[Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) - new opportunity in two-stage liver resection in patients with colorectal cancer metastases].

Major hepatic resection is often necessary for cure in patients with multiple colorectal cancer metastases but low future liver remnant (FLR) volume makes surgery risky because of the posthepatectomy liver failure (PHLF). Right portal vein ligation/embolization and two-stage hepatectomy were proposed previously to overcome this problem. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel approach aimed for FLR volume hypertrophy. During the first stage right portal vein is ligated followed by liver parenchyma in situ splitting. Right liver lobe removal is performed during the second stage when FLR hypertrophy becomes sufficient. Three patients with colorectal cancer liver metastases were scheduled for major hepatic resection. ALPPS was applied because of insufficient FLR volume. We observed FLR hypertrophy of 77, 90 and 70% after 7, 7 and 14 days waiting period. FLR/Total Liver Volume ratio increased from 22, 23 and 15% to 33, 35 and 32% respectively. The second stage was performed successfully in all patients. All patients are alive and they have not disease relapse after 17, 15 and 15 months after surgery. ALPPS is promising technique that allows rapid FLR hypertrophy and enables curative liver resections in initially unresectable patients. But it is necessary more data concerning ALPPS safety and long-term results.

[Novel approach to two-stage hepatic surgery (in situ splitting)].

Two-stage liver surgery with preliminary right portal vein occlusion procedure (ligation or embolisation) became standard in clinical practice and allows liver resections in 60-82% of initially inoperable patients. Right portal vein ligation with concomitant liver partition in situ (in situ splitting, ISS) is innovatory and promising approach. Right portal vein ligation and in situ splitting was performed in 40 years old male with two metachronous rectal metastases in right liver lobe and insufficient volume of future liver remnant (22%). MRI on 7th postoperative day showed left liver lobe hypertrophy rate of 77% and left liver lobe volume increase from 22 to 33.5%. Right hemihepatectomy was performed on day 8 after the first stage. There were no signs of postoperative liver failure. Conclusion. New two-stage surgery approach (ISS) can decrease number of patients who were inoperable because of insufficient volume of future liver remnant and high risk of postoperative liver failure.

[The surgical hepatology in SCS: from the beginning to development].

The article highlights survey stakes of surgical hepatology in world and Russia, and the 20 years experience of the Russian Scientific Center of Surgery named after B.V. Petrovskiy. 472 liver resections were performed during the period. Main indications for surgery were malignant liver tumors, predominantly metastatic (75.8%). Technical and tactical questions, as well as treatment results were discussed. The issue compares own data with world's experience.

[Alveococcosis of liver: retrospective analysis of treatment of 51 patients].

51 patients with liver alveococcosis were operated on: radical operations with the whole hydatid tumor removal, cytoreductive operations with 50-80% of the tumor removal and alveococcal nodes' preserving on vital organs; and palliative manipulations, aimed the relief of complications were performed. According to the treatment results, the radical liver resection proved to be the most effective. When the complete tumor removal is impossible, cytoreductive operations are possible. Combination with antiparasitic therapy is required.

[The colorectal cancer progression after the right branch of vena porta occlusion].

Liver resections by metastatic colorectal cancer are considered to be seldom applicable on the reason of bilobar lesions and insufficient volume of the left liver lobe. The two-stage operations have been suggested for such situations. Of 276 patients, treated in our centre, 52 cases, unsuitable for the single-stage liver resection according to the preoperative data, had been retrospectively chosen. All these patients had the procedure of the right branch of vena porta occlusion, which aimed the compensatory hypertrophy of the left liver lobe. The efficacy of the occlusion was up to 73%. The median left lobe enlargement was 11%. The increase of the summary diameter of metastases was 60,4% (from 53 mm to 85 mm; p < 0,0001). The follow-up time was from 3 to 96 months. The three-year survival time was significantly higher in patients with the completed two-stage surgical treatment in comparison with those, who were refused the liver resection--77 and 43%, respectively. The multifactorial analysis revealed the only independent factor of the survival time--the extrahepatic intraabdominal lesion (p = 0,014).

[Experimental grounds of a new concept of Opisthorchis felineus infection formation in a definitive host].

In the course of experiments in was found out that golden hamsters having the bilious duct operationally blocked display receptivity to the infection with the non-excysted Opisthorchis felineus metacercariae passed to the stomach. Excysted metacercariae injected to the system of the portal vein settle down in the bilious pathways of the liver and develop there up to the adult stage. In vitro, the metacercariae survive in the blood serum of the intact golden hamsters during one day. Based on the experiments, it is hypothesized that the early stage of O. felineus infection in the bilious duct of definitive hosts is performed by means of hematogenic migration of metacercariae through the portal veins system from the mucous layer of the alimentary tract of the host.

[Surgical treatment of major duodenal papilla neoplasm]. / Opyt kliniki v khirurgicheskom lechenii raka bol'shogo sosochka dvenadtsatiperstnoi kishki.

Immediate and long-term results of pancreatoduodenal resections in 33 patients undergone surgery for adenocarcinoma of bile papilla from 1984 to 2003 were studied. Majority of patients had II and III stages of diseases. Correct diagnosis before surgery was made in 27 (81.8%) patients. Morphologic study revealed metastasis in 11 patients. Lethality was 9.1%, moreover last 18 pancreatoduodenal resections had no lethal outcomes. Long-term results were studied in 25 (83.3%) patients: 1-year survival was 90.4%, 3, 5 and 10 years survived 71.4, 61.2 and 51% patients respectively. Only metastatic lesion of lymph nodes and later stage of disease had negative influence on long-term results. Such factors as gender, diameter of carcinoma, lymphadenectomy and pylorus-saving variant of surgery did not influence on long-term results. It is concluded that pancreatoduodenal resection must be surgery of choice in the treatment of resected cancer of bile papilla.

[Problems of hemostasis and hermetic properties in liver resections with application of fibrin-collagen substance]. / Problemy gemostaza i germetizma pri rezektsiiakh pecheni s ispol'zovaniem fibrin-kollagenovoi substantsii.

Forty-seven patients with various diseases of the liver were treated from 1992 to 2002. Patients had undergone liver resections of different scope. In 20 patients (study group) wound covering "Tachokomb" was used for final hemostasis and high hermetic properties of wound surface. Conventional suturing of the vessels and bile ducts was performed in 27 patients of the control group. Reliable hemostasis of the hepatic stump after anatomic resection was achieved in all the patients of the study group. Application of wound covering decreased time of final hemostasis, severity of hemorrhage and blood transfusion during surgery. Biliary complications after surgery were seen more often. Application of combined glue composition failed to reduce significantly rate of biliary complications after surgery, their rate increased proportionally to extension of liver resection.

[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.

[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.

[Errors and hazards in the surgical treatment of hepatic echinococcosis]. / Oshibki i opasnosti khirurgicheskogo lecheniia ékhinokokkoza pecheni.

The article analyses the results of operative treatment of 455 patients for hydatid disease of the abdominal organs, in particular the errors and hazards of surgical management of hydatid disease of the liver. Difficulties occur in the differential diagnosis in suppuration of hydatid cysts which had not been operated on, as well as in residual cavities in patients who had undergone surgery for this disease. The authors dwell on the diagnostic algorithm and the surgical tactics depending on the size and location of the hydatid cysts. Some problems of the operative techniques and intraoperative measures for the prevention of recurrences in complicated forms of hepatic hydatid disease are discussed. The suggested diagnostic algorithm and the surgical tactics allowed the authors to reduce diagnostic errors in this pathological condition to 3.5% and surgical mortality rates to 3.07%.

[Low-frequency ultrasonics in the surgical treatment of pulmonary echinococcosis]. / Ul'trazvuk nizkoi chastoty v khirurgii ekhinokokkoza legkikh.

The article discusses the results of surgical treatment of 29 patients suffering from hydatid disease of the lungs with the use of low-frequency ultrasonics for rendering harmless the germinal elements so as to prevent recurrence of the disease. It was demonstrated that low-frequency ultrasonics causes death of the germinal elements of the parasite in sonication both directly in the cyst and in the residual cavity of the fibrous capsule of the echinococcus and in the pleural cavity. The methods of application of low-frequency ultrasonics in surgical treatment of various forms of hydatid disease of the lungs are described. In examination of patients in postoperative periods of 6 months to 2 years no recurrences of the disease were revealed.