Journal of Clinical Practice

BACKGROUND: Bariatric surgery is indicated to patients with morbid obesity and aged 18–60 years. In older aged patients, such surgery can also be taken into consideration, however, the procedure of selecting the patients is not included into the clinical recommendations, which determines the topicality of the research. AIM: To establish a protocol for surgical treatment of morbid obesity in patients older than 60 years. METHODS: The research included 800 patients operated during the period of 2018–2023 at the Federal State Budgetary Institution “Federal Scientific and Clinical Center” of the Federal Medical-Biological Agency of Russia due to the presence of morbid obesity, of which 38 had an age of 61 and older. All the patients underwent only two types of surgery — laparoscopic longitudinal resection and laparoscopic Roux gastric bypass surgery. All the patients of the older age group underwent personalized selection for surgical treatment, screening procedures were arranged in order to detect the senile asthenia syndrome and, retrospectively, to stratify them using the GeriBari prognostic scale. During one year of follow-up, the remote results were assessed in all the patients along with the quality of life. RESULTS: There were no postoperative complications in the older age group, the 30-day mortality was 2.6% (1 patient has died from the complications of the coronaviral infection). The weight loss was found to be significantly less in the older age group (61 and older) comparing to the main group of patients (18–60 years): for laparoscopic longitudinal resection — 55.5% versus 73%, respectively (р=0.01), for laparoscopic Roux gastric bypass surgery — 58% versus 77.5% (р=0.0008). The remission of type 2 diabetes was achieved in 70.6% of the patients of the older age group. The quality of life among the patients of the older age group, even with the slight decrease of the excess body weight, was significantly better 12 months after surgery. CONCLUSION: Among the elderly patients with morbid obesity, it is possible to perform bariatry surgeries safely and effectively when following the proposed protocol.

BACKGROUND: Demographic ageing of the society and the growing demand for medical service among the elderly citizens require perfecting the anesthesiology approaches. AIM: Evaluation of the efficiency of using various types of electroencephalography-based monitoring when performing general anesthesia in the settings of ENT-surgery in geriatric patients. METHODS: The randomized study included 99 patients (70–85 years old, ASA III–IV) who underwent surgery under general anesthesia for ENT pathology. The patients were distributed into three groups: Group A (n=33) — anesthesia controlled by CONOX — monitoring, Group В (n=33) — no cerebral monitoring, Group C (n=33) — controlled by BIS monitoring. The controlled parameters included the dosage of the medicinal products (Propofol, Fentanyl, Sevoflurane), the hemodynamics, the rates of intraoperative awakenings, postoperative nausea and vomiting, the need for additional pain medications and the parameters of the cognitive functions before and after surgery. RESULTS: The Propofol dosage in Group B was higher than in Groups А and С (p=0.016 and p=0.012 respectively). The concentration of Sevoflurane in Group С was lower (p=0.016), than in Groups А and В. Hemodynamic disorders and postoperative nausea/vomiting were more often observed in group В. Intraoperative awakenings were reported in 3% of the patients in Group А, in 9% for Group В and in 6% patients in Group С. Additional pain management was required in 39% of the patients in Groups А and В along with 42% in Group С, no statistical difference was found between the groups. Cognitive functions were better preserved in Group А with the duration of general anesthesia being more than 120 minutes (p=0.044). CONCLUSION: Anesthesiology monitoring based on electroencephalogram parameters, optimizing the dosages of the medicinal agents, decreases the rates of hemodynamic disorders, of intraoperative awakenings and of postoperative nausea and vomiting. Combined with the clinical monitoring of the electroencephalogram parameters, this accelerates rehabilitation and improves the surgery outcomes. The optimization of the dosage of opioids with controlling the anesthesia depth index (the Nociception Index, qNOX) positively affects the postoperative cognitive status of the patients.

An analysis of data from national and foreign literature was carried out in terms of intraoperative determination of the intestinal viability in cases of developing the diseases in the abdominal cavity organs, associated with impaired intestinal blood supply. The basis of this work is the analysis of the modern literature on the methods of intraoperative evaluation of mesenteric ischemia. Impaired mesenteric blood supply is often the consequence of a number of reasons of developing critical conditions (mesenteric thrombosis, acute adhesive intestinal obstruction, incarcerated hernia etc.), also representing a high risk factor for lethal outcomes. Special attention is paid to the occlusion-related pathogenetic mechanism of developing mesenteric ischemia, which is accompanied by rapid development of irreversible morphological changes in the tissues and by significant disorders in the homeostasis systems of the organism. The generally available method for visual evaluation of the intestine viability is not always valid in terms of determining the degree of intensity of the ischemic changes in the intestinal wall. The algorithm of determining the intestine viability includes the determination of the intestine color, the peristaltic motions, the pulsation and the blood filling of mesenteric vessels with dynamic evaluation of these signs after the injecting the local anesthetic drug solution into the mesenterium and after “warming” the intestine with towels soaked in warm sodium chloride solution. In the current surgical conditions, a more precise method is required for intraoperative determination of the tissue viability. For the purpose of the objective evaluation of the intestinal blood supply, the recommendations include using intraoperative ultrasonic and laser Doppler flowmetry, as well as the regional transillumination angiotensometry of the intramural vessels in the small intestine. At the same time, a number of optical spectroscopy and visualization methods show high sensitivity to changes in blood microcirculation without using exogenous contrasting, which can also be successfully used when evaluating the intestinal circulation. According to data from modern literature, there is still controversy on the efficiency of various methods for intraoperative evaluation of disorders of the regional blood microcirculation and the intestine viability, which justifies the conduct of further research works.

“Lung-on-a-chip” (LoC) is a microfluidic device, imitating the gas-fluid interface of the pulmonary alveole in the human lung and intended for pathophysiological, pharmacological and molecular-biological studies of the air-blood barrier in vitro. The LoC device itself contains a system of fluid and gas microchannels, separated with a semipermeable elastic membrane, containing a polymer base and the alveolar cell elements. Depending on the type of LoC (single-, double- and three-channel), the membrane may contain only alveolocytes or alveolocytes combined with other cells — endotheliocytes, fibroblasts, alveolar macrophages or tumor cells. Some LoC models also include proteinic or hydrogel stroma, imitating the pulmonary interstitium. The first double-channel LoC variant, in which one side of the membrane contained an alveolocytic monolayer and the other side — a monolayer of endotheliocytes, was developed in 2010 by a group of scientists from the Harvard University for maximally precise in vitro reproduction of the micro-environment and biomechanics operations of the alveoli. Modern LoC modifications include the same elements and differ only by the construction of the microfluidic system, by the biomaterial of semipermeable membrane, by the composition of cellular and stromal elements and by specific tasks to be solved. Besides the LoC imitating the hematoalveolar barrier, there are modifications for studying the specific pathophysiological processes, for the screening of medicinal products, for modeling specific diseases, for example, lung cancer, chronic obstructive pulmonary disease or asthma. In the present review, we have analyzed the existing types of LoC, the biomaterials used, the methods of detecting molecular processes within the microfluidic devices and the main directions of research to be conducted using the “lung-on-a-chip”.

A literature review is presented on the conservative and minimally invasive methods of treating the Dupuytren contracture. The investigators discuss both the methods implemented into clinical practice and those, which are currently at the stage of clinical and laboratory trials, including the minimally invasive methods, which can be used not only at the later stages, but also in cases of early manifestations of the disease. Among them there are the combined use of conservative methods, the radiation therapy, the injections of collagenase and steroids, the use of immunodepressive medicines and the needle aponeurotomy. These methods can be used at the earliest stages of the disease, however, the absence of proper evidence base often hinders their wide implementation. Up to the present moment, there is no commonly acknowledged approach to managing and treating the patients with early stage of the disease. The modern approach is focused on the invasive treatment of only later disease stages and of the severe contracture cases. This is why we would like to emphasize the potential of minimally invasive methods at the early stages of the Dupuytren disease, as well as the necessity of further research in this direction along with the importance of implementing such methods into everyday practice of the physicians.

BACKGROUND: In clinical practice, pulmonary edema still remains one of the threatening conditions with high mortality, despite the sufficiently large attention from the investigators. The classic pulmonary edema is well studied, having its specific x-ray signs, while the unilateral pulmonary edema occurs rarely and causes difficulties in the differential diagnostics performed by the radiologist. CLINICAL CASE DESCRIPTION: The presented material includes cases of ipsi- and contralateral unilateral reexpansion pulmonary edema. These complications have developed as a consequence of rapid evacuation of the pathological content from the pleural cavity. CONCLUSION: Reexpansion pulmonary edema is a rare, though potentially life-threatening condition, which usually occurs as a result of rapid expansion of long-term collapsed lung, for example, in cases of pneumothorax and pleural effusion. The edema may develop several hours after the expansion of the atelectasis.

BACKGROUND: Spinal myeloischemia is a rare but severe neurological disease, associated with high incapacitation level and high social-economical costs due to complications developing during the acute phase. The reasons for its development can include vascular malfomations, spinal stroke, extra- and intramedullary tumors, compression of the spinal cord in cases of vertebral fractures, intervertebral disc herniations, stenosis of the spinal canal at the cervical segment, medical manipulations and impaired segmental circulation during the anesthesia, lumbar puncture and surgical interventions. CLINICAL CASE DESCRIPTION: The presented clinical observation provides a description of the iatrogenic complication that has developed in a patient aged 52 years after discectomy and installation of the disc prosthesis due to the development of disco-radicular and spinal conflict, resulting due to the С5/С6 dorsomedial intervertebral hernia, the clinical manifestations of which, besides pain, included weakness in the left upper limb, causally related to the focus of intramedullary ischemia at the unilateral side. At the early post-surgery period, asymmetrical tetraparesis was revealed with the predominance in the distal segments of the left upper limb and with impaired functions of the pelvic organs, caused by the expansion of the ischemia zone in the gray and white matters in the anterior areas of the lower cervical segments of the spinal cord. CONCLUSION: The timely initiation of combined medication therapy and the staged rehabilitation, conducted by the multi-disciplinary team, have provided the restoration of the impaired functions and the quality of life for the patient. The proposed methods can be useful in the treatment of patients with compression-related and non-compression-related vascular myelopathies.