Aim. To describe the main endovascular interventions used in portal hypertension. The paper presents modern endovascular procedures for treating patients with portal hypertension and varicose transformation of the esophageal and gastric veins: transjugular intrahepatic portosystemic shunt, balloon-occluded retrograde transvenous obliteration, balloon-occluded antegrade transvenous obliteration, partial embolization of the splenic arteries and gastric veins. The study extensively discusses the radical shunting surgery related to portal hypertension – transjugular intrahepatic portosystemic shunt. The paper involves historical aspects of the development of this treatment procedure, indications, techniques, variations depending on the nature of the disease and clinical situation, along with an analysis of the surgical approach in the event of endovascular intervention complications.

Aim. To analyze first experiences and demonstrate the results of balloon-occluded retrograde transvenous obliteration in patients with liver cirrhosis and variceal transformation of the gastric veins.

Materials and methods. In the period from November 2023 to August 2024, balloon-occluded retrograde transvenous obliteration was performed on six male patients with liver cirrhosis and gastric varices for secondary prevention of bleeding. The mean age of the patients comprised 56.5 years. Significant gastrorenal shunt and predominantly right-sided drainage of gastroesophageal varices were considered technical indications for the procedure.

Results. No fatalities or complications necessitating reoperation were reported. The follow-up period revealed no recurrences of bleeding. The overall survival rate over six months comprised 100%. Progression of gastric varices was noted in two out of six patients: one patient underwent a repeat procedure, while the other underwent liver transplantation.

Conclusion. Balloon-occluded retrograde transvenous obliteration is recognized as a safe and effective radiological intervention for addressing complications associated with portal hypertension. However, it obtains several limitations and potential adverse effects, which necessitate careful monitoring during follow-up.

The present paper explores current views on the pathological anatomy of the vessels within the portal vascular bed with a specific focus on the gastric varices. In addition, it discusses the mechanisms of hemodynamic alterations in venous circulation among patients with intrahepatic portal hypertension. The emphasis on the condition of the gastric varices arises from a series of unresolved issues that persist regarding surgical strategies and the differentiated selection of various interventions in the context of gastric varices and the risk of bleeding. An understanding of the pathomorphology and hemodynamics of the gastric venous system is considered crucial for the effective treatment of patients with varicose transformation of the gastric veins.

Aim. To present current views on the architectural characteristics of the vessels within the portal vascular beds, as well as the pathomorphology of the gastric varices in the context of intrahepatic portal hypertension.

Aim. To analyze the results of modern prevention and treatment strategies applied for bleeding from gastric varices in patients with portal hypertension syndrome.

Materials and methods. The study enrolled 276 patients with portal hypertension, including 187 cases of liver cirrhosis and 89 cases of extrahepatic portal hypertension. 24% of the patients with liver cirrhosis were classified as Child-Turcotte-Pugh Class A, 50% as Class B, and 26% as Class C. The portal vein thrombosis was confirmed in 80% of extrahepatic portal hypertension cases, while isolated splenic vein thrombosis was observed in 20%. Varices GOV1 (Sarin classification) were identified in 126 patients (45.7%), GOV2 in 110 patients (39.8%), and IGV-1 in 40 patients (14.5%). The following interventions were performed: endoscopic ligation, endoscopic sclerotherapy, endovascular techniques (transjugular intrahepatic portosystemic shunt, balloon-occluded retrograde transvenous obliteration), laparoscopic gastric devascularization, and distal splenorenal anastomosis.

Results. Following endoscopic procedures, recurrence of gastric varices was noted in 20% of cases, and bleeding occurred in 7%. The efficacy of endoscopic treatment amounted to 71%; endoscopic ligation for bleeding from GOV1 varices appeared effective in 94.4% of cases. Early recurrence of bleeding developed in 29.4% of patients. The efficacy of endoscopic sclerotherapy for bleeding from GOV2/IGV1 varices comprised 96.7% with early recurrence occurring in 12.9% of patients. The secondary prevention involved multiple endoscopic interventions that led to complete eradication of gastric varices in 34% of cases with recurrent bleeding noted in 9.3% of patients, while persistent recurrence of gastric varices was observed in 66%. A splenorenal anastomosis provided reliable prevention of recurrent bleedings. No shunt thrombosis or mortality was recorded; however, the incidence of post-shunt encephalopathy comprised 16.5%. Transjugular intrahepatic portosystemic shunt facilitated a significant reduction in portal pressure and the enlargement of esophageal and gastric varices. Post-shunt encephalopathy occurred in 48.6% of patients. In the long-term follow-up, a recurrence of esophagogastric bleeding was recorded in one patient. Laparoscopic azygoportal disconnection contributed to the regression of varices in the esophagus and stomach; however, a recurrence of gastric varices developed in 30% of cases and a recurrence of bleeding in 12.5%.

Conclusion. Current medicine obtains a sufficient arsenal of modern methods for the treatment and prevention of bleeding from gastric varices. The choice of treatment and prevention strategies for bleeding in portal hypertension necessitates a differentiated approach, taking into account the etiology and degree of disease decompensation.

Aim. To analyze the effectiveness of transjugular intrahepatic portosystemic shunt in complicated portal hypertension of cirrhotic origin aggravated by portal vein thrombosis, and to assess the portal decompression achieved through the reduction in the portosystemic pressure gradient.

Materials and methods. In the period of 2017–2024, transjugular intrahepatic portosystemic shunt was performed on 26 patients with liver cirrhosis and portal hypertension complicated by portal vein thrombosis. Mortality, recurrence rate of variceal bleeding, shunt thrombosis, rethrombosis of the portal vein, and overall survival were analyzed.

Results. All patients exhibited a decrease in portal vein pressure from 36.0 ± 3.4 mmHg to 21.9 ± 1.5 mmHg (t = 3.77, p < 0.001) and in the portosystemic pressure gradient from 28.5 ± 3.1 mmHg to 11.5 ± 1.1 mmHg (t = 5.17, p < 0.001). The maximum duration of follow-up accounted for 78 months. The six-week mortality rate comprised 7.7%, 8 patients (30.8%) died within one year. All patients underwent surgery due to a high risk of bleeding. 14 patients remain under observation.

Conclusion. Achievable portal decompression is considered effective in terms of reducing mortality and prolonging the non-transplantation period. Long-term anticoagulant therapy is found mandatory. The shunting procedure should be complemented by selective embolization of the inflow pathways to the esophagogastric varices.

Aim. To evaluate the accuracy and feasibility of using the most common criteria and models for predicting the survival and risk of hepatocellular carcinoma recurrence in clinical practice based on own experience in liver transplantation.

Materials and methods. The single-center retrospective study included data on 70 patients who underwent transplantation from May 2010 to December 2022. Compliance with the criteria (Milan, UCSF, 5-5-500, etc.) was determined and the values of predictive models (Metroticket 2.0, Pre-ALRAL, etc.) were calculated for each observation. Survival rates, as well as efficiency of criteria and models were analyzed using sensitivity, specificity, F1 score, and C-index.

Results. At the time of transplantation, the interquartile range for the number of tumors comprised 1–3, tumor sizes ranged from 1.8 to 5 cm, total tumor size ranged from 2.4 to 8.5 cm, and alpha-fetoprotein levels accounted for 14.7–150 ng/mL. During the follow-up period, hepatocellular carcinoma recurrence was recorded in 26% of patients. Disease-free and overall survival at 1, 3, and 5 years amounted to 89%, 76%, 63%, and 89%, 74.3%, 68%, respectively. The F1 score and C-index for predicting hepatocellular carcinoma recurrence after liver transplantation varied from 0.65 to 0.83, with the 5-5-500 criterion demonstrating the best performance. This criterion provided a five-year disease-free survival rate of 86% and an overall survival rate of 79%, with non-compliance leading to a decrease in survival to 33% and 46%.

Conclusion. The studied criteria and models can be used to assess the risk of hepatocellular carcinoma recurrence after liver transplantation, although their predictive accuracy remains imperfect. An online calculator has been created to assess patient compliance with criteria and to predict disease-free and overall survival (https://nadit.ru/criterii). The development of own model and criteria within the framework of a Russian multicenter study, as well as the search for new objective methods for assessing the risk of hepatocellular carcinoma recurrence after liver transplantation, remain promising research areas.

Aim. To compare the learning curve of laparoscopic liver resection under a mentoring program with that of an expert-level surgeon who mastered the procedure independently.

Materials and methods. A retrospective analysis was conducted on the outcomes of laparoscopic liver resections performed from 2015 to 2020 by an expert-level surgeon (referred to as Surgeon 1) and a surgeon trained under a mentoring program (Surgeon 2). The CUSUM method was employed to assess changes in the difficulty score and perioperative outcomes during the surgeon training. The resection difficulty was evaluated using IWATE criteria.

Results. Surgeon 1 performed 174 operations, while Surgeon 2 performed 37 operations. The initial learning period consisted of 20 resections for Surgeon 1 and 16 for Surgeon 2, while the period of expansion of indications included resections 21 to 40 for Surgeon 1 and 17 to 37 for Surgeon 2. The two surgeons revealed no significant differences in the resection difficulty scores (p = 0.131), the intraoperative blood loss (p = 0.505), and the incidence of postoperative complications (p = 0.552) during the initial period. However, the operative time for Surgeon 1 was significantly longer than that for Surgeon 2 (p = 0.007). In the comparative analysis of the second period of learning, Surgeon 1 had a significantly higher difficulty score (p = 0.008). No differences were observed in the incidence of postoperative complications: 4 cases (20%) for Surgeon 1 and 3 cases (15%) for Surgeon 2 (p = 0.507). During the period of expansion of indications, Surgeon 2 demonstrated significantly less blood loss (p = 0.033) and a shorter average operative time (p = 0.002).

Conclusion. Learning laparoscopic liver resection occurs faster under mentoring. Learning under a mentoring program reveals a tendency towards reduced operative time and blood loss. The transfer of experience from a mentor allows for the possibility of lacking expert-level proficiency in open liver resection surgery but implies the necessity for skills in performing open resections of low and moderate complexity.

Aim. To identify the most appropriate surgical treatment method for patients with colorectal cancer metastases to the liver by means of a comparative analysis of immediate and long-term outcomes of anatomical and parenchyma-sparing liver resections.

Materials and methods. A retrospective analysis was conducted on the surgical treatment outcomes of 87 patients with colorectal cancer metastases to the liver who underwent surgery between 2008 and 2023. The analysis involved the pseudorandomization method to eliminate the influence of unaccounted factors and improve the statistical validity of the study. Age, sex, body mass index, synchronous nature of metastasis, number of metastases, tumor burden, etc. were used as variables to calculate the probability factor.

Results. A total of 87 observations were analyzed. Using the pseudorandomization method, 18 pairs of patients who underwent anatomical resection and parenchyma-sparing surgery were formed. The volume of blood loss was significantly lower in the parenchyma-sparing resection group (Me 250 ml; 187–525 ml) compared to the anatomical resection group (Me 850 ml; 315–2325 ml; p = 0.001). The duration of hospital stay after parenchymal-sparing resections accounted for 12 days, while after anatomical resections, it comprised 18 days (p = 0.031). The incidence of postoperative complications revealed no significant difference (p = 0.348). Positive resection margins were more frequently found in patients who underwent parenchyma-sparing surgery (16.7% and 5.6%, p = 0.289). The difference in overall and disease-free survival was not statistically significant.

Conclusion. Parenchymal-sparing liver resection is found to be a safe alternative to anatomical resection, allowing for the maximum preservation of liver tissue while achieving adequate oncological outcomes.

Aim. To investigate the severity criteria of acute biliary pancreatitis in various causes of bile outflow obstruction into the duodenum, including biliary sludge, and to analyze the treatment outcomes of patients.

Materials and methods. A retrospective analysis was conducted on the diagnostic and treatment results of 89 patients with a confirmed cause of obstruction of the common bile duct following endoscopic papillosphincterotomy. The severity of pancreatitis was assessed in terms of organ failure, pancreatic necrosis, and the severity of cholangitis. The presence of sludge in the gallbladder was evaluated by means of ultrasound, and papillitis was assessed during esophagogastroduodenoscopy.

Results. In Group 1, 23 patients had biliary sludge as the cause of bile outflow obstruction; in Group 2 (n = 32), the cause lied in an impacted stone; and in Group 3 (n = 34), in choledocholithiasis. Organ failure was noted in 11 patients of group 1, in 13 patients of group 2, and in 7 patients of group 3 (p < 0.04). In group 1, organ failure occurred against the background of pancreatic necrosis (n = 7) and acute cholangitis (n = 4); in group 2, all 13 patients exhibited acute cholangitis (p < 0.05). The proportion of patients with papillitis was significantly higher in Groups 1 and 2. Sludge in the gallbladder was detected in 14 patients of Group 1, 4 patients of Group 2, and 8 patients of Group 3 (p < 0.001). Nasobiliary drainage after endoscopic papillosphincterotomy was applied in 34 cases, pancreatic duct stenting in 33 cases, and invasive interventions for peripancreatitis in 9 cases. 3 patients (3.4%) died.

Conclusion. Pancreatic necrosis and acute cholangitis determined the severity of acute biliary pancreatitis, which is consistent with the concept of 2 types of disease – pancreatic and biliary. Biliary sludge in the bile duct, alongside impacted stones, caused bile duct obstruction in patients with organ failure. Sludge in the gallbladder and papillitis, along with signs of biliary hypertension, suggest its presence in the common bile duct and indicates the need for endoscopic papillosphincterotomy. The identified patterns appear relevant and may be considered in protocols for subsequent prospective studies.

Aim. To describe the experience of multivisceral surgeries involving pancreaticoduodenectomy for tumors of various localizations, performed in two Russian medical institutions.

Materials and methods. A retrospective study was conducted on the outcomes of 251 multivisceral surgeries with pancreaticoduodenectomy performed in two medical institutions from January 2011 to April 2024.

Results. Tumors of pancreatic head, duodenum and large papilla of duodenum were detected in 180 cases (71.7%); colorectal tumors in 36 cases (14.3%); gastric tumors in 24 cases (9.6%); extrahepatic bile duct and gallbladder tumors in 7 cases (2.8%); renal tumors in 3 cases (1.2%); retroperitoneal tumor in 1 case (0.4%). In 107 cases, the surgery was combined with liver resection, including hemihepatectomy in 7 cases. Pancreaticoduodenectomy was combined with colorectal resection in 95 cases. Despite the extreme variability in the extent of multivisceral surgeries with pancreaticoduodenectomy, the complication rate and mortality amounted to 65.7% and 7.2%, respectively.

Conclusion. The structure of multivisceral surgeries with pancreaticoduodenectomy appears to be extremely heterogeneous in terms of localization, tumor histogenesis, and the volume of surgical interventions. The frequency of postoperative complications and mortality indicates acceptable tolerability of such surgeries.

Aim. To determine the efficacy of nonsteroidal anti-inflammatory drugs in preventing the development of pancreatitis following endoscopic retrograde interventions.

Materials and methods. The study enrolled 865 patients who underwent transpapillary interventions for various hepatopancreatoduodenal diseases from 2019 to 2023. Patients in the main group (n = 470) were additionally prescribed Diclofenac suppositories (100 mg) 20–30 minutes prior to the procedure.

Results. In the main group, acute post-ERCP pancreatitis developed 1.8 times less frequently than in the control group. Nonsteroidal anti-inflammatory drugs reduced the incidence of acute post-ERCP pancreatitis by 3.6% (p = 0.006).

Conclusion. Nonsteroidal anti-inflammatory drugs decrease the incidence of acute post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. Regardless of their application, additional measures for preventing complications are required. The role of nonsteroidal anti-inflammatory drugs in preventing complications following endoscopic retrograde interventions warrants further research in larger patient groups.

The paper presents the results of successful regional chemotherapy applied in the treatment of two patients with unresectable cholangiocellular carcinoma. In the first case, a 57-year-old female patient with metastatic cholangiocarcinoma demonstrated an overall survival of 8 years following a regimen that combined systemic and regional chemotherapy. Within 6.5 years, the patient underwent 25 cycles of endovascular treatment, three of which were conducted post-relief of mechanical jaundice using a stent. The adverse effects of chemotherapy, characterized by mild anemia and thrombocytopenia, necessitated no additional treatment. In the second case, a 73-year-old patient with bilobed tumor underwent 31 cycles of regional chemotherapy in combination with systemic therapy; the overall survival accounted for 5 years. The combination of regional and systemic chemotherapy can be considered safe and effective for the management of advanced cholangiocellular carcinoma. The combination of endovascular chemoembolization and chemoinfusion is regarded as promising.

Surgical intervention remains a fundamental component of radical treatment for locally advanced gastrointestinal stromal tumors of the duodenum. The paper presents a clinical experience in the diagnosis and organ-sparing surgical treatment of a gastrointestinal stromal tumor located in the lower horizontal segment of the duodenum, which involved the left kidney. The tumor was excised en bloc along with the anatomically involved structures, and then the left kidney was isolated from the excised tissue and successfully autotransplanted to a heterotopic position. The authors argue that ex vivo isolation of the kidney from the tumor mass, followed by heterotopic autotransplantation, represents a promising organ-sparing technique in oncological surgery for locally advanced abdominal tumors. Notably, the biological characteristics of the tumor are to be considered when planning organ-sparing surgical procedures.

Aim. To analyze the most promising scientific and practical directions regarding the role of intestinal microbiota and its metabolites in the pathogenesis and clinical course of acute pancreatitis.

Materials and methods. The study involved a systematic literature review of the databases PubMed, EMBASE, and Cochrane for the last 20 years. A total of 5 meta-analyses, 234 clinical trials, 127 reviews, and 428 experimental studies were identified. Ultimately, 36 clinical trials, 2 reviews, and 18 experimental studies were selected for the inclusion. The systematic review was carried out in accordance with PRISMA recommendations.

Results. The structure of the intestinal microbiota significantly differs in healthy control groups and patients with acute pancreatitis. The microbiota of patients with acute pancreatitis closely correlates with systemic inflammation and intestinal barrier dysfunction. Cases of severe acute pancreatitis revealed an increase in Enterococcus, Proteobacteria, Escherichia, and Shigella, alongside a decrease in overall microbiome diversity and in Bifidobacterium, Prevotella, Faecalibacterium, Blautia, Lachnospiraceae, and Ruminococcaceae. Short-chain fatty acids, the concentration of which in the blood may indicate an increase in intestinal wall permeability, are directly involved in the pathogenesis of acute lung injury associated with acute pancreatitis.

Conclusion. Further study into the composition of the intestinal microbiota, its metabolites, and potential modulation strategies in various patient groups obtains high potential as a foundation for new diagnostic, therapeutic, and preventive approaches to acute pancreatitis.

Pancreatic fistula refers to the most common and serious complication following pancreaticoduodenectomy. Various prognostic scoring systems have been developed and validated to reduce the risk of postoperative pancreatic fistula. These prognostic scores are based on preoperative data and intraoperative assessments of gland density, pancreatic duct diameter, and other parameters. The most frequently used and widely recognized prognostic scores include FRS, a-FRS, and ua-FRS. Evolution in instrumental methods of diagnosis, development of artificial intelligence, and accumulation of experience in managing patients with periampullary malignancies shift the focus towards preoperative evaluation based on CT data.