[Corrective plastic surgeries as a conclusive stage of surgical treatment of patients with alimentary-and-constitutional obesity].

The authors performed analysis of Russian and foreign literature (64 items) dedicated to long-term postoperative problems following corrective plastic surgery for morbid obesity. The analysis shows that literature does not contain clear criteria for patient selection and timing of surgery, and does not provide sufficient coverage of plastic surgical techniques. There are no data on the rate of complications and complex preventive measures.

[Resection of the stomach with Roux anastomosis].

Results of surgical treatment of patients with gastric ulcer and cancer of the stomach using resection of the stomach with Roux technique were analyzed. Acid-producing and evacuatory functions of the stomach were assessed in different periods after surgery. Dynamic scintigraphy provided evaluation of indices of duodenogastric reflux and state of gastric mucous barrier after various types of surgeries. Quality of life was studied late after surgery with original questionnaire. It is concluded that Roux resection of the stomach is not inferior to Bilrot-I resection by functional results, but it has advantages by quality life and rate of operated stomach diseases compared with Bilrot-I and Bilrot-II techniques.

[Moot points of diagnosis and treatment of hormone-producing neuroendocrine tumors of pancreas].

Based on literature data and own experience of treatment of 225 patients with neuroendocrine tumors (NET) authors discuss moot points of diagnosis and treatment of this severe category of patients. It is demonstrated that the most appropriate algorithm of diagnosis before surgery is the combination of US with endoscopic US and angiography. Intraoperative diagnosis must be performed with intraoperative US and endoscopic transillumination. Authors demonstrate positive results of staged surgical treatment of MEN-1 syndrome. Malignant NET with distant metastases is not contraindication for surgical treatment. This situation is indication either for radical surgery with excision of all metastases or for cytoreductive surgery with subsequent chemoembolization and chemotherapy.

[Comparative characteristics of efficacy of operations in ulcerous pyloroduodenal stenosis]. / Sravnitel'naia kharakteristika éffektivnosti operatsii pri iazvennom piloroduodenal'nom stenoze.

1107 patients with ulcerous pyloroduodenal stenosis (UPDS) were operated since 1968 to 2000. Duodenal ulcers caused stenosis in 1053 (95%) patients, gastric ulcers of types II and III--in 54 (5%). Various stomach resections were performed in 287 (92%) patients organ-saving operations--in 795 (71.8%) patients Longterm outcomes were studied in 797 (71.9%) patients, 491 (61.6%) of them were examined in hospital and 306 (38.4%) responded to questionnaires. Mean follow-up was 17 +/- 8.4 years. Early postoperative complications were in 138 (12.5%) patients, after resections--in 20.5%, after organ-saving operations--in 9.3%. General lethality after UPDS surgery was 0.6%, after organ-saving operations--0.2%, after resections--1.3%. Pathologic syndromes were seen in 31% patients. Recurrence of ulcer after organ-saving operations was revealed in 11% in remote terms. Demping-syndrome was in 22.9% patients. Most often it was revealed after 2/3 stomach resection by Bilrot-II in Gofmeister--Finsterer (G--F) modification, less often--after SPV with duodenoplasty. The only operation preventing reflux-gastritis was economic stomach resection with Roux anastomosis and trunk vagotomy (TV + Er Roux). Good and excellent results by Visick scale were achieved in 85% patients with UPDS. Evaluation by D. Johnston scale demonstrated best results after SPV in duodenoplasty (238 points) and TV + ER Roux (272 points), the worst results--after B-1 (773 points) and B-II G--F (1124 points). Optimal results like healthy quality of life was seen after TV + ER Roux and SPV with duodenoplasty.

[Diagnosis and treatment of gastrin-producing pancreatic tumors]. / Diagnostika i lechenie gastrinprodutsiruiushchikh opukholei podzheludochnoi zhelezy.

Current literature data on the clinical course, diagnosis and treatment of gastrinoma, one of the most frequent neuroendocrine tumors of the thyroid, as well as 23 cases with Zollinger-Ellison syndrome treated by the authors are analysed in detail. Peculiarities of the clinical course, difficulties of syndrome diagnosis, principles of updated topical diagnosis of gastrinoma, conservative and surgical treatments including treatment of multiple endocrine neoplasia syndrome are described.

[Use of regulated silicone bandage in horizontal gastroplasty in patients with morbid obesity]. / Ispol'zovanie reguliruemogo silikonovogo bandazha pri gorizontal'noi gastroplastike u bol'nykh morbidnym ozhireniem.

From 1984 in N.N. Burdenko Surgical clinic of I.M. Sechenov MMA more than 500 horizontal gastroplasties (HGP) were performed for the treatment of patients with extreme degree of alimentary-constitutional obesity. In 1996 for the first time in our country HGP was performed, including laparoscopic method, with use of regulated silicon bandage "Lap-Band" (LB) made by "Bioenterics", USA. Laparoscopic HGP was performed in 29 patients (7 males, 22 females), aged from 23 to 60 years, mean age was 34.2 +/- 10 years. Minimal body weight was 85 kg, maximal--180 kg, mean--131 +/- 27.2 kg. Mean body mass index was 47 +/- 9.9 kg/m2. Open operations were performed in 14 cases, laparoscopic operations--in 15 cases. 11 laparoscopies were performed in initial stages in very stout patients and in the absence of laparoscopic equipment. In 3 cases the conversion from laparoscopic to open operation was necessary: in 1st case because of hemorrhage from lesser omentum's vessels, when hemostasis cannot be performed by laparoscopy; in 2nd case as a result of bronchospasm associated with tense pneumoperitoneum in the patient with bronchial asthma; in 3rd case because of significant enlargement and rigidity of liver left lobe, which didn't permit to create the space for manipulations in cardial portion of the stomach. The mean bed day turnover after traditional HGP with LB and after laparoscopic HGP was 12.2 and 5.4 respectively. Intraoperative complication was observed in one case--hemorrhage from lesser omentum's vessels. One complication was observed in immediate postoperative period, on the 6th day after traditional HGP: the eventration as a result of hard diarrhea due to antibacterial treatment was diagnosed. One more complication was observed in a year after traditional HGP: small stomach evacuatory function disorders as a result of its significant dilatation. These disorders occurred because of gastric mucosa inflammatory edema, decrease of anastomosis diameter and frequent vomiting due to aspirin taking. In this case the repeated operation--bandage's reposition was performed. There were no other complications. The rate of repeated operations was 4% which agrees with literature data.

[Functional condition of gallbladder after stomach resection by Roux]. / Funktsional'noe sostoianie zhelchnogo puzyria posle rezektsii zheludka s anastomozom po Ru.

This study examined the results of surgical treatment of 90 patients with ulcerative stenosing disease of the stomach and duodenal ulcer between 1984 and 1995. 30 patients (study group) underwent stomach Roux resection. Truncal vagotomy with stomach Bilroth-I resection (control group) was made in 20 patients, 20 patients had a truncal vagotomy with pyloroplasty according to Heineke-Mikulicz (control group), and 20 patients had a selective proximal vagotomy with gastroduodenostomy by Joboulay (control group). Motor and evacuation functions of gallbladder were assessed by dynamic US and radioisotope scintigraphy. After a Roux stomach resection and a stomach Bilroth-I resection, respectively, hypokinetic and hyperkinetic types of the gallbladder's dyskinesia was established. After a selective proximal vagotomy with gastroduodenostomy by Joboulay and truncal vagotomy with pyloroplasty according to Heineke-Mikulicz essential change of the gallbladder refractive function wasn't observed.

[Treatment of malignant pancreatic islet cell tumors]. / Lechenie zlokachestvennykh insulinom podzheludochnoi zhelezy.

Among 142 patients with islet cell tumor who were admitted to hospital between 1982 and 1999, 15 patients (10.6%) had malignant tumours. The mean age was 45.3 +/- 5.8 years. Islet cell tumors were located in the head and corpus of the pancreas in 26.6% and 26.6% of the patients, respectively, in the tail of the pancreas in 46.8% of the patients. The mean size of the tumor was 2.9 +/- 0.7 cm, in 6 patients (40%) liver metastases were found. US, CT and angiography which sensitivity were 72.7, 100 and 85.7%, respectively, were used for topical diagnosis of the islet cell tumors. 12 patients were operated on (15 operations) and 3 patients were treated conservatively by streptozocin. Surgical procedures included distal pancreatic resection (n = 11), enucleation of the tumor (n = 2), hepatic resection (n = 1), abdominal exploration (n = 1). In 2 patients palliative pancreatic resections were combined with transarterial embolization and devascularisation of the liver metastases and 2 patients were treated by systemic chemotherapy. To reveal malignancy before and during the operation was possible only by evaluation of distant metastases and the adjacent organs infiltration. In other cases to determine the diagnosis was possible only after planned histological identification of the resected specimens. 5-year survival rates after conservative and surgical treatment were 33% and 62.5%, respectively. In patients without distant metastases 5-year survival rate was 100%.

[Functional condition of pancreas after stomach resection according to Roux]. / Funktsional'noe sostoianie podzheludochnoi zhelezy posle rezektsii zheludka s anastomozom po Ru.

Available are the results of surgical treatment of 90 patients with stenotic gastroduodenal ulcer in Burdenko Surgical Faculty Hospital of Sechenov Moscow Medical Academy between 1984 and 1985. 30 patients (study group) underwent stomach Roux-type resection. Truncal vagotomy with a stomach Bilroth-I resection was made in 20 control patients, after 20 control patients had a truncal vagotomy with pyloroplasty according to Heineke-Mikulicz, and 20 patients had selective proximal vagotomy with gastroduodenostomy by Joboulay (the third control group). Exocrine function of the pancreas was assessed by serum concentration of immunoreactive trypsin, endocrine function by fasting blood sugar, oral glucose tolerance and serum concentration of immunoreactive insulin. The authors came to the conclusion that exocrine function of the pancreas was equally damaged in patients with a Roux stomach resection, stem vagotomy with a stomach Bilroth-I resection and a stem vagotomy with pyloroplasty Heineke-Mikulicz. After selective proximal vagotomy a level of immunoreactive trypsin was normal. After a Roux stomach resection relative incompetence of basophil cells of the pancreas and long increase of insulin in the blood were observed but without influence on the glucose curve. The changes of glucose curve and level of immunoreactive insulin were similar in the control groups.

[Plastic surgery in patients with obesity late after horizontal banded gastroplasty]. / Plasticheskie operatsii u bol'nykh ozhireniem v otdalennye sroki posle gorizontal'nli gastroplastiki.

The results of 361 plastic operations in 296 patients with morbid obesity late after horizontal gastroplasty were analyzed. Plastic and corrective operations aimed at removal of redundant lipocutaneous "aprons" at the anterior abdominal wall, thighs, thoracic wall, gluteal region and the arms, represent a final stage of surgical treatment of patients with morbid obesity. The indications, technique and the results of plastic operations performed from 1985 to 1998, are thoroughly elucidated. The analysis of early postoperative complications has established, that it a reasonable to perform such operations 1-3 years after gastroplasty when body weight stabilizes and there are no vitamin deficiency, iron deficient anemia, hypoproteinemia, hydroionic disturbances or other complications of the later period. Complex prophylactic measures for prevention of pyoseptic and thromboembolic complications in patients with obesity late after gastroplasty permits to avoid severe complications and lethal outcomes in patients after plastic operations.

[Laparoscopic and standard cholecystectomy: comparison of immediate results]. / Laparoskopicheskaia i traditsionnaia kholetsistéktomia: sravnenie neposredstvennykh rezyl'tatov.

The advantages of laparoscopic cholecystectomy (LChE) are undoubtable in comparison with traditional one. However the experience showed, that LChE is not devoid of some shortcomings. It is characterized by the same typical complications as in ChE, besides it may be followed by some specific complications. The literature concerning the rate of complications in LChE are controversial. The comparative analysis has been carried out concerning the rate of complications after ChE (6800 operations) and LchE (900). The mean age of patients with choledocholythiasis--61.4 years. 40% of the patients had severe accompanying diseases coronary artery disease, complicated forms of arrythmia, arterial hypertension, diabetes mellitus, obesity. There were no significant differences between patients who underwent ChE (group 1) and LChE (group 2) by their age and the rate of accompanying diseases. Intraoperative cholangiography was performed in 3.5% of cases of group 1 and in 1.1%--in group 2. The average rate of the operations on extrahepatic bile ducts in group 1 was also lower--choledocholithotomy was carried out in 2.7%, transduodenal papillosphyncterotomy--in 1.7% of cases, drainage of the choledochal duct--in 1.9%. Combined operations were carried out in 10% of patients of group 1 and in 9.1% cases of group 2. The rate of intraoperative bleedings which demanded repeated operations made up in patients of group 1 0.1%, in patients of group 2 0.5%. Intraoperative damage of the choledochal duct in group 1 were detected in 0.14% and in group 2--in 0.11% of cases (the only complication of LChE in a patient was assessed as a endogenous wall clipping).

[Intraoperative ultrasonography in surgery on organs of abdominal cavity and retroperitoneal space]. / Intraoperatsionnoe ul'trazvukovoe issledovanie organov briushnoi polosti i zabriushinnogo prostranstva.

Since 1984 to 1999 intraoperative US examination (IOUSE) was made in 863 patients. 236 of them had diseases of the liver, 137 diseases of the gall bladder and biliary tract, 158 pancreatic disorders, 151 diseases of gastro-intestinal tract, 72 diseases of the adrenal glands, 101 constitutional obesity, 3 splenic disorders and 5 gunshot wounds of the organs of the abdominal cavity and the retroperitoneal soft tissues. In masses of the liver IOUSE showed limits for resection of the liver, location of the diseased area with the vessels and biliary ducts, unpalpablefoci. OUSE allowed to perform US-guided puncture and sclerosizing small metastatic nodes as well as a puncture and antiparasitic treatment of inaccessible echinococcal cysts. In cholelithiasis IOUSE allows to reveal or to rule out the presence of the concrements in bile ducts. In cases of diseases of the pancreas IOUSE helps to localize pathologic area, defines its interrelations with adjacent major vessels and ducts, reveals unpalpable masses and enables US-guided puncture of the major pancreatic duct followed by its further opening. In gastric tumors it is possible under US control to determine precisely the limits of the infiltration of gastric wall which defines the volume for resection. In operation on the adrenals from thoracophrenolumbar approach IOUSE through the diaphragmatic cupula determines the place and the length of phrenotomy and elucidates interrelations of the tumor with adjacent organs. Sensibility of IOUSE made up from 87 to 100%, and specificity--92-100% depending on the disease.

[Multiple endocrine neoplasia of the first type (Wermer's syndrome)]. / Mnozhestvennaia éndokrinnaia neoplaziia 1-go tipa (sindrom Vermera).

11 patients with Wermer's syndrome (WS) aged 24-67 years were treated. They had a total of 30 tumors: 4(13.3%) hypophyseal, 11(36.7%) pancreatic, 9(30%) parathyroid, 4(13.3%) adrenal and 2(6.7%) duodenal. Each patient had two tumors minimum and 8 tumors maximum. In 8 cases WS presented clinically as hypoglycemia, in 3 cases as Zollinger-Ellison syndrome. The diagnosis was made using ultrasonography, CT, MRT and angiography. Cytogenetic examination was made in 2 cases. All the patients were operated. Six of them were operated two times, one--four times. The following surgery was made: 4 removals of parathyroid adenomas, 4 adrenalectomies, 1 removal of the hypophysis, 4 enucleations of pancreatic insulinomas, 5 distal hemipancreatectomies, 1 distal subtotal resection of the pancreas, 1 gastropancreatoduodenal resection. Clinically symptomatic tumors should be operated first.

Obesity surgery in Russia.

BACKGROUND: In Russia, 40% of the population are overweight, and 26% are obese. As was mentioned at the IFSO Symposium in Cancun, very little is known about obesity surgery in Russia. METHODS: The authors undertook a literature search and interviewed surgeons who are known to perform bariatric procedures. RESULTS: Jejunoileal bypass (JIB) was used in the 1970s but has been abandoned by most surgeons. Since 1977, 334 JIBs, of a total of 360 bariatric operations, have been performed at I Saint Petersburg Medical University. The remaining 26 operations included 14 gastric bandings, 6 horizontal and 4 vertical gastroplasties, and 2 gastric bypasses. Since 1984, 545 gastric banding procedures have been done at the Moscow Medical Academy, where the current approach is the lap-band type of gastric banding. The laparoscopic technique of adjustable gastric banding is beginning to be used. Vertical banded gastroplasty (VBG) was begun in the early 1990s. At the Russian Research Center of Surgery in Moscow, 48 Mason VBGs have been done. The other group in Moscow reported 28 VBGs without the creation of a window and including covering the stoma by polypropylene mesh. There are only a few known cases of gastric bypass procedures. No data on biliopancreatic diversion were found. CONCLUSIONS: Obesity surgery is not being performed enough to satisfy the requirements of the Russian population. Simple operations are more common than complex ones. The use of the laparoscopic approach has begun and probably will increase.

[Effectiveness of duodenal ulcer surgical treatment]. / Effektivnost' khirurgicheskogo lecheniia duodenal'noi iazvy.

Effectiveness of medical aid means prevented loss of health due to optimal treatment. Measurement of effectiveness of surgical treatment could be realised by measurement of patients' quality of life. For the first time the authors have described a method for evaluation of effectiveness of surgical treatment for duodenal ulcer by studying quality of life of the patients in postoperative period. For this purpose original questionnaire ("IKG FKhK") was designed which enables to assess a common level of life quality and its components and to compare these values with those of healthy people. The authors have examined 351 patients after 8 types of operations: TPV, TPV with duodenoplasty, TPV with gastric drainage procedure, truncal vagotomy with gastric drainage procedure, truncal vagotomy with antrumectomy and anastomoses by Billroth-I and ROUX, as well as resection of 2/3 of the stomach by Billroth-I and Billroth-II. According to the examination data, it was established, that quality of life in patients after truncal vagotomy with antrumectomy by ROUX more precisely corresponded to values of healthy people and the possibility of obtaining "good" and "excellent" results was the highest. The minimal probability to reach the level of the quality of life of healthy people after resection of the stomach is resection of its 2/3. The authors have determined the influence of the type of surgical treatment, the terms after operation, patients' age, functional results (the values of gastric secretion, rate and character of evacuation of food from the stomach, duodenal reflux, etc.), manifestations of the disease of operated stomach. The authors established, that quality of treatment (adequate solution of technical and tactical problems) predetermines quality of life of the patients with duodenal ulcer in postoperative period.