Expanding indications for laparoscopic parenchyma-sparing resection of posterosuperior liver segments in patients with colorectal metastases: comparison with open hepatectomy for immediate and long-term outcomes.

BACKGROUND: Laparoscopic liver resection (LLR) of posterosuperior segments (PSS) is still technically demanding procedure for highly selective patients. There is no long-term survival comparative estimation after LLR and open liver resection (OLR) for colorectal liver metastases (CRLM) located in PSS. We aimed to compare long-term overall (OS) and disease-free survival (DFS) after parenchyma-sparing LLR with expanding indications and open liver resection (OLR) of liver PSS in patients with CRLM. METHODS: Two Russian centers took part in the study. Patients with missing data, hemihepatectomy and extrahepatic tumors were excluded. One of contraindications for LLR was suspicion for tumor invasion in large hepatic vessels. Logistic regression was used for 1:1 propensity score matching (PSM). RESULTS: PSS were resected in 77 patients, which accounted for 42% of the total number of liver resections for CRLM. LLR were performed in 51 (66%) patients. Before and after matching, no differences were found between groups in the following factors: median size of the largest metastatic tumor; proximity to the large liver vessels; the rate of anatomical parenchyma sparing resection of PSS; a positive response to chemotherapy before and after surgery. Regardless of matching, the size of the largest metastases was above 50 mm in more than one-third of patients who received LLR. Before matching, intraoperative blood loss, ICU stay and hospital stay were significantly greater in the group of OLR. No 90-day mortality was observed within both groups. There were no differences in long-term oncological outcomes: 5-year OS after PSM was 78% and 63% after LLR and OLR, respectively; 4-year DFS after PSM was 27% in both groups. CONCLUSION: Laparoscopic parenchyma-sparing resection of PSS for CRLM are justified in majority of patients who have an indication for OLR if performed in high volume specialized centers expertized in laparoscopic liver surgery.

[Treatment of severe post-resection liver failure. Analysis of the specialized center]. / Lechenie postrezektsionnoi pechenochnoi nedostatochnosti tyazheloi stepeni. Analiz spetsializirovannogo tsentra.

Posthepatectomy liver failure is one of the most serious complications of large liver resections. OBJECTIVE: The analyzes the management and results of treatment of patients with severe posthepatectomy liver failure (Grade C ISGLS) in a specialized hepatosurgical department. MATERIAL AND METHODS: In the period from January to December 2019, 175 liver resections were performed in the Department of liver and pancreatic surgery at the A.S. Loginov Moscow Clinical Scientific Center. Major-volume liver resections (hemihepatectomies and resections of more than three liver segments) were performed in 80 (45%) patients. In 125 (71%) cases liver resctions were performed for malignant liver and bile duct diseases. Laparoscopic liver resections were performed in 77 (44%) patients. RESULTS: Postresection liver failure developed in 18 (10.2%) patients. Severe (class C according to ISGLS) developed in 6 (3.4%) patients. In the postoperative period (90-day mortality), 4 patients (2.3%) died, while in two patients, mortality was not associated with liver failure. Hyperbilirubinemia was observed for more than 5 days in 2 (33.3%), coagulopathy in 4 (66.6%), ascites in 5 (83.3%), encephalopathy in 5 (83.3%), hypoglycemia in 3 (50%), and uncontrolled sepsis in 2 (33.3%) patients, respectively. Correction of surgical complications was required in 100% of cases, which consisted in drainage of abscesses and abdominal bylomas, and the the bilio-digestive anastomosis fistulas. Inotropic support was required in all 6 (100%) patients, invasive ventilation in 4(66.6%), and extracorporeal detoxification in 5 (83.3%). CONCLUSIONS: Posthepatectomy liver failure is a complex problem even in a specialized center. A comprehensive approach to treatment allows to achieve noticeable results and reduce mortality.

Percutaneous radiofrequency-assisted liver partition versus portal vein embolization before hepatectomy for perihilar cholangiocarcinoma.

BACKGROUND: Percutaneous radiofrequency-assisted liver partition with portal vein embolization in staged liver resection (PRALPPS) represents an alternative to portal vein embolization (PVE) followed by major liver resection in patients with perihilar cholangiocarcinoma. METHODS: This was an observational case-control study. Both procedures were applied in patients with a future liver remnant (FLR) volume of less than 40 per cent. The main end points of the study were short-term morbidity and mortality for the two procedures. The study also compared the efficacy of the preresection phases estimated by kinetic growth rate (KGR), time interval and degree of hypertrophy of the FLR. RESULTS: The first phase (preresection) was completed in 11 and 18 patients, and the second phase (resection) in nine and 14 patients, in the PRALPPS and PVE groups respectively. Major morbidity after the first stage did not differ between the groups. There were no differences in blood loss, severe morbidity or liver failure rate after the second stage, with no deaths. The mean KGR of the FLR after the preresection phase for PRALPPS was 3·8 (0·6-9·8) per cent/day, and that after PVE was 1·8 (0-6·7) per cent/day (P = 0·037). The mean time interval for FLR hypertrophy in the PRALPPS and PVE groups was 15 (6-29) and 20 (8-35) days respectively (P = 0·039). CONCLUSION: Short-term outcomes were similar for PRALPPS and PVE in terms of safety. Remnant hypertrophy was achieved more rapidly by PRALPPS.

ANTECEDENTES: La partición hepática asistida por radiofrecuencia percutánea con embolización de la vena porta en la resección hepática en varios tiempos quirúrgicos (percutaneous radio-frequency assisted liver partition with portal vein embolization in staged liver resection, PRALPPS) representa una alternativa a la embolización de la vena porta seguida de resección hepática mayor (portal vein embolization, PVE) en pacientes con colangiocarcinoma perihiliar (perihiliar cholangiocarcioma, PHCC). MÉTODOS: Se trata de un estudio observacional de casos y controles. Se efectuaron ambos procedimientos en pacientes con un volumen hepático remanente futuro (future liver remnant, FLR) < 40%. Los resultados principales del estudio fueron la morbilidad a corto plazo y la mortalidad de ambos procedimientos. En el estudio también se comparó la eficacia de las fases de pre-resección mediante la tasa cinética de crecimiento (kinetic growth rate, KGR), el intervalo de tiempo y el grado de hipertrofia del FLR. RESULTADOS: Se completaron la primera (pre-resección) y la segunda (resección) fase en 11/9 y 18/14 pacientes en los grupos PRALPPS y PVE, respectivamente. La morbilidad mayor tras el primer tiempo no difirió entre los grupos. No se observaron diferencias en la pérdida de sangre, morbilidad grave y tasa de insuficiencia hepática tras el segundo tiempo, sin que ocurriera ningún fallecimiento. La media de KGR del FLR tras la fase de pre-resección fue de 3,8 (0,6-9,8) %/día en el grupo PRALPPS y de 1,8 (0-6,7) %/día tras PVE (P = 0,037). La media de intervalo de tiempo de la hipertrofia del FLR en los grupos PRALPPS y PVE fue de 15 (6-29) días y 20 (8-35) días, respectivamente (P = 0,039). CONCLUSIÓN: Los resultados a corto plazo fueron similares en términos de seguridad. La hipertrofia del hígado remanente se alcanzó más rápidamente con la PRALPPS.

Important problems in the diagnosis and treatment of primary sclerosing cholangitis (based on the Russian consensus on diagnosis and treatment autoimmune hepatitis. Moscow, 2018).

The article is published based on the results of the Russian Consensus on the diagnosis and treatment of primary sclerosing cholangitis (PSC), discussed at the 44th annual Scientific Session of the CNIIG "Personalized Medicine in the Era of Standards" (March 1, 2018). The aim of the review is to highlight the current issues of classification of diagnosis and treatment of patients with PSC, which causes the greatest interest of specialists. The urgency of the problem is determined by the multivariate nature of the clinical manifestations, by often asymptomatic flow, severe prognosis, complexity of diagnosis and insufficient study of PSC, the natural course of which in some cases can be considered as a function with many variables in terms of the nature and speed of progression with numerous possible clinical outcomes. In addition to progression to portal hypertension, cirrhosis and its complications, PSC can be accompanied by clinical manifestations of obstructive jaundice, bacterial cholangitis, cholangiocarcinoma and colorectal cancer. Magnetic resonance cholangiography is the main method of radial diagnostics of PSC, which allows to obtain an image of bile ducts in an un-invasive way. The use of liver biopsy is best justified when there is a suspicion of small-diameter PSC, autoimmune cross-syndrome PSC-AIG, IgG4-sclerosing cholangitis. Currently, a drug registered to treat primary sclerosing cholangitis which can significantly change the course and prognosis of the disease does not exist. There is no unified view on the effectiveness and usefulness of ursodeoxycholic acid and its dosage in PSC. Early diagnosis and determination of the phenotype of PSC is of clinical importance. It allows to determine the tactics of treatment, detection and prevention of complications.

[Eras protocol for laparoscopic Frey procedure (in Russian only)]. / Protokol uskorennogo vosstanovleniia bol'nykh pri laparoskopicheskoi operatsii Freia.

AIM: To assess the use of ERAS in laparoscopic Frey procedure. MATERIAL AND METHODS: From August 2012 to November 2017 laparoscopic Frey procedure were performed in 35 patients. Fully laparoscopic were performed 31 (88.5%) procedures. We use fast-track protocol from 13 patients. We included from statistic analyses patients where procedure was changed or was conversion or was simultaneous procedure. The total number of patients analyzed was 27. The patients were divided into two groups: I - before the fast-track protocol (n=11), II - after the protocol implementation (n=16). RESULTS: The operating time was 460 (365-530) minutes in I group and 420 (295-540) minutes in II group. Blood loss was 150 (5-300) and 150 (40-700) ml. The median postoperative stay period was 10 (5-25) days and 6.5 (3-11) days (p=0.007). CONCLUSION: The combination of laparoscopic technologies and fast-track protocol reduces the duration of the postoperative stay period.

[Early outcomes of robot-assisted liver resection]. / Robot-assistirovannye rezektsii pecheni. Otsenka blizhaishikh rezul'tatov.

AIM: To assess an experience of robot-assisted liver resection using CUSUM-test. MATERIAL AND METHODS: The results of 46 robot-assisted liver resections were retrospectively analyzed by using of CUSUM-test. RESULTS: There were 3 periods in development of the technology. The 1st period - procedures with the lowest index of difficulty (n=16), the 2nd period - expansion of the indications for difficult resections (n=18) and the 3rd period - stabilization of the results (n=12). The dynamics of difficulty index, intraoperative blood loss, duration of procedure and morbidity (Clavien-Dindo Grade II-V) were evaluated. Five liver resections were needed to decrease blood loss and duration of the procedure. Expansion of indications was feasible after 16 procedures. Stable results were obtained after 34 liver resections.

[Intrahepatic cholangiocarcinoma followed by vascular invasion: is surgical treatment justified?] / Vnutripechenochnaia kholangiokartsinoma s invaziei v sosudy: opravdano li khirurgicheskoe lechenie?

Intrahepatic cholangiocarcinoma (ICC) is one of the most aggressive tumors associated with poor prognosis. Radical surgery is still the main method of treatment in resectable cases. Certain difficulties are observed in case of locally advanced tumors followed by inferior vena cava (IVC) and portal vein (PV) invasion. AIM: To analyze safety of advanced liver resections combined with great vessels repair for locally advanced large and multiple cholangiocellular carcinoma. MATERIAL AND METHODS: Since January 2014 till April 2017 eighty ICC patients have undergone advanced liver resection. There were 62 patients with portal cholangiocarcinoma and 18 with ICC. 4 ICC patients required vascular repair: IVC replacement in 2 cases (i.e. under venous bypass in 1 of them), tangential and circular resection of portal vein bifurcation - in 2 cases. RESULTS: Postoperative complications Clavien-Dindo IIIa developed in all cases. There were no vascular complications. The length of hospital-stay was 14 - 35 days. There were no lethal outcomes. Annual survival was 50%, 2-year - 25%. Adjuvant chemotherapy was used in all patients. CONCLUSION: Advanced liver resection followed by IVC and PV repair for locally advanced ICC may be safely performed and subsequently allows chemotherapeutic treatment.

[Laparoscopic pancreatic head resection]. / Laparoskopicheskaia rezektsiia podzheludochnoi zhelezy.

AIM: To analyze the features and efficacy of laparoscopic Frey procedure. MATERIAL AND METHODS: For the period from August 2012 to May 2017 Frey procedure was carried out in 31 patients with chronic calculous pancreatitis Buchler type C. There were 20 men and 11 women aged 48.6±9 years. Mean pancreatic head dimension was 35.5±14 mm, diameter of the main pancreatic duct - 9.6±2.7 mm. RESULTS: Completely laparoscopic procedure was made in 28 (90.3%) cases. One patient required intraoperatively Beger's technique without conversion. The last was need in 2 (6.5%) cases. Time of surgery and blood loss were 447.3±90.4 min and 215±177.7 ml respectively. Mean postoperative hospital-stay was 8.4±4.5 days. Postoperative complications occurred in 7 patients. Mortality was absent. Follow-up was 1-41 months. Recurrent pain syndrome was observed in 1 case. However, it was less severe and does not require analgesia.

Russian consensus on exo- and endocrine pancreatic insufficiency after surgical treatment.

The Russian consensus on exo- and endocrine pancreatic insufficiency after surgical treatment was prepared on the initiative of the Russian "Pancreatic Club" on the Delphi method. His goal was to clarify and consolidate the opinions of specialists on the most relevant issues of diagnosis and treatment of exo- and endocrine insufficiency after surgical interventions on the pancreas. An interdisciplinary approach is provided by the participation of leading gastroenterologists and surgeons.

[The Russian consensus on the diagnosis and treatment of chronic pancreatitis: Enzyme replacement therapy]. / Rossiiskii konsensus po diagnostike i lecheniiu khronicheskogo pankreatita: zamestitel'naia fermentnaia terapiia.

Pancreatology Club Professional Medical Community, 1A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow; 2A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow; 3Kazan State Medical University, Ministry of Health of Russia, Kazan; 4Kazan (Volga) Federal University, Kazan; 5Far Eastern State Medical University, Ministry of Health of Russia, Khabarovsk; 6Morozov City Children's Clinical Hospital, Moscow Healthcare Department, Moscow; 7I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, Saint Petersburg; 8Siberian State Medical University, Ministry of Health of Russia, Tomsk; 9M.F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow; 10Maimonides State Classical Academy, Moscow; 11V.I. Razumovsky State Medical University, Ministry of Health of Russia, Saratov; 12I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow; 13S.M. Kirov Military Medical Academy, Ministry of Defense of Russia, Saint Petersburg; 14Surgut State Medical University, Ministry of Health of Russia, Surgut; 15City Clinical Hospital Five, Moscow Healthcare Department, Moscow; 16Nizhny Novgorod Medical Academy, Ministry of Health of Russia, Nizhny Novgorod; 17Territorial Clinical Hospital Two, Ministry of Health of the Krasnodar Territory, Krasnodar; 18Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint Petersburg; 19Rostov State Medical University, Ministry of Health of Russia, Rostov-on-Don; 20Omsk Medical University, Ministry of Health of Russia, Omsk; 21Russian Medical Academy of Postgraduate Education, Ministry of Health of Russia, Moscow; 22Novosibirsk State Medical University, Ministry of Health of Russia, Novosibirsk; 23Stavropol State Medical University, Ministry of Health of Russia, Stavropol; 24Kemerovo State Medical University, Ministry of Health of Russia, Kemerovo; 25N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia, Moscow; 26A.M. Nikiforov All-Russian Center of Emergency and Radiation Medicine, Russian Ministry for Civil Defense, Emergencies and Elimination of Consequences of Natural Disasters, Saint Petersburg; 27Research Institute for Medical Problems of the North, Siberian Branch, Russian Academy of Sciences, Krasnoyarsk; 28S.P. Botkin City Clinical Hospital, Moscow Healthcare Department, Moscow; 29Tver State Medical University, Ministry of Health of Russia, Tver The Russian consensus on the diagnosis and treatment of chronic pancreatitis has been prepared on the initiative of the Russian Pancreatology Club to clarify and consolidate the opinions of Russian specialists (gastroenterologists, surgeons, and pediatricians) on the most significant problems of diagnosis and treatment of chronic pancreatitis. This article continues a series of publications explaining the most significant interdisciplinary consensus statements and deals with enzyme replacement therapy.

[Comparative analysis of static scintigraphy and computerized tomography in assessment of remnant liver volume after advanced hepatic resection]. / Cravnitel'nyi analiz staticheskoi stsintigrafii i komp'iuternoi tomografii v otsenke ob''ema ostatochnoi parenkhimy pri obshirnykh porazheniiakh pecheni.

AIM: To perform a comparative analysis of computerized tomographic volumetry and scintigraphic liver volumetry in assessment of remnant liver volume after advanced hepatic resection. MATERIAL AND METHODS: Static hepatobiliary scintigraphy and CT volumetry were performed in 45 patients with various liver tumors who underwent advanced hepatectomies (more than three segments). RESULTS: There were no any significant differences in volumetric parameters obtained by CT and scintigraphic volumetry. CONCLUSION: Scintigraphic volumetry data are similar to those of CT volumetry in evaluation of future remnant liver volume. Scintigraphic volumetry may be used as an alternative in assessment of future remnant liver volume after advanced hepatic resections.

Short-term Total Hepatic Vascular Exclusion in Difficult Caudate Lobe Dissection in Living-donor Liver Transplantation Recipients.

BACKGROUND: Recipient hepatectomy can be complicated by severe bleeding during caudate lobe dissection in living-donor liver transplantation (LDLT), especially when the inferior vena cava is encased or with dense adhesions from prior interventions. Total hepatic vascular exclusion (TVE) including total hepatic inflow (Pringle maneuver) and occlusion of supra- and infra-hepatic inferior vena cava during the partial hepatectomy has been studied well, but it has not been mentioned regarding recipient hepatectomy in LDLT. The aim of this study is to evaluate hemodynamic impact and surgical outcome by using the technique of TVE in LDLT. METHODS: From April 2010 to June 2010, 30 consecutive LDLT recipients at Kaohsiung Chang Gung Memorial Hospital with TVE (TVE group, n = 14) or without TVE (non-TVE group, n = 16) for the caudate lobe dissection were analyzed retrospectively. RESULTS: The TVE group had a mean decrease in systolic blood pressure and cardiac index of 21% and 41% during caudate dissection in recipient hepatectomy, respectively. The TVE group had shorter time for caudate mobilization and less blood loss compared with the non-TVE group (3904 mL vs. 5650 mL, P = .461). Two patients in the non-TVE group were shifted to TVE as a salvage procedure to control bleeding. Three patients in the non-TVE group underwent relaparotomy for homeostasis. CONCLUSIONS: Short-term TVE is a technically feasible procedure and should be considered during recipient hepatectomy with difficult caudate lobe dissection in LDLT to create a bloodless surgical field. Most patients tolerated the TVE without hemodynamic impact under anesthetic management.

[Reconstruction of hepatic veins in liver resection. Technique and possibility of prophylaxis of posthepatectomy liver failure].

BACKGROUND: Invasion of hepatic veins by liver tumor limits parenchyma-preserving liver resection. We analyzed different technique of hepatic vein reconstruction and possibility of prophylaxis of post hepatectomyliver failure in patients with compromised liver function. METHODS AND CLINICAL DATA: From 2010 to 2015 performed 199 liver resections. Reconstruction of hepatic veins performed in 9 (4.5%). Among them 3 patients was with hepatocellular carcinoma and 6 patients with colorectal liver metastases. Resections of segment 7, 8 was performed in 2 patients, resection of segments 4, 5, 8 - in 3 patients, right hepatectomy in 2 patients, left hepatectomy in 1 patient, resection of segment 4A, 8 - in one patient. Reconstruction of right hepatic vein was performed in 6 patients (Gortex), middle hepatic vein in three patients (2 - gonadal vein, 1 - inferior mesenteric vein). RESULTS: Blood lost was estimated from 150 1700 ml. All patients had R0 radical resection There was no mortality. One patient had severe hepatic failure. Thrombosis of reconstructed of hepatic vein happened in one patient on 9(th) day post operation. CONCLUSION: Reconstruction of hepatic veins allow to safely perform radical parenchyma-preserving liver resection in patients with compromised liver function due to liver cirrhosis, fibrosis or steatosis.

[Role of octreotide and prednisolone in prophylactic of poshepatectomy liver failure. Experimental study].

AIM: Comparative morphologic assessment of the liver tissue response to the preoperative infusion of octreotide and prednisolon after the major hepatic resection was studied in rats. MATERIAL AND METHODS: 25 male Wistar rats weighing 230--280 g were used. All rats underwent 70--80% hepatectomy. The rats were divided into three groups according to the infusions before hepatectomy: group 1 (n=7) -- received octreotide, group 2 (n=8) -- prednisolone, group 3 (n=10) -- 0.9% saline solution as the control. Histologic features of the remnant liver were evaluated in the sacrificied rats after 72 hours post-hepatectomy. RESULTS: In the group 1 we observed more rapid decrease of edema and tendency to the accelerated regeneration process of hepatocytes. CONCLUSION: Octreotide infusion before the major hepatic resection may have protective effect on hepatocytes and accelerate the regeneration in the remnant liver.

[Surgical treatment of chronic pancreatitis in combination with duodenal ulcer disease]. / Khirurgicheskoe lechenie khronicheskogo pankreatita v sochetanii s iazvennoi bolezn'iu dvenadtsatiperstnoi kishki.

Results of two surgeries--total and subtotal resection of pancreatic head in combination with selective proximal vagotomy (SPV)--performed for chronic pancreatitis and duodenal ulcer disease (DUD) are presented. In one case surgery was supplemented with circular resection of the duodenum and fundoplication. Reconstructive stage of both surgeries included creation of pacreato- and biliodigestive anastomosis on Roux intestinal loop. Choledochojejunoanastomosis was created on the same loop of the small intestine either "end-to-side" with supraduodenal part of common bile duct or "side-to-side" with its pancreatic part. The former surgery was finished with duodenoduodenoanastomosis "end-to-end" for recovery of duodenal passage. This surgery was characterized by complete removal of pancreatic head. The latter surgery corresponded to Beger's operation. There were no complications in the nearest postoperative period. Long-term results were favorable and followed up during 17.5 and 7 months, respectively. This experience testifies that resection of pancreatic head with SPV may be considered as alternative to pancreatoduodenal resection in surgical treatment of patients with chronic pancreatitis.

[Pancreatoduodenal resection with preservation of the pylorus]. / Pankreatoduodenal'naia rezektsiia s sokhraneniem privratnika.

Experience with 106 pancreatoduodenal resections (PDR) with pylorus savage for tumors and benign diseases of pancreatic head and periampullar zone is analyzed. Features of mobilization of pancreatoduodenal complex in PDR are shown. They permit to reduce the rate of complications (gastrostasis). Necessity of differential approach to choice of creation of biliodigestive anastomosis is demonstrated. Risk of postoperative pancreatitis is highest in non-dilated pancreatic duct and small-changed pancreatic parenchyma. In these cases terminolateral pancreatojejunostomy with external drainage of pancreatic duct (12 patients) and pancreatogastrostomy (21) are preferable. PDR with pylorus savage permitted to use wider pancreato-, bilio- and duodenoenteroejunoanastomosis on one loop of the jejunum. Gastrostasis was seen in 50% patients after PDR with pylorus savage. Technical features of surgery and also postoperative complications leading to gastrostasis are demonstrated.