[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.

[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.

[Improving of the efficiency of combined treatment for locally advanced gastric cancer with the use of neoadjuvant selective arterial oil chemoembolization].

The study presents a summary of results of examination and treatment of 40 patients with locally advanced gastric cancer for the period from 2009 to 2015. The most frequently there were diagnosed III C and II B stages of the disease, while 62.5% of all cases were of stage III. Adenocarcinoma of low and moderate differentiation was diagnosed in 30 (67.2%) cases. Most cases (87.5%) occurred in the body and antrum. Men were 21 (52.5%), women - 19 (47.5%). The mean age of patients was 60.9±11.4 years. At the time of initiation of treatment complicated course of locally advanced gastric cancer was in almost all patients. Anemia of varying severity was diagnosed in 24, signs of bleeding were found in 6 patients. Subcompensated stenosis of the antrum was detected in 9 patients. All patients underwent diagnostic angiography to study the vascular anatomy hepatopancreatoduodenal zone as well as to determine the nature of vascularization of tumor of the stomach and the sources of its blood supply. In 34 patients, whose vascular anatomy of tumor was represented by the presence of main supply vessel, the first phase of the combined treatment was selective intraarterial oil chemoembolization. Surgical stage of combined treatment was carried out in 30 patients. Distal subtotal gastrectomy was performed in 13 patients, total gastrectomy - 15 patients. Radical removal tumor (RO) was achieved in 26 patients with a relatively small number of postoperative complications. Wherein optimum interval between rentgenoendovascular intervention and surgery was 1-4 weeks, during which primary response of tumor and its metastases in regional lymph nodes on neoadjuvant regional chemotherapy was maximally realized.

[Regional chemotherapy in treatment of patients with unresectable liver metastases of uveal melanoma].

PURPOSE: Retrospective efficacy analysis of transcatheter arterial treatment for unresectable liver metastases of uveal melanoma. MATERIALS AND METHODS: There were performed 38 courses: hepatic arterial chemoembolization with Lipiodol (HACE, n 9) and combination of HACE with hepatic artery infusion (HAI, n = 29). In 9 patients we used the following chemotherapeutic agents: doxorubicin (10-50mg), carboplatin (150 to 450 mg), dacarbazine (200-400mg), mustophoran (360-624mg) and mitomycinum C (5-10mg). RESULTS: There were no mortality or serious complication. According to mRECIST, partial response, stabilization and progression of liver metastases was seen in 1, 3 and 5 patients, retrospectively. The mean survival after arterial treatment was 9,4 (2-34) mo. The 6-, 12- and 18- mo survival rates were 56%, 22% and 11% respectively. CONCLUSION: Transcatheter therapy in unresectable liver metastases of uveal melanoma is safe and can prolong survival of selected patients up to 34 mo.

ARTERIAL CHEMOINFUSION IN PATIENTS WITH LOCALLY ADVANCED AND METASTATIC PANCREAS CANCER.

The chemoinfusions (310) were carried out in celiac trunk in 167 patients with non-removed pancreas cancer at the period from 2000 to 2015. Locally advanced timorous process (stage III, n=79) was revealed in 79 patients and liver metastases (stage IV, n=88) were noted in 88 cases. The celiac axis infusion by Gemcitabine (1000 mg/m²) was applied for patients and GEMOX (Gemcitabine+Oxaliplatin 75 mg/m²) has been using since 2012. Symptomatic improvement such as decrease of pain, growth of body weight was noted in majority of patients. An average lifetime, median and one-year survival consisted of 7,6 months, 5,8 months and 10%. The patients (133) were treated by 1­2 cycles and after that by course of total body chemotherapeutics. There weren't any serious complications. Toxic manifestations of chemotherapy weren't higher than I­II degree and they were arrested by corrective therapy in 92 patients (55%). The celiac axis infusion is safe in patients with locally advanced and inoperable pancreas cancer. Symptomatic improvement showed the most patients. The objective response to the treatment had 20% patients and performance of repeated cycles led to increase of their survival.

[Long-term results of combined x-ray endovascular surgical treatment of patients with ductal adenocarcinoma of the pancreatic head].

On the basis of the results of treatment of 105 patients with locally advanced ductal adenocarcinoma of the pancreatic head the authors present the results of work over a period of time since 1999 to 2009. In the main group the combined treatment was used for 51 patients: the non-adjuvant selective chemoembolization of the pancreatic head adenocarcinoma was performed, than standard gastropancreatoduodenal resection with lymphodesection and 6 cycles of adjuvant chemoinfusion in celiac trunk were completed. In control group standard gastropancreatoduodenal resection was performed. In the group of combined treatment the 1-, 2-, 3-year survival rates consist of 80.4%, 58.8% and 43.1%, respectively. The average life span was 22.3+/-2.1 months. The average life span of 54 patient of control group was 8.4+/-2.1 months and a common 3-year survival consists of 13%. There was no lethality after the performance of X-ray endovascular procedures and gastropancreatoduodenal resection. Postoperative complications reliably didn't differ in both groups.

[Roentgenoendovascular hemostasis of arterial bleeding after major surgery for pancreatic cancer].

The efficacy of angiographic hemostasis in cases of massive arterial bleeding after major pancreatic resection was evaluated. Late life-threatening arterial hemorrhage developed in 3 out of 65 patients (4.6%) within 12, 20 and 42 days after pancreatic carcinoma resection. In all cases emergency roentgenoendovascular procedures were fulfilled for hemostasis. Six therapeutic angiographic procedures (from one to three per a patient) were performed. All of them were clinically and technically successful. Depending on the bleeding localization and the character of vascular lesion, the embolization (n = 5) or stent-grafting (n = 1) were used. The further prognosis was dependent on the success of treatment of complications and the course of the malignant disease. The emergency angiography with endovascular hemostasis appears to be the method of choice in treatment of postoperative visceral bleedings especially in patients with high surgical risk.

[Complications of trans- and suprapapillary percutaneous and transhepatic stenting of bile ducts in patients with mechanical jaundice of tumorous etiology].

The authors made an analysis of complications in percutaneous endobiliary prostheses in 82 patients for obturative jaundice of tumorous etiology. The stents were placed over the major duodenal papilla and transpapillary. There were no lethal outcomes. Complications developed in 10 patients (12.2%) were: purulent cholangitis, stent migration or occlusion, abscess of the anterior abdominal wall, formation of biloma and hemobilia. Complications were arrested using conservative methods of treatment and/or minimally invasive procedures. Endoprostheses of bile ducts were shown to be an effective and relatively safe method of correction of mechanical jaundice of tumorous etiology. The number of complications in transpapillary stenting was not greater than in suprapapillary method.

[Role of intrventional radiology in pre- and postoperative periods of liver transplantation].

The purpose of this study was to prove the use of interventional radiological procedures before and after liver transplantation (LT). Between 1998 and 2009 years, 54 LT were performed in 52 patients. 18 patients received 19 interventional radiological treatments including 11 preoperative (trans-catheter oily chemoembolization of hepatocellular carcinoma, n=3; transjugular intrahepatic portosystemic shunting, n=8) and 8 postoperative (drainage or stenting of biliary strictures, n=4; balloon dilatation and/or stenting of inferior vena cava or cava-caval anastomosis, n=3; splenic artery embolization in sleal syndrome, n=1). It is concluded that before LT, trans-catheter embolization delays the growth of hepatoma and prolongs time for donor liver waiting. Transjugular portosystemic shunt decreases the risk of fatal variceal bleeding. Post-LT complications such as vascular or biliary strictures and steal syndrome can be also effectively corrected by methods of interventional radiology.

[Methods of correcting hepatic arterial blood supply for subsequent implantation of the "port-catheter" infusion system].

The study was undertaken to investigate the feasibility of using surgical and roentgenoendovascular redistribution of the hepatic arterial blood flow for adequate implantation of the "port-catheter" infusion system. Between December 2001 and March 2008, we performed surgical (n = 25) or transcutaneous (n = 22) implantations of the infusion systems for carrying out regional chemotherapy in a total of forty-seven patients presenting with hepatic metastases of colorectal carcinoma. Anatomical variants of the hepatic arteries were observed in eleven cases. The blood stream was corrected by means of either transcatheter embolization (n = 7), ligation (n = 2), or transposition (n = 2) of the aberrant arteries. No complications were encountered. In all the cases, the "port-catheter" system was implanted successfully, with adequate hepatic perfusion achieved. Both transcatheter embolization and surgical reconstruction turned out to be efficient methods in correction of the blood flow in various anatomical structures of the hepatic arteries, thus favourably contributing to increased efficacy of regional chemotherapy.

[Transcatheter treatment of liver metastases from breast cancer].

Transcatheter treatment for liver metastases from breast cancer was given to 55 patients (1995-2006): hepatic artery infusion (HAI) with 5-fluorouracil, doxorubicin and carboplatin--11; hepatic artery oil chemoembolization (HAOC) with doxorubicin--14; taxotere (Docetaxel)--17; HAI+HAOC--13. Partial response was reported in 18%, stabilization--27%, metastatic progression--55%. Mean survival (MS) of all deceased patients--11.9 +/- 1.5; 1-, 2- and 3-year survival--40, 20 and 0%, respectively. HAOC: partial response and stabilization--42%, progression--58%. As of January 2007, 7 patients survived 8-22 months (mean 14.3 months); 24 deceased had survived 16.8 +/- 3.3 months. HAOC+HAI: complete response--8%, partial--23%; stabilization--44%; progression--25%. Three patients have survived 24, 33 and 82 months; mean survival of 10 deceased--19.9 +/- 4.5 months, their 1-, 2- and 3-year survival was 90, 60 and 20%, respectively.. Mean survival of doxorubicin-treated patients was 18.9 +/- 1.6, taxotere--24.8 +/- 5.1 months (p < 0.05); 1-, 2- and 3-year survival- 57, 29 and 7%, and 88, 35 and 24%, respectively. HAOC+HAI was the most effective while application of taxotere was followed by longest mean survival.

[Rentgenoendovascular interventions into treatment of patients with unresectable metastases of gastric cancer into the liver].

In the period from 1992 through 2006 transcatheter therapy was carried out in 46 patients with unresectable metastases of gastric cancer (MGC) into the liver. Repeated cycles of chemoinfusions in the hepatic artery (CIHA) with 5-fluorouracil, doxorubicine, mitomicine C and carboplatin were made to 35 patients. Chemioembolization of hepatic arteries (CEHA) using the same cytostatics and oil contrast agent was made toll patients. After CIHA a partial response to treatment and stabilization of the tumor growth was noted in 14 (40%) patients, progressing metastases in 21 (60%) patients. Mean survival period of 32 dead was 14.6 +/- 1.5 month and the indices of 1-, 2- and 3 years survival were 46, 15 and 5 % respectably. After CEHA a partial response and stabilization of the tumor growth were noted in 7 (63%) patients and in the rest 4 patients (37%) there was progressing. The mean survival period of 9 dead patients was 15.5 +/- 3.3 months; the indices of 1-, 2- and 3 years survival were 55, 18 and 10 % respectively (p(CINA-CEHA) > 0.01). The methods of interventional radiology are thought to be perspective for treatment of unresectable metastases into the liver.

[Intraarterial chemotherapy using implantable port-catheter system in patients with colorectal liver metastases].

We evaluated the tentative clinical results of port-catheter system implantation in 32 patients (18 males and 14 females) with liver metastases of colorectal cancer (2001-2006). Laparotomic approach was used in 17 and percutaneous transfemoral implantation - in 15 patients. There were no complications nor technical problems. All patients received a total of 160 cycles of infusion chemotherapy, ranging 2-11 (4 on the average); mean follow-up - 241 (57-730) days . At present, 21 patients have survived for 5-28 months. Three of them (14%) report complete response, 13 (62%) - stabilization and 5 (24%) - tumor progression. One-year survival in all patients was in 76.5%. Eleven patients died through tumor progression unrelated to the liver.

Preoperative portal vein embolization for liver malignancies.

BACKGROUND/AIMS: To study effectiveness of preoperative portal vein embolization before extensive hepatic resection in patients with primary or secondary liver malignancies. METHODOLOGY: Between December 1997 and May 2003, right portal vein embolization was performed in 24 patients. The indication to the procedure was a small amount (< 30%) of the future remnant liver. Ultrasound-guided percutaneous transhepatic puncture of the portal vein and embolization of its right lobar branch with Lipiodol, ethanol, gelatin sponge and/or steel coils were used. RESULTS: There were no complications of the procedure. In 19-56 (mean, 30) days, CT or MRI showed significant increase of the future remnant liver volume from 25% to 35% of the whole liver; the mean increase was 40%. Laparotomy was performed in 15 patients. Right, extended right hepatectomy, and repeated resection were performed in 7, 6, and 1 patient respectively, while one patient underwent only exploration because of tumor progression. Of 14 resected patients, 11 showed no postoperative liver failure. The latter was medically cured in two of three remaining patients, while one patient (future remnant liver < 30% even after the embolization) died from liver failure in 20 days after the surgery. Hepatic resection is planning in 4 of 9 non-operated patients. The 5 patients were not operated because of tumor progression. CONCLUSIONS: Right portal vein embolization is a safe and technically simple procedure that decreases the risk of postoperative hepatic failure after major liver resection.