Aim. To study pathological and molecular features of liver metastases of colon adenocarcinoma.
Material and methods. DNA mismatch repair (MMR), CXCR4 expression, Ki-67 proliferative activity were investigated in 125 cases of colon adenocarcinoma with liver metastases. First group consisted of 94 cases of tumor with liver metastases at diagnosis. The second group consisted of 31 cases with stage II disease at diagnosis, but subsequently these patient metastases. In second group KRAS mutation was investigated. The control group included 22 cases of stage II colon adenocarcinoma without disease progression. MMR was studied in 325 cases of colon adenocarcinoma without known stage.
Results. MMR deficiency (dMMR) didn’t revealed in group 1 and 2. The frequency of deficiency MMR in the general population of colon adenocarcinoma was 8%. Low level of expression of CXCR4 in group I and II was revealed in 16% of cases, in control group – in 73%. Low level of Ki-67 was revealed in 5% of cases of liver metastases (group 1 and 2), the frequency of KRAS mutations was 45%.
Conclusion. Colon adenocarcinoma with liver metastases is characterized by aggressive immunophenotype: high expression rates CXCR4, Ki-67, and preferentially retained MMR function.

Aim. To study the capabilities of ¹⁸F-FDG PET/CT in the differential diagnosis of colorectal liver metastases.
Materials and methods. A retrospective analysis of ¹⁸F-FDG PET/CT data of 126 patients with colorectal cancer was carried out. The final diagnosis of colorectal cancer was established based on the analysis of morphological material obtained from the primary tumor. The metastatic or benign origins of the liver foci was confirmed by histological examination or by the results of radiation examination (dynamic observation). Sensitivity and specificity of this method were determined using ROC analysis using the SUV as a numerical classifier.
Results. Colorectal liver metastases were detected in 51 (40.5%) patients. Advanced extrahepatic tumor process was detected in 25 (19.8%) cases. There were no progression in 50 (39.7%) patients. Benign tumors were detected in 22 patients with colorectal cancer: in 10 cases coupled with liver metastases, in 12 – without them. Totally 166 focal liver lesions were found: 125 (75.3%) metastases and 41 (24.7%) benign tumors. According to ROC analysis, sensitivity and specificity of ¹⁸F-FDG PET/CT with SUV ≥ 3.0 in the diagnosis of liver metastases were 84.8% and 97.6% respectively, the area under the ROC curve – 0.893 (95% CI 0.836–0.936 , p < 0.0001), positive predictive value and negative predictive value were – 99.1% and 67.8%, respectively.
Conclusion. ¹⁸F-FDG PET/CT is a highly informative imaging method in the differential diagnosis of colorectal liver metastases larger than 10 mm. The use of quantitative data processing with a threshold value SUV ≥ 3.0 allows to achieve high sensitivity and specificity of the method.

Aim: to improving the treatment outcomes, quality and life expectancy, prognosis in patients with colorectal liver metastases.
Materials and methods. The long-term results of the treatment of 94 patients with colorectal cancer liver metastases (2014–2019) were analyzed. In 87 cases (92.6%) various surgical procedures were performed. Segmentectomy was performed in 23 patients, segmentectomy with radiofrequency ablation – 7, segmentectomy with cryoablation – 3, segmentectomy with radiofrequency ablation and cryoablation – 3. Also, hemihepatectomy was performed in 15 patients, extended hemihepatectomy – 13, hemihepatectomy with radiofrequency ablation – 1. Radiofrequency ablation and cryoablation were performed in 8 cases, transarterial chemoembolization in 12 cases. The average age of the patients was 56.3 ± 3 years. All patients subsequently underwent adjuvant chemotherapy. In 9 case the regional chemoembolization was added.
Results. Postoperative morbidity was 30 cases (34.5%) in the immediate postoperative period. Actuarial survival in the patients undergoing surgery was 1 year – 63%, 3 years – 34% and 5 years – 28%.
Conclusion. A differentiated approach in local destruction of colorectal liver metastases allows satisfactory long-term results in multiple bilobar lesions. The key to success is a multidisciplinary approach to treatment.

Aim. To estimate the effectiveness of intraarterial chemotherapy in treatment of patients with unresectable colorectal liver metastases resistant to systemic chemotherapy.
Materials and methods. Between 2011 and 2018, 64 patients were treated. Previously performed 3–35 cycles of systemic chemotherapy was assessed as ineffective in 58 and discontinued in 6 patients because of grade III–IV toxicity. The most effective cytostatics previously used in systemic chemotherapy was used for intraarterial therapy. In the absence of effective drugs, monotherapy with Mitomycin C was done. For hypovascular metastases hepatic arterial infusion was performed using 4–6 g 5-fluorouracil, 15–20 mg Mitomycin C, 150–200 mg Oxaliplatin or 160–200 mg Irinotecan per cycle. For hypervascular metastases was used oily chemoembolization included selective infusion of suspension consisted of Lipiodol with Mitomycin C 10–20 mg or Irinotecan 160–200 mg or Doxorubicin 50–80 mg followed by occlusion of feeding arteries with gelfoam. Combination TACE + HAI was performed in anatomical variants of hepatic artery.
Results. We performed 238 cycles of intraarterial chemotherapy (from 2 to 16, average 3,7 per patient). There were no major complications and mortality. Progression-free survival after the intraarterial chemotherapy was 11.7 months. The median survival from the start of first cycle of systemic chemotherapy was 22 mo. in group patients with synchronous and 23 mo. with metachronous metastases.
Conclusion. Preliminary results show promising intraarterial chemotherapy for treatment of patients with chemoresistant colorectal liver metastases. The application of the method makes it possible to reduced tumor growth for one year after interruption of systemic chemotherapy.

Aim. To compare survival after open liver resections and laparoscopic liver resection based on the experience of two large Russian surgical centers using the propensity score matching.
Material and methods. The primary point of the study was the assessment of long-term overall and disease-free survival after laparoscopic and open liver resection. The secondary point were immediate outcomes. Propensity score matching was used for balancing covariates and reducing the drawbacks of observational study.
Results. The study included data from 185 patients after 93 laparoscopic liver resection and 92 open liver resection. The immediate outcomes of 176 patients (95%) were analyzed. Long-term results were evaluated in 157 patients (85%) with propensity score based analysis. Forty-three pairs were matched. The blood loss and the hospital stay were less in the group of laparoscopic liver resection before matching. After matching, the blood loss was equal in both groups. The length of hospital stay remained significantly shorter in laparoscopic liver resection group after matching. No differences in severe morbidity was observed between groups. No death was registered after open and laparoscopic liver resection. The overall 5-year survival rate in the laparoscopic and open liver resection groups did not differ before and after matching (56%/68% and 72%/76%, respectively). Disease-free 5- and 4-year survival did not differ either, but revealed the trend to be longer after laparoscopic liver resection before and after matching (52%/10% and 58%/28%, respectively).
Conclusion. Laparoscopic liver resection for colorectal liver metastases reduced the hospital stay. The overall survival of patients did not depend on the type of approach. Disease-free survival discovered the trend to improve after laparoscopic liver resection.

Aim. To improve the results of treatment recurrent colorectal liver metastases after liver resection with its isolated lesion.
Materials and methods. The results of repeated surgical treatment of recurrent colorectal liver metastases in 78 patients were analyzed. Postoperative complications frequency and blood loss was similar during primary and repeated resections. The five-year survival rate after repeated liver resection with reccurens of colorectal cancer liver metastases was 49 ± 9%.
Results. Multivariate analysis revealed 3 predictors of the favorable prognosis of liver resection: removal of all extrahepatic metastases at the repeated resection, radicality of the repeated procedure, chemotherapy after repeated resection.
Conclusion. Long-term results of the repeated surgical treatment of recurrent colorectal liver metastases recognize the feasibility of repeated liver resection in a separate category of patients. The treatment strategy for colorectal cancer liver metastases requires a combined multidisciplinary approach. This approach may include methods of local, regional or systemic antitumor effects in addition to resection, if indications exist.

Aim. To improve treatment outcomes for patients with hepatocellular carcinoma progression after liver transplantation.
Material and methods. Patients with hepatocellular carcinoma progression after liver transplantation (n = 30) were divided into two groups retrospectively. Group 1 included 20 patients who underwent specialized surgical and chemotherapeutic treatment, and group 2 included 10 patients who received palliative care in connection with the advanced of the cancer.
Results. Tumor progression rate was ten times higher in patients with tumors that do not meet the Milan criteria (57.8% vs 5.7%, respectively). Early progression (within 24 months) after liver transplantation was occured in 19 (63.3%) patients. The median overall survival in patients with early and late progression was 17 and 74 months, respectively. Multiorgan metastases were found in 40% of patients. One-, three- and five-year overall survival in the group 1 and 2 were, respectively, 90%, 71%, 50% and 30% and 0%. The median overall survival in the group 1 and 2 was 37.8 and 12 months respectively.
Conclusion. Tumor lesion volume is the determining risk factor for the hepatocellular cancer progression after transplantation. Late disease progression associated with better prognosis. Multidisciplinary approach in treatment of hepatocellular carcinoma progression after liver transplantation significantly improves overall survival.

Objective. Todeterminethe role ofendoscopicultrasonography in preoperative differentialdiagnosis of bilio pancreatoduodenal tumorsand choice of further treatment strategy.
Material and methods. A retrospective analysis included medical records of 89 patients hospital-ized with suspected biliopancreatoduodenal tumor.Pancreatic head tumor was diagnosed in 41(46.1%) patients, tumorof major duodenal papilla – in 15 patients (16.9%), tumor of distal seg-ment of common bile duct – in 10 patients (11.2%), cicatricial and inflammatory strictures of distal segment of common bile duct – in 19 patients (21.3%), post-necroticpseudocysts of pancreatic head – in 4 patients (4.5%).
Results. Sensitivity ofendoscopic ultrasonography for tumors of pancreatic head, major duodenal papilla, distal common bile duct, cicatricial and inflammatory strictures of distal segment of com-mon bile duct and postnecroticpseudocysts of pancreatic head was 90.2%, 100%, 80%, 94.7% and 100%, respectively. Specificity was 97.9%, 94.6%, 98.7%, 98.6% and 100%, respectively. Overall accuracy was 94.4%, 95.5%, 96.6%, 97.8% and 100%, respectively. False-negative results were obtained in 7 cases. Tumor was not excluded in these patients, but there was a conclusion about an-other primary source of growth.
Conclusion. Endoscopic ultrasonography is associated with high accuracy of preoperative differen-tial diagnosis of malignant and benign biliopancreatoduodenaltumors and useful to clarify diagnosis in patients with mechanical jaundice syndrome. These data are usedas an objective criterion to de-termine further treatment strategy depending on the results of endoscopic ultrasonography.

Aim. To identify the risk factors for biliary complications after liver transplantation.
Materials and methods. From December 2011 to September 2017, 85 adult patients underwent liver transplantation. Living donor liver transplantation was performed in 68 (80%) patients, deceased donor liver transplantation was performed in 17 (20%). Whole liver transplantation was performed in 17 (20%), right liver lobe transplantation – 60 (70.6%), left liver lobe – 7 (8.2%), posterior-lateral sector – 1 (1.2%).
Results. Duct to duct anastomosis was performed in 76 (89.4%) recipients, 13 (17.1%) of them developed biliary complications. Double duct-to-duct anastomosis was performed in 5 (5.9%); biliary complications occurred in 3 (60%) of them. Cholangiojejunal biliary Roux-en-Y anastomosis was performed in 2 (2.4%) patients, there were no complications. Combined biliary reconstruction (Duct-to-duct and cholangiojejunal biliary Roux-en-Y anastomosis) was performed in 2 (2.4%), of which 1 (50%) had a stricture of cholangiojejunostomy.
Conclusion. Preoperative and intraoperative examinations of the bile ducts contribute to plan the type of biliary reconstruction. Biliary splinting in duct-to-duct anastomosis reduces the incidence of biliary complications.

Despite the great technical achievements in the field of tomographic examinations (CT, MRI), the problem of differentiation of focal liver lesions cannot always be solved only in a non-invasive way. At the same time, MRI with a hepatospecific agent, gadoxetic acid, can solve many problems, primarily related to the diagnosis of liver metastases and monitoring of nodules in cirrhotic liver.
The aim. To show the advantages of MRI with hepatobiliary MRI contrast agents as the final phase of non-invasive diagnosis of focal liver lesions.
Material and methods. Abstracts of 183 scientific articles (2010–2019) were selected in the PubMed information and analytical system for the keywords “focal liver lesion” and “gadoxetic acid”. Articles about special aspects of MRI examination or general information were excluded. 29 full-text articles were selected for analysis.
Results. The analysis data are grouped in three categories as “diagnosis of liver metastases”, “diagnosis of HCC against the background of normal hepatic parenchyma”, “MRI diagnosis of HCC against the background of cirrhosis”.
Conclusion. The main achievement of MRI diagnostics with gadoxetic acid is the differentiation of small focal liver lesions, including metastases, regenerative nodes, dysplastic nodes, and highly differentiated HCC. This allows you to increasingly avoid invasive methods in the diagnosis of focal liver lesions. Integrated MRI technologies (MRI-DVI and MRI with gadoxetic acid) are currently the most informative, safe and in demand. In MRI with hepatobiliary contrast agents, the intensity of the HCC signal in the hepatospecific phase is considered as an imaging tumor biomarker. Border small liver nodules are usually not hypervascular, they are hypointensive in the hepatospecific phase.

Currently, the strategy for preoperative management of patients with malignant obstructive jaundice is not defined. The indications for biliary drainage procedures, the choice of biliary drainage technique and duration of preoperative drainage are still disputable. Analysis of international trials revealed that routine preoperative biliary drainage procedures are not recommended. The indications for biliary drainage in resectable tumors are determined considering severity of obstructive jaundice, cholangitis, dates of major surgery and Bismuth-Corlette tumor type in case of proximal biliary stricture. The choice of retrograde or antegrade preoperative biliary drainage depends on the type of biliary stricture (distal or proximal) and possibilities of medical institution. The majority of studies showed that retrograde (endoscopic) biliary drainage procedures are preferred for distal strictures, antegrade (transhepatic) – for proximal ones. Duration of preoperative biliary drainage depends on normalization of biochemical values. Prolonged drainage may be followed by increased incidence of early postoperative complications. The optimal period of
preoperative biliary drainage is 2 weeks. It is necessary to determine the causes of obstructive jaundice as early as possible for successful treatment. This is also essential to define optimal treatment strategy in certain case. Advisability and certain technique of biliary decompression should be determined in accordance with the chosen treatment strategy.

Objective. To improve the outcomes in patients with obstructive jaundice by well-timed prognosis, early diagnosis and effective treatment of “rapid” biliary decompression syndrome.
Material and methods. The outcomes in 5792 patients with obstructive jaundice for the period 2007–2018 were analyzed. There were 7179 minimally invasive drainage procedures including 5013 (69,8%) endoscopic transpapillary interventions, 288 (4,0%) percutaneous transhepatic procedures and 1878 (26,2%)combined interventions. Incidence of postoperative complications including “rapid” biliary decompression syndrome and mortality rate were analyzed.
Results. Twelve patients died due to progression of hepatic failure (n = 5) and hepatorenal syndrome (n = 7). “Rapid” biliary decompression in early postoperative period was diagnosed in 11 patients. Clinical and laboratory prognostic criteria and signs of “rapid” biliary decompression syndrome were proposed using calculation of biliary decompression rate and decrease of bilirubin level. A treatment algorithm was developed.
Conclusion. Preoperative biliary drainage in patients with severe obstructive jaundice can result “rapid” biliary decompression syndrome. Clinical manifestations of this syndrome include various symptoms (hepatic failure, hepatorenal syndrome, hepatic encephalopathy and coagulopathy) and their combination that requires emergency management.

Aim. Assessment of the capability of early identification of the bile ducts using near infrared light and fluorescent agent indocyanine green in laparoscopic cholecystectomy in patients with an increased risk of bile duct injury.
Methods. Laparoscopic cholecystectomy using fluorescent imaging system was performed in 16 patients with different risk factors for bile duct injury.
Results. The use of intraoperative imaging in a number of cases facilitated the identification of tubular structures in the Calot triangle and allowed to avoid the conversion.
Conclusion. The first experience of intraoperative imaging of bile ducts using indocyanine green in laparoscopic cholecystectomy indicate that this method can become an important additional diagnostic procedure in patients with an increased risk of bile duct injury. Further research is needed to optimize methods, dosage, time and patient selection criteria.

A 67-yearold woman with acute cholecystitis and choledocholithiasis undergoing cholecystectomy, choledocholithotomy, choledochoduodenostomy by Yurash-Vinogradov is reported. Postoperative period was complicated by biliary peritonitis, bile accumulation under the liver and partial external biliary fistula. The patient underwent a staged x-ray endoscopic minimally invasive treatment including stenting of bile accumulation and the right hepatic duct. Treatment resulted complete recovery. Postoperative follow-up was 2 years, there were no signs of recurrent biliary obstruction. Literature review devoted to iatrogenic injury of the bile ducts and modern approaches to their minimally invasive elimination is presented.

Case report demonstrates long-term recurrence-free survival of a patient who underwent gastrectomy combined with left-sided hemihepatectomy for locally advanced stomach cancer with metastases in the left liver lobe.Aggressive surgical strategy with advanced intervention for metastatic gastric cancer may be justified by the achievement of R0-resection in some cases.