Vol 11, No 4 (2019)

Poor results of surgical treatment of hiatal hernias. Is there a solution to the problem?
Bechvaya G.T., Vasilevsky D.I., Akhmatov A.M., Kovalik V.V.

Hiatal hernias are the most common violation of visceral anatomy. Indications for surgical treatment of this pathology include refractory gastroesophageal reflux or anatomical changes, which carry a risk of developing life-threatening conditions. An unresolved problem in this area of surgery is the high recurrence rate of the disease, reaching 10–40%. Subjective causes of unsatisfactory results are technical errors in performing interventions and violations of perioperative management. Compliance with the methodology of operations and the rules of patient management can minimize this group of factors. Large size of the hiatal opening, mechanical weakness of diaphragm crura and shortening of the esophagus are considered to be objective causes for the recurrent disease. An effective way to increase the reliability of the plastic esophageal opening of the diaphragm is the use of prosthetic materials. When the esophagus is shortened, it is possible to increase its length with the stomach (gastroplasty) or with the formation of a fundoplication wrap in the chest. Another option to increase the reliability of the operation may be fixing the stomach to the anterior abdominal wall (gastropexia) to prevent its redeployment to the chest. The use of this arsenal of techniques allows to reduce the frequency of unsatisfactory results after surgical treatment of hiatal hernias by up to 5–10%.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):5-10
Circulating tumor DNA as specific biomarkers for early diagnosis and prognosis of pancreatic cancer
Tarmaev A.A., Beylerli O.A.

Pancreatic adenocarcinoma is considered one of the most aggressive cancers with high mortality and low 5-year survival rate. This is mainly due to its late detection. Complex anatomical location creates certain difficulties for imaging and puncture biopsy methods, while standard tumor markers do not have high sensitivity and specificity. Thus, the search for specific biomarkers for early diagnosis and prognosis of the disease, as well as monitoring patients with pancreatic cancer during treatment, is a priority to improve patient survival in this terminal disease. Liquid biopsy, which has recently gained a lot of attention including the study of free-circulating tumor DNA (ctDNA) in plasma or serum, is a promising additional method of research. In this review, we will consider the latest findings from the ctDNA study as early and prognostic biomarkers for pancreatic cancer and monitoring the disease during treatment.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):11-17
Original researches
Capabilities of perfusion computed tomography in colorectal cancer detection and differential diagnosis of pathological conditions of the colon. Early results
Kabanov M.Y., Borovik I.K., Belikova M.Y., Sementsov K.V., Itskovich I.E., Gorshenin T.L., Rozengauz E.V.

The article presents the results of preoperative CT diagnostics of colorectal cancer using perfusion technique. It was found that CT perfusion can improve the diagnostics of local prevalence of colon cancer compared to standard computed tomography, as well as to differentiate colorectal cancer and inflammatory bowel disease.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):19-26
The attitude of doctors of various specialties to the problem of flatfoot
Kenis V.M., Dimitrieva A.J., Sapogovskiy A.V.

Purpose: to assess the subjective perception of flatfoot’s prevalence in children, its age dynamics and the main approaches to the diagnosis and treatment by doctors of various pediatric specialties with different medical experience and working in medical facilities at various levels by anonymous questionnaire.

Materials and methods. Questionnaire data from 80 orthopedists (50 outpatient doctors, 30 doctors from a specialized scientific research institute and orthopedic departments of city hospitals (research institutes / hospitals) and 30 neurologists (polyclinic).

Results: our study demonstrated that outpatient orthopedists diagnose the flatfoot on average in half of the cases. The orthopedists diagnose flatfoot only by means of visual examination in 46.1% of cases (neurologists — in 85.7% of cases). According to our data, 58.9 % of outpatient doctors recommend wearing special orthopedic shoes (46.1 % — only if the foot alone is affected) and 95.1 % of specialists recommend wearing individual orthopedic insoles (53.6 % — if there are complaints). While 88.2 % of the orthopedic surgeons from specialized research institutes and hospitals do not recommend wearing orthopedic shoes; 26.7 % of experts recommend wearing individual orthopedic insoles only in the presence of complaints. On the other hand, the neurologists recommend wearing orthopedic shoes 5.3 times more often than the orthopedists do.

Conclusion: our study demonstrates that the specialty of the doctor (orthopedist, neurologist) and the type of health care facilities in which the specialist works have the greatest impact on his subjective perception of the prevalence and age dynamics of flatfoot in children, tactics of diagnostics and treatment. The outpatient orthopedists diagnose “flatfoot” 4.2 times more often than the orthopedic surgeons from the specialized research institute and hospitals. Also, the outpatient orthopedists prescribe wearing orthopedic shoes 4.9 times more often (insoles — 3.6 times more often) in comparison with the orthopedic surgeons of the specialized research institute and orthopedic hospitals. Summarizing the above mentioned, we would like to note that due to the fact that the current assessment of the age limits of the arch height feet is ambiguous, there is a need to introduce a unified system for assessing the foot’s shape and posture with defining the concepts of “average height” and “typically developing foot”.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):27-36
Peculiarities of percutaneous stenting interventions on the bile ducts
Yakovleva D.M.

Bile duct stenting is not a common intervention in most multidisciplinary hospitals in our city. The article presents our 5-year experience with 84 antegrade prosthetic interventions using self-expanding nitinol stents and endoprostheses. The interventions were carried out in 2 stages: percutaneous transhepatic cholangiography drainage followed by biliary stenting or endoprosthetics. All patients were operated on for obstructive jaundice: 10 benign genesis, 74 — malignant. The analysis of postoperative pancreatitis with primary drainage intervention development allowed us to find the algorithm for its prediction, early detection and treatment. The possibilities of using partially-coated nitinol stents in different variants of the biliary tree anatomy were considered. The article also provides evidence for advisability of endoprosthesses in benign strictures of the bile ducts.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):37-46
Chronic fatigue syndrome in the routine hematology practice
V.G.Potapenko V.G., Ballyuzek M.F.

Purpose. Presentation of clinical signs and laboratory profiles of the patients with chronic fatigue syndrome, and comparison of their symptoms with those of the patients with iron deficiency anemia.

Materials and methods. Retrospective analysis of the patients’ symptoms referred to the hematologist outpatient clinic during the period between January 2016 and December 2018.

Results. There were 560 patients(162 males and 398 females) referred for a primary consultation by a hematologist. Median age was 52.5 (18–94) years. The unexplained fatigue was reported by 27 (4.8%) patients (1 male and 26 females), median age — 41 (24–66) years. Diagnosis “chronic fatigue syndrome (CFS)” was confirmed based on the criteria in 17 (63%) patients. 10 patients (47%) with symptoms partially meeting the criteria were diagnosed idiopathic fatigue syndrome (SIF). Half of the patients connected the onset of the diseases with emotional trauma (family issues etc.). The prevailing complaints (>30%) were represented by: prolonged fatigue, mild memory impairment and distraction, arthralgia and insomnia. The most frequent reason to see a hematologist was fatigue and borderline changes in the blood tests. Five patients with CFS and 2 patients with SIF were known to have previously diagnosed iron deficient anemia (IDA). Median level of hemoglobin in the patients with severe fatigue and IDA was 10.7 (8.4–11.7) g/dl. Median follow up duration was 28 (6–40) months. In the observed group (n = 23) 17% of the patients (n = 4) showed spontaneous improvement. The rest of the patients had reported no changes. The comparison group (n = 64) included the patients with IDA. Most of them (n = 38) did not report fatigue as their initial symptoms (median level of hemoglobin was 9.35 (5.5–11.9) g/dl). Twenty six patients reported fatigue; median level of hemoglobin was 8.15 (5.9–11.7) g/dl. The difference between the hemoglobin levels in two groups was significant (р < 0.05). However, there was no correlation between the level of hemoglobin and fatigue in the patients with CFS and SIF. The correlation was found in the patients with CFS and SIF between fatigue and patients’ perception.

Conclusion. The main symptoms accompanying CFS are fatigue and other non-specific symptoms which are often related to patients’ emotional status. Considering CFS as a differential diagnosis when dealing with fatigue is essential.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):47-54
Standartized indicators of masticatory muscles functional activity for patients with transversal intermaxillary anomalies
Nikolaev A.V., Popov S.A.

The study involved patients with a normal intermaxillary ratio and with a transversal maxillary deficiency. The age of the patients varied between 25 and 40 years. In all the examined patients, orthodontic treatment had not been previously performed. The group of patients with transversal anomalies involved 45 clinical cases, the group of patients with neutral occlusion involved 42 cases. Superficial electromyographic research was carried out according to the method of Professor V.F. Ferrario. The comparison of the functional activity parameters of the maxillofacial region using standardized coefficients of surface electromyography revealedsignifica abnormal indicators in the patients with transversal anomalies compared to the patients with neutral occlusion. This fact must be taken into account when planning orthodontic treatment.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):55-58
The role and diagnostic value of the most common methods for diagnosing Helicobacter pylori infection
Tryapitsyn A.V., Mal’kov V.A.

The purpose of the study was to identify and evaluate the practical value of the most common diagnostic methods for Helicobacter pylori infection in patients with chronic inflammation of the gastric mucosa.

Materials and methods. The study involved 104 people. All the patients examined underwent esophagogastroduodenoscopy with a rapid urease histochemical test for Helicobacter pylori and a standard five-point biopsy of the gastric mucosa for morphological evaluation and bacterioscopy. If the result of the quick urease histochemical test coincided with the data of the biopsy study on Helicobacter pylori, no further examination was carried out. In case of discrepancy the patients additionally underwent the 13C-urease breath test.

Results. It was found that the sensitivity of the rapid urease histochemical test in the area of the proposed model, according to our study, was 89.74% and the specificity was 46.15% when validating it using the additional methods. Similar calculations for the diagnostic method of staining by Giemsa showed sensitivity of 100% and specificity of 97.4%. The total number of the infected in the survey was 78 out of 104 people, which amounted to 75%.

When analysing the severity of activity, inflammation and atrophic changes in the gastric mucosa, it was found that in the patients with two positive tests, the severity of the processes was significantly higher than in those with one positive test or all the tests were negative (p < 0.05). When comparing the same processes in cases where only a quick urease histochemical test was positive and no signs of Helicobacteriosis were detected in any test, no significant differences were detected.

Discussion. The rapid urease histochemical test showed good sensitivity of 89.74%, but unsatisfactory specificity of 46.15%, which severely limits its use. An unexpected result for this methodology was a large number of false positive tests, while the European recommendations indicate a more frequent occurrence of false negative results, which can be explained by differences in the production technology of the test systems. High sensitivity and specificity of the Helicobacter pylori test using Giemsa staining strongly depends on observing the methodology and experience of a specialist and cannot be recommended as a standard in the routine medical use.

The study confirmed the recommendations for using at least two diagnostic tests to diagnose the infection, while the most common rapid urease histochemical test always needs confirmation. As a result of the analysis, it can be said that esophagastroduodenoscopy with a rapid urease histochemical test for Helicobacter pylori and standard diagnostic biopsy is the optimal method for diagnosing the pathology of the “upper” sections of the gastrointestinal tract. Moreover, 13C-UDT seems to be almost ideal as a screening technique and for evaluating treatment in cases where endoscopic monitoring is not necessary.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):59-66
Opportunities of polyhepatography in the assessment of diastolic function of the right ventricle in patients with essential hypertension
Apresyan A.G., Ermolov S.Y., Ermolova T.V., Manasyan S.G., Serdyukov S.V., Talan A.S.

The article presents a new method for determining diastolic function of the right ventricle in patients with essential hypertension through evaluation of intrahepatic blood flow by the method of polyhepatography.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):67-74
Minimally invasive surgery in the treatment of acute pancreatitis
Topuzov E.E., Tsatinyan B.G., Topuzov E.G., Balashov V.K., Arshba E.A., Ali A.K., Ataev G.B.

Background. In recent years, the lethality from acute pancreatitis in Russia has not undergone significant changes and according to various data is from 15% to 25%.

Purpose. The evaluation of the performing minimally invasive interventions in the treatment of patients with moderate to severe acute pancreatitis.

Materials and methods. The authors retrospectively analyzed the medical records of 169 patients, the structure of mortality and complications depending on the choice of surgical intervention for the patients with acute pancreatitis of moderate and severe degree.

Results. Lethal outcomes in the group of patients using minimally invasive interventions amounted to 11.5%, in the group of patients using traditional operations — 37.5%, p < 0.05. Laparoscopic interventions were effective in 88.8% of the cases, and drug therapy had a positive effect in 81.2% of the cases, p > 0.05.

Conclusion. It is shown that the use of minimally invasive techniques in the treatment of pancreatic necrosis significantly reduces the levels of mortality, postoperative complications, which improves the overall results of acute pancreatitis treatment.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):75-80
Case report
Hemangioma of the major duodenal papilla complicated with bleeding
Rayn V.Y., Ionin V.P., Persidskiy M.A.

Herein we report a case of hemangioma with a rare localization in the major duodenal papilla presenting with a recurrent intraluminal bleeding in a 60-years old patient. Late onset, clinical and endoscopic signs suspicious for malignancy and inability to rule out cancer by preoperative biopsy defined an aggressive surgical approach. The patient underwent classical Whipple procedure after failing an attempt of endovascular embolization of the posterior pancreatoduodenal artery with unfavorable surgical outcome. Available preoperative diagnostic modalities and their accuracy levels are discussed.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2019;11(4):81-85

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