[Neuroendocrine tumors of a pancreas: 30 year's experience of clinic of faculty surgery of N.N. Burdenko].

N.N. Burdenko surgery clinic have an experience of treatment of 342 patients with gastroenteropancreatic neuroendocrine tumors. Original algorithms of diagnosis, complex treatment and postoperative management were applied. We achieved 100% five-year survival rate after radical surgery and reduced postoperative complications 1.6 times.

[Prognostic factors of the immediate results of surgical treatment of organic hyperinsulinism].

The clinic obtains the experience of treatment of 245 patients with organic hyperinsulinism. The main goal of the treatment of that category of patients is an improvement of immediate results of surgical treatment which leads to the decrease in mortality level. Authors set the diagnostic and intra- and postoperative treatment algorithm, as well as the major prognostic factors of postoperative morbidity rates. The use of the algorithm allowed the 1,5 decrease in postoperative morbidity and twice decreased the lethality rate.

[Challenges and opportunities for endoscopic ultrasound in the preoperative diagnosis of topical insulin the pancreas].

Insulinoma in most cases is monohormonal orthoendocrine tumor. This fact limits its searching area by a pancreas. However the insulinoma's clinical picture can be caused by other pathology. Therefore the main task of visual the tumor but also to use all the possibilities of each method for defining type of surgery and avoiding such errors and complications, as pancreatorrhage, damage of bile or pancreatic duct, necrosis of duodenal wall, etc. On the basis of our own experience of endoscopic ultrasound for 61 patients with 66 insulinomas, we have allocated the basic variants of insulinoma ultrasound pictures: hypoechoic, heteroechoic, isoechoic tumor, and also foci without a trustworthy contour. On the basis of the analysis of our own errors we have essentially added the technique, having used multiplane pancreas scanning and biplane tumor scanning. Important points in EUS algorithm are also the following items: detecting tumor relationship to pancreatic surface, distance from the tumor to the ducts, gastrointestinal wall and vessels--for definition of possibility of the tumor enucleation; careful scanning of pancreas even after detecting one tumor--for an exception of multiple tumors, especially at MEN-I; careful scanning of a contour of the gland for an exception of parapancreatic insulinomas; estimation of vascularization not only of the detected tumor and suspicious foci, but also of all the gland--for detection of hypervascularized isoechoic tumors; revealing and the description of focal changes, especially more homoechogeneous in comparison with surrounding parenchyma-- for selection patients for examination by other methods; scanning of zones of possible metastasis. Examination of patients with organic hyperinsulinism demands combined application of two or more techniques. Use of all modern possibilities of endosonography can put this technique on one of the first places in the diagnosis of insulinomas.

[Noncontrast computed tomography in the diagnosis of tumors of the major salivary glands].

Non-contrast computed tomography (CT) of the major salivary glands was made in 127 patients, which revealed 95 space-occupying lesions (88 intraglandular and 7 extraglandular ones). Pleomorphic tumors of the parotid glands are solitary, round, high-density (29.6 +/- 4.2 HU) masses with well-defined, smooth margins. Salivary cysts were characterized by the presence of a dense capsule; the density of cyst contents was 8.0 +/- 2.0 HU. Salivary lipomas had a characteristic tomographic pattern due to the presence of adipose tissue; the lipoma density was -108.3 +/- 7.8 HU. Malignant parotid tumors were characterized by the presence of higher-density masses with irregular shapes and ill-defined, indistinct margins. Benign submandibular gland tumors had no well-defined margins that separated the tumor from the gland; the density of a tumor matched that of the parenchyma; the mean tumor size was 3.6 +/- 1.3 cm; there was an increase in the sizes of the gland as compared to those of the contralateral gland, as well as a displacement of the adjacent soft tissues. Malignant submandibular gland neoplasms tumors were characterized by the presence of inhomogenous lower-density masses with irregular shapes. Enlarged paraglandular lymph nodes were observed. The sensitivity, specificity, and accuracy of native CT in diagnosing space-occupying lesions of the salivary glands were 97.6, 96.4, and 97.6%, respectively.

[Volumetric dynamic computed tomography angiography in the topical diagnosis of sporadic insulinomas].

The authors analyzed the data of contrast-enhanced multislice spiral computed tomography (MSCT) angiography versus those of volumetric dynamic computed tomography, percutaneous and endoscopic ultrasonography, selective angiography, and arterial stimulation blood sampling in the diagnosis of sporadic insulinomas depending on the size and site of the tumor. Forty-five patients (25 women and 20 men) aged 20 to 55 years (mean age, 43.4 +/- 2.8 years) with characteristic clinical symptoms and Whipple's triad, were examined. These were found to have 45 sporadic insulinomas that were located in the head and isthmus (n = 13 (28.9%)), body (n = 19 (42.2%)), and tail (n = 13 (28.9%)). The insulinomas measured 4.0 to 10.0 mm (mean size, 6.5 +/- 2.1 mm) (n = 9), 11.0 to 20.0 mm (mean size, 13.2 +/- 2.5 mm) (n = 23), and 21.0 to 25.0 mm (mean size, 22.6 +/- 2.8 mm) (n = 13). Volumetric dynamic CT angiography increases detection rates for tumors less than 1.0 cm in size to 77.8%. It enabled insulinomas to be localized in 82.2% of cases.

Endovascular treatment of supra-aortic extracranial stenoses in patients with vertebrobasilar insufficiency symptoms.

PURPOSE: Stenoses and thromboses of vessels feeding the vertebrobasilar territory can evoke serious disturbances including ischemic stroke. We present our experience of endovascular interventions for patients with signs of vertebrobasilar insufficiency (VBI) resulted from subclavian, vertebral and brachiocephalic arterial stenoses. METHODS: Twenty-one patients (10 men) aged from 35 to 84 years (mean 64.3 years) with symptoms compatible with VBI underwent balloon angioplasty and stenting of subclavian (SA), innominate (IA) and vertebral (VA) arteries. Procedures were done by radiologists experienced in systematic stenting of the lesions. VBI was manifested by persistent signs in 15 patients, and by transitory ischemic attacks in the posterior circulatory territory in 4 (19%). Two patients (10%) experienced ischemic strokes (in the vertebrobasilar circulation in both cases). In 3 patients (14%) VBI was accompanied by upper limb vascular insufficiency symptoms. All cases were resistant to medical treatment. A neurologist assessed complaints, initial VBI signs and their alteration after intervention in all patients. Outcomes were measured with the 5-point scale suggested by Malek et al.: (1) excellent result (asymptomatic, no neurologic deficits and no symptoms of vertebrobasilar ischemia); (2) good (no neurologic deficits, at most one transient episode of vertebrobasilar ischemia over a period of 3 months after treatment); (3) fair (minimal neurologic deficit and at most one transient episode per month of vertebrobasilar ischemia); (4) poor (no improvement compared with neurologic status before treatment and/or persistent symptoms of vertebrobasilar ischemia); (5) death (regardless of cause). Endovascular treatment was performed for SA stenosis in 15 patients, for SA occlusion in 2, for IA stenosis in 2, and for VA stenosis in 2. There were 15 cases of atherosclerosis, 2 of aortoarteritis, 4 of proximal SA kinking. SA and IA stenoses ranged from 60% to 100% (mean 74.5%), VA stenoses were 90% in both cases. RESULTS: Initial technical success was achieved in 96% of cases. There were no postprocedural complications or deaths. During 6-36 months (mean 21.3 months) of follow-up all patients showed improvement in VBI symptoms or upper limb ischemia. Within 36 months after the procedure outcomes were estimated as excellent and good in 13 patients (76%) and poor in 2 (12%), the last being attributed to atherosclerosis progression in other vascular areas. Restenosis in the stented area has developed in 1 patient (6%). CONCLUSIONS: Balloon angioplasty and stenting of extracranial vertebrobasilar arterial stenoses appeared to be effective in endovascular treatment of medically resistant VBI. Further investigations are required to clarify the role of subclavian artery kinking in VBI development and indications for various methods of its correction.

[Mini-invasive technologies in diagnosis and treatment of major vessels diseases].

Experience with 150 endovascular stents and endoprostheses including ones of vertebral and carotid arteries (first experience in Russia) is analyzed. Mini-invasive surgery is indicated for patients with isolated arterial lesions (segmental stenosis, short occlusions), changed and hard for surgery parts of vascular system (renal, visceral arteries, branches of aortic arch), restenosis after traditional surgeries and also for patients with severe concomitant diseases. Rate of complications of carotid endovascular stenting was 4,3%. The follow-up ranged from 2 months to 5,5 years. There were no restenoses in the stented zone. Complete absence of complains and regress of neurological symptoms were seen in 89% patients.

[Hemangioendothelioma of the nasal cavity complicated by polypous sinusitis]. / Gemangoéndotelioma polosti nosa v sochetanii s polipoznym sinusitom.

Three patients were observed who had small angioma in the region of the middle nasal passage. Angioma was the cause of recurrent nasal bleeding. In one of the patients the vascular tumor was covered with massive edemous polyps for which the patient was referred for polypotomy. Introduction of computed tomography, endoscopic methods of examination allows detection and assessment of the tumor spread, selective angiography followed by embolization enables operations with minimal blood loss.

[Diagnosis and treatment of gastrin-producing pancreatic tumors]. / Diagnostika i lechenie gastrinprodutsiruiushchikh opukholei podzheludochnoi zhelezy.

Current literature data on the clinical course, diagnosis and treatment of gastrinoma, one of the most frequent neuroendocrine tumors of the thyroid, as well as 23 cases with Zollinger-Ellison syndrome treated by the authors are analysed in detail. Peculiarities of the clinical course, difficulties of syndrome diagnosis, principles of updated topical diagnosis of gastrinoma, conservative and surgical treatments including treatment of multiple endocrine neoplasia syndrome are described.

[Treatment of malignant pancreatic islet cell tumors]. / Lechenie zlokachestvennykh insulinom podzheludochnoi zhelezy.

Among 142 patients with islet cell tumor who were admitted to hospital between 1982 and 1999, 15 patients (10.6%) had malignant tumours. The mean age was 45.3 +/- 5.8 years. Islet cell tumors were located in the head and corpus of the pancreas in 26.6% and 26.6% of the patients, respectively, in the tail of the pancreas in 46.8% of the patients. The mean size of the tumor was 2.9 +/- 0.7 cm, in 6 patients (40%) liver metastases were found. US, CT and angiography which sensitivity were 72.7, 100 and 85.7%, respectively, were used for topical diagnosis of the islet cell tumors. 12 patients were operated on (15 operations) and 3 patients were treated conservatively by streptozocin. Surgical procedures included distal pancreatic resection (n = 11), enucleation of the tumor (n = 2), hepatic resection (n = 1), abdominal exploration (n = 1). In 2 patients palliative pancreatic resections were combined with transarterial embolization and devascularisation of the liver metastases and 2 patients were treated by systemic chemotherapy. To reveal malignancy before and during the operation was possible only by evaluation of distant metastases and the adjacent organs infiltration. In other cases to determine the diagnosis was possible only after planned histological identification of the resected specimens. 5-year survival rates after conservative and surgical treatment were 33% and 62.5%, respectively. In patients without distant metastases 5-year survival rate was 100%.

[Long-term results of balloon dilatation in the treatment of esophageal achalasia]. / Otdalennye rezul'taty ballonnoi dilatatsii pri lechenii akhalazii pishchevoda.

25 patients (aged from 32 to 58 years) with achalasia of the esophagus during 1985-1997 years underwent balloon dilatation of the esophagus. 18 patients had stage IV, 5--stage III and 2--stage II of the disease. Mean diameter of the stricture's area in the esophagus made up. 7.2 +/- 2.0 mm. Balloon dilatation was performed in 4 patients by 2-4 balloons d = 10 mm in one stage, and in the test patients by balloon "Rigiflex" d = 40 mm. 2-3 procedures were carried out with the interval 7-10 days. In all cases balloon dilatation was successful. Mean diameter of the esophageal lumen after dilatation has increased to 16.0 +/- 2.5 mm. In 2 patients with IV stage of the disease relapse was detected within 6-8 months. 5 year follow-up results were satisfactory in 4 patients, from 5 to 10 years--in 14 patients, and over 10 years--in 5 patients. Prolonged clinical follow-up (for 7.5 years) demonstrated complete absence of dysphagia and normal regime of nutrition. Balloon dilatation is safe, available and effective method of nonoperative treatment for achalasia of the esophagus.

[Adrenal tumors found by chance. Surgical treatment or follow-up?]. / Sluchaino vyiavlennye opukholi nadpochechnikov. Khirurgicheskoe lechenie ili dinamicheskoe nabliudenie?.

206 case records of the patients treated from 1985 to 1998 for various diseases of the adrenal glands were analyzed. In 39 (18.9%) patients tumors were chance finding at ultrasound examination or computer tomography of the abdominal cavity and retroabdominal space. 25 patients from this group were operated on, 14 patients were not operated and were followed up from 1 month to 7 years. All the patients underwent complex examination including analysis of the complaints, anamnesis and physical examination data, hormonal status examination (ACTH, hydrocortisone, 11-oxycorticosteroids, 17-ketosteroids, aldosterone, renin, adrenalin, noradrenalin, vanillyl-mandelic acid), device methods of examination USE, CT, MRT, superselective phlebography with separate catheterization of adrenal veins and blood intake per floor, fine needle aspiration biopsy under ultrasound control. Comparison of the results of complex clinical examination with morphological data of removed adrenal glands was carried out retrospectively. Arteriography and superselective phlebography with separate catheterization of adrenal veins and per floor taking of blood samples, performed in 36 patients, enabled not only to supplement and define more exactly the other methods of topical diagnosis, but also to asses objectively functional actively of the affected and contralateral adrenal. Despite the fact that during the study of hormonal level in peripheral blood of patients it was normal analysis of the data obtained by superselective phlebography of adrenal veins and per floor taking of blood samples showed significant increase in hormones level in blood of all operated patients. Comparison of the data of superselective phlebography with separate catheterization of adrenal veins and per floor taking of blood samples and clinical picture of the disease made it possible to suggest the presence of preclinical (subclinical) Cushing or Conn syndrome. Operative treatment was not indicated in the absence of hormonal activity of the tumor (i.e. preclinical syndromes by Icenko-Cushing, Conn, pheochromocytoma, the virilizing and feminizing tumors), tumors of small size (less than 3 cm), in absence of malignant growth features confirmed by complex instrumental examination (USE, CT, MRT, fine-needle aspiration biopsy under US control, superselective phlebography with per floor taking of blood samples). Such patients were reexamined in 6 months. During the follow up period no changes of tumor size, homogeneity, hormonal status were revealed.

[Diagnosis and surgical treatment of organic hyperinsulinism]. / Diagnostika i khirurgicheskoe lechenie organicheskogo giperinsulinizma.

From 1982 to 1998 144 patients (males 31.7%, females 68.3%) with organic hyperinsulinism underwent surgery. Mean age of the patients was 44.2 +/- 4.6 years. The causes of the development of this disease were benign insulinoma (82.6%), malignant insulinoma (6.9%), beta-cells hyperplasia and microadenomatosis (4.2%). In 6.3% of the patients the origin of the disease was not established. The location of the insulinoma in the pancreatic head was detected in 33.8%, in the body--in 35.2%, in the tail--31%. The sensitivity of the used methods of topical diagnosis was the following: US--40.3%, CT--28.6%, angiography (selective celiacography and upper mesentericography)--76.9%, blood samples from the right hepatic vein after intraarterial stimulation of different parts of the pancreas by Ca with measurement of immunoreactive insulin level--87.2%, intraoperative palpation--86.5%, intraoperative US examination--100%. Preoperatively, the authors used combined angiographic examination, the sensitivity of which made up 94.9%, this study being a single one which allows to reveal the region of the lesion of the pancreas in beta-cells hyperplasy. Tumor enucleation (59 patients), distal resection of the pancreas (50), the excision of the insulinoma (25), duodenopancreatic resection (1), explorative laparotomy (9) were made. Postoperative complications rate arose in 43.6% of the patients, mortality rate--7.7%. The best results were achieved in enucleation of insulinoma and distal resection of the pancreas. The authors suggest that in preoperative diagnosis of insulinomas the preferable methods should be US-examination and combined angiographic examination. Intraoperative revision should be made with use of US examination. Depending on the intraoperative findings the preference should be given either to enucleation of insulinoma or to distal resection of the pancreas.

[Catheterization translumbar angiography of the aorta and its branches]. / Kateterizatsionnaia transliumbal'naia angiografiia aorty i ee vetvei.

Method of complex angiographic examination and treatment from translumbar approach (CTLA) in patients with diffuse occlusive lesions of arterial bed was developed. 529 patients (516 males and 13 females) aged from 20 to 80 years (53.1 +/- 1.6 years) were examined and operated with the use of translumbar approach: they underwent various angiographic examinations of peripheral, visceral and coronary arteries as well as interventions on arteries. The quality of contrasting of arterial bed in CTLA was higher in comparison with results of punction translumbar aortography and intravenous digital angiography, complications rate being minimal. Application of CTLA in practice made it possible to perform practically all kinds of angiography and many invasive procedures in patients with occlusions of peripheral arteries and after reconstructive operations on vessels.

Preoperative and intraoperative topographic diagnosis of insulinomas.

Altogether 120 patients with organic hyperinsulinism underwent clinical examination and treatment (38 male, 82 female, mean age 44.2 +/- 4.6 years). The cause of hyperinsulinism was benign insulinomas in 96 (80.0%), malignant tumors in 9 (7.5%), and hyperplasia of beta cells in 6 (5.0%). In 9 (7.5%) patients the origin of hyperinsulinism was not diagnosed. The tumor was localized in the head, body, and tail of the pancreas in 31.8%, 36.4%, and 31.8% of cases, respectively. Intraoperative ultrasonography (IOUS) was undertaken in 37 patients, and in 83 cases only intraoperative palpation was done. Arterial stimulated venous sampling (ASVS) was performed in 17 patients (blood was sampled from the right hepatic vein for determination of the insulin level after arterial stimulation by calcium gluconate in different parts of the pancreas). The sensitivity of ultrasonography (US) was 29.5%, computed tomography (CT) 24.2%, angiography 55.9%, superselective angiography (branches of the celiac trunk) 72.2%, and intraoperative palpation 90.0%. ASVS showed an accuracy of 90.0%. Combining angiography with ASVS gave an exact diagnosis of hyperinsulinism in 100% of cases, and IOUS revealed tumors in 100% of cases. Hyperplasia of beta-cells was diagnosed only by means of ASVS. A total of 117 patients underwent surgery, including distal resection of pancreas (n = 39), enucleation of tumor (n = 70), and laparotomy (n = 8). The postoperative mortality associated with insulinomas was 7.7%. The frequency of postoperative complications was 43.6%. Benign insulinomas recurred at a rate of 5.4%. Patients with malignant insulinomas had a 5-year survival of 66.0%. The diagnosis of insulinomas was achieved by a combination of selective angiography, ASVS, and IOUS.

[Computed tomography in the diagnosis of salivary gland neoplasms]. / Kompíuternaia tomographiia v diagnostike novoobrazovanii sliunnykh zhelez.

To evaluate the efficiency of computed tomography (CT) in the diagnosis of salivary neoplasms, 68 patients (50 with benign tumors of the salivary glands, 10 with theirs malignant tumors, 8 with salivary cysts) were examined. The authors revealed the high informative value of CT in the diagnosis of salivary bulky lesions. CT defined the site of a tumor, the benign or malignant pattern of its growth, the extent of tumorous invasion. The diagnostic value of CT in the diagnosis of salivary glands was as follows: its sensitivity, specificity, and accuracy were 97.0, 81.8, and 94.9%, respectively.

[The potentials of computed tomography in the diagnosis of salivary gland diseases]. / Vozmozhnosti komp'iuternoi tomografii v diagostike nekotorykh zabolevanii sliunnykh zhelez.

Computer-aided tomography (CAT) was carried out in 68 patients with tumors of the salivary glands and 45 with sialolithiasis. CAT detected the tumors and located them, showed the type of the tumor (benign or malignant) and the tumor invasion. Sensitivity of CAT in tumors of the salivary glands was 97%, specificity 81.8%, accuracy 94.9%. In sialolithiasis CAT not only detected the concrements, but helped assess the status of the gland and the adjacent structures; its sensitively, specificity and accuracy were 95.5, 100 and 98.0%, respectively.