[Moot points of diagnosis and treatment of hormone-producing neuroendocrine tumors of pancreas].

Based on literature data and own experience of treatment of 225 patients with neuroendocrine tumors (NET) authors discuss moot points of diagnosis and treatment of this severe category of patients. It is demonstrated that the most appropriate algorithm of diagnosis before surgery is the combination of US with endoscopic US and angiography. Intraoperative diagnosis must be performed with intraoperative US and endoscopic transillumination. Authors demonstrate positive results of staged surgical treatment of MEN-1 syndrome. Malignant NET with distant metastases is not contraindication for surgical treatment. This situation is indication either for radical surgery with excision of all metastases or for cytoreductive surgery with subsequent chemoembolization and chemotherapy.

[Diagnostic approach in mechanical jaundice, complicated by purulent cholangitis]. / Diagnosticheskii podkhod pri mekhanicheskoi zheltukhe, oslozhnennoi gnoinym kholangitom.

Up-to-date high-informative non-invasive diagnostic methods were used in 54 patients with obstructive jaundice (OJ) complicated by purulent cholangitis (PC). Treatment-diagnostic algorithm can to improve results of diagnosis. This algorithm is the following: ultrasonic examination as a screening method; if a case of jaundice is unclear and obturation is prolonged magnetic-resonance tomography and magnetic-resonance cholangiopancreaticography are carried out; in block of a distal part of the common bile duct--spiral computed tomography with bolus amplification and duodenoscopy. Invasive diagnostic methods--endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography (PTCG) are performed in buit indications in possibility to perform lithextraction and effective endoscopic decompression or in the tumor of Vater's papilla in case of low block. PTCG is used in high block and finished by percutaneous transhepatic bile outflow. General diagnostic efficacy of the complex in OJ was 97.8%. Diagnostic algorithm permitted us to make diagnosis and to start treatment in 85% during 1-2 days after hospitalization. Bile ducts decompression as a main stage of PC treatment was performed in the first 2 days after hospitalization. Diagnostic quest was performed at the same time with therapy after detoxication and correction of hemostasis disturbances.

[Ultrasound investigation and mini-invasive ultrasound-assisted technologies in diagnosis and treatment of extra-organ separate fluid formations in abdominal cavity]. / Ul'trazvukovoe issledovanie i maloinvazivnye tekhnologii pod kontrolem UZI v diagnostike i lechenii vneorgannykh otgranichennykh skoplenii zhidkosti v briushnoi polosti.

The authors discuss the use of ultrasound-assisted percutaneous puncture and drainage for diagnosis and treatment of extraorganic separate fluid formations in abdominal cavity (abscess, limited non-infected fluid formation, hematoma with clotted blood), determination of their sizes and obtaining material for laboratory study. 307 patients with various extraorganic separate fluid in formations in abdominal cavity were examined. Ultrasonic symptoms of abscess were described in 54 patients, of limited non-infected fluid formation--in 234, of hematoma with clotted blood in 19 patients. 146 patients were cured conservatively, 75 patients underwent US-assisted puncture, 76--US-assisted drainage. Mean time of drainage was 14 days (ranged from 10 to 20). There were neither complications nor lethal outcomes. Ultrasound examination and US-assisted mini-invasive surgery permit to detect precisely the nature of fluid formation, to perform timely and low-traumatic treatment.

[Diagnosis and choice of surgery of non-parasitic cysts of the liver]. / Diagnostika i vybor metoda khirurgicheskogo lecheniia neparazitarnykh kist pecheni.

Results of treatment of 342 patients with non-parasitic cysts of the liver (NCL) were analyzed. Based on obtained data diagnostic algorithm was developed. Indications and contraindications for transcutaneous and laparoscopic methods in NCL are clarified and substantiated. Features of laparoscopic operations in different location of cysts are presented. In mini-invasive surgeries postoperative complications rate was minimum, there were no lethal outcomes. The authors believe that conventional surgeries in NCL should be performed in critical states only.

[Complex use of ultrasound in the diagnosis and treatment of surgical diseases of the lung and pleura]. / Kompleksnoe primenenie ul'trazvuka dlia diagnostiki i lecheniia khirurgicheskikh zabolevanii legkikh i plevry.

Since 1980 the N.N. Burdenko Faculty Surgical clinic, I.M. Sechenov Moscow Medical Academy, has been using a combination of high- and low-frequency ultrasounds for the diagnosis and treatment of surgical diseases of lung and pleura in 156 patients for the diagnosis of pleuritis of various genesis, in 40 patients for transthoracic aspiration biopsy of lung tumors in the preoperative period, in 156 patients for pleural puncture and drainage, in 40 patients for the intraoperative differential diagnosis of peripheral lung tumors and for the inspection of hematogenic and lymphogenic metastatic areas, in 100 patients for intraoperative prophylaxis, and in 20 patients for the treatment of acute postoperative pleural empyema. Ultrasound was demonstrated to be of high informative value in diagnosing different pleuritis. Transthoracic aspiration biopsy was shown to have some advantages over standard methods: use of needle catheters for pleural puncture permits one to avoid serious complications (pneumothorax, bleeding, etc). Ultrasound was used in intraoperative diagnosis of peripheral lung tumors for the first time. The use of low-frequency ultrasound for the intraoperative prevention of acute postoperative pleural empyemas promotes reliable sanitation of the pleural cavity, as confirmed by bacteriologic control data. Timely rethoracotomies with low-frequency ultrasound treatment of the pleura promote more rapid inflammation elimination in the pleural cavity and prevents irreversible complications.

[Treatment of hydatid echinococcosis]. / Lechenie gitatidnogo ékhinokokkoza.

In Russia the first one-stage operation for hepatic echinococcosis was performed by A.A. Bobrov by his method in 1895. At present there is much experience in surgical treating echinococcosis. With the advent of new ultrasonic diagnostic methods, computed tomography, and new germicide treatment methods have changed. The analysis of 228 patients with echinococcosis treated from 1983 to 1999 was carried out. The traditional surgical interventions were performed in 121 patients; the mortality was 2.5%, the relapse rate 22.3%. Minimum invasive interventions (punctures, hydatid cyst drainage, followed by germicidal treatment) were performed as the only treatment in 68 patients and with subsequent traditional interventions in 22 patients. Experimental studies demonstrated that the retention of gigantic acephalocysts in traditional treatment is the main cause of echinococcal dissemination. 80-100% Glycerin is the most effective germicide. Chemotherapy as the only treatment may be applied only in very minor cysts inaccessible to puncture. A combination of minimum invasive procedures and preoperative (1 course) and postoperative (2-3 courses) chemotherapy is the most effective.

[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%.

[Intraoperative ultrasonography in surgery on organs of abdominal cavity and retroperitoneal space]. / Intraoperatsionnoe ul'trazvukovoe issledovanie organov briushnoi polosti i zabriushinnogo prostranstva.

Since 1984 to 1999 intraoperative US examination (IOUSE) was made in 863 patients. 236 of them had diseases of the liver, 137 diseases of the gall bladder and biliary tract, 158 pancreatic disorders, 151 diseases of gastro-intestinal tract, 72 diseases of the adrenal glands, 101 constitutional obesity, 3 splenic disorders and 5 gunshot wounds of the organs of the abdominal cavity and the retroperitoneal soft tissues. In masses of the liver IOUSE showed limits for resection of the liver, location of the diseased area with the vessels and biliary ducts, unpalpablefoci. OUSE allowed to perform US-guided puncture and sclerosizing small metastatic nodes as well as a puncture and antiparasitic treatment of inaccessible echinococcal cysts. In cholelithiasis IOUSE allows to reveal or to rule out the presence of the concrements in bile ducts. In cases of diseases of the pancreas IOUSE helps to localize pathologic area, defines its interrelations with adjacent major vessels and ducts, reveals unpalpable masses and enables US-guided puncture of the major pancreatic duct followed by its further opening. In gastric tumors it is possible under US control to determine precisely the limits of the infiltration of gastric wall which defines the volume for resection. In operation on the adrenals from thoracophrenolumbar approach IOUSE through the diaphragmatic cupula determines the place and the length of phrenotomy and elucidates interrelations of the tumor with adjacent organs. Sensibility of IOUSE made up from 87 to 100%, and specificity--92-100% depending on the disease.

[Application of ultrasound in differential diagnosis of pleurisy]. / Ul'trazvukovoe issledovanie v differentsial'noi diagnostike plevritov.

According to literature data, pleural exudate is diagnosed approximately in 10% of pulmological patients. The importance of differential diagnosis of pleuriesy is expained by variability of the diseases accompanied by pleural exudate. 146 patients with various diseases accompanied by pleural exudate were examined: 39 from them had pleural empyema, 53--diffuse pleurisy, 42--incapsulated pleurisy, and 12--tumors of the pleura. All the patients underwent ultrasound examination (USE) of the chest together with a routine roentgenography, as well as computed tomography. USE was performed on the. Toshiba and Hitachi egurpment, which work in real time regime with sectorial sensing element (3.5-5.0 mHz). The obtained data show, that USE is most effective diagnostic tool in incapsulated and diffuse liquor accumulations in pleural cavity. In 6 patients the diagnosis of pleuritis was possible only at USE of the pleural cavity. Evaluation of the structure of the liquor and detection of tumor conglomerates on parietal pleura have a substantial diagnostic value. It is noted that echotomographic picture might be insufficiently informative in some situations with a small length of the contact of the lesion with the thoracic wall (less than 3 cm) or thickness of pleural layers up to 4-5 mm, in the presence of artefacts due to pulmonary tissues and osteal structures of the thoracic wall (ribs, scapula, sternum).

[Multiple endocrine neoplasia of the first type (Wermer's syndrome)]. / Mnozhestvennaia éndokrinnaia neoplaziia 1-go tipa (sindrom Vermera).

11 patients with Wermer's syndrome (WS) aged 24-67 years were treated. They had a total of 30 tumors: 4(13.3%) hypophyseal, 11(36.7%) pancreatic, 9(30%) parathyroid, 4(13.3%) adrenal and 2(6.7%) duodenal. Each patient had two tumors minimum and 8 tumors maximum. In 8 cases WS presented clinically as hypoglycemia, in 3 cases as Zollinger-Ellison syndrome. The diagnosis was made using ultrasonography, CT, MRT and angiography. Cytogenetic examination was made in 2 cases. All the patients were operated. Six of them were operated two times, one--four times. The following surgery was made: 4 removals of parathyroid adenomas, 4 adrenalectomies, 1 removal of the hypophysis, 4 enucleations of pancreatic insulinomas, 5 distal hemipancreatectomies, 1 distal subtotal resection of the pancreas, 1 gastropancreatoduodenal resection. Clinically symptomatic tumors should be operated first.

[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 treatment of isolated subdiaphragmatic liquid accumulations under ultrasound control]. / Diagnostika i lechenie ogranichennykh poddiafragmal'nykh zhidkostnykh skoplenii pod kontrolem UZI.

The analysis of diagnostic abilities of ultrasound and miniinvasive treatment under ultrasound examination control in 39 patients with subdiaphragmatic local fluid accumulations in abdominal cavity has been carried out. The revealed by US examination manifestations of the abscess formation in 15 patients, local noninfected accumulation of fluid in 20 patients, haematomas (hemolized)--in 4 are described. Indications for the treatment by punctures and drainage of local subdiaphragmatic fluid accumulations under US control depending on the size, form and character of liquid accumulation are given. 11 patients were cured by a single puncture, 1--by multiple punctures, 27--by drainage under US-control. The use of miniinvasive technologies resulted in no complications and mortality in this group of patients. Laboratory examination of the material taken by punctures and drainage under US-control demonstrated in 20 patients infected material and in 14--uninfected one, in 5 patients hematoma was detected. Standard operations performed from 1946 in the surgical clinic resulted in lethality of 19%.

[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.

[Minimally invasive interventions in treatment of mechanical jaundice]. / Maloinvazivnye vmeshatel'stva v lechenii mekhanicheskoi zheltukhi.

For the period from 1972 to 1997 676 transcutaneous transhepatic and 370 endoscopical interventions in 953 patients with mechanical jaundice were carried out. In 58.5% of cases jaundice was caused by malignancies, in 41.4%--by benign strictures of bile ducts. 40 external biliary bypasses, 427 external-internal biliary bypasses, 55 cholecystostomies and 154 operations of biliary endoprosthetic reconstructions were conducted under US control and TV imaging. In 33.5% of cases biliary bypass and endoscopical procedures were made as a preliminary stage of preparation of patients for operation or as a final method of treatment after conventional operation procedures, in 66.5% of cases it was final method of treatment. There were no deaths caused by biliary bypass procedures nor complications related to laparotomy. Thus low invasive interventions, undoubtedly, are the method of choice in mechanical jaundice for preparation of patients before radical operations as well as for relief of the course of disease in patients with inoperable cancer which causes obstruction of biliary ducts.

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.

[Intraoperative instrumental examination in stomach cancer]. / Intraoperatsionnye instrumental'nye issledovaniia pri rake zheludka.

Ultrasound examination and laser autofluorescent spectroscopy were used intraoperatively for evaluation of gastric cancer dissemination. These methods were efficient in differentiation of cancer and benign tumors, estimation of cancer dissemination, revealing of metastases in the liver and lymph nodes. The use of these methods made it possible to increase sensitivity and specificity of estimation of cancer infiltration to 100% and of revealing lymph nodes metastases to 90% and 76%, respectively.