Changes Due to Ageing in the Glycan Structure of Alpha-2-Macroglobulin and Its Reactivity with Ligands.

Alpha-2-macroglobulin (α2M) is a molecule generally associated with inflammation, and chronic inflammation is associated with ageing and cancer. The degree of inflammation was recently proposed to be considered as a biomarker of biological ageing. In this study, glycans attached to α2M were analysed in a human population of different ages by lectin-based protein microarray. Higher reactivity of α2M with several lectins was detected in older individuals indicating an increased content of specific monosaccharides: α2,6 sialic acid, mannose and N-acetylglucosamine, and multiantennary complex type N-glycans. The increased glycosylation of α2M was accompanied by reduced binding of Zn ions and insulin-like growth factor-binding protein 2 (IGFBP-2). Glycosylation of α2M and its reactivity with IGFBP-2 is similarly affected by ageing and incidence of colon cancer, but the reactivity of α2M with Zn ions is differently affected, as the binding of Zn ions remains unaltered in patients with colon cancer compared to healthy middle-aged individuals. Thus, the binding of IGFBP-2 to α2M seems to be related to structural changes in the glycan moieties of α2M, whereas binding of Zn ions, most likely, is not.

Regulation of Insulin and Insulin-Like Activity in Malnourished Patients with Carcinoma Ventriculi Subjected to Total Gastrectomy and Personalized Nutritional Support.

BACKGROUND: Insulin and insulin-like growth factor (IGF) activities are disturbed during critical illness. Time-course changes in the concentrations of insulin, IGF-I and IGF-binding proteins (IGFBPs) were monitored in this study and their correlation with interleukin (IL)-6 was assessed in patients subjected to total gastrectomy and specific nutritional regime. METHODS: Patients were fed post-operatively according to the following scheme: parenteral nutrition on day 1, enteral nutrition combined with parenteral form from day 2 to 7, peroral nutrition from day 8 and full oral nutrition from day 14. Blood samples were taken periodically and the levels of IL-6, insulin, IGF-I and IGFBP-1 to -4 were determined. RESULTS: On day 1 post-operatively, the concentration of IL-6 reached its maximum and decreased afterwards. The concentration of insulin increased until day 3 and then started to fall. The concentration of IGF-I, already low preoperatively, continued to decrease. The concentration of IGFBP-1 peaked on day 1 post-operatively, whereas the concentration of IGFBP-3 decreased on that day. The concentration of IL-6 correlated positively with the concentration of IGFBP-1 and negatively with IGFBP-3. On day 14, the concentrations of IL-6, insulin and IGFBP-1 returned to or were close to their basal levels, whereas the concentrations of IGF-I and IGFBP-3 remained reduced. CONCLUSIONS: A 14-day post-operative recovery, which included specific nutritional support, was suitable to restore insulin concentration and re-establish IGFBP-1 regulation primarily by nutrition. Very low IGF-I level on day 14 after surgery and IGFBP-3 concentration still lower than before surgery indicated that the catabolic condition was not compensated.

IGFBP-3/transferrin/transferrin receptor 1 complexes as principal mediators of IGFBP-3 delivery to colon cells in non-cancer and cancer tissues.

PURPOSE: The aim of this work was to study the involvement of IGFBP-3/Tf complexes in the pathology of colorectal carcinoma (CRC), quantify them, investigate their relation to iron concentration and binding to transferrin receptor (TfR) in colon tissue (non-cancer and cancer), and to assess the priority of this pathway for internalization of IGFBP-3. METHODS: The presence of IGFBP-3/Tf complexes was analyzed in sera from healthy persons and patients with CRC, and in colon tissue by immunoblotting. Complexes were immunoprecipitated, quantified by immunoassay and structurally characterized by immunoblotting, lectin blotting and mass spectrometry. Complexes which interacted with colon cells were immunoprecipitated with anti-TfR1 antibody and studied. Colon tissue slides were subjected to immunohistochemical analysis. RESULTS: The concentration of IGFBP-3/Tf complexes was three times lower in patients with CRC. They were increasingly carbonylated, sialylated, contained more Galß4GlcNAc units, expressed altered charge density and increased affinity for metal ions. Immunoprecipitation experiments revealed more TfR1 on membranes than in cytosol of colon cells, also more in cancer than non-cancer tissue. TfR1 on membranes were less occupied with IGFBP-3/Tf complexes than in cytosol. Immunofluorescent staining indicated a remarkable degree of co-localization of IGFBP-3 and TfR1, evenly distributed in non-cancer tissue and both evenly and cell surface concentrated in cancer tissue. CONCLUSIONS: Increased expression of TfR1 on colon cell membranes in patients with CRC compensates for the reduced extracellular availability of IGFBP-3/Tf and TfR1 is the principal binding partner of extracellular IGFBP-3. IGFBP-3/Tf complexes in patients with CRC exhibit increased affinity for iron ions.

Complexes between insulin-like growth factor binding proteins and alpha-2-macroglobulin in patients with tumor.

The intention of this work was to systematically study the presence of insulin-like growth factor-binding protein 1 and 2 (IGFBP-1 and IGFBP-2) complexes with alpha-2-macroglobulin (α2M) in the circulation of patients with various types of cancer. Serum samples were collected from patients diagnosed with cancer and divided into eight groups according to the tumor type: liver, pancreas, colon, lung, prostate, breast, cervix and ovary. Results obtained for each cancer group were compared with results obtained for the age and gender-matched controls. Electrophoretic separation and densitometric evaluation of immunoreactive protein bands were performed. According to our results, IGFBP-1/α2M and IGFBP-2/α2M complexes did not exhibit the same presence in different tumors and were also not uniformly related to the amount of monomer forms. Variations in relative quantities of IGFBP-1 monomers and complexes in different tumor types were much more pronounced than those of IGFBP-2. The amount of IGFBP-2 monomer increased in sera from all studied patients compared to controls, whereas the amount of IGFBP-2/α2M complexes most often decreased, being significantly reduced in patients with pancreas, colon, breast or ovary tumor. Although there is still no confirmation of the physiological role of IGFBP-2/α2M complexes, their decreased concentration in the circulation provides greater amount of free IGFBP-2.

Molecular forms of the insulin-like growth factor-binding protein-2 in patients with colorectal cancer.

The components of the insulin-like growth factor (IGF) system and molecules with which they interact are associated with the neoplastic transformation of cells in colorectal cancer. The IGF-binding protein-2 (IGFBP-2) plays a significant role in mitotic stimulation of the cancer cells and its concentration is significantly elevated in tumor states. Little is known about IGFBP-2 at the molecular level and the purpose of this study was to examine the interactions between IGFBP-2 and some other proteins, the fragmentation pattern and posttranslational modifications that might have occurred due to a disease. Results have shown that the amount of monomer IGFBP-2 was 20-30% greater in patients with cancer and the amount of fragmented IGFBP-2 was doubled compared to healthy people, whereas the portion of IGFBP-2 in complex with α2 macroglobulin (α2M) was 2.5 times lower in cancer patients. According to this distribution, IGFBP-2 was not only increasingly synthetized in patients with cancer, but also the amount involved in complexes with α2M was reduced favoring the existence of binary IGFBP-2/IGF complexes, free to leave the circulation. Both IGFBP-2 and α2M were significantly more oxidized in patients with colon cancer than in healthy individuals and α2M was additionally sialylated. It can be speculated that the formation of IGFBP-2/α2M complexes is part of the control mechanism involved in the regulation of IGFBP-2 and, consequently, IGF availability. It also seems that posttranslational modifications are more important factors in determining the amount of IGFBP-2/α2M complexes than the actual quantity of these two proteins.

Detection and identification of oxidized insulin-like growth factor-binding proteins and receptors in patients with colorectal carcinoma.

Colorectal cancer (CRC) is one of the most prevalent cancers worldwide and also the one with the highest mortality rate. Tumor growth is assisted by various growth factors, and insulin-like growth factors (IGFs) are among the most important. A majority of the IGFs are bound to IGF-binding proteins (IGFBPs) and their release is dependent on the rate of IGFBP proteolysis. The action of free IGFs is exerted and controlled by binding to cell membrane receptors (IGF-Rs). The objective of this work was to connect two determinants of the CRC pathology: oxidation as a process that underlies tumor development and the members of the IGF system that control it. Carbonyl groups (CO) on IGFBP-2, IGFBP-3, IGF-1R, and IGF-2R were determined in samples obtained from patients with CRC, and IGF-binding properties of these proteins were analyzed. According to our results, IGFBP-2 and IGFBP-3 in serum had increased content of CO groups due to CRC. Oxidation of IGFBP-2 increased its affinity for IGF molecules, whereas oxidation of IGFBP-3 reduced it. As for receptors, only intact CO-IGF-2R was detected on solubilized colon membranes, whereas CO-IGF-1R was degraded into fragments. Oxidative changes in the IGF axis may be regarded as part of the mechanism of its action. IGFs bound to IGFBP-3 remain in the circulation, whereas those bound to IGFBP-2 freely reach target tissues. Therefore, oxidation supports IGF distribution toward tissues and, consequently, promotes tumor growth.

The importance of metal ions for the formation and isolation of insulin-like growth factor-binding protein 3-transferrin (IGFBP-3-Tf) complexes, and the analysis of their physiological involvement.

Insulin-like growth factor (IGF) binding protein 3 (IGFBP-3) is the most abundant IGFBP in the circulation and its main role is to regulate the amount of free, receptor-reactive IGFs that are involved in a broad range of metabolic and mitogenic activities. IGFBP-3 interacts with several other biomolecules forming complexes that might have IGF-dependent or independent functions. Transferrin (Tf) forms complexes with IGFBP-3, but the physiological significance of this interaction remains unclear. Tf is an iron-transporting protein, and is able to carry other metal ions as well. IGFBP-3, on the other hand, possesses one metal-binding domain. As both proteins have the ability to bind metals, the formation of the IGFBP-3-Tf complexes may be expected to influence the metabolism of metal ions and/or mitogenic/metabolic roles in which IGFBP-3 is involved. The aim of this study was to quantify the amount of complexes in the circulation, to investigate the importance of a specific metal ion for their formation and isolation, and to search for the possible physiological place of the IGFBP-3-Tf complexes. The effects of the following ions were analyzed: Fe(3+), Cu(2+), Ni(2+), Mg(2+) and Zn(2+). Results have shown that the amount of IGFBP-3 involved in the complex formation with Tf in healthy persons was 5.4 ± 1.02 nM and iron ions were substantial for their formation and isolation without employment of harsh conditions. The amount of IGFBP-3-Tf complexes was further determined in persons with iron over-load, patients with iron-deficiency anemia and patients with colorectal carcinoma-associated anemia. The amount of complexes was in direct correlation with the concentrations of iron and IGFBP-3. In the case of the colorectal carcinoma-associated anemia, the amount of complexes was inversely correlated with the concentration of ferritin. IGFBP-3, thus, appears to be a member of a network of iron-binding proteins that participates in cell signaling that involves iron-associated response.

Preoperative assessment and preparation of patients with diseases affecting the central nervous system.

PURPOSE OF REVIEW: This review will examine the most important issues of preoperative evaluation and preparation in relation to patients with deseases affecting the central nervous system. Those patients may undergo various forms of surgery unrelated to the central nervous system disease. We discuss the effect of physiologic and pharmacological factors on cerebral autoregulation and control of intracranial pressure alongside its clinical relevance with the help of new evidence. RECENT FINDINGS: Regardless of the reason for surgery, coexisting diseases of brain often have important implications when selecting anesthetic drugs, procedures and monitoring techniques. Suppression of cerebral metabolic rate is not the sole mechanism for the neuroprotective effect of anaesthetic agents. There are certain general principles, but also some specific circumstances, when we are talking about optimal anesthetic procedure for a patient with coexisting brain disease. Intravenous anesthesia, such as combination of propofol and remifentanil, provides best preservation of autoregulation. Among inhaled agents isoflurane and sevoflurane appear to preserve autoregulation at all doses, whereas with other agents autoregulation is impaired in a dose-related manner. During maintenance of anesthesia the patient is ventilated by intermittent positive pressure ventilation, at intermediate hyperventilation (PaCO2 25-30 mmHg). SUMMARY: Intraoperative cerebral autoregulation monitoring is an important consideration for the patients with coexisting neurological disease. Transcranial Doppler based static autoregulation measurements appears to be the most robust bedside method for this purpose.

Preoperative preparation of patients with pituitary gland disorders.

This paper presents the most common disorders of pituitary function: acromegaly, hypopituitarism, diabetes insipidus and syndrome similar to diabetes insipidus, in terms of their importance in preoperative preparation of patients. Pituitary function manages almost the entire endocrine system using the negative feedback mechanism that is impaired by these diseases. The cause of acromegaly is a pituitary adenoma, which produces growth hormone in adults. Primary therapy of acromegaly is surgical, with or without associated radiotherapy. If a patient with acromegaly as comorbidity prepares for non-elective neurosurgical operation, then it requires consultation with brain surgeons for possible delays of that operation and primary surgical treatment of pituitary gland. If operative treatment of pituitary gland is carried out, the preoperative preparation (for other surgical interventions) should consider the need for perioperative glucocorticoid supplementation. Panhypopituitarism consequences are different in children and adults and the first step in diagnosis is to assess the function of target organs. Change of electrolytes and water occurs in the case of pituitary lesions in the form of central or nephrogenic diabetes insipidus as a syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Preoperative preparation of patients with pituitary dysfunction should be multidisciplinary, whether it is a neurosurgical or some other surgical intervention. The aim is to evaluate the result of insufficient production of pituitary hormones (hypopituitarism), excessive production of adenohypophysis hormones (acromegaly, Cushing's disease and hyperprolactinemia) and the influence of pituitary tumours in surrounding structures (compression syndrome) and to determine the level of perioperative risk. Pharmacological suppressive therapy of the hyperfunctional pituitary disorders can have significant interactions with drugs used in the perioperative period.

Contemporary approach to preoperative preparation of patients with adrenal cortex hormones dysfunction.

Preoperative preparation of the patients with adrenal cortex dysfunction is based on the careful preoperative evaluation of the type and the severity of the disturbance. The dysfunction involving adrenal glands may be: insufficiency (severe, mild, expressed) and hyperfunction (hypercorticism and/or hyperaldosteronism). If we speak about the patients with limited adrenal reserve (Addison's disease, therapeutic glucocorticoid application etc.) they need necessary corticosteroid supplementation, during preoperative preparation, as well as, during complete perioperative period. Doses needed for the substitution are adjusted according to the severity of adrenal insufficiency and according to the extent of the planned surgical procedure. Patients with Cushing's syndrome (or other form of hypercorticism), as well as, patients with Conn's syndrome (or other forms of hyperaldosteronism), do have numerous organ dysfunctions, that are significant in preoperative preparation, anesthesia and for the outcome of the surgical treatment. Common feature for both of the above syndromes is hydroelectrolyte disbalance, with hypokalemia, metabolic alkalosis and hypertension. Disturbances related to the adrenal cortex hyperfunction must be corrected preoperatively, in order to avoid complications. When we speak about hypokalemia it must be promptly corrected even before urgent/vital surgical procedure because it may cause severe intraoperative cardiac arrhythmia.

Enhanced suppression of hormonal and metabolic responses to stress by application of combined spinal-epidural and general anaesthesia compared with combined spinal general anaesthesia during colorectal surgery.

The aim of the study was to determine the impact of combined spinal-epidural and general anesthesia (CSEGA) on the suppression of the hormonal and metabolic response to surgical stress and to compare it with the technique of combined spinal and general anesthesia (CSGA). Sixteen patients referred for elective colorectal surgery randomly divided into two groups on the basis of anesthesia (CSEGA and CSGA). Mean arterial blood pressure, heart rate, haemoglobin saturation, serum glucose, serum cortisol and urinary catecholamines (adrenaline, noradrenaline and dopamine) were determined at four distinct peri-operative time points. During the peri-operative period the overall haemodynamic and respiratory functions in patients that received CSEGA were superior compared to those in patients that received CSGA. Biochemical analysis revealed that in the sera of patients that received CSEGA the concentration of both glucose and cortisol was elevated to a lesser degree than that observed in the sera of patients that received CSGA. Furthermore, a significant reduction in post-operative urinary catecholamine (adrenaline and noradrenaline) excretion was apparent in the CSEGA group. We conclude that CSEGA is a more suitable form of combined anaesthesia for colorectal surgery with a clear advantage of a blunted surgery-mediated neuro-endocrine stress response.

Insulin-like growth factor I (IGF-I) as a sensitive biomarker of catabolism in patients with gastrointestinal diseases.

Gastrointestinal ailments evoke changes in the hypothalamic-pituitary-adrenal (HPA) axis and modulation of hepatic protein synthesis. We examined the catabolic effect of certain primary gastrointestinal diseases and surgery on the concentration of insulin-like growth factor I (IGF-I). Blood samples from patients with gastric cancer (GC), cholecystitis (CC), or inguinal hernia (IH) were taken before and after surgery. The concentrations of IGF-I, IGF binding protein-1 (IGFBP-1), insulin, cortisol, and glucose were determined. In GC patients the concentration of IGF-I was reduced and the concentrations of IGFBP-1 and cortisol were elevated preoperatively; after surgery, IGFBP-1 normalized. In CC patients the concentration of IGF-I was low and the concentration of IGFBP-1 was high before cholecystectomy; after surgery IGFBP-1 returned to normal and the concentration of cortisol increased. In IH patients the concentration of IGF-I was low and the concentrations of IGFBP-1 and cortisol were high before surgery; after laparotomy IGFBP-1 returned to normal. The metabolic changes were present in all analyzed patient groups, regardless of the severity of disease and nutrition. The concentration of IGF-I was reduced before surgery and remained reduced after, recommending IGF-I as a metabolic marker in both pre and postoperative examination of patients.

Differential influence of open surgery and sepsis on the circulating insulin-like growth factors and their binding proteins as representative metabolic markers.

OBJECTIVES: In critical illnesses and stress conditions many endocrine systems are disturbed. In the current study we determined the influence of open surgery, post-operative sepsis and its early therapy on the components of the insulin-like growth factor (IGF) system in patients with malignant gastric or pancreatic tumors. DESIGN AND METHODS: Twenty-one patients and eighty-one age- and sex-matched healthy subjects were included in this study. IGF-I, IGF-II, IGF binding proteins (IGFBPs), cortisol, insulin and protein concentrations (total, albumin and IgG) were determined pre-operatively, post-operatively, when sepsis was diagnosed and 48 h after initiating therapy. RESULTS: The concentrations of circulating IGF-I, IGF-II and IGFBP-3 were significantly lower in pre-operative patients compared to healthy subjects. Sepsis caused a further decrease in IGF-I and IGFBP-3 but an increase in IGFBP-1, IGFBP-2 and IGFBP-4 resulting in a redistribution of IGF molecules from ternary to binary complexes. CONCLUSIONS: The presence of malignant gastric or pancreatic tumors followed by post-operative sepsis caused a serious misbalance in components of the IGF system which failed to recover during the time of our longitudinal study.

A comparison of sevoflurane-fentanyl and neuroleptic anaesthesia for laparoscopic cholecystectomy of mildly obese patients.

The current study was formulated to evaluate the advantages and disadvantages of sevoflurane-fentanyl and neuroleptic anaesthesia for laparoscopic cholecystectomy surgery of mildly obese patients. Laparoscopic cholecystectomy was performed using either sevoflurane-fentanyl or neuroleptic anaesthesia. Intra-operative haemodynamic stability, surgical duration, awakening time, severity of post-operative pain and hormonal stress parameters (serum and urinary cortisol, serum insulinlike growth factor and serum insulin) were determined. The duration of both surgery and patient hospitalisation were similar in both study groups. Patients that received sevoflurane-fentanyl exhibited a significantly shorter awakening time compared to neuroleptic anaesthesia. In addition, the same group of patients had less post-operative complications (nausea, vomiting, urinary retention and respiratory insufficiency) despite more abdominal pain. The severity of postoperative pain and the requirement of additional analgesia (up to 12 hours post-surgery) were greater in patients that received sevoflurane-fentanyl. The serum and urinary cortisol concentrations were significantly increased in post-operative patients that received neuroleptic anaesthesia whereas the insulin-like growth factor-I concentration in both study groups significantly decreased post-operatively. Our results clearly show that neuroleptic anaesthesia attenuates the stress response to laparoscopic cholecystectomy to a lesser extent than sevoflurane-fentanyl. The latter anaesthesia is recommended for laparoscopic cholecystectomy of mildly obese patients.

The effect of laparoscopy on the IGF system in patients diagnosed with acute cholecystitis.

OBJECTIVE: IGFs and IGF binding proteins in the circulation are subject to modulation by a number of catabolic states including inflammation, trauma and surgery. We sought to determine the impact of laparoscopy on the IGF system in patients diagnosed with acute cholecystitis. DESIGN: The components of the IGF system, cortisol, glucose and insulin concentration in both the serum and urine of patients were compared to those from a healthy group of subjects. An additional comparison was made between pre- and post-laparoscopically assisted patients. PATIENTS: Thirty patients diagnosed with acute cholecystitis and 81 matched controls were included in the study. MEASUREMENTS: Radioimmunoassays were used to determine the IGF-I, IGF-II, insulin and cortisol concentrations. The concentration of IGFBP-3 was measured using an immunoradiometric assay. The GOD-PAP method was used to determine the glucose concentration. Gel filtration chromatography was performed to calculate the IGF binary/ternary complex ratio. The amount of sialic acid in IGFBP-3 was determined by affinity chromatography. The presence of IGFBPs in serum was determined by both immunoblotting and ligandblotting. RESULTS: The concentrations of circulating IGF-I, IGF-II and IGFBP-3 were significantly reduced in pre-operative patients compared to healthy subjects. No further reductions were observed post-laparoscopy. Immunoblotting and ligandblotting demonstrated a decreased amount of IGFBP-3 in both pre- and post-operative patients compared to healthy subjects. Increased levels of IGFBP-2 and IGFBP-1 were observed in pre-operative patients compared to healthy subjects, but laparoscopy did not cause further elevation. No alteration in the IGF binary/ternary complex ratio was witnessed between any of the study groups. A significant increase in the sialic acid content of IGFBP-3 was seen in both patient groups when compared to healthy subjects. The level of urinary cortisol was significantly increased in post-operative patients, whereas the urinary IGF-I concentration was decreased compared to healthy subjects. CONCLUSIONS: Our results indicate that acute cholecystitis causes several significant changes in the circulating IGF system. Laparoscopy, however, does not aggravate such changes, but elevates urinary cortisol.

[Advantage of combined spinal, epidural and general anesthesia in comparison to general anesthesia in abdominal surgery]. / Prednosti primene kombinovane spinalne, epiduralne i opste anestezije u odnosu na opstu anesteziju u abdominalnog hirurgiji.

Type and technique of anesthesia have an important effect on per operative surgical course. The aim of the study was prospective analyses of advantages of combined spinal, epidural and general anesthesia (CSEGA) versus general anesthesia (GA) in abdominal surgery according to: 1. operative course (haemodynamic stability of patients, quality of analgesia, undesirables effects), 2. postoperative course (quality of analgesia, unfavourable effects, temporary abode of patients in intensive care). Using prospective randomized double blind controlled study, we evaluated two groups of patients whom the same type of abdominal surgical intervention was planed and the only difference was the type of technique of anesthesia. First group of patients (n = 34), was treated with CSEGA and second group of patients (n = 33), was treated only with standard (GA). Both groups had intraoperative and 24-hour-long postoperative continued monitoring of blood pressure, central venous pressure, and dieresis. In the 24 hours postoperative period, the following parameters were analyzed: vigilance conditions, motor block level, pain intensity in rest and movement, necessity for a complementary analgesia, side effects and final subjective effect of analgesia. There was important difference in waking up the patients after a general anesthesia--in the first group this period was shorter. In the first 24 hours, patients from the first group didn't get any systemic analgesic, while the patients from the second group needed fractionary application of parenteral analgesics in the period of 4-6 hours. Patients from the first group were also physically faster and easier recovered and they had less respiratory complications and there was not any example of thromboembolsm and the intestine motility was faster re-established. First group of patients spent less time in intensive care (three days) than second group (six days). Final subjective effect of analgesia, according to verbal descriptive scale (VDS) of pain was satisfying with 75% of patients of the first group and 15% of patients of the second group. According to results investigation, advantages of CSEDGA versus GA in abdominal surgery manifold: better hemodynamic stability and perfusion of operative region, decrease of single doses of opioid analgesics, local and general anesthetics followed by the decrease of their side effects, better intensity and longer duration of analgesia, improved total functional capability of patients.

[Combined spinal epidural and general anesthesia in abdominal surgery]. / Kombinovana spinalna epiduralna i opsta anestezija u abdominalnoj hirurgiji.

Almost ten years has past since Eldor described combined spinal-epidural-general anaesthesia (CSEOGA) as a new concept in anaesthesia in which all of these components can be used, with sub-anaesthetic doses of drugs, due to its sinergist effect. The clinics studies has not demonstrated crucial advantages CSEGA comparing with combined epidural-general anaesthesia (CEDGA), in sense of analgesia, pulmonary function and neuro-hormomal inhibition. However we have been routinely practising our technique CSEGA in big abdominal and thoraco-abdominal surgery, since 1997. This study is a retrospective analysis of our technique and clinic observations, during 4.5 years, which include 293 patients. Their demographic characteristics can be seen in table 2. We perform combined spinal-epidural anaesthesia (CSE) in one or two interspinal spaces, depending on the type of surgery, but always before induction in general anaesthesia (GA). For preemptive and intraoperative analgesia we use 0.25% plain bupivacaine (B), both for spinal (SA) and epidural (ED) blockade. The most important detail in our technique, despite precise order to administrate drugs, is analgesic solution (AS) which contain B 4.5 mg, fentanyl (Fe) 50 mcg and morphine hydrochloride (Mo) 0.2 mg, in total volume of 3 ml, in SA. After the ED test dose with 2% lidocaine 60 mg (3 ml), before the induction in GA, we inject more 10 ml B, but intraoperative analgesia is almost performed with B 3 to 5 ml in intermittent bolus doses. This ED bolus dosis is particularly important, partly to sufficiently cephalic migration of the SA somatosensorieblock, as well as for intraoperative analgesia. For very light GA only artificial ventilation with 66% N2O in O2 and muscle relaxation with paneuronium is needed. Co analgesia with intravenous (i.v.) Fe, was exceptionally seldom needed, except for induction. Intraoperative drugs consumption was very small as we see in table 5. With adequate liquid compensation, this technique achieve exceptionally intraoperative homodynamic stability in patients, despite to long and big operations. Postoperative analgesia are supplied by SA the first 24 hours, but the next 72 ours is performed with intermittent ED bolus doses of 0.12% B with 2 mg Mo in total volume of 15 ml and 10 ml, depending on the epidural catheter (EDK) position in lumbar or thoracic part of spine. The break through of postoperative pain was between 20% to 34%, which was suppressed with metamisol. According to the verbal rating scale (VRS < 1) 90% patients were satisfied with this analgesia, which gave possibilities to mobilization and rehabilitation even the first postoperative day. All clinical sings show that thanks to inhibition of spinal and supraspinal sensitization, all principles of the preemptive analgesia (PA), inhibition of neuro-hormonal stress reaction are met and postoperative outcome is improved and satisfied. The complications we had were insignificant, in time observed and without any consequences.