Vol 10, No 4 (2019)

Original Research
The effect of the endovascular access on the effectiveness and safety of chemoembolization of the arteries of the liver with unresectable liver metastases
Lebedev D.P., Astakhov D.A., Zvezdkina E.A., Kosy V.V., Kedrova A.G., Ivanov Y.V., Panchenkov D.N.
Abstract

Background. Minimally invasive surgery techniques are widely used in the treatment of primary and metastatic liver cancer.

Objective. The goal was to evaluate the effect of the endovascular access on the efficiency and safety of chemoembolization of liver arteries (CELA) in patients with unresectable liver metastases.

Methods. In 30 patients with unresectable liver metastases, CELA was performed using the transradial and transfemoral approaches. The microcatheter technique was used for superselective chemoembolization of the liver arteries with introduction of drug-saturated microspheres (HepaSphere). All the digital material was statistically processed using the STATISTICA 6.0 software package (StatSoft, 2001). The results were considered statistically significant at p<0.05.

Results. In the normal type of the blood supply to the liver, only the left radial access with only the right hepatic artery embolization demonstrated a significantly shorter duration of CELA and fluoroscopy, which amounted to 33±4.3 min and 9.9±1.3 min, respectively (p<0.05). When performing CELA by means of microspheres 50–100 um from the right femoral access with embolization of only the right hepatic artery, the above assessment criteria were the highest — 67±11 min and 19.1±5.3 min, respectively, but without a significant difference between the other options for the puncture access. During the first CELA using a femoral access, the postoperative hospital stay in the studied group of patients was 7±0.8 days, and the postembolization period lasted 1.43±0.5 days, which is significantly longer (at p≤0.05) in comparison with the same parameters for the right radial arterial access, for which they were 3±0.6 days and 1.15±0.4 days, respectively, and for the left radial arterial access, for which they were 4±0.5 days and 1±0.001 days,respectively.

Conclusion. The use microspheres as a embolization material allowed the application of the microcatheter technique for hqTACE, and expanded the possibilities of the transradial access. A significantly better tolerance and safety of the transradial access was proven in 76.2% of the studied patients in whom it was applicable. The repetitions of CELA donot affect the severity of the post-embolization period, partially due to a lowered use of the contrast medium and superselective embolization of the affected areas of the liver with the preservation of a more intact parenchyma.

Journal of Clinical Practice. 2019;10(4):5-15
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Computer tomography in the diagnosis of small bowel diseases
Koshelev E.G., Kitayev S.V., Belyaev G.Y., Egorov A.A., Kurzantseva O.O.
Abstract

Introduction. The relevance of the study is caused by the difficulties in diagnosing diseases of the small bowel (SB). Due to the prevalence and widespread introduction of X-ray computed tomography (CT) into clinical practice, its capabilities in the diagnosis of small bowel diseases are of great interest and potential.

Objective. to reveal the possibilities of computed tomography using intravenous bolus contrast enhancement in identifying the symptom of “wall thickening” of the small bowel and its prognostic significance in various nosologies.

Methods. Analysis of the data from MSCT studies performed according to the Protocol for the study of abdominal organs using intravenous bolus contrast enhancement and oral water intake in adult patients from 18 to 87 years of age with small bowel diseases.

Results. The article shows the possibilities of multispiral computed tomography performed according to the standard Protocol in detecting thickening of the SB wall. The range of diseases was determined for which thickening of the SB wall was one of the main radiological symptoms of the lesion. The prognostic significance of this radiological symptom is presented. The features of thickening of the intestinal wall in various diseases and other distinctive features that can be used in the differential diagnosis are described.

Conclusion. Thickening of the wall is a common sign of SB damage, which is convincingly detected in CT studies with bolus contrast enhancement. In our study, the common causes of thickening of the SB wall in primary disease were: Crohn's disease (37%), lymphoma (20%) and anastomosis (13%). However, we determined thickening of the SB wall as a result of primary tumors (adenocarcinoma, sarcoma) in 7% and as a result of a secondary tumor lesion in 18.6% of cases. The considered diseases were different in the degree of thickening of the intestinal wall (from 6 to 70 mm), its spreading (focal thickening — 48%; segmental — 52%), number of affected areas (from 1 to 3) of their localization (proximal-middle or distal section), form of the transition area from the affected part of the intestine to the unchanged one (sharply defined or smooth), the presence or absence of symptoms of intestinal obstruction, and the features of contrast enhancement (severity and type).

Journal of Clinical Practice. 2019;10(4):16-29
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Comparison of strategies for myocardial revascularization in patients with coronary heart disease and multivessel coronary artery disease
Bocharov A.V., Popov L.V.
Abstract

Justification. To this day, the problem of choosing the method of complete revascularization in the category of patients with acute coronary syndrome without the ST segment elevation and multi-vascular lesions of the coronary bed does not lose its relevance. The goal of this study was to compare the results of surgical manipulations in patients who underwent percutaneous coronary intervention using 3rd-generation drug-coated stents and coronary artery bypass grafting, according to the two-year follow-up data.

Methods. The results of surgical and endovascular revascularization strategies were compared in 140 patients with ischemic heart disease and multivessel coronary disease after previously successfully performed stenting of a clinically dependent artery using 3rd-generation drug-coated stents for acute coronary syndrome without the ST segment elevation based on the results of a two-year follow-up.

Results. There were no statistically significant differences in clinical, demographic and operational characteristics between the groups, except for the number of smoking patients, wich was significantly higher in the PCI group. In the PCI group, there was a statistically significant difference in the frequency of repeated revascularizations and the combined MACCE point.

Discussion. The obtained results showed the advantage of CABG in a group of patients with previously successfully performed PCI of the clinically dependent artery for non -STEMI and multi-vascular lesions.

Conclusion. In patients with coronary artery disease and multivascular lesions of the coronary bed, who had successfully underwent stenting of the clinical-dependent artery using stents of the 3rd generation with drug coating for acute coronary syndrome without the ST segment elevation, and intermediate severity of lesions on the SYNTAX scale when performing full functional revascularization by coronary artery bypass grafting or stenting, there are no differences in the indicators of cardiovascular mortality, myocardial infarction, acute cerebrovascular disease, frequency of return of the clinic angina pectoris, with the exception of the frequency of repeated revascularization and composite MACCE points, which was statistically significantly higher in the group of stenting.

Journal of Clinical Practice. 2019;10(4):30-35
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The influence of smoking on the prevalence of respiratory symptoms among young people
Tubekova M.А., Bilichenko T.N.
Abstract

Background. Smoking is a preventable risk factor of chronic respiratory diseases.

Aim. To study the incidence of smoking and assess its impact on the prevalence of respiratory symptoms in the young population.

Methods. Based on the GA2LEN questionnaire, a survey of 1252 residents of one Moscow district aged 15–24 years was conducted (response rate — 85.0%). The statistical analysis was performed using the Statistica software package, version 10; EPINFO, version 7 (WHO).

Results. The incidence of smoking was 13.2% among men and 13.0% among women (p=0.895). Regular smoking in young people is registered from the age of 10 years and older. The intensity of smoking was higher in men than in women. The prevalence of respiratory symptoms in smokers (S) was higher than that in non-smokers (NS). 19.1% of NS and 26.3% (p<0.001) of S among men, as well as 15.9% of NS and 29.5% of S (p<0.001) among women noted wheezing in the chest; 30.3% of S and 19.3% of NS (p<0.001) among men and 33.0% of NS and 38.6% of S (p=0.009) among women experienced symptoms of allergic rhinitis in the last 12 months; 20.3% of NS and 25.0% of S (p=0.012) among men and 18.1% of NS and 27.3% of S (p<0.001) among women had nasal congestion for at least 12 weeks.

Conclusions. The adverse effects of smoking on the respiratory health of young people requires an active prevention to reduce the prevalence of respiratory symptoms and the severity of chronic respiratory diseases.

Journal of Clinical Practice. 2019;10(4):36-45
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Technology of intraoperative neuromonitoring by the method of polyprogram electric stimulation at reconstructive neuroplasty operations
Somova M.M., Domanskiy V.L.
Abstract

Introduction. When operating on the face and neck, a technology for intraoperatuve neurophysiological monitoring is used to ensure the right nerve function.

Aim. Development of a technology for the intraoperatuve neuromonitoring and a practical estimation of its efficiency in the reconstructive neuroplasty surgery.

Methods. In 120 patients with the paralysis of mimic muscles after the removal of a cerebellopontine angle neuroma and a facial nerve damage, neuroplasty was performed to restore the innervation. An original technique was developed for identification and monitoring of the functional state of the nerves and muscles — intraoperative visual neuromonitoring (IOVNM). Its concept consists in electric stimulation of the nerves within the surgical field and visual observation of the response muscular contractions. A special ESVM-1 electric stimulator with a set of built-in test programs has been created. The control of the instrument, selection of tests, their launch, visual observation of the reactions and the intraoperative monitoring itself are performed by the operating surgeon.

Results. The presented technology eliminates the need for a complex equipment for neurophysiological monitoring and does not require the participation of a specialist in neurophysiology.

Conclusion. The use of IOVNM during the operation provides an opportunity to assess the functional state of the facial nerve and mimic muscles, to optimize the operation scheme and accelerate its implementation.

Journal of Clinical Practice. 2019;10(4):46-52
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Reviews
The role of nimodipine and magnesium sulfate in the prevention and treatment of vascular spasm in patients in the acute rupture of cerebral aneurysms
Kalinkin A.A., Vinokurov A.G., Kalinkina O.N., Yusubalieva G.М., Chupalenkov S.M.
Abstract

Vascular spasm in patients with hemorrhage from rupture of cerebral aneurysms is the main cause of adverse outcomes of the disease. One way to treat persistent contraction of cerebral arteries is to use nimodipine and magnesium sulfate. This literature review presents studies on the use of nimodipine and magnesium sulfate in the treatment of vascular spasm, and highlights the main links of pathogenesis and drug action mechanisms.

Journal of Clinical Practice. 2019;10(4):53-60
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Spondyloarthrosis: pathogenesis, clinic, diagnosis and treatment (literature review and own experience)
Yarikov A.V., Denisov A.A., Perlmutter O.A., Dokish M.Y., Sosnin A.G., Masevnin S.V., Pavlova E.A., Boyarshinov A.A.
Abstract

85–90% of the elderly people are diagnosed with spondyloarthrosis There are various synonyms for this disease in the literature: facet syndrome, facet pain syndrome, arthrosis of the intervertebral joints, zygapophysial joint arthrosis and spondyloarthropathy. The article analyzes the pathogenesis, clinical picture and methods of diagnosis of this disease. Modern types of conservative and surgical treatment are presented. The advantages and disadvantages of the surgical methods for the facet syndrome treatment are analyzed: instrumental denervation (radio frequency, laser, etc.), chemical denervaion and intraarticular administration of drugs. The results of our own clinical work are presented. The facet joint denervation appears to be a productive minimally invasive method of treatment of the reflex forms of spondyloarthrosis. In the early and long-term postoperative period, it leads to a persistent decrease in the intensity of pain and improvement of the quality of life with a low risk of perioperative complications.

Journal of Clinical Practice. 2019;10(4):61-73
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Treatment of large, massive irreparable rotator cuff tears
Lazko M.F., Prizov A.P., Lazko F.L., Belyak E.A., Maglaperidze I.G., Kuznetsov A.V., Akhpashev A.A., Skipenko T.O.
Abstract

The rotator cuff is a complex anatomical and biomechanical structure which allows stabilization of the shoulder joint in the correct position and movements in it. The rotator cuff tears remain the most frequent injury as compared to those of other anatomical structures of the shoulder joint and reach the incidence of 21%, according to a number of authors. Such injuries are prone to inducing a fat replacement of muscle tissues in elderly patients against the background of degenerative changes in the structure of the rotator cuff. These injuries are hard-to-heal, and the incidence of relapses after the surgical treatment reaches 20–90%, according to several authors. Based on the investigation of the postoperative treatment failures, alternative methods for the replacement, transfer or surgical repair of damaged tendons are adopted, but there is still no single approach and method in the treatment of this pathology. In this literature review, we have analyzed the data on the anatomical structure and biomechanics of the rotator cuff, the role of the rotator cuff damage in the dysfunction of the shoulder joint and possible methods for its recovery.

Journal of Clinical Practice. 2019;10(4):74-80
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Non-coronarogenic causes of increased cardiac troponins in clinical practice
Chaulin A.M., Karslyan L.S., Duplyakov D.V.
Abstract

Cardiospecific isoforms of troponins are the most sensitive and specific biomarkers for the diagnosis of myocardial infarction. However, though elevated troponin levels indicate myocardial damage, they do not determine the cause and mechanism of the damage. With the new highly sensitive methods, very minor damages of the heart muscle can be detected. Myocardial damage can occur in many non-coronarogenic diseases. In this review, we discuss the mechanisms of elevation, the diagnostic value of cardiac troponins in the renal failure, tachyarrhythmias, endocarditis, myocarditis, pericarditis, sepsis, neurogenic pathologies (stroke), pulmonary embolism. In addition, we pay attention to the main reasons for a false-positive increase of the concentration of cardiac troponins: heterophilic antibodies, rheumatoid factor, alkaline phosphatase, cross-reactions with skeletal muscle troponins.

Journal of Clinical Practice. 2019;10(4):81-93
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Clinical case
Clinical case of syphilitic mesaortitis complicated by aortic aneurysm
Ignatenko G.A., Grekov I.S., Grushina M.V., Dubovyk A.V.
Abstract

The modern epidemiological picture of syphilis is such that the detection of syphilitic mesaortitis, as a manifestation of cardiovascular pathology in tertiary syphilis, represents only 10% of cases. One of the most frequent and serious complications of mesaortitis is an aortic aneurysm. The nonspecific nature of symptoms and clinical course of such aneurysms sometimes complicates the timely detection of this pathology, that leads to high mortality at the hospital stage. This article describes a rare case of syphilitic mesaortitis complicated by aortic aneurysm.

Journal of Clinical Practice. 2019;10(4):94-98
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Chronic inguinal pain after laparoscopic transabdominal preperitonal hernioplasty in inguinal hernia
Mykhaylichenko V.Y., Kerimov E.Y., Karakursakov N.E., Chernorotov V.A., Gladilin I.V., Samarin S.A.
Abstract

The ubiquitous application of inguinal hernioplasty performed by various methods does not exclude the occurrence of certain late postoperative complications, the cause of which is sometimes extremely difficult to establish. The article describes a clinical case of observing a patient with chronic postoperative pain 6 months after inguinal hernioplasty using the TAPP technique. When studying the possible causes, the presence of a fixing material (tacker) in the triangle of pain was found, the removal of the latter led to a complete leveling of the clinical picture. Thus, despite the simplicity of performing inguinal hernioplasty, the surgeon’s desire for excessive fixation and a violation of the principles of this operation can lead to undesirable complications and temporary disability of the patient.

Journal of Clinical Practice. 2019;10(4):99-103
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Discussion
How to decide surgical procedure for esophagogastric junction cancer?
Seto Y., Yamashita H.
Abstract

Standard surgical procedure for esophagogastric junction cancer, especially adenocarcinoma, has still remained controversial. Various procedures has been allowed and applied for Siewert type II tumors. Negative long resection margin had been regarded as essential in decision on the procedure. Recent papers have, however, shown the priority of invasion length to each side (esophagus and stomach), because it relates the frequency and sites of lymph node metastasis to be dissected. And, the size of remnant stomach is, also, important when a proximal gastrectomy is considered.

Journal of Clinical Practice. 2019;10(4):104-108
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The surgical procedure for esophagogastric junction cancer — discussing the tactics
Ischenko R.V., Pavlov R.V., Kuznetsova O.A.
Abstract

Introduction. Currently, there is no standardized surgical tactics for the esophagogastric junction cancer treatment. The issues of the resection margin, volume of lymphodissection and the optimal size of the gastric stump are still being discussed. This article analyzes the influence of these parameters on the recurrence-free survival and postoperative quality of life for patients, according to the literature data.

Objective. Analysis of the treatment outcomes for patients with esophagogastric junction cancer, depending on the surgical tactics.

Materials and Methods. The article analyzes the literature data evaluating various approaches in the surgical treatment of esophagogastric junction cancer. We present an example (from the Yasuyuki Seto study) of a patient with proximal gastric adenocarcinoma with a depth of T3 invasion and the surgical tactics regarding the size of the gastric stump. a A great advantage of the resection margin located at 2 cm from the proximal margin and at 5 cm from the distal margin has been shown. According to the results of our own observations, a patient with proximal gastric adenocarcinoma with an invasion depth of T3 underwent a resection with the proximal and distal resection margins of 13 and 65 mm, respectively. Negative resection margins were diagnosed intraoperatively. The patient's recurrence -free survival was 6 years. A total gastrectomy or esophagectomy are not the operations of choice because of the worsening of the patient's quality of life. When analyzing the depth of invasion according to the literature data, it has been found that an invasion in the esophagus of more than 30 mm is associated with an increased risk of metastatic lymph nodes of the superior and middle mediastinum. With a gastric invasion length of more than 40 mm, lymph nodes of lesser curvature along the right gastric artery are affected. According to the literature, a gastric stump with the size of more than two-thirds of the organ size was favorable in terms of the postoperative quality of life. Many authors indicate the positive effect of maintaining the gastroesophageal sphincter and cardia of the stomach. In the study by Yasuyuki Seto, proximal gastric resection was applied only if it was possible to maintain more than 12 cm in the small curvature and 25 cm in the large curvature.

Conclusion. When choosing the surgical tactics for the esophagogastric junction cancer, one needs to focus on the patient's quality of life after the surgery. It is necessary to achieve negative resection margins in each case. The resection margins should be more than 2 and 5 cm for the proximal and distal margins, respectively. Dissection of the lymph nodes of the middle and superior mediastinum should be carried out with invasion of the tumor into the esophagus by more than 30 mm, removal of the lymph nodes of the lesser curvature of the stomach along the right gastric artery must be carried out if the tumor invasion into stomach is more than 40 mm. It is optimal to keep the gastric stump equal to two-thirds of the size of the organ. The issue of the surgical tactics in cancer of the esophageal-gastric transition is of great practical importance and requires a further study.

Journal of Clinical Practice. 2019;10(4):109-114
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