Алтайский государственный медицинский университет, г. Барнаул, РФ 2 Клиническая больница «РЖД-Медицина» города Барнаула, г. Барнаул, РФ Цель: под контролем волемического статуса определить принципы проведения интраоперационной инфузионной терапии у больных морбидным ожирением� Методы: проспективное рандомизированное исследование 60 больных с индексом массы тела 45,57 (40,01; 48,65) кг/м 2 , которым проведена лапароскопическая резекция желудка в условиях сочетанной анестезии на основе низкопоточной ингаляции десфлурана в комбинации с продленной эпидуральной анальгезией ропивакаина� Больным разрешалось употребление 200 мл прозрачной жидкости за 3 ч, а твердойза 6 ч до операции� Пациенты делились на две группы (n = 30) в зависимости от состава инфузионной терапии: в 1-й группе использовали коллоиды (раствор желатина) со сбалансированными кристаллоидами в соотношении 1:1-1,5, во 2-й группе -сбалансированные кристаллоидные растворы� Исследовали показатели гемодинамики, индекс распределения водного сектора (ИРВС), гемоглобина, гематокрита, ионов калия, натрия, креатинина, лактата, кислотно-основного состояния� Интраоперационно проводился PLR-тест� Результаты. Выявлено, что у больных имелось неравномерное распределение жидкости между водными секторами с дефицитом ее во внутрисосудистом русле, о чем свидетельствовал положительный PLR-тест, а также низкий ИРВС� При проведении целенаправленной инфузионной терапии в 1-й группе был использован меньший объем инфузионных растворов, однако это позволило добиться стабилизации гемодинамических показателей за счет перераспределения жидкости между водными секторами, о чем также свидетельствовали изменения лабораторных показателей� Заключение. У больных ожирением имеется внутрисосудистый дефицит жидкости за счет неравномерного распределения между водными секторами� Включение в состав инфузионной терапии коллоидного плазмозаменителя способствует ликвидации гиповолемии и сокращает объем переливаемых сред�

Objective. To analyze the long-term results of the effect of mini-bypass surgery for morbid obesity on the state of carbohydrate metabolism and the dynamics of changes of BMI.Materials and methods. A prospective uncontrolled randomized study was conducted on the basis of the Clinical Hospital ‘Russian Railways – Medicine’ ofCity of Barnaul (Russia), which included patients aged 22 to 56 years with an average body mass index of 45.23 kg/m2 and having a violation of carbohydrate metabolism: 17 patients with an established diagnosis of type 2 diabetes, 20 patients with insulin resistance. Patients with DM were canceled prior to surgery and short-acting insulin preparations were prescribed situationally. Laparoscopic minigastric bypass surgery was performed, for which anesthesia with limited use of opioids was used. Indicators were determined: fasting blood glucose in the pre- and early postoperative period, after 6 months and 2 years, glycated hemoglobin, HOMA-IR index, BMI before surgery and in control measurements.Results. The positive dynamics of the studied indicators was demonstrated in patients with impaired carbohydrate metabolism by the time of discharge from the hospital, which was performed on 4–5 days from the moment of surgery. In most patients, this trend persisted for 2 years after surgery. Positive changes in carbohydrate metabolism occurred against the background of a significant decrease of BMI.Conclusions. Laparoscopic mini-bypass surgery is an effective method of treating morbid obesity with concomitant metabolic syndrome for a long time.

BACKGROUND: The presence of various comorbid conditions in patients with obesity increases operational risk, and high sensitivity to sedatives and opioid drugs can contribute to their aggravation. OBJECTIVE: To compare and evaluate two methods of perioperative analgesia, namely, multimodal without opioid and non-opioid when performing longitudinal gastric resection for patients with morbid obesity using the enhanced recovery after surgery protocol. MATERIALS AND METHODS: A prospective randomized study of patients with morbid obesity was conducted. Depending on the type of analgesic component of anesthesia, the patients are divided into two groups. In both groups, low-flow desflurane inhalation was used; in group 1 (n=30), the technique of non-opioid analgesia was used, which included intraoperative infusion of ketamine, dexmedetomidine, lidocaine, and magnesium sulfate. In group 2 (n=30), traditional combined anesthesia using fentanyl was administered. In the postoperative period, the infusion of the above drugs continued for 10 h in group 1. Central and peripheral hemodynamic parameters, and the depth of anesthesia were studied, and TOF-monitoring was carried out. Postoperative rehabilitation was assessed based on the time of extubation, achievement of 13 points on the PARS scale, first getting up on ones feet, appearance of overstrain, and gas discharge. Postoperative analgesia was assessed on a 10-point visual analog scale, and anesthesia-related complications were recorded. RESULTS: Surgical intervention under low-flow inhalation anesthesia based on desflurane in combination with multimodal opioid-free analgesia reduced the need for opioid analgesics intraoperatively (in group 1, the fentanyl dose was 0.2 [01; 0.2] mg; in group 2 0.4 [0.3; 0.5] mg; p=0.002), provided less fluctuation of intraoperative hemodynamic parameters (AvBP: stage 1: group 1 102 [100; 103]; group 2 102 [98; 105], p=0.96; stage 2: group 1 93 [90; 95]; group 2 96 [93; 99], p=0.003; stage 3: group 1 95 [95; 97]; group 2 100 [96; 102], p 0.001; stage 4: group 1 95 [92; 97]; group 2 98 [98; 101], p 0.001; CI stage 1: group 1 492.2; group 2 49.52.2, p=0.39; stage 2: group 1 44.42; group 2 44.62.1, p=0.26; stage 3: group 1 45.52.11; group 2 50.62.8, p=0.001; stage 4: group 1 44.52.1; group 2 48.82.5 p 0.001), and contributed to a lower level of pain and faster rehabilitation. In addition, anesthesia-related complications such as postoperative nausea and vomiting, hypoxemia, and dysphoria were less frequently recorded. CONCLUSION: The use of multimodal non-opioid analgesia contributes to a lesser fluctuation in hemodynamic parameters, a low level of postoperative pain, early activation of patients and restoration of peristalsis, and a decrease in the number of postoperative complications in patients who underwent longitudinal gastric resection for morbid obesity.

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