[Abdominal wall repair after total resection of desmoid fibroma in a patient with diabetes mellitus type 1]. / Rekonstruktsiya perednei bryushnoi stenki posle radikal'noi rezektsii desmoidnoi fibromy na fone sakharnogo diabeta 1-go tipa.

Desmoid fibroma (DF) is a rare connective tissue tumor comprising about 0.03-0.13% of all neoplasms. DF has a low potential for malignant transformation, but it is characterized by aggressive course and unfavorable prognosis. The main contingent of patients consists of women of reproductive age. Despite the nearly two-century history of study, there are certain unsolved problems including endocrine problems associated with this disease. We report a 30-year-old female with DF and diabetes mellitus type 1. Total resection of the affected right rectus abdominis muscle was performed in a single block with aponeurotic sheath and peritoneum after normalization of carbohydrate metabolism. Muscular aponeurotic defect 27�10 cm was closed after separation of abdominal wall structures and implantation of polypropylene prosthesis. There are no X-ray and clinical signs of DF recurrence or postoperative hernia after 8 months.

Organic hyperinsulinism: radiological diagnostics and surgical treatment.

AIM: To optimize the diagnosis and surgical treatment of insulinoma and nesidioblastosis. MATERIAL AND METHODS: 42 patients with organic hyperinsulinism (OH) were operated. There were 39 cases of insulinoma including 2 patients with insulinoma combined with nesidioblastosis and 3 cases of nesidioblastosis alone. Preoperative ray imaging consisted of percutaneous, endoscopic and intraoperative sonography, contrast-enhanced computed tomography, magnetic resonance imaging (MRI). Functional test included arterial-stimulated blood sampling (ASBS). Laparotomy and robot-assisted techniques were used in 22 and 20 patients. RESULTS: Sensitivity was 62.0%, 76.9%, 83.3%, 87.5%, 94.8% and 100% in percutaneous sonography, CT, endoscopic sonography, MRI, intraoperative sonography and ASBS respectively. Postoperative complications were observed in 14 and 6 patients after conventional and robot-assisted surgery. 2 patients died. Overall mortality was 4.8%. None patient had recurrent hypoglycemic conditions in long-term postoperative period (mean follow-up 18.7 months). CONCLUSIONS: Comprehensive survey allowed to define the cause of OH. Minimally invasive organ-sparing surgery has satisfactory immediate and remote results in these patients.

[Nesidioblastosis (diagnosis, surgical treatment)]. / Nezidioblastoz (diagnostika i khirurgicheskoe lechenie).

INTRODUCTION: Nesidioblastosis (NB) is rare disease with organic hyperinsulinism syndrome and caused by diffuse hyperplasia and/or hypertrophy of pancreatic islands of Langerhans. MATERIAL AND METHODS: The results of surgical treatment of 3 patients with NB are presented. In all patients the diagnosis was suspected at the preoperative stage and confirmed by histological examination later. Herewith in 2 patients NB was combined with insulinoma. All patients underwent corpora-caudal pancreatectomy. RESULTS: In postoperative period one patient hadn't episodes of hypoglycemia for the entire follow-up period (5 months), in another patient hypoglycemic states occurred at 1.5 months after surgery. The third patient required pancreatic head extirpation at 11 days after surgery due to persistent severe course of organic hyperinsulinism. In immediate postoperative period in the same patient hyperinsular hypoglycemia was observed that pointed on extrapancreatic source of insulin secretion. However contrast-enhanced CT did not reveal any formations. CONCLUSION: Thus, corpora-caudal pancreatectomy is preferable as surgical treatment. Results of surgical management can provide a complete regression of the symptoms, but do not guarantee absence of recurrence and even any changes in frequency and severity of hypoglycemic states.

[Pancreatectomy for the pancreatic tumors].

23 pancreatectomies were made on the reason of various tumors of the pancreas during the period of 2009-2012yy. 15 patients had duct adenocarcinoma, 4 - neuroendocrine neoplasia, 2 - intraductal papillary-mucinous tumor, 1 had metastase of renal-cell carcinoma and 1 was diagnosed with serous cystadenoma. Pancreatectomy was indicated in case of invasion of the whole pancreas or in case of multiple tumor focuses. By adenocarcinoma the pancreatecomy was abstained in case of large vessels (a. mesenterica suoerior, truncus coeliacus and hepatic arteries) invasion or remote metastases presense or impossibility of R0 resection. Metastases and vessel invasion were not considered as contraindication to pancreatectomy in patients with neuroendocrine lesions. 10 (43.5%) patients had postoperative complications; 2 patients died. The survival median was 7 months for the duct adenocarcinoma. Postoperative life duration for patients with other pancreatic tumors was 6-36 months.

[The distal pancreatic stump extirpation on the reason of profuse arrosive intraabdominal bleeding].

11 patients with profuse arrosive intraabdominal bleeding after pancreatic resections were operated on the reason of pancreatic tumor. 9 patients had pancreatoduodenal resections (of the 6 pyloruspreserving), 2 patients had middle pancreatic resections. Bleeding was caused by postoperative pancreonecrosis and suture insufficiency in all cases. The source of bleeding were: vena porta, upper mesenteric and splenic veins, upper mesenteric and common hepatic arteries. 3 patients were relaparotomyzed and the vessel wall was sutured. Nevertheless, they died after bleeding recurrence within 2-3 days. The extirpation of the distal pancreatic stump was performed in 8 patients. Of them 3 patients died of multyorgan failure. The experience permits to consider the distal pancreatic stump the operation of choice by postoperative profuse bleeding.

[Carbohydrate metabolism abnormalities in patients with cancer of major duodenal papilla before and after pancreaticoduodenal resections].

56 Patients with cancer of major duodenal papilla were examined before and after pylorus-saving pancreaticoduodenal resection. Carbohydrate metabolism was estimated before and after the operation, impact of the operation on diabetes mellitus progression was detected. If there were no carbohydrate metabolism abnormalities in 75% before the operation, then there were 55% of such patients after the operation. After the pylorus-saving pancreaticoduodenal resection the impaired glucose tolerance was detected in 4 (7%) of patients whose carbohydrate metabolism had corresponded to norms before the operation. 7 (13%) of 17 (31%) patients had diabetes mellitus of mild severity after the pylorus-saving pancreaticoduodenal resection, the rest 10 (18%) had diabetes mellitus of moderate severity. In 7 (13%) patients after the pylorus-saving pancreaticoduodenal resection the diabetes mellitus of moderate severity was detected for the first time, at that in 4 patients diabetes mellitus of mild severity was detected, and in 3 patients--diabetes mellitus of moderate severity (everyone received insulin therapy in the long-term postoperative period) was detected. Checking protocol of the patients' carbohydrate metabolism in the perioperative period was described in detail. The possibility of prognostication of carbohydrate metabolism abnormalities in the long-term postoperative period by indications of carbohydrate metabolism before the operation and in early postoperative period was studied. Middle blood glucose level in early postoperative period is an informative indication for prognostication of carbohydrate metabolism state in the long-term postoperative period. An algorithm of patients' examination with cancer of major duodenal papilla before the operation and after it was offered; also checking protocol of carbohydrate metabolism indices and correction of the detected abnormalities in the early postoperative period were offered.

[Carbohydrate metabolism after pancreatoduodenal resections in patients with chronic pancreatitis].

The carbohydrate metabolism was analyzed in 70 patients with the complicated chronic pancreatitis before and after pylorus-preserving pancreatoduodenal resection (PPDR). Patients were aged 42±1,15 years, of them 64 were men and 6 - women. Bodymass index was 2,2±0,54kg/m2. Patients were divided in groups according to pre- and postoperative glucose metabolism disorders to define the diabetes morbidity by chronic pancreatitis and the influence of surgery on the first. According to the preoperative data, diabetes mellitus of mild severity had 9 of 70 operated patients, 18 patients had medium diabetes. After the operation only one patient demonstrated the aggravation of diabetes. However, the onset of diabetes mellitus was registered in 8 patients postoperatively. The increased glucose blood level in early postoperative period proved to have a high prognostic significance. Therefore, all patients of that category must be strongly recommended to be under the endocrinologist's observation after hospital discharge. That measure would provide a timely diagnose and treatment of the diabetes mellitus. All patients with chronic pancreatitis should be thoroughly investigated concerning glucose metabolism disorders before the operation.

[Hyperhomocysteinemia and plasma acute-phase proteins in patients with type 2 diabetes mellitus and severe course of atherosclerosis after vascular operations].

Interdependence between the level of homocysteine and acute-phase proteins was assessed in patients presenting with a severe course of atherosclerosis. We examined a total of 67 patients aged 62.3 +/- 1.03 years. Of these, 34 patients had type 2 diabetes mellitus and 35 were non-diabetic. The diabetic patients were found to suffer a severe course of the disease, with 65.6% having a decompensated form. We carried out a comparative analysis of the level of homocysteine, C-reactive protein, and that of fibrinogen. It was noted that diabetic patients significantly more often showed high levels of blood-plasma total homocysteine, C-reactive protein, and that of fibrinogen as compared to nondiabetic patients. Hyperhomocysteinemia appeared to correlate with elevated levels of C-reactive protein (r = 0.37, p = 0.04) and that of fibrinogen (r = 0.36, p = 0.04) at HbA1c > or = 7%. The obtained findings strongly suggest interrelationship of high levels of blood-plasma homocysteine and an elevation in acute-phase proteins in a decompensated form of diabetes mellitus and the presence of sluggish chronic inflammation in all patients, either with or without diabetes mellitus. Inclusion of homocysteine measuring and a highly sensitive method for determining C-reactive protein into the standard of examining patients with atherosclerosis improves diagnosis of the pathological condition, while timely correction of the impairments revealed promotes a decrease in the risk of the development of complications.

[Treatment of coagulation disoreders in patients with diabetes mellitus type II].

Efficacy of out-hospital treatment of coagulation disorders in patients with diabetes mellitus type II (DMII) in comparison with non-diabetic patients after aortic-femoral reconstruction was studied. Long-term results were obtained within 65,1±3,95 months after surgery. Data of 67 patients were obtained, of them 32 had severe DMII, 35 patients had no diabetic disorders. 94% of patients had various hypercoagulation disorders and thrombophilia stage I-II. Desagregant therapy was noneffective in 70,1% of patients. Patients with atherosclerosis after reconstructive vascular surgery showed disorders of both thrombocytic and plasma links of coagulation, which requires combined (anticoagulant and desagregant) therapy. Patients with DMII require also blood glucose and HbA1c control postoperatively.

[Long-term outcomes of aortofemoral reconstructions in patients with type 2 diabetes mellitus].

Studied herein are long-term outcomes of aortofemoral reconstructions in a total of 469 patients presenting with atherosclerosis. Of these, 201 (42.8%) patients were diagnosed as suffered from type 2 diabetes mellitus (DM). By the time of the survey, the age of the patients in this group averaged 64.7 +/- 1.2 years. The remaining 268 (57.2%) patients (mean age 62.5 +/- 1.7 years) turned out to be non-diabetic. Surgical interventions performed on the background of pronounced limb ischaemia (50% of the patients had critical ischaemia) had made it possible to save the limb affected and for a long time to increase the distance of pain-free walk in 85.9% of diabetic patients and in 93.1% of non-diabetic subjects. Nine years after the vascular reconstruction of the aortoiliac zone, the indices of the cumulative patency of the bypass grafts (72% for diabetic patients and 81% for non-diabetics) and the limb-salvage rate (78.9% for those with DM and 88.5% for those without DM) remained sufficiently high. The cumulative survival rate amongst the diabetic patients after 3 and 6 years was significantly lower (74.0% and 58.0%, respectively) as compared with that in the non-diabetic patients (93.0% and 72.0%), P < 0.01, whereas by the 9-year period of follow-up it turned out to be similarly low in the both groups of patients (amounting to 26.0% and 29.0%, respectively). In diabetic patients, the mortality rate was significantly higher, with deaths occurring earlier, than in those from the comparison group (43.1% at 56.0 +/- 2.4 months and 28.9% at 62.4 +/- 1.9 months, respectively). The underlying causes of death regardless of the presence of diabetes mellitus chiefly comprised cardiac complications which in diabetic patients were observed significantly more often and occurring at earlier terms (52.9% at 49.5 +/- 1.7 months and 31.1% at 62.1 +/- 1.5 months, respectively, P = 0.04). Hence, despite the presence of DM, aortofemoral reconstructions in the majority of cases (up to 80%) make it possible to reliably and for a long time prevent the development of critical ischaemia and to save the lower limbs.

[Carbohydrate metabolism disturbances after pancreatoduodenal resection in patients with cancer of the head of pancreas].

Carbohydrate metabolism was explored in 52 patients with cancer of the head of pancreas before and after pylorus-preserving pancreatoduodenal resection. Glycemia, insulin dosage, glucosuria and acetonuria were assessed retrospectively to reveal correlation with postoperative carbohydrate metabolism disturbances. Preoperatively 46.2% of patients had no metabolic problems, whereas postoperatively only 38.5% of patients showed normal sugar metabolism. 9 (17.3%) patients developed disturbed glucose tolerance, 5 (9.6%) patients developed mild diabetes mellitus and 18 (34.6%) patients had diabetes of medium severity. Combination of first diagnosed diabetes mellitus, progressive weight loss and abdominal pain proved to be the negative prognostic set of symptoms and should urge on pancreatic tumor search. Glucose level in early postoperative period is a valuable prognostic criteria for the development of carbohydrate metabolism disturbances in long-term postoperative period.

[Assessment of the level of homocysteine and the state of haemostasis in patients with and without type 2 diabetes mellitus in remote terms after reconstructive operations on the aorto-iliac segment].

The authors carried out a comparative analysis of the level of homocysteine and the state of haemostasis in patients with and without type 2 diabetes mellitus in the remote terms after endured reconstructive operations on the aorto-iliac segment. They examined a total of eighty-eight patients who had endured reconstructive operations on the aorto-iliac segment at various terms. Of these, forty-two patients were found to have a severe course of type 2 diabetes mellitus (59.9% with decompensation) and forty-six subjects without diabetes constituted the group of comparison. The average age of the patients amounted to 61.9 +/- 1.25 years, with all being smokers. The following parameters were assessed: patency of the bypasses and major arteries of the lower limbs (LL), homocysteine (Hey), fibrinolytic activity, fibrinogen, activated partial thromboplastin time (aPTT), factor XIII, thrombin time, prothrombin index, activity of antithrombin III (AIII), platelet aggregation with ADP, and glycosylated haemoglobin (Hb Aic).

[Analysis of quality of ambulatory follow-up of patients with type 2 diabetes mellitus after reconstructive operations on the aortoiliac segment].

The article is dedicated to assessment of quality of ambulatory management of patients suffering from type 2 diabetes mellitus in remote terms following reconstructive operations on the aortoiliac segment. The aspects investigated included the frequency of the of patients' visiting the district polyclinic, as well as frequency and quality of planned examinations and conservative treatment. Presented herein are the results of questioning and comprehensive examination of fifty-six patients suffering from type 2 diabetes mellitus (mean age 62.3 +/- 1. 7years) performed averagely 61.9 +/- 2.1 months after surgical treatment. Fifty percent of these patients appeared to have prior to the operation had critical ischaemia of the lower extremities. By the time of the check up examination, 62.5% of these preserved stage 1 or 2A ischaemia and 37.5% had stage 2B ischaemia, which on the whole was indicative of a long-term positive outcome of surgical interventions in this severely ill cohort of patients. During this time period, in 23 (41.1%) patients with baseline critical ischaemia it turned out possible to avoid limb amputation, and 62.5% were found to have considerably increased the distance of pain-free walking (stage 1 or 2A). Together with it, the obtained findings suggested virtually total lack of adequate angiological care for the postoperative patients at the ambulatory-polyclinic level. First of all, there are neither correctly organized dispensary follow up of patients nor continuity between the clinical hospital and the polyclinic. Analysing the check-up clinical evidence showed that 83.9% of patients required correction of blood glucose level, 96.4% that of lipid profile, and 73.2% that of the haemocoagulation system. Twenty-five (44.6%) patients required stagewise reconstructions due to an atherosclerotic lesion of the previously intact arteries of the lower limbs (21), prosthesis-leg thrombosis (1) and anastomotic restenosis (3). Hence, the clinical effect of a clinical intervention in diabetic patients is apparently evident. Correct and adequate organization of therapeutic and preventive care at the ambulatory and polyclinic level may substantially improve the remote results of vascular operations in this cohort of patients.