[Surgical treatment and prognostic factors in perihilar tumors]. / Khirurgicheskoe lechenie i faktory prognoza pri perikhilyarnoi opukholi.

OBJECTIVE: To study the results of surgical treatment in patients with perihilar tumors. MATERIAL AND METHODS: We analyzed 98 patients with perihilar tumors who underwent surgery. RESULTS: We prefer percutaneous transhepatic biliary drainage (n=58) for jaundice. Retrograde interventions were performed in 18 cases (20.5%), complications grade III-IV were more common (p=0.037) in the last group. Postoperative mortality was 12%. Complications developed in 81 patients (82.7%), grade ≥3 - in 39 (39.8%) cases. Portal vein resection (n=26) increased the incidence of complications grade ≥III (p=0.035) and portal vein thrombosis (p=0.0001). Chemotherapy after surgery was performed in 47 patients (48.0%), photodynamic therapy - in 7 (7.1%) patients. A 5-year overall survival was 28.1%, the median survival - 29 months. R2 resection and/or M1 stage (n=12) significantly worsened the prognosis and overall survival (16.5 vs. 31 months, p=0.0055). Lymph node (LN) lesion, microscopic status (R0 vs. R1) of resection margin, technique of decompression and isolated resection of extrahepatic bile ducts did not affect the prognosis, and we combined appropriate patients (n=72) for analysis. SI resection and excision of ≥6 lymph nodes were independent positive factors for disease-free survival (p=0.042 and p=0.007, respectively). Blood transfusion and high preoperative neutrophil-lymphocyte index (NLI ≥2.15) worsened overall (p=0.009 and p=0.002, respectively) and disease-free survival (p=0.002 and 0.007, respectively). The absence of adjuvant therapy worsened disease-free survival alone (p=0.024). CONCLUSION: SI liver resection, adequate lymph node dissection and adjuvant therapy should be used for perihilar tumors. Isolated resection of extrahepatic bile ducts is permissible in some cases. Blood transfusion and NLI ≥2.15 are independent negative prognostic factors.

[Irreversible electroporation in locally advanced pancreatic cancer]. / Neobratimaya elektroporatsiya pri mestno-rasprostranennoi adenokartsinome podzheludochnoi zhelezy.

OBJECTIVE: To determine the feasibility of irreversible electroporation (IRE) for locally advanced pancreatic adenocarcinoma. MATERIAL AND METHODS: Twenty-three patients underwent IRE after chemotherapy for locally advanced pancreatic cancer between 2015 and 2022. IRE was performed during laparotomy as a rule (n=22). In one case, IRE was combined with palliative pancretoduodenectomy. Nineteen (86.3%) patients received adjuvant chemotherapy after the procedure. The follow-up examination included contrast-enhanced CT/MRI of the abdomen, chest X-ray or CT, analysis of CA 19-9 marker one month after surgery and then every three months. RESULTS: Complications after IRE developed in 5 (21.7%) patients. Three patients (13.0%) had arrhythmia, two (8.7%) ones had pancreatic necrosis. A 90-day mortality after the procedure was 4.3% (n=1), the cause was pancreatic necrosis. According to intraoperative data and the first examination (CT/MRI), the entire tumor infiltrate was treated in 21 (91.3%) cases. Median follow-up was 19 months. Median period until local recurrence was 15 months. Isolated local recurrence was observed in 7 patients. Of these, 3 ones underwent radiotherapy, one patient underwent repeated IRE. Distant metastases were found in 11 patients; systemic therapy was restarted. Median time to progression was 7 months after IRE and 14 months after initiation of chemotherapy. The median overall survival was 16 months after electroporation and 25 months after chemotherapy. CONCLUSION: Irreversible electroporation may be useful in carefully selected patients with unresectable locally advanced pancreatic adenocarcinoma after successful induction chemotherapy. This procedure provides local control, but the impact on long-term outcomes and feasibility of routine use should be analyzed in randomized trials.

[Resection of liver segments VII-VIII: is right hepatic vein reconstruction advisable?] / Rezektsiya VII­VIII segmentov pecheni: est' li tselesoobraznost' rekonstruktsii pravoi pechenochnoi veny?

OBJECTIVE: To improve the treatment outcomes in patients with primary and metastatic liver tumors localized in segments VII-VIII involving the right hepatic vein and its branches. MATERIAL AND METHODS: There were 16 surgical interventions including resection of liver segment VII and/or VIII with resection of the right hepatic vein and its branches without reconstruction. All procedures were carried out at the Department of Liver and Pancreatic Tumors of the Blokhin National Medical Cancer Research Center for the period 2016-2020. The cause of surgery was colorectal cancer liver metastases in 8 patients, hepatocellular carcinoma in 2 cases, angiomyolipoma in 1 case and metastases of uterine cancer in 1 patient. Minor liver resection was additionally performed in 5 cases. RESULTS: Median surgery time was 150 (80-220) min, intraoperative blood loss - 400 (100-2000) ml. Afferent blood flow was blocked in 4 patients for 14 (12-25) min. None patient had intraoperative signs of impaired venous outflow. Biliary fistula in postoperative period occurred in 1 patient. No complications were noted in other cases. Median postoperative hospital-stay was 13 (9-19) days. There were no specific complications in long-term postoperative period that could be associated with venous outflow blockade through the right hepatic vein. CONCLUSION: Existing vessels and intrahepatic collaterals de novo can provide adequate venous outflow into the middle hepatic vein and short hepatic veins during resection of liver segments VII and/or VIII with resection of the right hepatic vein and its branches without reconstruction and the absence of inferior right hepatic vein.

[Metastatic renal cell carcinoma to the pancreas: experience of surgical treatment]. / Metastazy raka pochki v podzheludochnuyu zhelezu: opyt khirurgicheskogo lecheniya.

OBJECTIVE: To evaluate the outcomes in patients undergoing surgery for metastatic renal cell carcinoma (RCC) to the pancreas. MATERIAL AND METHODS: A retrospective analysis included 54 patients with pancreatic metastases (PM) of RCC who underwent surgical treatment at the Blokhin National Cancer Medical Research Center and Vishnevsky National Medical Research Center of Surgery in 1995-2018. PM were synchronous in 6 (11%) patients and metachronous in 48 (89%) patients. Solitary metastases were identified in 35 (65%), single metastases - in 14 (26%), multiple metastases - in 5 (9%) patients. Thirty (56%) patients had isolated PM, 24 (44%) patients - PM associated with another metastatic site. The following surgical procedures were performed: distal pancreatectomy (n=30, 55%), pancreatoduodenectomy (n=12, 21%), total pancreatectomy (n=6, 12%), pancreatic head resection (n=3, 6%), middle-preserving pancreatectomy (n=1, 2%), middle pancreatectomy (n=1, 2%), cryosurgical destruction of tumor (n=1, 2%). RESULTS: Median blood loss was 950 ml (interquartile range 400-1800 ml). Postoperative complications occurred in 52% patients. The 90-day mortality rate was 6%, overall 5-year survival 74±7%, median - 84 months. CONCLUSION: Surgery is associated with an acceptable perioperative complications and long-term survival in patients with synchronous and metachronous, solitary and multiple PM of RCC, including cases of extrapancreatic disease. This approach may be considered as a management option in these patients.

[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.

[Celiac trunk resection in patients with pancreatic cancer and severe pain syndrome]. / Rezektsiya chrevnogo stvola pri rake tela i khvosta podzheludochnoi zhelezy u bol'nykh s vyrazhennym bolevym sindromom.

AIM: To show the advisability, satisfactory tolerance and good analgesic effect of surgery for pancreatic ductal carcinoma with celiac trunk invasion. MATERIAL AND METHODS: Distal subtotal pancreatectomy with resection of celiac trunk and common hepatic artery was made in 21 patients. RESULTS: Early postoperative complications after distal subtotal pancreatectomy with celiac trunk resection occurred in 10 (47.6%) patients. There was no postoperative mortality. Resection edges including retroperitoneal space and pancreas did not contain tumor cells according to histological examination. Complete analgesic effect was obtained in 100% of patients after distal subtotal pancreatectomy with celiac trunk resection and neurodissection. 1- and 2-year survival was 59.1% and 21.5% respectively in patients with locally advanced pancreatic ductal carcinoma who underwent distal subtotal pancreatectomy with celiac trunk resection, median - 13 months, maximum lifetime - 57 months. CONCLUSION: Distal subtotal pancreatectomy with resection of celiac trunk and common hepatic artery is safe, provides significant analgesic effect, increases resectability and expands the indications for pancreatectomy.

[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.

[HEMIHEPATECTOMY FOR RESECTABLE HEPATIC METASTASIS FROM COLORECTAL CANCER WITH POOR PROGNOSIS].

The current study aimed at improvement of treatment effects for patients with resectable metastases of colorectal cancer in the liver with a poor prognosis. Overall 437 patients were enrolled with metastatic colorectal cancer in the liver exhibiting at least one adverse factor of long-term prognosis: multiple metastases, bilobar liver metastases, large metastases, the presence of extrahepatic metastases, etc. Combined treatment was performed for 339 (78%) patients: combined treatment with adjuvant systemic chemotherapy (163 patients), combined treatment with perioperative systemic chemotherapy (54 patients), or combined treatment of perioperative regional chemotherapy (122 patients). Surgical treatment was performed in 66 (15%) patients. The remaining group of 32 (7%) patients with resectable metastases who received only systemic chemotherapy was considered separately. All liver resections were extensive due to the widespread metastases. The complication rate stood at 56%. Mortality among operated patients was 4%. Postoperative mortality and complications as well as the intraoperative blood loss were not statistically different in two groups. Adding bevacizumab to preoperative chemotherapy did not increase blood loss. After combined treatment with adjuvant chemotherapy a 5-year survival was 26 ± 4% that significantly outperforming a 5-year survival rate after surgery (17 ± 5%), after just drug treatment a 5-year survival has not been reached, and also after combined treatment with perioperative systemic chemotherapy (13 ± 5%) and not statistically significant exceeded a 5-year survival after combined treatment with perioperative regional chemotherapy (20 ±5%). Thus our study demonstrates the benefits of combined treatment with adjuvant systemic chemotherapy for resectable metastases of colorectal cancer in the liver with a poor prognosis. For initially unresectable metastases with extrahepatic manifestations of the disease treatment should be begun with systemic chemotherapy. To liver resection in the latter cases there are resorted only after the transfer of patients in operable condition.

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.

Analysis of elastase 1 for evaluation of excretory function of the pancreas after gastropancreatoduodenal resection.

The level of elastase 1 in feces was markedly decreased in all patients with tumors of the pancreatic head or its involvement before and after gastropancreatoduodenal resection and was close to normal in patients with retroperitoneal tumors not invading the pancreas. Serum elastase 1 concentrations were virtually the same in patients, normal subjects, and patients without signs of pancreatic involvement. The presence of elastase 1 in feces reflects adequate function of the pancreato-digestive anastomosis, while low concentrations of the enzyme indicate impaired function of the pancreas, presumably because of operation trauma and tumor process. Measurement of elastase 1 in feces is a highly informative and specific test for evaluation of pancreatic function in patients with pancreatic tumors, which can be used in clinical practice.