H-shaped partial splenorenal shunting with the use of a reinforced graft made of porous polytetrafluoroethylene. / N-obraznoe partsial'noe splenorenal'noe shuntirovanie s ispol'zovaniem armirovannogo proteza iz poristogo politetraftorétilena.

AIM: The study was aimed at improving the immediate and remote results of splenorenal bypass grafting. PATIENTS AND METHODS: A total of 57 patients presenting with hepatic cirrhosis, portal hypertension, and recurrent haemorrhage from oesophageal varices underwent an H-shaped partial splenorenal shunt procedure using an externally reinforced 1.5-2.0-cm-long synthetic graft with a diameter equalling half of that of the splenic vein in an end-to-side fashion. Assessment of efficacy of shunting was based on intraoperative measurement of venous pressure in the portal system before and after shunting, the findings of Doppler ultrasonography of the linear velocity of blood flow in the portal, splenic, and left renal veins in the early postoperative period, as well as computed tomography, esophagogastroscopy, and assessment of the degree of hepatic encephalopathy in the remote postoperative period. RESULTS: The findings of intraoperative measurement of venous pressure in the portal vein system before and after shunting demonstrated a statistically significant decrease in (normalization of) portal pressure in all patients after bypass grafting (p≤0.05). There were no severe postoperative complications, in-hospital mortality, nor events of decompensation of hepatic insufficiency. According to the findings of Doppler ultrasonography of the linear velocity of blood flow and control computed tomography after surgery, the splenic vein, left renal vein and the conduit between them remained patent at all terms of postoperative follow up. The findings of control esophagogastroscopy revealed a statistically significant decrease in the degree of oesophageal varices at 3, 6, and 9 months after shunting (p≤0.05). There was no statistically significant difference in the change of the degree of hepatic encephalopathy at 3, 6, and 9 months after shunting (p=0.853, p=0.712, and p=0.581, respectively). At various terms after surgery, nine patients underwent deceased donor liver transplantation, with the splenorenal shunt ligated intraoperatively. CONCLUSION: This method of splenorenal shunting makes it possible to decrease the risk of bleeding from oesophageal varices and venous thromboses in vascular anastomoses, as well as complications resulting from using autovenous conduits, to decrease the risk of decomposition of hepatic insufficiency and the frequency of the development of encephalopathy in the postoperative period. Besides, this method makes it possible to easily dismantle the previously created artificial portocaval shunt in the process of liver transplantation.

Peculiarities of vitalization of grafts made of porous polytetrafluoroethylene in reconstruction of major veins (an experimental study). / Osobennosti vitalizatsii protezov iz poristogo politetraftorétilena pri rekonstruktsii magistral'nykh ven (éksperimental'noe issledovanie).

Increased incidence of locally disseminated malignant neoplasms with invasion of major veins compels modern surgery to search for an optimal material for reconstruction of major veins. Presented herein are the results of an experimental study aimed at exploring patency and peculiarities of vitalization of grafts made of porous polytetrafluoroethylene (7th generation, 2010) manufactured by the Closed Joint Stock Company 'Research and Production Complex 'Ecoflon' (St. Petersburg, Russia) with an internal diameter measuring 4.0 mm and used for reconstruction of major veins and arteries with a follow up period up to 270 days. Vitalization of porous polytetrafluoroethylene grafts in the venous position is comparable to that in the arterial position, having similar patterns. Both in the arterial and venous position, vitalization of the graft proceeds at the expense of 'crawling' of the neointima from the anastomoses to the centre of the graft. To distinctive peculiarities of vitalization of grafts in the venous position belong statistically significantly larger thickness of the neointima in the venous position at all stages of the study, lack of statistically significant difference of the neointimal thickness near the edges and in the central part of the graft in the venous position at 270 days. Neither thromboses nor haemodynamically meaningful stenoses of the porous polytetrafluoroethylene grafts and anastomoses in the venous position, despite low velocity of blood flow and its laminar pattern, were observed at any terms of follow up. The obtained findings are indicative of the possibility and validity of using porous polytetrafluoroethylene grafts for reconstruction of major veins in clinical practice.

[Influence of pancreatic segment graft autotransplantation on its exocrine function].

In experiments on dogs the exocrine secretion of pancreatic segment graft after its autotransplantation and of pancreatic stamps after proximal resection of the pancreas was investigated. More significant impairment of the exocrine secretion of the pancreas was revealed in animals after pancreatic graft autotransplantation in comparison with animals after the proximal resection of the pancreas. Maintenance of the adaptation of pancreatic exocrine secretion to the nutritional composition of the intestinal contents and "generalized inhibition" of pancreatic exocrine secretion caused by duodenal trypsin infusion was revealed in all groups.

[Pathogenesis of adhesions formation after intraabdominal operations].

The article describes the pathogenesis of adhesions formation after intraabdominal operations. Described predisposing factors leading of which is mechanical trauma, resulting from the use of surgical instruments, rough manipulations during surgery, damage to the mesothelium by dry gauze etc, which cause the adhesions. The pathogenesis of adhesions formation after intraabdominal surgery is presented in outline form, which described the changes occurring in the body starting with combination of predisposing factors and ending with the development of adhesions with blood vessels by 7-12 days after surgery. At the genetic level predisposition to adhesions formation and development of adhesive disease is treated as a manifestation of rapid acetylation phenotype, in which the intensity of fibrin formation exceeds normal rate of its catabolism. Thus, according to modem concepts, adhesive disease is a separate nosologic unit that dictates the necessity of its detailed study, development and introduction new universal methods of preventing the adhesions formation after intraabdominal operations.

[Pancreatic functional status after wedge resection of the duodenal wall and para-pancreatic micro-irrigation].

RESEARCH OBJECTIVE: To study influence parapancreatic microirrigation on morphological and functional condition of a pancreas and transformations of enzymatic activity of blood serum and enzymatic activity of lymph of a chest lymphatic channel after an operative trauma of a duodenum. MATERIAL AND METHODS: Research is executed on 140 not purebred dogs which have been divided into six groups and united in two series. In the first series (30 dogs) were studied changes pancreatic exosecretion in the postoperative period of resection of duodenum (group 1.1), in the postoperative period of resection of duodenum with preliminary infiltration of a parapancreatic tissue of 0.5% by a solution of Novocain (group 1.2) and after resection of duodenum with application parapancreatic microirrigation (group 1.3). In the second series (110 dogs) were studied frequency of development of acute pancreatitis, enzymatic activity of blood serum and enzymatic activity of lymph of thoracal lymphatic duct after resection of duodenum (group 2.1) and in the postoperative period of resection of duodenum with preliminary infiltration of a parapancreatic tissue of 0.5% by a solution of Novocain (group 2.2) and after resection of duodenum with application parapancreatic microirrigation (group 2.3). RESULTS: Application parapancreatic microirrigation does not lead to oppression pancreatic exosecretion at the first o'clock after duodenotomy, and substantially reduces the pancreatic hypersecretion observed in the postoperative period of resection of a duodenum. In addition, application parapancreatic microirrigation reduces frequency of development of acute pancreatitis and promotes less expressed increase enzymatic activity of blood serum and enzymatic activity of lymph thoracal lymphatic duct at development of the given complication after operational trauma of duodenum in comparison with resection of duodenum and after a resection of a duodenum executed against infiltration of a parapancreatic tissue of 0.5% by a solution of Novocain.

[The duodenal wall injury as a cause of acute pancreatitis].

Dynamics of cholecystokinin-like, secretin and somatostatin immunoreactivity of blood plasma and extracts of duodenal mucosa, frequency of acute pancreatitis (AP) after the resection of the duodenum was studied on not purebred dogs. Rising of a secretin concentration in blood plasma after the clinoid resection of the duodenum, accompanied by decreasing of its concentration in duodenal mucosa, was revealed. Decreasing of cholecystokinin concentration in a neutral extract was revealed. In 24 hours alter resection of the duodenum AP was observed in 38% of cases, infusion of the lorglumide was reduced the frequency of this complication up to 6.2% (p<0.05).

[The regulatory contours of correction of the pancreatic secretion].

It is offered to allocate three basic contours of regulation and self-regulation of pancreatic secretion: duodeno-pancreatoglandulary, hemato-pancreatoglandulary and ductulo-pancreatoglandulary, at which participation the correction of enzymatic structure of a secret of pancreas concerning permanent properties of duodenal chyme and variation of enzymatic spectrum of a secret in the postprandial period of secretion is carried out. In all three contours in quality of the regulatory factor acts actually a pancreatic secret and its components, and also condition of ductal hydrokinetics of a pancreatic secret. Is established, that the pancreatic secretion is provided with the large number of the functionally nonequipotential secretory-transport modules having certain determinants of their morpho-functional organization.

[Morphofunctional organization of pancreatic secretory activity (a new paradigm)]. / Morfofunktsional'naia organizatsiia sekretornoi deiatel'nosti pozheludochnoi zhelezy (novaia paradigma).

This is a review of physiological, morphological and clinical studies of pancreas secretion with the emphasis placed on pancreatic enzymes. It was established that different parts of the duodenal mucous coat have different chemosensory thresholds to the stimulators and inhibitors of pancreatic secretion. Secretory regions of the pancreas having a modular organization are also functionally different. The module is a set of pancreatic acinar and ductal cells (a secretory component), a system of ducts with their valve structures and a microdepository of secretion (a transport component) with control mechanisms specific for the module. Pancreatic secretion is a result of stimulation and inhibition of specialized secretory and transport modules.

[Pancreatic exocrine secretion in experimental acute postoperative pancreatitis]. / Vneshniaia sekretsiia podzheludochnoi zhelezy pri éksperimental'nom ostrom posleoperatsionnom pankreatite.

Transformations of parameters of pancreatic exocrine secretion after the direct operations on the pancreas of a dog were studied during the experiment. It was determined that the early post-operative period proceeds in the conditions of the expressed pancreatic hypersecretion, hyperenzymemia and ductal hypertension. Their intensity reduces as the destructive process in pancreas develops. This results in changes of pancreatic exosecretion in two phases: the increasing and decreasing hypersecretion. The role of augmentation of the secretory activity of pancreas in pathogenesis of the acute postoperative pancreatitis is discussed. Its development was observed in all operated animals. This enabled us to resolve all contradictions and to prove the expediency of the application of pancreas secretion inhibitors at the prevention of acute post-operative pancreatitis.

[Immediate results of pancreatoduodenal resection with end-loop pancreatoenteroanastomosis]. / Neposredstvennye rezul'taty pankreatoduodenal'noi rezektsii s ispol'zovaniem kontsepetlevogo pankreatoénteroanastomoza.

Immediate results of 151 pancreatoduodenal resections (PDR) were analyzed. This surgery was performed for tumors of gastropancreatoduodenal region in 88.1% patients, for chronic complicated pancreatitis--in 11.9%. Pylorus-saving PDR was performed in 82.8% patients, in combination with stomach resection--in 17.2%. Extended and regional pancreatectomy was performed in 20.3% patients with tumors of periampullar zone, extended lymphadenectomy--in 44.4%. Pancreatoenteroanastomosis was created in 82.8% patients, end-loop Wirsungenteroanastomosis by original author's method--in 52.3% of them, traditional Wirsungenteroanastomosis end-to-side--in 30.5%, complete external drainage of pancreas stump was performed in 13.9%, suturing of pancreas stump--in 2.6%, pancreatogastroanastomosis was created in 1 (0.7%) patient. There was no insufficiency of pancreatoduodenoanastomosis performed with original method, while in traditional Wirsungenteroanastomosis it was seen in 4.4% patients. End-loop anastomosis permitted to reduce number of complications after PDR 1.6--3 times. General lethality was 11.3%, in end-loop anastomosis--3.8% that significantly lower than after other methods of treatment of pancreas stump.

[Functional distinction of secreting pools of the pancreas and participation of the pancreatic ductal system in the development of the pancreatic secret properties]. / O funktsional'nykh razlichiiakh sekretornykh basseinov podzheludochnoi zhelezy i uchastii ee protokovoi sistemy v formirovanii svoistv pankreaticheskogo sekreta.

Acute experiments on dogs with separate secretion of the pancreatic enzymes, either stimulated or inhibited, from two lobes of pancreas, and investigation into the character of kinetics of the secretion from 5-7 ductal pools of the pancreas showed the functional specifics, with the device of ductal valves and microdepot of a secret of the pancreas ductal system playing an important role. The conclusion is made that the final secret of pancreas removed to the duodenum is a product of a secret-motor activation of non-equipotentional microregions of the gland, being the components of an intervisceral dynamical mosaic.

[Generalized and selective feedback inhibition of secretion of pancreatic enzymes]. / Generalizovannoe i selektivnoe obratnoe tormozhenie sekretsii pankreaticheskikh fermentov.

Selective inhibition of secretion of proteinases, amylase and lipase by the pancreas, was revealed. The inhibition is directly dependent on the dose of intraluminal enzymes. The latter's increase transforms the selective inhibition into a generalised one. Possible mechanisms of selective and generalised feedback inhibition of the exocrine pancreatic secretion is discussed, the secretion playing an important role in urgent adaptation of the pancreatic enzymes secretion to the duodenal chyme properties.

[Regulation and self-regulation of the pancreas secretion]. / Reguliatsiia i samoreguliatsiia sekretsii podzheludochnoí zhelezy.

A review of modern experimental and clinical research, including own author's data, on regulation of the periodical and postprandial external pancreas secretion and of the secretion phases. Focus on self-regulation of pancreas exosecretion with the pancreatic enzymes based on the principle of negative feedback, and on mechanisms of the feedback inhibition of pancreatic secretion. Description of the selective and generalised inhibition of secretion of pancreatic enzymes, the role of this mechanism in emergency adaptation of the fermental spectrum of the pancreas secretion in response to the nutritional composition and properties of the duodenal chemus. In conclusion, the experimental and clinical data are presented on use of intraduodenal injection of trypsin as a generalised inhibitor of pancreas secretion in case of acute pancreatitis.

[Intra-arterial regional perfusion in destructive forms of acute pancreatitis]. / Vnutriarterial'naia regionarnaia perfuziia pri destruktivnykh formakh ostrogo pankreatita.

The results of using regional infusion therapy in 17 patients with destructive pancreatitis are analyzed which appeared to be more effective, than the systemic infusion of drugs in stopping the symptoms of endotoxicosis leveling the functional insufficiency of the liver and kidneys, disturbances in hemodynamics and hemostasis. The best results have been obtained when using a modified method of regional therapy (celiac-aortal dislocational regional infusion) in the complex treatment of destructive pancreatitis. This method has a number of advantages as compared with intra-aortic variant of regional therapy. Hospital lethality in the process of using the methods of regional therapy in the complex treatment of destructive pancreatitis was 17.5%. In the control group of patients treated without regional infusion lethality was within the limits of 28%. A modified classification of endotoxicosis according to the degree of the disease is proposed. In order to estimate the severity of the syndrome of intoxication and effectiveness of the given therapy principally new integrative parameters of clinical and laboratory research are used.