Extraorganic Hepatic Artery Aneurysm: Failure of Transcatheter Embolization

Hepatic artery aneurysm (HAA) was diagnosed in a 62-year-old man who was a poor candidate for surgery because of severe liver cirrhosis and diabetes mellitus. Two attempts to occlude the HAA by transcatheter embolization failed because of recanalization of the aneurysm. Moreover, aneurysmal dilatation of the superior mesenteric artery and the left renal artery developed and progressed. Both the literature and the present case show that an individual approach to treatment of extraorganic HAA should be chosen in dependantan location and anatomy of the lesion

СПОСОБ ВОССТАНОВЛЕНИЯ ОТТОКА ЖЕЛЧИ ПРИ ОРТОТОПИЧЕСКОЙ ТРАНСПЛАНТАЦИИ ПЕЧЕНИ С ИСПОЛЬЗОВАНИЕМ ПУЗЫРНОГО ПРОТОКА

Method for restoration of bile outflow in orthotopic transplantation of liver using cystic duct may find application in anatomic version characterised by parallel location of cystic and common liver ducts in donor. After cholecystectomy, at the level of bile ducts donor segment intersection, common reservoir is formed with application of common liver and cystic ducts by dissection or wedge-shaped excision of partition segment between them. Level of bile ducts donor segment intersection is selected so that diameter of common reservoir coincides with diameter of recipient bile duct, with which biliobiliary anastomosis is formed. Biliobiliary anastomosis is formed as «end to end». If there are mucous and muscular layers in composition of partition between liver and cystic ducts, they are dissected. Edges of mucous layer are sutured. If only mucous layer is present in composition of partition, it is dissected without further suturing. Such approach supply possibility to overcome discrepancy of sutured ducts diameters and provision of bile outflow from liver in the most physiological version with «end to end» anastomosis. Описывается разработанный и клинически апробированный авторами способ восстановления оттока жел- чи при ортотопической трансплантации печени с использованием пузырного протока. Предлагаемый способ позволяет адаптировать диаметры сшиваемых желчных протоков путем создания резервуара за счет рассече- ния или клиновидного иссечения перегородки между общим печеночным и пузырным протоками и обеспе- чивает в наиболее физиологичном варианте отток желчи из печени путем формирования билиобилиарного анастомоза по типу «конец в конец».

РЕТРАНСПЛАНТАЦИЯ ПЕЧЕНИ: ОПЫТ РОССИЙСКОГО НАУЧНОГО ЦЕНТРА РАДИОЛОГИИ И ХИРУРГИЧЕСКИХ ТЕХНОЛОГИЙ (РНЦРХТ)

The article gives the report about the experience in repeated liver transplantation (LT). Totally 99 LT including 6 repeated operation at five patients performed between june 1999 and june 2011. In 3 of 6 cases bile ducts necroses was the indication to repeated LT. Retransplantations were connected with difficulties, enlargement of duration and replacement therapy volume, also explained high number of complication after operation. It is demonstrated that chronic biliary infection and bad condition of patients are the main reasons of complication and poor prognosis after repeated liver transplantation. В статье представлен опыт работы РНЦРХТ. С июня 1999-го по июнь 2011 гг. было выполнено 99 ортото- пических трансплантаций печени, из них 6 повторных у 5 больных. В половине наблюдений показанием к повторной трансплантации послужил некроз желчных протоков. Вмешательства были сопряжены со значительными техническими трудностями, заключавшимися в увеличении продолжительности опера- ции, объема заместительных инфузий. Это объясняло высокую частоту осложнений в послеоперацион- ном периоде. Неблагоприятными факторами прогноза были хроническая билиарная инфекция и тяжесть состояния пациентов перед повторной трансплантацией печени (ТП).

Selection of the resection volume of the liver in patients with Klatskin tumor

The objective of the study was to determine the possibilities of surgical treatment and to evaluate the criteria for selecting the resection volume of the liver in patients with Klatskin tumor.Material and methods. From 2005 to 2018, 36 patients with Klatskin tumor aged from 30 to 74 years were operated in the Department of surgery of «Russian scientific center of radiology and surgical technologies n.a. acad. A. M. Granov». Radical surgical interventions (R0) were performed in 28 (77.7 %) patients. 7 (19.5 %) patients underwent palliative surgery.Results. Selection of the resection volume of the liver and bile duct was carried out on the basis of assessment of the functional state, morphological changes in the liver and results of urgent intraoperative histological examination. As a radical intervention for IIIa, IIIb and IV types of Klatskin tumor (93.1 % of patients), extensive liver resection (left-sided or right-sided hemihepatectomy) with biliary and, in the presence of invasion into the main vessels, with vascular reconstruction was performed.Сonclusion. Timely and adequate liver resection with biliary reconstruction is a radical surgical intervention for Klatskin tumors. Selection of the resection volume of the liver, especially for type IV tumors, is determined by the morphological changes and the reserve capacity of the liver. The status of the resection edge is crucial for the selection of subsequent treatment tactics. Combination of methods of regional chemoinfusion and intraductal photodynamic therapy is necessary after non-radical intervention

METHOD FOR RESTORATION OF BILE OUTFLOW IN ORTHOTOPIC TRANSPLANTATION OF LIVER USING CYSTIC DUCT

Method for restoration of bile outflow in orthotopic transplantation of liver using cystic duct may find application in anatomic version characterised by parallel location of cystic and common liver ducts in donor. After cholecystectomy, at the level of bile ducts donor segment intersection, common reservoir is formed with application of common liver and cystic ducts by dissection or wedge-shaped excision of partition segment between them. Level of bile ducts donor segment intersection is selected so that diameter of common reservoir coincides with diameter of recipient bile duct, with which biliobiliary anastomosis is formed. Biliobiliary anastomosis is formed as «end to end». If there are mucous and muscular layers in composition of partition between liver and cystic ducts, they are dissected. Edges of mucous layer are sutured. If only mucous layer is present in composition of partition, it is dissected without further suturing. Such approach supply possibility to overcome discrepancy of sutured ducts diameters and provision of bile outflow from liver in the most physiological version with «end to end» anastomosis

Klatskin tumor complicated by obstructive jaundice and cholangitis in real practice: unresectable tumor or incurable patient?

The objective was to determine the effectiveness of biliary drainage/stenting before admission to the specialized Department of hepatobiliary surgery in patients with Klatskin tumors and the possibility of subsequent specific treatment.Methods and materials. During 2015-2019, 58 patients with Klatskin tumor (Bismuth - Corlette types: I - in 4 pts; II - 6; III - 36; IV - 12) were hospitalized with biliary drainage/stenting performed in outside hospitals because of obstructive jaundice. In 45 (78 %) patients due to uncontrolled cholangitis and /or obstructive jaundice, correction and/or additional drainage of the bile ducts was required: resetting from external to external-internal (n=23), additional drainage of the left lobe and Siv (n=16), removal of endoscopic stents and new percutaneous drainage (n=6). 48 patients received combination of intraductal photodynamic and regional chemotherapy. After 2-8 (average 3) cycles of specific therapy, 14 (24 %) patients underwent surgery: right hemigepatectomy - 4; left expanded hemigepatectomy - 4; left hemigepatectomy - 3; duct resection with Siv - 2; orthotopic liver transplantation - 1.Results. From the first appearance of obstructive jaundice to the beginning of specific treatment, it took 1 to 9 (average 3.1) months. The technical success of repeated endobiliary interventions was 100 %. There were no serious complications or mortality. Both the cholangitis and obstructive jaundice were controlled in 35 (78 %) patients. 14 out of 48 (30 %) patients showed a metabolic and biological response of the tumor to combined treatment (PET/CT with F 18FDG and CA-19.9) and underwent radical surgery. Specific therapy was not performed in 10 (17 %) patients with long-term jaundice and the development of biliary cirrhosis (n=6) and chronic cholangitis (n=4).Conclusion. Before the admission to the specialized Department, previously installed bile duct drains/stents were effective in 22 % of patients. Only adequate biliary drainage with regular x-ray monitoring allows to start aggressive specific therapy in 83 % of patients with Klatskin tumor. The advantage of photodynamic and regional chemotherapy after percutaneous biliary drainage is their repeatability with local control of tumor and the possibility of subsequent radical surgical treatment, including orthoptic liver transplantation

REPEATED LIVER TRANSPLANTATION: EXPERIENCE OF RUSSIAN SCIENTIFIC CENTER OF RADIOLOGY AND SURGICAL TECHNOLOGY (RSCRST)

The article gives the report about the experience in repeated liver transplantation (LT). Totally 99 LT including 6 repeated operation at five patients performed between june 1999 and june 2011. In 3 of 6 cases bile ducts necroses was the indication to repeated LT. Retransplantations were connected with difficulties, enlargement of duration and replacement therapy volume, also explained high number of complication after operation. It is demonstrated that chronic biliary infection and bad condition of patients are the main reasons of complication and poor prognosis after repeated liver transplantation