[Intra-abdominal hypertension in patients with severe acute pancreatitis].

The role of parapancreatitis in the intra-abdominal hypertension (IAH) progression in patients with severe acute pancreatitis with various forms of organs failure was studied. It was analyzed the treatment results of 63 patients with severe acute pancreatitis. The patients were divided into 4 groups: the first group (n=24) had not the signs of organs failure, the second group (n=15) - with symptoms of acute respiratory failure (ARF), the third group (n=11) - with a combination of ARF and acute cardiovascular failure (CVF) and the fourth group (n=13) - with a combination of ARF, CVF and acute renal failure. Intra-abdominal pressure (IAP) was measured at 1, 3, 5, 7- days from the beginning of the disease with calculation of the abdominal perfusion pressure and filtration gradient values. The prevalence evaluation of parapancreatitis was carried out on the basis of CT-data with bolus-dosing of the contrast agent, ultrasound, video laparoscopy as well as data obtained during operation and autopsy. It was defined that the intra-abdominal pressure (IAP) values was not significantly different and complied with intra-abdominal hypertension of the first grade in patients of the groups 1-3 at the first day. IAP was significantly higher and complied with intra-abdominal hypertension of the second grade in patients of the fourth group. IAP normalized to 5-7th days in patients of the first and the second groups. The patients of the third and the fourth groups had IAH of the second grade in the 7th day. There was reliable (p<0.01) average positive correlation (r=0.57) between the indications of IAH and the scale APACHE II. The patients with common parapancreatitis (n=39) had indications of IAP and APACHE II significantly higher than in patients with local forms of parapancreatitis (n=24; p<0.01). Common defeat of retroperitoneal fat determined persistent increase of IAP more than the presence of effusion in the abdominal cavity. In case of the first grade of IAH the mortality was 6.6%, the second grade - 37.5%, the third grade - 58.3% and the fourth grade - 80%. All died patients had a common parapancreatitis. The authors consider that the indications of IAP and APACHE II let to suppose an adverse outcome by the development of multiple organ failure in the early stages of the disease. Common parapancreatitis is the main feature of the persistent IAH (IAP increase during 5-7 days), which is an indication for early decompression operations on the abdominal wall.

[Chronic pancreatitis: resective and decompressive procedures].

PURPOSE: Definition of resective and decompressive operations in chronic pancreatitis. MATERIALS AND METHODS: A retrospective analyses of surgical management of 51 chronic pancreatitis patients is carried out. 24 patients underwent longitudinal pancreaticojejunostomy (PA), 27--pancreatic head ( PH) resective procedures: Beger--5, modified Frey (PH intraparenchimatose resection-- IR, supposing removal of fibrous masses from the ventral and greater part of the dorsal PH)--22. According to the character of the PH lesion the patients were divided in 3 groups: head dominant (13), total (11) and cystic pancreatitis (20). RESULTS: One early postoperative death developed after reoperation for adhesive intestinal ileus in patient with PA. No mortality was noted after IR. Remote results in terms of 4.8+/-0,7 years were studied in 32 (71%) patients underwent PA and IR. IR lead to good and satisfactory results. After PA poor results came to 5 (29.5%). CONCLUSIONS: Combination of PH IR and PA is indicated in head dominant and total chronic pancreatitis patients. In cases of pseudocysts and dilation of the main pancreatic duct (>6-7 cm) decompressive variant of procedure cysto-pancreato-jejunostomy is preferable.

[Causes, diagnosis and surgical treatment of strictures of lobar and segmental hepatic ducts].

Causes of strictures of lobar and segmental ducts after their injuries during open and laparoscopic cholecystectomy in 53 patients were analyzed. For correction of bile outflow precision non-wireframe (n=22) and wireframe (n=20) anastomoses were used. In 10 patients a combined anastomosis was established. In 1 patient the external drainage of hepatic ducts was performed. After surgery 3 patients died. 1-15 year long-term results were studied in 48 (96%) patients. Good results were achieved in 29 (60.5%), satisfactory -- in 13 (27%) patients. Recurrences of the strictures were diagnosed in 6 patients. It is concluded that dynamic control is necessary in patients operated on for bile ducts injuries. Underestimation of remittent cholangitis leading to biliary cirrhosis worsens prognosis of the disease.

[Morphologic and functional changers in B-cells and vessels of the islands of Langerhans in patients with insulin-dependent diabetes mellitus]. / Morfologicheskie i funktsional'nye izmeneniia B-kletok i sosudov ostrovkov Langerhansa u bol'nykh insulinzavisimym sakharnykh diabetom.

Pancreatic biopsies from 49 patients with IDDM were studied. Ultrastructurally, a heterogeneity of B-cell morphological changes and microangiopathy of the Langerhans islands were observed. Langerhans islands containing B-cells with destructive changes were found in 27 biopsies, sclerosis and hyalinosis of vascular wall in 6 biopsies. Langerhans islands sclerosis was found in 13 biopsies and in 9 biopsies, in normal structure of the acinar compartment of the pancreas, Langerhans islands were not found. The authors findings and literature data allowed the conclusion on the stage pattern of IDDM development. The basis is an immune, autoimmune mechanism of B-cell and endotheliocyte of the Langerhans islands damage, and therefore, a decrease of the (pro)insulin synthesis and its transport into the circulation. This process is genetically predetermined, this being confirmed by the lack of the dependence of B-cell and vessels damage in the Langerhans islands upon the age and small fluctuations in the manifestations and duration of the disease.

[Is localization of B-cells in the acini a normal condition or the sign of compensatory process in insulin-dependent diabetes mellitus?]. / Lokalizatsiia B-kletok v atsinusakh--obychnoe iavlenie ili priznak kompensatornogo protsessa pri insulinzavisimom sakharom diabete?

45 pancreatic biopsies from patients with insulin-dependent diabetes mellitus (IDDM), obtained in the process of surgical treatment were studied. A different degree of the Langerhans islands and morphological changes in B-cells was noted. The presence of endocrine-like cells in the acini and among the cells of the inter-acinar duct is of great interest. The granules of these cells were insulin-positive when studied immunohistochemically this permitting one to consider them as B-cells. Further study of these cells will allow to deepen the knowledge about the mechanism of IDDM development and to improve the methods of treatment.

[Diabetic glomerulonephritis--the first stage of diabetic glomerulopathy]. / Diabeticheskii glomerulonefrit--pervaia stadiia diabeticheskoi glomerulopatii.

20 puncture renal biopsies and 16 pancreatic biopsies from patients with insulin-dependent diabetes mellitus were studied ultrastructurally. The stages in the development of kidney changes depending on the functional state of Langerhans islands B-cells were established. The 1st stage includes signs of segmentary mesangioproliferative glomerulonephritis- segmentary increase of the mesangium due to the hypercellularity, variability of the basal membrane thickness in the glomeruli capillaries, leucocytes in the lumen, subendothelial deposits. This stage may be due to the persistence of the etiologic factors(virus), formation of circulating immune complexes, antibodies excess and relative preservation of B-cells and their function. Thinning of the capillary basal membrane, decrease of the mesangial matrix surface, cell destruction are characteristic for the 2nd stage- stage of the mesangiolysis. The duration of disease up to 15 years has no influence on the formation of glomerulosclerosis.

[Diabetic glomerulosclerosis--a prolonged stage of diabetic glomerulopathy]. / Diabeticheskii glomeruloskleroz--prolongirovannaia stadiia diabeticheskoi glomerulopatii.

Formation of diabetic glomerulosclerosis was followed by the electron microscopy of 21 puncture renal biopsy and 12 incisive pancreatic biopsies from patients with insulin-dependent diabetes mellitus. The influence of the B-cell destruction and the decrease or absence of their activity (the presence of serum C-peptide) on the degree of renal damage and clinical symptoms of the diabetic nephropathy (proteinuria, hypertension) is noted. Dynamics of the diabetic glomerulosclerosis formation is as follows: 1st group--thickening of capillary basal membrane in the glomeruli, mesangial ectopy, formation of nodules at the periphery of loops; 2nd group--increase of the mesangial matrix, doubling of the glomerular capillary basal membrane, hyalin droplets in the capsule membrane. 4 stages in the development of diabetic glomerulopathy are distinguished: diabetic segmentary mesangioproliferative glomerulonephritis, mesangiolysis, two stages of glomerulosclerosis progression. Duration of the disease more than 15 years predetermines the development of diabetic glomerulosclerosis.

[Determination of glycosylated hemoglobin by affinity chromatography on boron phenylagarose]. / Opredelenie glikozilirovannogo gemoglobina metodom affinnoi khromatografii na borfenilagaroze.

When Hb AIc was estimated by affinity chromatography where boron phenyl-agarose was used as a sorbent, the highest rate of Hb AIc binding with the sorbent was detected at pH 8.5-9.0 while the maximal elution of the protein occurred at 0.3-0.5 M concentration of sorbitol used as an eluent. Content of Hb AIc, estimated in 56 patients with insulin-dependent diabetes mellitus, constituted 12.3 +/- 0.4%, while in 20 healthy volunteers it was equal to 5.4 +/- 0.2%, which are consistent with the literature data obtained by other methods. At the same time, the data of Hb AIc estimation by means of affinity chromatography correlated exactly with the results of ion exchange chromatography (r = 0.98), thus corroborating the validity of the procedure used. Only the stable ketoamine fraction of Hb AIc was found to interact with boron phenyl-agarose.

[Two forms of aldose reductase in erythrocytes from patients with insulin-dependent diabetes mellitus]. / Dve formy al'dozoreduktazy v éritrotsitakh bol'nykh insulinzavisimym sakharnym diabetom .

Erythrocytes of patients with insulin-dependent diabetes mellitus contained two forms of aldose reductase a and b (EC No. 1.1.1.21) (the key enzyme in the sorbitol pathway of glucose utilization) as compared with those of healthy donors in whom the form b of the enzyme was only found. The aldose reductase a exhibited a higher maximal rate (Vmax = 16.7 +/- 3.2 IU/D280) and a lower substrate affinity (Km = 6.5 = 19 mM) than the enzyme b, Vmax = 43.8 +/- 0.6 IU/D280, Km = 3.0 = 4.0 mM, respectively. More severe development of the disease was observed in the patients whose erythrocytes contained only aldose reductase a (HbA1c = 14.56 +/- 0.69%) as compared with those in whom the enzyme a and b were found (HbA1c = 11.5 +/- 0.4%). Kinetic parameters of the enzyme showed that aldose reductase a may be active in hyperglycemia of diabetes mellitus, thus contributing to intensification of the sorbitol pathway in these patients.

[Urinary enzymes in insulin-dependent diabetes mellitus]. / K voprosu o fermenturii pri insulinzavisimom sakharnom diabete.

In patients suffering from insulin-dependent diabetes mellitus (IDDM) with or without preclinical and clinical signs of diabetic nephropathy, the degree of epithelial cell lesions in the renal tubules was assessed from the urinary activities of enzymes at various sites, such as lysosomal (N-acetyl-beta-D-glucosaminidase (NAG) and beta-galactosidase (beta-GA)), brush edge membranous (alanine aminopeptidase (AAP), and cytosolic (alpha-glucosidase (alpha-GL)). Patients from Groups 1 and 2 had no preclinical and clinical signs of nephropathy. In Group 1 patients, the magnitude of enzymuria was not different from that in normalcy. However, Group 2 patients exhibited significant increases in urinary NAG and beta-GA activities as compared to Group 1 patients and healthy individuals. In Group 3 patients with microproteinuria from 0.05 to 0.5 mg protein per ml urine, displayed a further enhancement of NAG and beta-GA activities as compared to Group 2 patients and significantly higher activity than did Groups 1 and 2 patients and healthy individuals. In Group 4 patients with macroproteinuria of > 0.5 mg/ml), greater increases in the activities of NAG, beta-GA, and AAP were not found, however, there was a significant increase in alpha-G1 activity. The findings suggest the varying degrees of epithelial cell damage in the renal tubules in patients of different groups and the possibility of early detection of lesion in the proximal portion of nephronic tubules in IDDM patients as assessed from urinary enzyme levels.

[Diagnosis and treatment of different types of high scar strictures of the hepatic ducts]. / Diagnostika i lechenie razlichnykh tipov vysokikh rubtsovykh striktur pechenochnykh protokov.

Results of treatment of 224 patients with scar strictures of the hepatic ducts (BSDH) are presented. Based on Bismuth's classification of BSDH E.I. Galperin (2002) proposed own one. According to this classification there were 17 (7,6%) patients with type "+2" (stump of common hepatic duct - CHD more than 2 cm), 26 (11,6%) - with type "+1" (stump of CHD 1 - 2 cm), 72 (32,2%) - with "0" type (stump of CHD less than 1 cm), 54 (24,1%) - with "-1" type (upper fornix of CHD confluence is not affected), 35 (17,4%) - with "-2" type (CHD confluence is destroyed), 20 (8,9%) - with "-3" type (strictures of segmental ducts). There were greater number of previous surgeries in the patients with "-1" and "-2" types (p<0,05). Jaundice and secondary biliary liver cirrhosis were seen more frequently in types "0" - "-3". Hepaticojejunostomy was the surgery of choice. For approach to unaltered wall of hepatic ducts (HD) section of lobar ducts in types "+1", "0", excision of portal plate and partial resection of IV hepatic segment (31 patients) in "-1" - "-3" types were used. Exchangeable transhepatic drainage (ETD) was applied in 31 patients due to impossibility to excise scar tissues completely. In early postoperative period 9 (4%) patients died due to purulent cholangitis (7 patients) and insufficiency of anastomosis (2 patients). Long-term results were evaluated in 180 (80,4%) patients from 1 to 14 (6,6+/-3,9) years of follow-up. Thirteen surgeries were performed for repeated strictures. The main cause of restrictures was inadequate resection of scar tissues and unreasonable refusal of ETD (7 patients). Developed surgical technique in different types of strictures permits to reduce postoperative lethality and the rate of restrictures.

[Selective-occlusive method of drug administration in the treatment of experimental liver tumors]. / Selektivno-okkliuzionnyi metod vvedeniia preparatov pri lechenii éksperimental'nykh opukholei pecheni.

263 experimental studies on 184 rats were carried out. Hepatic tumors were provoked by intraparenchymatous implantation of 0.1 ml 20% tumoral suspension of mucous cancer (RS-I). Treatment was realized on 10-12 day after vaccination. Photodynamic therapy with "Photosense" (PS) and laser irradiation (670 nm, 50-100 Dj, 4-13 mm), and also catalytic therapy (CT) with "Teraftal" (TF) and ascorbic acid (AA) were used. FS and TF were administered by developed selective-occilisive method (SOM). Rapid accumulation of drugs in occluded lobe of liver was revealed in SOM, that permitted to decrease administered dose of TF in 16.5 times. There was no growth of tumor after FDT unlike control group. Same results were obtained after CT with SOM, but there was further growth of tumor after systemic administration of drugs. Developed SOM of drugs administration in FDT and CT lead to good results in treatment of experimental hepatic tumors.

[Diagnosis and surgical treatment of pancreonecrosis]. / Diagnostika i khirurgicheskoe lechenie pankreonekroza.

Actual problems of diagnosis and treatment of pancreonecrosis (PN) are discussed. Results of treatment of 154 patients hospitalized with sterile necrosis SN (n = 133) and infected PN (n = 21) were analyzed. SN became infected in 49 patients. The diagnostic methods were as follows: USE, CT, biochemical examinations of blood, urine and exudate. Percutaneous puncture contrast retroperitoneography (PPCR) was developed. It is demonstrated that modern diagnostic methods and PPCR permit one to diagnose PN, detect location, zone of retroperitoneal fat's necrosis and characterize its infection. The size of lesion of retroperitoneal fat in patients with sterile PN (n = 133) does not determine severity of the patients' condition and early lethality, but increases the risk of infection and makes worse prognosis of the disease. In laparoscopic sanation of the abdominal cavity for fermentative peritonitis, compared with laparotomic one, infection developed less rarely (10.2 and 40%, p < 0.01) and lethality decreased. Lethality in repeated mini-invasive surgeries through burso- and retroperitoneostomas performed in 34 patients with infected pancreonecrosis was 17.6% that is lower than one in repeated relaparotomies (n = 21, lethality 47.8%).

[Compensation of experimental insular insufficiency by altering the portal blood flow]. / Kompensatsiia éksperimental'noi insuliarnoi nedostatochnosti putem izmeneniia portal'nogo krovotoka.

Experimental insular insufficiency and hyperglycemia in dogs was induced by subtotal resection of the pancreas. The diverting of venous blood from the pancreas into the systemic circulation via the spleno-caval venous anastomosis promoted a reduction of insulin metabolization in the liver on the first passage. This led to an increase in peripheral blood insulin and rapid compensation for hyperglycehia induced by resection of 80% pancreas. No gross morphological changes in the liver were revealed during 4 months after anastomosis establishment. A decrease in the glycogen content in the liver and peripheral muscles was noted after blood shunting. The subtotal resection of the pancreas coupled with pancreatic duct ligation resulted in gross fibrotic changes in the pancreas and atrophy of the exocrine tissue. On the other hand, the endocrine tissue gets hypertrophied, being less prone to fibrosis.

Results of pancreatic blood shunting into the systemic blood flow in insulin-dependent diabetics.

A new surgical method of treating patients with unstable insulin-dependent diabetes (IDD) has been developed--that of surgically shunting pancreatic blood into the systemic blood flow with the purpose of creating a more optimal interaction of subcutaneously administered insulin and pancreas-secreted glucagon. The long term results of the operation depend on the patency of a splenorenal anastomosis. This has been studied by following up 137 patients over periods from half a year to three years. Anastomotic patency was determined by renal and splenic venography and celiacy arteriography, which revealed a patent anastomosis in 114 patients, and an obliterated one in 23. Patients with patent anastomoses showed a lowering of glycosylated hemoglobin (HbA1c) from 13.3 +/- 0.3% to 9.3 +/- 0.6%, p < 0.05, a decrease of the injected insulin dose from 0.97 +/- 0.04 to 0.72 +/- 0.03 U/kg, p < 0.05, disappearance or considerable abatement of pain in the lower extremities, and of hypoglycemia. Improvement of clinical status was accompanied by an increase of glucagon in the systemic blood stream from 60.8 +/- 10.1 to 91.5 +/- 9.4 pg/ml, p < 0.05, a rise of tissue oxygen pressure, pO2, from 49.2 +/- 2.4 to 58.1 +/- 1.9 mm Hg, p < 0.05. In patients with oblivious anastomoses postoperative HbA1c levels did not change from preoperative values: 12.9 +/- 0.4% and 12.8 +/- 0.7%, p < 0.05, respectively; the insulin dose remained the same--0.91 +/- 0.07 U/kg and 0.85 +/- 0.07 U/kg, p < 0.05, no rise of the systemic blood glucagon content was noted, and former complaints continued. The suggested method is not an alternative for insulin therapy, but considerably enhances its potential.