[Biomarkers of system inflammation in local and diffuse peritonitis]. / Markery sistemnogo vospaleniia pri mestnom i rasprostranennom peritonite.

In cases of any acute surgical abdominal disease the progression of purulent inflammation can lead to local or diffuse peritonitis. The indicators of the degree and specificity of the inflammatory response in blood such as cytokine concentration, neutrophil activity, plasma antioxidant capacity (thiols concentration) could be considered as potential predictors of complications. The luminol-dependent chemiluminescence (CL) response of blood activated by the phorbol ester (PMA), and the concentration of cytokines IL-6, IL-8, IL-10, myeloperoxidase (MPO) and thiols in plasma were measured in patients with uncomplicated condition (group 1, n=8), local peritonitis (group 2, n=9) or diffuse peritonitis (group 3, n=9) at admission to surgery (before surgical operation, b/o), immediately after surgical operation (a/o) and a day after surgery (1 day) as well as in healthy volunteers (norm, n=12). In all time-points the cytokines and MPO concentrations measured by ELISA, in group 3 were higher than in healthy volunteers and in patients in groups 1 and 2. Blood CL demonstrated a more than 5-fold increase above the normal values in all patients, and was also higher in group 2 as compared to group 1 (b/o and a/o). Patients in group 3 had shown both maximum and minimum of CL values, which could be a consequence of neutrophil priming or exhaustion ("immune paralysis"), respectively. The same patients' plasma exhibited low thiol concentration (≤30% vs normal values). In patients with fatal outcomes (group 3, n=2) within a day after surgery, either a decrease of the CL to zero values concurrently with elevated IL-8 and IL-6 concentrations and low thiol levels was observed, or CL exceeded normal values more than 20 times with concurrent complete exhaustion of the plasma thiol pool. No clear dependency between the plasma parameters and neutrophil activity was found. Hence a parameter set for prognosis and/or early diagnosis of infectious complications in acute abdominal pathology should include different biomarkers of the inflammatory response: cytokine profile (IL-6, IL-8, IL-10), MPO and neutrophil activity, antioxidant plasma capacity (e.g., total thiols concentration).

[Diagnostic and treatment approaches for acute appendicitis in the Russian Federation. Results of the all-Russian survey]. / Diagnosticheskie i lechebnye podkhody pri ostrom appenditsite v praktike khirurgov Rossiiskoi Federatsii. Rezul'taty obshcherossiiskogo oprosa.

OBJECTIVE: To improve treatment outcomes in patients with acute appendicitis (AA). MATERIAL AND METHODS: An internet survey was performed. Questionnaire consisted of 15 questions concerning diagnosis and treatment of AA: application of prognostic scales, incidence and technical aspects of laparoscopic appendectomy (LA), antibiotic prophylaxis, postoperative management, compliance with international and national clinical guidelines. A total of 690 questionnaires were received and analyzed (3.67% of all surgeons in the Russian Federation). RESULTS: Eighteen percent of respondents use at least one prognostic scale. The vast majority of surgeons (92%) use antibiotic prophylaxis. Almost half of respondents place trocars in the triangulation position (44%), one third of surgeons ligate the mesentery of the appendix (35%), most respondents perform mesoappendectomy (60%) with monopolar and bipolar cautery. Forty-five percent of all respondents do not invert the appendix stump. Significant number of respondents use abdominal drainage routinely. Only 3.5% of surgeons use multimodal postoperative analgesia. Less than 22% of patients are operated under low-pressure pneumoperitoneum. Standardization of surgical technique and perioperative approaches including those specified in the guidelines is absent. We also found insufficient awareness of surgeons about international and national clinical guidelines. CONCLUSION: This study may be useful for standardizing treatment approaches, choosing the best practice, popularizing and improving of current clinical guidelines.

[Laparoscopic surgery for advanced appendicular peritonitis]. / Laparoskopicheskaya khirurgiya rasprostranennogo appendikulyarnogo peritonita.

OBJECTIVE: To evaluate the results of laparoscopic treatment of patients with advanced appendicular peritonitis. MATERIAL AND METHODS: There were 271 patients with acute appendicitis complicated by peritonitis. The main group consisted of patients who underwent laparoscopic appendectomy after diagnostic laparoscopy (n=231), the control group - diagnostic laparoscopy followed by conversion to median laparotomy (n=36). Four extremely ill patients were operated through laparotomy and excluded from the further analysis. RESULTS: Diagnostic laparoscopy was performed in 267 patients with advanced appendicular peritonitis. Laparoscopic appendectomy, debridement and abdominal drainage were performed in 231 (85.2%) patients. Mean age of patients was 44±18.5 years, duration of disease - 36.2±20.3 hours. Diffuse peritonitis was diagnosed in 219 (82%) patients, advanced peritonitis - in 48 (16.5%) cases. Incidence of conversion was 13.5%. Mortality was absent in both groups. Postoperative morbidity was significantly higher in the conversion group (72.2% vs. 29.4%, p<0.0001). CONCLUSION: Laparoscopic interventions for common appendicular peritonitis are feasible, effective and reduce postoperative morbidity.

[Fast-track rehabilitation for acute cholecystitis: intermediate outcomes of prospective randomized trial]. / Uskorennoe vyzdorovlenie pri ostrom kholetsistite: promezhutochnye rezul'taty prospektivnogo randomizirovannogo issledovaniia.

AIM: To analyze an efficacy of FT-protocol in patients with acute cholecystitis. MATERIAL AND METHODS: Prospective randomized study included 102 patients (45 of main group (FT) and 57 of control groups). Patients did not differ by TG13 severity index. The protocol included information, antibiotic prophylaxis, restriction of drainage, intraperitoneal anesthesia with long-term anesthetics, low pressure pneumoperitoneum, antiemetics in the presence of risk factors, early activation and feeding of the patient. Pain was assessed by VAS immediately after surgery, and 2, 6 and 12-24 hours postoperatively. RESULTS: Surgery time was similar in both groups. Need for anesthesia and pain severity were significantly lower in the FT group. A total absence of pain (VAS 0-1) on the 1st postoperative day was noted in 8 (17.7%) of the FT group and 2 (3.5%) patients of the control group (p=0.038). Shoulder pain developed in 4 (8.9%) cases of the main and 22 (38.6%) cases of the control group (p=0.001). Postoperative nausea developed in 13% of the FT group vs 40.5% in the control group (p=0.05). Hospital-stay was 1.29±0.7 days and 2.7±1.6 (p<0.0001), respectively. The time of the first stool was similar. Twenty-four (53.5%) patients of the FT group and 8,9% of the control group were discharged on 1st postoperative day. There were 2 (IIIA) complications in the main group and 3 - in the control group (IIIA, IIIB and IV). There were no mortality and readmissions. CONCLUSION: FT protocol in AC reduce postoperative pain, dyspepsia, shoulder pain and in-hospital stay with equal number of postoperative complications.

[Comparison of standard and fast track rehabilitation in patients with acute appendicitis. Intermediate results of multicenter prospective randomized trial]. / Sravnitel'naia otsenka metodov standartnoi i uskorennoi reabilitatsii bol'nykh s ostrym appenditsitom. Promezhutochnye rezul'taty mnogotsentrovogo prospektivnogo randomizirovannogo issledovaniia.

AIM: To analyze outcomes of fast track rehabilitation in patients with acute appendicitis. MATERIAL AND METHODS: Prospective, randomized multi-center trial including 86 patients was conducted. There were 38 patients in the main group and 48 in the control group. All patients underwent laparoscopic appendectomy under endotracheal anesthesia. Protocol included informing, no premedication, glucose infusion prior to surgery, antibiotics administration, mesoappendix excision, limited deployment of drainage tubes, intraabdominal prolonged anesthesia, minimal pneumoperitoneum, limited irrigation, minimum power monopolar electrocautery, antiemetics, early activation and eating (2 and 6 hours after surgery). Pain was evaluated by visual-analogue scale. Auscultative peristalsis was considered every 2 hours after surgery. Cortisol level was assessed preoperatively, in 6 and 12-24 hours after surgery in 11 (29%) and 15 (31%) patients of the main and control groups respectively. Discharge criteria: no leukocytosis, fever and pain syndrome requiring anesthesia, no signs of complications and patient's consent. RESULTS: Terms of disease, gender, age and comorbidities were similar in all patients. Duration of surgery under minimal pneumoperitoneum and standard pressure was also similar: 69.2±3.98 and 70.9±3.89 min (p=0.762). Pain syndrome grade and need for analgesics were significantly lower in the main group within entire follow-up. Pain syndrome was absent at the 1st postoperative day in 16 (42%) and 2 (4.1%) patients of both groups, respectively (score 0-1). Phrenic nerve syndrome was observed in 36.8% of the main group and 60.4% of the control group (p=0.05). Incidence of dyspepsia and terms of peristalsis onset were similar. Length of hospital-stay was 1.45 days in the main group and 3.15 days in the control group (p=0.002). In the main group 18 (47%) patients were discharged on the first day after surgery. There were only 4 (8.3%) patients with similar hospital-stay in the control group (p<0.001). There were no repeated hospitalizations. Postoperative cortisol concentration was similar in both groups as well as in complicated and uneventful postoperative period. In the main group postoperative intestinal paresis (Clavien-Dindo grade 2) occurred in 1 patient. In the control group 7 patients had postoperative infiltrate and 1 patient - intestinal paresis (Clavien-Dindo grade 2). Postoperative drainage tube was deployed in 3 out of 7 patients with postoperative infiltrates and 6 of them received antibiotic therapy. Medication was successfully applied in all patients with complications. CONCLUSION: There are some advantages of FTR for AA including reduced pain syndrome, morbidity and less length of hospital-stay. Issue of cortisol concentration requires further trials.

[Optimal time of surgery for acute adhesive small bowel obstruction]. / Vybor sroka operativnogo lecheniia pri ostroi spaechnoi tonkokishechnoi neprokhodimosti (mul'titsentrovoe prospektivnoe randomizirovannoe issledovanie).

AIM: To define optimal terms of surgery for acute adhesive non-strangulatory small bowel obstruction. MATERIAL AND METHODS: The analysis included 703 publications from e-LIBRARI.RU (342 works) and NCBI (361 works) databases for acute adhesive intestinal obstruction. The vast majority of articles presented retrospective analysis of single-center experience. RESULTS: It has been established that short course of medication is predominantly used for acute adhesive intestinal obstruction in the Russian Federation. International studies point 2-5 days for conservative treatment. The advantages and disadvantages of short and long courses of medication were analyzed. Therefore, multicenter, prospective, randomized trial 'Comparison of early operative treatment (12-hour medication) and long-term conservative treatment (48 hours) for acute adhesive small bowel obstruction' (COTACSO) was planned and registered (Unique Protocol ID: 14121729). The study protocol involves clinical, laboratory and instrumental exclusion of strangulation, randomization and conservative treatment of 2 groups of patients for 12 and 48 hours. Patients will undergo surgical interventions if obstruction will be present by that date. The main endpoint is mortality rate in both groups. The end of the study is December 2020.

Comparative Study of Sutureless Fixation of Lightweight Surgical Meshes for Hernia Repair in a Rat Model.

The aim of this study was to compare the efficacy of different methods of sutureless fixation of lightweight meshes made of different polymers for repair of experimental hernias. Two lateral hernia defects were modeled in male rats and covered with polyester and polypropylene prostheses. The meshes were fixed with Histacryl glue (group 1), or self-gripping meshes were used (group 2), or the meshes were implanted without fixation (group 3). On day 5 after surgery, mesh position and efficiency of fixation were evaluated. It was found that fixation is necessary for all light surgical meshes. Polyester meshes demonstrated better adhesive properties than polypropylene meshes. The most pronounced differences in the adhesive properties were found for self-gripping prosthesis, while in the groups with glue fixation, the differences were less pronounced.

Biomechanical compatibility of surgical mesh and fascia being reinforced: dependence of experimental hernia defect repair results on anisotropic surgical mesh positioning.

PURPOSE: We aimed to compare the effectiveness of experimental middle hernia defect repair in regard to the transverse and longitudinal positioning of anisotropic lightweight surgical mesh. METHODS: The mechanical properties of fascial layers and surgical mesh DynaMesh(®)-PP Light were determined in two perpendicular directions under uniaxial tension. In 12 male Wistar rats, middle hernia defect was repaired by the sublay technique. In six animals, the mesh was positioned across (DLH group) and in the other six along (DLV group) the midline. At 6 months after implantation, mesh deformation, structural rearrangement, and repaired abdominal wall biomechanics were evaluated. Histological sections were stained with van Giesen and Mallory's trichrome. RESULTS: The anisotropic mechanical properties of the mesh and fascial layers coincided in the DLH group, but did not correspond to each other in the DLV group. In the DLV group, meshes were stretched in width by 11.4% and reduced in length by 12.7%. In all animals, the lower edge of the mesh was shifted to a defect area with margin hernia formation in two rats. Constant shear stress caused disproportional connective tissue formation. Repaired abdominal wall lost its natural elasticity. In the DLH group, the mesh deformation was minimal. Formed connective tissue was tightly associated with the anterior layer and did not differ from it in composition. The mechanical properties of repaired abdominal wall were close to those of the anterior layer. CONCLUSIONS: In prosthetic hernia repair, the mechanical properties of surgical mesh should correspond with those of the fascia being repaired. A mismatch of mechanical properties may result in implant deformation, abdominal wall biomechanics impairment, and recurrent herniation at the edges of the meshes.

Comparison of the results of hernia defect plasty with standard and light surgical meshes with identical knitted structure.

Standard and light surgical meshes with identical knitted structure: Parietene Standard/Parietene Light and Premilene/Optilene were chosen for hernioplasty in 20 rats. Six months after surgery, the complications were primarily related to inflammation in groups with implanted standard meshes and with prosthesis deformation in groups with light meshes. The character of complications was determined by characteristics of knitting structure and mechanical proprieties of surgical meshes.

Impact of position of light mesh endoprosthesis with anisotropic structure for the efficiency of anterior abdominal wall reconstruction.

Mechanical testing of light mesh endoprosthesis Ultrapro for tension and bending resistance showed strong anisotropy of the material along and across the loop columns. Ultrapro endoprosthesis was placed parallel and perpendicularly to the midline during plastic repair of a hernial defect in rats. Six months after surgery, the development of hernias and violation of endoprosthesis structure were observed in the group with longitudinal orientation of the endoprosthesis. Transverse orientation of the endoprosthesis led to fortification of the defect site. However, the meshes were in some cases misshapen and formed folds across the loop columns, because of insufficient bending rigidity and elasticity of the material.

Impact of position of light mesh endoprosthesis with anisotropic structure for the efficiency of anterior abdominal wall reconstruction.

Mechanical testing of light mesh endoprosthesis Ultrapro for stretching and bending resistance showed strong anisotropy of the material along and across the loop columns. Ultrapro endoprosthesis was placed parallel and perpendicularly to the midline during plastic repair of a hernial defect in rats. Six months after surgery, the development of hernias and violation of endoprosthesis structure were observed in the group with longitudinal orientation of the endoprosthesis. Transverse orientation of the endoprosthesis led to fortification of the defect site. However, the meshes were in some cases misshapen and formed folds across the loop columns, because of insufficient bending rigidity and elasticity of the material.

Comparison of biomechanical properties of light mesh endoprostheses with different structural characteristics.

Three types of light mesh endoprostheses with different jersey structure were implanted into the anterior abdominal walls of 18 rabbits. Changes in the geometrical size and mechanical properties of the prostheses detected 3 months after implantation largely depended on the jersey structure and distribution of mature connective tissue in the structure of the material.

Experimental study of the impact of the textile structure of mesh endoprostheses for the efficiency of reconstruction of the anterior abdominal wall.

Endoprostheses made from knitted fabric of 3 loop types were used for hernioplasty in rats. Biocompatibility of implanted textile constructions was evaluated after 6 months. The intensity of inflammatory reaction and types of complications in animals depended on the loop type and method of finishing of the mesh endoprosthesis tissue.

Activity of antioxidant enzymes in the skin during surgical wounds.

Full-thickness skin wounds (460 mm(2)) in rats were associated with increased blood chemiluminescence and neutrophil infiltration of the wound tissue and surrounding skin (recorded by myeloperoxidase activity). Activities of glutathione peroxidase and glutathione S-transferase in the skin and wound tissue increased on days 4 and 8. A correlation was revealed between activities of these enzymes and myeloperoxidase activity. Activities of myeloperoxidase and catalase increased in patient's skin excised during plastic surgeries of more than 2.5 h duration.

Protective effect of complex antioxidant preparation containing vitamins and amino acids in rats with burn trauma complicated by endotoxemia.

Burn trauma increased blood chemiluminescence, while lipopolysaccharide in a dose of 1 mg/kg potentiated this effect, activated LPO, and decreased plasma antioxidant activity. In erythrocytes, superoxide dismutase activity increased, while activity of peroxide-utilizing enzymes decreased. Myeloperoxidase content increased in the lungs and epidermis. The preparation of alpha-tocopherol, selenium aspartate, and ubiquinone abolished the effect of lipopolysaccharide, but did not modulate the increase in chemiluminescence under the influence of this agent.

[Antioxidant enzymes in skin experimental burn trauma].

The effect of experimental burn trauma (20%) on myeloperoxidase (MPO) and antioxidant enzymes (catalase, glutathione peroxidase (GPO), glutathione-S-transferase (GST)) was studied in unburned skin, epidermis (20 mm from the burned area) and the wound tissue of rats. The most common features were the increase of MPO on the 1st day and a delayed increase of GPO and GST after the 4th day. The additional operations (necrectomy) and lipopolysaccharide administration induced marked inflammatory reaction in skin and epidermis (evaluated by the increase in MPO and GPO/GST activities).

[Examination of the local antioxidative system of the eye in experimental corneal burn injury and the prospects for pharmacological correction of its parameters].

The present paper deals with the study of the efficiency of oral use of the antioxidative drug Immugen (a complex of alpha-tocopherol, oubichinone, selenium aspartate, methionine, and soyabean phospholipids) on a rabbit model of severe alkaline-induced corneal burn. The investigations have indicated that addition of Immugen to the rabbit feed exerts a significant positive effect on the parameters of the local antioxidative system of the eye and causes an increase in the activity of superoxide dismutase and catalase, and, on day 14, in antioxidative activity. The early experimental periods were marked by a slight rise in the frequency of deep corneal ulcerations. Moreover, the long-term clinical effect of use of Immugen appears as a significant increase in the area of the transparency-preserving affected cornea. The findings suggest that the antioxidants can show their optimal effect in the complex therapy for burn processes, including the use of proteinase inhibitors.

Wound-healing effect of papaya-based preparation in experimental thermal trauma.

Treatment with the phytopreparation from papaya accelerated wound healing and reduced the severity of local inflammation in rats with burn wounds. The effect of this phytopreparation can be related to an increase in the effectiveness of intracellular bacterial killing by tissue phagocytes due to the inhibition of bacterial catalase. Antioxidant activity of the preparation decreases the risk of oxidative damage to tissues.

Preventive and therapeutic effect of complex antioxidant preparation in rats with burn trauma.

The production of blood radicals and activity of superoxide dismutase in erythrocytes increased in rats with contact burn trauma (20%). In animals with burn trauma antioxidant activity of the plasma was much lower, while myeloperoxidase content in the lung tissue and epidermis was higher than in control rats. The complex of antioxidants (Immudzhen) inhibited radical generation at the peak of inflammation (day 4), increased antioxidant activity of the plasma, and normalized myeloperoxidase content in the lung tissue.

Morphological changes in the anterior abdominal wall of rats with peritonitis and implanted synthetic film.

Histological study and electron microscopy of the anterior abdominal wall and laparotomy wound closed using a polytetrafluoroethylene film was performed on rats with experimental peritonitis. We studied 4 types of polytetrafluoroethylene films differing in the size of micropores and technology of treatment. The tissue response differed after implantation of various films. A multilayer film with minimum size of pores was optimal to repair the laparotomy wound.