[Diagnosis and treatment of different types of high scar strictures of the hepatic ducts]. / Diagnostika i lechenie razlichnykh tipov vysokikh rubtsovykh striktur pechenochnykh protokov.

Results of treatment of 224 patients with scar strictures of the hepatic ducts (BSDH) are presented. Based on Bismuth's classification of BSDH E.I. Galperin (2002) proposed own one. According to this classification there were 17 (7,6%) patients with type "+2" (stump of common hepatic duct - CHD more than 2 cm), 26 (11,6%) - with type "+1" (stump of CHD 1 - 2 cm), 72 (32,2%) - with "0" type (stump of CHD less than 1 cm), 54 (24,1%) - with "-1" type (upper fornix of CHD confluence is not affected), 35 (17,4%) - with "-2" type (CHD confluence is destroyed), 20 (8,9%) - with "-3" type (strictures of segmental ducts). There were greater number of previous surgeries in the patients with "-1" and "-2" types (p<0,05). Jaundice and secondary biliary liver cirrhosis were seen more frequently in types "0" - "-3". Hepaticojejunostomy was the surgery of choice. For approach to unaltered wall of hepatic ducts (HD) section of lobar ducts in types "+1", "0", excision of portal plate and partial resection of IV hepatic segment (31 patients) in "-1" - "-3" types were used. Exchangeable transhepatic drainage (ETD) was applied in 31 patients due to impossibility to excise scar tissues completely. In early postoperative period 9 (4%) patients died due to purulent cholangitis (7 patients) and insufficiency of anastomosis (2 patients). Long-term results were evaluated in 180 (80,4%) patients from 1 to 14 (6,6+/-3,9) years of follow-up. Thirteen surgeries were performed for repeated strictures. The main cause of restrictures was inadequate resection of scar tissues and unreasonable refusal of ETD (7 patients). Developed surgical technique in different types of strictures permits to reduce postoperative lethality and the rate of restrictures.

[Treatment of extrahepatic bile ducts injuries due to laparoscopic cholecystectomy]. / Lechenie povrezhdenii vnepechenochnykh zhelchnykh protokov, poluchennykh pri laparoskopicheskoi kholetsistéktomii.

The department of hepatic surgery of I.M. Sechenov Moscow Medical Academy has gained experience of treatment of 25 patients with injuries of bile ducts inficted in laparoscopic cholecystectomy (LCE). All the patients underwent LCE in other hospitals. 4 patients were hospitalized with recent injuries (within 24 hours after injury) and 21--later. Injuries of the duct in LCE characterized by early clinical manifestation, injury in proximal portion of hepatic duct, technical difficulties of anastomosis creation during the first operation due to thin-walled duct of small diameter. Reconstructive operations yielded good results in 22 patients. Recurrent strictures were revealed in 3 patients who required repeated intervention. There were no lethal outcomes.

[Treatment of cicatricial strictures fo hepatic ducts]. / Lechenie rubtsovykh striktur pechenochnykh protokov.

Retrospective evaluation of experience in treatment of 378 patients (1972-1997 years) with cicatricial stricture of hepatic ducts is presented. For the period for 1972 to 1986 years the basic principle consisted in obligatory use of a drainage--frame for prolonged (not less than 2 years) drainage of the biliary anastomosis aimed at a decrease of the recurrence risk. Changeable transhepatic drainage (CTD) was used. 199 patients were operated on, 18 died. In postoperative period a number of specific complications caused by CTD were observed: leak into infradiaphragmatic space (hemobilia, bile biliduodenal fistula, etc.). At follow-up period after restorative operations (34) relapse of cicatricial stricture was observed in 8 patients, which was a consequence of complications due to CTD. After reconstructive operations CTD was removed in 109 patients, relapse being detected in 5 (4.5%). Atraumatic needles with inert monifilament sutures as well as resolving suture threads enabled creation of high bilio-intestinal anastomoses without drainage-frame. Since 1987 to 1997 years 130 patients were operated on. Dissection of the hepatic ducts was made proximally to the cicatricial tissues, longitudinal cut of the left hepatic duct was performed. Atraumatic needles with threads of small size were used, the bilio-intestinal anastomosis was established by one layer nodular suture with nodules exteriorly faced and without seizure of intestinal mucous membrane. Complications in postoperative period were observed in 24 patients, no lethal outcomes occurred. In late postoperative period unsatisfactory results were documented in 7 patients. At present time we give preference to operations without drainage-frame. CTD is indicated in the presence of severe pyogenic and inflammatory infiltration at hepatic porta with involvement of the bile ducts' walls, cyrrhosis of the liver and portal hypertension hindering hepatic ducts' dissection; cicatricial stricture of the right hepatic duct followed by sclerosing process in sectoral ducts.

[Iatrogenic injuries of bile ducts during cholecystectomy]. / Iatrogennye povrezhdeniia zhelchnykh protokov pri kholetsistéktomii.

Having analyzed case histories 266 patients with cicatrical strictures of bile ducts, due to iatrogenic trauma in cholecystectomy who were admitted to clinic for reconstructive operation, the authors established that in 53% of patients the injury of bile ducts was not revealed during the operation. In missed bile ducts injury there were 5 varieties of clinical manifestations in the early postoperative period: 1) mechanical jaundice (72 patients); 2) exterior bile leakage (33 patients); 3) diffuse biliary peritonitis (23 patients); 4) mechanical jaundice and exterior bile leakage (5 patients); 5) mechanical jaundice and subhepatic abscess formation (6 patients). From 117 patients in whom iatrogenic trauma of the biliary tract was revealed in cholecystectomy, in 55 biliobiliary anastomosis was carried out, in 40--biliodigestive anastomosis in 22-external drainage procedure of biliary tract was accomplished. In the recent iatrogenic trauma of biliary ducts the authors have operated on urgently 12 patients, in 5 of which reconstructive operations were carried out (in 2--with removal transhepatic drainage, in 3--with T-shaped drainage) and in 7 patients--precisional biliointestinal anastomosis without framed drainage. In all the patients after reconstructive operation with T-shaped drainage in long-term period cicatricial stricture of hepaticocholedochus has developed. Favourable result was observed in patients after reconstructive operation with changeable transhepatic drainage and in patients with precisional biliointestinal anastomosis. The last variant of correction of the iatrogenic bile ducts T injuries is the most preferable. The external drainage procedure of bile ducts should be used when there are no suitable conditions for accomplishment of reconstructive surgery.

Results of pancreatic blood shunting into the systemic blood flow in insulin-dependent diabetics.

A new surgical method of treating patients with unstable insulin-dependent diabetes (IDD) has been developed--that of surgically shunting pancreatic blood into the systemic blood flow with the purpose of creating a more optimal interaction of subcutaneously administered insulin and pancreas-secreted glucagon. The long term results of the operation depend on the patency of a splenorenal anastomosis. This has been studied by following up 137 patients over periods from half a year to three years. Anastomotic patency was determined by renal and splenic venography and celiacy arteriography, which revealed a patent anastomosis in 114 patients, and an obliterated one in 23. Patients with patent anastomoses showed a lowering of glycosylated hemoglobin (HbA1c) from 13.3 +/- 0.3% to 9.3 +/- 0.6%, p < 0.05, a decrease of the injected insulin dose from 0.97 +/- 0.04 to 0.72 +/- 0.03 U/kg, p < 0.05, disappearance or considerable abatement of pain in the lower extremities, and of hypoglycemia. Improvement of clinical status was accompanied by an increase of glucagon in the systemic blood stream from 60.8 +/- 10.1 to 91.5 +/- 9.4 pg/ml, p < 0.05, a rise of tissue oxygen pressure, pO2, from 49.2 +/- 2.4 to 58.1 +/- 1.9 mm Hg, p < 0.05. In patients with oblivious anastomoses postoperative HbA1c levels did not change from preoperative values: 12.9 +/- 0.4% and 12.8 +/- 0.7%, p < 0.05, respectively; the insulin dose remained the same--0.91 +/- 0.07 U/kg and 0.85 +/- 0.07 U/kg, p < 0.05, no rise of the systemic blood glucagon content was noted, and former complaints continued. The suggested method is not an alternative for insulin therapy, but considerably enhances its potential.

[Cicatricial strictures of the hepatic ducts and area of their junction (stricture 0)]. / Rubtsovye striktury pechenochnykh protokov i oblasti ikh sliiania (striktura 0).

The article deals with experience in the treatment of 187 patients (in 1980-1992) with cicatricial stricture of the hepatic ducts in the region of their coalescence (0 stricture). A high cholecystoenteric anastomosis, was formed, on a transhepatic drain in 117 (group I) and a precision anastomosis in 70 patients (group II). Analysis of the results of the operations showed that in group I patients, the early postoperative period was quite severe with the development of specific complications due to use of a replaceable transhepatic drain (hematobilia, leakage of bile into the subdiaphragmatic space, subdiaphragmatic abscess). Ten patients died (8.5%), a recurrent stricture was encountered in 4 patients. In group II patients, the early postoperative period followed a favorable course, there were no fatal outcomes, only one patient had a recurrent stricture. Experience shows that a high precision cholecystoenteric anastomosis can be formed in cicatricial stricture of the hepatic ducts in the region of their coalescence by means of some methodical manipulations. However, it should not be considered an alternative to operations with framed drainage of the bile-draining anastomosis.

[Endoscopic removal of calculi from the choledochus. Are there debatable questions in this problem?]. / Endoskopicheskoe udalenie kamnei iz kholedokha. Est' li spornye voprosy v dannoi probleme?

The article generalizes experience (1986-1991) in the treatment of 246 patients with choledocholithiasis with the performance of endoscopic papillosphincterotomy. Most patients (61%) were over 60 years of age, many had serious concomitant diseases. Among patients with occlusion of the bile ducts, 53.6% had obstructive purulent cholangitis, 53.6% had acute biliary pancreatitis, and 30.9% had acute cholecystitis. Typical as well as atypical cannulation EPST was applied. To exclude an X-ray load on the patient and doctor, the orifices of the terminal part of the common bile duct and of the main pancreatic duct were identified in most patients by an elaborated method of cannulation with aspiration control without preliminary contrast X-ray examination. After EPST the concrements were removed completely in 194 and partly in 52 patients. Complications occurred in 35 patients (bleeding in 5, acute pancreatitis in 8, acute cholangitis in 6, acute cholecystitis in 8, perforation of the duodenum in 1, and wedging of Dormia's basket in 8 patients. Eight patients died after EPST from unresolved purulent cholangitis and multiple cholangitic abscesses of the liver. The long-term results were studied in follow-up periods of 12 months to 7 years. Recurrent cholelithiasis was encountered in 2 patients. On the basis of the accumulated experience we believe EPST to be the method of choice in the management of: residual and recurrent choledocholithiasis, patients with cholecystocholedocholithiasis and operation risk factors, patients with acute biliary pancreatitis and acute obstructive cholangitis.

[Characteristics of surgical treatment of benign bifurcation strictures of the hepatic ducts]. / Osobennosti khirurgicheskogo lecheniia dobrokachestvennykh bifurkatsionnykh striktur pechenochnykh protokov.

Experience in the treatment of 195 patients with benign bifurcation stricture of the hepatic ducts is discussed. This group was made up of patients with the cicatricial process involving the region of the bifurcation or continuing to one or both lobar hepatic ducts. Two basic methods of bile--diverting operations were used: with carcass drainage (mono- and bilateral) of the anastomosis and hepatic ducts (n-155) and without a carcass drainage with the formation of a widecholecysto- intestinal anastomosis (through inclusion of the left lobar hepatic duct) by means of interrupted sutures without grasping the mucous membranes of the hepatic ducts and intestine (h-36). A combined method was used in 4 patients with an isolated stenosis of the right hepatic duct and an intact left hepatic duct. Intubation of both lobar hepatic ducts is considered necessary in patients with a bifurcation stricture in the existence of indications for carcass drainage of the bile-diverting anastomosis. Analysis of the immediate and late--term results showed that the postoperative period was more favourable in patients with bilateral carcass drainage of the bile-diverting anastomosis and in those with a precision anastomosis that in patients with monolateral drainage (complications occurred, respectively, in 16.3% and 46.6% of patients, and a good late-term results was encountered, respectively, in 78.5% and 55% of patients). The stricture did not recur in patients with a precision anastomosis and in those with bilateral carcass drainage.

[Precision sutures of bile ducts in experimental cholangitis]. / Pretsizionnyi shov zhelchnykh protokov pri éksperimental'nom kholangite.

Experimental study of the use of the precision suture techniques in application to the hepaticocholedochus and in formation of biliodigestive anastomoses in cholangitis revealed the advantages of the precision suture over the "traditional" one. The precision suture is very strong and air-tight, provides adequate adaptation of the coats of the hepaticocholedochus and the small intestine and creates thus optimum conditions for healing; when used in combination with absorbable suture material it excludes the formation of ligature cholelithiasis and reduces the risk of cicatricial stenosis.

[Compensation of experimental insular insufficiency by altering the portal blood flow]. / Kompensatsiia éksperimental'noi insuliarnoi nedostatochnosti putem izmeneniia portal'nogo krovotoka.

Experimental insular insufficiency and hyperglycemia in dogs was induced by subtotal resection of the pancreas. The diverting of venous blood from the pancreas into the systemic circulation via the spleno-caval venous anastomosis promoted a reduction of insulin metabolization in the liver on the first passage. This led to an increase in peripheral blood insulin and rapid compensation for hyperglycehia induced by resection of 80% pancreas. No gross morphological changes in the liver were revealed during 4 months after anastomosis establishment. A decrease in the glycogen content in the liver and peripheral muscles was noted after blood shunting. The subtotal resection of the pancreas coupled with pancreatic duct ligation resulted in gross fibrotic changes in the pancreas and atrophy of the exocrine tissue. On the other hand, the endocrine tissue gets hypertrophied, being less prone to fibrosis.