Aim: to assess the role of hepatobiliary scintigraphy for prognosis of hepatic failure after liver resection; to determine threshold index of hepatic uptake of radioactive agent as an indication for surgical prevention of hepatic failure. Material and Methods. The study included 2 groups of patients who underwent hepatobiliary scintigraphy. The 1st group consisted of 50 patients with diffuse liver diseases (chronic hepatitis, liver cirrhosis) in whom histological examination of liver was performed according to METAVIR. 49 patients with liver tumors underwent advanced liver resections (over segments by Couinaud). Results. The highest median of hepatic uptake (2,86) was revealed in patients with liver fibrosis F1, the lowest (2,02) – in patients with liver fibrosis F4. Threshold value of hepatic uptake was 2,4. In 18 patients with hepatic uptake index <2,4 and remnant liver <40% surgical prevention of hepatic failure was performed: portal vein ligation (1), portal embolization (12), percutaneous embolization with radiofrequency ablation along the plane of future liver dissection (5). An increase of hepatic uptake index up to 2.7 ± 0.47 was revealed in the areas of liver regeneration and hypertrophy in 14–21 days after surgery. Conclusion. Combined static and dynamic hepatobiliary scintigraphy is valuable to assess volume and function of different liver segments. Threshold hepatic uptake index of 2.4 is sensitive to predict postoperative liver failure in case of future remnant liver <40%.

Non-invasive methods are increasingly used in recent years to assess liver functional reserve. The widespread application of ¹³C-methacetin respiratory test in clinical practice promises to improve the assessment of liver functional reserve and to specify prognosis in liver cirrhosis patients. Features of 13C-methacetin respiratory test application are presented.

Aim. Combined evaluation of liver functional and volumetric reserves prior to advanced liver resections. Material and Methods. The study included 24 patients who underwent extended liver resections for the period 2013– 2016. Clinical and laboratory data, indocyanine green (ICG) clearance, CT volumetry, static polypositional hepatoscintigraphy were assessed in all cases. Results. Individual tests showed sufficient functional reserve of FLR in all patients. However in 7 (29.2%) cases advanced resections were refused in favor of less liver volume removal, two-stage surgery or portal vein embolization to increase remnant liver volume. The reasons for refusal were compiled simulation of extended resection using PET combined with scintigraphy and comprehensive analysis of all factors affecting postoperative liver failure. Conclusion. Comprehensive assessment of functional and volumetric reserve prevents postoperative liver failure. At present time transition from evaluation of total liver parenchyma reserves to isolated assessment of FLR reserve is the most actual problem.

Aim. Assessment of stomach and duodenal injury early after extended hemihepatectomy. Material and Methods. The experiment was performed on 100 white mongrel male rats. 80 of them underwent advanced hemihepatectomy, 20 animals consisted of control group. After 12 hours, 1, 3 and 7 days after surgery stomach and duodenum were histologically analyzed to detect chemiluminescent homogenates. Results. After 12 hours light sum and “fast” flash in the stomach were increased by 2.5 and 1.5 times, respectively, “slow” flash was decreased by 2 times. Growth of all parameters was observed in duodenum. There were significant decrease of “fast” flash and increase of light sum and “slow” flash in homogenates during 3 postoperative days. By the 7th day light sum was increased in stomach and duodenum, besides the duodenum increased “slow” flash. Structural changes were visualized after 12 hours in the form of erosions and ulcers of the stomach and duodenum. In 7 days reparative changes were predominant. Conclusion. In 12 hours after hemihepatectomy rapid activation of free-radical oxidation was observed in stomach and duodenum. Herewith inhibition of antioxidant enzymes have been already showed in stomach. Structural changes in the stomach (ulcers) have already been irreversible by this time. So, this period is critical for acute stomach and duodenal injury.

Objective. To evaluate technical and morphological aspects of laparoscopic left lateral liver segment explantation for transplantation. Material and Methods. In Privolzhsky Federal Medical Center of FMBA of Russia 3 series (14 interventions) of laparoscopic left lateral liver sector resection were performed. Operations were performed in compliance with the principles of donor liver resection. In each series different variants of tools and hardware systems were applied. Indications were benign neoplasms of II-III segments including focal nodular hyperplasia in 12 cases and hemangioma in 2 cases. Severity of liver parenchyma damage was assessed in excised specimen. Results. Postoperative complications were not observed, patients were discharged in terms from 3 to 6 days. The average hospital stay was 3.8 days. Morphological study of histological preparations of liver tissue revealed different severity of cholestasis and steatohepatosis, fibrosis, mixed inflammatory infiltration (lymphocytes, polymorphonuclear leukocytes). Identified changes were chronic. Signs of acute ischemic damage of liver parenhima were not found. Conclusion. Laparoscopic liver resection (left lateral sector) for subsequent transplantation is technically feasible with the accumulation of experience of laparoscopic procedures.

Aim. Analysis of the outcomes in patients with pancreatic pseudocysts who underwent percutaneous puncture-draining interventions. Material and Methods. Minimally invasive percutaneous interventions were used in 164 patients with chronic pancreatic pseudocysts. The cause of pancreatic pseudocysts was severe acute pancreatitis 0.5–5 years ago. Cystic dimensions ranged from 4 to 20 cm. Multiple cysts were observed in 17 patients. 17 patients (10.4%) had purulent pseudocysts, in 30 (18.3%) patients clinical symptoms of cystic compression were presented. Indications for surgery were diameter over 5 cm, signs of compression, infection, pancreatic hypertension. Results. Percutaneous techniques were effective in 155 (94.5%) patients. In 110 patients the cysts successfully regressed after percutaneous drainage and conservative therapy. Mortality was absent. Puncture was applied in 54 patients with good effect in 29 of them. Percutaneous drainage followed by elective sanations was effective in 10 patients with purulent pseudocysts. In 22 of 30 patients with clinical signs of compression puncture-draining operations were successful. In 8 patients endobiliary drainage was made additionally, in 19 cases nasointestinal probing for nutritional support and bile return was applied. Conclusion. The results show high efficiency of percutaneous minimally invasive techniques in сhronic pancreatic pseudocysts management. So, they are considered as the main and final methods of treatment for these patients.

 

Aim. To systematize world literature data for robot-assisted pancreatic surgery. Material and methods. 31 publications for the period 2010–2014 were analyzed. In these articles 856 robot-assisted pancreatic operations were assessed. Results. 90% of robot-assisted pancreatic operations include pancreaticoduodenectomy (55%) and distal pancreatectomy (35%). Median time of robot-assisted pancreatoduodenectomy was 342 ± 209 minutes, distal pancreatectomy time – 200 ± 131.9 minutes. Median blood loss during robot - assisted operations was referred to class 1 by WHO (2001) classification. The number of complications is increased as far as the number of robotic assisted operations is augmented. Conclusion. Analyses demonstrates growing interest of pancreatic surgeons in robotic technologies. At the same time there is no unique strategy of robotic pancreatic surgery. Certain indications and contraindications for pancreatic robotassisted surgery are absent. There is no methodological base describing technical aspects of these difficult interventions. So, further researches of robot-assisted techniques are advisable to eliminate these limitations.

 

Aim. To improve the results of minimally invasive treatment of “minor” injuries of the biliary tract during cholecystectomy. Material and Methods. For the period 2010-2016 there were 24 patients with “small” intraoperative damage of the biliary tract during cholecystectomy (Class “A” by Strasberg, 1995). Bile accumulation in gallbladder area was found in 16 cases, external bile leakage through the drain was observed in 8 patients. All 16 patients with subhepatic collection of bile underwent US-assisted drainage with self-locking drainage “pig tail” №8 Fr by Seldinger technique followed by fistulography. In 4 patients with external bile leakage retrograde cholangiopancreatography was made that verified cystic duct stump failure. Also they underwent endoscopic papillosphincterotomy to restore biliary passage into duodenum. Percutaneous transhepatic drainage of non-expanded bile duct was the first step of treatment in four observations. In 2 patients it was definitive treatment of biliary fistula. In two other cases antegrade balloon papillodilatation was performed. Results. In 5 cases external drainage was a final treatment. In 11 cases retrograde cholangiography revealed choledocholithiasis, residual stenosis of major duodenal papilla, that required endoscopic papillosphincterotomy. In 9 of 24 patients (37.5%) temporary external drainage alone or with antegrade papillodilatation were sufficient to eliminate “small” biliary injuries. There were no complications after percutaneous transhepatic cholangiostomy on nonunexpanded ducts and percutaneous drainage of subhepatic biliary collections. Acute postmanipulative pancreatitis developed in 3 of 15 cases after endoscopic papillosphincterotomy. Conservative therapy was successful in all of them. In one case antegrade balloon papillodilatation was accompanied by transient amilazemia without clinical manifestations of acute pancreatitis. Conclusion. Biliary hypertension followed by bile leakage in “minor” biliary injuriesis transient in 37.5% of cases and can be stopped by temporary percutaneous drainage of subhepatic biliary collections and/or temporary cholangiostomy. Balloon dilatation of major duodenal papilla may be also applied additionally.

Aim. To improve the diagnostic and treatment approaches for patients with unresectable liver cholangiocarcinoma. Material and Methods. Diagnosis and treatment of 14 patients are presented. Videofluorescent module was developed for diagnostics. For the first time in Russia we received videofluorescent image of bile ducts tumors and determined the accumulation of photosensitizers. In 12 patients the diagnosis was morphologically confirmed. Patients with unresectable cholangiocellular cancer underwent US- and X-ray-assisted percutaneous drainage of bile ducts. Videofluorescent diagnostics, photodynamic therapy of tumoral stricture and stent deployment were made after release of jaundice. Photodynamic therapy was performed using a fiber-optic system. Controlled balloon catheter on the distal segment was used if it was necessary to dilate the stricture and for uniform irradiation. Nitinol stent was deployed after photodynamic therapy. Photosens, Radachlorin and Photolon photosensitizers were used. Results. We acquired videofluorescence image of the tumor and determined the accumulation of photosensitizer in all patients. Cholangiocellular cancer was morphologically confirmed in 12 patients. The effectiveness of unresectable cholangiocellular cancer management was evaluated by survival. One patient was alive for 21 months, 3 patients – for 11, 13 and 17 months respectively. Five patients are under dynamic observation: two – for 12 and 18 months, three – from 3 to 6 months. Five patients died within 3 ± 1 months after treatment and initially had a lot of distant metastases. Conclusion. Videofluorescent diagnosis of cholangiocellular cancer determines the malignant nature of biliary lesion with high probability. Biliary stenting combined with photodynamic therapy allows us to establish a regular biliary passage and antineoplastic treatment that is associated with better results.

Aim. To study morphofunctional peculiarities of erythrocyte depending on the severity of jaundice. Materials and Methods. Obstructive jaundice was modeled in 48 pigs. Morphological and functional characteristics of red blood cells were studied using atomic force microscope INTEGRA NT-MDT (Russia, Zelenograd). Results. The study proved that erythrocytes transformation is associated with severity of jaundice. In peripheral blood erythrocytes with clearly contoured membrane and homogeneous cytoplasm are observed along with those of domical shape and with spinous outgrowths on the membrane. Average roughness of red blood cells surface decreases from 40-44 to 26-30 nm2 , dispersion – from 112 to 84 nm2 , violations of membrane integrity increased. Erythrocyte’s volume increased up to 12.3 ± 2.6 mm3 , intracellular pressure – from 0 kPa in normal animals up to 2.2 kPa in animals with obstructive jaundice class C (by E.I. Galperin, 2012) that perhaps contributes to destruction of erythrocytes. Conclusion. Erythrocytes are extremely convenient model to study the effect of exogenous and endogenous factors due to their structural and physiological characteristics, as well as the availability to research them. So red blood cell may be used as an informative test object to assess the state of organism in various pathological processes including acute liver failure in obstructive jaundice. Moreover, features of pathogenesis, morphogenesis and optimal management may be determined.

Aim. To analyze the results of diagnostics and treatment of patients with splenic echinococcosis and to determine the criteria for selection of surgery. Material and Methods. The analysis included 51 patients with splenic echinococcosis. There were 33 women and 18 men aged 14–78 years (mean 49 ± 4.2 years). Three patients were previously operated in other hospitals for splenic echinococcosis. Isolated splenic lesion was noted in 22 (43.13%) cases. Combined lesions were also identified: spleen and liver (15), spleen and abdominal cavity (4), spleen and retroperitoneal fat (4), spleen, liver and lungs (2), spleen, liver and kidney (1) and spleen and lungs (1). In most cases dimensions of parasitic cysts were 5-15 cm. Total and multiple hydatid splenic lesion was noted in 12 (23.53%) cases. Laparotomy was performed in 86.27%: splenectomy (25), pericystectomy (11), perfect echinococcectomy (8). Laparoscopic pericystectomy was made in 4 cases, splenectomy – in 2 cases. US-assisted percutaneous drainage was made in 1 (1.96%) case. Results. Spleen was preserved in 24 (47.5%) cases. RFA has been applied for splenic resection (Cool-Tip). Ultrasonic cavitation and cryodestruction were used for residual cavity processing after chitin shell removal. We evaluated immediate and long-term results. Recurrent echinococcosis was noted in 1 patient. Conclusion. “Ideal” echinococcectomy or pericystectomy should be preferred for splenic hydatid disease. Organ-sparing spleen resection may be considered if previous interventions are impossible. Current surgical techniques (cryoablation, radiofrequency ablation) are able to avoid recurrences.

Aim. To generalize an experience of minimally invasive navigation technologies in multi-field hospital. Material and Methods. For seven years 2117 US- and X-ray-assisted operations were performed in the department of ultrasonic and X-ray diagnosis and treatment including 1110 interventions for hepatopancreatobiliary diseases, 443 for postoperative complications, 624 for defeat of other organs. 33% of operations were diagnostic, 67% – curative. An amount and quality of drainage, general state of patient, laboratory and instrumental data were assessed in postoperative period to determine an efficiency of minimally invasive interventions. Results. Navigation technologies are the most valuable for obstructive jaundice, acute destructive pancreatitis, parasitogenic liver diseases, postoperative complications. Two-stage approach including percutaneous or endoscopic obligatory biliary decompression followed by subsequent decision about either surgery or stenting is preferable in case of tumoral obstructive jaundice regardless further tactics of treatment. Possibilities of multi-field hospital allow to apply minimally invasive technologies for either local accumulations and complicated forms of acute pancreatitis. Timely use of these methods is associated with 3-fold decrease of mortality in these patients. The main role in treatment of parasitogenic lesion of abdominal organs is belonged to conventional surgery. Percutaneous minimally invasive interventions have the best results for mono-vesicular cysts without fibrous capsule calcification. Dimensions of cysts have no fundamental significance as a rule. Removal of all germinal cystic elements is obligatory. Minimally invasive intervention is the method of choice in postoperative complications management. Conclusion. Modern navigation technologies are dynamically developing and improving. They occupy more deserving place in clinical practice and are very perspective according to Russian and foreign data. Their further development and introduction into clinical practice require multidisciplinary approach, active and wide scientific discussion.

Case report of successful surgical treatment of giant cavernous hepatic hemangioma combined with generalized sarcoidosis is presented. Information about etiology, pathogenesis and management of these diseases, brief literature review are exhibited. The role of modern methods of diagnostic visualization, preoperative endovascular superselective embolization as well as features of blood-sparing extensive liver resection are discussed.