Aim. To investigate the major risk factors and influence of surgical aggression on development of postoperative complications in surgical treatment of patients with liver cirrhosis and portal hypertension.
Material and Methods. Features of early postoperative period in 300 patients with liver cirrhosis and portal hypertension were analyzed. The groups of patients were defined where the influence of various technical aspects of operations on surgical results was studied. Also impact of changes of the main parameters of nutritionally-metabolic status, central and porto-hepatic hemodynamics, tissues’ “oxygen regime” on the development of postoperative complications was
assessed.

Results. An important role in the development of postoperative complications should be assigned to surgical technique, optimal design of the vascular anastomosis and composition of operations on the stomach. Surgery tolerance caused by baseline disease compensation. Surgical aggression reduces the reserve capacity deficit and compensation capacity on average by 10–15%. Under the influence of surgical aggression depending on the type of surgery and the initial severity of chronic liver failure the disorders in nutritionally-metabolic status, central hemodynamics, portohepatic circulation and some parameters of tissues’ “oxygen regime” may occur. Conjugation and mutual influence of “trophic homeokinesis”
violations carrying great responsibility in the development of postoperative complications were revealed. “Trophic homeokinesis” disorganization is the most important tool that provides pathological course of the postoperative period. The hypothesis and the universal scheme of pathogenesis’s common pathways of early postoperative
complications are presented.
Conclusion. Besides surgical techniques postoperative complications in patients with liver cirrhosis and portal hypertension are the result of non-compliance between initial severity of the disease, compensation of liver failure and level of organism’s reserve capacity on the one hand and requirements presented to organism by surgery on the other hand.

Aim. To improve the results of treatment of patients with portal hypertension and bleeding from esophageal and gastric varices by improving diagnostic and treatment tactics.
Material and Methods. It was analyzed the results of treatment of 440 patients with esophageal and gastric varices. In 367 patients portal hypertension was caused by liver cirrhosis and in 73 patients – by extrahepatic portal block. Endoscopic ligation (EL) of esophageal veins is made in 114 patients, sclerotherapy – in 196 patients, endoscopic ligation of stomach veins type I – in 62 cases, sclerotherapy for stomach varices type II – in 44 patients. Splenectomy was performed in 23 patients with isolated varicose veins of the stomach fundus.
Results. Sclerotherapy is the most effective method to stop ongoing bleeding from esophageal and gastric varices among other endoscopic interventions. Delayed endoscopic ligation and sclerotherapy after primary hemostasis by tip-obturator improve the performance of techniques’ application and increase resistant hemostatic effect of sclerotherapy in esophagus from 58.3% to 72.1%, in stomach – from 30.0% to 77.8%; ligation in esophagus from 60.0% to 91.7% and in stomach was 92.9%. In the prevention of recurrent bleeding from esophageal and gastric varices routinely hemostatic effects of sclerotherapy in esophagus was 93.9%, in stomach – 100%; ligation in esophagus – 84.5%, in stomach –
91.7%. Features of the ES in the primary prevention of bleeding from varices limited to the large size of varices and development trophic complications. Endoscopic ligation has advantages in the prevention of first bleeding in esophagus and in stomach. In patients with isolated varices of the gastric fundus preferential treatment is splenectomy. Survival rate and hemostatic effect up to 3 years was 100%.

Conclusion. Presented data indicate the need for detailed diagnosis to make decision about possible endoscopic interventions for different types of varicose veins

Aim. To perform a comparative analysis of the results of portosystemic shunting with other competitive methods in patients with liver cirrhosis.
Materials and Methods. During the period from 1976 to 2015 in the department of portal hypertension and pancreatoduodenal zone surgery conventional portosystemic shunting (PSSh) was performed in 925 patients with portal hypertension (PH). Liver cirrhosis and extrahepatic obstruction caused portal hypertension in 867 (94.3%) and 58 (5.7%) patients respectively.
Results. Three study groups were analyzed: the first group – PSSh implementation phase for the period from 1976 to 1992; the second group – stage of partial shunts implementation (1992–1998); the third group – current stage with the introduction of portocaval drainage restrictions by the original method and the implementation of the TIPS technique (1998–2015). Main complication was fatal liver failure which accounted for over 70% of cases. For the last follow-up
on background of prophylactic hepatopetal flow-preserving bypass immediate postoperative mortality rate decreased to 2.7% in case of central bypass and to 3.9% in the selective decompression.
Conclusion. Traditional selective or partial central portosystemic shunting should be considered as an actual alternative in patients with functional classes A and B if the immediate prospect for liver transplantation is absent.

Aim. To analyze the dynamics of hepatic encephalopathy after transjugular intrahepatic portosystemic shunting (TIPS).
Material and Methods. It was analyzed the results of complex survey of 52 patients who underwent TIPS. Self-expanding stents 8–10 cm, diameter of 8–10 mm and stent-graft were applied for portosystemic shunt creation.
Results. The two main complications of TIPS are hepatic encephalopathy progression and shunt’s malfunction. The
increased degree of portosystemic encephalopathy in 18 months postoperatively was revealed in 3 (10%) patients. Symptoms of encephalopathy were eliminated and did not effect on the patients’ life quality after discharge.
Conclusion. Assessment of encephalopathy’s degree and individual therapy in each patient significantly decrease the severity of encephalopathy postoperatively followed by improved life quality

Aim. To identify the factors of long-term survival in patients with liver cirrhosis after selective and partial portocaval shunts.
Materials and Methods. Different types of portocaval shunts were performed in 221 patients including distal splenorenal anastomosis in 131 (59.3%) cases, partial anastomoses in 83 (37.6%) patients, TIPS in 7 patients. Child-Pugh class A was detected in 28.9%, class B – in 56.1%, class C – in 14.9%.
Results. Postoperative esophageal bleeding occurred in 13 (8.3%) patients. Thrombosis of mesentericocaval H-anastomosis was diagnosed in 6 cases. There were no thromboses of other portacaval anastomoses during the observation period of more than 10 years. Postoperative mortality was 4.1% among patients with Child-Pughclass C. Life expectancy was determined by the degree of hepatic dysfunction. 1-year survival in patients class A was 98.7 ± 1.3%, 3-year – 87.1 ± 3.2%, 5-year – 66 ± 6.8%, 10-year – 34.1 ± 6.7 %, median is 87 months. Survival rates in Child–Pugh class B were lower: 1-year – 86.5 ± 3.5%, 3-year – 67.4 ± 3.7%, 5-year – 46.6 ± 4.4%, 10-year – 23.2 ± 5.6%, median – 64 months (p = 0.01).
Patients of class C had the worst performance (p = 0.001). The Child–Pugh scale was characterized by low predictive accuracy (c-statistic = 0.70). Main predictors of long-term survival were absence of ascites, the portal blood flow > 600 ml / min (c-statistic = 0.81), liver’s volume> 1200 cm3 (c-statistic = 0.80), plasma elimination rate of indocian green > 8% / min (c-statistic = 0.82).

Conclusion. Selective and partial portocaval shunts provide sufficient decompression of the portal system and reliable prevention of esophageal-gastric bleedings. Surgical decompression of portal system based on predictors of survival improves the results of surgical treatment of patients with liver cirrhosis

Aim. To improve the results of treatment of patients with different forms of portal hypertension syndrome (PH) based on introduction of the new diagnostic technologies and differentiated approach to the choice of surgical treatment in clinical practice.
Material and Methods. Treatment of 65 patients with PH for the period from 2006 to 2013 was analyzed. 57 patients (87.7%) had liver cirrhosis, 8 patients (12.3%) – extrahepatic portal hypertension. 37 and 28 patients were operated routinely and urgently respectively. In 28 patients with diffuse parenchymal lesion features of the vascular bed architectonics were studied angiographically. 3D ultrasound investigation of the esophagus and stomach veins was made in 23 patients. 30 patients had the
thermography of anterior abdominal wall.
Results. Vascular architectonics of the liver allows to evaluate the level of vascular compensation and, thus, to predict the
chance of gastro-esophageal bleeding. 3D ultrasonography allows noninvasive patient’s monitoring in the postoperative period, and the thermography gives the objective information about the development of collateral blood flow through the vessels of anterior abdominal wall.
Conclusion. After portocaval bypass surgery performed routinely complications occurred in 27.3% of cases and postoperative
mortality was 4.5%. After esophageal and gastric varices ligation complications occurred in 33.3% of cases, deaths were not observed. In case of emergency surgery complications were diagnosed in 57.1% of cases, postoperative mortality was 35.7%.

Aim. To evaluate the effectiveness of simultaneous combined operations in patients with synchronous metastases of colorectal cancer in the liver.
Material and Methods. Liver resections were performed in 35 patients. 17 patients with synchronous metastases (main group) underwent one-stage combined operations: removal of the primary tumor and liver metastases within single surgical procedure. 18 control patients with metachronous metastases isolated liver resections were performed. Advanced liver resections dominated in both groups.
Results. Postoperative mortality was absent in both groups. The average duration of operation in main group was 230 minutes. Thus it exceeded the same parameter in the control group at 75 minutes. The incidence of complications in the main group was insignificantly higher than in the control due to general surgical complications. Among them postoperative wound suppuration and lymphorrhea dominated. Mean duration of postoperative period in main group
2 bed-day surpassed that in the control group. The median survival in patients of the main group was 37 months, in the control group – 32 months.
Conclusion. One-stage combined operations in patients with synchronous colorectal cancer metastases in the liver is accompanied by an acceptable incidence of postoperative complications and encouraging long-term results and therefore it looks very reasonable and promising

Background. Benign tumors of the pancreas are intraductal papillary mucinous neoplasia, mucinous cystic neoplasia, serous cystic adenoma, solid pseudopapillary neoplasia and endocrine tumors, most frequently insulinomas. The evolution of limited local surgical procedures for benign pancreatic lesions like enucleation (EN), pancreatic middle segment resection (CP) and duodenum-preserving total or partial pancreatic head resection (DPPHRt/p) shifted options of surgical treatment to application of local techniques.

Objectives. Surgical treatment of benign cystic neoplasms and neuroendocrine tumors using local surgical extirpation techniques are evaluated based on present knowledge about indication to surgery, early postoperative complications and late outcome perspectives.
Results. Tumor enucleation is recommended for all symptomatic neuroendocrine adenomas of a size up to 3 cm and non-adherence to pancreatic main ducts. EN was applied predominantly for neuroendocrine tumors and less frequently for cystic neoplasms. About 20% of enucleations are performed as minimal invasive procedures. Surgery-related severe postoperative complications with the need of reintervention are observed in 11%, pancreatic fistula in 33%, but hospital mortality was below 1%. Major advantages of EN are low procedure-related early postoperative morbidity and a very low hospital mortality. CP is applied in two thirds for symptomatic cystic neoplasms and in one third for neuroendocrine tumors. The high level of pancreatic fistula and severe postoperative complications are associated with management of the proximal pancreatic stump. Hospital mortality of 0.8% is a benefit of this procedure. DPPHRt/p has been applied in about 50% as total pancreatic head resection with segment resection of the peripapillary duodenum and the intrapancreatic common bile duct. Two thirds of patients suffered symptomatic or asymptomatic cystic neoplasms and 10% neuroendocrine tumors. Major advantages of local pancreatic head resection compared to Whipple type pancreatico
duodenectomy are highly significant preservation of the exo- and endocrine functions and a low hospital mortality below 0.5%. The level of evidence for EN and CP is low, because of retrospective data evaluation and absence of results from controlled studies. For DPPHRt/p results of 9 prospective controlled studies, 3 case controlled studies and 2 retrospective controlled studies underline the advantages of DPPHRt/p compared to partial pancreaticoduoden ectomy.
Conclusion. The application of tumor enucleation, pancreatic middle segment resection and duodenum-preserving total or partial pancreatic head resection are associated with low level of surgery-related early postoperative complications and a very low hospital mortality. The major advantages of the limited procedures are preservation of exo- and endocrine pancreatic functions and maintenance of peripancreatic GI-tract tissue

Aim. To determine criteria of efficiency, duration and advisability for only minimally invasive treatment of necrotic suppurative complications of acute severe pancreatitis.
Material and Methods. The research is based on results of treatment of 115 patients with necrotic suppurative complications of acute severe pancreatitis. Patients were divided into 2 groups: the first included 33 (28.7%) patients who received conventional operation; the second – 82 (71.3%) patients who underwent primarily minimally invasive interventions.

Results. Postoperative complications were observed in 6 (18%) patients from the first group including arrosive hemorrhage (5 cases), colic fistula (1 case). Mortality rate among patients of moderate severity was 39.3%, in case of severe condition – 36.3%. There were postoperative complications in 19 (23%) patients from the second group including arrosive hemorrhage (5 cases), colic fistula (11 cases) and pancreatic fistula (14 cases). Overall mortality rate was 23%. In the second group mortality was 2 times lower and duration of hospital-stay – about 1.5 times longer.

Conclusion. Minimally invasive techniques under ultrasonic and X-ray control may be always performed in patients with necrotic suppurative complications of acute severe pancreatitis. However in case of intoxication syndrome retention during 20 days postoperatively it is necessary to take decision about adequate necrosequestrectomyusing laparotomy or laparoscopy

Aim. To determine the efficiency of selective vasoconstrictor terlipressin in blood loss reduction during large abdominal
surgery.
Material and Methods. Results of abdominal surgical operations in two comparable clinical groups (1st control group of 30 patients and 2nd research group of 38 patients) in aspect of intraoperative blood loss volume are analyzed. Patients underwent liver resection, pancreatic resection, biliodigestive reconstructive surgery and splenectomy for “huge” spleen. Intraoperative blood loss and some parameters of postoperative period were studied. Patients of the 2nd group received terlipressin (Remestyp®) 1000–3000 μg intravenously in addition to standard surgical procedures to reduce blood loss.
Results. An optimal algorithm of terlipressin (Remestyp®) administration for blood loss reduction during abdominal surgery was determined: 1000 μg for 30 minutes before intervention plus 500–1000 μg during operation and 1000 μg if duration of surgery is over than 4 hours. There is the most demonstrative reduction of blood loss in cases of repeated biliodigestive reconstructions and splenectomy for “huge” spleen – 484.2 ± 36.1 ml vs. 352.8 ± 22.5 ml (р < 0.01) and 560.4 ± 76.2 ml vs. 314.2 ± 38.8 ml (р < 0.01).
Conclusion. Surgical technique is most important factor for blood loss reduction in abdominal interventions. However sometimes intraoperative use of terlipressin is substantively effective. Selective vasoconstrictor-assisted upper abdominal surgery in patients with portal hypertension should be obligatory

It is presented rare clinical observations of diagnosis and success surgical treatment of splenic artery aneurysm. According to results of preoperative complex examination true atherosclerotic splenic artery aneurysm without clinical signs was found out in three cases. False aneurysm was revealed in one patient with acute pancreatitis in anamnesis. Computed tomography, celiacography and endo-ultrasound are the most informative methods in diagnosis of splenic artery aneurysm. Based on the results of above-mentioned procedures it is possible to ensure accurate diagnosis and to ascertain therapeutic approach. Timely surgery makes possible to prevent fatal complications of splenic artery aneurysm

It is presented the clinical observations of various bile ducts diseases including cholangiocarcinoma developed on background of chronic diseases in pancreato-biliary area. Complexities of instrumental diagnosis at early stage of disease are reflected. Probe confocal laser endomicroscopy was first applied to clarify and verify the diagnosis in all cases. Technique of research is described; its results are compared with other diagnostic methods. The authors suggest that in diagnosis of pancreatic and biliary diseases probe confocal laser endomicroscopy may be crucial in case of inefficient or uninformative other methods

It is presented an unusual case of successful angiographic embolization of post-traumatic extrahepatic arterioportal fistula in patient with liver cirrhosis, portal hypertension, recurrent gastroesophageal variceal bleeding despite previous ligation and splenectomy. In 6 months postoperatively anastomosis and signs of portal hypertension were absent. For 5 years postoperatively the patient remained free of disease. Data about etiology, pathogenesis and brief literature review
are presented

The article presents a chronological review of developments in pancreatic surgery. It gives an account of authors, their approaches to the management of diseases of these organs, development and introduction of surgical procedures that represent milestones in the history of hepato-pancreato-biliary surgery

Review on the book: M.V. Danilov, V.G. Zurabiani, N.B. Karpova "Complications of miniinvasive surgery (Surgical treatment of complications after miniinvasive procedures on the biliary tract and pancreas). Guidance for physicians"