Vol 46, No 6 (2018)


Hepatocellular cancer and liver transplantation: necessity to go from chaos to order

Lerut J., Iesari S., Foguenne M., Ackenin K., Lai Q.


The care for liver-diseased patients presenting with hepatocellular cancer (HCC) is changing rapidly. Many treatment possibilities and caregivers belonging to a multitude of specialities troubled the therapeutic algorithm of the liver cancer patients. HCC in both normal and diseased livers has to be considered firstly as a surgical disease. The possibilities of surgery, including liver resections, as well as liver transplantation, have been underestimated and even been minimalized mainly as a consequence of many studies promoting in an unlimited way all different kinds of locoregional non-surgical and systemic therapies. Locoregional therapies and surgical procedures should not be seen as competing, but as complementary treatment options. Locoregional therapies are of value if surgery is not possible; in the context of transplantation they have an important role as ‘downstaging procedures’ allowing for bringing of transplantable patients into the required inclusion criteria. Systemic therapies and living donor liver transplantation will without any doubt occupy a more important role in the future therapeutic scheme of HCC.

Almanac of Clinical Medicine. 2018;46(6):552-559
pages 552-559 views


Liver transplantation in the Novosibirsk Region: evolution of the program and its outcomes

Porshennikov I.A., Pavlik V.N., Shchekina E.E., Kartashov A.S., Korobeinikova M.A., Yushina E.G., Bykov A.Y.


Objective: To assess early and late outcomes of the orthotopic liver transplantation (LTx) program in the Novosibirsk Region from August 2010 to June 2018.

Materials and methods: This retrospective study included 176 patients aged 41.5 ± 16.69 years (from 5 months to 69 years; median 44 years), who underwent 185 LTx procedures including nine retransplantations.

Results: Some particulars of vascular and biliary reconstruction in various LTx types are discussed. The incidence of vascular and biliary complications was 1.6% and 10.3%, respectively. The duration of stay in the intensive care unit was 7 ± 7.1 days (from 0 to 69 days, median 5) and mean total duration of hospital stay was 33 ± 18.1 days (from 1 to 136 days, median 30). Early graft dysfunction was observed in 28 (15.9%) of the recipients. Perioperative (up to 90 days) mortality was 4.5% (8 recipients, including one intra-operative death). There was zero mortality in the liver fragment recipients. The overall 5-year patient and graft survival rates were 71% and 65%, respectively.

Conclusion: The Novosibirsk Region has a well-established LTx program, with its outcomes being comparable to those of the leading Russian centers and large worldwide registries. In 2017, LTx prevalence was 12.9 per million of the population. Thus, the region has become one of the most provided with this type of medical care in the Russian Federation.

Almanac of Clinical Medicine. 2018;46(6):560-571
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Liver transplantation in the Moscow Region: the regional project and its implementation

Moysyuk Y.G., Malinovskaya Y.O., Bel'skikh L.V., Bogomolov P.O., Lobakov A.I., Ammosov А.A., Sidorenko A.B., Grigor'ev N.S., Kosov A.A.


Rationale: Liver transplantation is the only curative treatment for diffuse end-stage liver disease and some liver neoplasms. The amount of these interventions in the Moscow Region is very low.

Aim: To analyze the results of the first series of liver transplantations done in the Moscow Regional Research and Clinical Institute (MONIKI), to compare it with those done currently in Russia and worldwide, and to establish the optimal volume and trend of development for this new regional center.

Materials and methods: More than 200 patients with liver cirrhosis, polycystosis and alveococcus invasion have been examined from May 2016 to August 2018; 70 of them were eligible for liver transplantation and were put on the waiting list. From October 2016 to July 2018, 29  liver transplantations from deceased donors (including 2  retransplantations) and one living related transplantation of the right lobe have been performed. Among the indications to the transplantation, the leading one was viral (HCV or HBV-related) cirrhosis. Four patients were diagnosed with hepatocellular carcinoma.

Results: The waitlist mortality was 19%. Median waiting time was 5.5 [3; 9] (0 to 27) months. Until now, the results were followed till 22 months, with median follow-up of 7  [2; 13] months. The survival rate of the recipients was 96.4%, of the grafts 93.3%. In-patient mortality was 3.6%. Early allograft dysfunction was seen in 33%  of cases. Median length of the in-hospital stay was 22 [19; 25] days.

Conclusion: The successful implementation of the liver transplant program at its initial stage demonstrates the results that meet current efficacy criteria. Achieved level of organ procurement from deceased donors in the Moscow Region could ensure at least 30  liver transplantations annually, with current facilities and a potential for further growth. An increase in the transplantation number would depend on the improvement of transplantation service facilities in MONIKI and on the stable financial support of the program. Finally, it would promote increased availability of this transplantation technology in the region, lower waitlist mortality and shorter waiting times.

Almanac of Clinical Medicine. 2018;46(6):572-583
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Short-term results after minimally invasive and open liver resection for liver metastases of colorectal cancer: a single center experience

Efanov M.G., Alikhanov R.B., Tsvirkun V.V., Kazakov I.V., Kim P.P., Vankovich А.N., Grendal K.D., Zamanov Е.N.


Rationale: Until now, safety of minimally invasive liver resection (MILR) has not been studied sufficiently.

Aim: To assess immediate results of MILR and open type resections in patients with colorectal metastases, performed in the Russian center of surgical hepatology specialized at implementation of minimally invasive techniques.

Materials and мethods: This was a retrospective observational case-control study. Patients who underwent surgery for isolated liver metastases of colorectal cancer in a  single center from October 2013 to February 2018 were included into the study.

Results: As per December 2017, over 500 resections have been performed in the study center, including 226 MILR. One hundred two patients underwent open resection and MILR for colorectal metastases. From 83 patients enrolled into the study, 51 (61%) had MILR, including 7 robotic MILR. The open resection and MILR groups did not differ in terms of gender, age, ASA score, primary tumors location and stage by the time of primary intervention. There were no between-group differences for factors that determine the tumor spread and influence the resection problems, i.e. the difficulty index of MILR, rate of anatomic resection, resection of complex segments, vascular involvement, size and number of metastases, multiple liver lesions and bilobar metastases. No difference was found for immediate outcomes in terms of frequency of the free surgical margin > 2 mm, rate of the Pringle maneuver implementation, duration of the procedure, blood components transfusion, severe complications (Clavien-Dindo Grade > II), and time in intensive care unit. Compared to open procedures, MILR were associated with significantly less blood loss: 583 (50–3000) mL vs. 308 (0–3300) mL (p = 0.012), respectively, and shorter duration of hospital stay: 10 (4–29) days vs. 9 (4–29) days (р < 0.001), respectively.

Conclusion: In a specialized surgical hepatology center, MILR can be performed equally to complex open procedures without changes in the rates and types of complications, but with an improvement of immediate outcomes.

Almanac of Clinical Medicine. 2018;46(6):584-591
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Simultaneous laparoscopic liver resection: a single-center experience

Akhaladze G.G., Grebenkin E.N., Chkhikvadze V.D., Stanojević U.S., Goncharov S.V., Ragimov V.A., Kolesnikov R.V., Abramov A.A.


Background: About 15 to 25%  of colorectal cancer patients have synchronous liver metastasis at diagnosis. In the recent years, the strategy of simultaneous removal of colorectal cancer and liver metastases has been preferred. Development of minimally invasive technologies in abdominal and hepatopancreatobiliary surgery allows for active advance to fully laparoscopic approach to these types of interventions.

Aim: Comparative analysis of simultaneous and isolated laparoscopic liver resections performed in the Department of Surgery, Russian Research Center of Roentgenoradiology (Moscow).

Materials and methods: We have analyzed intra- and postoperative results of 29 laparoscopic procedures for metastatic liver disease. Group 1 included 14 patients who had undergone simultaneous laparoscopic primary tumor resection and laparoscopic liver resection for metastatic disease. Group 2 included 15 patients who had undergone isolated laparoscopic liver resection for metastatic lesions.

Results: Mean (± SD) blood loss in the simultaneous and isolated procedures groups was 469 ± 176 and 408 ± 124  mL, respectively (p = 0.2), whereas the duration of surgeries was 296 ± 107  and 204 ± 82  min, respectively (p = 0.01). Conversion rate in the isolated resection group was higher (26% vs. 14%). This difference is to be explained by the learning curve in laparoscopic liver surgery. All liver resections in both groups were carried out in R0 mode. No deaths and significant complications were seen in any of the groups.

Conclusion: The study demonstrated feasibility and safety of simultaneous, fully laparoscopic liver resections, including those for difficult localization of primary tumors and metastatic lesions.

Almanac of Clinical Medicine. 2018;46(6):592-597
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Vascular reconstruction and outcomes of 220 adult-to-adult right lobe living donor liver transplantations

Voskanyan S.E., Artemyev A.I., Sushkov A.I., Kolyshev I.Y., Rudakov V.S., Shabalin M.V., Naydenov E.V., Maltseva A.P., Svetlakova D.S.


Rationale: Adult-to-adult right lobe living donor liver transplantation is a  viable alternative to whole liver transplantation from a  deceased donor. The key aspect of the surgical procedure is the restoration of adequate graft blood flow and maintenance of sufficient volume of well vascularized parenchyma in the donor. Specific features of vascular anatomy in the donor and the recipient can be eventual cause for significant technical difficulties during transplantation. They can also increase the risk of complications and deteriorate graft functioning.

Aim: To identify the incidence of various types of afferent and efferent vascularization of right lobe of the liver, potential techniques of vascular reconstructive procedures, rates and types of postoperative complications, as well as immediate surgical results.

Materials and methods: We retrospectively analyzed the data on 220 right lobe liver transplantations adult patients, consecutively performed from 2010 to 2017 in one center. Specific characteristics of liver vascularization in donors and recipients were determined by pre-operative computed tomography and intra-operatively. The information on the types of vascular reconstruction, complications and results of surgical procedures was obtained from patients' medical files.

Results: The following variants of blood supply to the right liver lobe were seen most frequently: portal vein trifurcation 22%, shortened trunk of the right portal vein branch 13%, supplementary v. hepatica from SgVIII with a diameter of > 5 mm 22%, supplementary lower right v. hepatica 17%, isolated venous outflow from all right lobe segments 2%, two arteries 2%. In addition, 17% of the recipients had portal vein thrombosis and 1% portal vein fibrosis. During the follow-up all donors remained alive. The rate of surgical complications was 12.5%, among them bile pocket or biloma 8.5%, intra-abdominal bleeding 2.5%, wound complications 1.5%. The rate of early post-operative complications in the recipients was 31.5%, with 4.5% of them being vascular and 15.5% biliary. The 6-months and 4-years survival of the recipients (Kaplan-Meier) was 98% and 95%, respectively.

Conclusion: Immediate and longterm survival of the recipients of living donor right lobe live grafts, as well as absence of fatalities among their donors, confirm high effectiveness and expedience of this type of intervention. The observed anatomic variety of blood supply to the right liver lobe stipulates stringent requirements to the quality of preoperative diagnostics, deliberate donor selection, thorough planning of the procedure and high qualification of the surgical team. A  relatively high rate of postoperative complications warrants the necessity of an intensive diagnostic monitoring in the early post-operative period and active strategies of their correction.

Almanac of Clinical Medicine. 2018;46(6):598-608
pages 598-608 views

The results of surgical treatment in patients with liver alveococcosis in a hepato-pancreato-biliary center (a 10-years’ experience)

Kiselev N.M., Gorokhov G.G., Belskiy V.A., Bobrov N.A., Mukhanzaev S.K., Zagainov V.E.


Background: Aggressive course of liver alveococcosis makes it possible to designate it as a “parasitic liver cancer”. The main treatment method for the disease is surgery. The parasitic mass is resected according to R0 principles, with concomitant plastic surgery of the major vessels and bile ducts to increase resectability.

Aim: To assess the potential of surgical treatment in patients with advanced liver alveococcosis using transplantation techniques.

Materials and methods: We retrospectively analyzed in- and outpatient medical files of 62 subjects with confirmed liver alveococcosis, who had been treated in the Volga District Medical Centre (Nizhny Novgorod, Russia) from 2008 to 2018. Thirty two (32) patients had advanced liver alveococcosis with involvement of afferent and efferent vasculature and biliary tract. Surgical procedures were used in 50/62 patients (or 4.2% of the total number of liver resections performed during this time interval, n = 1197). Complications occurred in 46% (23 / 50) of the cases. Twenty nine (29, or 58%) patients had been operated before (mostly cytoreductive resections and/or explorative laparotomies). Distant lung metastases were found in 2 (4%) patients.

Results: Fifty (50) patients had curative surgical procedures: liver resections in 45, deceased donor orthotopic liver transplantations in 5. Most common were extensive liver resections (more than 4 segments). Resection and reconstruction of the main vessels were necessary in 50% (25 cases) of the patients, including v. cava inferior in 25 cases and the portal vein in 24 cases. In 31 patients, resection and reconstruction of extra-hepatic bile ducts was performed, and in 17 (33%) patients resections of the neighboring organs, such as diaphragm, lung, right adrenal, duodenum, stomach, and colon. In 4 cases, resections were performed ex situ ex vivo, followed by auto-transplantation, including 2 cases with reverse auto-transplantation of the left lateral sector to the right. The incidence of liver failure events grade A  and B (by International Study Group of Liver Surgery, ISGLS) did not exceed 10% (4 patients). Complications were seen in 25 cases, including Clavien – Dindo Grade II in 5, Grade IIIb in 13, Grade IVb in 2, and Grade V in 5. The number of bile leakage events (ISGLS) class B was 6 and class C 10. All patients underwent obligatory adjuvant anti-parasitic therapy.

Conclusion: At present, surgical treatment of liver alveococcosis remains a method of choice, that requires that the hepato-pancreato-biliary center would have in place a well-developed transplantation program, adequate equipment and well-trained surgical and anesthetic teams.

Almanac of Clinical Medicine. 2018;46(6):609-617
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Diagnostic and treatment challenges in focal liver disease

Zhao A.V., Karmazanovsky G.G., Bugaev S.A., Chugunov A.O.


Finding a focal liver lesion during screening may not uncommonly lead to a misinterpretation of the results of radiological diagnostics. Based on the consolidation of our wide experience (more than 1000 cases) of surgical treatment of patients with various focal liver diseases, we analyzed the main causes of diagnostic pitfalls and, as a consequence, errors in the treatment of these patients. The most typical objective and subjective diagnostic pitfalls that may lead to a wrong treatment strategy are discussed with clinical cases taken as examples. The objective factors are related to the rarity of disease, absence of pathognomonic semiotics, as well as limitations in the resolution power of imaging methods. In addition, a misinterpretation of results of ultrasound examination, magnetic resonance imaging and multiaxial computed tomography may be explained by identical properties of images in different tumors related to similar physical and chemical properties of a  lesion. The subjective factors are related to a wrong interpretation of clinical and instrumental assessment data, or insufficient evaluation needed in an individual patient. The number of diagnostic and treatment errors could be decreased by a multidisciplinary approach taking into account the opinions of various profile experts.

Almanac of Clinical Medicine. 2018;46(6):618-630
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Technique of the laparoscopic pelvic exenteration

Galliamov E.A., Biktimirov R.G., Sergeev V.P., Aminova L.N., Sanzharov A.E., Agapov M.A., Volodin D.I., Gallyamov Е.E., Gololobov G.Y.


Background: Laparoscopic surgery has proved itself to be a “golden standard” for treatment of most abdominal and retroperitoneal cancers. Such a serious procedure as pelvic exenteration continues to be a complex surgical intervention usually performed through a  conventional laparotomic access. However, studies on minimally invasive approach for this intervention have becoming increasingly published in the world literature.

Aim: To describe the laparoscopic pelvic exenteration technique of pelvic exenteration, as well as to assess short- and long-term results of these interventions.

Materials and methods: From 2011 to 2018, 21 procedures of laparoscopic pelvic exenteration have been performed in 6  surgical centers (Moscow, Russia). Six (6) patients had previously confirmed cervical cancer, 7 patients had bladder cancer, 4 patients had rectal cancer, 1 patient had vaginal cancer, 2 patients had relapsing vaginal cancers after previous uterine extirpation, and 1 patient had an ovarian neoplasm.

Results: The laparoscopic pelvic exenteration volumes were as follows: 9  total, 7 anterior and 5 posterior procedures. In 19 out of 21 cases, negative resection margin (R0) was possible. Median duration of the procedure was 254 minutes, median blood loss was 515 ml, and median postoperative hospital stay was 13 days. Postoperative complications were registered in 6 (28.6%) patients. The 3-year overall survival was 85.71%.

Сonclusion: The choice of laparoscopic access can reduce blood loss, decrease the rates of early postoperative complications, contributes to a more comfortable postoperative period with early activation and less severe pain syndrome, and leads to a reduction in the duration of hospital stay. These results of the laparoscopic technique are comparable with those of laparoscopic and open pelvic exenteration published by other authors.

Almanac of Clinical Medicine. 2018;46(6):631-639
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Laparoscopic interventions in the pancreas: an 11-year experience of a specialized center

Khatkov I.E., Tsvirkun V.V., Izrailov R.E., Vasnev O.S., Tyutyunnik P.S., Mikhnevich M.V., Baychorov M.E., Andrianov A.V.


Introduction: Due to anatomical and functional specifics of the pancreas, its surgery emerged somewhat later than that of other areas of abdominal surgery, i.e. in the last 25 to 30 years of the last century. Minimally invasive laparoscopic interventions on the pancreas are still used insufficiently.

Aim: To evaluate an 11-year experience of various laparoscopic interventions in the pancreas accumulated by one surgical team.

Materials and methods: From November 2007 to May 2018, 371 patients (153 male and 218 female) underwent various laparoscopic pancreatic procedures for cancers of the biliopancreatoduodenal zone (n = 260), benign pancreatic tumors (n = 37), and chronic pancreatitis (n = 74). We performed 245 laparoscopic pancreaticoduodenal resections, 52  laparoscopic distal resections (LDR), 35  laparoscopic Frey procedures (FP), 18  laparoscopic total duodenopancreatectomies, 8  laparoscopic longitudinal pancreaticojejunostomies (LLPJ), 8 laparoscopic cystoenterostomies (LCE), 3 enucleations, and 2 Beger procedures (BP).

Results: Laparoscopic gastropancreatoduodenal resection was performed in 197 (80.4%) cases and pylorus preserving pancreatoduodenal resection in 48 (19.6%) cases. The duration of the procedures was 412 ± 101  minutes, with blood loss volume of 220 ± 152 ml, and postoperative hospital stay of 19 ± 9 days. LDR was done laparoscopically in 50 (96.2%) patients; its duration was 228 ± 74 minutes, blood loss 40 ± 50  ml, and postoperative hospital stay 8 ± 5 days. FP, LLPJ, BP, and LCE were performed laparoscopically in 53  (93%) cases. FP lasted for 436 ± 95, LLPJ for 406 ± 82, BP for 585 ± 134, and LCE for 327 ± 90 minutes. The respective volumes of blood loos were 227 ± 217 mL in FP, 150 ± 156 mL in LLPJ, 175 ± 106 mL in BP, and 60 ± 90 mL in LCE. The postoperative hospital stay lasted for 8 ± 4 days after FP, 9 ± 7 days after LLPJ, 4.5 ± 0.7 days after BP, and 10 ± 9 days after LCE.

Conclusion: Laparoscopic surgery of the pancreas is associated with minimal blood loss, absence of wound infection, and more rapid patient activation and rehabilitation. Compliance with the necessary requirements to implementation of laparoscopic technologies in high-volume centers should improve surgical results.

Almanac of Clinical Medicine. 2018;46(6):640-647
pages 640-647 views

The use and evaluation of prevention methods to reduce inflammatory and diffuse septic complications in patients undergoing pancreatic resection

Korobka V.L., Korobka R.V., Shapovalov A.M.


Background: Surgery for chronic pancreatitis and pancreatic neoplasms is associated with a  risk of acute destructive pancreatitis and pancreaticojejunal anastomotic leakage in the early postoperative period. Despite the availability of multiple surgical and pharmaceutical approaches to prevent these complications, they continue to be associated with high mortality.

Aim: To evaluate the efficacy of the clinical use of our original preventive methods of postoperative pancreatitis and diffuse inflammatory and septic complications in patients undergoing pancreatic resection due to its benign and malignant diseases.

Materials and methods: We retrospectively analyzed the results of surgical treatment of 524  patients following pancreatic resection. All patients underwent pancreatic surgery in the Rostov Regional Clinical Hospital (Rostov-on-Don, Russia) from February 2005 to April 2018 for the following indications: complicated chronic pancreatitis in 221 patient, pancreatic and major duodenal papilla tumors in 303 patients. Organ-preserving procedures were performed in 250 patients, and radical extended resections of the pancreas in 274  patients. In 489  patients, the procedures were finalized with the formation of anastomosis between the pancreatic duct and jejunum. In 373  patients, the reconstruction step included enterostomal drainage of the pancreatic duct. To prevent acute postoperative pancreatitis and diffuse septic and inflammatory complications, in 298 patients we used our original techniques, while 226 patients underwent conventional procedures.

Results: Among 226  patients, who had underwent conventional procedures, the complications occurred in 75 (33.19%), with septic complications in 29.33% (22 patients). Of 298 patients, in whom any of the original prevention techniques had been used, the complications were seen in 67 (22.48%), with septic complications in 13.43% (9 patients). Seventeen (17, or 11.97%  of the total number) patients had to be re-operated, with 15 (6.64%) having been initially operated without additional preventive measures, and 2 (0.67%) with the use of the original prevention techniques. Overall postoperative mortality was 2.48%. The causes of death were: peritonitis in 4 patients, arrosive bleeding from visceral arteries in 4, bleeding from pancreatic head stump into the omental sac in 2, bleeding at the pancreaticojejunal anastomosis in 1, and cardiac disorders in 2.

Conclusion: The study results have shown that the use of techniques to prevent the spread of inflammation and septic in the abdominal cavity and decreasing the rates of postoperative necrotic pancreatitis in pancreatic resections allows for a reduction of these complications and related mortality.

Almanac of Clinical Medicine. 2018;46(6):648-659
pages 648-659 views

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