Vol 15, No 3 (2024)

BACKGROUND: Chronic cardiac failure belongs to the most threatening and delayed manifestations of cardiotoxicity in oncology patients receiving the treatment with antitumor medicines. As of today, only two groups of drugs were proven to have significant cardioprotective effects in these categories of patients: angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and beta-adrenergic blockers. Recently, the first data were published on the successful use of sodium-glucose cotransporter type 2 inhibitors in patients with chronic cardiac failure, receiving anthracycline therapy.

AIM: optimization of cardioprotective therapy in the treatment of chronic cardiac failure in oncology patients receiving cardiotoxic chemotherapy.

METHODS: A prospective observational open-label research was carried out with an enrollment of 116 oncology patients with verified chronic cardiac failure, which were receiving cardiotoxic chemotherapy, of which 60 patients of the control group were receiving double cardioprotective therapy (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers) and the 56 patients of the test group were receiving similar therapy with an addition of Dapagliflozin at a dosage of 10 mg once daily in the morning. The controls of the results were conducted in 6 months by means of laboratory and instrumental examinations, as well as by using additional methods of controlling the results.

RESULTS: The groups compared did not differ by the combined primary clinical endpoint (the rate of hospitalizations due to cardio-vascular reasons, the refusal to undergo chemotherapy for the reason of chronic cardiac failure progression and the safety of using the drug products: the presence of urinary tract infections and sepsis), but they differed by the surrogate clinical endpoints that included the dynamic trend of the levels of the groups compared did not differ by the combined primary clinical endpoint (the rate of hospitalizations due to cardio-vascular reasons, the refusal to undergo chemotherapy for the reason of chronic cardiac failure progression and the safety of using the drug products: the presence of urinary tract infections and sepsis), but they differed by the surrogate clinical endpoints that included the dynamic trend of the levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and the global longitudinal strain (GLS) of the left ventricle, determined within the timeframes established for the research — before the initiation of chemotherapy and in 6 months. The patients that have passed all the control tests (n=47), after the end of the 6 months period, underwent a comparison of the levels of troponin Т, left ventricle ejection fraction (LVEF), NT-proBNP and GLS. It was found that the dynamic changes of troponin T levels in both groups did not significantly differ (p=0,260), as well as the LVEF indicator (p=0.340), while the NT-proBNP level was significantly decreasing in the test group — by 7.8% comparing to the control group (p=0.006). Comparable data were obtained for the GLS (the decrease in the test group by 6.5% in relative values) comparing to the control group (p=0.008). In 22/47 (46,8%) patients, chronic cardiac failure was diagnosed before the initiation of chemotherapy, in 25/47 (53,2%), chronic cardiac failure was developing during the antitumor medication therapy. In both groups, a total of 17 (16%) fatal outcomes were registered, none of which was caused by the cardiac failure.

CONCLUSION: We suppose that the decrease in the levels of the cardiac failure marker and the less intensive impairment of the left ventricle longitudinal strain with a background of adding sodium-glucose cotransporter type 2 inhibitors to baseline therapy for chronic cardiac failure in oncology patients receiving cardiotoxic chemotherapy, reflects their cardioprotective potential. Thus, the sodium-glucose cotransporter type 2 inhibitor Dapagliflozin slows down the progression of chronic cardiac failure in oncology patients receiving cardiotoxic chemotherapy.

The editorial policy of the “Clinical Practice” journal is supposed to be oriented to Applied Clinical Researches, the results of which practicing physicians could use in their routine work. The main objective of creating the journal was informing the physicians on the novel approaches in the diagnostics and treatment of various diseases, as well as rehabilitation and restoration of the quality of life. For this reason, the editorial board had often refused to publish the articles from the authors of well-planned and performed animal research works, even despite the fact that the clinical specialty certificate 3.1.9 “Surgery” supposes the experimental development of new methods.

In this specific case, the decision was made to publish the article.

Bariatric surgery in Russia is only passing its development phase. Despite the fact that such surgeries are indicated to a significant part of the population, their yearly number remains very small. A considerable role in this is contributed by mass media, which are regularly publishing the cases of complications resulting from the obesity-related surgeries and the consequent judicial proceedings.

Safety issues take the central place in bariatrics, for surgical aggression is applied to a healthy organ for the reason of the general disease, not causing a direct threat to life.

Longitudinal gastric resection (sleeve gastrectomy) is the most popular bariatric surgery type in Russia. According to data from the National Bariatric Surgery Register, this type of procedure represents 56% of all the primary surgeries. Machine suture incompetence is a rare but the most threatening complication of such a surgery, associated with high mortality rates. In Russia, from 2013 until 2022, a total of 70 cases were reported for suture line disruption, which corresponds to 0.4%, with that being said, three such patients died within the first week after surgery. Due to the high pressure inside the created gastric tube, the treatment of these complications is long-term and requires substantial financial costs. The methods for intraoperative diagnostics of problematic areas of the machine suture line, which require additional suture reinforcement, are deemed necessary. Traditionally, many surgeons use the so-called “bubble-test”, which can detect only large defects and which shows low informational capability. With all of these, two large researches were published recently, which have confirmed the concerns of some investigators about the fact that rapid inflation of air into the nasogastral tube can damage the tissue and can increase the risk of incompetence. In a systematic review and meta-analysis by Ma L., et al. (2024.), involving 469 588 patients, in case of performing the intraoperative diagnostics, the risk was 0.38%, while in absence of such — 0.31% (р=0.000) [1]. When analyzing the database of the American Society for Metabolic and Bariatric Surgery (MBSAQIP) within a time period of 2015–2019, based on the evaluation of data from the research works including 283 520 patients, the risk of incompetence during the intraoperative diagnostics was 1.1 (95%CI 1.0–1.4) [2]. Based on these research works, it is possible to recommend the surgeons to avoid the routine use of the “bubble test”. But the alternative option is required. Data on the use of Indocyanine green are still sparse. The research performed by А.А. Kovalev et al., must serve as a basis for more frequent use of this method, especially in complex situations. The editorial board of our journal shall eagerly await for the team of authors to present the results of the clinical approbation of the said method.

BACKGROUND: Thoracoscopic thymectomy performed with using the lateral intercostal access in cases of non-invasive thymic tumors is the commonly used technique. Most frequently, the three-port and the single-port techniques are used. As the experience was accumulating, it became evident that the intercostal access has a number of disadvantages, such as unsatisfactory visualization of the nerve on the opposite side and of the cervical portion of the thymus, along with a probably of developing chronic pain syndrome. One of the possible solutions for this issue can include the use of sub-xyphoid access.

AIM: An evaluation of direct results obtained when using the unified sub-xyphoid access during thoracoscopic thymectomy in patients with non-invasive epithelial thymic tumors.

METHODS: An experience was analyzed that was gained after the treatment of 14 patients undergoing thoracoscopic thymectomy using the unified sub-xyphoid access for non-invasive epithelial tumors of the thymus. The age of the patients ranged from 24 to 70 years (median — 42 years); 9 of them were females (64.3%) and 5 were males (35.7%). In all the patients, at the moment of surgical treatment, stage I disease was diagnosed. The minimal dimension of the excised thymoma in this research was 15 mm with the maximal dimension being 65 mm, the median value was 38 mm.

RESULTS: Two surgeries (14.3%) were accompanied with technical difficulties due to the presence of an adhesion process after a previous episode of pulmonary inflammation, which resulted in more significant intraoperative blood loss, which was 200 ml. The surgery duration varied from 60 to 180 minutes with the median of 82.5 minutes. In the majority of cases (97.6%), the pain syndrome level did not exceed 4 points of the visual analogue scale for pain. During the postoperative period, a single surgical complication was reported — the development of the retrosternal hematoma; no fatal outcomes were reported.

CONCLUSION: The thoracoscopic thymectomy from the unified sub-xyphoid access is a justified option for cases of non-invasive epithelial thymic tumors. This method allows for performing the surgery in full range, not violating the oncology principles. It was proven that, for tumors measuring up to 65 mm, this method does not result in an increase in surgery duration or an increase in the rates of intraoperative complications.

BACKGROUND: Distraction arthroplasty of the ankle joint is the treatment method used for the cases of terminal osteoarthritis of the ankle joint that allows for delaying the arthrodesis or the total endoprosthesis replacement. The therapeutic effect is being achieved due to the separation of the articular surfaces (arthrodiastasis) with using the Ilizarov frame (or other devices for external fixation) for a period of 8–12 weeks. Only one research was described with the patients undergoing repeated arthroscopy of the ankle joint after the distraction arthroplasty in a combination with microfracturing of the cartilage defects, or repeated arthroscopy at the moment of removing the external fixation device (after 3 months).

АIM: To study the changes in the articular surfaces according to the Outerbridge before and after the distraction arthroplasty of the ankle joint using the repeated arthroscopy of the ankle joint.

METHODS: A total of 17 distraction arthroplasty surgical interventions of the ankle joint were performed (7 [41.2%] females and 10 [58.8%] males; the mean age of the patients was 48.5±13.57 years). Repeated arthroscopy of the ankle joint due to the recurrence of anterior impingement-syndrome after the distraction arthroplasty of the ankle joint within up to 12 months from the moment of removing the Ilizarov frame was carried out in 4 patients. For the evaluation of the treatment results, the Foot and Ankle Ability Measure (FAAM) scales were used, with an evaluation of pain, functions, deformity and the alignment of the foot and of the ankle joint (АОFAS Ankle-hindfoot scale), with subjective evaluation of pain (VAS); the status of the cartilage tissue in the ankle joint was evaluated using the modified Outerbridge scale.

RESULTS: In all the patients, a statistically significant improvement of the functional result was found in 12 months from the moment of surgery when using the FAAM (р=0.0006) and АОFAS Ankle-hindfoot scales, as well as after removing the Ilizarov frame in 1, 3 and 6 months. The pain intensity according to the VAS scale has decreased from 6.17±1.32 cm before surgery to 2 cm (1.4; 2.1) (p=0.00002) in 12 months. The arthroscopic findings upon the repeated interventions demonstrate the development of the massive arthrofibrosis with its further degradation to the end of 6 months, also showing the restoration of the cartilage defects from Outerbridge grade IV to grade II–III.

CONCLUSION: Upon the repeated arthroscopy, including the one performed at the end of 12 months after the distraction arthroplasty of the ankle joint, signs of regeneration were observed in the cartilage tissue defects with further defect coverage with a cartilage-like tissue, which, probably, determines the analgesic effect of the distraction arthroplasty of the ankle joint.

The rehabilitation of pediatric patients with oncology diseases localized in the maxillofacial area is a complex and long-term process. Most frequently, the resection area involves the maxilla or the mandible, which, in turn, impairs the functioning of the whole dentofacial system. The restoration of the integrity of the facial structures is the key task in the treatment of such patients. One of the main materials used for reconstructing the jaws is the titanium alloy. However, despite its beneficial properties and characteristics, there is a high risk of inflammation, encapsulation or failure of the endoprosthesis. The aim of the research was to analyze the data available up to date on the methods of perfecting the surfaces of titanium endoprostheses based on the published research works. After analyzing the articles devoted to the modification of the surface of titanium constructions used for endoprosthetics, for the period from 2008 until 2022 (n=41), we came to a conclusion that the modification of the surface of titanium endoprostheses results in an increase in its osteointegration, which decreases the risks of failure for the constructions.

Gliomas are the reason of fatal outcomes in an overwhelming number of patients with oncology diseases located in the central nervous system. The diagnostics of such neoplasms requires using stereotaxic biopsy, which cannot be performed in a certain percentage of the patients. Besides, this disease is characterized by high recurrence rates, despite the advances in developing resection and chemotherapy — based technologies. The early detection of oncological diseases located in the central nervous system and the differential diagnostics of tumor pseudo progression, not affecting the survival of the patient, represents a challenge for modern Medicine. Liquid biopsy is a minimally invasive diagnostic method based on the analysis of tumor derivatives (such as extracellular tumor DNA and RNA), contained within the biological fluids of the organism. For the purpose of defining the presence of the tumor component, the tests are used to detect the so-called hot-spot mutations and the patterns of epigenetic regulation, found in specific types of tumors. The technology can be used for detecting tumor recurrences and for the differential diagnostics of space-occupying mass lesions in patients, in which stereotaxic biopsy is contraindicated. The review contains a discussion on modern advances of fluid biopsy based on the analysis of the extracellular tumor DNA and RNA levels in blood plasma and in the cerebrospinal fluid of glioma patients.

Deep vein thrombosis and pulmonary artery thromboembolism are the most commonly occurring cardio-vascular complications of oncological diseases, which may develop at any stage of the oncological process. These life-threatening complications take the leading positions within the structure of mortality among cancer patients, giving place only to the oncology disease itself. It is important to note that the patients with cancer-associated thromboses are the most difficult group of patients, in which the development of thromboses and thromboembolisms may not only delay the vitally important treatment of the main disease, but also to completely cease the treatment due to the lack of possibility for its adequate performing. This is an important social and economic task, taking into consideration the costs for the healthcare system required to treat the disease itself and its concomitant complications. Thus, there is a criticality factor of not only the treatment itself, but also of the prevention of oncology-associated thromboses and thromboembolisms. Currently, due to the wide spreading of the said complications, the therapy and the prevention of them undergo significant changes. The traditionally used warfarin is being switched to low molecular weight heparin. At the present moment, oral anticoagulants are used more and more often. The analysis of special scientific literature has allowed for evaluating the novel principles of treatment in cases of oncology-associated thromboses and thromboembolisms depending on the location of the process, on its stage, on the severity of the patient status, as well as to define the risk factors of oncology-associated thromboses, the practicability and possible methods of its prevention in various groups of patients.

BACKGROUND: The posterior dislocation of the humerus head occurs up to 4.5% of all cases of dislocated humerus. Low prevalence and difficulties in diagnosing this type of injury often lead to the formation of old shoulder dislocations. Old cases of back dislocation of the humerus head, especially with reversible bone defects, are accompanied by limitations of movement in the shoulder joint, expressed by pain syndrome. The presence of bone defects in the head of the humerus makes it necessary to replace the latter with bone or soft tissue structures, in surgical practice tendons of the subcutaneous and sub-carpal muscles are most often used. In old cases, scar post-traumatic rebirth is often impossible.

CLINICAL CASE DESCRIPTION: The article presents a new method of operative treatment of the old clutch, in the framework of which the use of a new method of operative treatment of the reversal fracture of Hill-Sachs with a long-term stuck back dislocation of the shoulder is considered. The main goal, which is the operative treatment of reversible osteochondral defect up to 25% of the area of the humerus head, due to the deficiency of bone mass of the shoulder head. By moving the corrugated tendon of the long head of the bicep to the impaction zone and fixing it with anchor clamps in the defect zone, resulting in the stabilization of the shoulder joint.

CONCLUSION: The outcome of this clinical case is restoration of the function of the shoulder joint and absence of clinical symptoms of instability in it in the late postoperative period. The use of the proposed method of operative treatment makes it possible to reduce the risks of developing postoperative restriction of movements in the joint, instability of the head of the humerus bone, especially in the long-term cases of dislocation of the head of the humerus.