The aim of this work is to describe a clinical case of a serious life-threatening adverse reaction in the form of neurotoxicity (convulsions, apnea requiring mechanical ventilation) to the polymyxin B drug, and also to remind that manifestations of neurotoxicity can be extremely varied and nonspecific, and do not occur after every administration, can be delayed, require vigilance and careful monitoring both from the attending physicians and from anesthesiologistsresuscitators, neurologists, ophthalmologists, etc. A 62-year-old female patient diagnosed with stage IIIB T4G3N0M0 pleomorphic soft tissue sarcoma of the right thigh, condition after combination treatment, developed infection and necrosis of the postoperative wound (recto-abdominal flap). According to the results of a microbiological study and an antibiogram, the patient received polymyxin B as part of combination antibacterial therapy. On days 4, 5, 6, 7 of polymyxin administration, the patient experienced the following symptoms in various combinations: weakness, numbness of the face, paresthesia, paresis of the limbs, partial convulsions, respiratory depression, and apnea. After establishing a connection between neurologicalsymptoms and intravenous administration of polymyxin B (the total score on the Naranjo scale was 6 points, the degree of reliability of the “adverse reaction–drug” relationship was probable) and drug withdrawal, manifestations of neurotoxicity completely disappeared and did not reoccur. The patient was discharged in satisfactory condition. In a patient with symptoms of damage to the nervous system, it is necessary to conduct multiple differential diagnostic search to exclude stroke, epilepsy, encephalitis, hereditary and acquired neurodegenerative diseases, as well as side effects of medications. At the slightest suspicion of the likelihood of an adverse reaction to polymyxin B/colistimethate sodium, the Naranjo algorithm must be used to establish a cause-and-effect relationship between the adverse reaction and the drug.

The objective was to demonstrate a clinical case of iatrogenic injury of the trachea, which, despite its large size (length 65, width up to 25 mm), wastreated conservatively and, thus, avoided risks for the patient associated with the need for technically complex surgical intervention.Materials and methods. A 65-year-old patient diagnosed with peripheral cancer of the lower lobe of the left lung pT2aN0M0 stage IB, who routinely underwent thoracoscopic left lower lobectomy with mediastinal lymph node dissection. During anesthesia, tracheal intubation with a double-lumen tube of the R. Shaw type was carried out with technical difficulties; during intubation, a defect in the posterior wall of the trachea in its membranous part was formed. The defect was diagnosed on the first postoperative day.Results. Despite the large size of the tracheal defect, the patient had no symptoms of respiratory failure, and there were also no signs of mediastinitis or damage to the esophagus, which almost completely covered the resulting hole in the posterior wall of the trachea. Such circumstances made it possible to avoid a potentially dangerous and complex surgical intervention, carry out conservative therapy and wait for the resulting defect to heal through granulation tissue. Enhanced antimicrobial therapy was carried out; in order to sanitize the tracheobronchial tree and monitor healing, fiber-optic bronchoscopy was performed, which made it possible to clearly demonstrate both the damage itself and the stages of its healing.Conclusions. The described case clearly demonstrates the potential for healing of even very extensive tracheal wall defects with conservative therapy. However, it is important to note that success in this clinical case was the result of a combination of circumstances – only the membranous part of the trachea was damaged; the defect was almost completely covered by the intact esophagus, which reduced the risk of developing mediastinitis and prevented the development of severe pneumomediastinum and subcutaneous emphysema. There were no signs of respiratory failure. The patient was transferred from the intensive care unit on the 13th day of the postoperative period, discharged from the hospital on the 22nd day.

3D printing has opened new opportunities for the development of personalized systems for prosthetics of extensive chest wall defects after radical surgical interventions for malignant tumors. However, risk factors for an adverse outcome of such operations have not yet been identified. Clinical cases . A 65-year-old man with primary chondrosarcoma of the V rib, underwent surgical resection of three ribs, plasty with local tissues, and an individual 3D printed titanium implant was installed on the sternum and IV-VI ribs. Follow up for 26 months showed no complaints or signs of recurrence. A 52-year-old woman with radiation-induced soft tissue sarcoma of the chest wall, that developed 9 years after radiation for breast cancer, underwent resection of four ribs and pectoral muscles and a 3D printed titanium implant was installed on the sternum and II-V ribs. The operation was complicated by the marginal necrosis of the soft tissue flap and infection of the endoprosthesis, which required removal of the metal structure and reconstruction using TRAM flap. After 9 months, a local recurrence of the tumor was diagnosed. Discussion. As a factor of a positive outcome in a man should be noted a thick layer of subcutaneous fat with muscle tissue, due to which plastic surgery was performed, covering the defect without tension. An extensive resection of the pectoral muscles in a woman created a tissue deficit. Another factor of an unfavorable outcome can be considered the radio-induced nature of the sarcoma. Further research is needed to improve the strategy for selecting patients with malignant tumors of the chest wall for prosthetics.

Numerous publications show that, depending on the type of pathology, protein-energy malnutrition develops in 20– 50 % of surgical patients directly in the hospital in the early postoperative period. Rather a great number of patients with surgical diseases are already hospitalized with varying degrees of malnutrition. From 30 % to 69 % of patients are admitted to the hospital with I–III grade of protein-energy malnutrition and require mandatory nutritional support. Risk factors for protein-energy malnutrition development are determined in 60–70 % of hospitalized patients. This clinical practice recommendations present the basic principles of nutritional support in the perioperative period.

Цель: представить литературные и собственные данные по распространенности карбапенемаз у микроорганизмов, вызывающих тяжелые инфекции у онкологических больных и дать сведения о предпочтительном лечении при выделении основных карбапенем-резистентных грамотрицательных возбудителей ( Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae ). Методы исследования: обзор литературы за последние 10 лет, включая международные рекомендации по лечению мультирезистентных инфекций (2021–2022 гг.). Также представлены собственные данные по частоте выделения карбапенемаз в биоматериалах от больных с нозокомиальными инфекциями, находившимися в НМИЦ онкологии им. Н. Н. Блохина, в 2021–2022 гг. Результаты: представлены обобщенные данные, касающиеся возможностей комбинированной терапии нозокомиальных инфекций, вызванных трудно поддающимися лечению возбудителями (карбапенемазопродуцирующими грамотрицательными микроорганизмами), дан подробный разбор механизмов резистентности, обусловленных бета-лактамазами (карбапенемазами). Заключение: При наличии тяжелых инфекций, сепсиса / септического шока универсальных схем антибиотикотерапии не существует. Необходимо знание особенностей лечения в зависимости от молекулярно-генетических характеристик возбудителей инфекции.

Многочисленные публикации указывают, что, в зависимости от вида патологии, белково-энергетическая недостаточность (БЭН) развивается у 20–50 % хирургических пациентов непосредственно в стационаре в ран- нем послеоперационном периоде. Достаточно большое количество пациентов с хирургической патологией уже госпитализируются в стационары с различной степенью нутритивной недостаточности. От 30 до 69 % больных поступают в клинику с БЭН I–III степени и нуждаются в обязательном проведении нутритивной поддержки. Факторы риска развития БЭН выявляют у 60–70 % госпитализированных. В методических рекомендациях представлены основные принципы проведения нутритивной поддержки в периоперационном периоде.

Aim. Current clinical recommendations address the epidemiology, causes, clinical manifestations and pathogenesis of possible immediate and long-term complications, as well as the problematic issues related to treatment and rehabilitation of adult short bowel syndrome patients.Key points. Short bowel syndrome (SBS) is a symptom complex of impaired digestion caused by the reduction of small intestine absorptive surface and manifested by intestinal failure (IF) of various severity (maldigestion and malabsorption) developing into malnutrition and systemic somatogenic disorders. The vital strategic aspects of its treatment are the personalisation of liquid, macro- and micronutrients consumption as well as avoidance of intestinal failure- and parenteral nutrition-associated complications. Various nutritional support regimes and the indications for infusion therapy and maintenance parenteral nutrition are considered in this patient category, also in outpatient settings. To mitigate the dependence on intravenous fluid- and nutrient administration and attain enteral autonomy in SBS-IF patients, the use of recombinant glucagon-like peptide-2 (GLP-2) is justified as exerting a pronounced trophic effect on the epithelial regenerative potential as well as structural and functional adaptation of intestinal mucosa. The SBS-IF patients prescribed with home parenteral nutrition and/or their caregivers should be trained in a special programme that covers the catheter care, preparation of infusion solutions and nutrient mixture container, infusion pump operation as well as the prevention, recognition and management of complications. The main referral indications for small bowel transplantation (SBT) are: fast-progressing cholestatic liver disease-complicated irreversible intestinal failure; thrombosis of two or more central venous conduits used for parenteral nutrition; recurrent catheter-associated bloodstream infection.Conclusion. Current recommendations on diagnosis and treatment as well as the developed criteria of medical aid quality assessment are applicable at different levels of healthcare.

Introduction. Interactions between the 2 microbiota components – bacteria and fungi – are of interest as diagnostic and prognostic markers in selection of treatment tactics for oncological patients.Aim. To study microbiota of the oral cavity in patients with primary squamous cell carcinoma of the oropharyngeal area before and after surgical intervention to find biomarkers for rational selection of antifungal drugs.Materials and methods. At the Surgical Department of Head and Neck Tumors of the N. N. Blokhin National Research Center of Oncology, three-component study was performed: investigations of spectrum of Candida spp. isolates, Candida spp. strains’ resistance to antifungals, and oral washes in primary patients before and after surgery. mALDI-Tof microflex LT (Biotyper, Bruker Daltonics, germany) was used for strain identification; Sensititre Yeast ONE, YO10 (Trek Diagnostic System, united kingdom) plates were used for determination of minimal inhibiting concentrations of anti fungals. values of minimal inhibiting concentrations were evaluated based on the European Committee on Antimicrobial Susceptibility Testing (EuCAST) criteria (version 10.0).Results. four-year observation of patients at the surgical department of head and neck tumors of the N. N. Blokhin National Research Center of Oncology showed that the most common species of Candida is C. albicans (73.5 % of cases). Candida spp. resistance to antifungals was detected only for fluconazole (9.3 % of cases) and micafungin (8.0 % of cases), mostly among C. albicans strains. In 31.8 % of primary patients, oral washes prior to surgery showed growth of Candida spp. (probably, tissue colonization). After surgical intervention, Candida spp. growth was detected in 36.4 % of cases, only 1 of which was diagnosed as invasive mycosis. In 54.5 % of cases before and in 72.7 % of cases after surgery, gram-negative rods were detected. After surgical intervention, percentage of enterobacteria and non-fermenters significantly increased: 59.1 % versus 27.3 % (p <0.05) and 63.6 % versus 27.3 % (p <0.02), respectively. prior to surgery, non-fermenting gram-negative bacteria were represented only by P. aeruginosa; after surgery, the spectrum of non-fermenting gram-negative bacteria became wider but percentage of P. aeruginosa remained high: 71.4 %. ERG11 gene was identified only in 1 strain: C. albicans. FKS1 gene also was identified only in 1 strain: C. inconspicua. virulence factor genes were detected in 57.1 % of strains.Conclusion. Surgical intervention is associated with changes in bacterial microbiota but not fugal microbiota. presence of virulence factor genes and resistance genes in Candida spp. strains should be considered a biomarker allowing to differentiate between colonization and candida infection and can be used for rational selection of antifungal drugs in prevention and treatment of invasive candidiasis, especially in the absence of criteria for interpretation of measured minimal inhibiting concentrations of antifungals.

The study was performed in 9 cancer patients with sepsis. A clinical blood test of patients with sepsis was accompanied by a neutrophilic leukemoid reaction, with the appearance in the differential count of white blood cells of young cells (myelocytes, metamyelocytes). According to the literature, it is shown that in severe sepsis, a local infection is accompanied by systemic of neutrophil activation (NF). Moreover, excessive activation and location of NF in the microvasculature, especially its young forms and the formation of extracellular trap networks (NETs), can contribute to pathological manifestations of multiple organ failure and thrombosis.

In the blood serum of 93 patients with various localities of the malignant process, the content of nitric oxide (NO), indicators of lipid peroxidation (POL): superoxide dismutase (SOD), malondialdehyde (MDA) and glutathione in red blood cells were determined. 9 patients with ovarian cancer were examined during chemotherapy (6 courses), 40 patients with colon cancer, previously operated, were with malignant liver damage. In 39 patients with anemia, NO indicators were compared with the level of interleukin 6 (IL-6) and hepcidin-25 (GP-25). As a control, 60 practically healthy individuals were examined. It was shown that the NO content was significantly reduced in 69.7% of patients, regardless of the location of the primary tumor. There was a gradual increase in the NO content before each course of chemotherapy. A high concentration of NO (more than 22 µM) was detected in 22 patients with functional iron deficiency (FJ) against the background of anemia of chronic diseases (AHZ), which was accompanied by hyperexpression of IL-6 (27.0±10.5 pg/ml) and GP-25 (25.2±7.1 ng/ml). In contrast, the lowest NO values (less than 22 µM) were observed in 17 patients with IDA. There is no doubt that there is a certain relationship between the development of oxidative stress with the accumulation of highly toxic lipoperoxidation products that affect the overall homeostasis of the body, and the development of anemic syndrome.

ЖУРНАЛ ИМЕНИ АКАДЕМИКА Б.В.ПЕТРОВСКОГО Том 9 ■ № 1 ■ 2021 Гемангиома сердца относится к редким доброкачественным опухолям, которые чаще локализуются в предсердии или в желудочке и гораздо реже в стволе легочной артерии.В статье представлено клиническое наблюдение успешного хирургического лечения больного с гемангиомой ствола легочной артерии с распространением на ее клапан и левую легочную артерию.Финансирование.Исследование не имело спонсорской поддержки.

КЛИНИЧЕСКАЯ И ЭКСПЕРИМЕНТАЛЬНАЯ ХИРУРГИЯАктуальность.Известно, что частота локального рецидива тимомы B3 после тимэктомии может достигать 8-30% случаев.Однако даже при необходимости в резекции смежных атомических структур средостения доля повторных радикальных операций, по данным литературы, составляет 45-71%, что обеспечивает общую 5-летнюю выживаемость на уровне 72%.Цель работы -представить клиническое наблюдение успешного удаления рецидивной тимомы B3 с экстирпацией и протезированием верхней полой вены.Материал и методы.Пациент, 59 лет, поступил в стационар с клиническим диагнозом: злокачественное новообразование вилочковой железы, тимома В3.Хирургическое лечение 2010 г.Рецидив 2018 г.Химиолучевая терапия декабрь 2018 г. (СОД 35 Гр + карбоплатин, 3 курса).Стабилизация.В плановом порядке выполнена стернотомия, удалена рецидивная опухоль, проведены экстирпация и протезирование верхней полой вены с помощью Y-образного протеза с резекцией обоих диафрагмальных нервов.Ранний послеоперационный период осложнился дыхательной недостаточностью в связи с двусторонним парезом диафрагмы, которая купирована длительной искусственной вентиляцией легких, восстановительным -реабилитационным лечением.Результаты.При контрольном осмотре через 12 мес состояние больного удовлетворительное, способен выполнять умеренный физический труд, данных за рецидив опухолевого процесса в средостении нет, наблюдается неполная реканализация левой брахиоцефальной ветви Y