Vol 46, No 6 (2018)

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.

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.

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.

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.

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.