Aim. To analyze of the optimal time of surgical treatment of acute cholecystitis based on the results of evidence-based studies of domestic and foreign clinical guidelines.

Materials and methods. A review has been conducted based on an analysis of the clinical recommendations of the Russian Federation and other countries and meta-analyzes of clinical trial, published since 2015.

Results. The surgical method is the main treatment approach of acute cholecystitis both in our country and abroad. Possible differences in assessing the results of surgical interventions are due to different ways of determining the time to perform the surgery (report from the onset of the disease, from the diagnosis, and also taking into account the time of hospitalization).

In the majority of the world evidence-based studies early cholecystectomy have been defined as a surgery within 3-7 days after onset. The expediency of performing early operations with a persistent attack of acute cholecystitis is due to the inability to control the course of gallbladder's inflammation, the shorter duration of hospitalization and cost-effectiveness advantages.

Conclusion. In clinical practice, taking into account the heterogeneity of the patient population with acute cholecystitis and various conditions for the provision of surgical care, early operations within the first three days from the onset of symptoms remains preferred.

Aim. To develop rational surgical tactics for the treatment and prevention of bile duct lesions in patients with acute calculous cholecystitis.

Materials and methods. The results of examination and surgical treatment of 1,645 patients with acute calculous cholecystitis at the second and third levels of medical care were studied. The results of diagnostics and elimination of the bile ducts injuries in 21 patients who developed during laparoscopic cholecystectomy for acute cholecystitis in second-level medical institutions were analyzed. Integrative assessment of the examination results is based on taking into account the results of laboratory and instrumental examination. Based on the analysis, a rational treatment strategy for this category of patients was formed and tested.

Results. The main factors that influenced the occurrence of bile duct injuries were: performing the operation in an inflammatory infiltrate and within 72 hours of the onset of the disease, intrahepatic location of the gallbladder, male gender and age over 63 years (p ≤ 0.05). The provision of assistance in case of complete damage to the main bile ducts in medical organizations of the second level should be completed by performing external drainage with further evacuation of the patient, after stabilization of his condition, to medical institutions of the third level. Partial common bile ducts injury can be eliminated by performing restorative suturing of the defect of the common bile duct the T-drainage at all levels of healthcare organization. It was clarified that patients with acute cholecystitis Grade I are shown timely laparoscopic cholecystectomy within 72 hours from the onset of the disease. For patients with acute Grade II cholecystitis complicated by inflammatory infiltrate, without signs of destruction and blockage of the gallbladder at all levels of medical care it is advisable to conservative treatment, surgery after 3 months. With the progression of endogenous intoxication with destruction of the gallbladder, cholecystostomy is advisable. Patients with acute grade II cholecystitis and complicated course who are being treated in a second-level medical organization, are shown to be transferred to a third-level medical organization for endoscopic intervention on the duodenal papilla.

Conclusion. Implementation of the proposed surgical tactics for patients with acute cholecystitis allows performing timely and rational surgical intervention, increasing the effectiveness of treatment, reducing the number of postoperative complications and mortality.

Aim. To analyze the results of treatment of patients in the general network of level 2 surgical hospitals for compliance with the main provisions of the Tokyo Guidelines (2007—2018) and the National Clinical Recommendations of the Russian Society of Surgeons “Acute cholecystitis” (2015).

Materials and methods. A database of the results of surgical treatment of 754 patients with acute cholecystitis at 8 hospitals that function as hospitals of the 2nd level in Moscow, Yekaterinburg, Volgograd and Kislovodsk was formed and analyzed. As additional criteria, the Cushieri scale and the Integral Complications Severity Index (ICSI) developed by the authors on the basis of the “Accordion” classification were used.

Results. Activation of surgical tactics up to 4—6 hours of observation and refusal to management clearly destructive and obstructive forms of acute cholecystitis of mild and moderate severity is an effective way to improve treatment results. The advantage of the combined use of 3 main methods of cholecystectomy in the general network of surgical hospitals has been proven. Early laparoscopic cholecystectomy turned out to be preferable, being undertaken in a timely manner and with a mild course of cholecystitis, as well as under favorable local conditions in a number of patients with a moderate course of the disease. The mini-access cholecystectomy is safer in anatomically more complex situations. The results of interventions performed from a wide laparotomy were the least favorable. An increase in the frequency of “difficult” cholecystectomies is shown 60 hours after the onset of the disease with mild cholecystitis and 36 hours after acute cholecystitis of moderate severity. With the modern level of technical equipment, it is advisable to perform intraoperative cholangiography in all patients with an average probability of cholangiolithiasis.

Conclusion. The most promising trends in the assistance of emergency surgical care to patients with acute cholecystitis are the activation of surgical tactics, the differentiated use of the entire spectrum of minimally invasive technologies by multidisciplinary teams working around the clock. Their implementation requires the enlargement of hospitals, appropriate material and technical re-equipment and training of personnel with the development of related professional skills. Small surgical hospitals with a limited list of modern surgical technologies need to create special treatment and diagnostic algorithms that can improve the results of their activities.

Objective. To determine the need and role of transpapillary endoscopic interventions in acute cholecystitis complicated by the main bile ducts pathology based on refined diagnostics using modern radiology examination methods.

Materials and methods. The experience of treatment of 1137 patients operated on for acute cholecystitis during the last three years was analyzed. A differentiated approach for the use of highly informative methods of radiology diagnostics was based on clinical, anamnestic, laboratory and ultrasound data. In the selected groups of increased risk of bile duct pathology, endoscopic ultrasonography and magnetic resonance cholapgiopancreatography were used to clarify the diagnosis. The need for these studies was substantiated in 23.4% of cases. Based on the data obtained, indications for minimally invasive interventions aimed at decompression and correction of pathological changes in the biliary tract were formulated. They were performed in 182 (16%) patients, mainly by the endoscopic transpapillary route. Results. The need for a detailed assessment of clinical, laboratory, and ultrasound data is shown, indicating a possible biliary tract pathology and justifying the use of high-tech methods of radiology diagnosis. The options of decompression interventions, their rational sequence and combinations in acute cholecystitis complicated by bile ducts pathology are considered. Attention is focused on the need for careful monitoring of the effectiveness of interventions with a view to timely correction. Using the proposed diagnostic and treatment algorithm, the mortality rate was 0.26%.

Conclusion. In acute cholecystitis, a detailed assessment of clinical, laboratory, and ultrasound data allows us to identify the “alarming” symptoms of a possible bile ducts pathology. These patients require an in-depth assessment of the state of the biliary tract using high-tech non-invasive diagnostic methods — endoscopic ultrasonography or magnetic resonance cholangiopancreatography. The detected changes (choledocholithiasis, stenosis of large papilla of the duodenum) should be eliminated by endoscopic transpapillary interventions as the first stage of treatment before removal of the gallbladder.

Aim. To compare clinical, ultrasound and morphological data in the treatment of patients with acute cholecystitis based on the recent recommendations and personal experience in the treatment of acute cholecystitis.

Materials and methods. For 18 months 2019—2020 of 219 patients with acute cholecystitis, 118 (53.8%) underwent surgical treatment. There were 36.4% of men, 63.6% of women; age ranged from 23 to 82 years. Patients of employment age accounted for 61.8%. According to generally accepted recommendations, all patients were divided into groups according to the severity of the disease. The severity of the disease was G1 in 66 patients, G2 — in 52. A retrospective expert assessment of clinical, ultrasound and morphological data was carried out. The histopathological assessment of inflammatory and destructive changes was performed according to the national and international classification, taking into account the depth of the lesion of the gallbladder wall (A.1, A.2).

Results. In 118 operated patients G1 and G2, the coincidence of clinical, anamnestic and morphological data according to the classification of A.1 and A.2, excluding ultrasonography data, was observed in 58 (49.2%) patients: A.1 (necrosis of the gallbladder mucosa) was revealed in 34 patients, A.2 (necrosis of all walls) — in 24. The addition of ultrasonography results in the expert assessment of the “depth” of necrosis made it possible to confirm the data on mucosal necrosis (A.1) in 57 (86.4%) patients and destruction of a deeper muscle-serous layer (A.2) in 31 (59.6%). The modern diagnosis, taking into account clinical and laboratory data and ultrasonography results, should combination of the definition of the disease, the etiological factor (calculous, emphysematous and acalculous), the severity of the course (G1—G3) and the depth of histopathological changes (A.1—A.2).

Conclusion. The results of palpation, the duration of the disease, the level of leukocytosis and the nature of body temperature in acute cholecystitis make it possible to establish the severity of the course of the disease (G1—G3). Ultrasonography in acute cholecystitis can confirm the diagnosis with a high probability of determining the depth of destruction (inflammation) of the gallbladder wall (A.1, A.2). Histopathological examination of the gallbladder in acute cholecystitis should reflect the depth of destruction (inflammation) of the gallbladder wall A.1 or A.2. The terms “catarrhal”, “phlegmonous”, “gangrenous”, “perforated” are not fully determine the essence of the pathological process. To determine the treatment tactics, the diagnosis should include the severity of the disease (G1—G3) and the depth of destruction (inflammation) of the organ wall.

Aim: to improve the results of surgical treatment of patients with acute cholecystitis due to the widespread introduction of early laparoscopic operations, reduction of indications for conservative treatment and decompression puncture methods.

Material and methods. This paper summarizes the experience of treating 3140 patients with acute cholecystitis, who underwent laparoscopic cholecystectomy. The author adheres to active surgical tactics — laparoscopic surgery in the first 2—15 hours from admission in the absence of absolute contraindications to the pneumoperitoneum.

Results. The technical features of laparoscopic operations for various forms of acute cholecystitis are considered. The reasons for the unsatisfactory results of surgical treatment of the disease are discussed — late hospitalization and the use of ineffective conservative therapy.

The negative consequences of multi-stage acute cholecystitis treatment methods are reflected. The algorithm of early radical surgical intervention was determined. The nature of inflammatory changes in the gallbladder wall and nearby space tissues, as well as the adhesions in the abdominal cavity, did not influence the decision on the timing of the operation and the choice of method.

Conclusion. Thus, radical surgery in the laparoscopic version in the vast majority of patients with destructive cholecystitis, in the shortest possible time from the onset of the attack or admission to the hospital, should be considered as a “surgery of choice”, accompanied by a minimum number of complications.

Purpose. To assess the liver density according to the data of native CT studies in patients with COVID-19, depending on the severity of the pulmonary parenchyma damage and the prescribed treatment, to compare the data with biochemical indicators, and also to demonstrate changes in density indicators over time.

Material and methods. Lung CT data from 200 patients with COVID-19 were retrospectively analyzed. The density of the liver, spleen, and subcutaneous fat tissue was measured in all patients on the images of the upper abdominal cavity that entered the scan area. The ratio of the density of the liver to the spleen and to the density of the fat tissue was assesed. These indicators were compared with each other in two groups of lung tissue damage: CT 1—2 and CT 3—4. The CT 3—4 group was assessed in detail: the density indicators of the liver were studied in dynamics, and their relationship with biochemical indicators — during the initial study. A comparison was also made between two subgroups: patients taking tocilizumab and those without tocilizumab.

Results. A decrease in liver density and the ratio of liver density to spleen density was observed in 35.5% and 47.5% of patients respectively. Liver density and the ratio of liver density to spleen density were lower in the CT 3—4 group than in the CT 1—2 group, and amounted to 43.9 HU versus 49.3 HU (p < 0.008) and 0.9 versus 1.0 respectively (p < 0.014). In the initial study, there were a moderate (r = -0.30; p < 0.05) and weak (r = -0.26; p < 0.05) negative correlation of liver density and the ratio of liver density to spleen density with serum albumin. When assessing the dynamics in patients in the CT 3—4 group, with each subsequent study, an increase in the density of the liver parenchyma and the ratio of liver density to spleen density was noted. The difference between the mean values of liver density at the first and at the fourth CT examinations was 11.85 HU. Liver density values were independent of treatment with tocilizumab.

Conclusion. Liver density values were lower in patients with COVID-19 with the degree of lung parenchyma lesion CT 3—4, increased during treatment and did not depend on the prescription of tocilizumab. Evaluation and monitoring of the dynamics of liver density could become a useful parameter in determining the severity of the disease course. No strong relationships were found between the density parameters during primary CT and any of the biochemical parameters. A more detailed analysis of these changes in dynamics is required, which may suggest the prevailing mechanism of liver damage in COVID-19.

Aim. To study the possibility of using radiological interventions in the staged treatment of intraoperative bile ducts injury and the prevention of biliodigestive anastomotic stricture.

Materials and methods. A retrospective analysis of the treatment of 20 patients with “large” (classes B—E) iatrogenic damage to the extrahepatic biliary tract was performed. In all cases, percutaneous transhepatic cholangiostomy was performed before reconstructive Roux-en-Y hepatico- or bighepaticojejunostomy. Biliary drains installed before surgery were retained to control the anastomosis in the early postoperative period, as well as for 6 months for possible correction of the forming narrowing. Preoperatively established biliary drains were retained to control the anastomosis in the early postoperative period, as well as for 6 months for possible correction of the anastomotic stricture.

Results. In 2 cases with a B-class injury, it was possible to restore the patency of the common hepatic duct by balloon dilatation without subsequent reconstructive surgery. Roux-en-Y hepatic or (bihepatico)-jejunostomy was performed in 18 patients. In 10 cases antegrade interventional radiological reconstruction of the common bile duct was performed on the external-internal drainage, including 4 cases with partial excision of the common bile duct (class E). Temporary (6 months) antegrade stenting of the partially excised right lobe duct and the confluence zone was performed in 2 cases with trauma classes D and E. There were no lethal outcomes or complications of interventional radiological surgery. Narrowing of the anastomosis was avoided in all patients. The follow-up period varied from 6 months to 13 years.

Conclusion. Regardless of the period of detection of biliary tract injury in the postoperative period, tactics of stage treatment, involving the drainage of the biliary tree, with subsequent endoscopic or radiologic intervention, are advisable. Percutaneous biliary drainage in case of “large” iatrogenic injuries of the bile ducts in the postoperative period makes it possible to control biliodigestive anastomosis, timely detect and adequately correct its stricture.

The presented review of literature reflects the endocrinological aspects of patient management after total duodenopancreatectomy without в-cell transplantation in the immediate and late postoperative period. Peculiarities of carbohydrate metabolism after total duodenopancreatectomy require other approaches and methods of correction. Mortality in specialized centers in the last decade is <3—5%. The largest number of life-threatening complications occurs in the early postoperative period and remains high (49% and higher) despite the observance of international treatment standards, starting from the intensive care unit. In the early postoperative period, imitation of insulin secretion from a healthy pancreas is of particular importance.

The use of devices of the “closed loop” type after total pancreatectomy made it possible to identify the required dose of short-acting insulin (100-200 units per day intravenously) to maintain plasma glucose in the range 4.4—7.7 mmol/l, ensured patient safety, and reduced the number of surgical complications. Individually selected insulin therapy, enzyme replacement therapy and balanced nutrition in the long-term postoperative period provide patients who have undergone total duodenopancreatectomy an acceptable standard of living comparable to the quality of life of patients with type 1 and type 2 diabetes.

The article presents an analysis of the results of the three most important international consensus conferences on the development, dissemination, assessment of the efficacy and safety of laparoscopic liver resection (2008, 2014 and 2017). An analysis of world experience has demonstrated the slow but steady diffusion of the new technology.

It is proved that the immediate outcomes of laparoscopic liver resection are superior to those for open resections, and the long-term results do not differ in the treatment of the most common oncological and benign liver tumors in selected patients. Unlike laparoscopic surgery of other organs of the abdominal cavity, many issues regarding the technology, safety and reproducibility of the operation did not receive a final solution due to the slower data set and other objective obstacles associated primarily with the complexity of the surgical anatomy of the liver. In this regard, a clear achievement of the expert's work should be considered a clear definition of the strategy for mastering the technology of laparoscopic liver resection, as well as selection of patients to avoid serious errors and discrediting the method. All conferences remained in line with the initially emerging trends, adding more evidence-based research to confirm and refine the capabilities of the technology. There is still a shortage of prospective randomized trials and large national and international registries. Further analysis of experience in this direction will allow us to correct the previously obtained data and more clearly indicate the role and place of laparoscopic liver resection in the arsenal of methods of modern surgical hepatology.

This article demonstrates a review of scientific works enlightened to combined treatment options for common bile duct cancer patients. The role of adjuvant therapy is highlighted. It has been shown that only capecitabine can be routinely prescribed in the postoperative period: median survival rate in general group of patients consisted 51 month versus 36 month in control group, (p = 0.028). Neoadjuvant chemotherapy for common bile duct cancer patients is still less studied and the research works results are mostly negative. At present, preoperative chemotherapy for patients with primary resectable tumors should not be applied currently excepting the scientific research protocol boundaries. A new chemotherapy regimen including gemcitabine, cisplatine and nab-paclitaxel has appeared which demonstrates a partial response to therapy reaching 45% for the patients with unresectable biliary cancer. The data of the retrospective study showing the positive role of neoadjuvant radiotherapy combined with gemcitabine: 70% of patients had a partial response as well as reliable improvement of recurrence-free (p = 0.0263) and overall (p = 0.00187) survival rates was observed compared to the group of patients who had no neoadjuvant therapy. The necessity of search for new additional treatment options for the common bile duct cancer patients in preoperative and postoperative period leaves no doubt.

Intraductal papillary mucinous neoplasm (IPMN) and solid pseudopapillary neoplasm (SPN) are rare tumors of the pancreas. The combination of these two pancreatic neoplasms is extremely rare. Case of synchronous solid pseudopapillary neoplasm of the pancreatic tail and intraductal papillary mucinous neoplasm of the pancreatic head associated with ductal adenocarcinoma is presented. Pancreatoduodenectomy with resection of the pancreas body, resection of the mesenteric-portal trunk, distal pancreatectomy, splenectomy was performed. Thus, part of the pancreatic tissue was preserved, which allowed to avoid pancreatic insuffiency.

A clinical case of successful surgical treatment of a patient with recurrent bleeding from vascular malformations of the duodenum is presented. Attention is focused on the difficulties of diagnosis and the choice of treatment tactics in such patients. Surgery should be performed if other treatment methods are ineffective. In order to provide greater functionality and a better quality of life for the patient in the long term, preference should be given to organ-preserving techniques.

Intrahepatic cholangiocarcinoma is the primary adenocarcinoma of the intrahepatic bile ducts and the second most common liver tumor. Liver resection remains the most effective treatment. However, the possibilities of surgical treatment may be limited by the unresectability of the tumor and the inoperability of the patient due to concomitant diseases.

It is known that radiofrequency ablation is effective in the treatment of hepatocellular carcinoma and metastases of colorectal cancer in the liver, however, only a few clinical observations have been reported regarding its effectiveness in intrahepatic cholangiocarcinoma.

The accumulation of experience regarding the effectiveness of local destruction methods in intrahepatic cholangiocarcinoma especially in inoperable patients is of clinical value.

The accumulation of experience with local destruction methods in intrahepatic cholangiocarcinoma, especially in inoperable patients, is of clinical value.

This clinical observation presents the result of effective treatment of a patient with intrahepatic cholangiocarcinoma with cirrhosis using radiofrequency ablation. Relapse-free survival in this case was 44 months.