[Prospects of qualitative and quantitative assessment of bowel perfusion by fluorescent angiography with indocyanine green in colorectal surgery. First experience]

OBJECTIVE

To assess the possibilities of fluorescent detection system in qualitative and quantitative assessment of bowel perfusion in colorectal resections.

MATERIAL AND METHODS

From May to August 2023, a single-center pilot cross-sectional unblinded study with inclusion of 18 patients with colon cancer (of left-sided - 12, of right-sided - 6, mean age - 72.9 years, m/w - 61/39%) was conducted. All patients underwent laparoscopic colorectal resections with extracorporeal stage of bowel transection. The evaluation of the bowel's ICG perfusion was conducted to assist in decision making about the level of its resection. Qualitative (visual) assessment was carried out in all 18 patients, in one patient twice, quantitative assessment of perfusion was conducted in 8 patients (left-sided resections - 6, right-sided hemicolectomy - 2). The qualitative evaluation was performed in real time on the analysis of the color gradient. The time parameters and fluorescence intensity at different level proximally and distally from the resection line were quantitatively estimated: Tstart - time of occurrence of minimal fluorescence in the areas of interest after the ICG injection (sec); Tmax - time to achieve maximum fluorescence intensity after the ICG injection (sec); Tmax-start - time interval between Tstart and Tmax, Imax - level of maximum fluorescence intensity (I).

RESULTS

Visual qualitative analysis of fluorescence revealed unsatisfactory perfusion characteristics (black, dark-gray color) in the area planned by the surgeon to anastomose the bowel in 3 of 18 patients (16.6%). When analyzing the quantitative data of this group of patients, there was a 2-6-fold decrease in Imax level, and one patient had an increase in Tmax-start at the level of intended resection compared to the bowel's sections in the favorable zone. In all cases, the final bowel transection was conducted in the area of good perfusion. There was no clinical evidence of anastomotic dehiscence in the study group.

CONCLUSION

Intraoperative evaluation of bowel perfusion is an important component of safe anastomosis formation in colorectal surgery. The use of ICG-FA allows to conduct qualitative and quantitative assessment of tissue perfusion of the bowel in order to assist in making intraoperative decisions. Quantitative evaluation of fluorescence provides more objective information about perfusion parameters. Imax and Tmax-start are the most promising quantitative indicators of local bowel's perfusion. Nevertheless, the precise interpretation of the quantitative indicators of ICG perfusion needs to be clarified.

Analysis of mutations spectrum in the ATP7B gene in patients with Wilson disease using massively parallel sequencing

The study aimed to search for mutations in the ATP7B gene using massively parallel sequencing in patients with Wilson disease in the Tomsk region. For 42 patients with suspected Wilson's disease (aged from 1 to 33 years) was performed molecular genetic analysis. Enrichment of the interest genome regions was carried out by the long-range PCR. DNA libraries with ligated adapters were constructed with Nextera DNA Flex (Illumina, USA) kit. Sequencing was performed on the Illumina MiSeq platform (Illumina, USA). As a result of this work, we identified 9 pathogenic genetic variants. All variants were previously described in the literature and were found in patients with Wilson's disease. Five missense mutations, one splice site mutation, and 3 frameshift mutations were identified. In patients with Wilson's disease in the Tomsk region, the most common variant was c.3207C>A, this variant is the most common both in the Russian Federation and in other European populations. Also, a pathogenic variant c.3036dupC was found, which is probably endemic to the Russian Federation.

[Method of individual evaluation of athletes' tolerance of maximal physical exertion under exposure to changed hypoxic and hypothermal environment]

The article covers a program determining order and method of gradual examination of highly qualified athletes engaged into winter sports in Sports Medicine and Rehabilitation Center in Bournazian FMBC of the FMBA of Russia, to assess physical performance and individual tolerance in changed climate (hypoxic and hypothermal) conditions.

[Cytoprotectors and their application in sports medicine]

The article presents data of literature review on potential use of cytoprotectors in sports medicine (exemplified by Mildronat medication). This group of medications improve metabolism and energy supply in tissues. One of leading indications to Mildronat use is state of low mental and physical performance, including that of athletes.

[Prevention and treatment of postoperative pain syndrome in extensive thoracoabdominal oncological surgery]

A procedure has been developed and tested to prevent and treat postoperative pain syndrome during extensive thoracoabdominal surgery for esophageal cancer. The procedure is based on the preventive (12 hours before anesthesia and surgery) application of Durogesic (fentanyl transdermal therapeutic system (TTS)) at an opioid release rate of 50 microg/h for 72 hours. By the end of surgery and anesthesia when intravenous injection of fentanyl is stopped, analgesia continues to be maintdined due to its therapeutic dose coming from TTS. This prevents the development of acute opioid tolerance, hyperalgesia, and destabilization state in the early postanesthetic period and creates the basis for continuous multimodal postoperative analgesia in combination with nonopioid components (lornoxicam, perfalgan) and with none or minimal need for the injectable opioid. This allows an operated patient to have a comfort and stable state. A further investigation on the comparative assessment of the developed procedure with other variants of perioperative systemic and combined anesthesia-analgesia is to be conducted.

[Lornoxicam (xefocam) as an agent for the prevention and treatment of postoperative pain among other nonsteroidal anti-inflammatory drugs]

Lornoxicam (xefocam) as an agent of perioperative antinociceptive defense was studied and compared with other nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac, ketoprofen). A comparative study was performed in 140 cancer surgical patients who were mainly middle-aged and elderly (51 +/- 10.9 years) and who had various concomitant diseases (ASA II-III). Extensive oncological operations under multicomponent general anesthesia were performed in these patients on the abdomen (n=60), small pelvis (n=46), and head and neck (n=34). All NSAIDs were used on the principle of preemptive analgesia, by intramuscularly injecting the therapeutic dose of an analgesic 40-60 min before surgery and by further continuing this basic therapy in combination with an opioid after surgery. Thirty patients received lornoxicam (xefocam, 16 mg/day), 30 had ketorolac (ketanov, 60-90 mg/day), 30, ketoprofen/ketonal (200 mg/day), and 20 patients, ketoprofen/artrozilene (320 mg/day). A control group comprised 30 patients who did not receive NSAIDs. In the patients of all the groups, the anesthesia scheme included one more antinociceptive agent--the kininogenesis inhibitor contrical (the total dose was 50,000-60,000 ATrU) (beginning from the stage of induction) and its administration (30,000 ATrU/day) was continued within 2 days after surgery. The studies performed have established that lornoxicam (xefocam) used in therapeutic doses shows a 50% reduction (versus 30% when ketorolac or ketoprofen is used) in a need for the potent opioid bepronorfine after extensive operations for cancer is one of the most effective NSAIDs. It has been noted that a short-term course of perioperative therapy with NDAIDs does not cause complications or side effects if individual contraindications to and limitations on their use are followed.

[Perspectives of prevention of postoperative neuropathic pain syndrome in cancer patients]

The paper deals with the anesthesiological problems in the prevention and therapy of neuropathic pain syndrome (NPS), including phantom pain syndrome (PPS) at different stages of surgical treatment in a cancer patient. A prospective study has been conducted; a protocol has been elaborated for the management of patients with preoperative chronic pain syndrome and those at a high risk for NPS after cancer operations associated with damage to nerve structures. A clinical case of successful therapy for severe NPS in a female patient after 4 surgical interventions, including exarticulation of the upper limb, is described. The undertaken prevention of NPS and its treatment policy that is based on the current views of the mechanisms responsible for this type of pain and included, in addition to opioid analgesics, different types of antineuropathic agents, including the recent generation anticonvulsant gabapentin (neurontin), are analyzed and investigated in detail.

[Preparations for peripheral and segmental level protection of the patient in the system of general anesthesia and postoperative analgesia]

The traditional general anesthetics and opioid seem to be insufficient for complete protection of the patient from operative trauma in major surgery. The prospective study has been done in 2 groups of patients undergoing abdominal oncological operations with multimodal general anesthesia based on midazolam, propofol, phentanyl and calipsol in microdose in preventive and postoperative analgesia by ketoprofen in the 1st group (35 cases) and the same general anesthesia in combination with prolonged epidural anesthesia with ropivacaine. Both complete anesthesia and postoperative analgesia have been achieved in each group of the patients, but in the 2nd group the doses of generally introduced analgesics with central action--phentanyl and calypsol--were threefold and twofold less, respectively, and restoration of gastric and intestinal peristalsis was more rapid (1.5 day) vs control group (3.5 days). The importance of using all the mentioned components of anesthesia and analgesia before, during and after operation to prevent the defects of antinociceptive protection and subsequent development of postoperative pain syndrome has been pointed out.

[Use of analgesics with peripheral action in the system of complex protection of the patient from operative trauma]

Obtained for many years experience of perioperative using of analgesics with peripheral effect is summarized. The special scientific analysis was carried out in 274 patients who got different analgesics with peripheral action (aspisol, baralgin, ketoprofen, ketorolak, contrikal) at different stages of preoperative period in combination with opioid. The control group included 30 patients who got monoanalgesia by promedol after abdominal operations. The dynamics of pain, hemodynamics, respiration, gas-exchange, blood coagulation and rheology indices as well as side effects of analgesics were estimated. The best results have been obtained in cases with preventive therapy by non-steroid anti-inflammatory drug 1 hour before beginning of operation and subsequent therapy continuation after operation. Under such conditions complete analgesia after operation with moderate traumaticity is achieved in combination with low dose of small opioid (tramal) in daily dose of 235 mg. The introducing of non-steroid anti-inflammatory drugs was not followed by any hemorrhagic complication, and as was evident from electrocoalugraphic data improved blood rheology. After severe traumatic abdominal or thoracal operations non-steroid anti-inflammatory drugs are used in combination with other potent analgesic with peripheral action--cortical and opioid buprenofine in minimal dose of 0.35 mg/day with good analgesic effect. To prevent the central sensitization during general anesthesia ketamine in microdose 0.5-1.0 mg/kg*hour is always used. The conclusion is made on the important role of multimodal preventive and continuous perioperative antinociceptive protection.

[General intravenous anesthesia with spontaneous respiration for noncavitary interventions in cancer]

Two new variants of total intravenous anesthesia with spontaneous respiration were used in 307 female patients subjected to noncavitary interventions for cancer and gynecological cancer. The patients were divided into 2 groups: 1) total anesthesia with midasolam, fentanyl, and calipsol and 2) the same + propofol. Preventive analgesia by preoperative injections of peripheral analgesics was carried out in both groups. Both methods proved to be effective, ensuring good protection from traumatic noncavitary oncological operations. Balanced anesthesia with two hypnotics midasolam and propofol should be preferred, as they mutually potentiate their effects and therefore can be used in the minimum doses, thus preventing the probable side effects, minimizing the use of central analgesics, and ruling out the probability of respiration depression.

[Preventive analgesia: a new trend in anesthesiology. An idea born and developed at the P.A. Herzen Institute of Oncology]

The authors summarize positive experience gained in the use of preventive anesthesia in oncosurgery. The new trend in anesthesiology has been developed at P. A. Herzen Institute of Oncology since the end of the eighties. A peripheral analgesic (aspisol, ketoprofene, ketorolac, etc.) was added to traditional premedication and anesthesia protocols in 522 patients subjected to extensive cavitary and other than cavitary surgery. Hemodynamic and metabolic parameters, homeostasis, stress criteria (hydrocortisone and glucose), pain intensity according to the verbal evaluation scale were studied at all stages of anesthesia and postoperative period, and side effects of postoperative analgesia were analyzed. Use of nonsteroid antiinflammatory drugs before the intervention and in the postoperative period prevented the development of strong postoperative pain and notably decreased the need in opioid analgesics in the presence of stable homeostasis. No serious side effects of analgesics, including hemorrhagic complications, were observed.

[Possibilities of transcutaneous monitoring of blood gases]

The authors analyze the experience gained in noninvasive transcutaneous monitoring of blood gases ptkO2 and ptkCO2 (MICROGAS device, Contron, France) in 33 oncological patients during surgery with irradiation of the operation wound (n = 13) under conditions of total intravenous anesthesia (TIA) with artificial ventilation of the lungs with a hypoxic respiration mixture (FiO2 10%) and during surgery for breast cancer under TIA with spontaneous respiration (n = 20). Transcutaneous monitoring was found to be a sensitive rapidly reacting method, more informative than pulsed oximetry, for intraoperative hypoxyradiotherapy with long-distance monitoring of a patient; under such conditions it can be the only possible method for monitoring the preset level of pO2. The results of measuring ptkO2 and ptkCO2 are close to the values in the arterial blood.

[Butorfanol tartrate (beforol) in cancer surgery]

The results of the clinical study of beforal (butorfanol) ("Spofa", Czechoslovakia), a synthetic analgetic from a class of opiate agonists-antagonists, in 17 cancer patients at all stages of surgical treatment have been summarized. It has been established that beforal is a potent analgetic analogous in antistressor properties to moradol ("Galenika", Yugoslavia), however differing by a more prompt onset and discontinuation of action, thus improving the control over general anesthesia. A comparative assessment of circulation parameters and stress factors (glucose, cortisol, blood plasma STH) has shown that beforal exceeds fentanyl in the efficacy of prevention of surgical trauma during and after extended cancer surgery.

[Norfin in oncological practice]

A synthetic opiate agonist-antagonist norphin (buprenorphin) has been studied in 297 cancer patients as an analgetic component of general anesthesia, in postoperative analgesia and in the treatment of chronic pain syndrome. In modified neuroleptanalgesia based on norphin, diazepam, droperidol and N2O the patient is more adequately prevented from surgical trauma than in conventional neuroleptanalgesia based on fentanyl. This is confirmed by greater stability in circulation, metabolism and stress hormone parameters, however this anesthesia technique is less manageable and may be accompanied by prolonged postanesthesia depression of the central nervous system. Good results have been obtained when norphin pills were used sublingually for the treatment of long-lasting intensive chronic pain syndrome in incurable cancer patients. Norphin is no less effective than morphin, however, unlike morphin, it causes no severe adverse reactions.

[The new Soviet narcotic analgesic phenaridine as a component of general anesthesia during cancer surgery]

The results of studies on 65 cancer patients operated on under modified neuroleptanalgesia using fenaridine give evidence of a more potent and prolonged analgetic effect of a new Soviet narcotic analgesic fenaridine as compared to fentanyl. Fenaridine ensures stable neuroautonomous protection of the body during cancer surgery and is indicated in prolonged traumatic surgical interventions with cardiopulmonary bypass. Along with the above advantages fenaridine possesses all the complex of side effects typical of opiates associated with the depression of respiratory centres, psychoemotional sphere, activation of parasympathetic centres which may complicate the period following the patient's withdrawal from anesthesia and necessitate prolonged controlled lung ventilation in the early postoperative period. Thus, during 3-5-hour-long surgery it is advisable to administer the basic amount of the overall drug dose during the first 1-1.5 h of anesthesia and surgery, which promotes the awakening of most patients 10-15 min after surgery. Another drawback of fenaridine is the onset of marked rigor and signs of microcirculation disturbances upon discontinuation of the drug effect.

[Synthetic analgesic moradol at various stages of surgical treatment of patients with cancer]

Moradol ("Galenika", Yugoslavia)/butorphanol tartrate ("Bristol--Mayers C.", USA)/, a synthetic analgesic representing a new generation of opiate receptors agonists-antagonists, devoid of any narcogenic potential has been used as the only analgesic at all stages of anesthesia during cancer surgery in 26 patients. For premedication moradol was used in a mean dose of 0.032 +/- 0.003 mg.kg-1 in combination with diazepam (0.153 +/- 0.005 mg.kg-1) and atropine (0.01 mg X X kg-1). For induction to anesthesia moradol was used in a dose of 0.72 +/- 0.003 mg.kg-1 and diazepam in a dose of 0.27 +/- 0.015 mg.kg-1. General anesthesia was maintained with moradol, diazepam, nitrous oxide and droperidol. The data presented in the paper demonstrate the advantages of moradol at all stages of intra- and postoperative analgesia, which ensures stable anesthetic background (according to hemodynamic parameters) and reduces considerably an overall postoperative analgesic dose.