Vol 16, No 3 (2025)

BACKGROUND: The modern military conflict is characterized by a significant number of wounded with the damage of the magistral arteries in the limbs. Such an injury is accompanied by the possibility of lethal outcome and by the high risk of limb amputation. The treatment of the injuries in the major arteries requires high qualification of the medical staff and sufficient equipment basis. The optimal tactics for this still remains the matter of discussion. AIM: to define the specific features of the surgical tactics in cases of injured magistral arteries in the settings of the civilian specialized in-patient hospital in the regions adjacent to the scene of military operations. METHODS: The analyzed data included the treatment results in 57 patients with battle injuries of the magistral arteries in the limbs, in which we have managed to track the direct result of restoring the arteries within not less than two days. The variety of manifestations observed in cases of injuries was demonstrated using 8 clinical cases. The surgical tactics was defined by the degree of ischemia in the muscles and the extent of damaging the tissues in the limb. Amputations were conducted in cases of developing the ischemic contracture or in cases of significantly damaged limb tissues. RESULTS: The resection of the artery with autovenous prosthetic replacement was done in 49 cases, while the circular resection of the artery with the direct anastomosis — in 8 cases. Within the earliest post-surgery period (first two days) due to the post-ischemic syndrome, the usage of the extracorporeal detoxication methods was required in 5 (9%) wounded. The restoration of the peripheral circulation was observed in 56 (98.2%) cases, the secondary amputation of the lower limb was done only in 1 (1.8%) operated patient. No fatal outcomes were reported (0%). CONCLUSION: In the modern military conflict, the battle contact line can be located in the direct proximity from the well-equipped civilian healthcare institutions, at the premises of which the high-tech medical aid is accessible. Our experience shows that, in case of performing the complex surgeries, the follow-up within the early period is practicable to be organized at the site with avoiding the immediate evacuation. In cases of damaging the magistral artery in the limb, the main parameter affecting the possibility of saving the limb itself, is the degree of ischemia in the muscles. The irreversible ischemia is often hard to define and the development of the ischemic contracture should be taken as the guidance. The time of injury, the absence of pulse, of the active movements or sensitivity cannot serve as an indication for amputation. The algorithm developed by us has shown its high efficiency.

BACKGROUND: The impact of various risk factors on the development of post-operative cognitive dysfunction in neurosurgical patients requires research for decreasing the probability of developing this complication. AIM: To determine the effects of extra- and intraoperative risk factors on the development of post-operative cognitive dysfunction in neurosurgical patients after undergoing a vertebral column surgery with long-running anesthetic support. METHODS: The research was carried out among the neurosurgical patients with previous surgical intervention in the vertebral column, within the premises of the Neurosurgery Department of the State Budgetary Healthcare Institution of the Tyumen Oblast “Regional Clinical Hospital No. 2”. The evaluation included the cognitive functions before surgery and on Day 3 after the surgical intervention using the Montreal Cognitive Assessment (MoCA), along with a panel of Isaac tests and the Munsterberg test. The calculated coefficients were the Pearson’s and the point biserial correlation coefficients regarding the following intraoperative risk factors: type and duration of anesthetic management, medications used for anesthesia and muscle relaxation, as well as the type of surgery. Evaluations were also made for the interrelation between the development of post-operative cognitive dysfunction and the following extra-operational risk factors: the age, the body mass index, the number of education years, the presence of arterial hypertension or diabetes and smoking. RESULTS: A notable positive correlation was observed between the development of post-operative cognitive dysfunction and the age (r=0.53; p <0.01), moderate correlation with the body mass index (r=0.35; p <0.01) and with the presence of arterial hypertension (r=0.42; p <0.05). A moderate negative relation was observed for the number of education years and the development of post-operative cognitive dysfunction (r=-0.36; p <0.01). The relation of the presence of diabetes with post-operative cognitive dysfunction did not show significant correlation. Smoking and surgery duration show low level of interrelation, which does not allow to comprehensively interpret the obtained results as significant. The type of surgical intervention and the duration of anesthetic support did not correlate with the development of post-operative cognitive dysfunction (r <0.1; p <0.01). A moderate correlation was found for the anesthesia conducting using a drug combination of desflurane+fentanyl (r=0.31; p <0.05) along with the mild one when combining sevoflurane+fentanyl+ketamine (r=0.25; p <0.05). The usage of fentanyl together with sevoflurane (r=0.07), propofol (r=-0.1) and sodium oxybutyrate (r=0.05) does not lead to post-operative cognitive dysfunction (p <0.05). CONCLUSION: Elderly age, high body mass index, presence of arterial hypertension and low education level increase the risks of developing post-operative cognitive dysfunction. Using the desflurane+fentanyl and sevoflurane+fentanyl+ketamine combinations can also contribute to the occurrence of cognitive disorders.

BACKGROUND: Cardiosurgical interventions in the settings of artificial circulation are usually characterized by the significant blood loss and by the need for transfusing donor blood components. Besides the systemic inflammatory reaction, hemodilution and hypocoagulation, an important contribution into the development of perioperative anemia is added by the blood loss associated with the finishing stage of the artificial circulation. AIM: An optimization of the finishing stage of artificial circulation for decreasing the blood loss during the heart surgeries. METHODS: The patients operated in the settings of artificial circulation (n=62) were randomized into two groups. In the main group (n=31) upon the end of the artificial circulation, the whole blood volume in all the tubes of the artificial circulation equipment was returned to the central vein of the patient. In the comparison group (n=31), the method used was the return of residual blood from the pipelines of the artificial circulation equipment by means of substitution with physiological saline. The analysis included the data obtained using the laboratory and instrumental methods of examination. RESULTS: The intraoperative blood loss in the main group was significantly lower comparing to the one in the comparison group (500 ml [470–520] versus 800 ml [760–830], р=0.0001). In 24 hours after surgery, the levels of creatinine, alanine aminotransferase and amylase were higher in the main group than in the comparison group. At the end of surgery, the main group also had higher values of the cardiac output (3.1 [2.8–3.6] versus 2.8 [2.6–3.1], р=0.018) and the global ejection fraction (28 [22–31] versus 22 [19–24], р=0.011). In the comparison group, the global end-diastolic volume index has significantly decreased comparing to the initial level (753 [665–900] and 647 [615–820] respectively, р=0.019). No adverse events or reactions were registered during the research. CONCLUSION: The complete return of blood after the artificial circulation into the organism of the patient results in an increase in the levels of hemoglobin and hematocrit at the early post-surgery period, and it is accompanied by lesser volume of blood loss and higher levels of the cardiac index and the global ejection fraction after the main surgery phase with a background of the absence of significant adverse events.

Renal cell cancer is one of the most widespread oncourological diseases (90% of all the malignant neoplasms in the kidneys) with high mortality. Every year worldwide, approximately 120,000 new cases of renal cell cancer are diagnosed, which is approximately 2% within the structure of the cancer incidence rates, and 65% of the patients are being diagnosed in the developed countries. Nephrectomy is the main method of radical therapy for such patients. In cases of tumor thrombosis of the inferior vena cava, which develops in 25–30% of the cases of renal cell cancer and represents a lethal complication of this disease due to the fragmentation of the thrombotic masses and developing pulmonary embolism, nephrectomy with thrombectomy is indicated. A special category includes the patients with renal cell cancer, complicated by the tumor thrombosis of the inferior vena cava with grades III (thrombus located at the level or above the hepatic veins, but below the diaphragm) and IV (thrombus spreading into the supradiaphragmatic inferior vena cava or into the right atrium) according to the classification by the Mayo Clinic, in which the surgical strategy is accompanied by significantly traumatic manipulations with the liver, the suprahepatic segment of the inferior vena cava, as well as with the heart chambers, suggesting the parallel cardiosurgical intervention. Surgical interventions with this background are accompanied by the complete or the parallel methods of extracorporeal circulation. The initially burdened status of the patient (tumor-related intoxication, anemia, hyperazotemia, in a number of cases thrombosis of the venous system in the lower limbs along with the concomitant abnormalities) and the extent of surgical intervention determine the high risk of complications (up to 93%) and hospital mortality (up to 10%). The preoperative evaluation of the risks of surgery, defining the most favorable tactics for the patient and the thorough preoperative preparation are necessary for the safest course of surgery and for the early rehabilitation of the patient. Currently, there is no unified commonly accepted algorithm adopted for managing such patients, while the developed commonly available standards often have a generalized type, not reflecting the specific features found in the patients with tumor thrombosis of the inferior vena cava. This review attempts to compile the specific features of the anesthetic management in cases of nephrectomy with thrombectomy in patients with renal cell cancer, to describe the main pathophysiological features of the tumor thrombosis of the inferior vena cava, the complications of the perioperative period, the methods for their prevention and treatment. The main directions were provided for the combined diagnostics and treatment, special attention was paid to the multi-disciplinary (urologists, oncologists, cardiovascular and cardiosurgery specialists, anesthesiologists and intensivists) team-based approach to perioperative management of the patients with tumor thrombosis of the inferior vena cava.

Lung cancer represents a heterogeneous group of malignant neoplasms, among which two main forms can be distinguished — the non-small-cell and the small-cell lung cancer. These subtypes significantly differ by the histological, the molecular-genetic and the clinical characteristics, which defines the necessity of precise differential diagnostics for selecting the optimal treatment tactics. The review highlights the modern methods of diagnostics for the non-small-cell and the small-cell lung cancer, including the instrumental diagnostics, the histological and immunohistochemical examinations. Special attention was paid to the pros and cons of the promising non- and minimally invasive approaches, such as the analysis of circulating tumor cells, of the extracellular DNA, of the miRNA, of the marker proteins, of the volatile organic compounds and of the modern medical visualization (radiomics). Despite the significant progress in developing new diagnostic approaches, the problems remain that are related to the heterogeneity of tumors, the limited accessibility of the materials of small-cell lung cancer and the necessity of standardizing the new methods. The promising direction seems to the integration of multimodal approaches, combining the fluid biopsy, radiomics and the algorithms of machine learning, which can increase the precision of diagnostics and optimize the personalized treatment of the patients with various subtypes of lung cancer.

BACKGROUND: FXTAS Syndrome (Fragile X-Associated Tremor/Ataxia Syndrome) is a neurodegenerative disease with late onset, which manifests in men and women carrying the mutation in the FMR1 gene, located in the X-chromosome. The disease manifests with high phenotypic variability (tremor, cerebellar ataxia, parkinsonism, oculomotor disorders, cognitive and mental disorders). Due to the insufficient awareness among the physicians on this disease, FXTAS Syndrome patients often get incorrect diagnosis (essential tremor, Parkinson disease, multisystem atrophy, spinocerebellar ataxia etc.). CLINICAL CASE DESCRIPTION: The case presented is the patient aged 68 years with a severe past medical history (ischemic heart disease, post-infarction cardiosclerosis with the formation of post-infarction aneurism, arterial hypertension, pulmonary tuberculosis, chronic obstructive pulmonary disease, type 2 diabetes), in which the FXTAS Syndrome has first manifested with tremors, impaired coordination of motions, balance problems, cognitive disorders and affective disorders. The disease was confirmed by the genetic test (in the FMR1 gene, 96 CGG repeats were found). The patient’s daughter was examined with detecting the premutation of the FMR1 gene, while the grandson has a Martin-Bell syndrome. CONCLUSION: Neurologists and specialists of adjacent fields should keep in mind the FXTAS Syndrome (Fragile X-Associated Tremor/Ataxia Syndrome) and, in case of the patient having the corresponding symptoms, should rule out this rare neurodegenerative disease by arranging the genetic testing to reveal the mutation in the FMR1 gene.

BACKGROUND: Acute retinal necrosis is a serious uveal syndrome of viral origin, which manifests with inflammatory reaction in the vitreous body and in the anterior chamber of the eye, along with the rapidly progressing peripheral necrotic retinitis and occlusive vasculitis. This condition is complicated by retinal detachment in 65–75% of the cases, which may lead to the complete loss of vision. The prognosis for the patients with acute retinal necrosis is generally unfavorable: in case of late diagnostics and insufficient treatment, there is a risk of irreversible blindness, while in 60% of the cases, a decrease in the visual functions below 0.1 is observed. CLINICAL CASE DESCRIPTION: The female patient М., aged 57 years, in 2023 was admitted with the complaints of decreased vision acuity and photophobia in her right eye developing 2 months after a previous episode of acute respiratory viral infection. Physical examination data for the right eye (OD): best corrected visual acuity 0.2, intraocular pressure 29 mm.Hg., the anterior-posterior size is 23.06 mm; according to the biomicroscopy data — pericorneal injection of the conjunctiva and variously sized white-colored precipitates along the whole corneal endothelium. 3 weeks after the initial treatment, the patient had retinal detachment with a decrease in visual acuity to light perception with proper light projection. After the conducted conservative and surgical ophthalmological treatment, including the treatment prescribed by the Infectious Disease Physician, from the beginning of 2024 and to the present day, the periodical control examinations reveal the best corrected visual acuity of 0.1–0.2 in the right eye (OD) of the patient. The intraocular pressure is 15–16 mm.Hg, the anterior-posterior size in 2025 became equal to 21.63 mm. The field of vision has changed insignificantly, without any clear negative changes. Ophthalmoscopically and according to the data from the optical coherence tomography, there is a persisting cystous intraretinal edema, tangential-traction syndrome and pre-retinal membrane in the right eye with no negative changes; the retina is attached in all the meridians. CONCLUSION: This case underlines the importance of the combined and multidisciplinary approach to the diagnostics and treatment of ophthalmological diseases caused by viral infections.