[Combined operations for prophylaxis of gastroesophageal bleedings at the patients with portal hypertension].

Results of portocaval bypass (1st group), suture ligation of gastric and esophageal varicose veins (2nd group), and combined operations (3rd group) performed in early postoperative period at 759 patients with liver cirrhosis and extrahepatic portal hypertension are analyzed. Long-term results were studied at 549 patients. Early recurrence of bleeding was occurred at 41 (12.9%) patients of 1st group, at 17 (8.5%) of 2nd, and at 2 (4%) patients of 3rd group. Lethality due to bleeding recurrence at 1st group was 5.1% among the patients with liver cirrhosis and 1.9% among ones with extrahepatic portal hypertension. Recurrence of bleeding at 2nd group was seen at 52.8% patients with liver cirrhosis, and at 36.4% - with extrahepatic portal hypertension. Lethality due to bleeding recurrence in this group was 7%. The best results were achieved in 3rd group: the recurrence of bleeding was diagnosed at 2 (7.7%) cases, there was 1 lethal outcome. It is concluded that combined surgical procedures at the patients with portal hypertension permit to reduce the rate of early recurrences of bleeding in 2.5 times. It allow to perform widely the partial portocaval anastomoses at the patients with liver cirrhosis and the bypass procedures at extrahepatic portal hypertension.

[Diagnosis and treatment policy in trauma of duodenum]. / Diagnosticheskaia i lechebnaia taktika pri travme dvenadtsatiperstnoi kishki.

Experience of treatment of 70 patients aged from 17 to 71 years with trauma of duodenum (TD) was analyzed. Majority of them was men -- 57 (81.4%). Open TD were seen in 61.4% cases, closed -- in 38.6%. There were no pathognomonic symptoms. X-ray examination of abdominal cavity is the important procedure permitted to suspect TD. Diagnostic algorithm in abdominal trauma for exclusion of TD before surgery was developed. Yellow-green imbibition, mass of air vesicles in retro-abdominal space, hematomas in duodenal zone were the indications for revision of duodenum during surgery. Hematoma of duodenal wall was indication for it revision for exclusion of penetrating wound. In 55 (77.1%) patients with wounds penetrating into duodenum (or disruption of duodenum) suture of defects was performed. "Exclusion" of duodenum was performed in 20 (28.6%) patients when there was threat of sutures insufficiency. Lethal outcome was seen in 20 (28.6%) patients including 13 (18.6%) cases during first day due to combined injuries and massive blood loss. Developed algorithm and treatment policy permitted to improve results of this severe variant of abdominal trauma.

[Late results of portacaval surgical shunt in patients with extrahepatic portal hypertension]. / Otdalennye rezul'taty portokaval'nogo shuntirovaniia u bol'nykh s vnepechenochnoi portal'noi gipertenziei.

Late outcomes of portocaval shunting (PCS) were analyzed in 135 patients with extrahepatic portal hypertension (EPH). It was established that the methods of choice in such patients should be splenorenal anastomosis, mesentericocaval anastomosis (MCA) "side by side" and H-type with autovenous or synthetic insertions. The best results were detected in a combination of portocaval anastomosis with the suturing pf stomach and esophageal varicose veins, if the diameter of the anastomosed vessel was small and portal pressure was reduced by less than 25% (100 mm of water column). The ineffectiveness of MCA "end in side" by Bogoras and cavamesenterial anastomosis was shown due to low efficiency and severe complications, respectively. These data demonstrate efficacy of endovascular dilatation in PCA stenoses, yet the possibilities of severe complications still exist. The best result of endoscopic PCS estimation 1 year after the surgery suggested complete recovery of patients with EPH in most cases.

[Results of suturing of esophageal and gastric varicose veins in patients with extrahepatic portal hypertension]. / Rezul'taty proshivaniia varikozno-rasshirennykh ven pishchevoda i zheludka u bol'nykh s vnepechenochnoi portal'noi gipertenziei.

Experience in gastrectomy with suturing of varicose veins (VV) of the esophagus and stomach (M.D. Patsiora's surgery) in 349 patients with extrahepatic portal hypertension (EPH) is reviewed. Short and long-term results of this surgery through abdominal and transthoracal approach are analyzed. Postoperative lethality in patients with EPH after elective surgery was 5.0%, urgent surgery--16%. Recurrence of esophagogastric bleeding in postoperative period was seen in 23 (6.6%) patients. 286 patients were followed up from 1 to 10 years. Recurrence of esophageal-gastric bleeding was seen in 104 (36.4%) patients and led to death in 19 (18.3%) of them. It is concluded that suturing of esophageal and gastric VV in patients with EPH is a method of choice both in prolonged bleeding and as preventive elective surgery when creation of vascular anastomosis is impossible.

[Surgical treatment of resistant ascites in patients with portal hypertension]. / Khirurgicheskoe lechenie rezistentnogo astsita u bol'nykh s portal'noi gipertenziei.

Surgical methods of treatment of diureticoresistant ascites in 198 patients with portal hypertension are analyzed: portocaval bypass (n = 16), lymphovenous anastomosis (n = 64), ductolysis (n = 24), and peritoneovenous bypass (n = 94). The most stable positive results was achieved after portocaval bypass, but it can be performed only in a small part of patients. Peritoneovenous bypass and lymphovenous anastomosis demonstrated shorter effect but they had less risk and were better tolerated than portocaval bypass. Efficacy of these surgeries depends not only on accurate indications and contraindications but also on functional resource of the liver and organism's reserves. Following these conditions and individual approach to choice of surgical methods of resistant ascites' treatment may improve quality of life and lifespan of patients with portal hypertension.

[Vitaflon vascular graft for portocaval shunt: experimental and clinical study]. / Eksperimental'no-klinicheskoe issledovanie sosudistykh protezov "Vitaflon" pri portokaval'nom shuntirovanii.

Native "Vitaflon" vascular graft made of spongeous polytetrafluoroethylene for portocaval shunt was evaluated in patients with portal hypertension. Experimental series in grey rabbits proved high biological inertness of the graft. It was used for portocaval shunt in 13 patients. The follow-up from 1 to 32 months demonstrated successful results in 12 cases.

[Orthotopic liver transplantation]. / Ortotopicheskaia transplantatsiia pecheni.

Orthotopic liver transplantation is the only method of choice for many severe liver diseases with poor prognosis. The development of liver transplantation programmes is based on medical science achievements and high technology in surgery, anesthesiology and perfusiology. The experience of the Surgery Research Center, Russian Academy of Medical Sciences, made it possible to obtain positive results of liver transplantation and posttransplantation management. This in turn provided longer survival for 80% of recipients. At the same time the mortality of potential recipients was 60.4%, which is due to the greater shortage of donor organs and which is the main problem in the development of organ grafting in Russia. The fact that there is a high proportion of children who are recipients for the donor's liver requires that liver transplantation from living related donors should be developed.

[The evolution of surgery for extrahepatic portal hypertension]. / Evoliutsiia khirurgii vnepechenochnoi portal'noi gipertenzii.

30 years' experience of elective surgical treatment of 600 patients with extrahepatic portal hypertension is summarized. Insufficient effectiveness of splenectomy in bleeding from varicose veins (VV) of the stomach and the esophagus (40% of relapses) is shown as well as frequent development (25%) of asplenic hemorrhagic thrombocytopenia. Partial esophagogastrectomy also has failed initial hopes due to severe agastric anemia which developed in 49.6% patients and relapses of erosion and ulcerogenous hemorrhage from the gastric stump (30%). Introduction of microsurgical methods, contemporary suturing material, usage of the jugular vein's segment for performing H-shape anastomoses enabled in the last decade to carry out porto-caval shunt using distal segments of superior mesenteric vein with diameter 5-9 mm and thus to increase the number of radical operations to thoroughly rehabilitate the patients, and to decrease postoperative mortality rate from 11.1% to 0.7% as well. Vascular anastomoses were not feasible, the operation of choice may be suturing of VV of the esophagus and the stomach with subsequent endoscopic sclerosis formation.

[The donor stage of orthotopic liver transplantation]. / Donorskii étap ortotopicheskoi transplantatsii pecheni.

First clinical experience of the harvesting (donor) stage of orthotopic transplantation of the liver in Russia is represented. During 5-year period in National Research Center of Surgery RAMS 16 orthotopic transplantations of the liver were carried out. Surgical modes of harvesting of the donor liver are detailed ("standard" and "fast"), the regimes and methods of preservation of the liver were determined. The influence of various parameters on function of the graft in postoperative period was established. Adequate selection of donors, correct and proper choice of donor-recipient pair, limited time of preservation allow to decrease the number of graft function failure and to eliminate primarily nonfunctioning grafts.

[Application of wound coat "Tachocomb" in surgical interventions on liver and pancreas]. / Primenenie ranevogo pokrytiia "Takhokomb" pri khirurgicheskikh vmeshatel'stvakh na pecheni i podzheludochnoi zheleze.

From May 1994 to December 1996 the wound coat "Takhocomb" was used in surgical procedures in 23 patients with various diseases of the and the pancreas. "Takhocomb" was mostly applied in various anatomical resections of the liver. Initial hemostasis of the hepatic stump was carried out by careful suturing of bleeding vessels. "Takhocomb" was used in 3 patients during pancreatoduodenal resection for chronic pancreatitis, adenocarcinoma of papilla Vateri and adenocarcinoma of the pancreatic head. The application of the wound coat "Takhocomb" in various resections (12) an hepatic ruptures (2), as well as in echinococcectomies (3) and removal of hepatic hemangioma (1) contributed to favourable hemostatic effect in all the patients. In 2 cases formation of external biliary fistulas due to technical errors in liver resection was detected in postoperative period. The fluid accumulation at subhepatic space or at the bed of resected liver after rightsided liver resections was considered as the tissue fluid production frown retroperitoneal fat.

[The system of hemostasis in experimental liver transplantation]. / Sistema gemostaza transplantatsii pecheni v eksperimente.

The status of haemostatic factors in 28 pigs after orthotopic liver transplantation was evaluated. The major changes took place in fibrinolytic system during the "non-liver" stage: rapid increase of fibrinolytic activity, plasmin activity, plasmin activator activity. From the moment of blood supply restoration to a transplanted liver the tendency to normalisation of fibrinolysis was detected. The deficiency of plasma haemostatic factors and platelets has increased during all the follow-up period and should be corrected in time. The following principles of corrective therapy are formulated: inhibition of fibrinolysis, correction of antithrombin-3 and blood clotting factors. Correction of haemostasis should be done in "pre-non-liver" period and later in "non-liver" reperfusion periods.

[Orthotopic liver transplantation: surgery research center's experience]. / Opyt ortotopicheskoí transplantatsii pecheni v Nauchnom Tsentre Khirurgii RAMN.

From 1990 to 1996, 178 patients with severe diffuse and advanced focal liver diseases with grave prognosis were observed for indications to orthotopic liver transplantation (OLT). According to the revealed indications and contraindications, 95 patients were enrolled for the procedure. Eighteen patients underwent 19 OLTs, including 1 urgent retransplantation and 3 living related graftings. Surgical techniques were conventional; with these, intraoperative mortality and biliary complications could be avoided. Long-term survival (6 to 68 months) was achieved in 8 recipients, including in those after liver retransplantation. Double or triple suppressive regimens were used. These included corticosteroids, cyclosporin A, azathioprine, antithymocytic globulin. The life quality of recipients promoted restoration of their working capacities. Two recipients gave birth to healthy babies.

[Iron metabolism in patients with portal hypertension]. / Sostoianie obmena zheleza u bol'nykh s portal'noi gipertenziei.

Ninety-four patients with portal hypertension (48 with cirrhosis of the liver and 46 with pathological changes of the portal vein trunk) were examined. The main parameters of iron metabolism were determined by the radioimmunoassay and the iron deports in the liver and spleen biopsy material were revealed. Tissue iron deficiency was found in all patients. The results of the tests were marked by essential peculiarities. In sharp reduction of the level of serum iron and ferritin the parameters of total and latent iron-binding capacity were decreased.

[Traumatic injuries of the pancreas]. / Travmaticheskie povrezhdeniia podzheludochnoi zhelezy.

Retrospective analysis of surgical treatment of 153 patients with traumatic damage to the pancreas is discussed. The injury was closed in 67.3% and open in 32.7% of cases. All cases were grouped in 4 degrees of severity: 1st degree--contusion of the gland without damage to the capsule (22.2%); 2nd degree--rupture of the gland without injury to the pancreatic duct (34.6%); 3rd degree--rupture of the gland with damage to the duct; 4th degree--combined pancreatoduodenal injury (15.7%). The therapeutic tactics was determined by the degree of injury inflicted to the pancreas. In 1st degree operation on the pancreas was not needed. In 2nd and 3rd degrees "abdominization" with drainage was the operation of choice. Distal resection was expedient only in crushing of the organ. The tactics in pancreatoduodenal injuries depended on the character of the duodenal wound. Thirty-nine (25.5%) patients died, 24 (61.5%) of them died in the first two postoperative days from shock. Pancreatitis was the prevailing postoperative complication, it occurred in 41 (31.8%) patients. All patients with injuries to the pancreas should be managed as cases of potential pancreatitis.

[Use of a gastrointestinal tube in the treatment of gastric and duodenal ulcer]. / Primenenie gastrointestinal'nogo zonda v lechenii iazvennoi bolezni zheludka i dvenadtsatiperstnoi kishki.

The trial of a gastrointestinal tube in gastroduodenal ulcer indicates its high efficiency for enteral tube feeding in serious ulcer cases and as a therapeutic modality in noncomplicated cases. The tube introduction in 55 patients out of 89 promoted the defect healing within 2-3 weeks, in 30 out of 36 cicatrization occurred on week 3-5. The presence of the tube produced no effect on acid production in the stomach, cicatrization of the ulcer took place without basic therapy in remaining hypo-achlorhydria and hyperchlorhydria. Clinico-endoscopic evidence and data on gastroduodenal motility and evacuation suggest the conclusion on the neuro-reflex mechanism of the tube action which eliminates painful syndrome and motor-evacuatory abnormalities which are believed essential in pathogenesis of peptic ulcer.

[Orthotopic liver transplantation (first clinical experience)]. / Ortotopicheskaia transplantatsiia pecheni (pervyi klinicheskii opyt).

The article deals with the results of work conducted according to the orthotopic liver transplantation (OLT) program from January 1990 to January 1992. To select the patients for OLT, 54 persons (24 males and 30 females aged from 12 to 55 years) with diffuse (34) and focal (20) diseases of the liver were examined. OLT was indicated for 19 patients who were registered in the waiting list. In the period of waiting for the donor organs, 5 persons died, 3 refused to undergo OLT, and 4 remain on the waiting list. Eight OLT (including one retransplantation) were conducted on 7 patients. The indications for OLT in these patients were: unresectable hepatocellular carcinoma (4), cirrhosis of the liver of viral etiology (1), fulgurant form of hepatitis B (1), transplant rejection crisis which could not be arrested (1). Immunosuppression was conducted by the two- and three-component programs with the use of corticosteroids, cyclosporine A, and azathioprine. Eight crises of transplant rejection were encountered, successful retransplantation of the liver was accomplished for one of two crises which could not be arrested. The survival of the operated on recipients ranged from 3 days to 15 months. Various complications (mainly hemorrhagic and infectious) were encountered in the posttransplantation period. At the time that the article is written, 3 patients are living for 15, 9, and 4 months (after retransplantation of the liver in the last case), their condition is satisfactory. The death of the other recipients was caused by candidosepsis (on the 40th day), polyorganic insufficiency (on the 10th and 3rd days), sepsis (on the 12th day). The results of the liver transplantation program correspond to those of transplantation centers in other countries in the period of OLT mastering.

[Diagnosis and therapy of acute cholecystitis in liver cirrhosis]. / Diagnostika i lechenie ostrogo kholetsistita pri tsirroze pecheni.

The article deals with information on 12 patients with acute cholecystitis and cirrhosis of the liver (class A--with maintained hepatic function in 3, class B--with subcompensated hepatic function in 8, and class C--with decompensated stage of cirrhosis of the liver in one patient). The clinical picture was atypical and the course severe (purulent complications, hepatic insufficiency). Nonoperative management of the attack should be limited to 24 hours. Sparing decompression (laparoscopic or laparocentetic cholecystostomy) is the optimal method of treatment of class B and C patients. The tactics in class A patients does not differ from the commonly accepted tactics. Unfavorable outcomes (3) were linked with performance of emergency cholecystectomy in patients with disturbed hepatic function.