[Pancreaticoduodenectomy - results and prospects (two-center study)]. / Pankreatoduodenal'naya rezektsiya ­ rezul'taty i perspektivy (dvukhtsentrovoe issledovanie).

OBJECTIVE: To summarize the results of pancreaticoduodenectomy (PD) for pancreatic tumors and complications of chronic pancreatitis regarding prediction and prevention of postoperative complications. MATERIAL AND METHODS: There were 336 PD procedures between 2016 and mid-2022 in two centers. We assessed the factors influencing specific postoperative complications (postoperative pancreatitis, pancreatic fistula, gastric stasis, arrosive bleeding). Several risk factors were distinguished: baseline pancreatic disease and tumor size, CT-signs of a «soft¼ gland, intraoperative assessment of the pancreas, number of functioning acinar structures. We assessed surgical prevention of pancreatic fistula via preserving adequate blood supply to the pancreatic stump. The last one is provided by extended pancreatic resection and reconstructive stage of surgery, i.e. Roux-en-Y hepatico- and duodenojejunostomy with isolation of pancreaticojejunostomy on the second loop. RESULTS: Postoperative pancreatitis underlies specific complications after PD. The risk of pancreatic fistula in case of postoperative pancreatitis increases by 5.3 times compared to patients without pancreatitis. Postoperative pancreatic fistula is more common in patients with T1 and T2 tumors. According to univariate analysis, only pancreatic fistula significantly affects the risk of gastric stasis. Among 336 people who underwent PD, pancreatic fistula occurred in 69 patients (20.5%), gastric stasis - in 61 (18.2%), pancreatic fistula complicated by arrosive bleeding - in 45 (13.4%) patients. Mortality rate was 3.6% (n=15). CONCLUSION: Modern prognostic criteria are valuable to predict specific complications after PD. A promising way to prevent postoperative pancreatitis can be extended pancreatic resection considering angioarchitectonics of the pancreatic stump. Roux-en-Y pancreaticojejunostomy is advisable to reduce aggressiveness of pancreatic fistula.

[Enucleation of pancreatic tumors: a multiple-center study]. / Enukleatsiya opukholei podzheludochnoi zhelezy (mnogotsentrovoe issledovanie).

OBJECTIVE: To evaluate the immediate results of enucleation of pancreatic neuroendocrine tumors (pNETs). MATERIAL AND METHODS: The results of enucleation of pancreatic neuroendocrine tumors (pNETs) were analyzed in 95 patients between 2016 and 2021. Functioning tumors (mean size 16.8 mm) were found in 70 patients, non-functioning (mean size 25 mm) - in 25 patients. Intraparenchymal tumors were found in 48 people, extraorganic lesion - in 47 patients. RESULTS: There were 262 patients with pNETs who underwent various surgeries between 2016 and 2021. Various resections were performed in 167 (63.8%) cases, enucleations - in 95 (36.2%) patients. Traditional surgical approach was used in 65 patients. Pancreatic fistula occurred in 21 patients (type B - 17, type C - 4), while arrosive bleeding occurred in 6 patients with unfavorable outcomes in 2 cases. Minimally invasive surgeries were performed in 30 patients. Eight patients with intraparenchymal tumors required conversion to open surgery. Type B pancreatic fistula occurred in 5 patients that led to arrosive bleeding in 2 cases (hemostasis was provided by endovascular method). Comparison of intraparenchymal and extraorgan tumors regarding the incidence of pancreatic fistula revealed odds ratio 5.26 (95% CI 1.5355; 18.0323, p=0.0041). Postoperative mortality was 2.1%. CONCLUSION: Enucleation is advisable for highly differentiated pancreatic neuroendocrine tumors up to 2 cm. Minimally invasive enucleation is indicated for extraorgan tumors. Intraparenchymal tumors significantly increase the risk of postoperative complications.

[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.

[OPEN NECROSECTOMY IN THE COMPLEX TREATMENT OF THE SEVERE ACUTE PANCREATITIS].

The aim of the study was to determine the indication for the method of open abdomen-open necroseqtomy in the complex treatment of acute pancreatitis. 74 patients with the diagnosis of acute pancreatitis were selected for the treatment. Patients were divided by severity of disease: mild acute pancreatitis - 29 patients were treated by conservative method; moderate acute pancreatitis - 29 patients were treated by following methods: 17 patients - by conservative method; 4 patients by conservative treatment with fasciotomy; 8 patients - by open abdomen method without fasciotomy after conservative treatment. Severe acute pancreatitis - 16 patients were treated by following methods: 2 patients by open abdomen technique with single necroseqtomy and sanitation after fasciotomy, 8 patients - with the method of open abdomen from which 3 patients needed a single necroseqtomy and sanitation, 3 patients had a double necroseqtomy and sanitation and 2 patients three and four times the necreseqtomy and sanitation were used with a fastener, 6 patient were treated conservatively. We identified indication and contraindication for treatment of severe acute pancreatic necrosis by open necroseqtomy. Indications: 1) Pancreatic and/or peripancreatic necrosis (based on contrast-enhanced dynamic CT scan) complicated by documented infection (guided FNA culture or extraluminal retroperitoneal gas). 2) Sterile necrosis with progressive clinical deterioration despite maximal medical treatment. Contraindications: 1) Pancreatic and/or peripancreatic necrosis without evidence of infection or clinical deterioration. 2) Early operation (within a week from onset of acute pancreatitis) before the systemic inflammatory response syndrome (SIRS) is stopped and intensive conservative treatment is still required.

[Leiomyosarcoma of the splenic vein]. / Leiomiosarkoma selezenochnoi veny.

Vascular leiomyosarcoma (LMS) is an extremely rare disease. Venous lesion is approximately 5 times more common than arterial. LMS is usually found in retroperitoneal veins and in inferior vena cava. Lesion of the splenic vein is extremely rare. A 52-year-old woman with recurrent abdominal pain is reported in the article. Abdominal contrast-enhanced CT revealed a 6 cm tumor of the pancreatic tail. The patient underwent laparoscopic distal pancreatectomy with splenectomy en bloc. Histological and immunohistochemical studies revealed LMS originating from the smooth muscles of the splenic vein. Surgery was followed by adjuvant chemotherapy. There was no local recurrence in 1 year after surgery. In this article, we analyze the available information on leiomyosarcoma of the splenic vein.

[FASCIOTOMY IN THE COMPLEX TREATMENT OF THE ABDOMINAL COMPARTMENT SYNDROME FOR PANCREATIC NECROSIS].

The long-term history of studying of a problem of acute pancreatitis in its different aspects, is fight against a pancreatic necrosis and a pancreatic infection. Technology progress in improvement of diagnostic methods and treatment of a pancreatic necrosis and its complications, changed a situation, but treatment of such patients remains the most difficult task for the doctors dealing with pancreatitis issues. The main factor of risk at a pancreatic necrosis are: gland necrosis volume, the severity of enzymatic endo intoxication, degree of intraabdominal hypertension, a translocation of microbes from intestines in the blood circulation and an abdominal cavity. The Abdominal Compartment Syndrome (ACS), at a pancreatic necrosis is connected with presence of multiorgan insufficiency, caused by intraabdominal hypertension. Definition of indications of a fasciotomy in the complex treatment of the adominal compartment for pancreatic necrosis was our research objective. Management of intraabdominal hypertension and ACS consists of a maintenance therapy and if necessary, an abdominal decompression which is considered one of treatment methods. The difficulty of a decompression of an abdominal cavity at ACS which arose on the background of a pancreatic necrosis is that laparotomy in the first phase of its treatment is extremely undesirable and even harmful manipulation which is related to infecting necrotic zones that considerably aggravates the prognosis. These requirements are met by a fasciotomy i.e. broad section of an aponeurosis on the white line of a stomach. The volume of an abdominal cavity at this manipulation increases at the expense of a diastasis of rectus muscle and stretching of skin and peritoneum, while the abdominal cavity hermetism is maintained. We have performed subcutaneous fasciotomy in 4 patients for ACS treatment. The fasciotomy is a targeted mini invasive method for the complex treatment of pancreatic necrosis. Performing fasciotomy and use of a modern complex of an intensive care will allow to achieve improvement of results in the treatment of patients with pancreatic necrosis, without performance of traumatic laparotomy and a laparastomy.

[Relationship of tumor necrosis factor alpha expression with activation of sphingomyelinase and lipid peroxidation after removal of cholestatic factor].

The goal of this work was to study the expression of tumor necrosis factor alpha (TNFalpha), sphingomyelin cycle activation, and lipid peroxidation (LPO) processes after the removal of a cholestatic factor in the liver subjected to different durations of cholestasis. Restored bile flow after a 9-day hepatic cholestasis normalized sphingomyelinase (SMase) activity and levels of TNFalpha and LPO products. The removal of a cholestatic factor after a 12-day cholestasis did not normalize the studied parameters: SMase activity and the levels of TNFalpha and LPO products remained much higher compared to control. A significant positive correlation between TNFalpha expression, SMase activity, and LPO rate has been revealed. The obtained data indicate that hepatocyte apoptosis after bile outflow restoration in late cholestasis can be due to the activation of the sphingomyelin cycle, LPO, and TNFalpha expression. The synergistic interaction can sharply increase the proapoptotic capacity of each of these factors since TNFalpha activates SMase and LPO, SMase activity depends on the LPO rate, while ceramide, an SMase-produced secondary messenger of apoptosis, can induce oxidative stress.

[Chronic pancreatitis: resective and decompressive procedures].

PURPOSE: Definition of resective and decompressive operations in chronic pancreatitis. MATERIALS AND METHODS: A retrospective analyses of surgical management of 51 chronic pancreatitis patients is carried out. 24 patients underwent longitudinal pancreaticojejunostomy (PA), 27--pancreatic head ( PH) resective procedures: Beger--5, modified Frey (PH intraparenchimatose resection-- IR, supposing removal of fibrous masses from the ventral and greater part of the dorsal PH)--22. According to the character of the PH lesion the patients were divided in 3 groups: head dominant (13), total (11) and cystic pancreatitis (20). RESULTS: One early postoperative death developed after reoperation for adhesive intestinal ileus in patient with PA. No mortality was noted after IR. Remote results in terms of 4.8+/-0,7 years were studied in 32 (71%) patients underwent PA and IR. IR lead to good and satisfactory results. After PA poor results came to 5 (29.5%). CONCLUSIONS: Combination of PH IR and PA is indicated in head dominant and total chronic pancreatitis patients. In cases of pseudocysts and dilation of the main pancreatic duct (>6-7 cm) decompressive variant of procedure cysto-pancreato-jejunostomy is preferable.

[Changes in sphingomyelinase activity, tumor necrosis factor alpha level, and lipid peroxidation rate in the course of development of cholestatic liver injury].

Changes in sphingomyelinase activity, tumor necrosis factor alpha expression, and lipid peroxidation rate in the course of development of cholestatic liver injury have been studied. The same type phase shifts in the parameters analyzed were observed, which included a marked decrease at the early stages of cholestasis (days 3-6) and a pronounced increase at the later stages (days 12-16), i.e., under the conditions of developed pathology. There is a significant positive linear correlation between tumor necrosis factor alpha expression, sphingomyelinase activity, and lipid peroxidation rate during cholestatic injury. The changes detected may reflect balance between the effects of the two major bile components--bilirubin, which is accumulated in the liver at the early stages of cholestasis, and bile acids, whose influence dominates at the later stages of pathologic process. Our results indicate that tumor necrosis factor alpha overexpression, the sphingomyelin cycle activation, and lipid peroxidation intensification may cause apoptosis of hepatocytes at the late stages of cholestasis.

Extracorporeal immunopharmacotherapy in patients with chronic septic cholangitis.

An immunological examination of patients with septic cholangitis revealed secondary immunodeficiency. Traditional methods of therapy and immunocorrection were ineffective in eight patients with septic cholangitis. They were treated with extracorporeal immunopharmacotherapy using diuciphon. For the accomplishing detoxication, this was used in combination with plasma exchange. The course of treatment consisted of 3 or 4 procedures, within a 3- or 4-day interval. As a result of extracorporeal immunocorrection, patients were observed to have positive immunological indexes, demonstrated by the normalization of the lymphocyte count in 5 of 6 patients, CD3+ and CD4+ in 3 patients, and CD8+ in 4. Four patients had clinical remissions (0.5 year), and 3 patients underwent surgery with no septic postoperative complications.

[Biliary sepsis: some peculiarities of pathogenesis]. / Biliarnyi sepsis: nekotorye osobennosti patogeneza.

Results of clinical study of 87 biliary sepsis patients and experimental study on 54 rats with obstructive jaundice and cholangitis are presented. Own and literary data are compared. Specific immune and portal haemodynamic changes, provoced by obstructive jaundice are main pathogenic factors defining specific course of biliary sepsis. These changes are: 1) gut bacterial and endotoxin translocation, portal endotoxaemia; 2) reduction of RES and Kupfer cell function and endotoxin break into the systemic circulation; 3) liver parenchyma ischemia and milliary abscess formation; 4) portal blood flow shunting into the general circulation additionally increasing systemic endotoxaemia. These factors determine rapid, even fulminate development of milliary abscesses of the liver and multiorganic failure. The authors suggest that etiologic and pathogenic factors, causing peculiarities of the clinical course should be indicated in the diagnosis of septic patient.

[Doppler ultrasonic evaluation of hepatic functional reserve]. / Ul'trazvukovaia dopplerovskaia otsenka funktsional'nogo rezerva pecheni.

Ultrasonic Doppler measurement of the blood flow in the portal vein and hepatic artery was conducted to evaluate the function and functional reserve of the liver in 146 patients with various forms of cholangitis combined with biliary cirrhosis and hepatic insufficiency. The functional reserve of the liver was judged by comparison of the basic blood flow on a fasting stomach with the blood flow after a functional histamine load. Five types of responses of the portal vein blood flow to the functional load according to the degree of disturbed hepatic function were revealed. Comparison of the flow of blood along the portal vein in healthy individuals with that in patients with diabetes mellitus and a formed splenorenal shunt showed that disconnection of the blood flow from the splenic vein has no effect on the flow of blood in the portal vein. The latter is regulated at the level of microcirculation in the liver, which is confirmed by the correlation between the blood flow in the portal vein and in the hepatic artery.

[Disorders of organic hemodynamics of the liver and their correction in suppurative cholangitis]. / Narusheniia organnoi gemodinamiki pecheni i ikh korrektsiia pri gnoinom kholangite.

The blood flow in the portal vein and hepatic artery was studied by means of ultrasonic Doppler flow measurement to investigate organic and regional hemodynamics of the liver in purulent cholangitis. The blood flow in the portal vein was found to be significantly diminished in patients with acute cholangitis and hepatic failure. Hepatic microcirculation was studied on a experimental model of obstructive jaundice and obstructive purulent cholangitis in rats by polarographic measurement of hydrogen clearance. Considerable reduction of the volume rate of the local blood flow was noted, and the degree of the reduction was related to the severity and duration of the disease. Decompression of the biliary tract by external drainage improved the local blood flow rate which, however, diminished again in prolonged external drainage. The use of pharmacological agents for correction of microcirculation in decompression of the biliary tract led to total and rapid correction of the volume rate of the local blood flow.

[Diagnosis and surgical treatment of pancreonecrosis]. / Diagnostika i khirurgicheskoe lechenie pankreonekroza.

Actual problems of diagnosis and treatment of pancreonecrosis (PN) are discussed. Results of treatment of 154 patients hospitalized with sterile necrosis SN (n = 133) and infected PN (n = 21) were analyzed. SN became infected in 49 patients. The diagnostic methods were as follows: USE, CT, biochemical examinations of blood, urine and exudate. Percutaneous puncture contrast retroperitoneography (PPCR) was developed. It is demonstrated that modern diagnostic methods and PPCR permit one to diagnose PN, detect location, zone of retroperitoneal fat's necrosis and characterize its infection. The size of lesion of retroperitoneal fat in patients with sterile PN (n = 133) does not determine severity of the patients' condition and early lethality, but increases the risk of infection and makes worse prognosis of the disease. In laparoscopic sanation of the abdominal cavity for fermentative peritonitis, compared with laparotomic one, infection developed less rarely (10.2 and 40%, p < 0.01) and lethality decreased. Lethality in repeated mini-invasive surgeries through burso- and retroperitoneostomas performed in 34 patients with infected pancreonecrosis was 17.6% that is lower than one in repeated relaparotomies (n = 21, lethality 47.8%).

[Double internal drainage in benign choledochal lesions]. / Dvoinoe vnutrennee drenirovanie pri dobrokachestvennykh porazheniiakh kholedokha.

Double internal drainage of ductus choledochus was performed in 122 patients by a combination of transduodenal papillosphincterotomy and supraduodenal choledochoduodenostomy which makes up 10.3% of all the operations on extrahepatic biliary ducts. The results of double internal drainage of ductus choledochus in benign lesions were favourable: postoperative lethality was in 2,5%, good remote results were noted in 83,2%, satisfactory--in 13,3%, unsatisfactory--in 3,5% of cases.

Relationship between parameters of lipid peroxidation during obstructive jaundice and after bile flow restoration.

Restoration of bile flow after 9-day cholestasis in rat liver normalized the content of lipid peroxidation products. The removal of the cholestatic factor after 12-day cholestasis was not followed by recovery of these parameters. We showed that measurement of serum concentration of lipid peroxidation products in patients with cholelithiasis during the preoperative period holds promise for selection of the optimum time for surgical treatment and prediction of the risk of postoperative complications.