No 40 (2015)

ИСТОРИЯ МОНИКИ

ПАМЯТИ АННЫ РОМАНОВНЫ ЗЛАТКИНОЙ ПОСВЯЩАЕТСЯ

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Abstract

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Almanac of Clinical Medicine. 2015;(40):6
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SIBERIAN.ESSAY ON ANNA R. ZLATKINA

Klimova G.D.

Abstract

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Almanac of Clinical Medicine. 2015;(40):7-11
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АКТУАЛЬНАЯ ПРОБЛЕМА

PHYLOMETABOLIC CORE OF INTESTINAL MICROBIOTA

Sitkin S.I., Tkachenko E.I., Vakhitov T.Y.

Abstract

The authors  discuss the  theory  of human  superorganism and its microbiota (microbiome), whose mutualistic  interactions  is realized within the  microbiota – gut – brain axis that includes endocrine, immune and neurohumoral pathways. The newest concepts  of microbiome enterotypes and core microbiota  are  presented, which are  important  for understanding of the  role of symbiotic  microorganisms  in human  vital activities, for explanation of pathophysiology of many  chronic  human  diseases  (beyond  gastrointestinal disorders), as well as for the  search of effective therapeutic targets. As highly promising are considered  the functional approaches to studies  of microbiota  that  allowed to formulate the concept  of phylometabolic (phylofunctional) core. This is a series of evolutionally stable microorganisms  responsible  for majority of the  main microbiome  functions, such as fermentation  of polysaccharides  (glycans), production of short-chain  fatty acids (butyrate, propionate, acetate), hydrogen  utilization, production of lactate, metabolism of aminoacids, bile acids, choline, production  of vitamins and  some  biologically active substances – anti-inflammatory, anti-microbial, immunostimulatory. The authors are first to describe the main functional groups  of microorganisms  of   gut microbiota phylometabolic core, providing key metabolic functions, as well as the leading characteristics of the  phylometabolic core as such. The perspectives  of modification  of composition  and functions  of phylometabolic microbiota  core are discussed based on metabiotics  as a virtually new class of therapeutic agents. A hypothesis has been proposed that  the  ratios  between main  components of the key gut microbiota may reflect fundamental  processed  related  to a mutualistic interactions between microbiota and human body, as well as they may serve as effective biological markers of dysbiotic states  determining the  development of  various  pathologic   conditions.  For  example, the  ratio between Bacteroides spp. and  butyrate producing  bacteria  that  indirectly indicates  total numbers  of microbial genes  can be used both for assessment of chronic inflammation of various localization (starting  from inflammatory  bowel disease to fat tissue inflammation related to metabolic syndrome), and for control of treatment efficacy.
Almanac of Clinical Medicine. 2015;(40):12-34
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IMMUNOLOGICAL FUNCTION OF INTESTINAL MICROFLORA, ITS ABNORMALITIES AND POSSIBILITIES OF CORRECTION

Ursova N.I.

Abstract

The review presents  current  data  indicating  that normal   microflora  plays  an  important  role  in the development of intestinal immune system. Intestinal microorganisms stimulate maturation of intestinal  lymphoid  tissue, synthesis  of secretory immunoglobulin A,  activate  phagocytosis, stimulate  the  cytokine and  interferon  system. Of interest is the discussion of tolerance  phenomenon which is highly significant for formation of a stable   micro-biocenosis. Probiotics are increasingly used for controlled  formation  or restoration  of abnormal micro-biocenosis. Confirmation of the useful properties  of every strain of a probiotic culture in controlled clinical trials is recognized as one of the key requirements to probiotics.
Almanac of Clinical Medicine. 2015;(40):35-46
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ARTICLES

A SHORT COURSE OF TRIPLE TELAPREVIR-BASED ANTIVIRAL THERAPY: THE PRINCIPLES OF PATIENTS SELECTION

Bogomolov P.O., Matsievich M.V., Kokina K.Y., Kuz'mina O.S., Koblov S.V., Voronkova N.V., Petrachenkova M.Y., Bueverov A.O., Uvarova O.V., Fedosova E.V., Trofimova M.N., Beznosenko V.D., Kudryavtseva E.N., Kondratenko E.M., Gorbunova L.S., Shilkina I.M., Sheshukova T.N., Kovalev I.N., Sadovskaya G.V., Kosheleva N.V., Gumerova Y.Y., Azarova I.N., Ivannikova S.V., Cherenkova E.N., Gorshilina N.A., Samsonyan M.L., Sinitsyna V.A., Kiyan S.I., Kudrya O.A., Chernyavskaya G.G.

Abstract

Background: The beginning of a new era of direct acting antivirals sets up its own rules, that is, to achieve the highest efficacy with the shortest duration of treatment. It is assumed that the use of the first generation of direct acting antivirals, similarly to interferon-free regimens, would allow for personalization of approaches to their prescriptions.
Aim: To identify the most important parameters that can predict the greatest efficacy of triple antiviral therapy of 12 week duration in patients with chronic hepatitis C genotype 1.
Materials and methods: The study included 204 patients with chronic hepatitis C virus (HCV) genotype 1 at an early stage of liver disease (METAVIR score F0-F2), who were either treatment-naive or had a history of relapse after standard of care antiviral therapy. In addition to routine work-up, all patients were screened for IL28B polymorphism; in the course of the treatment viral kinetics was assessed by an ultrasensitive polymerase chain reaction (PCR) (with lower limit of quantification of 12 IU/ml). Duration of the triple therapy (pegylated interferon-α2a, ribavirin and telaprevir) was reduced to 12 weeks if a rapid virological response was achieved; otherwise the patients continued their treatment in according with guidelines.
Results: A complete rapid virological response was achieved in 174 patients (81.6%), in whom the duration of triple therapy was 12 weeks. According to the protocol, 25 patients with a partial rapid virological response continued their standard antiviral therapy for 12 weeks more. In those who achieved a rapid virological response, there was an association between IL28B-CC genotype at rs12979860 and maintenance of zero viremia at 12 weeks after termination of antiviral therapy (r = 0.38, p < 0.001). In all such patients there was a stable virological response at 12 weeks of the follow-up. Monitoring of viral load after 14 days of antiviral treatment was not predictive of its success. The preliminary results of a shortened (12 week) course of triple telaprevir-based viral therapy allowed to identify the most significant parameters of 100% efficacy, i.e., absence of the virus in blood at 12 weeks after termination of antiviral therapy.
Conclusion: A 12 week course of triple telaprevir-based combination therapy is an optimal regimen for achievement of a stable virological response after 12 weeks of the follow-up in treatment-naïve patients with HCV genotype 1 or with a relapse after previous conventional antiviral treatment, who have IL28B – CC polymorphism, are at an early stage of liver disease and who achieve a rapid complete virological response confirmed by a highly sensitive PCR.

Almanac of Clinical Medicine. 2015;(40):48-57
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ANALYSIS OF PREVALENCE, HOSPITALIZATION RATE AND MORTALITY LEVELS RELATED TO GASTROINTESTINAL DISORDERS IN THE MOSCOW REGION

Gurov A.N., Katuntseva N.A., Belousova E.A.

Abstract

Rationale: According to prognosis made by World Health Organization experts, by mid-21st century gastrointestinal disorders will be among the leaders, partially due to lifestyle of a modern man (stress, unhealthy diet, lack of physical exercise, unhealthy habits), environmental pollution, genetically modified and low quality foods.
Aim: To provide informational support of activities aimed at improvement of organization of medical care to patients with gastrointestinal disorders and at further development of specialized gastroenterological care to the population of the Moscow Region, its better availability and higher efficacy and quality.
Materials and methods: We calculated and analyzed gastrointestinal morbidity in 2014 (according to referrals) among the main age categories (children, adolescents, adults) of the population of the Moscow Region, as well as hospitalization rates and in-hospital mortality. The information was taken from the Federal Statistical Surveillance report forms # 12 and # 14.
Results: In 2014, the highest prevalence of gastrointestinal disorders was registered in adolescents, being by 42.7% higher than that in adults and by 11.7% higher than that in children. The leading causes of referrals in all age categories were gastritis and duodenitis, as well as gall bladder and bile tract disorders. The structure of morbidity was characterized by a high proportion of pancreatic disorders, stomach and duodenal ulcers in adults. The rate of hospitalizations due to gastrointestinal disorders was 17.8 cases per 1000 patients, being 17.4‰ in adults and 19.8‰ in children and adolescents. The main reasons for hospitalization in adults were diseases of pancreas (23.9% of all hospitalization due to gastrointestinal disorders), gall bladder and bile tract disorders (16.3%). In children and adolescents, the main reasons for hospitalizations were intestinal disorders (36.4%), gastritis and duodenitis (17.9%). In-hospital mortality from gastrointestinal disorders in adults was 3.3%, in children, 0.02%.
Conclusion: The statistical data obtained, as well as the results of the analysis of organization, quality and efficacy of medical care to patients with gastrointestinal disorders can be used for improvement of gastroenterological care at all levels and further development of this service in the region.

Almanac of Clinical Medicine. 2015;(40):58-62
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QUALITY OF LIFE IN PATIENTS WITH CHRONIC PANCREATITIS IN THE MOSCOW REGION

Belyakova S.V., Belousova E.A.

Abstract

Rationale: Chronic pancreatitis is characterized by progression with gradual insufficiency of pancreas and can be associated with complications. Various clinical signs and symptoms of the disease may affect patient's quality of life.
Aim: To assess quality of life in various groups of patients with chronic pancreatitis, living in the Moscow Region, who have uncomplicated and complicated course of the disease, depending on their compliance level, compared to that in patients regularly seen by doctors of other specialities.
Materials and methods: One hundred patients with chronic pancreatitis living in the Moscow Region completed the Medical Outcomes Study – Short Form (MOS SF-36) questionnaire.
Results: In chronic pancreatitis patients, there was a clear decrease in quality of life parameters on all subscales. It was found that the presence of any complications did not contribute to deterioration of quality of life, with no significant difference in quality of life parameters in any subscale (р > 0.05). Quality of life was better in the patients who were fully adherent to their treatment (n = 28). In non-compliant patients (n = 72), there was a significant decrease (р < 0,05) of the following quality of life parameters: physical role functioning (29 points), emotional role functioning (45 points), as well as general health (32 points), pain intensity (44 points) and social functioning (51 point). Patients who were regularly seen by a gastroenterologist, had better quality of life (р < 0.05), compared to those seen by an internist, on the following subscales: physical role functioning (56 and 29 points, respectively), pain (60 and 45), general health (46 and 31), vitality (48 and 32), social functioning (69 and 52), emotional functioning (75 and 46). In patients who had not been regularly seen by any doctor, there was a statistically significant decrease in quality of life (р < 0.05) on the same subscales (0, 24, 17, 22, 35, 17 points, respectively).
Conclusion: To improve quality of life in patients with chronic pancreatitis, it is necessary to increase the level of doctor's knowledge in pancreatology, to improve patient adherence to treatment, to ensure regular visit to doctors, as well as to establish the continuity of treatment from an in-patient to an out-patient unit.

Almanac of Clinical Medicine. 2015;(40):64-71
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PATHOGENETIC RATIONALE FOR COMBINATION THERAPY OF PATIENTS WITH CHRONIC PANCREATITIS

Grinevich V.B., Sas E.I., Kravchuk Y.A., Shcherbina N.N.

Abstract

Background: Chronic pancreatitis is characterized by an imbalance of pro-inflammatory and anti-inflammatory cytokines, reflecting the presence of chronic systemic inflammation. The functional state of microbial-tissue complex of the intestine determines the severity of chronic systemic inflammation. Restoration of normal microbial-tissue complex functioning of the intestine reduces the severity of inflammatory changes in the pancreas.
Aim: To study clinical efficacy of combination of chronic pancreatitis through correction of the functional state of intestinal microbial-tissue complex.
Materials and methods: The analyzed patient sample included 117 patients with uncomplicated chronic pancreatitis and moderate pain syndrome, moderate exocrine and endocrine, with their mean age of 43.9 ± 11.6 years (men, 40.9 ± 13.5 years and women, 48.6 ± 11.7 years). Patients with chronic pancreatitis were divided into 2 groups, with the Results: After combination therapy of chronic pancreatitis with the agent for correction of the functional state of intestinal microbial-tissue complex, there was a significant (p < 0.05) reduction in the representation of pathogenic and conditionally pathogenic microflora, with a significant increase in the primary intestinal flora, as well as a decrease in cytokines TNF-α (74.32 ± 11.22 ng/ml before treatment, 31.34 ± 8.92 ng/ml after treatment) and IL-1β (25.32 ± 4.36 ng/ml before treatment, 10.52 ± 3.52 ng/ml after treatment), a significant decrease in cortisol (456.53 ± 68.99 nmol/ml before treatment, 382.61 ± 60.24 nmol/ml after treatment). The significant improvement of metabolic abnormalities was associated with positive clinical dynamics and improvement of quality of life.
Conclusion: Treatment strategies in chronic pancreatitis should include agents restoring the functioning of intestinal microbial-tissue complex and positively affecting metabolic and hormonal milieu.

Almanac of Clinical Medicine. 2015;(40):72-81
pages 72-81 views

SOME ASPECTS OF TREATMENT FOR LEFT-SIDED ULCERATIVE COLITIS

Makarchuk P.A., Tsodikova O.M., Buzunova Y.M., Belousova E.A.

Abstract

Background: There is no published data on changes in the endoscopic activity index within first weeks of treatment with various pharmaceutical forms of mesalazine.
Aim: Comparative assessment of clinical efficacy and safety of various pharmaceutical forms of mesalazine (tablets, enemas and foam) in the treatment of left-sided ulcerative colitis.
Materials and methods: Thirty patients with chronic relapsing left-sided moderate ulcerative colitis participated in the study. They were administered mesalazine either orally (group 1, n = 10) or rectally in micro-enemas (group 2, n = 10) and as foam (group 3, n = 10). Activity of ulcerative colitis was accessed before and after the treatment, along with collecting of patient responses regarding the ease of their use.
Results: The mean index of ulcerative colitis activity among all patients before treatment was 7.2 ± 0.8 points. After 1 week of treatment with oral mesalazine, the index of ulcerative colitis activity decreased to 5.2 points and in those patients who were using microenemas and foam, to 4.6 and 3.4 points, respectively, with the difference before/after treatment being significant only in the group 3 (p < 0.05). At 2 weeks of treatment, the activity index decreased more than 2-fold in all groups (p < 0.05). According to the questionnaire, 83.3% of patients accepted the oral intake of the agent as the most convenient one. The highest proportion of compliant patients was in the group using the foam.
Conclusion: Mesalazine is highly effective, as shown by a 2-fold decrease in the ulcerative colitis activity index after 2 weeks of treatment. The endoscopic activity index shows more rapid decrease after the use of mesalazine foam (already at 1 week of treatment).

Almanac of Clinical Medicine. 2015;(40):82-88
pages 82-88 views

THE EXPERIENCE OF ENTECAVIR USE IN PATIENTS WITH HEPATITIS B VIRAL INFECTION ON AN OUTPATIENT BASIS

Mel'nikova L.I., Il'chenko L.Y.

Abstract

Aim: To evaluate retrospectively the efficacy and safety of entecavir in treatment-naïve patients with hepatitis B viral infection.
Materials and methods: Based on patient medical documentation, we analyzed the results of clinical, virologic and instrumental assessment of 36 patients with chronic hepatitis B, 6 of whom were HBeAg-positive, and 1 had a highly active progression of acute hepatitis B. Duration of entecavir therapy (at a dose of 0,5–1 mg daily) was 48 weeks.
Results: In most patients with chronic hepatitis B, treatment with entecavir, regardless of the HBeAg status, promoted a virologic response (94.4%) and HBeAg serum conversion with anti-HBe formation (83.3%), which was associated with a clinical improvement, normalization of liver enzyme activity, reduction of liver fibrosis by 1 point (assessed by fibroelastometry). There were no changes in serum HBsAg during the antiviral therapy. A clinical case of successful entecavir therapy of hepatitis B viral infection is presented.
Conclusion: Entecavir is a highly effective and reliable agent that can suppress viral replication in various forms of acute and chronic hepatitis B viral infection. A relatively rapid recurrence of viral replication after withdrawal of the drug justifies further research to optimize treatment of chronic hepatitis B.

Almanac of Clinical Medicine. 2015;(40):90-100
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THE EFFICACY OF PLASMA SORPTION (LIVER SUPPORT) IN LIVER FAILURE IN PATIENTS WITH MECHANICAL JAUNDICE

Fomin A.M., Lobakov A.I., Titova G.V., Zakharov Y.I.

Abstract

Background: New methods of extracorporeal hemocorrection and detoxification in liver failure of patients with mechanical jaundice need an assessment of their efficacy and safety, especially with consideration of baseline hypocoagulation and systemic heparin administration.
Aim: To assess the efficacy of plasma sorption with Plasorba BR-350 in liver failure patients with mechanical jaundice.
Materials and methods: The study was conducted in 12 patients (aged from 47 to 67 years) with mechanical jaundice as a consequence of biliary obstruction (choledocholithiasis). At baseline, total bilirubin level was from 101.9 to 611 µmol/l. Extracorporeal hemocorrection (The Liver Support procedures) was carried out with the Octo Nova device (Asahi Kasei Medical, Japan) and Plasorba BR-350 sorbent based on were measured prior, during and upon termination of a procedure. Results: By the end of the procedure, there was a trend towards decrease in total bilirubin level by 18.6 ± 3.8% (p = 0.13), conjugated bilirubin by 14.6 ± 6.4% (p = 0.06), unconjugated bilirubin by 16.9 ± 9.8% (p = 0.17), and aspartate aminotransferase by 18.67 ± 2.3% (p = 0.077), with a statistically significant decrease in alanine aminotransferase 17.07 ± 3.4% (p = 0.002). Other blood chemistry parameters did not show any changes. There were no changes in hemoglobin and platelets throughout the study and no negative changes in the international normalized ratio, activated partial thromboplastin time, and fibrinogen, prothrombin, and anti-thrombin III levels. During hemosorption procedures no bleeding complications were noted in any patient.
Conclusion: Plasma sorption (Liver Support) allows for correction of hyperbilirubinemia in liver failure patients with mechanical jaundice without a significant influence on other blood chemistry parameters. Due to the absence of bleeding complications during the procedure and lack of chang- es in the coagulogram after the procedure, this method of the liver support can be recommended for patients with high bilirubin levels in mechanical jaundice during preparation for surgical treatment for the bile ducts obstruction and postoperatively.

Almanac of Clinical Medicine. 2015;(40):101-108
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OPPORTUNITIES OF LAPAROSCOPY IN THE TREATMENT OF ESOPHAGEAL ACHALASIA

Allakhverdyan A.S., Mazurin V.S., Frolov A.V., Anipchenko N.N.

Abstract

The article describes opportunities and results of laparoscopic oesophagocardiomiotomy and laparoscopic transhiatal oesophagus removal without hand assistance in esophageal achalasia (cardiospasm). In total, such operations were performed in 196 and 31 of cases (of 423 patients), respectively. There were minimal numbers of relapses (below 2.3%) after laparoscopic oesophagocardiomiotomy done by the proposed technique. All cases of reflux esophagitis were diagnosed after esophagocardiomiotomy with Dor fundoplication.
After cardiodilatation, disease relapses were registered in 57% of patients. The advantages of a laparoscopic access for oesophagectomy are shown and technical particular of this intervention are analyzed based on a case history. The principles of Fast track surgery in this patient category are discussed that allow for reduction of the length of hospital stay by 40%.

Almanac of Clinical Medicine. 2015;(40):109-116
pages 109-116 views

LAPAROSCOPIC FUNDOPLICATION IN THE TREATMENT OF BARRETT’S ESOPHAGUS

Allakhverdyan A.S., Mazurin V.S., Anipchenko N.N., Shabarov V.L.

Abstract

The  results  of  treatment  of  Barrett's  oesophagus diagnosed in 22 (9.2%) of 238 patients  with gastroesophageal reflux disease  and  hiatal  hernia are  presented. A high  degree  dysplasia  was found  in 54.5%  (12/22) of patients. All patients were administered combination therapy with proton   pump  inhibitors, prokinetics, third  generation  H2 histamine  receptor  blockers  for 3 to 4 weeks. If no regress of dysplasia was obtained,   Barrett's epithelium  was removed  by a holmium laser  (14 patients). The advantages of a laparoscopic fundoplication  technique proposed by the authors  in the treatment of Barrett's oesophagus were shown. This surgical intervention reliably prevents  the gastroesophageal reflux that has led to the development of this disease.
Almanac of Clinical Medicine. 2015;(40):117-120
pages 117-120 views

DEVELOPMENT OF A METHOD FOR ADAPTING THE SIZE OF LAPAROTOMY TO TOPOGRAPHIC-ANATOMICAL PARAMETERS OF THE ABDOMEN OF PATIENTS WITH SMALL BOWEL OBSTRUCTION

Amarantov D.G., Fedorova N.A.

Abstract

Background: Optimization of the size of the surgical access exerts a positive effect on recovery dynamics. The size of median laparotomy in operations for small bowel obstruction is usually determined without consideration of specifics of the abdominal cavity anatomy of the patient. Aim: To improve the results of treatment of patients with acute small bowel obstruction by adapting the parameters of the median laparotomy to constitutional characteristics of the patient.
Materials and methods: The results of treatment of 101 patients with acute small bowel obstruction were analyzed. In 49 patients of the group I, laparotomy was performed with the newly developed method to determine the size of laparotomy. Fifty two patients of the group II were treated at the time when the method was still in the process of development. To identify optimal parameters of the laparotomy, we performed anatomical experiments in 90 cadavers with dolicho-, mesoand brachymorphic constitution. Results: During the anatomical experiments, we found that in individuals with dolychomorphic constitution, the average depth of the abdominal cavity amounted to 58.07% of the distance between the upper anterior iliac spines, in those with mesomorphic body build, this parameter was 42%, and in individuals with brachymorphic constitution, 37.67% of this distance. Based on the analysis of surgical accessibility parameters, we found that the optimal length of median laparotomy in individuals with dolichomorphic body build was 63.877% of the distance between the front upper iliac spines, in mesomorphic ones, 46.2%, and in brachymorphic, 41.437% of this distance. The described method of determination of the surgical incision length was applied in 49 patients from the group I. The average size of laparotomic incision was 121.74 ± 10.4 mm. The use of the proposed method for determination of the length of surgical incision allowed for reduction of the mean duration of hospitalization from 13.32 ± 3.4 to 10.02 ± 2.1 hospital days. On average, patients from group I could defecate without stimulation one day earlier than those from group II, with abdominal pain intensity being much lower.
Conclusion: A differentiated approach to laparotomy depending on the constitution of a patient with acute small bowel obstruction allows to reduce operational trauma and improve the recovery dynamics.

Almanac of Clinical Medicine. 2015;(40):121-125
pages 121-125 views

REVIEW

CHRONIC HEPATITIS B VIRUS INFECTION IN PREGNANCY: STRATEGIES OF ANTIVIRAL THERAPY

Bogomolov P.O., Matsievich M.V., Kokina K.Y., Voronkova N.V., Kuz'mina O.S., Bueverov A.O.

Abstract

Treatment of chronic hepatitis B during pregnancy is an extremely complicated issue. Despite  implementation of immune prophylaxis, a significant proportion of babies born by mothers with  high viral load are infected by hepatitis B virus.  Cumulative data suggest that antiviral therapy in  the 3  trimester of pregnancy is an effective intervention in the event of unsuccessful immune prord phylaxis. To minimize fetal effects of nucleoside  and nucleotide analogues, antiviral therapy during  pregnancy should be administered to mothers with high risk of disease progression and/or uncontrolled hepatitis B virus infection. The safety  data obtained indicate that telbivudine and tenofovir can be used during pregnancy. Nevertheless,  antiviral therapy requires a  thorough assessment of the risk to benefit ratio.
Almanac of Clinical Medicine. 2015;(40):126-131
pages 126-131 views

THE POSSIBILITY OF CONSERVATIVE MANAGEMENT OF BLUNT AND PENETRATING LIVER TRAUMA OF VARIOUS SEVERITY

Pankratov A.A., Khat'kov I.E., Izrailov R.E., Kapustin V.I., Mamonov D.A.

Abstract

Until now, surgery is a standard  treatment strategy in liver trauma. However, continuous evolution and  improvement of imaging  and  interventional techniques open  a wide perspective  for conservative  management of liver trauma  patients. In the recent years, this method is getting  more and   more widely used  and becomes  a component of the standard  care protocols for patients  with liver trauma in tertiary centers. 

Almanac of Clinical Medicine. 2015;(40):132-137
pages 132-137 views

CLINICAL CASES

LAPAROSCOPIC CHOLECYSTECTOMY IN SITUS INVERSUS TOTALIS VISCERUM

Grigor’ev N.S., Sidorenko A.B., Lobakov A.I.

Abstract

The article describes cases of laparoscopic cholecystectomy in patients  with chronic calculous cholecystitis and situs inversus totalis viscerum. Placing of surgical team members and location of trocars for manupulations are described in details.
Almanac of Clinical Medicine. 2015;(40):138-142
pages 138-142 views

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