Radiofrequency thermal destruction (thermoablation) remains one of the most popular methods of local destruction of liver tumors. There are perennial international experience in oncology, numerous trials and practical issues are rarely discussed. However, there are still strategic questions: when, to whom, in what cases. In fact, specialists recognizing effective impact do not always sure when thermoablation potential will be realized as much as possible. In this review the authors summarized world experience of liver malignancies thermoablation and tried to identify key positions in determining treatment strategy using this approach. Interdisciplinary approach is an absolute priority in optimal treatment of these patients.

Aim. To analyze radiofrequency ablation per se and in combination with other X-ray surgical procedures in patients with liver and bile ducts malignancies. Material and methods. Radiofrequency ablation was used in three groups: percutaneous intervention or in combination with liver resection – group 1 (n = 111); ablation combined with intra-arterial chemoembolization (n = 3) – group 2; RFA followed by right portal vein embolization (RALPPES) in order to induce liver hypertrophy to enable liver resection – group 3 (n = 20). Results. There were no recurrences after radiofrequency ablation. Two-year survival was 55% in patients with hepatocellular carcinoma and liver cirrhosis.Colorectal cancer metastases were followed by 4-year survival near 55%. RFA combined with intra-arterial chemoembolization were associated with complete tumor destruction in patients with hepatocellular carcinoma over 4–5 cm and stabilization in patients with progressive intrahepatic cholangiocarcinoma. Liver hypertrophy was over 50% in two weeks after RALPPES that enables liver resection in 95% of patients. Symptoms of liver failure after hemihepatectomy were not observed in any patients. Conclusion. Combination of interventional methods is able to improve outcomes in patients with liver and bile ducts malignancies.

Aim. To improve quality and duration of life in patients with locally advanced pancreatic cancer. Material and methods. Cryosurgery through laparotomy has been performed in 36 patients with locally advanced pancreatic cancer since 2012. There were 14 (38.9%) men and 22 (61.1%) women (mean age 58 ± 6.8 years). Dimensions of pancreatic tumors were from 4 to 10 cm. Domestic devices “CRYO-MT”, “CRYO-01”, “ELAMED” and cryoapplicators with a diameter 2–5 cm were applied. Target temperature was about 186 °С, time of exposure – 3–5 min. There were 1–5 sessions of cryoablation (mean 2.4) and their number depended on tumor dimensions. Local cryodestruction was supplemented by bypass anastomoses in 18 patients (50%). All patients subsequently underwent adjuvant chemotherapy with additional regional chemoembolization in 10 of them. Results. There were no lethal outcomes during cryodestruction and in postoperative period. Early postoperative complications occurred in 14 (38.8%) patients, severe complications – in 13.6%. Cryodestruction was followed by complete regression (39.2%) or significant improvement (41.6%) of pain syndrome. 6-, 12-, 24- and 36-month survival was 92%, 84%, 48% and 14%, respectively. Median survival was 18.2 months. Conclusion. Cryodestruction is able to improve patients’ quality of life due to reduced pain syndrome in case of locally advanced pancreatic cancer. Certain increase of survival was observed in additional chemotherapy.

Material and methods. Ultrasound ablation has been performed in 165 patients with metastatic liver cancer (metastases of colorectal cancer as a rule) and in 17 patients with unresectable pancreatic neoplasms for the period from April 2009 to December 2017. All patients with metastatic liver cancer underwent previous surgery for primary tumor. In 53% of cases unresectable pancreatic tumor was complicated by mechanical jaundice that required biliary drainage and stenting before ablation. Ultrasound and contrast-enhanced CT were applied to assess changes of tumor dimensions, its structure compared with initial data, vascularization grade, continued growth or de novo metastases with positive changes within destruction area. Percutaneous biopsy of liver and pancreatic tumors was carried out in 136 patients (75%) to assess morphological changes of tumor in pre- and postoperative period. Results. There were no intra – and postoperative complications. Three types of changes occurring within destruction area were revealed. Positive changes including changes of tumor structure, reduced dimensions and volume were observed in 76 (46%) patients. 38 (23%) patients had either augmentation of dimensions and volume of destruction area or appearance of additional tumor tissue on the periphery of metastasis. De novo liver metastases or other distant ones occurred in 51 (31%) patients with positive changes in destruction area. Oncologists of our center evaluated immediate and long-term outcomes of combined treatment. Reduced tumor dimension on the background of mild or absent pain syndrome were confirmed in 12 (72%) patients after ablation of pancreatic tumor. In 8 out of 12 patients weight gain and absent pain syndrome were observed within 48 months. Conclusion. Ultrasound ablation is effective and safe for local destruction of secondary liver tumors and unresectable pancreatic tumors. This approach is indicated for inoperable cases and as a stage of combined treatment.

Aim. To assess overall survival and recurrence-free period in patients with locally advanced pancreatic cancer who underwent irreversible electroporation of the tumor in combination with chemotherapy. Matherials and methods. It was performed a prospective analysis of overall survival in 23 patients who underwent irreversible electroporation of unresectable pancreatic cancer for the period from May 2012 to March 2017. Control group consisted of 35 patients with pancreatic cancer stage III who received standard chemotherapy alone. Results. Mean age of patients was 61 years (range 45–80). All procedures were successful. Fifteen patients had pancreatic head cancer, 8 – cancer of pancreatic body. Preoperative chemotherapy has been applied in 20 (86.9%) patients for 4 months prior to surgery on the average. Seventeen (73%) patients underwent chemotherapy after electroporation procedure. 90-day mortality was 4.3% (n = 1) in electroporation group. Surgery was followed by improved local recurrence-free survival (12 and 6 months, respectively, p = 0.01) and distant recurrence-free survival (15 and 8 months, respectively, p = 0.03). Overall survival was 18 and 11 months, respectively (p = 0.03). Conclusion. Irreversible electroporation of locally advanced pancreatic cancer is safe. Four-month chemotherapy followed by surgical procedure is associated with good local response and better overall survival compared with chemotherapy alone. These data will be validated in further multicenter study.

Aim. To determine the indications for staged treatment in planning of advanced liver resections using SPECT. Material and methods. There were 26 patients for the period 2007–2016 who required advanced liver resections at the surgical clinic of the Botkin Hospital. Anatomic FLR (aFLR) was less than 30% in all cases that is an indication for right portal branch embolization. Two-stage treatment has been applied in 15 patients (group 1) for the period 2007–2014. Preoperative examination has included SPECT since 2015. Indication for two-stage treatment was functioning FLR (fFLR) less than 30% (group 2). The second group included 11 patients. Results. In the first group (n = 15), all patients underwent right portal branch embolization. Nine of them underwent surgery including advanced right-sided hemihepatectomy in 5 cases and right-sided hemihepatectomy in 4 cases.Acute postoperative liver failure occurred in 1 (11.1%) patient (ISGLS class A). In the second group (n = 11) need for portal embolization was determined after SPECT. In 5 patients fFLR was over 30%. Thus, advanced right-sided hemihepatectomy and conventional right-sided hemihepatectomy were carried out in 2 and 3 cases, respectively. Six patients had fFLR less than 30% and two-stage approach was indicated. Five patients underwent radical surgery: advanced right-sided hemihepatectomy and conventional right-sided hemihepatectomy were carried out in 2 and 3 cases, respectively. There were no cases of acute postoperative liver failure and mortality in this group. Conclusion. Preoperative SPECT is able to predict high risk of acute postoperative liver failure after advanced liver resection. Therefore, certain measures for prevention of this complication may be considered.

Aim. To analyze management of severe acute destructive pancreatitis and to determine the main tactical, anatomical and pathophysiological factors determining risks of adverse outcomes. Material and methods. 3581 patients with acute pancreatitis were enrolled. Retrospectively, 239 patients were assigned to severe pancreatic necrosis; invasive surgical techniques were applied in 210 cases. Twenty-nine patients with pancreatic necrosis underwent endoscopic papillosphincterotomy with main pancreatic duct stenting. Results. Overall mortality in patients with severe pancreatic necrosis was 32.3%, in case of minimally invasive techniques – 29.6%, conventional approach – 34.1%. There were similar outcomes regardless surgical technique in patients with pancreatic necrosis (p > 0.05), although introduction of main statements of national recommendations for treatment of pancreatic necrosis (regardless severity) reduced mortality from 25.4% to 9.5% (p < 0.001). Advanced parapancreatitis was accompanied by mortality near 36.5%. Stenting of main pancreatic duct was followed by death of 3 out of 29 patients with pancreatic necrosis (10.3%). Conclusion. Indications and choice of surgical approach according to national recommendations are not accompanied by improved postoperative mortality in patients with severe pancreatic necrosis and multiple organ failure. However, according to analysis on the whole, there is reduced postoperative mortality regardless severity of disease if these recommendations are sustained. Widespread involvement of retroperitoneal structures is adverse prognostic factor. Early endoscopic intraduodenal drainage in effective to prevent parapancreatic tissues.

Aim. To determine the ways to reduce postoperative morbidity and mortality in acute cholecystitis. Material and metods. Retrospective (2013–2014 years) and prospective non-randomized (2015–2016) analysis of outcomes in 804 patients with acute cholecystitis was performed. Analysis was carried out within two periods – before and after acceptance of national clinical recommendations “Acute cholecystitis” (2015). Protocols of diagnosis and treatment developed by our clinic were applied in the first period (2013–2014). 220 patients (group I) underwent surgery in the first period, 290 (group II) – in the second period. Results. There was significantly reduced incidence of conversions for laparoscopic and minimally invasive cholecystectomy from 4.09% to 2.41% (p < 0.05) (OR – 1.724; 95% CI 0.632–4.705). Incidence of extrahepatic bile ducts lesion, postoperative thrombotic, thromboembolic complications, cardiovascular complications (including myocardial infarction) were similar in both groups (p > 0.05) (for cardiovascular complications OR – 0.758, 95% CI 0.047–12.183). There was reduced length of hospital-stay from 11.5 ± 0.8 to 9 ± 0.5 days (p < 0.05). Slight augmentation of postoperative mortality in the second period (from 0.45% to 1.37%) was observed (p < 0.05) (OR – 3.063, 95% CI 0.340–27.599). Conclusion. Reduced number of conversions was predominantly caused by cholecystectomy in patients with milder gallbladder inflammation. It is explained by earlier surgery (within 24–48 h) when severe infiltration of surrounding tissues is absent. Preoperative prolonged medication (3–5 days) aggravates these processes, creates significant intraoperative technical difficulties and increases incidence of conversions.

Aim. To improve outcomes of laparoscopic cholecystectomy in patients with chronic cholecystitis and signs of “nonfunctioning” gallbladder via development of preventive, curative and diagnostic measures. Material and methods. Laparoscopic cholecystectomу was performed in 14 764 patients with chronic cholecystitis. Incidence and causes of intraoperative injury of extrahepatic bile ducts were retrospectively analyzed. Three basic forms of “non-functioning” gallbladder (hydropsy, sclerosis and atrophy, total filling by stones) were. Results. Biliary injury followed by bile leakage occurred in 38 (0.25%) cases. Intraoperative and early postoperative diagnosis was in 11 (28.9%) and 27 (71.1%) patients, respectively. Tangential trauma of common bile duct was found in 3 (7.8%) cases, complete intersection – in 8 (21%) patients. Herewith, 6 of them had sclerosis, 2 – total filling of gallbladder by stones. New diagnostic and curative approach was followed by only 2 (0.04%) cases of early postoperative bile leakage in 2010–2015. Injury of common bile duct was absent within the same period. Sclerosis and atrophy of gallbladder were diagnosed prior to surgery. Conclusion. There are 3 types of “non-functioning” gallbladder with risk of biliary trauma during laparoscopic cholecystectomy. Sclerosis and atrophy of gallbladder are predominantly followed by certain difficulties during laparoscopic cholecystectomy. New diagnostic and curative approach is useful to prevent iatrogenic biliary trauma.

Review is devoted to current problems of classification, diagnosis and treatment of pancreatic neuroendocrine tumors. According to modern views, all pancreatic neuroendocrine tumors over 5 mm or those followed by clinical manifestations are biologically malignant. It is shown that certain proportion of pancreatic neuroendocrine tumors are non-functioning. Diagnosis of neuroendocrine tumors is highly difficult issue. Currently, surgery is only radical and adequate approach for functioning pancreatic tumors. Need to optimize diagnostic and surgical algorithm for improvement of outcomes in these patients is emphasized.

World literature data and our own findings of the influence of biomolecular markers expression on the prognosis of cholangiocarcinoma are analyzed. The most significant adverse predictors are tumorspread grade, positive regional lymph nodes, cell differentiation grade, perineural and microvascular invasion. Epithelial-mesenchymal transition grade is important for tumor progression in patients with portal cholangiocarcinoma and accordingly may be used as a predictor of long-term survival.

Case report of patient with severe autonomous advanced pancreatic necrosis followed by compartment syndrome is presented. Augmentation of intra-abdominal pressure from 18 to 30 mm Hgwas accompanied by aggravation of respiratory, renal and intestinal insufficiency. Urgent video-assisted fasciotomy was applied with dissection of linea alba while peritoneum was preserved. Postoperative period was characterized by reduced intra-abdominal pressure followed by its normalization after 24 hours. Favorable clinical effect was achieved. Subsequent medication was able to avoid surgery and minimally invasive procedures. Patient was discharged after 28 days.