[Surgical policy in echinococcosis of the liver with affection of bile ducts].

Short-term results of surgical treatment of 277 patients with hepatic echinococcosis associated with affection of bile ducts are analyzed. If it is impossible, additional drainage of bile ducts and residual cavity is indicated. Pericystectomy is recommended when hydatid cyst has calcified fibrous capsule. It is demonstrated that rational surgical policy permits to achieve favorable results: postoperative complications were seen in 25.9% cases, lethality was 1.4%.

[Surgical policy in patients with chronic calculous cholecystitis complicated by choledocholithiasis]. / Khirurgicheskaia taktika u bol'nykh khronicheskim kal'kuleznym kholetsistitom, oslozhnennym kholedokholitia.

Results of surgical treatment in 116 patients with chronic calculous cholecystitis complicated by choledocholithiasis were studied. Introduction in clinical practice of endoscopic papillosphincterotomy (EPST) and laparoscopic cholecystectomy changed surgical policy for benign combined lesions of gall bladder and extrahepatic bile ducts. Complex endoscopic treatment is preferable if contraindications are absent. Complex endoscopic treatment was used in 26.7% cases, combined surgical and endoscopic (trans-papillar surgeries) - in 30.2%, conventional surgical - in 33.6%. Isolated EPST and endo-biliary procedures were performed in 9.5% patients. Complex endoscopic treatment is preferable for chronic calculous cholecystitis complicated with choledocholithiasis. Combined and conventional surgical policy is indicated when appliance of endoscopic technologies is not possible.

[Diagnosis of bile ducts lesions in echinococcosis of the liver]. / Diagnostika porazhenii zhelchnykh protokov pri ékhinokokkoze pecheni.

The results of examination and surgical treatment of 277 patients with hepatic echinococcosis with bile ducts lesion are analyzed. Symptoms of bile ducts lesion serve the indication for direct roentgenocontrast methods of bile ducts examination (endoscopic retrograde pancreaticocholangiography, percutaneous transhepatic cholangiography, fistulography). Jaundice in anamnesis, dilatation of hepaticocholedoch, abundant outflow of bile from residual cavity after echinococcectomy require additional examinations during surgery (USE, cholangiography, chromatic reaction). Instant chromatic diagnosis of internal cystobiliary fistulas is highly informative, particularly in cases when complete revision and visualization of wall of residual cavity is impossible.

Successful bariatric surgery in a patient who underwent more than 100 various operations.

A 44-year-old woman who weighed 130 kg (height 158 cm, BMI 52) with a complicated psychiatric history was referred for obesity surgery because of severe sleep apnea, obesity hypoventilation syndrome with frequent pneumonias, arterial hypertension, diabetes mellitus, polyarthralgia and back pain, venous insufficiency, dysmenorrhea, severe heartburn, and incisional hernia. From childhood until 1983, she had undergone 106 operations, mainly for septic/pyemic and intra-abdominal abscesses, 86 of them under general anesthesia. In the 4 years before undergoing bariatric surgery, she had gained 40 kg, nonoperative attempts at weight reduction had failed. Some months before obesity surgery she could fall asleep while standing, and she noticed an entire loss of capacity for work. Respiratory disturbance index measured during sleep by Mesam-4 device was 68 events per hour. Preoperative controlled positive airway pressure (C-PAP) therapy was used. Vital indications for weight reduction were established. Bariatric surgical steps included six operations: (1) vertical banded gastroplasty (VBG); (2) relaparotomy with suspicion of peritonitis, no complications found; (3) hernioplasty simultaneously with panniculectomy; (4) revision and removal of additional flap because of marginal skin necrosis; (5) bilateral thigh dermatolipectomy simultaneously with right-side saphenectomy; and (6) removal of intramammary abscess. Twenty-four months after VBG, she had lost 39 kg (56.5 % EWL) and was doing rather well. Obesity-related diseases except back pain were relieved.

[Functional reserve in benign volumetric lesions]. / Funktsional'nyi rezerv pecheni pri ee dobrokachestvennykh ob''emnykh obrazovaniiakh.

For evaluation of functional status of hepatocytes in patients with benign volumetric growths of the liver (BVGL) of various genesis the authors performed radionuclide investigation with the use of Tc99m. At the same time the terms of maximal accumulation of the preparation Tmax' the period of half elimination from the liver (T1/2) and the time of entering of the drug into the bowel (T bowel) were evaluated. Basing on the results of the analysis of clinical examinations in 67 patients before and after operations (51 patients with BVGL and 16 patients of control group), the authors have revealed correlation between the size, site disposition of volumetric growth and function of hepatocytes of intact parenchyma of the liver. The results have evidenced that the rate of decrease in functional values of the liver in groups of patients with BVGL < 5 and > 5 cm in diameter significantly (p < 0.05) differed in parameters Tmax (33.3 and 78.3%) and T1/2 (50 and 95.7% of cases, respectively. It has been determined that the more is the size of the growth and the deeper it located in hepatic parenchyma the more significant is the decrease of function of hepatocytes. Comparison of the results of examination in patients with BVGL of various genesis before and after various surgical intervention of decompressive type has revealed significant (p < 0.05) improvement of functional capacity of hepatocytes, depending on the above factors. The results of investigation made it possible to substantiate differential approach to surgical policy in uncomplicated BVGL depending on the size of the tumor (< 5 and > 5 cm in d.), location and position of the growth in the organ, as well as adequately evaluate effectiveness of surgical intervention.

[The lipid profile in patients with obesity who have undergone vertical gastroplasty]. / Lipidnyi "profil'" u bol'nykh s ozhireniem, perenesshikh vertikal'nuiu gastroplastiku.

The effect of vertical banded gastroplasty (VBG) on the lipid profile in obese patients is considered. The antiatherogenic effect of VBG and of the following weight loss consists in significantly decreased plasma triglycerides, increased content of high-density lipoproteins and decreased atherogenic coefficient. Patients with hypercholesterolemia have significantly lower total plasma cholesterol by the period of the body mass stabilization. The effect of VBG is compared with that of other methods of correction of dyslipidemia. The possibility to improve this effect is also discussed.

[Treatment and prevention of cicatricial strictures and fistulas of biliary ducts]. / Lechenie i profilaktika rubtsovykh striktur i svishchei zhelchnykh protokov.

The paper summarizes the experience gained by the Department for Surgery of the Liver, Biliary Ducts, and Pancreas, Surgery Research Center, in treating patients with corrosive strictures and fistulas of the biliary ducts since 1967. It considers the causes of this abnormality, the nature of corrective operations on the great biliary ducts, complications due to the type of a surgical intervention. Analyzing the reasons for poor postoperative outcomes provides the optimal time of carcass drainages, the optimal diameter of the biliodigestive anastomosis made to have good results. Emphasis is laid on the specific features of biliary surgery if there are profound inflammatory and infiltrative or scarry and commissural changes in the hepatoduodenal ligament to prevent possible damage to the great biliary ducts.

[An algorithm for differential diagnosis searching in space-occupying lesions of the liver]. / Algoritm differentsial'no-diagnosticheskogo poiska pri ob''emnykh obrazovaniiakh pecheni.

The experience of examination of 584 patients with volumetric masses of the liver (VML) of various origin is presented. For successful differential diagnosis of VML and definition of rational surgical policy the algorithm of examination was considered with due regard for diagnostic stages, each of them being characterized by definite complex of tests. It is thought necessary to begin examination with noninvasive and highly informative tests. Complex of radioimmunologic evaluation of tumor markers level is advisable to include in diagnostic algorithm of patients with VML. The use of invasive methods of diagnostics is justified in complicated diagnostic situation. For evaluation of regional function of the liver radionuclear examination should be used. Liver puncture are feasible only whenever parasitic nature of cystic masses of the liver is excluded. If it is found to be impossible to determine the character of VML the question of advisability of diagnosis laparotomy should be resolved in its favour. The most efficient use of various methods of examination in 584 patients with VML of various genesis made it possible to increase accuracy of diagnosis of hepatic hemangioma, in nonparasitic cysts--1.7 times and in parasitic cysts--1.2 times.

[Vertical gastroplasty as a treatment method in morbid obesity]. / Vertikal'naia gastroplastika kak metod lecheniia morbidnogo ozhireniia.

Since November 1992 in the RRCS. RAMS 38 patients aged 16-61 years (mean body mass 149.9 kg) for obesity of 3-4 grade underwent operation of vertical gastroplasty (VGP) by E. Mason's method. In 78.9% of patients uncomplicated course of early postoperative period was observed. One patient died due to thromboembolism of pulmonary artery. Two patients underwent regastroplasty due to tearing away of the staples of vertical mechanical suture and restoration of body mass (BM). Up to now stabilization of BM was detected in 19 patients. In this group mean values of surplus BM lowering made up 54.1% and maximal--60.1%. Positive influence of performed operations on the course of majority of the concomitant diseases in the absence of serious metabolic after-effects was observed. Initial results of operations seemed to be favourable, but for final conclusions about the effectiveness of VGP in far off period the accumulation of the experience and prolongation of follow-up period together with standardization of operation procedure are necessary.

[The surgical risk factors in patients with nonmalignant space-occupying lesions of the liver and the importance of immunological studies in assessing their extent]. / Faktory khirurgicheskogo riska u bol'nykh s nezlokachestvennymi ob''emnymi obrazovaniiami pecheni i znachenie immunologicheskikh issledovanii v otsenke ego stepeni.

Results of surgical treatment of benign new growths of the liver (BVML) depend not only on timely diagnosis of local growth but on precise analysis of surgical risk factors (SR) as well as accurate definition of its significance. The proposed classification helps to evaluate factors of SR in these patients. Results of the investigation showed that in majority of patients (94.7%) with BVML without complications immune system was were not suppressed. The fact may be considered as a favourable sign, demonstrating potential immunologic safety of patients in definite period of BVML development. Patients with lowered parameters of immunologic status made up a group of a high risk to develop inflammatory and septic complications in postoperative period. Definite correlation between the extent of immunodeficiency and frequency of postoperative complications has established the necessity of action to prevent the provocation of immunological status disturbances.

[Surgical treatment of chronic calculous cholecystitis and its complications]. / Khirurgicheskoe lechenie khronicheskogo kal'kuleznogo kholetsistita i ego oslozhnenii.

Introduction of endoscopic and laparoscopic methods in surgical treatment of chronic calculous cholecystitis and its complications has changed not only the character of surgical interventions, but the surgical policy as well. The operation of choice in uncomplicated calculous cholecystitis is laparoscopic cholecystectomy, which whenever indicated, is advisable to be combined with other surgical interventions allowing the recovery from the concomitant surgical diseases. In complicated calculous cholecystitis in dependence on the character of bile ducts disorder and patient's condition, 3 versions of surgical interventions are possible: one stage radical correction of all pathologic changes of the biliary tract and surgical treatment, including 2-3 separate, less traumatic and more tolerable procedure. The choice of optimal policy of treatment reduces the risk of operation, decreases postoperation mortality rate and complications.

[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.

[Diagnosis and surgical policy in benign lesions of liver]. / Diagnostika i khirurgicheskaia taktika pri dobrokachestvennykh ob''emnykh obrazovaniiakh pecheni.

The results of the treatment of 430 patients with benign tumors of the liver (BTL), including hemangiomas (41), nonparasitic solitary cysts (49), polycystosis (65) and parasitic hepatic lesions (alveococcosis-91, echinococcosis-184). To determine the character of a volume structure the accuracy of ultrasound and duplex sonography was tested (87.1-91.7%), as well as the accuracy of computer tomography (91.4-96.8%), angiography (90.6-96.3%), serological and radioimmunoassays. The use of these methods has increased the accuracy of diagnosis 2.2 times (in hemangiomas), nonparasitic cysts-to 1.2 times. The proposed methods of differential diagnosis and choosing of a proper treatment policy in patients with BTL made it possible to formulate indications and contraindications for the surgery, work out an optimal treating policy, depending on a character, location of BTL. The improvement of the surgical technique has decreased the rate of morbidity and mortality (2.5 and 1.5 times respectively).

[Diagnosis and surgical treatment of liver echinococcosis]. / Diagnostika i khirurgicheskoe lechenie ekhinokokkoza pecheni.

The results of surgical treatment of more than 600 patients with liver echinococcosis are analysed. The accuracy of ultrasound in diagnosis of the character of the damage is 88%; the combination of ultrasound methods with serology tests and computer tomography has increased the accuracy to 98-100%. New treatment approaches have been proposed depending on a character, location and extent of liver damage. The improvement of surgical technique made it possible to decrease the frequency of postoperative morbidity to 17.4% and mortality-to 3%.

[Results of use of sandostatin in pancreatoduodenal resections]. / Rezul'taty ispol'zovaniia sandostatina pri pankreatodyodenal'nykh rezektsiiakh.

From February 1995 to July 1996 pancreato-duodenal resection has been performed in 12 patients in RCS (7 men and 5 women, mean age 53.6 years). The operation was indicated in malignant tumors of the pancreatic head, big duodenal papilla, distal part of common bile tract (9 patients); benign diseases of pancreas (3 patients). Sandostatin (0.3 mg/day for 4-7 days) was used in all cases to prevent postoperative pancreatitis and pancreato-jejuno-anastomosis incompetence. The levels of alphfa-amylase, blood glucose, leucocytes were monitored, as well as the duration of pancreato-jejuno-anastomosis drainage use, rate and seriousness of postoperative complications and duration of in-patient treatment. The results were compared to a control group, consisting of 6 men and 6 women (mean age 53.8 years) with malignant tumours of big duodenal papilla, head of the pancreas, common bile tract. The use of Sandostatin has decreased the level of alphfa-amylase in the first postoperative day to 292.8 +/- 152.2 u/l vs. 594.9 +/- 368.79 in a control group (p > 0.05), duration of the drainage use: 6.1 +/- 1.5 days vs. 12.9 +/- 7.2 days (p < 0.05). The number and rate of severity of postoperative complications were significantly less: 58.3% vs. 100%. The frequency of pancreato-jejuno-anastomosis incompetence has decreased 3 times; the rate of abdominal cavity abscesses has decreased by 30%, the number of bile tract complications has decreased too (1 vs. 2). The rates of postoperative mortality were 8.3% in both groups. The use of Sandostatin made it possible to decrease the frequency and severity of postoperative complications and decrease the duration of in-patient treatment.

[The device for placing ligature in deep wounds]. / Ustroistvo dlia ligatury v glubokikh ranakh.

A special device has been designed to provide safe and convenient placing of a ligature to the dissector or clamp in a deep wound. The device contains fork-shaped working part and a handle. The handle has an obtuse-angle curve and is connected with the working part by a hinge. It also has a handler-spring for fixing a ligature. The device prevents a chance of damaging nearby tissues in placing the ligature that makes it possible to hasten surgery.

[Congenital cystic diseases of liver and extrahepatic bile ducts]. / Vrozhdennye kistoznye porazheniia pecheni i vnepechenochnykh zhelchnykh protokov.

The paper presents 30-year experience in treating 158 patients with congenital cystic diseases of the liver and bile ducts. Depending on the pattern of hepatobiliary lesions, the diagnostic value of techniques, such as ultrasound, computerized tomography, scintigraphy of the liver duodenoscopy with THCG was defined. Analyzing the late outcomes provided recommendations for the most optimal surgical management: cystic fenestration and tunneling in hepatic polycystosis, pericystectomy in solitary cysts of the liver, different varieties of bile draining operations in choledochal cysts and Caroli's disease.

[Basic principles of surgical policy in complicated chronic pancreatitis]. / Osnovnye printsipy khirurgicheskoí taktiki pri oslozhnennom khronicheskom pankreatite.

The paper presents some experience with surgical treatment of 183 patients with complicated forms of chronic pancreatitis. The type of a surgical intervention depended on the pattern of pancreatic morphological changes. Operations of internal drainage of the pancreas in 103 patients with ductal hypertension provide the largest percentage (92.4%) of good and satisfactory results. Resectional methods of surgical treatment for chronic pancreatitis (n = 36) without signs of intraductal hypertension and with the prevalence of predominant lesions in some portions of the gland yield 80% good and satisfactory results. The incidence of postoperative complications following pancreatic resections is higher than those after drainages (16.2 versus 11.6%). The paper gives a concept of combined operations on the pancreas and bile ducts in chronic pancreatitis complicated by stricture of the distal common bile duct, revealed in 24.4% of cases.

[Gallbladder cancer in chronic calculous cholecystitis]. / Rak zhelchnogo puzyria pri khronicheskom kal'kuleznom kholetsistite.

127 cases of gallbladder cancer are analysed. Among them there were 99(78%) women and 28(22%) men. The majority of the patients were at the age from 61 to 70 years; 19 (15%) patients were younger than 50 years. Mean average age of the patients was 61.7 years. Chronic calculous cholecystitis was detected in 116 (91.3%) patients. In 75 (59%) patients the duration of the disease exceeded 5 years. Women suffer more frequently than men because of higher rate of calculous cholecystitis in women. Radical surgery was possible only in 51 of 97 (52.7%) patients as a result of late diagnosis of the cancer. Cholecystectomy was performed in 32 patients, cholecystectomy in combination with liver resection in 9 patients, tumor removal in borderes of the healthy tissues in 10 patients. Palliative operations were performed in 46 (36.2%) patients. Long-term results of the surgery were followed up in 93 patients. 5 year survival after the radical surgery was 40%, 10 year survival--20%. Mean survival after the palliative surgery was 7 months. Gallbladder cancer is difficult for diagnosis and the results of its treatment are unsatisfactory. Timery surgery of chronic calculous cholecystitis is important in prevention of gallbladder cancer.

[Method of treatment of volumetric liver masses]. / Sposob lecheniia ob''emnykh obrazovanií pecheni.

The authors propose the mode of treatment of volumetric masses of the liver which provides possibility to perform ablastic and atraumatic removal of the tumor with prophylaxis of bleeding by creation of the coagulation pellicle in the bed of the removed tumor. The method is based on the rational combination of cryodestruction, mechanical excision and laser coagulation: evaporation by the disfocused laser beam of the frozen bed of the tumor after its cryodestruction and mechanical excision, the principles of the ablastics are being completely kept; at the surface of the hepatic tissue the coagulation scab is being formed. Bleeding and biliary leakage are absent. This is prophylaxis of abscess, fistulas and haematomas after surgery.