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Endoscopic subfascial dissection was performed in patients with chronic venous insufficiency of CEAP class 4-6. 76 surgeries were performed in 68 patients. Mean age of the patients was 56 years. The causes of chronic venous insufficiency were varicose (37) and postthrombotic diseases. Trophic ulcers were in 46 patients. Thirty patients underwent earlier various phlebectomies, including Linton's surgery (6 patients). In 33 patients endoscopic subfascial dissection of venous perforants was combined with various phlebectomy, in 37 patients -- with excision of ulcer with following autodermoplasty few days after surgery. Endoscopic subfascial dissection was carried out with special surgical R.Wolf endoscope with 6 mm instrumental canal, and also standard laparoscopic optical devices "Olympus". Complications during surgery were seen in 2 patients: bleeding in subfascial space (1.3%) and perforation of tissues in ulcer zone (1.3%). In postoperative period long (up to 14 days) lymphorrhea and suppuration of surgical wound were in 2 (2.6%) patients. It is concluded that endoscopic approach is optimal for elimination of pathological reflux through venous perforants in complicated forms of chronic venous insufficiency of the lower extremities, including trophic ulcers resistant to treatment.

A complex system of prophylaxis of thromboembolic complications (TEC) in laparoscopic surgeries based on study of hemodynamic disorders in cava vein bed and specific risk factors is discussed. System of TEC prophylaxis and prognosis of TEC risk degree was developed. Problems of prophylaxis of venous thrombosis in laparoscopic cholecystectomy in patients with chronic diseases of lower extremities veins are regarded in detail. This system permitted us to completely avoid TEC from 1996 in surgical treatment more than 2500 patients.

5-year experience of developed in PAMS A.V. Vishnevsky Institute of Surgery RAMS ultrasonic examination (USE) of the lung in thoracoscopic operations for focal lung lesions (FLL) is presented. Pilot experience of ultrasonic topical and differential diagnosis of FII opens a new page in diagnosis of respiratory diseases. Over 5 years 74 USE of FLL were performed. FLL were found in 91% cases. Detailed topical diagnosis of allows to design the lung resection with the best functional result. In postoperative X-ray examination neither atelectases nor zones of stable hypoventilation were detected. Normal echographic picture of lung tissue and echosemiotics of different focal lesions are descubed. The experience of diagnosis by echographic signs of FLL shows teasibility of differentiation of hamartomas from tuberculomas and focal metastatic lesions. The payential of differential diagnosis is illustrated. Differential diagnosis supported enucleation in superficial hamartomas and resection in suspected malignant tumor or tuberculosis. Use of intraoperative USE in the majority of cases of focal lesions located both in depth of lung tissue and subpleurally warrants the success of operation in thoracoscopic variant.

The authors offer the treatment and diagnostic algorithm in choledocholithiasis, stricture of a terminal portion of the common hepatic duct and papilla stenosis revealed in laparoscopic cholecystectomy (LCE). With the purpose of intraoperative assessment of bile ducts states during LCE, the diagnostic system including laparoscopic and ultrasonic examinations, cholangiography and choledochoscopy was developed and applied. In intraoperative revealing of choledocholithiasis without bile outflow disorders and wide cystic duct the authors prefer to remove the concrements during choledochoscopy through cystic duct without intervention on Vater's papilla (VP). In combination of choledocholithiasis with bile outflow disorders and also in isolated papilla stenosis and stricture of a terminal portion of the common hepatic duct, one-stage laparoscopic cholecystectomy, intraoperative antegrade papillosphincterotomy and retrograde calculus extraction is optimal. In cases when complete endoscopic calculus extraction is impossible, the drainage of the common hepatic duct by Cholsted's with subsequent delayed endoscopic papillosphincterotomy (EPST) is acceptable. During intraoperative examination in 49 patients (57.6%) the concrements in choledochus, not diagnosed earlier, were revealed, in 21--stricture of terminal choledochus portion and in 19 patients--papilla stenosis. In 12 cases the concrements were removed during choledochoscopy through the cystic duct stump, 4 patients with big concrements required laparoscopic choledocholithotomy. In 16 cases LCE with various variants of choledochus drainage was performed as the first stage, as the second stage--EPST and lithoextraction. Antegrade papillosphincterotomy was performed in 15 patients during LCE. In 12 cases intraoperatively revealed choledocholithiasis combined with papilla stenosis (7) and choledochus stricture (5) was the indications to intraoperative papillosphincterotomy. Papilla stenosis was the indication to antegrade papillosphincterotomy in 3 patients.

Up to present time there is no common view on the role of diverticuli of the papillar region of the duodenum (DPRD) in development of the strictures of terminal parts of the common bile duct and major pancreatic duct. The main method for the diagnosis of DPRD is fibroduodenoscopy (FDS). Relaxational FDS is the most informative method for detailed examination of diverticulum and for assessment of its interrelations with longitudinal crease and the major duodenal papilla (MDP). During the last 2 years all patients with DPRD underwent ERCPG, which helped to obtain more complete information of the presence and the character of the strictures of terminal parts of the common bile duct and the pancreatic duct. DPR has been revealed in 5% of patients with calculous cholecystitis and in 9.5% of patients with choledocholithiasis. Of the patients, admitted to the Institute for postcholecystectomy syndrome from 1994 to 1999, DPRD were revealed in 30% of cases. The patients with DPR and chronic pancreatitis of nonalcoholic and nonlithogenic etiology, made up 9% of all patients with DPR and chronic pancreatitis. In 87 patients with DPR, suffering from various surgical diseases, following changes of bile and pancreatic ducts were revealed: choledocholithiasis (47%), stenosis of the large bile duct (15%), strictures of terminal parts of the large bile duct and major pancreatic duct (10%). There is evidence, that para- and peripapillary diverticuli deteriorate evacuatory function of the bile and pancreatic tracts due to compression of terminal parts of the choledochus and the pancreatic ducts with strictures formation, which promote disturbances of the bile and pancreatic juice passage. Biliary stasis and pancreatic juice passage disturbances create favorable conditions for lithogenesis and promote development of cholangitis, mechanical jaundice and chronic pancreatitis. Patients with choledochal and major pancreatic duct strictures and stenoses of the papilla in DPR underwent EPST with favorable initial and long-term results. The authors suggest, that DPR are an important etiopathogenetic link in the development of many diseases of the organs of hepatobiliary region, associated with biliary and pancreatic hypertension.

This study was devoted to examination of efficacy of modern methods of diagnosis and surgical treatment of patients with small peripheral pulmonary masses (SPPM) with the use of videothoracoscopy. The results of examination and treatment of 126 patients with SPPM (80 patients underwent videothoracoscopy) were analysed. This study demonstrated high-quality of modern complex of clinicoradiological investigations for diagnosis of SPPM. The reliability of the complex is 91%. The necessity of immediate elective operation of the patients with SPPM is shown for verification of the process and adequate surgery. Videothoracoscopic surgery is effective method of treatment in patients with SPPM.

The detection rate of microbial contamination of burn wounds after flame burn was studied in dynamics to 3 weeks in 56 patients forming 2 similar groups: basic--with thermo-inhalation lesions (TIL) and control--without TIL. General area of skin burns in all the patients was less than 50% of the body surface, on average it was 40%, the area of deep burns was 23%. Cytological and bacteriologic methods were used for study microphlora in the sputum and in bronchoalveolar lavage. There were 186 cases of wound microbial contamination (gram-negative microorganisms--64.4% cases, gram-positive--34%, pathogenic fungi--1.6%). In 80% cases the microphlora of the wounds was polymicrobial, in 47% cases the microphlora were detected on the second week. Microphlora was detected 2 times more often in the basic group than in the control, corresponded to skin burn area; the greatest exceeding of critical level of wound contamination was revealed on the first 2 weeks. In TIL besides wound contamination, polymicrobial microphlora revealed in tracheobronchial tree, presented on the first 2 weeks with association of gram-positive and gram-negative microorganisms, combining on week 3 with fungal phlora. Early leukocytosis, not reducing during first 3 weeks of the study, due to intoxication by burn products, occurred in TIL. Early lymphopenia in TIL was the sign of resistant immunodeficiency.

Intraoperative ultrasound diagnosis (IOUSD) was made in several thoracoscopic interventions in 15 patients: diagnostic thoracoscopies (3) in patients with lymphogranulomatosis, carcinoid and peripheral lung cancer, enucleation and atypical resection of the lung (4) in patients with hamartochondromas, in excision of lung cyst (1), in removal of foreign body of the lung (1), in removal of celomic cysts (2) and in ablation of neurofibroma of the mediastinum (1), in atypical resection of the lung and enucleation of tuberculomas (2). Video thoracoscopy in combination with intraoperative ultrasound examination provides possibility for precisional diagnosis of focal disease of the lung and mediastinal organs, including local masses of small sizes, and is rather informative method of diagnosis. IOUSD allows to define the diagnosis more exactly and to determine the extent of pathological process, to prevent complications and locate intraparenchymal masses and foreign bodies in lung tissues, and thus enables to complete operation without thoracotomy.

A definition of a surgical access in laparoscopic interventions is formulated. The importance of use of various surgical accesses is stressed. The results of treatment of 410 patients with calculous cholecystitis are analysed. 72 of the patients have been previously operated on abdominal cavity. The cause of technical mistakes and failures are analysed. The original method of ultrasound evaluation of abdominal cavity adhesions in patients, who had been operated on previously is proposed. The method was used in 45 patients, and in 95% of the cases the evaluation was perfectly accurate. Indications for use of a particular surgical access, depending on a site of a previous operation, are formulated. The method of an open laparoscopy is described. It is indicated in case of previously performed low-middle laparotomy and ultrasonic picture of adhesions in the umbilical region; in umbilical hernias; in big and multiple choleliths (more than 30 cubic cm of total volume).

The authors present an original experience of using an ultrasonography and a computer scan for a preoperative diagnosis of VP mucocele. The laparoscopy has been used as a method for the final diagnosis as for an appendectomy. The authors also describe their understanding of VP mucocele pathogenesis and their opinion about diagnosis and treatment of such kind of a case.

The paper provides the results of two-year use of laparoscopic cholecystectomy as a treatment of calculous cholecystitis in patients with various clinical and morphological types of calculous cholecystitis. Less intraoperative trauma, a mild postoperative period, and early activization of patients, good cosmetic effect are indisputable advantages of this therapeutical method which is an alternative to an open operation for calculous cholecystitis.

Two alternative methods for the treatment of calculous cholecystitis are evaluated: extracorporeal lithotripsy was performed in 284 patients, laparoscopic cholecystectomy--in 130 patients. Even in strict selection of patients, lithotripsy was ineffective in 32 of them and they were subjected to an operation; in another group of patients elimination of the fragments from the gallbladder was incomplete. Therefore, extracorporeal lithotripsy may be used in no more than 10% of patients with cholelithiasis. Laparoscopic cholecystectomy was conducted in 130 patients. In 6 (4.5%) of them the operation had to be completed by laparotomy because complications occurred during the laparoscopic intervention. Laparoscopic cholecystectomy has some obvious advantages over open cholecystectomy: easier postoperative period, early activation of the patients, a good cosmetic effect. However, to determine the boundaries and possibilities of this method accumulation of experience is needed.

The article analyses the efficacy of extracorporeal lithotripsy by a LT-01 piezoelectric lithotriptor (EDAP, France). A total of 72 lithotripsy sessions were performed on 37 patients, in 2 of them who suffered from chronic calculous cholecystitis the procedure was conducted on the day before the operation. As a method for treatment, extracorporeal lithotripsy was applied in 35 patients for the following indications: solitary and multiple stones measuring in sum no more than 3 cm in the satisfactory functioning of the gallbladder and patency of the bile ducts. In 35 patients the stones were crushed to fragments of various size. In 29 patients extracorporeal lithotripsy produced a marked effect and was the final method of treatment. Six patients were operated on (cholecystectomy) due to exacerbation of chronic cholecystitis in 4 patients, pancreatitis in one patient; total destruction of calcinated large stone fragments could not be achieved after 6 sessions in one patient.

The paper presents the analysis of the results obtained for 319 patients at endoscopic interventions for large and giant tumors of the colon. Altogether 415 neoplasms were removed: 207 nodular, 126 creeping and 82 flat. The latter two were removed using specially developed technique of endoscopic electroresection of the intestinal mucosa along with the tumor. Malignancy was established in 16.1% of the cases. During the endoscopic procedure 2 patients were diagnosed to have colon perforations, 24 intensive hemorrhage which was stopped endoscopically in 22 cases. One patient developed subsequently necrosis of the intestinal wall. Surgical treatment was performed in 5 patients: for hemorrhage, colon wall perforation, malignancy in 2, 2 and 1 patient, respectively. One-eight-year follow-up of 316 patients reports cure in 217 (68.6%), relapses in 79 patients (71 of them were endoscopically successfully retreated), cancer in 15 and corrosive strictures in 5 patients.

The article analyses experience in the treatment of 81 patients with diffuse polyposis who underwent subtotal resection of the colon with abdominoanal resection of the rectum and downward displacement of the right parts into the anal canal. It is shown that growth of the remaining occasional polyps and appearance of new polyps are encountered in the maintained parts of the colon and upper parts of the gastrointestinal tract in the postoperative period. The authors found that endoscopic polypectomy allows the right colon to be preserved in 92.6% of cases and the upper digestive tract in 97.5% of cases at a minimum risk of a surgical intervention.

67 segments of rectum and sigmoid removed surgically because of carcinoma were examined: the surface of intestinal mucosa stained with methylene-blue was studied in order to determine the number and localization of focal changes in the macroscopically unchanged areas. Colon microscopy was performed clinically in 24 patients with carcinoma of the rectum and in 24 control individuals. 28 hyperplastic polyps and 1037 microscopic hyperplastic foci were found in operative material. An active metabolism is established by means of electron autoradiography in the cells of hyperplastic focus. Areas of dysplastic epithelium were rarely found in big hyperplastic polyps. Areas of diffuse hyperplasia (transitional mucosa) with crypt deepening and presence of a high number of goblet cells were found near tumour. A certain role of hyperplastic processes in carcinogenesis is forwarded. Numerous microscopic changes in the mucosa epithelium may testify against the carcinoma development de novo.

Clinical and endoscopic evidence gained at the follow-up of 93 patients with metachroneous colon cancer suggests that at present there is minimal change to predict the occurrence, time of onset and site of emergence of the secondary tumors as the latter grow rapidly and rise in macroscopically free-of-tumor colon segments. In some patients metachroneous tumors were associated with long histories of benign adenomas. The authors hold that patients operated on for colon cancer should remain under life-long clinical and endoscopic observation.

The authors describe the technical aspects, which observation makes it possible to safely remove polyps from any portion of the colon. Complications necessitating operative interventions were 3: one hemorrhage and two perforations of the colon.

The rates of colonic tumor growth were studied on the basis of evaluation of the case histories of 19 cancer patients in whom dynamic endocolonoscopy had been carried out. In some cases, malignant tumors appeared in the colon within 12 months after previous colonoscopy. Tumors were under 2.0 cm in size and were not accompanied by any clinical symptoms. Repeated endoscopic examinations performed within a period of 1-3 years detected large tumors which caused the constriction of colonic lumen. Clinical symptoms developed in such patients approximately 1-4 months prior to tumor detection. It is concluded that although the rates of growth of colonic malignancies are rather high, tumorigenesis is preceded by a long-term stage of preclinical disease.

The analysis of 540 ileoscopy findings from the material including more than 4000 colonoscopies in various pathological conditions of the great bowel is presented. The possibilities for an examination of the small bowel by means of various types of colonoscopes are compared and the most videly and frequently used techniques are described.

As a result of endoscopic removal of 238 malignant polyps of the large bowel, malignant tumors in other parts of this organ were found in 6 out of 142 cases (67.7%) followed-up during terms ranging 6 months--10 years. More polyps in different parts of the bowel were found during operation in 27 cases. A procedure for follow-up of cases of malignant polyps is discussed. Endoscopic removal of malignant polyps of the large bowel should be used as a method of choice, particularly, in aged patients suffering concomitant grave diseases.

In patients with proliferative and mixed forms of total polyposis of the digestive tract the intestinal polyps are mainly localized in the duodenum, with hamartomal polyposis--in the jejunum and ileus. The endoscopic polypectomy from the small intestine may be performed intraoperatively and during endoscopy under narcosis. 174 polyps with the diameter of 0.5-5 cm were removed in 27 patients. There were 3 complications (bleedings) after polypectomy.

The results of colonoscopy in 567 patients with malignant tumors of the colon have shown that in 10,0% of cases there were errors in primary endoscopic diagnosis due to inferior examination of the colon, missing of malignant tumors, misinterpretation of the alterations revealed. The authors believe that a single endoscopic examination can not be considered decisive, especially when tumor had been clinically or roentgenologically suspected. Only repeated dynamic observations during 12-14 months with 1-3 month intervals can give final conclusions. The authors believe the thorough early analysis, knowledge of endoscopic symptoms, correct estimation of the data of colonoscopy and biopsy to allow avoiding serious diagnostic errors in future.