Aim. To improve treatment results in patients with various manifestations of portal hypertension (PH) by simultaneously performing transjugular intrahepatic portosystemic shunt (TIPS) placement and partial splenic embolization.

Materials and methods. At the first stage of the study, the incidence of PH manifestations was retrospectively analyzed in 100 consecutive patients with cirrhosis. At the second stage, the safety and efficacy of simultaneously performing TIPS placement and partial splenic embolization were evaluated in a group of 20 patients with esophageal and/or gastric varices and hypersplenism. Control examination was performed at 3, 6, 9, 12, and 15 months after the procedure.

Results. Of 100 patients with liver cirrhosis, clinical and instrumental signs of portal hypertension were observed in 86 patients. In 49 (56.9%) patients, portal hypertension was manifested as esophageal and/or gastric varices along with hypersplenism. When TIPS and partial splenic embolization were used together, no in-hospital case fatality and postoperative complications were noted. During a dynamic observation, 2 (10%) fatal outcomes were reported that were not related to variceal bleeding. The severity of varices decreased in 19 (95%) patients while remaining unchanged in 1 (5%) patient. In 5 (25%) patients, encephalopathy was noted to worsen. Six months following the procedure, the platelet count increase reached 109.44 ± 34.26% (54–242), while 12 months later, it amounted to 96.37 ± 23.62% (41–166). After a 6-month follow-up period, an average increase in leukocyte count reached 34.14 ± 24.96% (0–89), amounting to 21.47 ± 18.46% (0–62) after a follow-up period of 12 months.

Conclusion. More than half of patients with cirrhosis and portal hypertension suffer from both esophageal and/or gastric varices and hypersplenism. In such patients, it is safe and effective to perform TIPS and partial splenic embolization simultaneously.

Aim. To improve treatment results in patients with the life-threatening complications of cirrhotic portal hypertension by making an informed choice of the optimal TIPS (transjugular intrahepatic portosystemic shunt) variant.

Materials and methods. A total of 234 patients suffering from the complications of cirrhotic portal hypertension underwent TIPS placement. The indications for shunt placement include esophageal and gastric varices exhibiting the signs of bleeding or carrying the risk of rebleeding (in 172 patients), refractory ascites (in 57 patients), and portal vein thrombosis in the setting of cirrhosis (in 5 patients). Patients from Group 1 underwent shunt placement together with the embolization of inflow pathways to esophageal and gastric varices. In Group 2, priority was given to perioperative therapy, while shunt placement was used together with embolization only in cases of severe varices. In Group 3, the shunt placement stage was combined with the portal blood flow restoration. Immediate and late results were studied in terms of complications, as well as mortality rate and survival rates.

Results. The maximum observation duration amounted to 140 months (11.7 years). TIPS efficacy in all patients was confirmed by a statistically significant decrease in the portosystemic pressure gradient. In Group 1, the highest mortality rate associated with rebleeding was observed in patients who had undergone only shunt placement (30.6%), while the lowest rate was noted in patients whose inflow pathways to varices had first been embolized and who then had undergone intrahepatic shunt placement (7.1%). Patients in Group 2 exhibited a reduction in ascites and the severity of varices. The technical feasibility of TIPS in the setting of portal vein thrombosis was enhanced by experience accumulation and preoperative planning relying on careful interpretation of computed splenoportography data.

Conclusion. It is reasonable to combine the shunt placement stage of TIPS for variceal bleeding with selective embolization of all radiologically detected inflow pathways to gastroesophageal varices. If the portal vein thrombosis is not accompanied by cavernous transformation, TIPS can achieve effective portal decompression provided the portal blood flow is restored.

Aim. To assess the clinical efficacy of preventing gastroesophageal bleeding in patients with liver cirrhosis.

Materials and methods. From 2008 to 2019, the surgical treatment of 710 patients with cirrhosis was considered. The long-term results of preventing gastroesophageal variceal rebleeding were studied in three groups of patients: portosystemic shunt placement (367 patients), total esophagogastric disconnection (62 patients), and endoscopic procedures (281 patients). Observation periods varied from 1 to 115 months.

Results. The lowest rebleeding rate of 15.5% was observed following shunt placement (χ² = 9.728; df = 2; р = 0.008), while the highest rate of 40.9% was observed following endoscopic treatment. By the 5th year of follow-up, only 37.5% of patients showed no signs of bleeding following endoscopic procedures. The percentage of patients who did not experience true gastroesophageal variceal rebleeding amounted to 44%, 76%, and 85% following shunt placement, total esophagogastric disconnection, and endoscopic procedures, respectively (p < 0.05).

Conclusion. Irrespective of the selected procedure, all patients with cirrhosis suffer from portal rebleeding in the longterm period. However, the lowest rebleeding rate is observed following portosystemic shunt placement.

Aim. To analyze various strategies aimed at mitigating complications of the portal hypertension syndrome at the Minsk Scientific and Practical Center for Surgery, Transplantology, and Hematology.

Material and methods. Patients who had undergone different types of treatment were retrospectively observed: shunt surgery to form portacaval anastomoses, transjugular portosystemic shunt placement, and liver transplantation. The following parameters were analyzed: incidence of complications, hospital mortality rate, survival rate, and perioperative indicators.

Results. Since 1980, 131 shunt surgeries have been performed at the Center, while 880 liver transplantations and 232 transjugular portosystemic shunt placement procedures have been performed since 2008. Among 68 patients with compensated cirrhosis who had undergone shunt placement, no hospital mortality rate was reported, whereas in patients with Child-Pugh B cirrhosis and Child–Pugh C cirrhosis, it reached 19.5% and 87.5%, respectively. Following TIPS, the overall case mortality rate amounted to 9.9% (following TIPS prior to transplantation – 8.2%, following TIPS used as the final treatment – 12.8%). After liver transplantation, in-hospital mortality rate reached 7.7%.

Conclusion. Over 50 years, the strategy for managing portal hypertension has undergone significant changes due to the establishment of institutions providing a complete cycle of all treatment measures for such patients. Patients suffering from the complications of the portal hypertension syndrome tend to receive the most effective treatment in hospitals having experience in rational conservative therapy, endovascular procedures, and transplantation.

Aim. To analyze the results of minimally invasive techniques to prevent and treat gastroesophageal bleeding in patients with cirrhosis.

Materials and methods. The study included 997 patients with liver cirrhosis: Child-Pugh class A – 21.7%; class B – 48.8%; class C – 29.5%. Esophageal varices of Grades III–IV were diagnosed in 95.5% of the patients, while gastric varices were observed in 17.4% of the patients. The following methods were used: endoscopic ligation, endoscopic sclerotherapy, TIPS, laparoscopic azygoportal disconnection, and distal splenorenal anastomosis.

Results. Following endoscopic procedures aimed at preventing the onset of gastroesophageal bleeding, variceal recurrence and bleeding were observed in 35.9% and 18.6% of cases, respectively. The efficacy of endoscopic ligation in case of bleeding amounted to 91.2%. Multiple endoscopic procedures provided means to treat esophageal and gastric varices in 56.2% of the patients. Rebleeding was observed in 9.3% of the patients, while esophageal and gastric varices persisted in 34.3% of the patients. TIPS was found to significantly reduce portal pressure and the grade of varices, with encephalopathy developing in 41.4% of the patients. In the long-term period, stent dysfunction was diagnosed in 22.5% of cases, while bleeding recurred in 10%. Laparoscopic azygoportal disconnection contributed to the regression of esophageal and gastric varices. In the long-term period, bleeding recurred in 42.3% of cases. Laparoscopic distal splenorenal anastomosis reliably prevented the recurrence of bleeding. No shunt thrombosis or lethal outcomes were observed, while the incidence of encephalopathy amounted to 14.7%.

Conclusion. A sufficient number of minimally invasive methods are currently available in the treatment and prevention of gastroesophageal portal bleeding. A case-specific approach to the choice of measures aimed at treating and preventing gastroesophageal bleeding in patients with cirrhosis is required, taking into account the degree of decompensation of portal hypertension and the severity of liver dysfunction.

Ten patients with cirrhosis and portal hypertension successfully underwent balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices. As an example, the paper presents a clinical observation demonstrating the use of a BRTO endovascular procedure. A spontaneous functioning gastrorenal shunt was distinctly observed during multidetector computed tomography in a patient with Child-Pugh А cirrhosis of alimentary-toxic and viral etiology, as well as portal hypertension and associated gastric varices (Type 2, Grade 3) with frequent recurrent bleeding. The presence of a shunt with no indications for TIPS procedure, as well as the inexpediency of a shunt surgery (taking positive immunoblot into account), enabled the formulation of indications for BRTO. This factor ensured regression of gastric varices, as well as eliminated the threat of recurrent gastric bleeding. 

Aim. To evaluate the efficacy of endoscopic transpapillary pancreatic stenting in the prevention and combination therapy of acute pancreatitis.

Materials and methods. The study examined 166 cases of pancreatic duct stenting intended to prevent acute postprocedural pancreatitis in 105 patients and to provide a combination therapy for acute pancreatitis in 61 patients. In this case plastic stents (3–7 Fr) were used that were removed on days 3–5 provided neither amylasemia nor clinical signs of acute pancreatitis were observed.

Results. Pancreatic stenting performed to prevent acute post-procedural pancreatitis in 100 patients yielded good results in 95.2% of the cases; elective surgery was performed in 16 of these cases after 2 weeks. In 3.8% of the cases, some complications were observed (pancreatitis, jaundice); one (0.95%) fatal case was reported. In the combination therapy of severe pancreatitis (APACHE II >10 points), recovery was observed in 86.9% of the cases involving pancreatic duct stenting. In 11.3% of the cases, stenting was accompanied by minimally invasive surgical procedures. The disease was found to have progressed in 12 patients (19.7%). Four patients were discharged from the hospital with pancreatic fistulas, while 8 patients (13.1%) died.

Conclusion. Preventive stenting of the pancreatic duct in the setting of complicated and atypical papillosphincterotomy reduces the incidence of acute pancreatitis to 3.8% at a case fatality rate of 0.95%. Pancreatic duct stenting is indicated for treatment of pancreatic necrosis in the setting of biliary pancreatitis involving impacted stones and severe acute pancreatitis at an amylase level of > 400 U/L during the first three days of the disease.

Aim. To improve the efficacy of minimally invasive surgical treatment for infected pancreatic necrosis.

Materials and methods. The study analyzed the data of 142 patients with moderate to severe infected pancreatic necrosis treated from 2012 to 2017. In 2012–2014, an incision and drainage procedure involving multiple drainage replacements and debridements was used in 84 (59.2%) patients comprising Group 1. Since 2015, 58 (40.8%) patients comprising Group 2 have been treated using large-diameter (30–32 Fr) tube drainage followed by debridement and transfistula videoscopic necrosequestrectomy.

Results. The best results were obtained by draining pathological cavities using large-diameter double-lumen drainage, as well as by actively removing sequestra using the developed technique of transfistula videoscopic necrosequestrectomy. In Group 2, the incidence of local complications amounted to 6.8% as compared to 22.6% in Group 1. Group 2 exhibited significantly lower case mortality rate (12.3% and 19.4%; t = 2.1; p ≤ 0.05), while patients in Group 1 required longer hospitalization: 96 ± 7.4 days as compared to 71 ± 3.2 days in Group 2 (t = 2.9 p ≤ 0.05).

Conclusion. Minimally invasive procedures involving transfistula videoscopic necrosequestrectomy improve treatment outcomes, as well as reducing case mortality rate in the setting of purulent-necrotic parapancreatitis.

Aim. To determine the character of bile outflow in patients who underwent biliary tract reconstructive surgery without any clinical and instrumental evidence of the stricture of biliodigestive anastomosis.

Materials and methods. The authors analyzed the findings of radionuclide biliary tract studies conducted in 102 patients with biliodigestive anastomosis from 2016 to 2020. The significant relationship between clinical data and hepatobiliary scintigraphy results was confirmed using Fisher’s exact test.

Results. In 75 patients (73.5%), bile outflow disturbance was attributed to the efferent loop motility. Of these cases, 3 (4%) involved paresis of the efferent loop, while 70 (93.3%) exhibited multiple episodes of reflux from the efferent loop into the biliodigestive anastomosis and the intrahepatic bile ducts. In 2 patients (2.6%) showing no clinical signs of chronic cholangitis, a rare reflux from the efferent loop into the biliodigestive anastomosis and the intrahepatic bile ducts was noted.

Conclusions. Efferent loop dysfunction can greatly disturb bile outflow following the formation of a biliodigestive anastomosis, thus creating conditions for the development of complications.

Aim. To evaluate the late results of staged endoscopic treatment of patients with corrosive bile duct strictures.

Materials and methods. The study included 41 patients with corrosive bile duct strictures varying in etiology and localization. The patients were observed over a seven-year period, most of whom had already undergone endoscopic treatment.

Results. The technical success rate amounted to 100%. The procedure of staged stenting was completed in 34 out of 37 patients under observation. The clinical success rate, defined as the release of a stricture, reached 94%. In the postoperative period, the incidence of complications amounted to 8.8%. Only 2 out of 34 patients who had undergone stenting exhibited stricture recurrence.

Conclusion. The staged placement of multiple plastic stents is characterized by high technical and clinical success rates while involving few complications, as well as a consistently low rate of stricture recurrence in the long-term period.

Clinical observation of surgical treatment received by a patient with pancreatoblastoma is described. In the preoperative period, specialists had difficulties in determining the nature of the neoplasm, which led to some tactical complications. The patient underwent pancreaticoduodenal resection that involved resection of the pancreatic body, as well as the confluence of the superior mesenteric and splenic veins. The histologic and immunohistochemical studies confirmed the diagnosis of pancreatoblastoma. Therefore, the patient was referred for chemotherapeutic treatment.

The paper presents a clinical study of a 53-year-old patient who underwent liver transplantation complicated by proper hepatic artery thrombosis. No clinical or laboratory signs of the complication were observed. The disruption of arterial blood supply to the transplant was established on day six following surgery by means of routine Doppler ultrasound. Following successful selective endovascular thrombus aspiration and balloon dilation, the arterial blood flow was restored. However, one day later, the thrombosis recurred. Hepatic revascularization was achieved through thrombus re-aspiration and the proper hepatic artery stenting. In the subsequent postoperative period, no complications were observed. The paper analyzes possible causes of thrombosis and recurrent thrombosis, as well as reviewing modern literature.

A rare clinical observation of using hyperthermic isolated hepatic chemoperfusion is considered in the setting of a pathologically altered hepatic arterial blood flow in focal hepatic lesions caused by uveal melanoma metastases. The technical feasibility and safety of performing hyperthermic isolated hepatic chemoperfusion through the portal vein against the background of the altered hepatic arterial bed were demonstrated.