[CLINICAL SIGNIFICANCE OF CARDIAC BIOMARKERS INCREASING AND THEIR INTERRELATIONS IN SURGERY WITH CARDIO-PULMONARY BYPASS.]

BACKGROUND: Levelfor cardiac troponin I (TrI) and MB-fraction of creatine kinase (CKMB) increases in cardiomyocyte necrosis, and B-type natriuretic peptide (of BNP) increasing reflects ventricular overload. THE AIM: to study the dynamics of BNP, TRI and CKMV in myocardial revascularisation with cardio-pulmonary bypass and to evaluate the clinical significance of these biomarkers elevated levels and establishing the relationship between BNP and markers of myocardial damage in the perioperative period Materials and methods. The study included 52 patients aged 62.5 (54.75; 70) years. Biomarkers concentrations was determined by immunofluorescence. RESULTS: The initial value of BNP were 57.9 (38.675;88.5) pg/ml, and then increased (p<0,01): at the end of the operation up to 91.75 (59.6;132.75) pg/ml, at 1st day following surgery - up to 260 (157;407) pg/ml, and at 2nd day - up to 184 (115.25;274.5) pg/ml. TrI and CKMV increased (p<0,01) up to 0.95 (0.4175;1.4525) ng/ml and up to 13.1 (5.575;15.525) U/L at the end of surgery, and up to 1,355 (0.76;3.8) ng/ml and 10.5 (5;18.325) U/L at thr Istpostoperative day. Preoperative BNP level and TrI level at the end of surgery were the predictors (p

[Microdialysis--a new method of monitoring of the transplanted cadaveric kidneys function].

PURPOSE: To assess ischemia-reperfusion injury of renal allograft by microdialysis. DESIGN: A pilot, single-center; prospective study. PATIENTS AND METHODS: The study included 7 patients (4 males and 3 females, average age was 46.71 ± 6.53 years) after cadaveric kidney allograft transplantation (CKA) under general combined anaesthesia. CONCLUSIONS: Microdialysis provides an opportunity of continuous monitoring of metabolic changes in the tissue of transplanted kidney. The main advantage of the monitoring by microdialysis is an opportunity of early identifying of ischemia-reperfusion complications. Thus, early assessment of CKA by microdialysis can be for the improving of patient's treatment in the early post operative period. Further clinical studies must be done to define the role of microdialysis.

[Tactics of surgical treatment of chronic pancreatitis].

585 patients were operated on the reason of chronic pancreatitis. 246 patients received various drainig operations: cystojejunostomy with Roux-en-Y anastomosis (n=97), longitudinal pancreatojejunostomy (n=86), external draining of the absceding postnecrotic cysts (n=51), internal draining (n=12). Resections of the pancreas were performed in 327 cases: Frey operation (n=83), Beger operation (n=46), pancreatoduodenal resection (n=61) - of them 55 were suspicious to cancer and 6 had pancreatic dystrophy. Distal resection of the pancreas was performed in 6 cases. 33 patients were operated on pseudoaneurisms, of the 12 patients received endovascular operations. Posoperative complications were registerd in 119 (20.3%) patients. 7 (1.2%) patients died.

[The postoperative pancreatitis after the pancreatic surgery].

The results of 302 operations on the pancreas were analyzed: of them 107 were pancreatoduodenal resections; 67 were distal resections of the pancreas; 74 were various resections of the head of the pancreas and middle resections and 54 other operations. The postoperative pancreatitis was registered in 178 patients. The preventive use of the octreotide intraoperatively and in early postoperative period showed no influence on the frequency and severity of the postoperative pancreatitis. The ultrasound was the optimal screening diagnostig method, whereas the computed tomography was the best in pancreonecrosis diagnostics and the volume of the pancreatic tissue damaged. Of 178 patients with the postoperative pancreatitis 17 died, the lethality rate was 9.5%.

[Surgical treatment of the unformed intestinal fistulae].

Treatment results of 5 patients with unformed intestinal fistulae are represented. High unformed intestinal fistulae are acknowledged to be completely unsuitable for conservative treatment and should be operated on. Complex treatment should include complete parenteral feeding, adequate fecal diversion with the use of aspirational drainage. Surgical treatment must be y the increase of fistula discharge or absence of fistula formation. Low intestinal fistulae should better be surgically dissected after their organization, otherwise urgent surgery is to be performed by complications development, such as purulent leakage into the abdominal cavity or severe wound infection.

[Intraductal papillary-mucinous tumor of the pancreas: difficulties and mistakes of diagnostics and treatment].

15 patients with intraductal papillary-mucinous tumors (IPMT) of the pancreas were observed. Clinical manifestation corresponded with chronic pancreatitis. Ultrasound study, including endosonography, contrast-enhanced computer and magnetic resonance tomography were used in complex observation of the patients. Dilation of main or lateral pancreatic ducts, connection of tumor with pancreatic duct system and absence of septal calcinosis are typical signs in radiodiagnostics of IPMT. Visualization of parietal papillary proliferations and their contrast enhancement are undeniable signs f or neoplastic character of pancreatic duct dilation. Sensitivity of CT, MRТ and endoUS amounted accordingly 66, 83 and 88%. All patients were operated. Extent of operation was determined by morphological character, localization and size of the tumor (pylorus-preserving pancreaticoduodenal resection was carried out to 6 patients, distal resection including robot-assisted - to 7 patients, midline resection - to 1 patient, duodenum-preserving resection of head and body of pancreas - to 1 patient). Intraoperative urgent histologic study of pancreatic section was carried out by all means. Tumors with borderline degree of malignancy were detected in 4 cases.

[Ultrasound diagnosis of extrahepatic portal hypertension in chronic pancreatitis].

AIM: To evaluate the potential of the color duplex scanning in revealing of the portal hypertension in patients with chronic pancreatitis. MATERIALS AND METHODS: 94 patients with chronic pancreatitis were investigated. In 61 patients (65%) pancreatitis was complicated by extrahepatic portal hypertension (EHPH) and 31 patients (35%) were without signs of rising of the portal pressure. RESULTS: Investigations in B-regime have shown that in patients with EHPH chronic calculous pancreatitis was revealed in 48%, development of pancreatic hypertension in 75%, increase of the pancreas head up to more than 40 mm in 58% of patients. We did not reveal statistically significant differences in pseudo-cysts in pancreas, extension of extrahepatic and intrahepatic ducts and infiltrative changes in parapancreatic cellular tissue in patients with and without EHPH. A development of EHPH in 31 (51%) patients was preconditioned by an extravasal compression of veins of portal system, combination of extravasal compression with thrombosis was found in 11 (18%) patients, in 12 (20%) patients thrombosis of the magistral veins of portal system was revealed and in 7 (11%) patients hemodynamics was not changed. Resections were found to be preferable operations for recovery of portal circulation. Increase and normalization of portal circulation found after transversal section of pancreas (Beger operation, pancreo-duodenal resection, distal resection of pancreas). A tendency to normalization of the blood flow was observed after the Frey operation.

[Treatment of patients with chronic pancreatitis complicated by pseudoaneurysms of the celiac trunk basin arteries].

The authors have analyzed results of treatment of 26 patients with chronic pancreatitis complicated by pseudoaneurysms. Hospitalization and treatment of such patients should be performed in specialized hospitals which can fulfill special examination in detail and carry out roentgen-endovascular operations. Intraintestinal bleeding is an absolute indication for emergent surgery for performing hemostasis. Conservative treatment is indicated for intestinal bleedings and after arrest of bleeding the patients should be transported to specialized institutions. Two types of the appearance of pseudoaneurysms were established depending on the pathological mechanism: when there was a relationship of the pseudocyst with the main pancreatic duct (I type) and when there was not (II type). For the I type roentgen-endovascular treatment (RET) followed by operation is indicated, for the II type RET is thought to be enough.

[Computer--tomographic resecability criteria at cancer head of the pancreas].

UNLABELLED: The aim of the study was to explore the possibilities of CT in evaluating resectability of pancreatic head adenocarcinoma, depending on the tumor. MATERIALS: The results of CT and intraoperative findings in 62 patients with cancer of the head of the pancreas. RESULTS: It was shown that the tumor localized in caudal glands, had higher resectability when compared with tumors of the cranial localization at tumor sizes of 3-4 cm in size tumor less than 3 cm, the probability that radical surgery was highest in patients with central localization of the tumor.

[Early activation of patients after myocardial revascularization as a means for optimization of cardiosurgical treatment].

Analyzing the commonest characteristics of early activation (EA) programs could objectively confirm the expediency of their wide introduction, by studying the commonest characteristics of EA as a means for improving anesthetic and resuscitative provision of surgery with extracorporeal circulation for coronary heart disease and postoperative rehabilitation.

[Choice of agents for early activation-oriented general anesthesia in patients operated on for ischemic heart disease].

The purpose of the study was to analyze the choice of agents for general anesthesia in the implementation of an early activation in patients operated on for coronary heart disease (CHD). Anesthetic maintenance protocols were analyzed in 1008 patients who were operated on under extracorporeal circulation (EC) in 1995, 1999, 2001, 2004, and 2006. After aortocoronary bypass grafting, the trachea was extubated in 45% of cases. 1999 was marked by a significant diference in the use of agents for general anesthesia in patients activated in the operating suite and in those who had prolonged artificial ventilation. In 2006, there were differences in the frequency of use of anesthetics in activated and inactivated patients. In 2006, the most popular anesthetics were propofol (82% of cases), midazolam (72%), isoflurane (37%), and sevoflurane (53%). The doses of fentanyl were reduced from 10.3 +/- 0.3 microg/kg/h in 1995 to 3.4 +/- 0.2 microkg/kg/h in 2006 (p < 0.05). During activation in the operating room, the frequency of naloxone use was reduced from 85.2% in 1999 to 21.1% in 2006 (p < 0.05). The authors paid particular attention to the pharmacodynamics of anesthetics used for the early activation of patients operated on under EC for CHD. It is concluded that early activation of patients operated on under EC for CHD is possible after general anesthesia based on diferent agents. Early activation substantially changes the concept of general anesthesia during myocardial revascularization operations.

[Left ventricular dysfunctions after correction of aortic stenosis].

The purpose of the investigation was to study central hemodynamics and left ventricular function in low cardiac output after correction of aortic stenosis. The study included 34 patients (28 males and 6 females) aged 59. 7+/-1.5 years, surged with cardiopulmonary bypass (CPB). Low cardiac output was detected in all cases in the post-CPB period. Inotropic support with dopamine and/or dobutamine was effective in 47% of the patients (Group 1) and ineffective in 53% (Group 2). There were no statistically significant differences in cardiac index and pulmonary wedge pressure between the groups. Group 1 patients had ultrasound signs of left ventricular systolic dysfunction (low left ventricular ejection fraction and larger left ventricular systolic and diastolic areas in the transgastric position). Group 2 patients had ultrasound signs of left ventricular diastolic dysfunction (high left ventricular ejection fraction and smaller left ventricular systolic and diastolic areas). beta-blockers were used in 10 patients from Group 2. Central hemodynamics and left ventricular function normalized in all these cases. It is concluded that it is possible to recognize left ventricular dysfunctions in low cardiac output after aortic valve replacement with transesophageal echocardiography. Inotropic support is effective in only patients with left ventricular systolic dysfunction. Patients with left ventricular diastolic dysfunction should receive beta-blockers.

[Early activation of patients after myocardial revascularization under prolonged extracorporeal circulation].

The purpose of the study was to analyze the experience with fast-track activation of patients after myocardial revascularization with cardiopulmonary bypass (CPB) longer than 150 min and to study the efficiency of these procedures. The study included 64 ischemic patients (56 males and 8 females) aged 58.7+/-1 years, surged with CPB. In all cases, surgery and CPB were uncomplicated. The time of CPB was 151-298 (187+/-4) min; that of aortic cross-clamping was 67-181 (121+/-4) min. Hemodynamics, pulmonary gas exchange, and laboratory parameters were virtually normal before activation. Tracheal extubation was performed in the operating room 27-117 (61+/-3) min following the end procedure. The length of intensive care unit (ICU) stay was less than 24 hours in 82.8% of patients. The remaining patients stayed at an ICU 2-15 (2+/-1) days, which was associated with cardiac, pulmonary, renal complications, etc. The doses of dopamine and/or dobutamine and norepinephrine, and the index PO2a/FiO2 were shown to be predictors of ICU stay. It is concluded that fast-track activation is appropriate for patients undergoing prolonged CPB. The patients enrolled in the fast-track programme after prolonged CPB are to meet the following requirements: minimum inotropic and vasopressor support and PO2a/FiO2 greater than 350 mm Hg.

[Substantiation of the selection of tactics for the surgical treatment of chronic pancreatitis].

177 patients with chronic pancreatitis and the pancreas head affection (CPPHA) were examined and these results were discussed. Option of the pancreatoduodenal resection (PDR) method was performed with due regard the greatest physiology of the operation and rare happening of the poor postoperative results. There are two methods operations of these patients--PDR or isolated resection of pancreas head (IRPH). Variations of IRPH have lesser the nearest unfa variable post operation results. There is no increase of postoperative lethality and complications if the right option and careful performance of IRPH (as Beger operation) was made.

[Risk factors of prolonged intensive care after early activation of cardiosurgical patients].

The purpose of the study was to reveal the predictors of more than 24-hour intensive care unit stay for patients activated early (up to 5 hours) after surgery under extracorporeal circulation and to explore the possibilities of predicting the prolongation of postoperative intensive care in the clinical situation under examination. The protocols of anesthetic maintenance, early activation, and postoperative intensive care were analyzed in 83 patients (50 males and 33 females) aged 31 to 82 years, who had been operated on under extracorporeal circulation for various cardiosurgical diseases. The multiple regression analysis showed that the significant predictors of more prolonged intensive care after early activation were the level of arterial lactatemia (p = 0.0021), the dosages of adrenaline and/or noradrenaline (p = 0.0048), age (p = 0.0051), and female sex (p = 0.0142). It was shown that the multiple regression analysis could approximately predict the duration of intensive care after early activation. The predicted and actual durations of intensive care in patients with an intensive care unit stay length of more than 24 hours coincided in 52% of cases. In patients with an intensive care unit stay length of less than 24 hours, the estimated and actual durations of intensive care were in agreement in 92% of cases. It is concluded that it is expedient to take into account the results of the performed analysis in choosing the optimum postoperative management policy in cardiosurgical patients who are to undergo early activation.

[Alveolar opening maneuver (mobilization) in intraoperative pulmonary oxygenizing dysfunction in cardiosurgical patients].

The purpose of the study was to investigate arterial oxygenation and hemodynamics during and after alveolar mobilization in the early post-cardiopulmonary bypass (CPB) period of cardiac surgery. The study involved 21 patients aged 30 to 73 years, who had a PaO2/FiO2 below 300 mm Hg in the early post-CPB period. PaO2/FiO2 was less than 200 mm Hg in 4 patients. Alveolar mobilization was performed by means of the "Open lung tool" function of a Servo-i respirator ("Maquet'). PaO2/FiO2 significantly increased (P < 0.5) from 244+/-11 to 472+/-20 mm Hg and thoracopulmonary compliance (Cdyn) increased from 53.3+/-3 to 67.5+/-2.9 ml/cm H20 (p < 0.5). Intrapulmonary shunt (Qs/Qt) significantly decreased from 14+/-1 to 10+/-1.5% (p < 0.5). The mean values of PaO2/FiO2 Cdyn and Qs/Qt were stable at the end of procedures. PaO/FiO, was greater than 350 mm Hg in 62% of the patients. Cardiac index considerably decreased from 2.7+/-0.1 to 225+/-0.1 l/min/m(2) at the peak of alveolar mobilization (p < 0.05); right atrial pressure and mean pulmonary artery pressure were moderately, but significantly higher at that moment. Hemodynamic parameters returned to the baseline levels after alveolar mobilization. There were no significant hemodynamic complications. It is concluded that alveolar mobilization is an effective technique in improving arterial oxygenation and lung biomechanics in cardiosurgical patients under anesthesia.