[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]

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]

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]

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.

[Treatment of malignant pancreatic islet cell tumors]

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 gallbladder after stomach resection by Roux]

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.

[Functional condition of pancreas after stomach resection according to Roux]

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.

[Intraoperative ultrasonography in surgery on organs of abdominal cavity and retroperitoneal space]

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.

[Laparoscopic and standard cholecystectomy: comparison of immediate results]

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).

[Diagnosis and surgical treatment of organic hyperinsulinism]

From 1982 to 1998 144 patients (males 31.7%, females 68.3%) with organic hyperinsulinism underwent surgery. Mean age of the patients was 44.2 +/- 4.6 years. The causes of the development of this disease were benign insulinoma (82.6%), malignant insulinoma (6.9%), beta-cells hyperplasia and microadenomatosis (4.2%). In 6.3% of the patients the origin of the disease was not established. The location of the insulinoma in the pancreatic head was detected in 33.8%, in the body--in 35.2%, in the tail--31%. The sensitivity of the used methods of topical diagnosis was the following: US--40.3%, CT--28.6%, angiography (selective celiacography and upper mesentericography)--76.9%, blood samples from the right hepatic vein after intraarterial stimulation of different parts of the pancreas by Ca with measurement of immunoreactive insulin level--87.2%, intraoperative palpation--86.5%, intraoperative US examination--100%. Preoperatively, the authors used combined angiographic examination, the sensitivity of which made up 94.9%, this study being a single one which allows to reveal the region of the lesion of the pancreas in beta-cells hyperplasy. Tumor enucleation (59 patients), distal resection of the pancreas (50), the excision of the insulinoma (25), duodenopancreatic resection (1), explorative laparotomy (9) were made. Postoperative complications rate arose in 43.6% of the patients, mortality rate--7.7%. The best results were achieved in enucleation of insulinoma and distal resection of the pancreas. The authors suggest that in preoperative diagnosis of insulinomas the preferable methods should be US-examination and combined angiographic examination. Intraoperative revision should be made with use of US examination. Depending on the intraoperative findings the preference should be given either to enucleation of insulinoma or to distal resection of the pancreas.

[Plastic surgery in patients with obesity late after horizontal banded gastroplasty]

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.

[Multiple endocrine neoplasia of the first type (Wermer's syndrome)]

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.

[Neuroendocrine tumors of pancreas (clinicomorphological, immunohistochemical and electron microscopic study)]

Neuroendocrine tumors of the pancreas were studied by histology, immunohistochemistry and electron microscopy. Tumors associated with organic hyperinsulinism showed heterogeneity in their ultrastructure, functional and proliferation activity. More than half of these tumors are multihormonal and 15% of them developed from polypotent cells which are capable for several types of differentiation.

[Laparoscopic horizontal gastroplasty]

The analysis of the first 14 operations of horizontal gastroplasty in patients with end-stage alimentary constitutional obesity was carried out, the operations being performed according to standard (9 patients) as well as laparoscopic method (5 patients). The mean body mass made up 133.6 kg, the mean height being 167.8 cm. Patients age was from 22 to 42 years. All the patients operated by laparoscopic method were women. Technique of laparoscopic horizontal gastroplasty is described, indications and contraindications to the operation are established. It is demonstrated, that laparoscopic gastroplasty, as well as previously performed 530 horizontal gastroplasties with the help of fluoric-lausan goffer band, performed in clinic since 1984, in present time is one of the most perspective method of surgical correction of obesity. The application of this method results in substantial and steady decrease of body mass of the operated patients with minimal risk of complications during surgical procedure as well as in postoperative period.

[Effectiveness of duodenal ulcer surgical treatment]

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.

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.

[Minimally invasive interventions in treatment of mechanical jaundice]

For the period from 1972 to 1997 676 transcutaneous transhepatic and 370 endoscopical interventions in 953 patients with mechanical jaundice were carried out. In 58.5% of cases jaundice was caused by malignancies, in 41.4%--by benign strictures of bile ducts. 40 external biliary bypasses, 427 external-internal biliary bypasses, 55 cholecystostomies and 154 operations of biliary endoprosthetic reconstructions were conducted under US control and TV imaging. In 33.5% of cases biliary bypass and endoscopical procedures were made as a preliminary stage of preparation of patients for operation or as a final method of treatment after conventional operation procedures, in 66.5% of cases it was final method of treatment. There were no deaths caused by biliary bypass procedures nor complications related to laparotomy. Thus low invasive interventions, undoubtedly, are the method of choice in mechanical jaundice for preparation of patients before radical operations as well as for relief of the course of disease in patients with inoperable cancer which causes obstruction of biliary ducts.

Preoperative and intraoperative topographic diagnosis of insulinomas

Altogether 120 patients with organic hyperinsulinism underwent clinical examination and treatment (38 male, 82 female, mean age 44.2 +/- 4.6 years). The cause of hyperinsulinism was benign insulinomas in 96 (80.0%), malignant tumors in 9 (7.5%), and hyperplasia of beta cells in 6 (5.0%). In 9 (7.5%) patients the origin of hyperinsulinism was not diagnosed. The tumor was localized in the head, body, and tail of the pancreas in 31.8%, 36.4%, and 31.8% of cases, respectively. Intraoperative ultrasonography (IOUS) was undertaken in 37 patients, and in 83 cases only intraoperative palpation was done. Arterial stimulated venous sampling (ASVS) was performed in 17 patients (blood was sampled from the right hepatic vein for determination of the insulin level after arterial stimulation by calcium gluconate in different parts of the pancreas). The sensitivity of ultrasonography (US) was 29.5%, computed tomography (CT) 24.2%, angiography 55.9%, superselective angiography (branches of the celiac trunk) 72.2%, and intraoperative palpation 90.0%. ASVS showed an accuracy of 90.0%. Combining angiography with ASVS gave an exact diagnosis of hyperinsulinism in 100% of cases, and IOUS revealed tumors in 100% of cases. Hyperplasia of beta-cells was diagnosed only by means of ASVS. A total of 117 patients underwent surgery, including distal resection of pancreas (n = 39), enucleation of tumor (n = 70), and laparotomy (n = 8). The postoperative mortality associated with insulinomas was 7.7%. The frequency of postoperative complications was 43.6%. Benign insulinomas recurred at a rate of 5.4%. Patients with malignant insulinomas had a 5-year survival of 66.0%. The diagnosis of insulinomas was achieved by a combination of selective angiography, ASVS, and IOUS.

[Secretion, evacuation function of stomach and duodenogastric reflux in patients with ulcerative stenosis of duodenum after various type of operations]

The results of surgical treatment of 118 patients with ulcerative disease of the duodenum, complicated by stenosis, were studied. 58 from them (49.2%) underwent selective proximal vagotomy (SPV) with duodenoplasty and 60 (50.8%) patients--SPV with gastroduodenoanastomosis by Zhabuley. In the early and long-term periods lowering of the audio productive function of the stomach was observed both in patients after SPV with duodenoplasty and after SPV with gastroduodenoanastomosis by Zhabuley. According to X-ray examination data in the long-term period after SPV with duodenoplasty the regular evacuation function has been restored in 95.5% of patients, and after SPV with gastroduodenoanastomosis--in 52.2% of patients the acceleration of evacuation was detected. The radionuclear examination after SPV with duodenoplasty manifested evacuation curves characteristic for healthy people in 93.3% of patients, and after SPV with gastroduodenoanastomosis--in 84% of patients the acceleration of the evacuation of various degrees, was revealed. The duodenogastral reflux (DGR) in long-term periods after SPV with duodenoplasty was revealed in 25% of patients, in most cases being periodic (18.8%). After SPV with gastroduodenoanastomosis DGR was registered almost 3 times more frequently (73.3%); permanent DGR was revealed in 46.7% of cases.

[Selective proximal vagotomy with duodenoplasty in the treatment of duodenal stenosis in patients with duodenal ulcer]

The results of surgical treatment of 118 patients with duodenal ulcer complicated with stenosis that have been operated on from 1981 to 1992 have been analysed. Selective proximal vagotomy (SPV) and duodenoplasty was performed in 58 (49.2%) patients (study group). SPV and gastroduodenal anastomosis by the method of Jabulay was performed in 60 (50.8%)-control group. The rate of postoperative morbidity in the study group-5.1%, in the control group-8.4%. The long-term follow up is from 1 year to 10 years (mean 5 + 0.6). The rate of recurrence of peptic ulcer is 8.6% in the study group and 10% in the control group. The modified scale (D. Johnson, 1976) was used for comparative evaluation of efficacy of two types of surgery. SPV and duodenoplasty was estimated in 175.1 points, that is 2.5 times less that SPV and gastroduodenal anastomosis (406.1 points). This demonstrates the advantages of SPV and duodenoplasty. The authors advocate SPV and duodenoplasty as a method of choice in the treatment of stenotic duodenal ulcer.

[The effect of various surgical management methods of stenosing duodenal ulcers on the stomach mucosa defence barrier]

The article deals with one of the pressing problems of clinical medicine-restoration of the mucosal defence barrier in surgery for stenosing duodenal ulcer (SDU). The authors studied the defence barrier of the mucosa of the upper part of gastrointestinal tract by measuring the transmural potential difference (TPD) and the level of oxygenation of the organ mucosa in the early and late periods after surgical treatment of 118 patients with SDU. The defence barrier of the gastric mucosa (GM) and the duodenal mucosa (D) was effectively restored after selective proximal vagotomy (SPV) with duodenoplasty (DP) performed in 58 (49.2%) patients. Evidence of this was an increase of the TPD values and oxygenation level of the mucosa, whereas after SDU with Jaboulay's gastroduodenoanastomosis (CDA) conducted in 60 (50.8%) patients, the desired restoration of the mucosal defence barrier did not occur and in some areas of the stomach and duodenum it was damaged. The incidence of recurrences was 8.6% after SPV with DP and 10% after SPV with CDA. Therefore, SPV with DP does not yield to SPV with CDA in efficacy, and from the standpoint of curing peptic ulcer it also promotes effective restoration of the defence barrier of the gastric and duodenal mucosa.

[Aspirative lipectomy in patients with alimentary-constitutional obesity]

The results of aspirative lipectomy in patients with 2nd and 3rd stage of alimentary-constitutional obesity are analysed. The effectiveness of lipectomy with surgical creation of a small ventricle and without previous surgery, has been demonstrated. The criteria of patients selection, based on their somatic and psychic features, are formulated. Aspirative lipectomy has certain advantages over other types of plastic surgery as it has the minimal rate of postoperative complications.

[Diagnosis and minor invasive methods of treatment of nonparasitic hepatic cysts]

135 patients have been evaluated to improve methods of diagnosis and treatment of nonparasitogenic liver cysts. Ultrasound, ETA, indirect hemagglutination were used for differential diagnosis. Target thin-needle aspiration biopsy under the ultrasound control with subsequent cytologic studies was performed in all the patients. Most informative data have been provided by enzyme immunoassay and indirect hemagglutination. 118 patients have been successfully treated with puncturing, drainage and sclerosing of the cavity walls with 96% ethanol. There were no cases of recurrence, morbidity, mortality. Surgery has not been performed in 17 patients with small-size cysts.

[Problems in the surgical treatment of calculous cholecystitis]

The article analyses experience of the N. N. Burdenko clinic in surgical treatment of cholelithiasis. A total of 4,733 operations for cholecystectomy were performed. 96.7% of them were of a planned order, 14.3% of patients who underwent operation 65 years of age and older. Cholecystectomy was expanded to choledocholithotomy in 2.7, papillosphincterotomy in 1.7, separation of biliodigestive fistules in 0.6% of cases. Various combined operations were carried out on 558 patients. Intraoperative complications developed in 0.96% of cases: damage to the hepaticocholedochus (0.14%) and to the hepatic artery proper (0.02%) and its right branch (0.02%). Relaparotomy was performed in 0.86% of cases: for bile leakage (0.54%) and for bleeding (0.15%). Suppuration occurred in 3.9% of patients who were operated on. Total mortality was 0.25% (0.09% after planned and 5.7% after emergency operations). Fatal complications were encountered in 0.1% of patients under 65 years of age and in 1.18% of older patients. Fatal outcomes occurred in 1.1% of 558 combined operations, one of which was cholecystectomy; in none of the cases could the fatal complication be connected with expansion of the intervention. As it can be seen from the above-discussed material, there are definite prospects for improving the results of cholecystectomy: an obligatory condition is conduction of the operation in a planned order and under 65 years of age. Careful assessment of the operative risk factors for each patients on the basis of modern mathematical methods will help in solving the problem of the possibility of surgical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transcutaneous drainage of pancreatic pseudocysts guided by ultrasound and computed tomography]

The method of transcutaneous sanation of pancreatic pseudocysts under control of USE and CT has developed quite widely in the recent years and is applied in clinical practice. In the period from 1987 to May 1993 thirty-three patients underwent transcutaneous drainage (TD) of pancreatic cysts at the Burdenko Facultative Surgical Clinic, MMA; a total of 35 procedures were performed. In all cases TD was conducted under control of USE and roentgeno-television (RTV) by Seldinger's method or with various types of stylet catheters. The transperitoneal approach was preferable in cysts of the head, in cysts of the body of the gland hze transgastric approach was used under control of gastroscopy for later attempt to accomplish transcutaneous cystogastrostomy. Contrast examination of the cyst immediately after puncture revealed its connection with the pancreatic duct (PD). Fistulography was repeated every 5-7 days. In the absence of a cystopancreatic fistula the cyst was sclerosed with 96 degrees ethyl alcohol. Complications were encountered in 11% of cases and a recurrent cyst developed in one patient. The TD method under control of USE and RTV is effective in the treatment of pancreatic cysts attended by a low incidence of complications. A large size of the cyst, its infection or connection with the pancreatic duct are not contraindications for TD.

[Results of surgical treatment of ulcer]

More than 2,000 patients with peptic duodenal ulcer (PDU) and approximately 500 patients with peptic gastric ulcer (PGU) have been operated on in the clinic since 1968. Selective proximal vagotomy (SPV) with or without a draining operation was carried out for duodenal ulcer 1,453 times; trunk vagotomy (TV) with pyloroplasty 208 times, and vagotomy in combination with economical resection of the stomach 380 times. PGU was treated by Billroth I operation in 172 patients, by Billroth II operation in 61, by TV with economical gastric resection in 90, by SPV in 27, and by TV with pyloroplasty in 218 patients. Most patients underwent complex examination in the immediate and late-term postoperative periods, on the grounds of which the advantages and shortcomings of the various operations could be determined and the optimal method of treatment chosen. SPV proved to be the method of choice in surgery for PDU, and SPV with a draining operation in the existence of a stenosis. It produces the best functional results and the incidence of a recurrent ulcer is no higher than 8.6%. TV with excision of the ulcer and pyloroplasty was the best operation in PGU. Repeated biopsy in gastroscopy and histological study of the excised ulcer during the operation is an obligatory condition for performing this operation. Only such tactics excludes malignant degeneration. With the performance of organ preserving operations in PDU and PGU the late-term results are significantly improved, the incidence of postoperative complications and invalidism is reduced, and the patients' mode of life is improved.

[Effect of fragmin, a low-molecular heparin, on hemostasis in patients with alimentary-constitutional obesity]

The authors conducted comparative study of the hemostasis indices before and in the immediate period after operation for formation of a small stomach in 31 patients with stage III-IV alimentary-constitutional obesity, in 50 patients without obesity who underwent operation on the stomach, and in 15 volunteers. Nonspecific prevention of thrombogenesis was performed in all patients with normal weight and those with obesity. Patients with obesity were given in addition specific thrombogenesis prevention with nonfractionated heparin (group I) and fractionated low-molecular heparin-fragmin produced by KABI (groups II and III). Study of the parameters of the hemostasis system in the postoperative period showed nonspecific prevention of thrombogenesis to be sufficient to reduce the risk of pulmonary artery phlebothrombosis and embolism in most patients without obesity. In patients with obesity the probability of phlebothrombosis and thromboembolism is much higher, in view of which they must be given heparin in addition to nonspecific prevention. Fragmin, as an agent for thrombosis prevention, has certain advantages over nonfractionated heparin and should be used more frequently in clinical practice in patients of the risk group, e. g. with pathological obesity, in a dose no less than 100 U/kg. With the use of fragmin laboratory control before each injection is not needed. Administration of nonfractionated and fractionated heparins must be combined with bandaging of the lower limbs and other measures of nonspecific prevention of thrombogenesis.

[The choice of an optimal variant in the reconstructive stage of gastrectomy]

The authors analyse 40-year experience in gastrectomy and extirpation of the gastric stump in carcinoma of the stomach. Operations were performed on 742 patients. The results show that the mechanical suture has advantages over the manual suture in the formation of the esophago-intestinal anastomosis. The functional results were found to be best when the continuity of the gastrointestinal tract was restored by establishing the esophago-intestinal anastomosis with a loop of the small intestine isolated according to Roux. Comparative appraisal of end-to-end and end-to-side esophago-intestinal anastomoses revealed the advantages of the last-named in relation to the incidence of postoperative complications and total outcomes. The effect of the surgeon's qualification on the frequency of postoperative complications is discussed.

[State of the liver in patients with obesity at distant periods after formation of a "small stomach"]

Histological study of biopsy specimens taken from the liver of 96 patients during operation for formation of a "small stomach" revealed fatty dystrophy of the liver in 93 patients (96.9%) which was attended by marked inflammatory and fibrous changes in 68 (70.8%) of them and by disturbed lobar structure of the liver (cirrhosis) in 2 patients (2.1%). Biochemical blood tests failed to show the pattern of the pathological changes before the operation. Study of the hepatobiliary system with methionine-75Se was the only method by which protein and pigment metabolism in the liver could be appraised. Examination of patients during 3 postoperative years showed a positive dynamics of changes in biochemical blood tests and improved protein metabolism in the hepatocytes according to the results of scanning of the liver with methionine-75Se. Thirteen repeated studies of the hepatic tissue collected from patients in different periods after operation for the formation of a "small stomach" showed a significant diminution of fatty dystrophy and inflammation of the parenchyma. The level of portal tract inflammation and portal fibrosis did not change. The findings suggest that there is an improved functional and morphological condition of the liver in weight loss caused by operation for the formation of a "small stomach", which allows this type of surgical intervention to be recommended for the treatment of patients with alimentary-constitutional obesity and initially diminished compensatory capacities of the liver.

[Changes in the degree of oxygenation of gastric mucosa before and after the operation of creating a small stomach in patients with the extreme degree of alimentary-constitutional obesity]

The authors examined 131 patients with alimentary-constitutional obesity of Degrees III-IV before and after operation for "small stomach" formation. All patients underwent pre- and post-operative endoscopy of the esophagus, stomach and duodenum. The level of gastric mucosa oxygenation was measured in 50 patients before and in various periods after surgery. For this purpose the authors suggested an original endoscopic +spectrum analyzer and a method for determining the level of oxygenation of the mucosa of the organ. The level of gastric mucosa oxygenation was significantly lower in patients with obesity than in healthy individuals of the control group. After the operation the oxygenation level increased significantly, which was connected with an altered diet regimen, reduced amount of the ingested food, loss of weight, and improved microcirculation in the mucous membrane of the organs of the alimentary tract. The authors emphasize in particular the absence of blood supply disorders at the site of application of a synthetic fluoronlavsan band (in the region of the anastomosis), which is among the indices of the physiological property of this method for surgical treatment of patients with alimentary-constitutional obesity.

[Late results of the treatment of patients with the extreme degree of alimentary-constitutional obesity by the method of formation of a small stomach]

The work analyses the results of treatment of 311 patients with extreme degrees of alimentary-constitutional obesity by formation of a small stomach. Fatal outcomes (1.9%) were encountered in the period of operative technique mastering. The late-term results were studied in 167 patients in follow-up periods of up to 3 years. The patients' average body weight was 149.4 kg, average height 166.2 cm, average body weight excess as compared to the ideal weight was 125.6%. Study of the late-term results of the operation showed that the postoperative weight loss depends on the initial weight excess and the diameter of the anastomosis formed between the proximal and distal parts of the stomach. The more the initial excess of weight as compared to the ideal value, the more the loss of body weight is. The diameter of the formed anastomosis should be no larger than 15 mm. Besides loss of weight, the activity of vital organs and systems is normalized after the operation, and arterial hypertension, diabetes mellitus, the Pickwickian syndrome, and metabolic polyarthritis take a milder course. The operation for formation of a small stomach made it possible for the patients to resume their customary occupation, freed them of the threat of invalidation, and reduced the duration of the disability period by 4.3 times. After surgical treatment the nature of the patients' life significantly improved; 95.8% of patients appraised the effect of the treatment as excellent and good.

[Results of surgical formation of small stomach in patients with morbid obesity]

The authors conducted a comparative analysis of the results of surgical treatment of patients with alimentary-constitutional adiposity (ACA) of extreme degrees. Operation for the formation of a small stomach (SSF) was carried out in 41 patients. The results in the same patients were analysed in postoperative periods of more than 2 years. The patients were divided into 2 groups. The first group was composed of 22 patients with morbid obesity and an average body weight of 140.2 +/- 4.47 kg (101.4 +/- 3.83% excess weight). The second group was made up of 19 patients with an average body weight of 170.2 +/- 6.5 kg (average excess weight 169.8 +/- 7.03%). The average weight loss in the first group was 41.9 kg (59.9% loss of excessive weight), the average weight loss in patients with hyperadiposis (second group) was 62.9 kg (99.4% loss of excessive weight). The results of operation for SSF for reducing body weight in patients with adiposity are better than those of vertical gastroplasty.