[Diagnostic and conservative treatment nuances in patients with obstructive jaundice: in the wake of Russian consensus].

The research was performed at the Loginov Moscow Clinical Scientific Center. It is based on Russian obstructive jaundice (OJ) consensus results, considered at the 45th annual Central Research Institute of Gastroenterology Scientific session Oncological issues in the gastroenterologist practice (1 March 2019). The article objective is to note the diagnostic and conservative treatment current issues in patients with OJ. The increase in the number of patients with OJ of different etiology provides problem actuality. In a large number of cases, medical treatment is delayed due to inadequate diagnostic and management, while correct patients routing today can be provided regardless of medical institution level. In this article the examination steps and conservative treatment role in patients with biliary obstruction management are presented.

[Long-term results of surgical treatment of intrahepatic cholangiocarcinoma]. / Otdalennye rezul'taty khirurgicheskogo lecheniya vnutripechenochnogo kholangiotsellyulyarnogo raka.

OBJECTIVE: To evaluate the long-term outcomes of surgical treatment of intrahepatic cholangiocarcinoma depending tumor dimensions, vascular invasion, lymph node metastases, cellular differentiation and quality of resection. MATERIAL AND METHODS: There were 46 patients with intrahepatic cholangiocellular cancer. Extended hemihepatectomy was made in 14 patients (30.4%), resection of two and three liver segments - in 17 cases (36.9%), standard hemihepatectomy - in 15 patients (32.6%). Liver resection was combined with extrahepatic bile duct resection in 5 (10.9%) patients. Liver resection was followed by biopsy of specimens. Dimension and number of tumors, differentiation grade, resection margin, liver capsule invasion, vascular invasion and regional lymph node metastases were analyzed. Forty-four (95.6%) patients were followed-up in long-term postoperative period. Statistical analysis was performed using Statistica 13.2 (Dell Inc., USA) and IBM SPSS Statistics v.25 (IBM Corp., USA) software package. Survival was analyzed using the Kaplan-Meier method. Overall 1-, 3- and 5-year survival rates with two-sided 95% confidence intervals (95% CI) were calculated using IBM SPSS Statistics v.25 software. RESULTS: Median survival was 37 months, 1-year - 75.9% (60.9-90.9%), 3-year - 57.6% (35.5-79.6%), 5-year - 36% (8.2-63.7%). Median survival after R1 resection was 37 months, R2 resection - 12 months. Median survival was not achieved in R0 group. We found significant differences in overall survival depending on quality of resection. Tumor dimension over 5 cm, low-grade adenocarcinoma, microvascular invasion and lymph node metastases were associated with impaired postoperative survival. However, differences were not significant. CONCLUSION: The main surgical strategy in patients with intrahepatic cholangiocarcinoma should be ensuring microscopically negative resection margin.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]. / Rossiiskii konsensus po aktual'nym voprosam diagnostiki i lecheniya sindroma mekhanicheskoi zheltukhi.

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

[Predictors of outcomes in surgery for hilar cholangiocarcinoma]. / Prognosticheskie faktory rezul'tatov khirurgicheskogo lecheniia vorotnoi kholangiokartsinomy.

AIM: To determine significant predictors of long-term outcomes of surgery for portal cholangiocarcinoma. MATERIAL AND METHODS: Analysis included 49 out of 84 patients who were operated at the Vishnevsky Institute of Surgery in 2003-2016. Morphological examination (2011-2016) revealed great percentage of following positive variables: micro- (42.9%) and lymphovascular invasion (11.8%), positive resection margin (59.2%), perineural invasion (83.3%), depth of invasion - (83.3%), cells in surrounding fatty tissue (92.3%), invasion of entire thickness of bile ducts' walls (57.1%). Hemihepatectomy was carried out in 50 (59.5%) cases, advanced hemihepatectomy - in 16 (19%) patients. Left-sided hemihepatectomy (34.6%) was more common compared with right-sided hemihepatectomy (8.6%) for biliary confluence lesion (Bismuth-Corlette type IV). RESULTS: TNM stage (p=0.29), tumor localization Bismuth-Corlette type (p=0.10), regional lymph nodes metastases (p=0.77) do not significantly affect survival in univariate analysis. At the same time, TNM stage was significant factor if patients dividing into groups was considered (p=0.05). In regression analysis tumor cells differentiation (p=0.00028), positive resection margin (p=0.0034), perineural invasion and depth of invasion (p=0,00086) were significant predictors of survival. Multivariate analysis confirmed prognostic role of lymphovascular invasion alone (p=0.05). There was no correlation between survival and TNM stage (η=0.057), depth of invasion (η= -0.229) and lymphovascular invasion (η= -0.143645). There was significant reverse moderate correlation between survival and perineural invasion (η= - 0.468750), resection margin (η= -0.558) and tumor differentiation grade (η= -0.481). CONCLUSION: Significant predictors of long-term outcomes of surgery for portal cholangiocarcinoma are TNM stage, lymphovascular invasion, tumor cells differentiation, perineural invasion.

[New criteria of radical surgery and long-term outcomes of hilar cholangiocarcinoma management]. / Novye kriterii radikal'nosti operatsii i otdalennye rezul'taty lecheniia vorotnoi kholangiokartsinomy.

AIM: To develop new criteria of radical surgery for hilar cholangiocarcinoma (HCC). MATERIAL AND METHODS: There were 165 HCC patients who underwent surgery in 1986-2016 at the Vishnevsky Institute of Surgery. TNM stage distribution: stage I - 4 (2.4%), II - 45 (27.3%) (29 of them are referred to the 1st period of work), IIIA - 23 (13.9%), IIIB - 41 (24.8%), IVA - 35 (21.2%), IVB - 17 (10.3%). 80 (48%) patients underwent hemihepatectomy, 17 (10%) - advanced hemihepatectomy, 16 (10%) - minor liver resection with common bile duct repair, 52 (32%) - common bile duct repair resection. Kaplan-Meier survival analysis was performed. Cox proportional hazard model was applied to access relationship between survival and prognostic factors. Log-rank test was used to compare both survival curves. RESULTS: R0-resection as followed by 5-year survival rate near 32%. Microvascular invasion was observed in 42.9%, lymphovascular invasion - in 88.2%, positive resection margin - in 59.2%, perineural invasion - in 83.3%, cells in surrounding fatty tissue were revealed in 92.3%. Resection may be considered radical (R0) if all variables are absent, 5-7 negative factors are followed by conditionally radical procedure (R+number of positive factors). Long-term outcomes and significance of new criteria were accessed (p=0.004). CONCLUSION: New criteria of radical procedure are presented. The last reflects the concept of dependence of 'pure' surgical edge from not only presence or absence of tumor cells in cut-off plane but also from important morphological features of tumor.

[Caecal volvulus after heart surgery with artificial circulation].

Presented herein is a description of a rare complication, i.e. caecal volvulus, after heart surgery. This case report illustrates difficulty of diagnosis of abdominal organs complications after artificial circulation and necessity of active surgical policy.

[BILIARY DECOMPRESSION ASSOCIATED WITH TUMOURS OF PROXIMAL BILE DUCTS].

The treatment of tumours of proximal hepatic ducts (Klatskin tumours) remains a serious challenge because most patients are referred to the clinic at later stages of the disease. Its most common symptom is obstructive jaundice syndrome. Various methods of bile tract decompression have been proposed to resolve manifestations of this syndrome in the course of preoperative preparation for surgery of potentially resectable tumours and palliative treatment of incurable neoplasms. However analysis of the literature shows that the choice of an adequate method for the purpose remains a matter of debate.

[Effect of risk factors in colorectal cancer hepatic metastases].

The risk factors, influencing late results of surgical treatment, were analyzed in 69 patients, suffering a colorectal cancer hepatic metastases. The significance of clinico-morphological (the metastases maximal size, quantity, localization, the tumor grade, the hepatic affection synchronicity with primary tumor appearance, the hepatoduodenal ligament lymph nodes affection, microvascular invasion, the resection edges) and molecular (CK 20, beta-cat, Ki 67, Muc 2 and 5A) factors of prognosis was studied up. The hepatic resection variant was chosen, depending on the largest metastasis size present, the tumor nodes quantity and localization, the extrahepatic foci present, the lymph nodes affection and hepatic functional reserve secured. Basing on estimation of the level and type of expression for molecular factors there was determined correlation with the tumor recurrence rate. High degree correlation was established for the CK 20, beta-cat, Ki 67 expression and the recurrence rate, but it was not true for the Muc 2 and 5A expression. One, three and five years have survived 85, 50 and 31% of patients accordingly, and without recurrences--68, 27 and 14% accordingly. No one of clinico-morphological factors, but the metastasis grade, have had influenced the disease prognosis.

[The early rehabilitation of the patients following extensive liver resection and transplantation].

This study included 500 patients who had undergone extensive liver resection and transplantation of whom 250 were treated with the use of remedial gymnastics, physiotherapeutic factors, and massage. The positive dynamics of objective characteristics of the patients' condition. None of the treated patients showed a negative response to the proposed program of medical rehabilitation and activation throughout the early postoperative period.

[Volume of surgical resection by liver focal lesions].

Results of surgical treatment of 109 patients with focal lesions of the liver were analyzed. Volume resection by malignant and benign liver lesions was defined, depending on size, localization, number of foci and functional liver reserve. Postoperative lethality of patients with colorectal cancer metastases was 4.3%. Method of surgical treatment depended directly on the tumor stage. Overall 5-year survival by stage IVA hepatocellular cancer was 48%, 3.5-year survival was 62%. Overall and disease-free survival by colorectal cancer metastases was 35.1 and 22.4%, respectively.

[The role of biliary decompression and correction of dysbiosis in the treatment of obstructive jaundice].

The article providing in-depth analysis of pathogenesis of obstructive jaundice shows that this disease is manifest not only as changes at the hepatic level (cholestasis, cholehemia, cholangitis, cholangio- and lymphovenous shunts, hepatic encephalopathy) but also as marked dysbiotic disturbances due to anacholia and toxic metabolites that cause bacterial translocation and endotoxemia complicating liver insufficiency. Based on the literary data and original observations, a new scheme for the treatment of obstructive jaundice is proposed including simultaneous correction of both components of hepatoenteric turnover, also, it permits to improve the outcome of the postoperative period.

[Albumin dialysis (MARS therapy) in patients with hepatic graft dysfunction].

A primary nonfunctioning graft, the complication that develops in less than 5% of patients within the first 24-48 hours after hepatic transplantation, is responsible for high death rates in recipients. Its manifestations are an extremely grave clinical condition, hypotension, unconsciousness, progressive signs of hepatocytic insufficiency with increases in bilirubin levels and serum transaminase activities, addition of renal failure, and development of multiple organ dysfunctions. Eight patients underwent a total of 17 albumin dialysis sessions (1 to 5; mean 2.1). Each session lasted 6 hours. Albumin dialysis caused a significant reduction in the levels of serum bilirubin and its conjugated fraction, by an average of 24.7 +/- 15.1% per session. The activity of the serum enzymes of cytolysis and cholestasis significantly decreased with the parameters being stabilized within 7 days. Stabilization of hemodynamic parameters and better neurological status were noted in patients during treatment. The survival rate was 75% on days 7, 20, and 30. Hepatic retransplantation was made in 2 patients; 4 were discharged home and 2 died from multiple organ dysfunctions. Albumin dialysis used in patients with graft dysfunction provides a possibility of maintaining the patient in the critical period of searching for a donor's organ or regenerating the graft's function.