Minimal fixed flow anesthesia for off-pump coronary artery bypass surgery: A parallel randomized trail.

Objectives: The aim of the present study was to test a safety of a fixed minimal (0.5 l/min) fresh gas flow (FGF) anesthesia as a method ensuring adequate oxygenation during off-pump coronary artery bypass grafting operations. Design: A randomized, prospective study. Setting: Single-center clinical hospital affiliated with a university. Participants: 208 patients underwent off-pump coronary artery bypass surgery. Interventions: All patients received endotracheal inhalational anesthesia with fixed minimal FGF. Half of them were anesthetized by sevoflurane and another half by isoflurane. The fresh (carrier) gas was pure oxygen in the control groups and a mixture of medical air and oxygen (FiO2 0.8) in the trial groups. Measurements and main results: In the control groups inhaled oxygen concentration changed minimally during the operation. In the trial groups in 28.8 % of cases inhaled oxygen concentration dropped below preliminary margin (0.4). Body surface area (BSA) (B = 38.7; p = 0.002) and patient's age (B = -0.47; p = 0.004) were retained into final logistic regression model as independent predictors. We divided BSA into subcategories and analyzed data by survival cox regression with Forward LR method. Patients with BSA>2.3 (Exp.B = 183) and BSA [2.2-2.3] (Exp.B = 59) had high chance to get less than 0.4 of inhaled oxygen concentration compared to the patients with BSA <2.0 (p < 0.001).Exp(B) or OR for the patients' age as independent predictor tested in multiple logistic regression was 0.628 In other words, for every year less the patient had 1/0.628 = 1.6 times more chance to reach the preliminary low margin (0.4) of oxygenation. Conclusions: Fixed minimal FGF 0.5 l/min with FiO2 0.8 may not be sufficient for the younger patients with BSA >2.0 to maintain inhaled oxygen concentration above 0.4. Using pure oxygen as a carrier gas during fixed minimal flow long term anesthesia is much safer and more reliable.

Successful primary repair in a late presentation of Boerhaave's syndrome. Case report.

We present a case of Boerhaave's syndrome successfully managed by open transabdominal approach 48 h after the acute event. A 55-year-old female presented with hydropneumothorax, chest pain, dyspnea, vomiting and fever. The urgent radiologic (X-ray, CT) and endoscopic study revealed the large defect of left posterolateral wall of esophagus with extrusion of fluid and gastric contents into the mediastinum and left chest. Emergency intercostal drainage insertion was performed and patient was transferred to our hospital. By open transabdominal approach after the wide sagittal diaphragmotomy the primary repair over the nasogastric tube using simple interrupted sutures (Vicryl 3/0) and partial fundoplication to cover the suture line was performed. Chest drainage tubes was then positioned near and parallel to the repaired esophagus and feeding jejunostomy was then performed for enteral nutrition. On the seventh postoperative day, a gastrografin swallow showed a small leak in the repair site without any collection, which was healed after 1,5 month of conservative treatment. We consider, that proactive surgical approach with primary surgical repair is still possible and feasible option despite the late presentation of Boerhaave's syndrome. KEY WORDS: Active drainage, Boerhaave's syndrome, Primary repair.

Challenges and perspectives of surgical treatment of liver failure. Current status and last achievements in Georgia.

Liver transplantation is considered to be the last hope of treatment for irreversible liver failure caused by different diffuse and/or space-occupying lesions of this organ. The strict limitation of the donor organs stipulates for development of alternative approaches for the solving this problem. The presented review of literature and our experience aims to discuss the modern aspects of management of different hepatic pathologies causing liver failure with the view of creation of the auxiliary, bioengineer-based functional tissues and/or organs and innovative surgical interventions allowing to conduct the operations in cases, which were up to date considered as inoperable. There are highlighted the last achievements of the experimental and translational studies performed in four University research centers of Georgia, which, on the one hand, provoke the specific professional interest, and on the other hand, require the international cooperation and collaboration for further progress and advances in this field of surgery. KEY WORDS: Artificial liver, Bio-Artificial organs, Liver failure, Innovative surgery, Tissue engineering.

Efficacy of percutaneous biliary and pancreatic duct drainage/stenting with double invaginated pancreatojejunostomy after pancreatoduodenectomy.

AIM: To evaluate the efficacy and feasibility of preoperative percutaneous pancreatic duct drainage (PPDD) and improve the safety of pancreatojejunal anastomosis, we refer to our experience from 2013 to 2017 that include the last series of 27 cases of PD for 14 pancreatic and 13 ampullary tumors. Apart from the standard "classic" Whipple procedure in 17 cases, and the "modified"pylorus-preserving variant (ppPD) in 10 cases, in 26 cases a pancreaticojejunostomy and in 1 case a pancreatico gastrostomy was performed. In last series the percutaneous biliary drainage procedure in 18 cases and dual biliary + pancreatic duct decompression in 4 casas was performed. In 21 cases the biliary drainage was used as transanastomotic stent during hepaticojejunostomy and in 3 cases the pancreatic duct drainage was also used as transanastomitic stent at our method of performing the double invaginated pancreatojejunostomy. RESULTS: Without operative mortality in our series of PD, there were however some complications requiring in two patients interventional radiologic and intensive care management, and 5 patients died at follow up period (6 months - 3 years). There was no postoperative pancreatic fistula in our last series of PD, where preoperative biliary and pancreatic duct drainage and our modified double invaginated pancreatojejunostomy was performed. CONCLUSIONS: Despite our limited experience, we can conclude that preoperative percutaneous biliary and pancreatic drainage is feasible, safe, effective and a realistic mini invasive procedure. The preliminary results obtained with the described method of double invaginated pancreatojejunostomy with transanastomotic stent and external pancreatic duct drainage are very encouraging and indicate that this technique is less complicated and time consuming, very safe, simple, easy to perform and also applicable almost to all situations. KEY WORDS: Invaginated Pancreatojejunostomy Pancreatoduodenectomy, Pancreatic Duct Drainage.

Textiloma: 28 years of foreign body mimicking pancreatic mass Case Report.

Problem of retained foreign bodies is still actual challenge at surgical practice at the present time. Retained surgical sponges (cotton or gauze pads), which can be mistakenly left behind during different surgical operations, represent a difficult diagnostic problem despite of using modern technologic procedures, such as US, CT, MRI and etc. These foreign materials may cause serious complications and may lead even to mortality. Here, we describe a case of textiloma in which the patient presented with abdominal discomfort, pain and fever after 28 years of partial gastrectomy operation. Imaging revealed an abscess-like a big size pancreatic mass in upper part of abdominal cavity. The differential diagnoses of this pathology and treatment options are discussed. KEY WORDS: Foreign body, Textiloma, Retained surgical swab.

A three-dimensional scaffold from decellularized human umbilical artery for bile duct reconstruction.

AIM: The main purpose of the study was to create in vitro bile duct equivalent out of decellularized human umbilical cord artery and use it to reconstruct common bile duct obstruction with preservation of sphincter of Oddi. MATERIAL AND METHODS: SDS and Triton X-100 were used for decellularization of the artery. Allogeneic isolated cholangiocytes were seeded onto the inner surface of the decellularized artery. Experimental study was held and 12 domestic pigs of both sexes, weighing 25-30 kg were used. They were divided in equivalent two groups. Common bile duct obstruction model was created in all animals. Animals of the first group (n=6) received no further treatment and were under observation. Animals of the second group (n=6) underwent relaparotomy after two days of initial intervention, lesion site (2 cm) was incised and defect was reconstructed with the bile duct equivalent with the size of 2-2,5 cm. Maximum observation period was 84 days. RESULTS: Laboratory, morphologic and radiologic investigations showed good integration with the host organism. DISCUSSION: Bile duct reconstruction is still a major of HPB surgery. This fact prompted this study to assess the efficacy of the novel method for bile duct reconstruction the experimental study by using appropriate laboratory, morphologic and radiologic investigations. CONCLUSION: Preliminary results obtained with the described method allows us to say that bile duct equivalent created by us with decellularized human umbilical artery and cholangiocytes can be successfully used for bile duct reconstruction with inclusion of the sphincter of oddi. KEY WORDS: Bile Duct Obstruction, Bile Duct Reconstruction, Decellularization, Human Umbilical Artery.

Miniinvasive surgical interventions in management of cholelithiasis A retrospective study.

The aim of the present study is to analyze outcomes after laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) for gallstone disease and determine the algorithm of treatment for different groups of patients according to the age, severity of disease and comorbid conditions. This is a multicenter retrospective review of 2997 patients who underwent LC or MC between January 1, 2002 and December 31, 2008. The patients were categorized into LC (1479) and MC (1518) groups. When preoperative examination data were not reliable, we performed abdominal wall lifting with the retractors to visualise abdominal cavity with laparoscope during minilaparotomy. There were statistically significant differences in conversion rate (47 LC and 22 MC cases) (P=0.002), mean operating time (76 and 55 minutes in LC and MC, respectively) (P<0.001), mean duration of usage of non-narcotic analgesics postoperatively (1.3 and 1.1 days in LC and MC, respectively) (P<0.001), intra (15 LC and 6 MC cases) (P=0.02) and postoperative complications (96 LC and 72 MC cases) (P=0.05) and in mean hospital stay (1.5 and 1.3 days in LC and MC, respectively) (P<0.001). The difference in outcomes was more significant in elderly and senile patients. Following the review of previous trials, the only clear significant difference between both procedures was a shorter operative time using MC 24. MC is an attractive alternative for elderly patients, with their high incidence of acute cholecystitis 23. The minilaparotomy cholecystectomy is effective, safe and optimal operative procedure. Especially, it is important for countries with lower economic capacity.

Perspectives of using of "aseptic" drains for abdominal drainage.

AIM: Aim of the study was to evaluate the effectiveness of using different types of drain tubes to prevent and reduce the drain-associated infection rate of abdominal drainage procedures. MATERIALS AND METHODS: 80 cases of used so called "standard", "coladerm" and "chlorhexidine" drain tubes for abdominal drainage were analysed. "Standard" drain tubes were used 35 times and "coladerm" and "chlorhexidine" tubes - 20 and 25 times respectively. There were adopted in different elective and emergency so called "clean", "potentially contaminated" and "contaminated" abdominal surgical procedures. The drain tubes were removed between 2 to 14 days after the operations followed by the bacteriological study in search of bacteria growth on the surface of drainage tubes were examined. RESULTS: Of all 35 cases of used "standard" drain tubes the bacterial growth was found in 23 cases, that means 65,7%; of 20 cases of drains covered by "coladerm" polymer the bacterial growth was found in 6 cases (30%) and only in 3 cases of 25 cases of drain tubes covered by polymer and "chlorhexidine" were positive, that means 12%. The most interesting data were obtained considering the so called "clean" and "contaminated" operations. After the so called "clean" operations the bacterial growth using "standard" drain tubes was found almost in 50% of cases and in 8,3% of cases using "chlorhexidine" drain tubes. After the "potentially contaminated" and "contaminated" operations the bacterial growth was found in 68,2% using "standard" tubes, and using "coladerm" and "chlorhexidine" drain tubes - in 50% and 16,7% respectively. CONCLUSIONS: In our limited experience using of new antimicrobial polymeric composites as coatings mean the adhesion of bacteria and formation of biofilm at drainage tubes is prevented, which can significantly reduce the drain-associated infection rate. KEY WORDS: Abdominal drainage, Bacterial growth, Infection rate.

A comparative study of laparoscopic and open Nissen fundoplication for GERD in Georgia.

AIM: The study compares and analyzes the effectiveness and outcomes of open A. Chernousov modified Nissen fundoplication (CMNF) and laparoscopic total fundoplication in Georgia for gastroesophageal reflux disease (GERD) concerning perioperative course, postoperative complications, symptomatic relief, recurrent disease and the need for reinterventional surgery. MATERIALS AND METHODS: A prospective randomized trial was performed. Twohundred fortythree patients with GERD were randomized, 123 patients underwent open CMNF procedure and 120 patients of laparoscopic total fundoplication. Pre- and postoperative tests included endoscopy, X-Ray, patient questionnaire (GERD - HQRL scale) and clinical assessment. Patients were followed for 10 years. RESULTS: This prospective randomized trial showed good and excellent long-term results after open and laparoscopic total fundoplication for GERD (92,7% vs 88,5% respectively) (p=0,03). After open CMNF procedure there were 3 cases of postoperative ventral hernia, 9 cases of mild dysphagia. There was no recurrence. After laparoscopic approach there were 7 cases of solid and transient dysphagia, 3 cases of hard stenosis of cardiacs caused by wrap. There were 2 cases of recurrence, 3 cases of reflux and 1 case of epigastral trocar hernia. CONCLUSION: In Georgia as well as throughout the world laparoscopic total fundoplication at the present time is the preferred method of choice for the treatment of GERD. It has best cosmetic effect, less pain and wound problems, shorter hospital stay, early return to work. Open CMNF is safe and effective procedure too. It prevents slippage syndrome and is characterized by better control of reflux and less frequency of recurrence and guarantees slightly better long-term functional results. KEY WORDS: Antireflux surgery, GERD, Modified Nissen fundoplication, Prospective randomized trial.

The actin binding protein destrin is associated with growth and perineural invasion of pancreatic cancer.

BACKGROUND/OBJECTIVES: The small actin-binding protein destrin is one of the key regulators involved in remodeling of the actin cytoskeleton, a process crucial for cytokinesis, cell migration and polarized cell growth as well as for cancer cell migration and invasion. METHODS: A novel ex vivo nerve invasion model mirroring perineural cancer cell invasion as a key feature of pancreatic ductal adenocarcinoma has been previously established. Using this model, highly nerve-invasive clones of human pancreatic cancer cell lines have been obtained. Genome-wide transcriptional analyses of these cells revealed up-regulation of destrin in highly versus lowly nerve-invasive pancreatic cancer cells. RESULTS: Increased expression of destrin in these nerve-invasive cells was validated using quantitative RT-PCR and immunoblotting; concomitant changes in cell morphology were demonstrated using immunofluorescence analysis. Silencing of destrin by two specific siRNA oligonucleotides in Panc-1 pancreatic cancer cells decreased invasiveness and migration, and reduced proliferation of these cells. CONCLUSIONS: Destrin is upregulated in nerve-invasive pancreatic cancer cells and its expression might be related to perineural invasiveness.

Modified Lichtenshtein hernioplasty prevents male infertility.

INTRODUCTION: Lichtenstein hernia repair made revolutionary progress in hernia treatment. Since that a lot of modifications have been proposed. In a few of them attention is drawn to spermatic cord isolation from a mesh for prevention of spermatic cord involvement into inflammatory process which may lead to disturbances in ejaculation act and spermatogenesis itself AIM OF THE STUDY: To compare morphological parameters of sperm prior and after hernia surgery in those groups of patients who underwent Lichtenstein and modified Lichtenstein (with spermatic cord isolation from a mesh by Gvenetadze) hernia repairs. CONCLUSION: Our experience showed that modified Lichtenstein hernioplasty which involves spermatic cord complete isolation from the mesh prevents male infertility especially in the case of bilateral hernia repair.