Aim. To compare the aspects of the use of various stents in hepatopancreatobiliary zone diseases.

Materials and methods. We analyzed the experience of using biliary plastic and metal self-expanding stents placed by the antegrade percutaneous (n = 45) or retrograde endoscopic method (n = 160). Pancreatic stenting with 5 Fr plastic stents was performed in 35 patients.

Results. Our experience shows the high efficiency of stenting performed by antegrade and endoscopic retrograde access for bile and pancreatic ducts obstruction. Pancreatic stenting is justified in the prevention of acute pancreatitis (in the presence of a risk factor) and in treatment of post-ERCP pancreatitis, as well as in the treatment of acute biliary pancreatitis with impacted stone in papilla Vater.

Conclusion. Minimally invasive technologies has a leading role in the treatment of patients with ductal failure of the hepatopancreatobiliary zone. Stenting should be used to prepare for radical surgery or as a final palliative treatment method. A differentiated approach is important in selecting a stent, depending on the specific clinical task. For biliary drainage in patients with obstructive jaundice of various etiologies, it is permissible to use both the retrograde and antegrade stenting. The choice of the decompression method depends on the level of the biliary obstruction, the cause of obstructive jaundice, the technical equipment of the department and the training of specialists in retrograde and (or) antegrade endobiliary technologies. Antegrade access is preferred for proximal obstruction of the bile ducts, retrograde endoscopic access is preferred for distal obstruction.

Aim. To evaluate treatment results of retroduodenal perforations after transpapillary endoscopic procedures, considering new possibilities of modern minimally invasive interventions.

Materials and methods. Perforations were identified in 29(0,5%) cases from 5943 endoscopic retrograde procedures in Moscow City Hospital №31 since 01.01.2010 to 01.01.2021. There were 24(82,8 %) women and 5(17,2%) men in the age from 29 to 89 years (median age – 64.2 ± 14.9 years) Endoscopic papillosphincterotomy was performed n 25 (86.2%) cases (in 5 – incisional), with additional lithoextraction in 12 (46.7%), endoscopic papillectomy – in 4 (10%) cases. Perforations developed in 27 (93,1%) patients with two and more risk factors.

Results. Combination of endoscopic and conservative treatment was applied to cure the perforation in 24 cases (82.8%). A fully covered self-expandable metal stent was placed in 16 (66.7%) cases, and clips were applied to stenting in 2(8.3%) cases. Isolated endocliping was performed in 5 (20.8%) patients, and a plastic biliary stent – in 1(4.2%) case. Other 5(17.2%) patients underwent conservative (3) and surgical (2) treatment only. Satisfactory results were achieved in 23(79.3%) cases, when combination of endoscopic and conservative therapy was performed. Mortality was observed in 6(20.7%) cases (isolated conservative therapy (3), surgical treatment (2) and endoscopic placement of a plastic biliary stent (1).

Conclusion. Retroduodenal perforations can lead to death in 20.7% cases, according to our data. Timely diagnosis and using a combination of conservative and endoscopic methods as biliary stenting with fully covered self-expandable metal stent and endocliping allowed to achieve recovery in all cases.

Aim. To improve the results of treatment for patients with complicated portal hypertension of cirrhotic genesis using the transjugular intahepatic portosystemic shunt with endovascular obliteration of the inflow pathways to the esophageal-gastric varicose veins.

Material and methods. Transjugular intahepatic portosystemic shunt was performed in 172 patients with gastroesophageal variceal bleeding. The patients were divided into 3 clinical groups. The shunting procedure was applied to 62 patients. Another 110 patients underwent transjugular intahepatic portosystemic shunt and selective obliteration of the esophageal-gastric vein inflow pathways. The short-term and long-term results (up to 140 months), the incidence of thrombosis, recurrent bleeding and mortality, as well as their relationship with the established risk factors for complications were traced.

Results. All patients achieved an effective reduction in the portosystemic pressure gradient and a reduction in the manifestations of portal hypertension. Recurrence of bleeding caused by shunt thrombosis occurred in 23 (13.3%) patients. In clinical group I (n = 62), this complication was noted in 9 (14.5%) patients, in II (n = 54) – 11 (20.4%) cases, in III (n = 56) – only in 3 (5.4%) cases. Bleeding-free survival decreased from 1.0 to 0.82 in 83.9 months, then plateaued. A sharp decrease in the Kaplan–Meier curve from 1.0 to 0.88 was observed within 24.5 months after the intervention. The largest number of deaths was in group I (30.6%), the smallest in group III (7.1%).

Conclusion. Transjugular intahepatic portosystemic shunt supplemented by obliteration the inflows of the esophagealgastric varicose veins provides complete eradication of varicose veins, helps to reduce the frequency of recurrent bleeding and death.

The aim of the study was to show new promising possibilities of direct perfusion test for the transplanted liver.

Materials and methods. We have performed 246 liver transplantations (1998–2020). Since 2015 arterial complications were detected in 24 (23%) patients after 105 transplantations complicated by liver hypoperfusion: splenic artery steal syndrome (n = 8), hepatic artery thrombosis (n = 7), combination of hepatic artery stenosis and steal syndrome (n = 6), hepatic artery stenosis (n = 3). Endovascular interventions were performed in these cases for revascularization. Direct perfusion test was performed in 8 patients.

Results. The liver perfusion index increased from 0.27 (0.13–0.45) to 0.62 (0.33–0.89) after endovascular procedures. Sufficient perfusion was ≥0.65.

Conclusion. Direct liver perfusion test makes possible to identify and objectify graft blood supply, timely and adequate correction, and reduces the risk of developing biliary ischemic complications.

Aim. Define the safety and effectiveness of rendezvous technique for choledocholithiasis.

Material and methods. We performed a retrospective and prospective analysis of the results in percutaneous transhepatic access to the bile ducts and endoscopic intervention in the rendezvous technique for choledocholithiasis in 100 elderly patients. The patients were divided into 2 groups for 50 people. The implementation of the rendezvous began from the antegrade stage in patients from group I; in patients of group II – from the retrograde stage. Postmanipulation complications and failures were When analyzed. The control point of the study is the identification of complications associated with manipulation from the next stages of the rendezvous technique.

Results. We revealed a direct dependence of the results in sequence of rendezvous technique for elderly patients with choledocholithiasis and obstructive jaundice. This fact allows recommending percutaneous transhepatic access before endoscopic intervention for these patients with statistical significance. The frequency of complications and failures in patients of group I was 18%, in group II – 52%. This allows for such patients percutaneous transhepatic access before endoscopic intervention in the rendezvous technique. The frequency of complications and failures in patients of group I was 18%, in group II – 52%.

Conclusion. Dilatation of intrahepatic segmental and subsegmental 2 and 3 biliary ducts with moderate and severe obstructive jaundice is a predictor of complications with ineffective endoscopic approach. In such situations, preventive antegrade drainage of the biliary tract with rendezvous technique makes possible to prevent cholangitis, effectively eliminate biliary hypertension, clarify the severity of stenosis of the papilla with antegrade balloon revision, and also secure delayed endoscopic resolution of biliary pathology.

Aim. To improve the results of treatment for patients with acute pancreatitis by optimizing the technique of performing percutaneous methods of drainage and sequestrectomy.

Material and methods. We have considered experience of treating pancreatic necrosis in 257 patients, confirmed by computed tomography, intraoperatively, and postmortem examinations. Moderate severity pancreatitis was detected in 159 (61.9%) patients, severe – in 98 (38.1%) cases.

Results. Small focal pancreatic necrosis was detected in 99 (62.3%) patients with moderate pancreatitis, large focal pancreatitis – in 60 (37.7%). Small-focal pancreatic necrosis was in 23 (23.5%) patients, large-focal – in 43 (43.9%), subtotal – in 29 (29.6%), total – in 3 (3.1%) among patients with severe acute pancreatitis. Percutaneous approach was used in combination with transluminal and open surgery in 59 (23%) patients. Infected necrosis was detected in 6 (3.8%) patients with acute moderate pancreatitis and in 44 (44.9%) patients with severe pancreatitis, sepsis – in 12 (12.2%) patients. 27 (10.5%) patient have died from septic shock in the first phase of pancreatitis, included 14 (5.4%) cases after surgery. Overall 41 (16%) patients with pancreatic necrosis have died.

Conclusion. Compliance of stages in surgical treatment technology allows optimally combine it with transluminal sequestrectomy, reduces surgical trauma, eliminates additional risks of open approach associated with complications and deaths.

Aim. Optimization of endobiliary stenting in patients with unresectable tumors of the organs in the hepatopancreatoduodenal zone, improving the prevention of complications, improving the immediate results of treatment and the quality of patient’s life.

Material and methods. From 2011 to 2020, 47 patients with unresectable tumors in the hepatopancreatoduodenal zone underwent endoscopic transpapillary stenting of the common bile duct for obstructive jaundice. A plastic stent was used in 28 patients, and a self-expanding nitinol stent in 19 patients. The results of endobiliary stenting, complications, efficacy and safety of stenting, side effects, quality of biliary tract decompression were evaluated.

Results. All patients were perform stenting of the common bile duct. Two complications were recorded during endoscopic transpapillary stenting: bleeding from the area of the major duodenal papilla, which was stopped endoscopically. In the immediate postoperative period – stent displacement was noted in 3 patients, blockage of the stent – in 2 cases, acute post-manipulative pancreatitis – in 1 case, cholangitis — in 2 patients. Satisfactory decompression of the biliary tract was achieved in 44 from 47 patients. There was 1 death.

Conclusion. Endoscopic transpapillary stenting of the common bile duct is a low-traumatic, safe and effective method of biliary decompression for tumor obstructive jaundice. Plastic stents should be used for biliary drainage with a life expectancy of ≤6 months. Self-expanding nitinol stents with full or partial coverage is the best chose for life expectancy > 6 months.

The management of biliary decompression in malignant hilar carcinoma remains controversial. This review shows the most relevant aspects of endoprosthetics for proximal biliary obstruction, including necessity of stenting and morphological verification before radical surgery, selection of approach to drain etc. The main contradictions and ways to solve them are presented in this article, based on evidence researches, international and expert consensus conferences.

Several clinical observations of rare complications of pancreatoduodenectomy in the early and long-term postoperative periods are presented. The authors tell about the bile leakage (severity C), arrosive bleeding, thrombosis of the liver vessels, as well as bowel obstruction from carcinomatosis. The possibilities of modern minimally invasive technologies are demonstrated: ante- and retrograde and endovascular methods in the treatment of these complications. Pancreatoduodenectomy should be performed in multidisciplinary medical centers with extensive experience and modern equipment that allows timely correction of postoperative complications.

Aim. To assess the efficacy and safety of interventional endovascular partial spleen embolization for the correction of thrombocytopenia in patients with liver cirrhosis.

Material and methods. From September 2019 to March 2020, 5 partial spleen embolizations were performed at the surgical clinic of the Botkin Hospital. The indication was the impossibility of conducting courses of regional chemotherapy for primary liver cancer in 2 patients with cirrhosis, portal hypertension, hypersplenism, thrombocytopenia, in 3 patients – the impossibility of conducting adequate antiviral therapy with cirrhosis as a result of chronic viral hepatitis C. The platelet count was < 25 thousand/μl (19.34 ± 1.34 thousand/μl) in all patients at the time of the procedure. The median spleen volume was 1967.54 ± 476.13 (1324.34–2163.54) cm3 . We used Progreat® Terumo 2.8 Fr microcatheter 130 cm for catheterization branches of the splenic artery. Endovascular embolization was performed with microspheres 600 ± 75 nm – 2 ml before occlusion. Computed tomography scan of abdominal cavity with intravenous contrast enhancement and laboratory test of platelet levels were performed. Follow up of patients was carried out at 1, 3 and 6 months after this intervention.

Results. The postoperative period in all patients was uncomplicated. Postembolization syndrome (pain, hyperthermia) developed in the early postoperative period in all patients on the next day after the procedure. Computed tomography scan of the abdominal cavity revealed areas of an irregular shape of low density that did not accumulate a contrast agent. The duration of hospitalization was 7.63 ± 3.32 (5–11) days. There were not in-hospital and 30-day mortality in our study.

Conclusion. The first experience of endovascular partial spleen embolization showed its safety and efficacy in the correction of thrombocytopenia in patients with liver cirrhosis.

Aim. To evaluate the relationship between the future liver remnant volume and function and determine the possible threshold values of these parameters for predicting posthepatectomy liver failure in children.

Methods. Data of 57 patients who underwent major hepatectomy from July 2017 to February 2021 were retrospectively analyzed. Before surgery all children underwent the CT-volumetry and 99mTc-Mebrofenin hepatobiliary scintigraphy. The threshold values for the future liver volume and function were considered 25%, and 2.7%/min/m2 , respectively. After surgery the ISGLS and 50–50 criteria for posthepatectomy liver failure were assessed. The principal components method was used to identify risk factors for its development. The correlation analysis included the maximum value of total bilirubin after hepatectomy, as well as the values of total bilirubin, albumin, urea, prothrombin index, international normalized ratio and platelets on the postoperative day 5.

Results. The posthepatectomy liver failure was observed in 2 patients: grade B developed in a patient with FLR-V 43%, FLR-F 1.8%/min/m2 , grade A in a patient with FLR-V 16.5% and FLR-F 4.78%/min/m2 . A significant statistical relationship of average strength was revealed between the indicators of FLR-F and FLR-V (Pearson η = 0.409; p < 0.01). However, direct pairwise comparison did not reveal the relationship between future liver remnant volume, function and the laboratory parameters. The principal components analysis showed that during the postoperative period, the prothrombin index and international normalized ratio value were the most sensitive to the large volume of the liver parenchyma loss. The threshold value of FLR-F (3%/min/m2 ) was calculated. The decrease below this value can lead to posthepatectomy liver failure, which will manifest as a hemostasis disorder.

Conclusion. Planning a one-staged hepatectomy not only the future liver remnant volume should be taken into account, but also its function. The threshold for future liver remnant volume in children is below the generally accepted level 25%. To perform one-stage hepatectomies in such patients, the FLR-F must be at least 2.7%/min/m2 . The future investigations in this field is waranteed.

Aim. Study of anatomical variations of the pancreatic neck blood supply, which may affect the results of pancreaticoduodenectomy.

Material and methods. Anatomic characteristics of arterial blood supply of pancreas were studied in 42 autopsied cases, who died from diseases not associated with abdominal organs failure. Clinical part of our study included 62 patients. Arterial anatomy was examined during early arterial phase of computer tomography. Options of the origin of the dorsa pancreatic artery were noted. All patients had “soft” pancreas confirmed by morphological examination and computer tomography. Main group included 20 patients. Dissection of the pancreas during pancreatoduodenectomy in this group were performed 10–15 mm left of portal vein confluence. Control (retrospective) group included 42 patients performed standard procedure, when pancreas was dissected above the portal vein confluence.

Results. It was found that the neck of pancreas was supplied from dorsal pancreatic artery, found in all specimens. In 76% of cases it was a branch of splenic artery, in other cases – a branch of superior mesenteric artery. CT scan revealed the dorsal pancreatic artery in 54 (87.1%) people, in 8 patients the artery could not be identified. The dorsal pancreatic artery was a branch of the splenic artery in 64.8% of cases. In other cases it was a branch of the superior mesenteric artery, common hepatic artery, gastroduodenal artery and middle colon artery. If the dorsal pancreatic artery was a branch of the superior mesenteric, common hepatic, gastroduodenal artery, it was transected during lymphadenectomy. This led to higher frequency of postoperative pancreatic fistula.

Conclusion. Localization of dorsal pancreatic artery must be taken into account during the pancreatoduodenectomy. That allows to decrease probability of postoperative pancreatic fistula.

Aim. Expand and determinate indications for using of extraction balloon catheters in endoscopic biliary surgery, as an additional and auxiliary endoscopic technique, which optimizes the technical conditions for performing medical and diagnostic tasks.

Material and methods. We used disposable two- and three-lumen extraction balloon catheters with a diameter of 7.5 Fr. The catheters assumed delivery of an extractor balloon along a conductor with a diameter of 0.35 in into the bile duct, and also made it possible to inject a radiopaque substance. 136 retrograde endoscopic interventions were performed on the bile ducts using extraction balloon catheters.

Research results. Indications for the use of an extractor balloon have been determined and proposed as a conventional standard. Interventions on the bile ducts were carried out using only a balloon catheter and in combination with a Dormia basket (n = 61). An extraction balloon catheter was used during retrograde endoscopic intervention on the bile ducts as an additional diagnostic endoscopic manipulation to facilitate the performance of the diagnostic task (n = 38). The device was also used to optimize the technical conditions of medical and diagnostic tasks (n = 37). 116 patients had benign diseases, 20 patients had tumor lesion.

Сonclusion. The main function of an extraction balloon catheter is to move or displace the contents from the proximal to the distal parts of the bile duct, followed by its extraction into the duodenum. The design characteristics of the instrument make it possible to significantly expand the indications for its use, including not for its intended purpose, but as an additional method, optimizes the technical conditions for performing medical and diagnostic tasks. The endoscopic extraction balloon catheter is a multipurpose instrument that can be used to solve both diagnostic and therapeutic tasks of retrograde interventions on the bile ducts.

The paper analyzes modern literature data regarding post-resection hemorrhagic complications in surgical pancreatology. The modern classification system, epidemiological data and risk factors for postoperative bleeding are analyzed in detail. Critical analysis of the use of postpancreatectomy hemorrhage classification was carried out.

Liver resection in patients with HCC is the treatment of choice. In patients with insufficient future liver remnant (FLR) and compensated liver function performing the Associated Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is possible. The classic version of ALPPS consists in ligation of the right branch of the portal vein with transection of the parenchyma and then performing right hepatectomy or right trisegmentectomy. This paper describes the first case in Russia of performing ligation of the left portal branch with transection of the parenchyma and then performing left trisegmentectomy (“reversal” ALPPS) in a patient with HCC and cirrhosis. Reversal ALPPS can be successfully performed in patients with insufficient future liver remnant in well-selected patients.

A clinical case of successful surgical treatment of a patient with chronic pancreatitis, complicated by suppuration of a postnecrotic cyst and the formation of a cysto-gastric fistula. As a result of the conservative and minimally invasive treatment, the pseudocyst was drained, and the cystogastric fistula was closed. The staged treatment was completed by resection of the head of the pancreas with the formation of an anastomosis.