CORTICAL INTRAMEDULLARY FIBULAR GRAFT IN SURGICAL TREATMENT OF LONG BONES NONUNION.

Aim of the study is clinical evaluation of usage of cortical intramedular autografts, while treatment of long bones non-unions. During 2003-2013 years, in Traumatology Orthopedical Clinic "Syntese" and L.T.D. "Centre of Urgent Surgery and Traumatology" we have treated 35 patients with diafisial fractures of long bones by use of intramedular grafting. Among them were 12 cases of femoral fracture, 10 - cases of humeral and 13 cases of tibial fractures. Age distributions of patients was: from 16 years up to 30 years - 5 patients (14%): 31- 45 years 21 patients (60%), over 45 years - 9 patients (26%). Types of bone regeneration violation: research group: hypertrophic - 9 (26%), hypotrophic - 11 (31%), athrophyc - 22 (44%). Bone healing was reached in all cases. Average period of healing was 4.9 months. But it ranged from 4 up to 7.7 months. Not satisfactory result was found in 1case, satisfactory result in 2 cases, good result in 32 cases, condition of nearby joints was found as perfect in 72% of cases, good in 14% of cases, satisfactory in 12% and not satisfactory in 2% of cases. Usage of cortical fibular intramedular autografts, authentically increases range of positive results, while treatment of long bones non- unions.

Council of Europe Black Sea Area Project: International Cooperation for the Development of Activities Related to Donation and Transplantation of Organs in the Region.

BACKGROUND: In 2011, the European Directorate for the Quality of Medicines & Healthcare of the Council of Europe launched a 3-year collaborative project to address the organ shortage and improve access to transplant health services in Council of Europe member states in the Black Sea area (Armenia, Azerbaijan, Bulgaria, Georgia, Moldova, Romania, Turkey, Ukraine, and the Russian Federation) through the development of safe and ethical donation and transplantation programs. OBJECTIVE: Support the development of donation and transplantation programs through close interstate cooperation between national health organizations and relevant stakeholders. METHODOLOGY: Several work packages (WP) were established: WP1, project coordination (European Directorate for the Quality of Medicines & Healthcare); WP2, development and implementation of an effective legislative and financial framework (Czech Republic and France); WP3, establishment of National Transplant Authorities (Italy and Portugal); and WP4, clinical practices (DTI Foundation). Data collection, surveys, and expert visits allowed for the collection of first-hand information from each participant country at national, regional, and hospital levels. RESULTS: Data analysis showed the positive impact of the project represented by a tendency to increase the total donation rates (per million people) in the participant countries (2011 vs 2013): Azerbaijan, +7.3; Armenia, -0.7; Georgia, +3.3; Bulgaria, +0.9; Moldova, +2.5; Ukraine:, +0.8; Romania, +2.3; and Turkey, +2.7. CONCLUSIONS: Increases in total donation rates are the result of a number of initiatives in the Black Sea area, including the stepwise implementation of legislative, organizational and institutional country-specific recommendations tailored by the CoE, efforts of the respective Ministries of Health in each country and synergism with other European projects in the region. These countries should invest further in implementing the recommendations that emerged from this project to improve their organ donation and transplantation programs and progress toward self-sufficiency.

[NONSPECIFIC ULCERATIVE COLITIS COMPLICATED WITH MULTIPLE REPETITIVE PERFORATIONS AND DIFFUSE FECALIC PERITONITIS (CASE REPORT)].

Nonspecific ulcerative colitis is disease with complicated and not fully studied etiology and pathogenesis, and treatment of its complications is very difficult. Especially complicated is disease course with repetitive bleeding, toxic megacolon and perforation. We present a quite rare case of complication with multiple, especially repetitive perforations of transverse colon. After 13 days from the performance of subtotal colectomy, the patient underwent to the relaparotomy because of secondary perforation of sygmoid colon 2-3 cm lower from its cult and iliac intestine 0.2-0.3 cm distance from nearby ileostoma. The full eventration took place on the 6th day and was performed repetitive laparotomy. On the 8th day patient was released from artificial ventilation of lungs and on the 66th day from hospitalization patient was discharged from the hospital with satisfactory status. Such kind of serious course of the treatment process was determined by the late hospitalization and developed serious complications. Situation mentioned above more impressively underlines the value of the positive result of presented case.

A RARE CASE OF RIGHT DIAPHRAGM AGENESIS.

Diaphragmatic agenesis is the most extreme and rare form of congenital diaphragmatic maldevelopment and therefore diagnosis of it are only few in literature, especially in children. It may be unilateral or bilateral. Frequently, diaphragmatic agenesis is accompanied with diaphragmatic hernia, when through a congenital defect of the diaphragm liver, intestine and other viscera herniate into the chest. Diagnostics typically are made early in infancy and is generally associated with other genetic anomalies, especially aneuploidy syndromes. It is associated with a high mortality, if not treated in infancy. However, according to published literature only a few patients have survived till adulthood. In this report, we describe the case of a 63 years old male patient who admitted in a hospital with small bowel intussusception because of strangulated intestinal obstruction and peritonitis. While surgical operation and revision of abdominal cavity, partial right-sided agenesis of the diaphragm was revealed. Two operations were performed on a patient; one because of strangulated intestinal obstruction and accompanied peritonitis and the second, because of stitch insufficiency after 5 days from the first surgical operation. Taking into account the heavy overall status of the patient, diaphragm plastic was not performed and its performance postponed for future.

[Optimization of the venous return during experimental hepatectomy in rabbits].

A traditional bypass pattern applied in hepatectomy (venous return in superior vena cava system) is frequently attended by blood congestion in cranial veins. The study objective is the maintenance of hemodynamic indices in normal physiological ranges via application of the new bypass scheme in the experimental model of the anhepatic period. 12 rabbits of Chinchilla breed were involved in the experiments, with weight ranging between 3,0-3,5 kg, which were divided into three groups (with 3 animals in each): I control group - hepatectomy under the condition of non-compulsory liver bypass with the return of the venous flow in brachiocephalic vein. II group - hepatectomy with the compulsory bypass, with an in-take of blood in the apparatus and injection in the brachiocephalic vein. III group - hepatectomy via non-traditional method of compulsory bypass in suprahepatic vena cava. The outcomes of the experiments indicated that blood congestion in cranial venous system occurred only in I and II groups, which was verified by the pressure rise (5,9+/-1,2 mmHg and 4,7+/-0,5 mmHg, respectively) and diminished blood flow rate (3,0+/-1,8 ml/min and 2,0+/-0,7 ml/min) in external jugular vein. These indices corresponded with the levels of 0,6+/-0,2 mm Hg and 9,0+/-2,5 ml/min respectively in the III group. Application of the artificial, compulsary bypass circuit has been established to be reasonable in anhepatic period, for achieving the blood return to the heart through portal vein and from the lower parts of the body. During blood return in suprahepatic portion of vena cava, the congestion in cranial venous system is prevented. Maintenance of the pressure and volume indices between normal physiological limits in venous system provides the opportunity of safe prolongation of the anhepatic period.

Differences in rejection grading after simultaneous pancreas and kidney transplantation in pigs.

Clinical observations suggest that recipients of multiorgan transplants from the same donor can have disparate immunological reactions to each organ. We studied this phenomenon in 36 diabetic (streptozotocin-induced), bilaterally nephrectomized, immunosuppressed (cyclosporine, azathioprine, prednisone) pig recipients of simultaneous (same donor) pancreas (bladder drained) and kidney allografts by grading the histological intensity of rejection in biopsies of each organ at defined intervals posttransplant. Graft function was monitored by plasma glucose (PG) and urine amylase (UA) for the pancreas and serum creatinine (Cr) for the kidney. Interstitial rejection was graded as absent, mild, moderate, and severe in, respectively, 8%, 25%, 42%, and 25% of pancreas vs. 4%, 12%, 27%, and 57% of kidney biopsies at 1 week; and 0%, 43%, 29%, and 29% of pancreases vs. 10%, 0%, 30%, and 60% of kidneys at two weeks. Although the distribution of grades was similar in the two organs (P > 0.1), the grade of rejection for each pair at 1 week (n = 24) was discordant in 75% (42% differed by one and 33% by > or = 2 grades) and at 2 weeks (n = 7) in 57% (29% by 1 and 29% by > or = 2 grades). The inability to use the severity of interstitial rejection in one organ to predict the findings in the other is exemplified by the fact that for the two pancreases without interstitial rejection at one week, the corresponding kidney showed moderate or severe rejection, and for the 1 kidney without rejection the corresponding pancreas showed moderate rejection. Vascular rejection grades (absent, mild, moderate, severe) also showed a similar distribution for the pancreas (57%, 30%, 9%, 4%) vs. kidney (50%, 38%, 0%, 12%) at 1 week, and at 2 weeks (57%, 29%, 0%, and 14% for the pancreas vs. 78%, 11%, 0%, and 11 for the kidney) (P > or = 0.64). However, the grading of vascular rejection in organ pairs was dyssynchronous in 54% at 1 week (n = 22) and 29% at 2 weeks (n = 7). No vascular rejection in the pancreas with rejection in the kidney was seen in 5 pairs at 1 week (23%) and 0 at 2 weeks (0%), while no rejection in the kidney with rejection in the pancreas was seen in 5 pairs at 1 week (23%) and 2 pairs at 2 weeks (29%).(ABSTRACT TRUNCATED AT 400 WORDS)

Differences in rejection grading after simultaneous pancreas and kidney transplantation in pigs.

Clinical observations suggest that recipients of multiorgan transplants from the same donor can have disparate immunological reactions to each organ. We studied this phenomenon in 36 diabetic (streptozotocin-induced), bilaterally nephrectomized immunosuppressed (cyclosporine, azathioprine, prednisone) pig recipients of simultaneous (same donor) pancreas (bladder drained) and kidney allografts by grading the histological intensity of rejection in biopsies of each organ at defined intervals posttransplant. Graft function was monitored by plasma glucose (PG) and urine amylase (UA) for the pancreas and serum creatinine (Cr) for the kidney. Interstitial rejection was graded as absent, mild, moderate, and severe in, respectively, 8%, 25%, 42%, and 5% of pancreas vs. 4%, 12%, 27%, and 50% of kidney biopsies at 1 week; and 0%, 43%, 29%, and 29% of pancreases vs. 10%, 0%, 30%, and 60% of kidneys at two weeks. Although the distribution of grades was similar in the two organs (P > 0.1), the grade of rejection for each pair at 1 week (n = 24) was discordant in 75% (41% differed by one and 35% by > or = 2 grades) and at 2 weeks (n = 7) in 57% (29% by 1 and 29% by > or = 2 grades). The inability to use the severity of interstitial rejection in one organ to predict the findings in the other is exemplified by the fact that for the two pancreases without interstitial rejection at one week, the corresponding kidney showed moderate or severe rejection, and for the 1 kidney without rejection the corresponding pancreas showed moderate rejection. Vascular rejection grades (absent, mild, moderate, severe) also showed a similar distribution for the pancreas (57%, 30%, 9%, 4%) vs. kidney (56%, 30%, 0%, 13%) at 1 week, and at 2 weeks (57%, 29%, 0%, and 14% for the pancreas vs. 78%, 11%, 0%, and 11% for the kidney) (P > or = 0.64). However, the grading of vascular rejection in organ pairs was dyssynchronous in 51% at 1 week (n = 22) and 29% at 2 weeks (n = 7). No vascular rejection in the pancreas with rejection in the kidney was seen in 5 pairs at 1 week (23%) and 0 at 2 weeks (0%), while no rejection in the kidney with rejection in the pancreas was seen in 5 pairs at 1 week (23%) and 2 pairs at 2 weeks (29%).(ABSTRACT TRUNCATED AT 400 WORDS)

Rejection in single versus combined pancreas and kidney transplantation in pigs.

Clinically, the incidence of reversible renal allograft rejection episodes appears to be higher in recipients of simultaneous pancreas/kidney (SPK) than of kidney transplantation alone (KTA); conversely, the rate of irreversible pancreas allograft rejection appears to be higher in pancreas transplant alone (PTA) than SPK recipients. Clinical/histological correlation of graft rejection in these three groups has not been precise. Therefore, we studied the incidence and histological severity of the rejection process in a large animal (pig) model of SPK (n = 36), PTA (n = 31), and KTA (n = 36) allotransplantation. SPK and PTA recipients were made diabetic pretransplant by streptozotocin (150 mg/kg). Pancreas graft exocrine secretions were bladder-drained via a duodenocystostomy for urine amylase (UA) monitoring; endocrine function was monitored by plasma glucose (PG) levels. SPK and KTA recipients underwent native nephrectomy, and renal allograft function was monitored by serum creatinine (CR). Cyclosporine, azathioprine, and prednisone were given in tapering doses from the time of transplantation. Grafts were biopsied weekly to grade histologic severity of interstitial and vascular rejection on light microscopy (LM) and for intensity of T cell infiltration on immunofluorescence. Pancreas graft exocrine function (UA above pretransplant baseline), present in 62% of PTA and 68% of SPK recipients at one week, persisted in only 7% of PTA vs. 64% of SPK pigs at 2 weeks (P = 0.0004). Likewise, pancreas graft endocrine function (PG < 200 mg/dl off insulin) was sustained longer in SPK than PTA recipients (100% vs. 84% at 1 and 91% vs. 27% at 2 weeks; P = 0.0006). However, renal allograft functional survival (serum creatinine < 3.0 mg/dl) was not significantly different (P = 0.471) between SPK and KTA recipients (36% vs. 30% at 1 and 23% vs. 13% at 2 weeks). Graft functional parameters partially correlated with biopsy observations. Pancreas allograft biopsies showed a significantly (P = 0.03 at 1 and P = 0.05 at 2 weeks) lower incidence of moderate/severe interstitial rejection in SPK than PTA recipients (67% vs. 95% at 1 and 57% vs. 92% at 2 weeks); rejection was absent in 8% of SPK and in no PTA biopsies at 1 week. Vascular rejection was moderate/severe in significantly fewer (P = 0.0013 at 1 and P = 0.023 at 2 weeks) SPK than PTA pancreas grafts (13% vs. 37% at 1 and 14% vs. 38% at 2 weeks).(ABSTRACT TRUNCATED AT 400 WORDS)

Streptozotocin-induced diabetes mellitus in pigs.

We induced, as a precondition for a pancreas transplant, insulin-dependent diabetes mellitus in 67 Yorkshire Landrace pigs by administering streptozotocin. A dosage of 150 mg/kg body weight gave rise to a long-lasting diabetes mellitus that persisted with time (follow-up period: 26 weeks). Consecutive measurements of serum glucose and plasma insulin, before and up to 30 hours after administering streptozotocin, revealed triphasic behavior: initial hyperglycemia (1st to 3rd hour), pronounced hypoglycemia (12th to 18th hour), then hyperglycemia (22nd hour on). IVGTTs done 1 to 7 days after administering streptozotocin revealed a reduction of the K-value (glucose disappearance rate) from 0.3 (day 2) to 0.07 (day 4). Immunohistochemical studies revealed a complete loss of all beta-cells, concomitantly with a relative increase in glucagon- and somatostatin-positive cells. We also observed a complete loss of pp (pancreatic polypeptide)-positive cells. Diabetes induced by streptozotocin at 150 mg/kg body weight is complete and permanent; our mortality rate was 0%. Given the high morbidity rate after pancreatectomy, streptozotocin should be the method of choice for inducing diabetes mellitus in pigs.