[Stomach and spleen preserving total pancreatectomy]. / Total'naya duodenopankreatektomiya s sokhraneniem zheludka, selezenki, zheludochnykh i selezenochnykh sosudov.

INTRODUCTION: Pancreatic surgery expands the indications and the use of total pancreatectomy. Considering a rather high rate of postoperative complications, the search for the ways to improve its outcomes is extremely relevant. The purpose of this study is justification and implementation of organ-preserving variants of total pancreatectomy. MATERIAL AND METHODS: Retrospective analysis of treatment results after classic and modified total pancreatectomy in the surgical clinic of Botkin Hospital was performed from September 2010 to March 2021. During the development and implementation of pylorus-preserving total pancreatectomy with preservation of the stomach, spleen, gastric and splenic vessels, we thoroughly analyzed aspects of exocrine/endocrine disorders and changes of the immune status after performing the modified technique. RESULTS: We performed 37 total pancreatectomies, including 12 pylorus-preserving total pancreatectomies with preservation of the stomach, spleen, gastric, and splenic vessels. General and specific postoperative complication rate in patients after the modified operation was significantly lower compared to the results of classic total pancreatectomy with gastric resection and splenectomy. CONCLUSION: Modified total pancreatectomy is a method of choice for pancreatic tumors of low malignant potential.

[Preoperative radiation navigation in determining surgical strategy for liver echinococcosis]. / Predoperatsionnaya luchevaya navigatsiya v opredelenii khirurgicheskoi taktiki pri ekhinokokkoze pecheni.

OBJECTIVE: To analyze the technology for diagnostic modeling of liver echinococcosis. MATERIAL AND METHODS: In the Botkin Clinical Hospital, we developed a theory of diagnostic modeling of liver echinococcosis. Treatment outcomes were analyzed in 264 patients who underwent various surgical interventions. RESULTS: A retrospective group enrolled 147 patients. When comparing the results of diagnostic and surgical stages, we identified 4 models of liver echinococcosis. The choice of surgical intervention in the prospective group was based on previous models. Diagnostic modeling reduced the number of general surgical and specific complications, as well as mortality in the prospective study group. CONCLUSION: The technology for diagnostic modeling of liver echinococcosis made it possible not only to identify 4 models of liver echinococcosis, but also determine the most optimal surgical intervention for each of model.

[Spleen-preserving total pancreatectomy for low-grade tumors]. / Pilorosokhranyayushchaya pankreatektomiya s sokhraneniem selezenki pri opukholyakh s nizkim potentsialom zlokachestvennosti.

OBJECTIVE: To justify organ-preserving variants of total pancreatectomy. MATERIAL AND METHODS: We retrospectively analyzed the results of classic and modified total pancreatectomy between September 2010 and March 2021. Implementing pylorus-sparing total pancreatectomy with preservation of stomach, spleen, gastric and splenic vessels, we thoroughly analyzed exocrine/endocrine disorders after total pancreatectomy and changes in immune status after splenectomy. Serum C-reactive protein and ferritin were assessed in 1, 3, 5, 7, 14 and 30 days after surgery in both groups. We also estimated daily glycemic profile after total pancreatectomy in classical and organ-preserving modifications. RESULTS: We performed 37 total pancreatectomies including 12 pylorus-preserving total pancreatectomies with preservation of stomach, spleen, gastric and splenic vessels. General and specific postoperative complication rate was significantly lower after modified surgery compared to classic total pancreatectomy with gastric resection and splenectomy. CONCLUSION: Modified total pancreatectomy is preferable for low-grade pancreatic tumors.

[Management of a patient with diabetes mellitus after total pancreatectomy. Case report].

In modern diabetology, the most important condition for a personalized approach to patient management is to determine the type of diabetes mellitus. Particular attention is drawn to a large, but at the same time insufficiently studied group of patients with diabetes mellitus due to diseases of the pancreas or as a result of surgical interventions on the pancreas, in particular, patients who, for a number of vital indications, undergo total pancreatectomy and the mechanism of development of impaired glucose homeostasis have not been studied in these patients. To date, there are no specific algorithms for managing this category of patients. This clinical example emphasizes that the management of glycemia in patients with diabetes mellitus as a result of total pancreatectomy is an extremely difficult task that requires a multidisciplinary approach in the treatment of this category of patients, the participation of an endocrinologist at all stages of patient treatment.

[Selecting the most appropriate surgical treatment of true splenic artery aneurysm]. / Vybor sposoba khirurgicheskogo lecheniya istinnykh anevrizm selezenochnoi arterii.

OBJECTIVE: To analyze the results of diagnosis and treatment of true splenic artery aneurysms. MATERIAL AND METHODS: We analyzed the results of diagnosis and treatment of 27 patients with true splenic artery aneurysm. All ones underwent surgical treatment at the Botkin Municipal Clinical Hospital between 2017 and 2021. Splenic artery aneurysm >1 cm was an indication for surgical treatment. Surgical option depended on aneurysm location. Laparoscopic splenectomy and aneurysmectomy were performed in 4 cases (14.8%), 5 (18.5%) patients underwent endovascular intervention, laparoscopic clipping was performed in 18 (66.7%) cases. Methods of surgical treatment, general and specific postoperative complications according to the Clavien-Dindo and ISGPS classifications were analyzed. RESULTS: Laparoscopic clipping was accompanied by fewer general and specific postoperative complications. Specific complications after laparoscopic splenectomy occurred in 2 patients (BL according to the ISGPS 2016 classification). There was one case of acute pancreatitis after endovascular interventions. In long-term postoperative period, aneurysm recanalization after endovascular intervention was observed in 1 case. CONCLUSION: Surgical treatment of splenic artery aneurysms requires a differentiated approach based on topographic and anatomical assessment of aneurysm relative to the arterial vessel.

[Modern approaches to the treatment of patients with a complicated form of gallstone disease in the Botkin hospital]. / Protokol lecheniya bol'nykh s oslozhnennoi formoi zhelchnokamennoi bolezni v khirurgicheskoi klinike Botkinskoi bol'nitsy.

OBJECTIVE: To determine the optimal timing of laparoscopic cholecystectomy in patients with gallstone disease complicated by cholelithiasis after endoscopic retrograde papillosphincterotomy with lithoextraction. MATERIAL AND METHODS: We analyzed treatment outcomes in 229 patients with gallstone disease complicated by cholelithiasis between 2016 and 2020. Simultaneous surgery was performed in 31 patients, early cholecystectomy (after 1-3 days) - in 78 cases, delayed cholecystectomy (after 4-7 days) - in 35 cases and delayed cholecystectomy in 14-30 days after endoscopic retrograde papillosphincterotomy with lithoextraction in 85 cases. RESULTS: Simultaneous laparoscopic cholecystectomy and surgery in early period after endoscopic retrograde papillosphincterotomy with lithoextraction are followed by less surgery time, few postoperative complications and less hospital-stay. CONCLUSION: Simultaneous laparoscopic cholecystectomy and early surgery after endoscopic retrograde papillosphincterotomy with lithoextraction are preferred for patients with complicated gallstone disease. However, this requires adherence to strict criteria for patient selection.

[Echinococcosis of the liver: evolution of surgical treatment]. / Ekhinokokkoz pecheni: evolyutsiya khirurgicheskogo lecheniya.

OBJECTIVE: To analyze the development of surgical approaches for hepatic echinococcosis. MATERIAL AND METHODS: We have analyzed diagnosis and treatment of 349 patients with liver echinococcosis; 97 patients were treated at the Botkin Clinical Hospital for the period from 2009 to 2019 and 252 patients were treated in surgical hospitals of Moscow city for the period from 2014 to 2019. RESULTS: General and specific postoperative complications, relapses and surgical approaches were assessed. The number of echinococcectomies performed in surgical hospitals of Moscow is 3 times higher compared to the Botkin Hospital. The number of liver resections is comparable in both groups. The number of pericystectomies is more than 2 times higher in the Botkin Hospital. PAIR technique was more common in surgical hospitals of Moscow. CONCLUSION: Evolution of surgical treatment from open echinococcectomy to anatomical liver resections and subsequent pericystectomy with PAIR technique becomes another round of evolutionary spiral in the development of surgical treatment of liver echinococcosis.

[Preoperative biliary drainage for malignant biliary obstruction: to drain or not to drain? And if drain, in what way?] / Predoperatsionnaya biliarnaya dekompressiya pri opukholevoi zheltukhe: drenirovat' ili net? I esli drenirovat', to kakim sposobom?

On the basis of the conducted literary search, a number of conclusions can be drawn. When performing preoperative biliary drainage (PBD), it is necessary to have a clear understanding: why is this procedure performed (severe liver failure, cholangitis, long preoperative preparation is required due to comorbid status, neoadjuvant chemotherapy is necessary, etc.)? Routine use of PBD is impractical. In the presence of indications for PBB in perihilar cholangiocarcinoma, percutaneous decompression is preferable, in periampullary tumors, endoscopic. Moreover, both methods can be alternative (for example, in case of technical failure of the first priority). There is also no convincing evidence of the superiority of metal stents over plastic ones for PBD (except in cases of long-term preoperative preparation or neoadjuvate treatment) for periampular tumors. To date, a decrease in overall survival and a higher incidence of implantation metastases have not been proven when using the antegrade PBD method. Large multicenter studies are required with differentiation of patients according to the nosological principle in order to more accurately understand the place of each method, as well as to determine clear indications for PBD and those clinical situations when its implementation is impractical.

[Mechanisms and prevention of biliary stent occlusion]. / Mekhanizmy okklyuzii biliarnykh stentov i vozmozhnye sposoby ee profilaktiki.

One of significant achievements of modern endoscopy is development of retrograde biliary stenting for obstructive jaundice. This method ensured widespread application of endoscopic decompression in the treatment of patients with malignant biliary obstruction as preparation before radical surgery and final palliative care. Endoscopic retrograde transpapillary stenting firmly took its place together with antegrade and percutaneous stenting. There are certain advantages of this technique including minimally invasiveness and favorable quality of life. However, this approach is associated with some drawbacks associated with stent occlusion and difficult correction of this complication. The maximum diameter of the plastic stent (PS) is determined by the width of the working channel of the duodenoscope. In this regard, self-expandable metal stents (SEMS) were developed to increase the diameter of bile drainage channel. SEMS are associated with prolonged function. However, there is another problem. It is a germination of SEMS followed by impossible removal of the stent for its subsequent replacement. A further step in development of endoscopic biliary stents was the use of special SEMS coating to exclude tumor or granulation ingrowth. The problem of biliary stent occlusion remains relevant despite some improvement of stenting results. Mechanisms of occlusion of biliary stents and prevention of these events are discussed in this review.

[Specific complications of liver resection and their prevention]. / Rezektsiia pecheni. Spetsificheskie oslozhneniia i ikh profilaktika.

AIM: To improve the results of treatment of patients with focal liver formations by preventing the development of postoperative complications after liver resections. METHODS: The study included 304 patients with benign and malignant liver lesions. In 196 (64.4%) patients, resections were performed for malignant liver damage, in 108 (35.6%) - for a benign process. To assess the impact of ongoing measures to prevent the development of postoperative complications, patients were divided into two time periods: from 2007 to 2012 and from 2013 to 2018. RESULTS: The introduction of a protocol of preoperative examination of patients for whom resection of 3 or more liver segments is planned, with the inclusion of SPECT/CT, which allows determining the volume of the remaining functioning liver parenchyma, allowed to reduce the percentage of development of acute post-resection liver failure from 11.6% to 3.6% during the second time period (p=0.0064). The use of modern suture material, surgical binocular loops, as well as the use of the concept of predominantly performing parenchyma-saving resections, reduced the number of biliary complications from 8.1% to 5.7% (p=0.1). The use of a proprietary dissection algorithm for the liver parenchyma significantly reduced hemorrhagic complications from 5.3% to 1.04% (p=0.0074). CONCLUSION: The use of modern pre- and intraoperative technologies has reduced the number of postoperative complications after liver resections from 38.3% to 20.9% (p=0.018) and mortality from 2.6% to 0.5% (p=0.004), thereby improving the results of liver resections.

[Comparative analysis of side-by-side antegrade stenting and Y-biliary stenting for malignant biliary stricture]. / Sravnitel'nyi analiz antegradnogo stentirovaniia side-by-side i Y-stentirovaniia pri zlokachestvennoi zhelchnoi strikture vorot pecheni.

In the time period from 2009 to 2017 in Botkin Hospital (Moscow) bilateral biliary stenting was performed in 43 patients with malignant common hepatic duct stricture. Patients were divided into 2 statistically homogeneous groups: 'side-by-side' stenting in 28 patients and percutaneous 'Y'-biliary stent placement in 15 patients. The causes of malignant obstruction were as follows: in the 1st group 13 (46.4%) patients with extrahepatic cholangiocarcinoma (46.4%), 8 (28.6%) patients with intrahepatic cholangiocarcinoma, 4 (14.3%) patients with gallbladder cancer, 3 (10.7%) patients with metastatic cancer. In the 2nd group 6 (40%) patients with extrahepatic cholangiocarcinoma, 4 (26.6%) patients with intrahepatic cholangiocarcinoma, 2 (13.3%) patients with gallbladder cancer, 3 (20%) patients with metastatic cancer. Characteristics of patients: age - 1st group 71.2±5.1 years, 2nd group 74.3±5.5 years; sex - (m/f) 1st group 18/10, 2nd group 9/6; location of stricture - 1st group Bismuth IIIa/IIIb 17/11, 2nd group Bismuth IIIa/IIIb 11/4; mean level of bilirubin - 1st group 284±8.2 µmol/l; 2nd group 311±7.4 µmol/l. Technically all procedures were successful (100%). No complications and mortality associated with the procedure was recorded. Clinically significant results were achieved in 26 (92.8%) patients in Group 1 and in 13 (86.7%) patients in Group 2 (p=0.043). Following stenting procedures, 23 (82.1%) patients in Group 1 and 11 (68.8%) patients in the Group 2 had chemotherapy (p=0.047). 19 patients from the 1st group and 10 patients from the 2nd group died due to tumor progression of the underlying disease, other patients are under care of a physician. Median survival rate: 1st group (12 patients - 50 days, 7 patients - 100 days, 9 patients are alive at the time of writing); 2nd group (7 patients - 50 days, 4 patients - 100 days, 4 patients are alive at the time of writing). The results of this study showed that 6 (21.4%) patients from the 1st group and 4 (26.7%) patients from the 2nd group had biliary stent occlusion (p=0.041). The average period of stent function in the 1st group was 78±4.5 days, and 63±4.8 days in the 2nd group (p=0.036). Based on the obtained results, it is recommended to use the 'side-by-side' method of bilobar biliary stenting in patients with malignant common hepatic duct strictures.

[Rare forms of the ductal carcinoma of the pancreas].

Clinical cases of patients with rare forms of ductal pancreatic carcinoma are described. Difficulties of preoperative radiologic verification of ostheoclast-like giantcell tumor and cricoids-cell carcinoma of the pancreas are described. Morphologigic and immunohistochemical features of these tumors are highlighted. One of the clinical cases demonstrate the aggressive tumor behavior, led to liver metastases 4 months after the radical operation. Literature review highlights historical aspects and the state-of-art of diagnostics and treatment of rare forms of the ductal carcinoma of the pancreas.

[The role of matrix metalloproteinases in pancreatic ductal adenocarcinoma].

Matrix metalloproteinases-7, -9 (MMP) are crucial factors for prognosis of pancreatic ductal adenocarcinoma (PDA). The expressions of MMP-2, 7, 9 increased in 60 patients with PDA and depended from stage of disease. Metastasis and invasive growth of tumor correlated with increase of MMP production and decrease of MMP inhibitors' expression, stimulated invasive growth of tumor.