venous diseases
Chronic venous diseases (CVD) is the most common lower extremity vascular pathology. Various vein-specific symptoms and syndromes associated with CVD negatively affect all components of the quality of life in the modern society. The appearance and development of vein-specific symptoms have been proven to be associated with C-nociceptor irritation evoked by the so-called algogens – biologically active substances occurred due to vascular inflammation and endothelial dysfunction along with local temperature elevation and intravenous pressure. Endothelial dysfunction in CVD is mainly due to phlebostasis with a decrease in shear stress, leading to hypoxia of endothelial cells. Further, a multi-stage mechanism of leukocyte-endothelial interaction is activated, which results in the development of venous microangiopathy at the microcirculatory level, as well as the valve apparatus injury and varicose transformation of the principal superficial veins at the macrocirculatory level. It is evident that suppression of the leukocyte-endothelial inflammatory reaction not only leads to a reduction or relief of vein-specific symptoms, but also prevents macro- and microcirculatory disorders. In this regard, the so-called phlebotropic, or venoactive, pharmacological drugs targeting different pathogenetic mechanisms of development and progression of CVD present great interest. In this case, despite the common to this group of drugs phleboprotective effect, the specific mechanisms for achieving it may have significant differences in various venoactive agents. In this review, we discuss the main indications and instructions for the use of phlebotropic drugs in patients with CVD, drawing on the most established international and Russian clinical guidelines.
Hemodynamic sclerotherapy in comprehensive management of varicose disease of lower-limb veins in patients with morbid obesity
Introduction. Endovenous laser ablation combined with sclerotherapy are effective treatment options for varicose veins of the lower limb. However, sclerotherapy is associated with an increased risk of side effects in patients with morbid obesity, which makes it challenging. Aim. To improve efficiency of the varicose veins of the lower limb treatment in patients with morbid obesity by using the aspects of “hemodynamic sclerotherapy”. Materials and methods. Prospective comparative study included 109 patients with C3–C5 classes of chronic venous diseases and morbid obesity was performed. All patients were treated with endovenous laser ablation combined with sclerotherapy. In the main group (n = 56) sclerotherapy was performed in the Trendelenburg position, in the control group (n = 53) – in the horizontal position. Results. The diameter reduction of the great saphenous vein by 22.5% in the Trendelenburg position with 15° incline was statically significant (p < 0.001). The perforating veins reflux in the Trendelenburg position with 15° incline was not detected in 72.3% of patients (p < 0.001). The occlusion rates of the varicose tributaries not treated with sclerosant in the main group was 41% (p = 0.032). In the main group only 12.5% of patients were found to have phlebitis (p = 0.029), the Visual Analog Score (p = 0.036) and local temperature (p = 0.049) were also significantly lower. The incomplete occlusion rate of the varicose tributaries in the main group was only 5.3%; however, the difference was not statically significant. Discussion. The perforating veins reflux in the Trendelenburg position and the incomplete occlusion of the varicose tributaries were only in obese patients with body mass index more than 55 kg/m2 and C4b–C5 classes. Conclusions. Sclerotherapy in the Trendelenburg position with the legs elevated at least 15° incline improves the efficiency of the varicose vein’s occlusion in patients with morbid obesity. Sclerotherapy in obese patients with body mass index more than 55 kg/m2 has less effect.
Efficacy and safety of cava filters in patients with an extremely high risk of venous thromboembolic complications
Introduction. In clinical practice, there are special situations when adequate anticoagulant therapy cannot be prescribed or does not prevent recurrence of PE. In such cases, the implantation of a cava filter seems to be the optimal treatment strategy, but the clinical efficacy and range of possible side effects of these devices remain unclear. Aim. To evaluate the effectiveness and safety of implantation of cava filters into the inferior vena cava for the prevention of PE. Materials and methods. The study included 530 patients with deep vein thrombosis of the lower extremities and an extremely high risk of PE in the period from 2008 to 2024. The CVF group consisted of 278 patients who had a cava filter implanted in the inferior vena cava, and the non-CVF group consisted of 252 patients who refused CVF implantation but had indications for its implantation. The primary endpoints of the study were death from any cause, confirmed PE with clinical manifestations, large or moderate bleeding, and the development of inferior vena cava syndrome. The secondary point in the CVF group was an embolism in the cava filter according to ultrasound examination. Results. There were no significant differences between the groups in terms of clinical and demographic indicators, primary endpoints. The frequency of detection of thrombotic masses in the cava filter at the hospital stage was 23 cases (8.27%). Discussion. When analyzing the Recommendations, CVF implantation in NSAIDs is recommended to be considered in special cases, however, according to the instructions of the ACCP, AHA and BSH, there are no indications for CVF implantation in all patients with DVT and/or PE who may be prescribed anticoagulant therapy. Conclusion. Any implantation of a cava filter, as a potentially unsafe device, should be carried out only after the decision of a multidisciplinary consultation.
The use of echoscleroobliteration in patients with recurrent varicose veins
Introduction. Currently, surgeons are increasingly using endovasal treatment methods to treat patients with recurrent varicose veins. The most common method of eliminating recurrent varicose veins is echosclerobliteration. The question of the isolated use of echoscleroobliteration in patients with recurrent varicose veins remains unexplored. Aim. To develop an algorithm for the optimal use of echosclerobliteration of recurrent veins and to improve the results of treatment of patients with recurrent varicose veins. Materials and methods. Puncture echosclerobliteration was performed in 67 patients with relapses of varicose veins with clinical class C2, C3, C4 according to the CEAR classification. Among them there were 46 (68.7%) women and 21 (31.3%) men aged 21 to 79 years. Results. The feasibility of echosclerobliteration of recurrent veins was 100%, the average course of treatment consisted of 2.5 ± 0.3 sessions. The development of thrombotic complications was observed in 10 (14.9%) patients, neurological disorders – in 3 (4.5%), hyperpigmentation – in 16 (23.9%), secondary telangiectasia – in 11 (16.4%). After 2 years, a recurrence of the disease was detected in 5 (7.5%) patients. In the process of dynamic follow-up, all patients after echosclerotherapy showed a decrease in the clinical manifestations of varicose veins by 4.3–82.1%, an improvement in all quality oflife factors by 12.1–24.8%. Discussion. The use of echoscleroobliteration in patients with recurrent varicose veins allows achieving good clinical results, reliable obliteration of recurrent veins was achieved in 62 (92.5%) patients after 2 years, and the positive dynamics of all quality oflife factors 1 year after treatment was 12.1–24.8%. Conclusion. The use of echoscleroobliteration allows to provide a good clinical, cosmetic result of treatment, to improve the quality of life in patients with recurrent varicose veins.
The role of the micronized purified flavonoid fraction drug in lower extremities chronic vein diseases treatment
Chronic venous diseases of the lower extremities, including varicose veins, are one of the most common pathologies in modern society, affecting up to 73% of women and up to 56% of men. Despite significant advances in surgical treatment, the role of conservative therapy in the treatment of this disease does not diminish. The main group of drugs used in the conservative treatment of venous pathology are the so-called phlebotropic drugs, which are a fairly diverse group of medications of both natural and synthetic origin. One of the leading places among phlebotropic drugs is occupied by micronized purified flavonoid fraction, which is a venoactive drug consisting of diosmin 900 mg and flavonoids, in terms of hesperidin 100 mg. The effectiveness of micronized purified flavonoid fraction in relation to venous symptoms, including pain, heaviness, edema, trophic disorders and others has been demonstrated in many studies. When using MPFF, venous trophic ulcers healed faster and more frequently than in the control group without the drug. The drug was effective in patients who received invasive treatment for varicose veins, both sclerotherapy and open and endovascular interventions. The drug also proved itself in patients with various comorbid disorders, such as phlebogonarthrosis. There is a significant amount of data demonstrating the effectiveness of MPFF in pelvic varicose veins. Currently, in addition to the original drug, there are 4 generics on the market, to which, according to the current point of view, the effects proven in the study of the original drug cannot be transferred. However, the drug Detravenol in a comparative study demonstrated the same efficacy and safety profile as the original drug. This gives our patients the opportunity to choose between the original and the reproduced drug.
Venous foot pump: A literature review and commentaries
The growing interest in chronic venous diseases of the extremities reflects their increasing prevalence in modern society, particularly among lower socioeconomic groups. Over the past 75 years, significant research has expanded our understanding of venous return physiology within the inferior vena cava system. However, when examining this topic, the understanding of the anatomy and physiology of the venous pump in the lower extremities appears fragmented. Key components are often considered in isolation, leading to an overemphasis on certain structures, such as the musculovenous pump of the calf and the venous valve system, while other essential elements like the venous pump of the foot and the role of fascia are underestimated or overlooked. Moreover, insufficient attention has been given to the interplay between the components of the venous return system and how they integrate into the mechanics of the step cycle. The venous return mechanism is predominantly examined in two scenarios – upright walking andlying down – while the more common body positions in modern industrial society, such assitting and standing, remain inadequately studied. The purpose of this literature review isto synthesize data from domestic and international sources to trace the evolution of concepts surrounding the anatomy and physiology of the foot’s venous pump. It aims to consolidate available information, highlight the significance of the foot venous pump in the overall venous return system, and underscore the connection between venous return function and the mechanics of the step cycle.
Surgical treatment of varicose veins of the lower extremities and the current comorbid background
Introduction. Varicose veins of the lower extremities are a common pathology affecting about 25–33% of the adult population. The treatment of this disease requires studying the influence of comorbidities on the choice of surgical treatment tactics for varicose veins. Aim. To assess the degree of influence of comorbid conditions on decision-making regarding the method of surgical intervention and to develop an algorithm for a personalized treatment approach. Materials and methods. A retrospective analysis of 500 medical records of patients who underwent surgical treatment for varicose veins was conducted using multivariate statistical analysis and machine learning methods to identify significant correlations. To assess long-term results, a prospective observation of 100 patients was additionally conducted for one year after surgery. Results. The results of the study showed that the presence of cardiovascular diseases increases the risk of postoperative complications by 23%, which requires correction of surgical tactics. A significant association between diabetes mellitus and increased duration of postoperative wound healing was revealed (p < 0.01). The analysis of long-term results showed that patients with comorbidities have a higher risk of varicose vein recurrence, especially in the presence of obesity and diabetes mellitus. Discussion. The results demonstrate the necessity of differentiated approach to the choice of surgical tactics taking into account the individual profile of the patient’s comorbidity. Conclusions. The developed prognostic algorithm and the proposed recommendations can serve as a basis for the creation of clinical guidelines aimed at improving the efficacy and safety of surgical treatment of varicose veins in patients with comorbidities.
The role of the complex application of compression knitwear in the treatment of patients with chronic venous diseases
The article provides a review of the literature on the role of compression knitwear in the complex treatment of chronic venous disease (CVD). The pathogenesis of CVD and its complications is analyzed, with the consequent need to follow a precisely calibrated pressure profile (graduated compression) when choosing compression knitwear. Based on the literature data, it has been shown that it is precisely a strictly selected pressure gradient that guarantees the flow of blood to the heart, and not in the opposite direction or the distribution of blood through the superficial veins. Correct graduated compression reduces venous hypertension, improves the functioning of the musculoskeletal pump, facilitates venous return and improves lymphatic drainage, exerting positive physiological and biochemical effects affecting the venous, arterial and lymphatic systems. It is necessary to take into account the fact that patients with a pronounced violation of venous outflow have increased skin sensitivity, a tendency to atopic reactions, irritations and various discomfort when wearing compression knitwear. This often leads to its irregular use, which increases the duration of treatment. Thus, the effectiveness of compression therapy can only be ensured by high-quality compression knitwear, confirmed by clinical studies, having international certificates of conformity and a wide range of sizes, allowing to select compression knitwear for each patient individually. An impressive evidence base is provided, including both international clinical trials and domestic observations, attesting to the compliance of mediven® elegance compression knitwear with RAL-387 quality standards. CVD and flat feet are related conditions. With flat feet, the muscles of the lower leg suffer greatly, which are forced to be under increased stress while working with increased stress. It is their work that ensures the normal outflow of venous blood. To reduce the risk of developing CVD with flat feet, it is recommended to use orthopedic insoles in combination with compression knitwear, which reduces the load on the legs and helps slow down the development of varicose veins. The combined use of orthopedic insoles and compression knitwear will reduce pain, swelling and heaviness in the legs, create comfort, increase confidence when walking, ensure proper foot position due to their design, improve the functioning of the shin muscles and, as a result, venous outflow.
Features of the influence of micronized purified flavonoid fraction on remodeling of the venous wall during hypodynamia in the experiment
Introduction. The issue of protecting venous wall remodeling in individuals with reduced physical activity remains relevant and requires study. Aim. To study the effect of micronized purified flavonoid fraction (MPFF) on venous wall remodeling during hypodynamia in an experiment. Materials and methods. The experiment was performed on 15 sexually mature mongrel male dogs. The 1st group (control) included 5 dogs, in which the normal anatomy of the medial saphenous vein was studied. In the remaining groups, a model of varicose veins of the lower extremities was created. To create conditions of hypodynamia, walking the dogs was excluded. 5 dogs of the 2nd group (hypodynamia) did not receive pharmacological support. 5 dogs of the 3rd group (hypodynamia + MPFF) received MPFF orally with food for 30 days once a day at a dose of 23.5 mg/kg of body weight, equivalent to the daily dose for a human weighing 70 kg. All animals underwent a staged duplex study followed by morphological study of the medial saphenous vein. Results. In both experimental groups, clinical and morphological signs of varicose veins were established. The 2nd group was characterized by pronounced atrophic processes in the smooth muscle and connective tissue components with disruption of the histoarchitecture, a decrease in wall thickness (p < 0.005), with a significant expansion of the lumen (p < 0.005) and lymphohistiocytic infiltration of the outer shell. The 3rd group was also characterized by atrophic changes. However, ectasia of the vein lumen was not established in all sections (p < 0.005). First of all, this fact is associated with the preservation of the muscular layer of the vein, probably due to the absence of inflammatory changes in the form oflymphohistiocytic infiltration. Conclusion. The use of MPFF preparations reduced venous wall hypotrophy during hypodynamia in a chronic experiment. This effect requires further study in clinical trials for possible extrapolation to the prevention of varicose disease in risk groups. Lymphohistiocytic infiltration of the outer wall of the vein also requires further study.
Polypeptides in treatment of patients with obliterating atherosclerosis of the arteries lower extremities
Introduction. Treatment of patients with chronic lower limb ischemia against the background of obliterating atherosclerosis should be aimed at restoring the impaired hemodynamics of the vascular bed. In atherosclerosis, a violation of the peptide composition leads to a decrease in the ability of the vascular wall to prevent the development of pathological processes. Aim. To evaluate the efficacy and safety of using a drug based on bovine vascular polypeptides in patients with obliterating atherosclerosis of the lower limb arteries. Materials and methods. 105 patients with chronic lower limb ischemia of grades IIA and IIB against the background of obliterating atherosclerosis. There were 96 men and 9 women, the average age was 60 ± 5.6 and 70 ± 3.8 years, respectively. All patients received conservative treatment. In the 1st group (n = 34) additionally – cilostazol; in the 2nd group (n = 35) – additionally sulodexide; in the 3rd (main) group (n = 36) – additionally – sulodexide according to the above scheme and Polipeptydi. Results. After 3 months from the start of treatment, a good therapeutic effect was maintained in all groups. After 6 months, negative dynamics were noted in the 1st and 2nd groups of patients. Repeated courses of conservative treatment were required. These patients were excluded from further study. In the 3rd group (Polipeptyd + sulodexide), the therapeutic effect was maintained for 9 months from the start of treatment. Discussion. If it is impossible to reconstruct arterial blood flow, it is necessary to prescribe drugs that increase the rheological properties of the blood, improve direct blood flow in the affected limb, and also have a positive effect on metabolism. Conclusions. The inclusion of Polipeptydm, a peptide regulator, in the complex conservative treatment of patients with obliterating atherosclerosis of the arteries of the extremities allows for an increase in its effectiveness and a significant prolongation of the positive therapeutic result.
Experience in outpatient management of patients after hybrid interventions on the arteries of the lower extremities
Introduction. Currently, due to the unsatisfactory results of arterial reconstructions in severe atherosclerotic lesions of the lower leg arteries, the development of postoperative management methods for this patient population is relevant. Aim. To develop a method for outpatient management of patients after distal hybrid reconstruction using the drug sulodexide. Materials and methods. The prospective study included 12 people who underwent hybrid surgery for severe atherosclerotic lesions of the femoral and lower leg arteries. All patients underwent the installation of the Cellular Arterial port system (6.5F) intraoperatively after the completion of the main stage. The administration of drugs into and evaluation of the effectiveness of the administration of drugs into the reconstruction area were carried out on an outpatient basis. The first group (n = 6) received sulodexide (Tromboliks® Pro) into the port system, and the second (n = 6) received heparin. The follow-up period for patients was 90 days. The SPSS Statistics 17.0 program was used for statistical data processing. Results. The results showed that there were no significant differences in the course of the early postoperative period before discharge in the study groups. In the late postoperative period, the average number of recurrences of critical ischemia (group 1 – 2.8 ± 0.8; group 2 – 3.9 ± 0.4, p < 0.05), thrombosis of the tibial arteries (group 1 – 1.8 ± 0.3; group 2 – 2.9 ± 0.2, p < 0.05), repeated operations (group 1 – 2.8 ± 0.2; 2 group – 3.9 ± 0.3 ml, p < 0.05), small amputations (group 1 – 1.9 ± 0.6; group 2 – 2.7 ± 0.7 ml, p < 0.05) of the limb were significantly higher in the control group. In addition, the described complications were observed in the study group from 14 to 21 days, while in the control group – from 30 to 90 days. Discussion. The antithrombotic effect of heparin on the area of extensive postoperative atheromatosis had a short-term effect. At alater date, a persistent angioprotective effect of thrombolysis was noted, based on an increase in prostaglandin synthesis on 30–90 days after surgery. Conclusion. The use of the port system with prophylactic courses of heparinization of the vascular reconstruction area with sulodexide in patients after distal hybrid reconstruction with severe atherosclerosis of the lower leg arteries has good clinical results, more pronounced on 30-90 days of the postoperative period.
Experience in the use of collagen dressings in surgical practice
Introduction. Trophic ulcers of the lower extremities represent one of the serious problems in modern medicine, especially among patients with diabetic foot syndrome (DFS). Despite significant advances in developing new treatment methods, this pathology remains difficult to cure due to prolonged wound healing periods and a high risk of amputations. Aim. To evaluate the effectiveness, safety, and convenience of using collagen dressings for treating chronic wounds with long healing times at various stages of the wound process. Materials and methods. The study was conducted based on the surgical department of Dr. Begma’s Medical Center. The results of treating 37 patients with trophic ulcers caused by DFS, who were treated with the collagen dressing Digestol, were analyzed. Dynamics of wound healing, changes in surrounding tissues, reduction of pain syndrome, and other indicators were assessed. The article also includes a clinical case of applying a collagen wound dressing. Results. As a result of using the collagen dressing, there was a significant reduction in the time required for ulcer defects to heal, an improvement in the condition of surrounding tissues, and a decrease in pain and edema. The average full-healing period was 12 weeks, which is significantly shorter than that achieved through traditional treatment methods. Discussion. The obtained results confirm the high efficacy of collagen dressings in treating trophic ulcers, particularly under conditions of long-term chronic disease progression. They demonstrated the ability to maintain optimal moisture levels, provide non-traumatic effects, and facilitate rapid tissue repair. Conclusions. Biological collagen dressing is an effective tool for treating trophic ulcers. Using the biological dressing as part of complex therapy allows for faster wound cleansing, accelerates the healing process of ulcerative lesions of the lower limbs, improves patient quality of life, and reduces the risk of amputations.
Absorbent dressings at the outpatient stage of treatment of tissue defects in patients with diabetic foot syndrome
Introduction. Diabetic foot syndrome (DFS) occurs in 25% of DM patients and is an indication for performing 40–60% of lower limb amputations of a non-traumatic nature. The problem of effective local action on purulent infection in diabetes mellitus remains unresolved to this day. Aim. To study the local effect of modern sorbent dressings on the course of the wound process in diabetic foot syndrome. Materials and methods. A rhabdomized prospective study was conducted to study the effectiveness of superabsorbent bandages with a silicone contact layer (Zetuvit Plus Silicone) in the topical treatment of SDS in 296 patients. The main group included 154 patients, average age 54.7 ± 12.63 years, of which 74 were men and 80 were women. The comparison group included 142 patients, average age 52.5 ± 13.67 years, of which 70 were men and 72 were women. Results. Ulceration and the appearance of granulations when applying Zetuvit Plus Silicone dressings occurred after 14.4 ± 0.7 days, the appearance of marginal epithelialization and complete wound healing occurred on 17.2 ± 2.6 and 21.0 ± 3.6 days, respectively. Discussion. The introduction of sorbent dressings into clinical practice has brought significant benefits to patients with SDS, minimizing the risk of injury and pain associated with the use of adhesive and adhesive bandages. The spread of this technique of local treatment of trophic ulcers in DM ensures satisfaction with the treatment results of patients and doctors. Conclusions. Zetuvit Plus Silicone superabsorbent dressings act at all stages of the wound process and improve the tissue regeneration process.
Obesity and chronic venous diseases as comorbid pathologies in surgical practice
This review is devoted to the modern view of morbid obesity in the development and treatment of chronic venous diseases (CVD) and includes a compilation of data from domestic and foreign literature, including clinical recommendations of WHO and the Russian Ministry of Health. Currently, there is evidence of an aggravating association of morbid obesity (BMI ≥ 40 kg/m2 or with BMI ≥ 35 kg/m2 in the presence of serious complications associated with obesity) with CVD, while both conditions are widespread in the world with a tendency to progress. Often they exist simultaneously in the patient, which increases the risk of vascular events and radically changes the management tactics of such a patient. The outcomes of developing remodeling in the walls of the veins in the form of, first of all, an inflammatory process are reflected in the arterial bed, which increases the relevance of the issue and emphasizes the need for timely correction and, mainly, adequate surgical treatment. The results of various surgical interventions at venous incompetence worsen along with an increase in BMI. In this regard, today, patients with extremely (≥40 kg/m2) high BMI are primarily recommended to treat not venous insufficiency, but to correct weight, including through bariatric surgery, which is due to the ineffectiveness of the reverse approach.
Combined drug therapy of hemorrhoidal bleeding
Hemorrhoidal disease is one of the most common proctological pathologies. The main risk factors are physical inactivity, obesity, pregnancy, and chronic constipation, including dysynergic bowel movements. Systemic bioflavonoids (diosmin and hesperidin) demonstrate high efficacy, especially in the early stages of the disease. These substances strengthen blood vessels, reduce inflammation and improve microcirculation. Studies confirm that the combination of systemic flavonoids with topical agents such as sodium alginate accelerates the regression of symptoms. Sodium alginate in the form of candles has hemostatic, wound-healing and anti-inflammatory effects. When comparing the isolated use of bioflavonoids (Venarus® ) and combination therapy (Venarus® and Venaproct Alium), it was demonstrated that the combination of drugs is more effective in reducing the frequency of bleeding, reducing the size of hemorrhoids and reducing the frequency of relapses. The presented authors’ own experience demonstrates that the use of Venarus® and Venaproсt Allium drugs is effective in bleeding hemorrhoids. The results of treatment of 23 patients (11 men/12 women), aged 43 ± 5 years, who came for an initial consultation with complaints of blood discharge from the anus during defecation and who had not previously undergone colon examination, were analyzed. The use of a combination of Venarus® and Venaproct Alium, taking into account the therapeutic effects of each of the drugs, may be promising not only as an independent conservative therapy for hemorrhoids, but also at the stage of rehabilitation after surgical interventions, this requires further research.
Evaluation of the effectiveness of products for comprehensive perianal skin care in conservative treatment of patients with hemorrhoids and anal fissures
Introduction. Hemorrhoids are one of the most common proctological disorders affecting a significant portion of the adult population. In recent years, efforts have been focused on developing conservative treatment methods that minimize invasive interventions while maintaining high efficacy. Aim. To evaluate the effectiveness and safety of Prestogel® for comprehensive perianal skin care as an adjunct to standard therapy in the treatment of hemorrhoids and anal fissures. Materials and methods. The study included a two-center prospective comparative analysis of 218 patients: the control group of 110 (50.5%) patients received treatment including diet therapy, basic pharmacotherapy using systemic and local drugs to relieve symptoms; the main group of 108 (49.5%) patients received basic therapy equivalent to the main group in combination with the use of Prestogel® for comprehensive perianal skin care. Results. The results demonstrated significant advantages of using Prestogel® in combination with basic therapy compared to standard therapy alone. The main group showed more pronounced symptom regression, including pain, bleeding, itching, and burning, at all stages of the study. The greatest difference between the groups was observed on day 14 of treatment, confirming the effectiveness of Prestogel® in accelerating symptom resolution. Discussion. Modern methods of conservative treatment of hemorrhoids include the use of systemic and local drugs. Venotonics, dietary fiber, suppositories with natural components, ointments with corticosteroids and anesthetics are used with varying effectiveness. Our study showed a rapid and pronounced effect in reducing symptoms such as pain, itching and bleeding when using the Prestogel® complex anal skin care product. Conclusion. Prestogel® for comprehensive perianal skin care can be recommended as a rational addition to basic conservative therapy for patients with acute and chronic hemorrhoids and anal fissures. It may also be recommended for routine use in daily clinical practice.
A modern approach to the treatment of constipation and preparation of the intestine for instrumental examination in outpatient coloproctology
Introduction. In outpatient coloproctology, when preparing the intestine for instrumental examination, great importance is attached to the effective treatment of constipation and elimination of coprostasis. Aim. To evaluate the clinical efficacy of the rectal laxative to eliminate coprostasis caused by constipation and prepare the distal intestine for instrumental examination in coloproctological patients on an outpatient basis. Materials and methods. The study included 135 patients with manifestations of functional constipation and coprostasis, who were divided into three groups. Oral laxatives were used empirically in 41 patients (group 1). Standard cleansing enemas were performed in 49 patients (group 2). The combined rectal laxative (group 3) was used in 45 patients. The quality of training was assessed based on the unified Boston scale. Subsequently, within the study groups, in 60 patients with various proctological diseases of benign genesis, identified during the examination, complex treatment of constipation was continued using the above methods. Results and discussion. The best results were obtained when preparing the intestines with the rectal laxative (group 3 patients). In this case, the number of patients with excellent and good training was 95.5%. At the stage of subsequent treatment of chronic constipation in coloproctological patients with laxative Lax Canon, 82.8% of patients showed the formation of softened feces (type 3 and 4) or mushy stools (type 5 and 6). This exceeded similar results obtained in the treatment of constipation with oral laxatives (39.3%) or through cleansing enemas (74.7%). Conclusion. The use of the rectal laxative in outpatient coloproctology makes it possible to eliminate coprostasis as quickly as possible and in 95.5% of cases to qualitatively prepare the distal parts of the intestine for instrumental examination. The use of the studied agent in the complex treatment of chronic constipation in proctological patients helps restore regular bowel movements in 90% of cases.
Evaluation of the efficacy of lanolin-based cream-balm in the treatment of anal canal wounds: A pilot study
Introduction. Wound healing of the anal canal and perineum after surgery is a complex process, often accompanied by prolonged recovery and the risk of non-healing wounds. There are 2 stages of postoperative rehabilitation. It is the second stage of rehabilitation that is the most difficult for the patient and the doctor. Aim. To study the effectiveness of lanolin Superlimf® cream-balm in the treatment of anal canal wounds and its practical application in the postoperative period in patients with benign diseases of the anal canal, rectum and perianal region. Materials and methods. A total of 15 patients (mean age 39 ± 7 years) who underwent hemorrhoidectomy were enrolled in the pilot interventional non-comparative study. The patients applied the cream-balm to the wounds 2 times a day starting from day 15 after surgery. The follow-up observation included monitoring of wound healing status, assessment of pain syndrome, discomfort, the nature of discharge and treatment satisfaction. The wound assessment and documentation of findings were conducted every 5 days. Results. Complete epithelialization of subcutaneous wounds within 45 days was recorded in 87% (13/15) of cases. At the same time, the effect of local therapy was completely satisfactory to patients, due to the low level of pain and discomfort in the anus, and the nature of the discharge. Cream-balm has shown a good safety profile, which is confirmed by the absence of adverse events. Discussion. When assessing effectiveness regarding skin wound healing, accelerated epithelialization and angiogenesis were observed with the use of MSC-CM (mesenchymal stem cell conditioned medium) compared to placebo. Cytokine proteins isolated from pig blood are suitable for humans due to their highly conserved structure and comparability of properties observed in different mammalian species, which makes it possible to model experimental data and approaches from one mammal to another. Conclusion. Cream-balm has demonstrated efficacy and safety in the treatment of wounds of the anal canal and perianal area.
Impact of bladder neck preservation in transurethral resection of the prostate on postoperative retrograde ejaculation
Introduction. Prostatic enlargement with bladder outlet obstruction is one of the major problems that face many men after reaching 40 years old. There are different modalities for management of obstructed benign prostatic hyperplasia (BPH), while choose certain modality depends on many factors. Aim. To evaluate the safety and efficiency of transurethral resection of the Prostate (TURP) with preservation of the bladder neck and compare it with the conventional standard TURP and its impact on retrograde of ejaculation. Materials and methods. This prospective randomized comparative clinical study was conducted on 70 patients with obstructed benign prostatic hyperplasia attended to urology department outpatient clinic at Ain Shams university hospitals during the period from July 2021 to September 2023. Results. Mean operative time was 57.14 min in group A and 56.66 min in group B. Reduction of hemoglobin postoperative was 1.24 g/dl in group A and 1.21 g/dl in group B. Mean hospital stay postoperatively was 2.71 days in group A and 2.77 days in group B. Catheter was removed after mean 2.96 days in group A and 3.11 days in group B. As regard postoperative incontinence, at the third month of follow up there were two patients in group A and eight patients in group B with statistically significant difference between the two groups. Discussion. The study evaluated the safety and effectiveness of transurethral resection of the prostate (TURP) with bladder neck preservation compared to standard TURP. Bladder neck preservation significantly reduces retrograde ejaculation rates (14.3% vs. 74.1% after 12 months) while maintaining comparable efficacy and complication rates. Conclusion. The TURP with preservation of the bladder neck is applicable technique for men with obstructed BPH with good efficacy and outcome comparable to conventional TURP. TURP with preservation of the bladder neck plays an important role in the armamentaria of ejaculation preservation post TURP.
Invasive luminescent spectroscopy in determining surgical tactics in lower limb amputation
Introduction. Currently, due to the increase in amputations, it is becoming relevant to reduce its level for better rehabilitation of patients. Aim. To evaluate the results of the use of invasive photoluminescence spectroscopy to determine the level of limb amputation. Materials and methods. A prospective, open-ended, non-randomized study involved 24 people with a clinical picture of KINK after endovascular reconstruction. For gangrene of the foot, amputation was performed at the level of the upper third of the lower leg on day 6–7. The patients were monitored during 1 turnout. All patients were divided into 2 groups. Group 1 (n = 10) consisted of patients who had no complications after amputation, group 2 (n = 14) – who had complications from the stump. In all patients, photoluminescence measurements of the affected limb were performed according to our proposed method at thelevel of future amputation. The results of the study were presented in the form of an average value, standard deviation or median and the 25th, 75th percentiles. Results. The intensity of the glow was higher in the second group of the study, where various complications later developed. When comparing the intensity of photoluminescence with the area of necrotically altered muscle fibers detected by microscopy, a direct relationship between these two indicators is noted. An 11-fold increase in the number of necrotically altered fibers was revealed at luminescence intensity above 10,000 × 105 photons. Discussion. With an increase in the degree of blood supply, a decrease in the degree of tissue ischemia, a decrease in the luminescence intensity at the nicotinamide dinucleotide peaks and a more intense signal reduction at the hematoporphyrin frequency were observed. These circumstances explain the decrease in the amplitude of the glow as the measuring needle moves from the surface of the skin deeper into the skin and approaches the main arteries. Conclusions. Luminescent spectroscopy is the method of choice for determining the level of amputation of the lower limb.
Heparin, escin and essential phospholipids gel as part of complex therapy in the early postoperative period in patients with lower limb varicose vein disease
Introduction. Chronic venous diseases of the lower extremities represent a common medical issue significantly impacting patients’ quality of life. Particular attention is paid to optimizing the postoperative period in the treatment of varicose veins. Aim. The study aimed to evaluate the effect of local application of gel based on heparin, escin and essential phospholipids on reducing pain, edema, and accelerating hematoma resolution in the early postoperative period in patients undergoing radiofrequency ablation combined with miniphlebectomy. Materials and methods. A prospective randomized controlled trial was conducted involving 60 patients divided into two groups: control (30 patients) and experimental (30 patients). Pain levels, edema dynamics, hematoma size, and quality of life were assessed. Results. The use of gel based on heparin, escin and essential phospholipids contributed to faster pain reduction (statistically significant differences from day 3), edema reduction (from day 3), and hematoma resolution (complete disappearance by day 14 in the experimental group). No statistically significant differences in quality of life between groups were observed one month after surgery. Discussion. The findings confirm the efficacy of gel based on heparin, escin and essential phospholipids in improving early postoperative outcomes due to its anti-inflammatory, anti-edema, and regenerative effects. Conclusions. Gel based on heparin, escin and essential phospholipids can be recommended as an adjunct to standard postoperative care to enhance patient comfort during the early postoperative period in the treatment of varicose veins of the lower extremities.
Radial fiber fragment detection during radiological diagnostics of a knee
This clinical case demonstrates the detection of the radial fiber fragment in subcutaneous fat of the upper calf during radiological diagnostics of the knee 8 years after endovenous laser ablation of the great saphenous vein. Due to moderate discomfort in this area, the encapsulated fragment was removed from a small incision without subsequent complications. The rarity of the incident and, more importantly, the radiographic picture determined interest and the relevance of the publication. The accumulated experience and the current case allow us to recommend obligatory intraoperative elimination of fragments due to possible local pain or, at least, ligation of the vein above the fragmentation for prevention of potential material embolism and subsequent observation and appropriate decision-making. The clinics regulations of endovenous laser ablation must prescribe a precise inspection of the integrity of the fibers both before and after the intervention.
Commentary to D.A. Borsuk et al.: "Radial fiber fragment detection during radiological diagnostics of a knee"
Evaluation of the results of conservative treatment of patients with distal forms of atherosclerosis of the arteries of the lower extremities based on computer capillaroscopy
Introduction. The choice of treatment tactics for patients with obliterating atherosclerosis of the arteries of the lower extremities is an urgent problem of vascular surgery, which has great medical and social significance. In case of OAANK stage IIA, conservative therapy is preferable. Aim. To study the results of using two conservative treatment regimens (sulodexide and sulodexide followed by pentoxifylline) in patients with distal atherosclerosis of the arteries of the lower extremities based on computer capillaroscopy. Materials and methods. The microcirculatory bed was assessed using computer capillaroscopy before and after treatment in patients. The results of conservative treatment of patients with distal atherosclerosis of the lower extremities were studied using computer capillaroscopy in 135 patients with obliterating atherosclerosis of the arteries of the lower extremities with stage IIA. The patients were divided into two groups, one group of patients received conservative treatment with sulodexide, the second group – combined conservative treatment with sulodexide (Thrombolix Pro®) and subsequent therapy with pentoxifylline (Trental®). Results and discussion. The results of the study showed that there is a statistically significant increase in the number of functioning linear capillaries and capillaries by area after conservative therapy with two different treatment regimens. At the same time, in the group using combined treatment (Thrombolix Pro® and continuation of Trental® therapy) the changes are more pronounced: the number of linear working capillaries was 5.5 ± 2.4 pcs. per 1 mm2, and the number of working capillaries by area was 16.7 ± 5.3 pcs. per 1 mm2. Conclusions. In the distal form of obliterating atherosclerosis of the arteries of the lower extremities of the femoral-popliteal-tibial segment with stage IIA, changes in the microcirculatory bed are noted after treatment in both groups of patients, but more pronounced changes after treatment according to the Thrombolix Pro® regimen and continuation of Trental® therapy.
Risk factors associated with the emergence and progression of ocular ischemic syndrome in carotid artery stenosis
Introduction. The ocular ischemic syndrome (OIS) is a condition characterized by insufficient blood supply to the eye due to occlusion or hemodynamically significant stenosis of the internal carotid artery. Aim. To study the risk factors for the occurrence and progression of OIS. Materials and methods. The study included 91 patients divided into two groups: Group I (61 patients with OIS) and Group II (30 control patients). The study design was cross-sectional, allowing for the identification of potential risk factors. Data collection was performed using a standardized questionnaire and medical records, as well as duplex scanning of the brachiocephalic arteries. Results. The results showed that the main risk factors increasing the likelihood of OIS are stenosis of the vertebral carotid artery (VCA) greater than 70% (AUC = 0.968; 95% CI: 0.925–1.000, p < 0.001) and occlusion of the VCA (AUC = 0.935; 95% CI: 0.864–1.000, p < 0.001). Other identified risk factors include nicotine dependence, arterial hypertension, dyslipidemia, obesity, and diabetes mellitus. The combination of risk factors for stenosis of the VCA greater than 70% includes nicotine dependence, arterial hypertension, dyslipidemia, and obesity, with a sensitivity of 88.6% and specificity of 91.4%. For VCA occlusion, key factors include arterial hypertension, obesity, and diabetes mellitus, with a sensitivity of 81.3% and specificity of 84.2%. Discussion. Our study identified key factors such as carotid artery stenosis, arterial hypertension, and diabetes mellitus that contribute to the development of ocular ischemic syndrome, which is consistent with findings from other studies. The severity of carotid artery stenosis is an important predictor of eye ischemia, as it directly affects blood supply to the ocular artery. Conclusions. The study allows for the identification of associations between risk factors and ocular ischemic syndrome, which may facilitate the development of prevention and treatment strategies, as well as the implementation of artificial intelligence for diagnosis. Key risk factors such as arterial hypertension, dyslipidemia, and obesity significantly increase the likelihood of developing OIS in cases of stenosis and occlusion of the carotid arteries.
Application of autologous platelet-rich plasma in herniology: First results of a chronic experiment
Introduction. The causes of complications of hernioplasty are technical errors and the biological conditions in which the implant is placed. PRP is rich in growth factors and, by influencing cellular mechanisms, can improve the integration processes of a mesh implant. Aim. To evaluate the quality of regeneration using PRP and improve the immediate and long-term results of allogernoplasty. Materials and methods. The experiment was conducted on 6 pigs of the breed Topigs Large white, which underwent allogernoplasty of the anterior abdominal wall Sublay. In the main group (n = 3), the operation was completed with the application of a PRP mesh implant obtained from the blood of an operated pig. In the control group (n = 3), the operation was completed without using PRP. The nature of the scar was determined by the Vancouver scale, the severity of the postoperative pain syndrome was determined by a combination of facial features. For morphological examination, two 2.5 x 0.5 cm biopsies were excised along the edges of the implant on days 7, 14, 21, and 28 of the experiment. Histological preparations were stained with hematoxylin and eosin. Results. The duration of epithelialization in the main group was 10 days, edema and hyperemia persisted for 48 hours. In the comparison group, the epithelialization time was 25 days, and edema resolution was on 5–6 days (p < 0.05). Morphological examination determined the granulation zone and thin-walled vessels on day 14 in the main group. On the 21st day, newly formed lymphatic vessels were detected. In the main group, alarge number of macrophages and cells of maturing and mature granulation tissue were detected at different stages of repair. On day 60, degenerative changes in nerve stem cells and perineural fibrosis were detected in the control group. Discussion. In the main group, the acceleration of epithelialization processes and early activation of animals were noted, as well as the course of inflammation different from conventional allogernoplasty – rapid elimination of decay products, replacement of neutrophilic inflammation by elements of the monocyte-macrophage series, healing without the formation of a rough scar and wrinkling of the implant, absence of perineural fibrosis. Active neovascularization processes indicate an influx of oxygen into the repair zone and adequate lymphatic drainage, which prevents tissue edema. Conclusion. The conducted experimental study confirms the expediency of using PRP in allogernioplasty.
Pilonadal disease: Rationale for the original method of radical surgery
Introduction. Considering the dissatisfaction with the results of existing methods for treating the pilonadal disease, the search for the most effective methods of radical surgery is currently ongoing. Aim. To evaluate the feasibility of using in patients with chronic epithelial coccygeal tract an original method of radical treatment, consisting of excision of the substrate of the disease, plastic surgery of the sacrococcygeal fascia and suturing of the soft tissue defect with vertical polyspaste sutures. Materials and methods. Main group: 34 patients who underwent an original method of radical surgical treatment. Comparison group: 34 patients who underwent traditional radical excision of the disease substrate. Results. In the main group, less severe pain was recorded (p < 0.05) on days 1–6 after surgery. In terms of the total number of complications, a significant difference in results was demonstrated with a predominance of the indicator in patients in the comparison group (χ2 = 12.324; p = 0.0004). A significant difference (p < 0.05) was also obtained in the healing time of surgical wounds, with thelowest values in patients after the original surgical technique. Discussion. The study demonstrated an alternative technique, the implementation of which resulted in a significant reduction in the number of wound complications, severity of pain in the intervention area, average wound healing time, and also noted better quality oflife indicators compared to patients who underwent traditional surgery. Conclusions. The implementation of an original method of radical surgical treatment of the epithelial coccygeal tract can reliably reduce the severity of pain on days 1–6 of the postoperative period, reduce the number of early postoperative complications by 38.23%, and also reduce the average wound healing time by 16 days compared with similar indicators after traditional radical excision of the pilonidal sinus.
The importance of surgeon experience for assessment of the outcomes of minimally invasive treatment for chronic haemorrhoids
Introduction. The impact of surgeon experience, changing during a study, on the characteristics of transmucosal laser vaporization and dearterialization of hemorrhoidal arteries has not been sufficiently studied. Aim. To determine the impact of the surgeon experience on the objectivity of the assessment of outcomes of treatment using hemorrhoidal dearterialization and hemorrhoidal laser ablation techniques in patients with chronic grade 2–3 haemorrhoids. Materials and methods. Ninety-five patients underwent transmucosal laser thermal ablation, and 132 underwent dearterialization. All operations were performed by the same surgeon. The following properties for the treatment techniques were assessed: operation duration, pain intensity and duration, and postoperative haemorrhages. The learning curve was studied by grouping patients into quartiles. Results. The attainment of mastery in laser vaporization required 23 operations, and that in dearterization required 33 operations. The characteristics of the treatment techniques that were studied with and without regard to the surgeon experience differed from each other according to all indications. The trend of their changes had the same pattern: all patients operated during the experience consolidation phase had better outcomes. The statistical significance remained after comparison of operation duration and assessment of pain syndrome, but ceased to be found after assessment of the number of complications. Discussion. The outcomes of treatment of chronic grade 2–3 haemorrhoids using hemorrhoidal dearterialization and laser thermal ablation techniques, which were measured by analysed characteristics, depend on the surgeon experience, and are more objective in patients who were operated during the surgeon experience consolidation. Conclusions. When assessing the outcomes of treatment of chronic haemorrhoids to establish the statistical significance of the analysis performed, it is important to take into account the surgeon experience in mastering these treatments.
The position of primary radical surgery for pilonidal cysts in the acute inflammatory phase
Introduction. Pilonidal abscesses are common surgical emergencies, typically managed through incision and drainage, requiring re-surgery after relief acute inflammation. The literature describes the use of primary-radical techniques, the essence of which lies in the one-stage economical excision of the suppurating epithelial tract with subsequent open management of the wound, which leads to its complete healing by secondary intention. Routine use of primary-radical operations in emergency proctological practice is limited by an insufficient number of studies that fully reflect the effectiveness of pilonidal disease treatment in the acute inflammatory phase. Aim. To evaluate the effectiveness of using primary radical operations in patients with acute inflammation of the pilonidal disease. Results. The average duration of the surgical intervention was 8.4 minutes (5 to 17 minutes), no intraoperative complications were recorded. The average hospital stay was less than 3 days. In 5 patients (3.9%), the postoperative period was complicated by bleeding from the postoperative wound at the hospital stage, which was stopped in the dressing room under local anesthesia. During the average observation period of 9.4 months (from 6 to 42 months), recurrence-free healing was recorded in 125 (97.6%) patients. The duration of postoperative scar formation ranged from 1.5 to 2.3 months (on average 1.7 months). Discussion. Drainage the purulent cavity during treatment of acute inflammation of the pilonidal cyst transforms the disease into a chronic form, which often requires a second stage of surgical treatment after stopping the symptoms of the acute phase of inflammation. One-stage excision of the suppurating pilonidal cyst allows performing surgical treatment of the pilonidal disease in one stage, which gives reason to consider the possibilities of a wider use of primary-radical operations. Conclusion. Primary radical surgeries can be safely used in patients with acute inflammation of the ECC.
Study of risk factors for recurrence of varicose veins after endovenous laser obliteration of the great saphenous vein to determine indications for crossectomy
Introduction. Currently, it is recommended to use lasers with a wavelength of 1470, 1560, 1940 nm, coupled with radial light guides, for EVLO. Aim. To study the risk factors for recurrence of varicose veins after endovenous laser obliteration of the great saphenous vein to determine the indications for crossectomy. Materials and methods. The study included 150 patients with varicose veins who underwent laser EVLO. There were 112 women (74.6%) and 38 (26.4%) men. The median age was 46.3 ± 9 years. Alaser with a wavelength of 1 470 nm and radial light guides were used. Phenotypic features characterizing undifferentiated connective tissue dysplasia were investigated. The study group included 75 patients who underwent crossectomy, and 33 (44%) had dysplasia. 75 patients made up the comparison group – without crossectomy, 36 (48%) – had dysplasia. Results and discussions. During 36 months of follow-up, 4 (5.3%) patients in the study group developed a recurrence of varicose veins and 14 (18.6%) in the comparison group (p = 0.0001). Studies conducted using the Cox regression method made it possible to identify independent risk factors for the development of disease recurrence: the presence of dysplasia, the number of collaterals in the zone of the sapheno-femoral anastosis, the diameter of the great saphenous vein, the diameter of v. epigastrica superficialis, as well as the thickness of the wall of the great saphenous vein. An integral assessment of independent risk factors for the development of recurrence made it possible to propose a method for determining indications for crossectomy during EVLO of the great saphenous vein. Conclusions. Risk factors for recurrence of varicose veins after EVLO of the great saphenous vein were identified, which made it possible to start developing a method for determining indications for crossectomy to reduce the number of recurrences of the disease. Acknowledgment. The study was carried out with the financial support of Saratov State Medical University as part of the scientific project NoSSMU-2022-005, the support did not affect the results of the study.
A shift of treatment approaches in internal carotid artery stenosis
The purpose of this review is to objectively present and discuss the scientific literature that is critical for decision-making on the optimal choice of prevention and treatment method for patients with atherosclerotic stenosis of the internal carotid artery (ICA). The evolution of approaches to the treatment of the disease over the past 3–4 decades is analyzed. A summary of the evidence base regarding the efficacy and safety of surgical and drug methods for the prevention and treatment of stroke in symptomatic and asymptomatic patients with ICA stenosis is provided. Conclusions are made regarding the current priorities in the choice of stroke prevention and treatment in patients with ICA stenosis. The review analyzes current randomized trials and explains why they are unlikely to determine routine indications for carotid artery procedures. Previous randomized trials have shown the effectiveness of carotid endarterectomy in reducing the risk of stroke. However, not all patients benefit from the procedure, especially asymptomatic patients. In any given patient, it is usually impossible to be certain of the cause of stroke or transient ischemic attack. Relevant global recommendations for carotid artery procedures, including ways to improve them, are discussed. Conclusion: The cornerstone of stroke prevention is optimal medical therapy, as this procedure is noninvasive and protects against all complications of atherosclerosis in various vascular beds in all at-risk individuals. The important question remains whether carotid surgery is beneficial to the patient in the modern era, and if so, for whom?
IХ конгресс амбулаторных хирургов Российской Федерации. 17–18 апреля 2025 года, г. Санкт-Петербург
17–18 апреля 2025 г. в Санкт-Петербурге состоится IX конгресс амбулаторных хирургов Российской Федерации.