Journal of Clinical Practice

BACKGROUND: Anastomotic leak is the most serious complication in rectal surgery. Predicting and preventing anastomotic leak remains an urgent task.

AIM: The purpose of the study is to analyze the 17-year-long experience of the Federal Research Clinical Center of Specialized Medical Care and Medical Technologies of FMBA of Russia in performing an anterior resection of the rectum in patients with cancer of the rectum and rectosigmoid junction and to establish the risk factors for the development of an anastomotic leak.

METHODS: The results of the treatment of 492 patients who underwent an anterior resection of the rectum in 2006–2022 have been studied. 21 patients developed an anastomotic leak. A retrospective comparison of the characteristics of two groups of patients was carried out: those with a smooth course of the postoperative period and those with the development of an anastomotic leak.

RESULTS: The reliable risk factors for the development of an anastomotic leak were identified and, based on the statistical analysis, a prognostic scoring model was proposed: smoking — 1 point, type 2 diabetes mellitus — 1 point, preoperative chemotherapy — 1 point, blood loss over 50 ml — 2 points, preoperative radiation therapy — 3 points, and the location of the colorectal anastomosis at a distance of up to 5 cm from the anus — 4 points. The sensitivity of the model was 85.6%, with the specificity above 97.4% when using a training set with 8 points or more.

CONCLUSION: The following tactics are proposed: in the case of 4 points and above by the developed scale, one should form a preventive intestinal stoma; in the case of 1–3 points, one should install a transanal drainage. The complete abandonment of these two preventive measures is possible only if the patient does not have any of the listed risk factors for the development of an anastomotic leak.

BACKGROUND: In patients with excessive body weight the diagnosis of complications, in particular, bleeding, at an early follow-up is extremely difficult due to the non-specificity of symptoms and clinical picture. This leads to the late detection and severe expensive multi-stage treatment in patients with initially expressed comorbid pathology.

AIM: to investigate a possibility of improving the diagnosis and therapeutic tactics in morbidly obese patients in case of internal bleeding in the early postoperative period.

METHODS: We have retrospectively analyzed the results of the diagnostics and treatment of 14 patients who had internal bleeding in the early postoperative period after bariatric surgeries. The following parameters were examined: age and sex of the patients, average body mass index, comorbidities, volume of the performed bariatric surgery, type of internal bleeding (intraluminal/intra-abdominal), technical peculiarities of each operation, average postoperative stay, efficiency of instrumental diagnostic methods, types and methods of hemostasis.

RESULTS: Clinical manifestations of bleeding in all the patients operated on for morbid obesity were detected on postoperative days 1–2. The main symptoms included: weakness and dizziness — in 12 cases (86%), blood pressure decrease to 90/60 mmHg — in 4 cases (29%), tachycardia (heart rate of 100 bpm and more) — in 100% of cases. The development of melena and vomiting with blood admixture was noted in 6 cases (43%), blood flow by drainage — in 8 patients (57%). In 4 patients (29%) the bleeding onset was preceded by a blood pressure increase up to (180–200)/(100–110) mmHg. In all 14 patients the hemoglobin level was decreased: in 6 patients (43%) it was not lower than 100 g/L (but decreased by more than 20% from the initial hemoglobin level), and in 8 patients (57%) it dropped below 100 g/L. Esophagogastroduodenoscopy was used to diagnose the bleeding inside the lumen of the stomach, intestine, anastomosis, and computerized tomography of the abdominal cavity with an intravenous and oral contrast was used for diagnosing the intra-abdominal bleeding. In 6 patients with intra-abdominal bleeding, a revision laparoscopy was performed as an emergency procedure. When the source of bleeding from the stapler line was revealed, the bleeding zone was additionally sutured with a Vicryl 3/0 thread using separate knotted sutures. In case of bleeding from the trocar wound, the hemostasis was performed with a Bersi needle using a 1/0 capron thread. No lethal outcomes were observed. All the patients were discharged in a satisfactory condition. The average hospital stay was increased by 2–3 days due to the complication.

CONCLUSION: The effective methods for the diagnostics and treatment of the intraluminal bleeding are endoscopic techniques with the possibility of reliable hemostasis. In case of the intra-abdominal bleeding, relaparoscopy with stitching or clipping of the bleeding source is indicated.

BACKGROUND: Aspergillosis of the lungs, which occurs against the background of COVID-19, develops as a life-threatening complication, especially in patients with a severe disease and those treated in intensive care units. Mortality rates vary significantly in the published materials, with inexplicably high levels in some of them. All the studies are united in the conclusion that, in the absence of a timely diagnosis and treatment, mortality can reach 100%. Obtaining a biological material for the laboratory diagnostics is often difficult. In such cases, computed tomography of the lungs serves as an informative instrumental study to exclude or confirm the presence of the mycotic lung damage, including aspergillosis, against the background of COVID-19. Thus, the systematization, generalization and analysis of CT changes in the lungs of COVID-associated pulmonary aspergillosis are required.

AIM: Determination of CT signs of a possible addition of pulmonary aspergillosis in patients with COVID-19 during a dynamic follow-up.

METHODS: The analysis of the case histories of 646 patients, in whom the results of CT monitoring of the lung condition for at least 2 months were obtained, was carried out. The total number of CT examinations is 5279, the average number of studies per patient is 8. The main group consisted of 144 patients. The leading inclusion criterion was the presence of radiological signs atypical for COVID-19, suspicious for fungal complications. The control group included 502 patients with the lung changes characteristic of COVID-19. All CT scans of the chest organs were performed without intravenous administration of a contrast agent in accordance with the standard scanning protocols.

RESULTS: The analysis of the obtained images revealed the primary signs suspicious for COVID-associated aspergillosis, which can be conditionally divided into typically bronchogenic and conventionally non-bronchogenic signs. Of the total number of patients in the main group, the bronchogenic signs (single and multiple intracellular foci, «peribronchial cuffs», bronchiectasis) were noted in 56 (38.89%) patients, and in 43 (76.79%) of them, the transformation into signs characteristic of a fungal lesion was revealed. Conventionally non-bronchogenic primary signs were identified in 88 (61.11%) patients. In the process of studying the dynamics of signs suspicious for COVID-associated aspergillosis, CT-signs typical of fungal lesions were obtained in 93 (64.58%) patients. Consolidations as a primary sign and a sign of transformation from foci were encountered in one time interval. This finding made it possible to collect all the signs of COVID-associated aspergillosis in a combined timing scheme.

CONCLUSION: The features of the clinical course of the disease in patients with COVID-19 do not allow us to confidently determine co-infection, such as aspergillosis. There are also difficulties in isolating the pathogen culture. Consequently, the role of computed tomography in identifying the semiotics of possible aspergillosis as a complication of COVID-19 is increasing. COVID-associated pulmonary aspergillosis on CT scans is characterized by signs of damage to the respiratory tract with the subsequent formation of cavitary structures.

BACKGROUND: The instability of the knee joint after a rupture of the anterior cruciate ligament and even after its reconstruction remains a pressing problem. The use of a special functional test with fast walking can be considered as a potential tool for verifying this instability.

AIM: to observe the presence of biomechanical differences in the joint function with and without instability, both before and after the anterior cruciate ligament reconstruction.

METHODS: A biomechanical study of the function of walking at fast speeds, including an electromyographic study, was used. 40 patients were examined, of which 22 underwent reconstruction of the anterior cruciate ligament. The patients were divided into two groups — 33 patients with symptoms of instability, and 7 patients without them; the control group included 20 healthy persons.

RESULTS: The time characteristics of the step cycle did not reveal significant differences between the patient groups and the control group. For the amplitudes of movements in the joints, there were also no significant differences between the patient groups and between the affected and intact sides. The only finding was a significant increase in both amplitudes in the knee joint compared to the control for the intact side in the group with instability. The electromyographic study also did not reveal significant differences.

CONCLUSION: The use of a functional test with fast walking does not allow differentiating the state of instability. Thus, the instability of the knee joint during normal walking, even at a high speed, does not manifest itself in any way. To detect it, it is necessary to develop special provocative tests.

The progressive decline in the physiological functions during aging leads to various diseases that place a heavy burden on patients, their families and the society as a whole. Due to the increasing average life expectancy, the problems of prevention and treatment of age-related diseases are becoming more and more relevant. As a part of the research on the regulation of the aging program, considerable attention has been focused on a small family of NAD⁺-dependent deacetylases and deacylases called sirtuins. These proteins are involved in the regulation of numerous intracellular processes, and disruption of their functions plays an important role in the development of various diseases, such as metabolic disorders, pathologies of the cardiovascular system and other organs, musculoskeletal diseases, and neurodegeneration. It is interesting to note that the activity of sirtuins can be modulated to some extent under the influence of pharmacological agents, which makes them promising targets for the prevention and therapy of age-related diseases. The aim of the current review is to summarize the effects of sirtuins on the development and pathogenesis of neurodegenerative diseases, taking into account the reported clinical trials on the pharmacologic agents affecting the sirtuins’ activity.

BACKGROUND: Lambert–Eaton myasthenic syndrome (G73.1 according to ICD-10) is a rare autoimmune disease associated with a presynaptic impairment of neuromuscular transmission due to the production of antibodies to voltage-gated calcium channels. The peculiarity of Lambert–Eaton myasthenic syndrome is manifested in a combination of increased muscle weakness and fatigue with the phenomenon of «working in» — an increase in the muscle strength against the background of muscle load after a short-term maximum contraction. Lambert-Eaton myasthenic syndrome is often associated with small cell lung cancer and very rarely develops with tumors of another localization.

CLINICAL CASE DESCRIPTION: We observed an 80-year-old patient with complaints of weakness and pain in the hips, shoulders, pelvic region, and half-ptosis of the eyelids. For half-ptosis of the eyelids, a differential diagnosis was conducted with myasthenia gravis. Stimulation electromyography revealed the M-response increment, i.e. the phenomenon of “working in”, which is typical for this syndrome. The examination revealed papillary thyroid cancer, which was later treated surgically.

CONCLUSION: This case illustrates Lambert–Eaton’s paraneoplastic myasthenic syndrome, a rare tumor form associated with thyroid cancer.

BACKGROUND: Transient Idiopathic Perivascular Inflammation of the Carotid artery (TIPIC) or carotidynia is a clinical and radiological syndrome manifested as ipsilateral neck pain and an ipsilateral perivascular infiltrate according to ultrasound and magnetic resonance imaging. Due to the low awareness of physicians, this pathology is often mistakenly regarded as dissection or atherosclerosis of the carotid arteries, which leads to additional unnecessary diagnosis and treatment.

CLINICAL CASE DESCRIPTION: Here, we present a case of idiopathic carotidynia with a discussion of the diagnostic algorithm and management of patients with unilateral neck pain.

CONCLUSION: Timely and competently interpreted ultrasound and magnetic resonance imaging studies of arteries is a key link in the diagnosis of carotidynia. The complete regression of symptoms and pathological changes in the arteries without a specific therapy classifies it as a benign variant of non-atherosclerotic arteriopathy.