[Vascular reconstruction and transplantation technologies in liver surgery (part II)]. / Sosudistye rekonstruktsii i transplantatsionnye tekhnologii v khirurgii pecheni (chast' II).

OBJECTIVE: To systematize tactical and technical aspects of liver resections with reconstruction of afferent and efferent blood supply and/or inferior vena cava; to study postoperative outcomes in patients with focal liver lesions using transplantation technologies. MATERIAL AND METHODS: We enrolled 413 patients with parasitic lesions, primary and secondary liver tumors involving great vessels (portal vein, hepatic artery, hepatic veins, inferior vena cava, right atrium). All ones underwent liver resections with vascular resection and reconstruction, as well as liver autotransplantation in vivo, ante situ (ex situ in vivo), extracorporeal liver resections with autotransplantation (ex vivo). RESULTS: We obtained satisfactory immediate results after liver resections using transplantation technologies. CONCLUSION: Transplantation technologies in liver surgery can significantly increase resectability of tumors and survival of patients. Transplantation technologies are an important new surgical strategy and necessary option in modern hepatic surgery.

[Vascular reconstructions and transplant technologies in liver surgery (part I)]. / Sosudistye rekonstruktsii i transplantatsionnye tekhnologii v khirurgii pecheni (chast' I).

OBJECTIVE: To systematize technical aspects of liver resections with reconstruction of afferent and efferent liver blood supply and/or inferior vena cava, as well as to analyze the results of surgical treatment in patients with focal liver lesions. MATERIAL AND METHODS: The study included 413 patients with parasitic lesions, primary and secondary liver tumors with great vessel invasion (portal vein, hepatic artery, hepatic veins, inferior vena cava, right atrium). These features excluded radical liver resections without vascular resection and reconstruction, as well as liver autotransplantation in vivo, liver autotransplantation ante situ (ex situ in vivo), extracorporeal liver resections with autotransplantation (ex vivo). RESULTS: Surgical interventions were systematized depending of surgical tactics and techniques, technical complexity, type and number of reconstructed vessels, the use of total vascular isolation and cold preservation techniques, resection and reconstruction of great vessels. Thus, 4 gradations were allocated (Grade I-IV). The definition of transplantation technologies in liver surgery was proposed. CONCLUSION: Transplantation technologies in liver surgery include liver resections supplemented with vascular reconstruction of afferent and efferent liver blood supply, inferior vena cava including total vascular isolation of liver under normo- or hypothermia. These measures can significantly extend the possibilities of resection.

H-shaped partial splenorenal shunting with the use of a reinforced graft made of porous polytetrafluoroethylene. / N-obraznoe partsial'noe splenorenal'noe shuntirovanie s ispol'zovaniem armirovannogo proteza iz poristogo politetraftorétilena.

AIM: The study was aimed at improving the immediate and remote results of splenorenal bypass grafting. PATIENTS AND METHODS: A total of 57 patients presenting with hepatic cirrhosis, portal hypertension, and recurrent haemorrhage from oesophageal varices underwent an H-shaped partial splenorenal shunt procedure using an externally reinforced 1.5-2.0-cm-long synthetic graft with a diameter equalling half of that of the splenic vein in an end-to-side fashion. Assessment of efficacy of shunting was based on intraoperative measurement of venous pressure in the portal system before and after shunting, the findings of Doppler ultrasonography of the linear velocity of blood flow in the portal, splenic, and left renal veins in the early postoperative period, as well as computed tomography, esophagogastroscopy, and assessment of the degree of hepatic encephalopathy in the remote postoperative period. RESULTS: The findings of intraoperative measurement of venous pressure in the portal vein system before and after shunting demonstrated a statistically significant decrease in (normalization of) portal pressure in all patients after bypass grafting (p≤0.05). There were no severe postoperative complications, in-hospital mortality, nor events of decompensation of hepatic insufficiency. According to the findings of Doppler ultrasonography of the linear velocity of blood flow and control computed tomography after surgery, the splenic vein, left renal vein and the conduit between them remained patent at all terms of postoperative follow up. The findings of control esophagogastroscopy revealed a statistically significant decrease in the degree of oesophageal varices at 3, 6, and 9 months after shunting (p≤0.05). There was no statistically significant difference in the change of the degree of hepatic encephalopathy at 3, 6, and 9 months after shunting (p=0.853, p=0.712, and p=0.581, respectively). At various terms after surgery, nine patients underwent deceased donor liver transplantation, with the splenorenal shunt ligated intraoperatively. CONCLUSION: This method of splenorenal shunting makes it possible to decrease the risk of bleeding from oesophageal varices and venous thromboses in vascular anastomoses, as well as complications resulting from using autovenous conduits, to decrease the risk of decomposition of hepatic insufficiency and the frequency of the development of encephalopathy in the postoperative period. Besides, this method makes it possible to easily dismantle the previously created artificial portocaval shunt in the process of liver transplantation.

[Use of polytetrafluoroethylene grafts for reconstruction of major veins of mesenteric-portal system]. / Ispol'zovanie protezov iz politetraftorétilena dlia rekonstruktsii magistral'nykh ven mezenteriko-portal'noi sistemy.

Surgical management of patients with tumour invasion of major veins by means of their resection and simultaneous reconstruction is an actively developing trend in modern surgery. The article describes a clinical case report concerning treatment of a patient presenting with disseminated neuroendocrine cancer of the pancreatic head and subjected to pancreatoduodenal resection with a complicated variant of mesenteric-portal reconstruction and the use of a graft made of porous polytetrafluoroethylene, followed by relapse-free survival of more than 5 years. In our case report, despite complexity of forming a proximal anastomosis, the findings of multislice computed tomography with 3D-reconstruction 4 months after the operation demonstrated uneven circular thickening of the graft's wall by 1-2 mm, which might be interpreted as neointimal hyperplasia. The maximum thickness amounted to 2 mm in the area of the distal anastomosis. Thus, the internal diameter of the graft varied from 8 to 9 mm. The minimum thickness was observed in the middle portion of the graft, amounting to 1 mm. The findings of computed tomography at 60 postoperative months demonstrated no evidence of the disease's progression, the portal system of the liver contrasted evenly, the mesenteric-portal graft fully patent, showing parietally a thin uneven low-density strip 1-2 mm thick (with the maximum thickness observed in the area of anastomoses and the minimum thickness in the centre of the graft). Thus, the obtained findings are suggestive of high efficacy, safety, and feasibility of using polytetrafluoroethylene grafts for reconstruction of major veins in clinical practice. More randomized studies are necessary to confirm our conclusions.

[Influence of pancreatic segment graft autotransplantation on its exocrine function].

In experiments on dogs the exocrine secretion of pancreatic segment graft after its autotransplantation and of pancreatic stamps after proximal resection of the pancreas was investigated. More significant impairment of the exocrine secretion of the pancreas was revealed in animals after pancreatic graft autotransplantation in comparison with animals after the proximal resection of the pancreas. Maintenance of the adaptation of pancreatic exocrine secretion to the nutritional composition of the intestinal contents and "generalized inhibition" of pancreatic exocrine secretion caused by duodenal trypsin infusion was revealed in all groups.

[Pancreatic functional status after wedge resection of the duodenal wall and para-pancreatic micro-irrigation].

RESEARCH OBJECTIVE: To study influence parapancreatic microirrigation on morphological and functional condition of a pancreas and transformations of enzymatic activity of blood serum and enzymatic activity of lymph of a chest lymphatic channel after an operative trauma of a duodenum. MATERIAL AND METHODS: Research is executed on 140 not purebred dogs which have been divided into six groups and united in two series. In the first series (30 dogs) were studied changes pancreatic exosecretion in the postoperative period of resection of duodenum (group 1.1), in the postoperative period of resection of duodenum with preliminary infiltration of a parapancreatic tissue of 0.5% by a solution of Novocain (group 1.2) and after resection of duodenum with application parapancreatic microirrigation (group 1.3). In the second series (110 dogs) were studied frequency of development of acute pancreatitis, enzymatic activity of blood serum and enzymatic activity of lymph of thoracal lymphatic duct after resection of duodenum (group 2.1) and in the postoperative period of resection of duodenum with preliminary infiltration of a parapancreatic tissue of 0.5% by a solution of Novocain (group 2.2) and after resection of duodenum with application parapancreatic microirrigation (group 2.3). RESULTS: Application parapancreatic microirrigation does not lead to oppression pancreatic exosecretion at the first o'clock after duodenotomy, and substantially reduces the pancreatic hypersecretion observed in the postoperative period of resection of a duodenum. In addition, application parapancreatic microirrigation reduces frequency of development of acute pancreatitis and promotes less expressed increase enzymatic activity of blood serum and enzymatic activity of lymph thoracal lymphatic duct at development of the given complication after operational trauma of duodenum in comparison with resection of duodenum and after a resection of a duodenum executed against infiltration of a parapancreatic tissue of 0.5% by a solution of Novocain.