Materials and methods. The experiment was performed on 20 male Chinchilla rabbits. The authors studied the effectiveness of various types of nutritional support in resection of the left lateral lobe of the liver. A comparative analysis was based on the results of treatment of 1275 patients with acute and chronic diseases of the liver and biliary tract, 659 (51.7%) of which corresponded to the Fast Track program, and 616 (48.3%) were the control group.

Results. The duration of inpatient treatment was reduced from 13.4 ± 4.2 to 9.3 ± 3.0 days (t = 2.08; p = 0.04), and hospital mortality decreased from 0.8% to 0.45% (p = 0.12). The postoperative morbidity fell from 4.2% to 3.2%, in particular, the proportion of III–V grade complications (Clavien–Dindo classification) reduced from 48.4% to 19.0% (t = 2.34, p = 0.025).

Conclusion. Clinical implementation of main Fast Track components in the early perioperative period in diseases of the liver and biliary tract reliably optimizes postoperative rehabilitation and reduces the incidence of postoperative complications. First promising results of this program suggest the need to correct traditional stereotypes ingrained in treatment programs for patients with hepatobiliary diseases, in order to improve the results of surgeries.

Aim. To assess the feasibility of enhanced recovery program for patients undergoing pancreatic surgery.

Materials and methods. Between January 2019 and May 2022, 47 patients with various pancreatic diseases underwent surgery at the University Clinic of A.I. Evdokimov Moscow State University of Medicine and Dentistry and FMBA of Russia. Male patients comprised 24 (51%), female – 23 (49%); the age of patients was 22 to 78 years (mean age 43.5 years). Pancreaticoduodenal resection was performed in 30 patients, distal pancreatic resection in 17 patients. All patients received some elements of the enhanced recovery program.

Results. An uneventful postoperative period was observed in 36 patients (76.6%). Gastric stasis developed in 4 cases (8.5%), pancreatic fistulas in 4 (8.5%), postoperative pancreatitis in 3 (6,4%). A reoperation was performed in 1 case (2.1%) with intra-abdominal bleeding. The average length of stay in the intensive care unit comprised 1.8 days.

Conclusion. The use of Fast Track in pancreatic surgery does not significantly increase the incidence of early postoperative complications, meanwhile it reduces the length of hospital stay after surgery and provides more cost- effective results. However, the development of a clear protocol for the management of patients requires further research and accumulation of data.

Aim. To explore the possibilities for assessing and reducing the severity of perioperative stress response to emergency surgery in patients with acute cholecystitis.

Materials and methods. 207 patients with acute cholecystitis were registered from January 2017 to January 2019. Patients were randomized into groups. Enhanced recovery techniques were used in the main group. Cortisol and Interleukin-6 levels were measured to examine the perioperative stress response and to identify biochemical predictors of complications associated with acute cholecystitis.

Results. The groups did not reveal a statistically significant difference in the number of postoperative complications. The length of postoperative stay was shorter in the main group (33.3 ± 19.6 h and 53.7 ± 32.7 h; p < 0.0001). Within 24 postoperative hours, 54.5% of patients in the main group and 19.8% of the control group were discharged from hospital. Early mobilization and enteral feeding reduced the time of return to physical activity and transition to habitual diet in the main group, which was also noted with a lower incidence of postoperative pain in the shoulder and/or neck: 12 (13.6%) compared to 35 (34.7%) observations. The application of the enhanced recovery protocol provided no significant effect on postoperative cortisol levels in the main group.

Conclusion. In surgical patients with acute cholecystitis, enhanced recovery improves the quality of the postoperative period, reducing the severity and frequency of postoperative pain, phrenicus and dyspepsia symptoms. The enhanced recovery techniques diminish the length of hospital stay without increasing the incidence of complications and re-hospitalizations.

Aim. To improve surgical outcomes in patients with chronic pancreatitis by means of enhanced recovery after surgery. Materials and methods. 112 patients with chronic pancreatitis underwent surgery over the past 5 years. Pancreatic head resection in different variants was performed in 78 patients (69.6%), and 34 patients (30.4%) underwent lateral pancreaticojejunostomy. All interventions were carried out through the midline laparotomy. Enhanced recovery after surgery was carried out for 48 patients (39.6%). The control group included 60 patients.

Results. After pancreatic resection, patients in the main group were in the intensive care unit only on the day of surgery. As soon as the pancreaticojejunoanastomosis was formed, the patients were immediately transferred to the surgical department. Patients in the control group were in the intensive care unit for at least two days. Intestinal motility was revealed in patients of the main group on day 2, in the control group – on days 3–4. Four patients (7.7%) of the main group and 11 in the control group (18.3%) developed complications. No lethal outcomes were registered in the main group. One patient (1.7%) died in the control group. The average length of hospital stay comprised 9 ± 2.5 days in the main group and 15 ± 4.7 days in the control group (p < 0.05).

Conclusion. Enhanced recovery after surgery in patients with chronic pancreatitis reduces the number of postoperative complications, the duration of stay in the intensive care unit, the length of hospital stay and, therefore, improves immediate postoperative outcomes.

According to the literature review, a nutritional support for patients after hepatopancreoduodenal surgery requires a differentiated approach. The paper presents data on the experience in providing nutritional support to this kind of patients. It is necessary to stress that nutritional risk screening should be performed prior to surgical intervention. The nutrition is recommended to be adjusted to protein and energy needs of the patient, taking into account concomitant diseases. Products for sip feeding are the method of choice. Enteral nutrition is preferable in the postoperative period. The nutritional support for patients undergoing pancreatoduodenal resection is increasingly recognized, and a randomized clinical trial is to be carried out to evaluate the effectiveness of enteral and parenteral nutrition. As a component of the enhanced recovery program, nutritional support can optimize outcomes in patients who have undergone hepatopancreatoduodenal resection. The nutritional status of a patient should be mandatorily assessed before surgery. Perioperative correction of nutritional status implies continuity and a multidisciplinary approach.

Aim. To present the technical features and results of transplantation of the right hepatic lobe from a living donor with various types of efferent venous anatomy.

Materials and methods. 306 liver transplantations from living related donors were performed from 2009 to 2021. Patients with previously described 14 subtypes of efferent vascular anatomy and classified into 3 types, were divided into 4 groups depending on the number of reconstructed vessels. The author analyzed anatomy variants of the right hepatic lobe, duration of surgery and anhepatic period, postoperative morbidity, volume of blood loss, including with allowance for the number of reconstructed vessels, as well as survivability.

Results. The study demonstrated the principles and features of the reconstruction of the efferent veins of the graft. Time of surgical intervention, duration of anhepatic period, and postoperative morbidity were greatest with a separate type of blood outflow (p < 0.05) Blood loss was greatest during reconstruction veins 3 and 4 (p < 0.05). No difference in blood loss was detected between groups 3 and 4. Survivability within 12, 36, 60 and 120 months accounted for 84%, 83%, 81% and 71%, correspondingly, without any difference between groups.

Conclusion. Successful transplantation of the right hepatic lobe requires precision mapping of the venous anatomy of the donor, preserving all potentially important efferent vessels, and commitment to the most complete reconstruction of them, irrespective of the vascular anatomy complexity.

Aim. To study the effect of the pancreatic necrosis configuration on the course and outcome of external pancreatic fistulas formed at the stage of acute pancreatitis.

Materials and methods. The authors studied the dynamics of external pancreatic fistulas existing from 2 to 143 months after invasive interventions for pancreonecrosis in 53 patients. Pancreonecrosis, its depth and configuration were diagnosed by means of CT scan.

Results. Pancreatic fistula closed in 30 out of 53 patients: all 10 patients with type 1 configuration in shallow (<50%) necrosis and all 5 patients with type 2 configuration, even in complete transverse necrosis. With deep necrosis of type 1, fistula closed in 15 out of 38 patients. The outflow of juice from the viable parenchyma distal to the necrosis was restored in 7 out of 15 patients. The process was performed by endoscopic recanalization of the duct through the necrotic zone at the stage of acute pancreatitis. The volume of parenchyma distal to the necrosis did not change in the follow-up period: 50.4 ± 19.9 cm3 and 40.7 ± 14.4 cm3 (p > 0.05). In 8 patients, the volume of functioning parenchyma distal to necrosis reduced from 20 ± 6.3 cm3 to 7.4 ± 2.7 cm3 (p < 0.001). In persistent pancreatic fistulas, 23 patients underwent resection and drainage interventions.

Conclusion. The type and depth of necrosis configuration, as well as the volume of functioning parenchyma distal to the necrotic zone should be considered to predict the dynamics of pancreatic fistula after pancreatic necrosis. Deep necrosis of the pancreatic parenchyma with type 1 configuration and large volume of viable parenchyma distal to the necrosis suggest a persistent pancreatic fistula. Endoscopic transpapillary recanalization of the pancreatic duct through the zone of deep necrosis at the stage of acute pancreatitis contributes to the closure of the pancreatic fistula and prevents long-term atrophy of distal and functioning pancreatic parenchyma. Shallow necrosis in type 1 configuration and necrosis in type 2 configuration in acute pancreatitis suggest rapid closure of the pancreatic fistula.

Aim. To carry out a comprehensive morphological study into pathological changes in the common bile duct wall following various periods of plastic and nitinol stent implantation; to examine telocytes in the common bile duct wall. Materials and methods. The study involves the material of 91 patients, who underwent surgery for periampullary carcinoma from 2014 to 2020. Plastic stents were inserted in 56 cases, nitinol stents – in 35. The study of morphological structure of the common bile duct wall took into account the type of stent and period of its implantation (14–30 days, 31–60 days, ≥61 days).

Results. Inflammatory processes in patients with nitinol stent implantation have been revealed to prevail over fibroplastic processes, leading to hyperplasia of the common bile duct mucosa. Following plastic stents implantation, fibroplastic and atrophic changes prevailed. It was found that cases with plastic stent implantation are more often subject to damage to the telocyte ultrastructure and loss of intercellular connections.

Conclusion. Structural changes in telocytes can reflect the degree of fibrosis in the common bile duct wall depending on the type of stent.

Literature review involved a thorough analysis of structural features and variants of hepatic, esophageal and gastric veins. Particular attention was paid to patients with liver cirrhosis, complicated by portal hypertension, and, specifically, variants of venous circulation of these organs. The information presented in the review will be useful in determining the surgical tactics in patients with portal hypertension, who may undergo such interventions as gastrocaval shunt, transjugular intrahepatic stent shunt, including selective embolization of gastric and esophageal veins. Since such patients often develop and relapse esophagogastric bleeding, the peculiarities of collateral venous outflow in the portal vein system are discussed in the paper. Literature review will also be relevant for therapists.

Aim. To evaluate the immediate and long-term outcomes in surgical treatment of concomitant vascular and bile duct injuries.

Materials and methods. 157 patients with cicatricial strictures of the bile ducts were observed from 2012 to 2021. According to the Strasberg-Bismuth classification of bile ducts injuries, type E1-2 was detected in 22 patients, type E3 – in 77, and E4 – in 56 patients. 141 patients underwent cholecystectomy and five of them (4%) were detected with concomitant vascular and bile duct injury.

Results. Hemihepatectomy with bile duct reconstruction was performed in two cases; three patients underwent bile duct reconstruction only. One patient died in the early postoperative period, three patients continue treatment. In one case, treatment was successfully completed.

Conclusion. Concomitant vascular and bile duct injury is a rare and severe complication of cholecystectomy. Success of treatment depends on the level and character of the vessels and bile duct damage, and treatment strategy.

The paper presents a clinical case of hepatocellular carcinoma complicated by rupture. The underlying disease was asymptomatic prior to the development of complications. Despite blood loss of about 30-35% of circulating blood volume, hemorrhagic shock dominated the clinical picture of the acute condition. Neoplasm of the left hepatic lobe with necrosis and rupture was diagnosed by means of videolaparoscopy. Final hemostasis was impossible without liver resection. The tumor was excised within healthy tissues (R0). The authors performed a literature review and analysis. The value of the clinical case is determined by its rare complication.

The paper describes a clinical case of successful combined modality treatment of a patient with pancreatic ductal adenocarcinoma with extension to the superior mesenteric artery and vein. The examination revealed an unresectable tumor. Twelve courses of FOLFIRINOX therapy showed good results, upon which the treatment plan was changed and a typical pancreaticoduodenal resection was performed. Pathological examination revealed ductal adenocarcinoma urT1N0M0R0, TRG 2. The postoperative period was uneventful. The efficacy of drug treatment for ductal adenocarcinoma has increased markedly in recent years. Neoadjuvant chemotherapy can be considered the most effective for locally advanced tumors.