[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.

[Recurrent hemangioendothelioma of the lower and middle segments of inferior vena cava with spread to previously installed prosthesis]. / Retsidivnaya gemangioendotelioma nizhnego i srednego segmentov nizhnei poloi veny s rasprostraneniem na ranee ustanovlennyi protez.

We report surgical treatment of a 65-year-old patient with recurrent hemangioendothelioma of inferior and middle segment of inferior vena cava with spread to previously established prosthesis. Advanced resection of inferior vena cava and right-sided nephrectomy were not followed by complications and resulted R0 resection. Surgery time was 180 min. Inferior vena cava cross-clamping time was 30 min. Total blood loss was 300 ml. Hemangioendothelioma is a rare tumor with unpredictable potential for malignant transformation and obligatory indications for surgical treatment. Resection and reconstruction of inferior vena cava and renal veins with a synthetic conduit is effective and safe procedure.

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.

[Salvage liver transplantation for hepatocellular carcinoma]. / Salvage-transplantatsiia pecheni pri lechenii gepatotselliuliarnoi kartsinomy.

OBJECTIVE: To analyze clinical course and the results of salvage liver transplantation in patients with recurrent hepatocellular carcinoma (HCC) after liver resection. MATERIAL AND METHODS: A 54-year-old man with HCV-infection and HCC and 22-year-old woman with fibrolamellar variant of HCC underwent resection of the right and left liver lobe, respectively. The first patient experienced recurrent HCC four times with an interval of 3-6 months within 2 years after surgery. Repeated liver resection was made in first three cases, right liver lobe transplantation - after the fourth recurrence. In the second patient, HCC recurred in 4 months after resection and was accompanied by subtotal portal vein thrombosis. Therefore, repeated liver resection was excluded and patient underwent right liver lobe transplantation. RESULTS: Patients are alive in 5 and 3.5 years after liver resection and in 2.5 and 3 years after transplantation, respectively. There are currently no signs of recurrent HCC in the graft.

[Pure laparoscopic DP-CAR procedure with portal vein resection]. / Polnost'yu laparoskopicheskaya dp-car s rezektsiei vorotnoi veny (klinicheskoe nablyudenie).

OBJECTIVE: To improve short- and long-term outcomes of locally advanced pancreatic body-tail cancer followed by major vessels invasion. MATERIAL AND METHODS: A case report of pure laparoscopic DP-CAR procedure with portal vein resection for locally advanced pancreatic body-tail cancer followed by severe abdominal pain in a 49-year-old patient is presented. RESULTS: Liver or stomach ischemia was not observed. Portal wall resection wasn't associated with any complication and resulted R0-resection. Postoperative period was complicated by Grade B pancreatic fistula. Preoperative abdominal pain completely disappeared after surgery. Surgery time was 330 min, intraoperative blood loss - 300 ml. The patient is currently undergoing FOLFIRINOX adjuvant chemotherapy. CT in 90 days after surgery confirmed no progression of disease or liver/stomach blood supply congestion. CONCLUSION: Modern technologies provide the opportunity to perform pure laparoscopic advanced surgical procedures with major vessels resection. Pure laparoscopic DP-CAR procedure with portal vein resection is effective and safe procedure that can be performed with all principles of open surgery and is associated with acceptable short- and long-term results.

[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.

Peculiarities of vitalization of grafts made of porous polytetrafluoroethylene in reconstruction of major veins (an experimental study). / Osobennosti vitalizatsii protezov iz poristogo politetraftorétilena pri rekonstruktsii magistral'nykh ven (éksperimental'noe issledovanie).

Increased incidence of locally disseminated malignant neoplasms with invasion of major veins compels modern surgery to search for an optimal material for reconstruction of major veins. Presented herein are the results of an experimental study aimed at exploring patency and peculiarities of vitalization of grafts made of porous polytetrafluoroethylene (7th generation, 2010) manufactured by the Closed Joint Stock Company 'Research and Production Complex 'Ecoflon' (St. Petersburg, Russia) with an internal diameter measuring 4.0 mm and used for reconstruction of major veins and arteries with a follow up period up to 270 days. Vitalization of porous polytetrafluoroethylene grafts in the venous position is comparable to that in the arterial position, having similar patterns. Both in the arterial and venous position, vitalization of the graft proceeds at the expense of 'crawling' of the neointima from the anastomoses to the centre of the graft. To distinctive peculiarities of vitalization of grafts in the venous position belong statistically significantly larger thickness of the neointima in the venous position at all stages of the study, lack of statistically significant difference of the neointimal thickness near the edges and in the central part of the graft in the venous position at 270 days. Neither thromboses nor haemodynamically meaningful stenoses of the porous polytetrafluoroethylene grafts and anastomoses in the venous position, despite low velocity of blood flow and its laminar pattern, were observed at any terms of follow up. The obtained findings are indicative of the possibility and validity of using porous polytetrafluoroethylene grafts for reconstruction of major veins in clinical practice.