Uncomplicated Postoperative Period Research Articles

IMMUNOSUPPRESSION AS A COMPONENT OF MULTIPLE ORGAN DYSFUNCTION SYNDROME FOLLOWING CARDIAC SURGERY

Aim. To defne the role of myeloid-derived suppressor cells in the development of persistent multiple organ dysfunction followed cardiac surgeries with cardiopulmonary bypass.Methods. 40 patients who have undergone cardiac surgery were included in the study. Granulocyte myeloid-derived suppressor cells (G-MDSC) were defned as cells with the HLA-DR– / CD11β+ / CD15+ / CD33+ phenotype, and monocytic MDSC (M-MDSC) as cells with the HLA-DR– / CD11β+ / CD14+ / CD33+ phenotype using flow cytometry. Levels of cytokines, IL-1β, IL-6, TNF-α, and IL-10 were measured with an enzyme immunoassay. All patients were assigned to three groups: Group 1 – patients with the uncomplicated postoperative period (n = 14), Group 2 – patients with non-persistent MODS and its early resolution (n = 16), and Group 3 – patients with persistent MODS at day 7.Results. We observed an increase in M-MDSCs and G-MDSC at day 1 following cardiac surgery. The most pronounced increase was found in monocytic-myeloid derived suppressor cells, i.e. an 8-fold increase in M-MDSCs in all study groups at day 1 after surgery. The number of M-MDSCs remained high in patients with persistent MODS at day 7 after cardiac surgery. Levels of IL-6 and IL-10 increased at day 1 after surgery. IL-6 reached its peak level, signifcantly exceeding baseline levels. By day 7, blood levels of all cytokines have decreased, except IL-10 levels, which remained above the baseline in patients with persistent MODS.Conclusion. An increase in M-MDSCs and elevated serum levels of the anti-inflammatory cytokine IL-10 have been found in patients regardless of the presence or absence of the complications in the early postoperative period after cardiac surgery with cardiopulmonary bypass. Persistent MODS with the SOFA scoring > 5 scores at day 7 after cardiac surgery, is associated with an increase in M-MDSCs and elevated levels of the anti-inflammatory cytokine IL-10, related to higher rate of hospital infections, prolonged intensive care unit stay and higher mortality.

1552P - Characteristics of the psychosomatic state of patients with lung cancer

Background: The important issue of psychophysiological adaptation to malignant process is poorly studied. The aim of the research was to elucidate characteristics of the psychic, adaptive and hormonal status of patients with lung cancer (LC). Methods: Studies were performed in 28 LC patients with receiving surgery and chemoradiotherapy. The patients were divided into 3 groups: 1 - unresectable tumors, 2 - resectable tumors with metastases, 3 - resectable tumors without detected metastases. Personal (PA) and situational anxiety (SA) (Spielberger-Khanin test), depression (Zung test), the types of the mental response to disease (LOBI, Bechterew Institute Personality Inventory) were evaluated. With the help of blood count and the original computer program "Antistress", we calculated the quantitative indicator (QI) of the general nonspecific adaptation reactions of the body (AR) (Garkavi L. H. et al., 1975). Hormone levels of thyroid and pituitary-adrenal (PAS) systems in the blood were determined by electrochemiluminescent method (Cobase 411E). Results: The studied groups did not differ in PA and SA. The signs of tension of the PAS, elevated thyroxine level and decline in the adaptive status were noted. At the same time, QI of AR in patients of the group 3 was 1.8-2.7 times higher than in patients of other groups (p < 0.05). Depression was observed in only one patient. The euphoric type of response to the disease dominated in the groups (39% of cases), the harmonic type was the second most frequent (18% of cases). The patients of group 3 with euphoric reaction (referred to non-rational types of response) were characterized by an uncomplicated postoperative period and the maximal QI of AR in the studied groups, which exceeded by 2 times the indices in the patients of group 3 with harmonic and other reactions (p < 0.01). Conclusions: QI of AR of patients with LC reflected the prevalence of the malignant process. In these patients depression was not expressed, and the euphoric reaction dominated. That could be due to central effects of thyroxin. We assumed that the euphoric reaction in the patients with resectable LC without detected metastases was a favorable diagnostic characteristic. So the questions arise about the clarification of the concept of the euphoric reaction and the ways of its identification. Legal entity responsible for the study: Ministry of Health of the Russian Federation. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Prediction of early postoperative complications of radical cystectomy with different method of urinary derivation through methods of mathematical modeling

The aim of the study was to develop a mathematical model for predicting the outcome of the early postoperative period in patients with musculo-invasive bladder cancer. Materials and Methods.Treatment of 120 patients that underwent open radical cystectomy (ORC) became the basis for the retrospective research with every 3rd patient having postoperative complications. To identify the predictors for the development of intra- and postoperative complications, all patients were divided into two groups according to the Clavien-Dindo classification: the first group comprised 76 (63.3%) patients with uncomplicated postoperative period; the second group included 44 (67.7%) patients who developed complications of various severity and required additional instrumental or operational intraoperative procedures. The value of the diagnostic coefficient (DK) was used to assess the objective parameters studied. The results are based on the method of the inhomogeneous sequential recognition procedure, which is based on the Bayes method. The calculation of the informativeness of both the individual ranges of characteristics and their total informativeness was carried out. Results. 60 indicators were analyzed in both groups of patients, 50 (83.3%) of which were uninformative. It was discovered and statistically confirmed that several factors play a role in the development of postoperative complications. Among them: surgical intervention, where the risk factors are its traumatism and duration (SI = 0.5), the volume of intraoperative blood loss (SI = 0.8), the choice of the method of urine diversion, and the duration of abdominal drainage and the initial nutritional insufficiency (SI = 6.15). The revealed factors of the negative prognosis of the course of the early postoperative period require preoperative correction, which can increase the cohort of patients who will be able to undergo radical surgical treatment of muscle-invasive bladder cancer. Conclusion. The mathematical model for predicting the outcome of the early postoperative period after ORC provides an objective quantitative assessment of the patient’s body parameters, allows for the mutual influence of different parameters on each other, and stratifies each individual patient in the appropriate group of postoperative course. It objectifies the tactics of surgical treatment based on the biological parameters of the patient’s organism on the development of complications of radical cystectomy. Further improvements of the proposed method for predicting postoperative complications of radical cystectomy in the form of computer software will improve the quality and accuracy of decision making in the choice of tactics for treating this category of patients.

Retroperitoneal Pancreas Transplantation With the Use of Duodenal Drainage via “Button Technique”: First Clinical Practice (Case Report)

The persistent relative high incidence of duodenum-associated surgical complications significantly reduces pancreas grafts' (PG) and recipients' survival rates. A 31-year-old female patient underwent retroperitoneal pancreas transplantation with the use of PG exocrine drainage into the recipient's duodenum via the “button technique” approach. An uncomplicated postoperative period with satisfactory function of both transplants (pancreas and kidney) was noted. This was the 1st time ever that the transplantation was performed with the use of retroperitoneal placement of the pancreas transplant and duodenal drainage via the “button technique” approach. It is possible that the absence of the duodenal stump in the donor's transplant has a number of benefits in the postoperative period, which can be confirmed during the follow-up observations.

Radical cystectomy: a comparative evaluation of perioperative outcomes in patients with a complicated and uncomplicated postoperative period

The objective: to evaluate the diagnostic capabilities of general clinical and special methods of patient examination in predicting complications after the radical treatment of bladder cancer. Patients and methods. This study is based on retrospective data from 126 patients who underwent open radical cystectomy (RCE), with one in three patients who had complications in postoperative period. All patients were divided into two groups according to the Clavien-Dindo classification to identify the predictors for the development of intra– and postoperative complications. The first group comprised of 82 (65,08%) patients with uncomplicated postoperative period. The second group consisted of 44 (34,92%) patients who developed complications of varying severity and required additional instrumental or surgical correction. Diagnostic possibilities of indicators of general clinical and special methods of examination of patients, available for quantitative registration, in predicting favorable and unfavorable outcomes and perioperative complications of RCE were evaluated. Results. As a result of the comparative statistical analysis, 33 objective quantitative indicators characterizing the history of the disease and the objective status of patients showed no statistically significant differences. The age of the patients in the first group was on average 60,8±12,8 years and 58,2±9,5 years in the second group, р>0,05. This insignificant difference indicates that the elderly age >70 years, in combination with systemic diseases, limit the possibilities and the volume of surgical interventions. As a result the majority of the sampled patients aged 55–60 years. The average period from biopsy and muscle-invasive bladder cancer (MIBC) diagnosis before the RCE was 53,1±42,7 days in the group with uncomplicated postoperative period and 146,9±94,4 days in the group with complications. The indicator in the second group of patients exceeds the limit recommended by the EAU, where this period is limited to 90 days from the time of diagnosis of MIBC and exceeds the terms by 1.6 times. Conclusions. The absence of statistically significant differences between all indicators in both groups indicates the need to create an algorithm to predict the development of postoperative complications for example – mathematical modeling.

RESULTS OF LAPAROSCOPIC GASTRIC BANDING

The article evaluated safety of laparoscopic gastric banding with alimentary-constitutional obesity, explored a possibility to prevent complications in the late postoperative period, periods of hospital treatment and temporary disability after laparoscopic gastric banding in the uncomplicated postoperative period.

Is the routine use of a water-soluble contrast enema prior to closure of a loop ileostomy necessary? A review of a single institution experience.

BackgroundThe aims of the study were to determine the radiological leak rate in those patients who had undergone a resection for left-sided colorectal cancer and to see if the presence of a leak can be related with the postoperative clinical period. We also aimed to identify any common factors between patients with leak.MethodsA retrospective analysis of prospectively collected data of all patients who underwent a left-sided colorectal cancer resection with formation of a defunctioning ileostomy was undertaken. Between 2005 and 2010, 418 such patients were identified.ResultsA water-soluble contrast enema was performed in 339 patients (81.1 %). Of these, 24 (7.1 %) were reported to show an anastomotic leak. Data for these 24 patients is presented in this study.Twenty-three (95.8 %) of the leaks occurred in patients who had undergone an anterior resection; 95.8 % of the patients with a leak were male. Fifteen (62.5 %) patients underwent neo-adjuvant radiation. The mean length of stay in those patients shown to have a subsequent radiological leak was 18.8 days (median), compared with the overall unit figures of 12 days. Only 29.2 % of the patients who had a leak identified had an uncomplicated postoperative period. Overall 87.5 % of the patients had a reversal of the ileostomy.ConclusionsRadiological leakage is not uncommon. The majority of patients, who were shown to have a radiological leak in this study, were male, had undergone an anterior resection, had received neo-adjuvant radiation, had a longer initial length of stay and had postoperative complications. Water-soluble contrast enemas could be selectively used in patients with these characteristics.

Exercise Training After Lung Transplantation Improves Participation in Daily Activity: A Randomized Controlled Trial

The effects of exercise training after lung transplantation have not been studied in a randomized controlled trial so far. We investigated whether 3 months of supervised training, initiated immediately after hospital discharge, improve functional recovery and cardiovascular morbidity of patients up to 1 year after lung transplantation. Patients older than 40 years, who experienced an uncomplicated postoperative period, were eligible for this single blind, parallel group study. Sealed envelopes were used to randomly allocate patients to 3 months of exercise training (n = 21) or a control intervention (n = 19). Minutes of daily walking time (primary outcome), physical fitness, quality of life and cardiovascular morbidity were compared between groups adjusting for baseline assessments in a mixed models analysis. After 1 year daily walking time in the treated patients (n = 18) was 85 ± 27 min and in the control group (n = 16) 54 ± 30 min (adjusted difference 26 min [95%CI 8-45 min, p = 0.006]). Quadriceps force (p = 0.001), 6-minute walking distance (p = 0.002) and self-reported physical functioning (p = 0.039) were significantly higher in the intervention group. Average 24 h ambulatory blood pressures were significantly lower in the treated patients (p ≤ 0.01). Based on these results patients should be strongly encouraged to participate in an exercise training intervention after lung transplantation.

Mechanisms of Development of Hemostatic Disorders after Liver Resection

Objective: to reveal the mechanisms of development of hemostatic disorders after liver resection. Material and methods. One hundred and twenty cases of liver resections for primary hepatic cancer were retrospectively analyzed. Patients with an uncomplicated postoperative period (Group 1.1), isolated hepatic coagulopathy (Group 1.2), and developed multiple organ dysfunction (MOD) (Group 1.3) were analyzed. The values of hemostasis, hemodynamics, and oxygen status (oxygen delivery, uptake, and utilization) and biochemical and acid-base homeostatic parameters were monitored in these patients twice daily. Results. A significant reduction in Factor VII levels within the immediate hours after surgery was an early hemostasiological marker of the development of hepatic coagulopathy (isolated or as part of MOD). In patients with further evolved MOD, the level of hemostatic system activation markers (fibrin degradation products and D-dimer) was increased from the first 24 postoperative hours, which suggested the development of disseminated intravascular coagulation (DIC) concurrent with hepatic coagulopathy. The development of energy deficiency was at least 24 hours ahead of the clinical manifestation of hepatic coagulopathy and DIC in the patients undergoing liver resection. Hypoxic energy deficiency (the decreased delivery and uptake of oxygen and its higher utilization coefficient, and elevated blood lactate values) was a predictor of the development of isolated hepatic coagulopathy. Further worsening of hypoxic energy deficiency (an increase in blood lactate values and a reduction in venous oxygen saturation) or its transformation to enzyme energy deficiency (lowered oxygen uptake and utilization) was a predictor of DIC development. Conclusion. In the patients undergoing liver resection, the development of energy deficiency is at least 24 hours ahead of the clinical manifestation of hepatic coagulopathy (which evolves in the presence of hypoxic – energy deficiency) and DIC (which manifests in the presence of enzyme energy deficiency). To correct the existing Адрес для к°рреспонденции (Correspondence to): energy deficiency is the key condition to determine the effectiveness of performed hemostasis-modulating therapy. Key words: liver resection, hepatic coagulopathy, disseminated intravascular coagulation, energy deficiency.

Oxidative Stress and Hepatic Monooxygenase Function in Coronary Heart Disease Patients with Multiple Organ Dysfunction

Objective: to study hepatic monooxygenase function (HMF) in cardiosurgical patients with multiple organ dysfunction (MOD). Subjects and methods. Twenty-six patients with MOD signs after operations on the open heart and 29 patients with an uncomplicated postoperative period were examined. The severity of HMF was evaluated by the SOFA scale and HMF was assessed by the pharmacokinetics of antipyrine (AP). Results. Within the first 24 hours after surgery, there were significant signs of MOD and a nearly two-fold reduction in HMF in the study group. A less significant depression of HMF was observed in the control group. On postoperative days 3—4, the total index of MOD noticeably decreased in the study group. There was an increase in HMF in both groups. On days 10—12 after surgery, the severity of MOD distinctly increased in the study group, which was accompanied by a considerable reduction in HMF. In this period, in the control group HMF corresponded to the baseline values. Correlation analysis revealed a direct relationship of the total index of MOD severity with AP Tj/2 and a negative correlation of the number of organ lesions with AP clearance. Conclusion. In cardiosurgical patients, MOD causes a more significant and longer diminution of HMF than in those with an uncomplicated postoperative period. The rate of HMF reduction is directly related to the number of organ lesions and the total index of MOD severity. Key words: hepatic monooxygenase function, multiple organ dysfunction, antipyrine, cardiosurgical patients.

Implication of Acute Lung Injury in the Pathogenesis of Hemostatic Disorders

Objective: to estimate the implication of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in the pathogenesis of hemostatic disorders, by studying the arteriovenous difference between hemostatic parameters. Subjects and methods. Venous and arterial hemostases were studied in 95 patients treated in an intensive care unit. Three groups were identified, which included: 1) 50 patients with an uncomplicated postoperative period and without any organ incompetence; 2) 21 patients with primary lung injury; and 3) 24 patients with secondary lung injury. Groups 2 and 3 patients were divided according to the degree of acute lung injury. Results. The arterial blood of patients with the uncomplicated postoperative period shows a lower coagulability than venous blood; there is no arteriovenous difference between fibrinolytic activity and platelet levels. The coagulation activity of arterial blood increases in primary lung injury; the higher fibrinolytic activity of arterial blood is a compensatory mechanism in moderate lung injury. Later on, in evolving ARDS, the hemostasiological balance between the pulmonary and systemic circulations impairs; disseminated intravascular coagulation (DIC) develops in both arterial and venous beds. Venous blood coagulability increases in secondary lung injury. By regulating the hemostatic system, the lungs produce a lower coagulation activity of and a higher fibrinolytic activity of arterial blood in ALI. With the development of ARDS, this function triples and DIC spreads to the arterial bed. Conclusion. The lung maintains the hemostasiological balance between the pulmonary and systemic circulations, by holding activated platelets and by enhancing the fibrinolytic activity of the blood flowing from it. The inducer of DIC is the suppressed fibrinolysis of the lesser circulation in patients with primary lung injury and hyperco-agulation in the greater circulation in patients with secondary lung injury. Key words: acute lung injury, arteriovenous hemostasis difference, disseminated intravascular coagulation.

A prospective trial of poly-L-lactic/polyglycolic acid co-polymer plates and screws for internal fixation of mandibular fractures

The aim of this study was to test the performance of poly-L-lactic/polyglycolic acid (PLLA/PGA) co-polymer plates and screws in the fixation of mandibular fractures. Following clinical and radiographic examination, internal fixation was achieved with PLLA/PGA co-polymer plates and screws in 31 patients. Elastic maxillomandibular fixation was maintained for 4 weeks and a blenderized diet for 6 weeks. Patients were followed up at 1 week, 6 weeks, and 3, 6 and 12 months post surgery, and evaluated clinically for swelling, pain, mucosal discoloration and occlusal relation. Segment stability, fracture healing and screw-hole ossification were assessed radiographically. Of the 29 patients who completed the trial, 20 had an uncomplicated postoperative period, resulting in complete bone union. Radiographic evidence of screw-hole ossification was noted in several patients, with considerable site-dependent rate variation. Nine patients developed complications ranging from minor dehiscence (4 patients) to frank sepsis requiring plate removal (5 patients), resulting in a 22.5% complication rate. There were no cases of non-union at the end of the fixation period. The reported complication rate following titanium internal fixation of mandibular fractures is 13.7%–43%. PLLA/PGA co-polymer plate and screw fixation of mandibular fractures, although technically more challenging and costly, is a viable alternative to traditional metal devices in selected patients.

Simultaneous Surgical Treatment of Abdominal Aortic Aneurysm (AAA) and Invasive Transitional Cell Carcinoma

A prospective case-control study on simultaneously occurring abdominal aortic aneurysm (AAA) and invasive transitional cell carcinoma of the bladder (TCCB) was carried out to evaluate short- and long-term mortality and morbidity of the one-stage surgical treatment. Methods From January 1995 to December 2000 16 patients presented a concomitant AAA and TCCB. A standard operative protocol included AAA graft replacement before bladder resection and urinary reconstruction. Control patients (16 AAA and 16 TCCB alone) matched according to time of intervention, type of vascular and urinary procedure and pathologic staging. Results No vascular complications and graft infections were observed. Systemic and urologic complications were similar in study and control groups. One patient simultaneously treated for AAA and TCCB died of MI 32 days after surgery after an uncomplicated postoperative period. Estimated 6–year survival rate was 68% in AAA and TCCB patients simultaneously treated, 93% and 54% in matched control patients undergoing AAA and TCCB treatment alone respectively. Conclusions The present study shows that the one-stage is a safe approach to simultaneous occurring AAA and TCCB. Long-term survival of treated patients is dependent upon cancer progression. Whenever endovascular treatment is not advisable, the simultaneous surgical treatment of coexisting AAA and TCCB is recommended in highly specialized centers.

Complete Sternal Cleft In Adolescence

Introduction: We report a complete sternal cleft associated with pectus excavatum who underwent successsful surgical repair of the sternal anomaly by direct approximation of the freshened sternal remnants to the midline. Case Report: A 13-year-old girl presented with a complete sternal cleft since birth, causing a cosmetic concern and constant fear of trauma. Physical examination was measured 4 cm wide at proximal and 1 cm wide at distal sternum, and pectus excavatum. Anaesthesia was induced with fentanyl 2 microg/kg, thiopenthone 6mg/kg and vecuronium 0,1 mg/kg and maintained with 50 %O2N2O and sevoflurane 1,5-2.0 %. Heart rate, ECG, arterial blood pressure, central venous pressure, SaO2 and arterial blood gases were monitored. After an uncomplicated postoperative period, the patient was discharged. Conclusion: Our effort was to preserve the normal anatomic and mechanical function of the thoracic cage as well as to achieve proper closure of the defect while protecting the heart and great vessels without using any synthetic material, with good cosmetic results.

Extrafocal osteosynthesis in open crus fractures

The purpose of this study was to compare the treatment of open crus fractures with pin (116 patients) versus rod (107 patients) extrafocal fixation devices. In all cases primary osteosynthesis was performed within the first hours after trauma. Authors consider that choice of extrafocal fixation technique depends on the pattern of open fracture. Rod fixation is preferred in simple or wedge fractures. Pin fixation provides better outcome in all types of comminuted shaft fractures. Rod fixators are of more simple design than pin ones and it takes less time to handle with them. Uncomplicated postoperative period was noted in 179 patients (80.3%) out of 223. Purulent complications were in 16.5% of cases (5.8% of cases in rod fixation, 10.7% of cases in pin fixation). The rate of other complications was 3.2%.

Preoperative antioxidant and allopurinol therapy for reducing reperfusion-induced injury in patients undergoing cardiothoracic surgery

Administration of vitamin E, vitamin C, and allopurinol to reduce reperfusion-induced injury remains controversial. Clinical trials are being conducted, and the results are promising. No adverse side effects have been reported with the short-term use of these drugs. The cost of the pre-operative medication is approximately $5 per week, which favors its use. The ability of nurses to be effective advocates of patients receiving these drugs is vital. What appears to be a trivial medication regimen may save myocardial cells and promote an uncomplicated postoperative period.

Operationen mit der Herz-Lungen-Maschine bei erwachsenen Patienten der Glaubensgemeinschaft ?Zeugen Jehovahs?

Members of Jehovah's Witnesses refuse blood transfusions and blood products under any circumstances. Because of an improvement in blood salvage techniques in our centre, they are not excluded from open-heart surgery. In recent years recombinant human erythropoietin (rhEPO) has been applied to correct perioperative anemia in these patients. METHODS. Seventeen members of Jehovah's Witnesses who were more than 18 years of age were operated on using various blood salvage technique, e.g., haemoseparation and a high dose of Aprotinin. We present the first three patients treated with 4 x 500 U of i.v. rhEPO/kg body wt. given within 11 days preoperatively. Thirteen of the patients operated on had elevated preoperative risk factors, for instance poor left ventricle, severe aortic valve stenosis, metabolic syndrome, age older than 70 years, etc. In other centres that perform cardiac operations on members of Jehovah's Witnesses, these risk factors represent contraindications for open-heart surgery in these patients. RESULTS. Patients with rhEPO treatment showed a preoperative hematocrit increase of 7 Vol.% within 10 days and no postoperative complications. At the 6th postoperative hour the hematocrit returned to the starting values; in patients without rhEPO, however, the hematocrit generally had not increased to preoperative values even by the 8th day after operation. In 9 patients with preoperative elevated risk factors and a postoperative relative decrease in hematocrit below 33% we observed an uncomplicated postoperative period. Four patients with these risk factors, a pronounced decrease in hematocrit and blood loss postoperatively had various severe complications. CONCLUSIONS. Preoperative treatment with a high dose of rhEPO to enhance the hematocrit and maturity by precursor red blood cells in patients with a hematocrit below 45 Vol.% is a possibility to compensate for the blood loss perioperatively and to avoid complications from a decrease in oxygen transport capacity. The anaemia and high blood loss postoperatively are the main causes for a slightly elevated operation risk in members of Jehovah's Witnesses in all heart centres that perform cardiac operations on these patients. Nevertheless, Jehovah's Witnesses should be not excluded from cardiac operations, since open-heart surgery without use of homologous blood is becoming a routine procedure.

Metabolic studies following thoracotomy for lung cancer with particular reference to postoperative atrial fibrillation.

Atrial fibrillation has proved to be a frequent complication after thoracotomy for lung cancer. In order to study the possibility that metabolic changes are the trigger mechanism of these arrhythmias, free fatty acids (FFA), glycerol, triglycerides, serum insulin and glucose were determined pre- and postoperatively in patients both with and without this postoperative complication. In the primary series of patients, FFA were found to be increased immediately after the start of the atrial fibrillation, partly in relation to the morning values and partly to the 24-hour curve. This is a possible expression of an increased lipolysis in a causal relationship to the arrhythmia. In another series of patients, the degree of lypolysis was demonstrated using the glycerol values. With this method, no signs of increased lipolysis were found in connection with the onset of atrial fibrillation. Thus, changes in the lipoid metabolism were not found to be the trigger mechanism of the postoperative atrial fibrillation. Reduced values of serum insulin and glucose were not demonstrated either during the uncomplicated postoperative period or at the start of atrial fibrillation.

Spontaneous rupture of choledochus

The author describes 2 cases in which, 5-8 weeks after choldochotomie with drainage and an uncomplicated post-operative period, the choledochus at the drainage site ruptured and bile peritonitis developed.