[Cholangiocellular cancer: the state of the problem and ways to improve the results of surgical treatment]. / Kholangiotselliuliarnyi rak: sostoianie problemy i puti uluchsheniia khirurgicheskogo lecheniia.

AIM: To improve the outcomes in patients with resectable biliary cancer. MATERIAL AND METHODS: There were 263 procedures for cholangiocellular carcinoma (CCC) for the period 1998­2017. Adjuvant chemotherapy was performed in 102 (38.8%) patients. Extensiveliver resections (78.9%) prevailed for intrahepatic cholangiocellular carcinoma (n=128), 6 (4.7%) patients required vascular resection. Seventy-seven pancreatoduodenectomies were performed for common bile duct cancer, portal vein resection was done in 8 (10.4%) patients. In case of Klatskin tumor (n=58) liver resection combined with bile duct resection (n=52) prevailed. Portal vein resection was done in 16 (27.6%) patients. RESULTS: Postoperative morbidity in patients with intrahepatic CCC was revealed in 68 (53.1%) cases, mortality ­ in 5 (3.9%) cases. Among patients with Klatskin tumor morbidity was revealed in 51 (87.9%) cases, mortality ­ in 6 (10.3%) cases. In patients with common bile duct cancer morbidity was revealed in 53 (68.8%) cases, mortality ­ in 4 (5.2%) cases. In whole cohort median overall survival was 30 months. R0-resection was associated with better long-term results (median 37 months) compared with R1­R2 resection (20 months; p=0.01). Lymph node involvement is associated with significantly worse prognosis (p=0.016), however 5-year survival is observed (25.6%). Adjuvant chemotherapy in R0-resection significantly improved long-term results: median was 46 months (vs. 30 in group without chemotherapy; p=0.02). In intrahepatic CCC patients multiple lesions or mechanical jaundice did not aggravate long-term results. CONCLUSION: R0-resection including lymphadenectomy, resection of adjacent organs and vessels is advisable for CCC. Isolated bile duct resection should be used as an exception. Adjuvant therapy improved long-term results. Multiple lymph node lesion or bile duct infiltration are not contraindications to surgery in intrahepatic CCC patients.

[Surgical strategy for locally-advanced right-sided colonic cancer]. / Strategiia khirurgicheskogo lecheniia mestno-rasprostranennogo raka pravoi poloviny obodochnoi kishki.

AIM: To present early and remote surgical outcomes in patients with locally-advanced right-sided colonic cancer, invasion of pancreatic head and/or duodenal wall. MATERIAL AND METHODS: Early and remote surgical outcomes were analyzed in 27 patients who underwent gastropancreatoduodenectomy combined with right-sided hemicolectomy (ileotransversostomy extirpation) for locally-advanced right-sided colonic cancer. RESULTS: Mean time of surgery was 300 (240-460) minutes, intraoperative blood loss - 2000 (500-7200) ml. Postoperative complications were observed in 15 (55.6%) patients. 3 (11.1%) patients died in early postoperative period. Overall 1-, 3- and 5-year survival was 92.7%, 48% and 36,5% respectively. Median was 33 months. CONCLUSION: Advanced combined surgery for locally-advanced right-sided colonic cancer, invasion of pancreatic head and/or duodenal wall is associated with acceptable incidence of postoperative complications, early and long-term mortality.

[Total pancreatectomy for pancreatic cancer]. / Total'naya pankreatektomiya pri opukholevom porazhenii podzheludochnoi zhelezy.

AIM: to determine the indications and to evaluate early and long-term outcomes of total pancreatectomy for pancreatic cancer. MATERIAL AND METHODS: Treatment of 29 patients who underwent one- and two-stage pancreatectomy for different malignancies was analyzed. RESULTS: Median of surgery duration and intraoperative blood loss was 280 min and 2200 ml respectively. Postoperative complications were observed in 9 (31%) patients. There were 2 (6.9%) deaths. 1- and 3-year overall actual survival was 61% and 16% respectively in case of ductal adenocarcinoma. Median was 18 months. Patients after surgery for primary multiple lesion (cancer of pancreatic body-tail and major duodenal papilla), pancreatic metastases of renal cancer, mucinous cystadenoma and neuroendocrine cancer are still alive. Follow-up periods are 4, 49, 49 and 65 months respectively. CONCLUSION: Total pancreatectomy is difficult intervention followed by severe metabolic disorders. However it can improve long-term survival with acceptable incidence of postoperative complications and quality of life if clear indications for surgery are present.

Surgical and combined treatment of patients with cholangiocellular carcinoma.

INTRODUCTION: Liver resection is the essential method of cholangiocellular carcinoma treatment. However due to low resectability and high incidence of recurrences search for additional curative methods is necessary. AIM: To improve the results of surgical treatment of patients with cholangiocellular carcinoma especially with complications and poor prognosis. MATERIAL AND METHODS: A total of 95 surgical procedures for intrahepatic cholangiocarcinoma have been performed in the department of liver andpancreatic tumors at N.N. Blokhin Russian Cancer Research Center since 1998 to 2014. 11 patients had obstructive jaundice as the first symptom of the disease. Extended liver resections were done in most cases (84.2%). Preoperative treatment was performed in 3 patients. Adjuvant chemotherapy after R0-resection was applied in 15 patients. RESULTS: The postoperative mortality rate was 4.2%. Postoperative complications were observed in 51 (53.7%) patients. Complication grade III after adjuvant chemotherapy was observed in one (6.7%) patient. Median survival after liver resection was 25 months, 5-year survival rate - 25.3%. In stage I-II five-year survival reached 66.7%. In patients with obstructive jaundice 5-year survival rate was 26.7%, median survival - 37 months. There was no improvement of survival in case of adjuvant therapy. CONCLUSION: Liver resection remains essential treatment of cholangiocellular carcinoma including patients with obstructive jaundice. Additional curative methods are necessary to increase resectability and decrease the risk of recurrence.

Surgical and combined treatment of patients with Klatzkin's tumor.

Surgery as being a preferential method of treatment of patients with cholangiocarcinoma is associated with high complications and mortality levels while demonstrating poor long-term outcomes. Optimization of preoperative management and improvement of the results of surgical treatment for patients with proximal extrahepatic bile duct carcinoma. From January 1998 to December 2013 surgical treatment was performed in 36 patients (19 males, 17 females) with Klatzkin's tumor, from whom 10 patients obtained postoperative chemotherapy. Bismuth-Corlette type III-IV tumor stage was determined in 30 (83.3%) patients. Portal vein resection was performed in 13 (36.1%) patients. 27 (75.5%) patients underwent R0 resection. Postoperative mortality rate consisted 16.7%, complications were revealed in 87.1% of cases. 6 (16.7%) patients required additional surgery and interventional procedures were performed in other 20 (55.5%) patients to fix postoperative complications. Overall 5-year survival rate in R0-resection group was 40.1%, median - 29 months. In postoperative chemotherapy group overall 3-year survival rate was 66.7% which was twice higher than in surgery group but the difference was not statistically significant (p=0.35). The improvement of short-term outcomes of surgical treatment for patients with Klatzkin's tumor requires optimization of preoperative management and detailed adherence of surgical techniques. Combination of surgery with postoperative chemotherapy showed the trend to improvement of overall survival.

[Results of the repeated hepatic surgery on the reason of malignant tumors].

The work is based on an analysis of 95 clinical observations of patients with primary and metastatic liver disease who were in the surgical department of tumors of the liver and pancreas of the State Research Institute named by N.N. Blokhin of RAMS from 1990 to 2011. All patients underwent two or more liver resections. Of all 95 patients included in this study, 64 underwent repeated interventions over a liver colorectal metastases. 10 patients had the operations, which were performed for primary hepatocellular carcinoma of the liver. In 21 patients re-resection were performed for metastatic lesions of other tumor nosology. Postoperative mortality in tumor lesions of the liver in patients who underwent repeat resection was 1.05%, postoperative complications occurred in 38.9% of patients. All patients with colorectal liver metastases who underwent repeat resection of various sizes, five-year survival rate was 53.3±8.8%. Median 35.9 months. The low level of mortality and acceptable level of postoperative complications in patients re-operated liver tumor, as well as high rates of long survival confirm the thesis about the need for such interventions as part of combined treatment of this difficult group of patients.

[Hepatopancreatoduodenal resection - are there any perspectives?].

1380 operations on liver, mostly for metastatic lesions were carried out during 1990-2010 years. Gastro-pancreaticoduodenal resection for lesions with periampullary localization was carried out to 580 patients. Combined surgical intervention on liver and pancreas was carried out in 20 cases. These observations formed our study. Direct and long-term results of treatment were analyzed in operated patients. It is shown gastropancreaticoduodenal resection though having high level of postoperative complications is well tolerated and can be recommended for wide application in clinical practice.

[Gastropancreatoduodenal resection for malignant tumors, complicated with obstructive jaundice].

The experience of 329 gastropancreatoduodenal resections for malignant tumors of the periampullary zone has been reviewed. The obstructive jaundice complicated the disease in 237 (70%) patients. The fact required various modalities of the preoperative artificial bile drainage. To evaluate the jaundice influence on the perioperative period, patients were divided in 4 groups, considering the bile drainage modality and bilirubin blood levels. The early postoperative period was respectively analyzed, which led to the conclusion that bilirubin blood level has no influence on either intraoperative characteristics or postoperative morbidity and mortality. For the reason of that, radical treatment of the periampullary cancer, complicated by the obstructive jaundice, does not require preoperative bile drainage.

[Surgical treatment of hepatocellular carcinoma].

Experience of surgical treatment of 171 patients, suffering hepatocellular carcinoma (HCC), was summarized. Extensive hepatic operations were performed in 99 (71.2%) patients, of them in 22.2%--on the concurrent hepatic cirrhosis background. Late results of treatment, depending on the main prognostic factors present, were analyzed. Cumulative survival in the terms of 5, 10 and 20 years have constituted 53.5, 37.3 and 28.8% accordingly. Accomplishment of a radical hepatic resection for HCC permits to achieve a durable remission of a tumoral process. While revealing a concurrent hepatic cirrhosis stage B (according to Child--Pugh classification) it is appropriate to use a hepatic transplantation and other methods of treatment, including chemoembolization, radiofrequency ablation, chemotherapy.

[Advanced hepatic resection for malignancy].

125 patients with hepatic neoplasms were observed during 1998-2008 years. Trisectionectomy was carried out to 84 patients with colorectal metastatic affection of liver, which amounted 67.2% of all cases. Hepatocellular carcinoma was the second most frequent malignancy to be observed--23 patients (18.4%). 6 patients (4.8%) with cholangiocellular carcinoma went further. 12 patients (9.6%) with non-colorectal metastatic tumors of liver were united into one group. In postoperative period adjuvant chemotherapy was carried out to 60 patients with colorectal metastatic affection of liver. In all patients with hepatic tumors undergoing trisectionectomy postoperative lethality amounted 6.4% (n=8), in patients with colorectal metastatic affection of liver--5.95% (n=5), in patients with primary hepatic tumors--3.45% (n=1), in patients with non-colorectal metastatic affection of liver--16.66% (n=2). Lethality was caused by acute hepatic failure in all observations. Postoperative complications were observed in 44.05% of patients with colorectal cancer and in 44.83% of patients with primary hepatic tumors. Hepatic failure was the most frequent complication. In case of colorectal metastatic affection three-year probability of survival amounted 30.94+/-6.6% in patients undergoing trisectionectomy, five-year--10.4+/-8%. Median 16 months. On conditions that adjuvant chemotherapy was carried out, three-year survival probability increased to 40.53+/-8.1%, five-year--to 10.4+/-8%. Median 17 months. One-year survival probability in patients with primary hepatic tumors undergoing trisectionectomy amounted 92.46+/-5.1%, three-year - 59.44+/-12.3%, five-year--44.58+/-15.8%. Median 42 months. Low level of postoperative lethality, allowable level of postoperative complications and good indices of survival probability in long-term period allow considering that trisectionectomy as a surgical technique is absolutely appropriate.

[The combined treatment of colorectal cancer with liver metastases].

The direct and follow-up results of surgical and combined treatment of colorectal cancer with liver metastases are presented. Complication rate after liver resections was 28.4% and lethality was 3.5%. Follow-up results evidence the decrease of survival in patients with adjuvant chemotherapy after surgery. The safety of oxalyplatin in patients after liver resections, including its intraarterial infusion through the hepatic artery is shown. Oxalyplatin-based chemotherapy regimen tended to be more effective in comparison with 5-fluorouracil scheme, especially in patients with synchronous or multiple liver metastases. Considering that the difference is not statistically significant, further studies of oxalyplatin influence on survival of patients with colorectal liver metastases are necessary.

[Multivisceral resections at disseminated abdominal tumors].

Overall 131 multivisceral resections at disseminated abdominal malignant tumors have been performed. The main arguments to extended operations were local dissemination of tumor (35.1%), synchronous hepatic metastases (49.6%), combination of local dissemination with synchronous metastases (6.1%), isolated synchronous tumors (6.1%), and multiple metastases with polyorganic localization (3%). The rate of postoperative complications and lethality at the patients undergone multivisceral operations were 34.3 and 6.8% respectively. There were no significant differences in postoperative complications rate and lethality between adjusted multivisceral and standard operations groups.

[Synchronous operations in metastatic cancer of the liver].

The resection of the liver has been performed in 661 patients including 154 (23.3%) cases of synchronous metastatic cancer of the liver. Among the latter patients primary tumor was removed in one stage with liver resection in 56% cases. Elderly age of the patients, multiple bilobular foci in the liver, size of the foci more than 10 cm, traumatic operations on the primary focus were not contraindications to synchronous operations. Surgical treatment for colorectal cancer should be supplemented with adjuvant chemotherapy. The long-term results demonstrate better survival after synchronous operations for colorectal cancer.

[Current approaches to surgical treatment of liver tumors]. / Sovremennye podkhody k khirurgicheskomu lecheniiu opukholei pecheni.

Since 1990, 230 operations for focal pathologies in the liver have been carried out at the Center's clinics using such advanced procedures and equipment as radio-isotope examination of hepatic function, ultrasonography of the liver during surgery, ultrasound aspirator, water-flow scalpel, argon coagulator and adhesive dressing materials. The study included 75 resections for primary hepatic tumor (lethality-14.6%), 114 resections-disseminated tumor (lethality-5.2%) and 41 resections for benign tumors and non-tumor pathologies (no lethality). Preoperative chemotherapy was found to significantly increase the risk of postoperative complications in cases of liver resection. Five-year survival in such patients with primary tumor was 33.3%. The seven most significant prognostic factors in primary hepatic carcinoma were: portal invasion by tumor cells, number of tumor nodes in the liver, alpha-fetoprotein concentration, tumor node size, concomitant cirrhosis, age and extent of surgery. In patients with hepatic resection for solitary metastasis of the large bowel, 5-year survival was 28.6%. A regimen of adjuvant chemotherapy for solitary metastasis of colorectal cancer into liver is suggested. The data on 37 surgical patients with hepatic metastasis of non-colorectal cancer are presented. It was demonstrated that the liver should be resected in cases of solitary metastasis of renal carcinoma, adrenal gland, ovary, tests, breast, gallbladder and carcinoid.

[The surgical treatment of malignant liver tumors]. / Khirurgicheskoe lechenie zlokachestvennykh opukholei pecheni.

From study of the data concerning 133 patients who underwent operation for tumor of the liver the authors found that 43 (32.2%) patients were treated by a radical operation and 34 (25.5%) were subjected to palliative interventions. Among the radical interventions hemihepatectomy was performed on 21 (48.8%) patients. The total number of complications after radical operations was 46.3%, the mortality rate 11.6%. The authors discuss problems of the prevention of some complications, intraoperative hemorrhages in the first place. Different variants of bile diversion accounted for most of the palliative interventions. Survival in radical operations was 38.56 months, in palliative operations 8.34 months, and in exploratory operations 5.9 months.

[Hepatopancreatoduodenal resection in locally advanced cancer of gallbladder]. / Gepatopankreatoduodenal'naia rezektsiia pri mestnorasprostranennom rake zhelchnogo puzyria.

A case of hepatopancreatoduodenectomy in advanced cancer of the gall bladder is presented as well as literature data on indications for this operation, technical peculiarities of its performance, postoperative complications, follow up results and advisability of carrying out such a complicated surgical intervention.

[Ways to improve tolerance to gastro-pancreatic-duodenal resection]. / Puti uluchsheniia perenosimosti gastropankreatoduodenal'noi rezektsii.

Immediate results of 125 gastropancreatoduodenal resection (GPDR) performed for cancer of the pancreatoduodenal zone are presented. Despite extended surgery volume (15 GPDR were extended, in 14 patients resection of the major vessels was performed) postoperative lethality decreased to 1.6% due to lowered rate of severe postoperative complications (first of all insufficiency of pancreato- and biliodigestive anastomosis). Ways of prophylaxis of these complications consist in conduction of percutaneous puncture transhepatic cholangiostomy as the method of choice for billiary decompression before surgery in patients with tumor obstructive jaundice, precise surgical technique, creation of pancreatogastroanastomosis on reconstructive stage of GPDR.

[Repeated resection of liver in primary and metastatic cancer]. / Povtornye rezektsii pecheni pri pervichnom i metastaticheskom rake.

164 operations for malignant tumors of the liver were performed in Cancer Research Center. 14 patients underwent repeated resections of the liver, 5 of them due to primary cancer of the liver and 9--with metastatic liver disease. Recurrence was revealed in 6 from 14 patients (42.8%), within a year after resection, in 4 (28.6%)--during two year after the first resection of the liver. In the rest 4 patients (28.6%) recurrence was revealed after two and more years. The indications for repeated resections were: recurrent cancer in the liver which should be localized, with absence of extrahepatic metastasis, good functional condition of the liver and absence of concomitant diseases. Repeated resections of the liver are technically more complicated due to the following causes: functional condition of the liver is rather deteriorated, especially after previous extended resections; anatomical interrelations are disturbed, there are intensive adhesions. There were no lethal outcomes after repeated resections of the liver. 3 years survival of operated patients was higher (60%) than in patients who underwent resection of the liver once, both in a primary cancer of the liver (46.8%) and in metastatic cancer (40%).

[Extended gastropancreatoduodenal resection (GPDR)]. / Rashirennaia gastropankreatoduodenal'naia rezektsiia.

The authors for the first time in Russia have begun serial performance of the extended GPDR. The operations were accompanied by careful morphological investigations of the removed organs and tissues. It was established that in all patients with exocrine cancer of head of the pancreas the tumor growth extended the region of the regional lymph nodes, i.e. standard GPDR in these patients oncologically could not be considered as adequate operation. Further performance of GPDR for pancreatic head exocrine cancer will expand knowledge about metastatic spread and will open opportunities to improve long-term survival of the patients with exocrine cancer of the head of the pancreas.

[The diagnosis and surgical treatment of metastatic liver tumors]. / Diagnostika i khirurgicheskoe lechenie metastaticheskikh opukholei pecheni.

The authors have carried out 48 resections of liver for it's metastatic injure. The most frequent source of metastatic spread in liver occurred to be colorectal cancer. Right liver lobe was found to be injured by the metastatic tumour more often. After liver resections of various value the frequency of complications was 37.5%, postoperative lethality--2.1%. Presented data evidence the necessity of widening recommendations to perform radical operative interventions in patients with solitary and single metastases in liver.