The facial allotransplantation technique was first introduced to the general public in 2005. The definition of the face as a complex system of organs that perform social functions made possible the adaptation of this operation into clinical practice. The year 2010 was the starting point for initial research in the Russian Federation. Based on previous achievements and existing world experience in this field, facial allotransplantation was used for the first time in 2015 in St. Petersburg. The goal of this operation was to reconstruct a soldier’s central facial area after an electric burn; he was injured in the military line of duty. This article describes complications faced regarding the preparation for this operation, the issues encountered for facial tissue removal, as well as donor selection criteria. Each stage of the composite facial allotransplantation, complications that can occur during operation, milestone results, as well as the subsequent rehabilitation and immunosuppressive therapy during the 4-year patient observation period following surgery, including the description of a single episode of cell-humoral rejection of transplanted tissue, are described in detail. The experience gained from the first facial allotransplantation performed in Russia shows the possibility of using a new composite allograft to correct deformities in the central area of the face with the achievement of a successfully functioning and aesthetically pleasing result after the operation. After 4 years of dynamic observation and individual rehabilitation programs, the main goal of the facial transplantation, that is, social re-adaptation of the patient, was achieved.
The aim of the investigation was to assess the immediate and long-term results of the liver transplantation in patients with unresectable hepatic alveolar echinococcosis.Materials and Methods. 22 liver transplantations were performed in the Center for Surgery and Transplantology of the A.I. Burnazyan Federal Medical and Biophysical Center between January 2011 and December 2016 for unresectable liver disease. Liver segments (the right liver lobe in all cases) from living related donors were transplanted to 21 patients, a posmortal donor liver was transplanted to 1 female patient. 16 patients (72.7%) had parasitic invasion of the inferior vena cava. All operations were done in R0 variant. Reconstruction of the great vessels was performed by synthetic PTFE-conduits if autoplasty was not feasible.Results. The duration of surgery was 430 (390-480) min. The intraoperative blood loss amounted to 1,500 (1,300-2,200) ml, cold ischemia lasted 30 (25-45) min. The morbidity rate of postoperative complications made up 45.4%. Biliary complications (Grade A, B, ISGLS, 2011) prevailed. Mortality rate was equal to 4.5%. The length of postoperative hospital stay averaged out to 20 (15-23.5) bed days. Long-term survival rate comprised 100%. Maximal follow-up period was 58 months.Conclusion. Liver transplantation with resection and reconstruction of the great vessels, including resection of the inferior vena cava and even the right atrium, may be the only radical method of treating unresectable hepatic alveolar echinococcosis, making it possible to provide satisfactory immediate and long-term results of surgical treatment of the patients seemingly doomed to death. These interventions should be performed only in highly specialized centers with a developed program of surgical hepatology and liver transplantation.
INTRODUCTION. At the moment, assessing adrenal dysfunction in patients in critical condition and ways to correct this function with hormone replacement therapy are extremely difficult. OBJECTIVE. Analysis of changes in the dynamics of adrenocorticotropic hormone (ACTH) and cortisol levels in blood plasma during extracorporeal membrane oxygenation (ECMO). MATERIALS AND METHODS. The prospective study was performed in intensive care unit (47 patients on ECMO). After connecting ECMO (D0), (D1-D3-D5-D7-D9), and until the completion of ECMO, assessment of cortisol and ACTH levels was carried out. RESULTS. The median level of cortisol in blood plasma was higher in the deceased patients on the third day (D3) (p = 0.05), D7 (p = 0.03); D13 (p = 0.05) and the last day of observation (p = 0.001), respectively. The level of ACTH in the blood of deceased patients was higher immediately on the day of ECMO initiation (D0) and on day 3 (D3) of observation: D0 (p = 0.018); D3 (p = 0.04), respectively. Analysis of the ROC curve showed that cortisol levels show a sensitivity of 71 % and a specificity of 89 % to an adverse outcome during ECMO. DISCUSSION. The life-saving ECMO technique, in critical conditions, is associated with a high risk of increasing of complications, including potentially lethal ones. Critical illness-related corticosteroid insufficiency (CIRCI) clinically manifests itself as inadequate adrenal activity, taking into account the augmentation of the disease severity. This activity is expressed in the form of a decrease in production and/or resistance to endogenous cortisol, as confirmed by the study. Consideration of CIRCI during the usage of ECMO reflects more objectively the violation of the pituitary-adrenal system. CONCLUSIONS. 1. CIRCI is detected in patients during ECMO. 2. High plasma cortisol levels are the predictor of an adverse outcome. 3. The level of ACTH in blood plasma is higher in patients with adverse outcomes. 4. High levels of cortisol in plasma are not a criterion for making the decision to initiate hydrocortisone therapy.
Assessing the viability and monitoring the function of liver graft in the early postoperative period are critical clinical tasks. One possible solution is to determine the changes in concentration of blood glucose, its metabolites and glycerol in the graft using interstitial microdialysis. Objective: to study the dynamics of interstitial glucose, lactate, pyruvate and glycerol in the early post-liver transplant period – depending on the initial graft function (IGF) – and to compare with the results of standard laboratory blood tests. Materials and methods. Four selected clinical observations of deceased donor liver transplantation are presented. Two of the observations showed normal IGF, one observation – early allograft dysfunction (EAD), complicated by hepatic artery thrombosis (HAT), while one observation demonstrated primary non-function (PNF). Collection of microdialysis samples began after arterial reperfusion of the liver graft and continued continuously for 7 days or until death. Standard blood biochemistry and coagulation tests were performed at least once a day. Results. With normal IGF and a smooth postoperative period, interstitial concentrations of glucose, lactate, pyruvate and glycerol remained stable throughout the observation period, ranging from 5 to 20 mmol/L, 1.1 to 7.5 mmol/L, 90 to 380 μmol/L, and 10–100 μmol/L, respectively. EAD was associated with initially higher levels of glucose, lactate, and pyruvate. With HAT development, there was a rapid (within 2–4 hours) five-fold increase in interstitial concentration of lactate with simultaneous decrease in glucose and pyruvate levels to 0.1 mmol/L and 11 μmol/L, respectively. In the case of PNF, there was an initially high concentration of interstitial lactate – 16.4 mmol/L, which increased further to 35.5 mmol/L. Glucose concentration was close to 0. Changes in interstitial glucose, its metabolites and glycerol concentrations chronologically preceded the corresponding changes in peripheral blood composition by 3–5 hours. Conclusion. Microdialysis measurement of interstitial glucose, lactate, pyruvate and glycerol concentrations facilitates real-time monitoring of liver graft viability and function. The high sensitivity of the method could help in accelerating diagnosis of vascular complications (HAT in particular), as well as graft dysfunction with other causes. Therefore, the method is feasible in clinical practice.
Rationale. There have been only single studies conducted in the Russian Federation to characterize the posthumous donor population.Objective: Identifying the main characteristics of the donor pool in N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department and in the State Research Center – A.I. Burnasyan Federal Medical Biophysical Center, FMBA, for the period from 2008–2017.Material and methods. The clinical records of 429 actual and effective posthumous donors were analyzed retrospectively. The following characteristics were studied: gender, age, permanent place of residence, cause of death, the duration of mechanical lung ventilation, type of donation, total number of harvested organs, and number of organs recovered per donor.Results. There were 281 male and 148 female donors. The increase in the mean age of donors from 37 to 48.5 years was noted. Cerebrovascular disease and traumatic brain injury became the main causes of death. Since 2012, the rate of cerebrovascular diseases as the cause of donor death has increased from 30% to 70%. Of 429 actual donors, the brain death was diagnosed in 366 (85.3%). Four hundred eight deceased became effective donors. A total of 1,247 donor organs (744 kidneys, 220 livers, 42 pancreas, 2 intestines, 180 hearts, 58 lungs, and 1 facial vascularized composite allograft) were obtained. The mean number of donor organs recovered per donor was 3.06.Conclusions. The results obtained can be used to develop unified protocols and results of posthumous donors and to assess the possible volume of transplant care. In the period 2008–2017 an increase in the average age of posthumous donors (from 38.1 to 48.7 years) due to the proportion of donors in the 18–29 age group (from 29 to 4%) and an increase in the proportion of donors in the age group over 60 (from 3 to 15%). From 2012 to 2017 (from 68 to 29%) due to an increase in the number of donors who died as a result of cerebrovascular diseases (from 30 to 71%). Among the posthumous donors delivered by ambulance teams directly to the intensive care units, 69% of the consciousness level was depressed to 5 and lower on the Glasgow coma scale.
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