[Clinical and economic justification of icg-cholangiography in «difficult¼ laparoscopic cholecystectomy]. / Kliniko-ekonomicheskoe obosnovanie kholangiografii s indotsianinom zelenym pri «trudnoi¼ laparoskopicheskoi kholetsistektomii.

OBJECTIVE: To prove from a clinical and economic point of view the expediency of using ICG cholangiography in patients with «difficult¼ laparoscopic cholecystectomy for the prevention of damage to the bile ducts. MATERIAL AND METHODS: The results of treatment of 173 patients with cholelithiasis at various levels of health care providing were analyzed with regard to assessment of indicators of surgery complexity, developed complications and economic costs. RESULTS: The effectiveness of the original scale of «difficult¼ laparoscopic cholecystectomy has been proved. The financial and economic costs of treatment of patients with damage of biliary ducts and patients with cholelithiasis without development of complications have been analyzed and evaluated. A comparative description of financial costs for patients with «difficult¼ laparoscopic cholecystectomy with the use of ICG-cholangiography has been given. A program on care delivery for patients suffering from cholelithiasis in the conditions of region with regard to safety and economic effectiveness has been developed. CONCLUSION: The implementation of this program provides the minimization of postoperative complications and fatality at all levels of surgical care delivery. It has been established that a rational approach to reducing the number of biliary ducts damages is their prevention by prediction of «difficult¼ laparoscopic cholecystectomy and performance of such interventions in medical organizations of III level with the possibility of modern technologies use.

[Implementation of the «safe cholecystectomy¼ program in the Leningrad Region]. / Realizatsiya programmy «bezopasnaya kholetsistektomiya¼ v Leningradskoi oblasti.

OBJECTIVE: To present a treatment program for patients with cholelithiasis in the region in accordance with modern requirements for the quality of medical care in the realities of a three-level system of surgical care. MATERIAL AND METHODS: The results of treatment of patients with cholelithiasis at various levels of medical care were analyzed with an assessment of the indicators of operational activity of performing cholecystectomy by laparoscopic and open methods, the development of complications of surgery and inpatient mortality. RESULTS: A programmatic approach has been developed to assist patients with cholelithiasis in the conditions of regional healthcare at different levels of surgical care. CONCLUSION: The implementation of this program minimizes the number of postoperative complications and mortality at the second and third levels of surgical care. It is determined that a rational approach to reduce the number of bile duct injuries is their prevention by impeccable compliance with the technique of surgical intervention on the organs of the upper floor of the abdominal cavity, and to reduce the number of negative consequences - compliance with the proposed algorithm of diagnosis and treatment.

[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.

APPENDICEAL MASS: DIAGNOSTICS AND TREATMENT STRATEGY.

One of the frequent complications of acute appendicitis is appendiceal mass (AM). This research aimed to specify the criteria of AM diagnostics and determine the rational treatment strategy. It was stated that the duration of disease more than 3 days in combination with palpable infiltrate in the right iliac region and absence of positive appendiceal signs allowed formation of the clinical diagnosis of dense AM and definition of the following diagnostics program. An application of ultrasound study gave the possibility to differentiate AM according to maturity into loose and dense cases. Сomputer tomography and irrigoscopy were used routinely in controversial сases of differential diagnostics of dense AM and oncological diseases of the right areas of the large intestine. Diagnostic laparoscopy should be rational in patients with uncertain clinical findings during dynamic monitoring of imaging of inflammatory infiltrate in the right iliac region and it could facilitate to assess of the possibility of its safe separation. The application of given method of dia gnostics algorithm determined the treatment strategy: laparoscopic appendectomy in case of loose AM and conservative therapy in case of dense AM.

[Modern technologies and diagnostics in treatment of neuroendocrine tumors of the pancreas].

The article presents the results of investigation and treat- ment of 124 patients with neuroendocrine tumors of the pancreas (NET P): insulinima (68 cases), gastrinoma (43 cases), rare forms of tumor (13 patients). It was stated that clinical manifestations of NET P resembled the signs of neurological and gastroentero- logical diseases. Thus, the terms of detection would be prolonged during pre-admission stage and this validated the reasonabil- ity of well-timed application of current laboratory methods of diagnostics. An appropriate clinic neuroendocrine syndrome could be confirmed in 93-96% of patients. The authors showed that available diagnostic technique of NET P were the helical computer tomography and endoscopic ultrasound study with sen- sitivity 75% and 91%, respectively. It was rational to complete study with the data of intraoperative sonography for final tumor localization and its assessment in relation to the connection with pancreas duct and vessels. At the same time, it could be used in case of suspicion to multiple neoplasia. Angiography in combi- nation with arterial-stimulated blood sampling from the hepatic vein and positron emission tomography with 18-fluorodeoxyglu- cose were the additional methods of diagnostics concerning the main forms of limited hyperinsulinism and generalized forms of NET P. Immunohistochemical study of removed pancreas tumor was the main method of morphological verification of the diagnosis and it's used to develop the further strategy of postop- erative treatment for patients. The surgical method of treatment of patients with NET P allowed elimination of clinical laboratory manifestations of neuroendocrine syndrome and getting general cumulative 5-year survival (69.3 ± 4.7%) of radically operated patients.

[RESULTS OF DIAGNOSTICS AND TREATMENT OF ADRENOCORTICAL CANCER].

The results of examination and treatment of 96 patients with adrenocortical cancer (ACC) were analyzed. Local forms of ACC (I and II stages (T1-2N0M0) were found in 19 patients, locally advanced forms (III stage (T1-4NIM0; T3-4N0M0) - in 62 cases and metastatic forms of ACC (IV stage (TxNxM1) - in 15 patients. The diagnostic approach to ACC was optimized. It allowed identifying ACC on early stages of oncological process and staging of oncological process preoperatively in order to justify a rational treatment option. Surgical interventions were performed on 85 patients. The authors used an open access in 75 patients and endovideosurgical - in 10. The most common way of surgery was to remove an affected adrenal gland with fat of upper paranephrium and regional for adrenal lymph nodes (n=56). The adrenalectomy and nephrectomy were fulfilled on 23 patients. A removal of the right adrenal with tumor and thrombus of the interior vena cava was carried out in 2 patients. Some patients (n=4) underwent the explorative interventions. Combined treatment was applied in 28 patients with ACC of III stage. This gave a possibility to increase their life-span from 17,5±8,4 to 36,3±6 months. The overall 3-year survival rate for patients with ACC was 41,2% and 5-year survival observed in 18,7%. An application of modified treatment-and-diagnostics algorithm allowed increasing detection of patients with local and locally advanced forms of ACC in 2,5 times. Therefore, the application of rational treatment options have reduced the number of intraoperative complications from 38,8% to 10,2% and postoperative complication rates- from 61,1% to 20,4%, the lethality :rate - from 7,1% to 0% in early postoperative period. These measures have increased the life-span and life quality in 2 times.

[SUBSTANTIATION OF SURGICAL APPROACH IN IATROGENIC INJURIES OF THE BILE-EXCRETING DUCTS].

The results of examination and treatment were analyzed in 51 patients with iatrogenic injuries of the bile-excreting ducts. Patients were divided into 5 groups according to international classification (EAES, 2013). It depended on the time of detection, the nature and scale of damage of the bile ducts, mechanism of injury, development of infectious and septic complications. Injuries of the main bile duct were detected intraoperatively (n = 14). The complete intersection was in 10 patients (the first group) and the edge intersection--in 4 cases (the second group). Iatrogenic injuries of the bile-excreting ducts were revealed in 37 patients in postoperative period. There were the complete intersections in 28 cases (the third group) and the edge intersections--in 7 cases (the fifth group). Injuries of additional bile ducts were determined in 2 patients (the fifth group). An analysis of the main qualifying features of iatrogenic injuries of the bile-excreting ducts allowed defining indications to reconstructive-restorative surgery in 60.8% patients, restorative operations--in 29.4%, an external drainage--in 5.8% and reclipping of additional bile ducts in relaparoscopy--in 3.9%. The rational surgical approach allowed obtaining perfect results in 65.8% and good, satisfactory results in immediate and long-term period with low postoperative lethality of 1.95%. The study of diagnostics results and treatment of the patients with iatrogenic injuries of the bile- excreting ducts indicated about reasonability of assessment of main factors, which are based on iatrogenic injuries according to the EAES classification. An individual program of examination and more rational variant of surgery could be chosen due to this approach, which provides minimization of negative results and good quality of life.

[Variants of choice of surgical treatment of chronic pancreatitis in consideration of morphological changes in the pancreas].

The results of examination and treatment of 445 patients with chronic pancreatitis were analyzed. It was established, that 298 (67%) patients had indications for treatment in the conditions of surgical hospital. The patients were divided into three groups according to the modified pancreatitis classification of Marseilles-Rome 1988. There were the calcifying form (n = 78), obstructive form (n = 81), inflammatory form (n = 139). The application of modern methods of diagnostics and treatment of chronic pancreatitis allowed modifying the classification by selection of subgroups for each form of the disease. It was stated, that the substantiation of variants of surgical treatment of chronic pancreatitis in consideration of morphological changes in the pancreas could improve the possibilities of medical care plan for patients with minimal complications and good quality of life in long-term period of time.

[Programmed approach to the treatment of secondary hyperparathyroidism in chronic renal disease].

Prevalence and course of secondary hyperparathyroidism were studied in 616 patients with chronic renal disease. Disorders of mineral metabolism, which develop when person has chronic renal disease, appear at the early stage of the disease. They practically cannot be corrected on predialytic stage of treatment and lead to the development of parathyroid adenoma in patients with substitutive renal therapy by hemodialysis, that requires surgical treatment. Disorders of mineral metabolism regress after successful transplantation of the kidney practically in all cases.

[New approaches in treatment of patients with perforated duodenal ulcer].

The results of examination and treatment of 152 patients with perforated duodenal ulcer were analyzed with the aim to make the ground of systemic approach to their surgical treatment in consideration of contemporary achievements of laboratorial and instrumental diagnostics and the opportunities of minimally invasive surgery. The results of conducted clinical study showed that in order to establish the correct preoperative diagnosis and the choice of rational treatment of patients with perforated duodenal ulcer it is necessary to conduct a purposeful complex investigation, including an assessment of general somatic state and the operative-anaesthetic risk of patients and changes of pyloroduodenal zone and the severity of peritonitis and prediction of lethality. The diagnostic algorithm let the authors make a diagnosis of perforated duodenal ulcer before the operation and decide on an adequate volume of surgical intervention. It is established, that the integral assessment of the examination results and surgery, the evaluation of the titres of antibody to ulcerogenic strains Helicobacter pylori, studying of psychophysiological profile of patient can justify the complex program of medicamentous therapy in postoperative period, providing the remission of peptic ulcer.

[Features of chronic pancreatitis pathomorphism in the validity of surgical approaches].

The results of examination and surgical treatment of 298 patients with chronic pancreatitis and the original morphological investigations of material of the pancreas were studied. The data allowed the detection of additional criteria features of inclusion of the patients with chronic pancreatitis to be made in groups according to foreign Marseilles-Roman classification (1988). It is shown, that the basis of study of morphogenesis of chronic pancreatitis is immunohistochemical method, which let the authors diagnose not only the pathological changes of exo- and endocrine sections of pancreas, but at the same time the structural features of nervous apparatus and vessels of microcircular bed. The revealed morphological features of different forms of chronic pancreatitis vs clinical finding characteristics and the data of instrumental and laboratory methods of research allow the substantiation of surgical treatment version to be made.

[The diagnosis and treatment of chromaffinomas].

The results of examinations and surgical treatment of 117 patients with chromaffin tumors are shown: one-sided localization in the adrenal in 88% of the patients, bilateral localization in 4.3%, and extraadrenal in 7.7%. An analysis of the possibilities of the laboratory-instrumental diagnosis of chromaffinomas has shown that the method should be used in case of valid need. The absence of changes to the level of catecholamines and their metabolites in urine does not exclude the presence of chromaffinomas. The optimal access for the ablation of chromaffinoma of the adrenal larger than 5 cm in diameter is thoracofrenotomy in the tenth intercostal space. Endovideosurgical interventions in the adrenals can be used for the size of chromaffinoma less than 5 cm in diameter and with the absence of signs of malignisation and marked hemodynamic disorders. The superior medial laparotomy is expedient for extraadrenal pheochromocytoma of the abdominal area and for bilateral localization in the adrenals.

["Silent" pheochromocytomas]. / "Nemye" feokhromotsitomy.

The results of surgical treatment of 126 patients with "hormonally inactive" and catecholamine secreting tumors of the adrenals were studied. Among them 2 cases (1.6%) of "dumb" pheochromocytoma were diagnosed. The clinical observations have shown the difficulties in the diagnosis of "dumb" pheochromocytoma before operation, risk of performing adrenalectomy and necessity to correct hemodynamic disorders during anesthesia in connection with latent catecholamine activity. The laboratory and instrumental means of examination of patients with suspected "hormonally inactive" tumor of the medullary substance of the adrenal are proposed. The variants of prevention and arrest of hemodynamic disorders during ablation of the "dumb" pheochromocytoma were considered. When the "dumb" pheochromocytoma had the diameter less than 5 cm and the adequate preparation was conducted the authors propose a laparoscopic access for adrenalectomy on the right, and retroperitoneoscopic access on the left. The detection of the catecholamine secreting tumor of more than 5 cm diameter, when problems with the clipping of the central vein of the adrenal take place, open accesses should be preferred--mainly thoracophrenotomy in the X intercostal space. If it was not possible to prove "dumb" pheochromocytoma before operation and it was started with endovideosurgical intervention during which it was not possible to first clip the central vein of the adrenal and the risk of hemodynamic disorders was high, the early transition to open operative intervention is thought to be expedient.

[Clinico-anatomic rationale for the access and technique in video-endoscopic adrenalectomy]. / Kliniko-anatomicheskoe obosnovanie dostupov i tekhniki éndovideokhirurgicheskoi adrenalektomii.

The results of surgical treatment of 60 patients with tumors of the adrenals with the help of endovideosurgical techniques were analyzed and described. The article also presents the data of experimental investigations performed in 31 corpses of subjects of different constitution and topography of the adrenals in the retroperitoneal space and different accesses to them with the help of endovideosurgical technique. The most effective and safe accesses and the method of endovideosurgical adrenalectomy have been developed, substantiated and approbated in clinical practical work. In most cases the right laparoscopic and left retroperitoneoscopic adrenalectomies should be considered the operations of choice in treatment of patients with tumors of the adrenals. It was proved that the decision for the optimal endovideosurgical access and the corresponding adrenalectomy should be made individually for each patient with special reference to the clinicoanatomical criteria found. The endovideosurgical adrenalectomy should not be opposed to open methods of surgery which are expedient in patients with large size of the tumor, signs of malignancy and possible intraoperative complications.