Klatskin’s tumor is a rare malignant neoplasm characterized by the absence of specific symptoms, challenges in verification and difficulties in assessing the true extent of the tumor. We present a clinical case of a patient with hilar cholangiocarcinoma. The patient received almost the entire modern complex of radiologic examinations for preoperative staging. However, concominant cholangitis, hard-to-reach anatomical localization and tumor’s creeping-growth distorted the results of instrumental studies. The true volume of the lesion was detected only intraoperatively and resulted in an expansion of liver resection volume.

This review summarizes the literature data about hepatic artery infusion chemotherapy in the treatment of advanced hepatocellular carcinoma. This method is safe and effective in tumors of very large volume and also in cases of portal vein tumor thrombosis when other interventional technologies (chemoembolization, radioembolization) are contraindicated or ineffective. Good results are the reasons for inclusion hepatic artery infusion chemotherapy in South-Asia clinical recommendations for the treatment of advanced hepatocellular carcinoma, but this method fails to attend in USA and European guidelines. Arterial infusion chemotherapy looks like non-expensive and technically simple procedure. It’s use in American and European patients including Russiais topical.

Purpose: To evaluate clinical effectiveness of arterial therapy in patients with gastrointestinal stromal tumors (GIST) metastases to the liver. Material and methods: Between 2005 and 2021, intra-arterial chemotherapy was performed in 11 patients: 6 men and 5 women aged 40–78 (mean 59) years with immunohistochemically verified liver metastases of GIST. Resection of gastric (n = 4), jejunal (n = 3), sigmoid (n = 1), and pancreatic tumor (n = 1) was performed in 9 patients; tumor of unknown primary origin was in 2 patients. Before intra-arterial treatment, all patients received specific treatment of liver metastases in outside hospitals (liver resection, radiofrequency ablation, tyrosine kinase inhibitors or systemic chemotherapy), but progressed. We performed 56 treatment cycles: oily chemoembolization (n = 37) or its combination with chemoinfusion (n = 19). Results: According to mRECIST, 1 patient showed complete and 3 partial responses. Stable disease in 4 and progression in 3 patients was seen. Liver resection was carried out in 3 responders. At present, 8 patients died in 28,4 mo (median 32 mo). Three patients are alive for 5–7 years. Conclusion: Intra-arterial chemotherapy seems to be safe and promising treatment of GIST liver metastases, including patients showing refractory to tyrosine kinase inhibitors.

We present two patients with advanced unresectable intrahepatic cholangiocarcinoma successfully treated with combined systemic-regional chemotherapy. Intra-arterial treatment included oily chemoembolization and chemoinfusion (GEMOX) with additional systemic chemotherapy (GEMCIS). Chemotherapy did not stop after extrahepatic progression: metastases to the lungs and bones. Continuous symptomatic nutritional support allowed to minimize chemotherapeutic toxicity and to maintain good quality of life. One patient is still alive for more than 4 years, the other died of tumor progression in three years ten months. The importance of factors contributing to the long-term survival of patients with advanced intrahepatic cholangiocarcinoma is considered.

Aim. To evaluate the safety and accuracy of percutaneous transhepatic biliary biopsy in patients with suspected Klatskin tumor.Materials and methods. Between 2013–2020, percutaneous transhepatic biliary drainage (PTBD) was performed in 52 patients with Klatskin tumor, complicated by obstructive jaundice. After successful PTBD, the diagnosis was verified by antegrade access. 74 procedures were performed: brush (n = 36; 48.6 %) or forceps biopsies (n = 38; 51.4 %).Results. There were no adverse events associated with a brush biopsy. Only grade I complications were after the forceps technique: 3 patients (7.9 %) developed hemobilia, which was corrected conservatively. Malignant lesions of the biliary tract were detected by forceps technique in 79.0 %, brush biopsy in 66.7 % (p >0,05). The degree of tumor differentiation was determined in 60.0 % (n = 18) vs 12.5 % (n = 3) (p < 0,01), respectively.Sensitivity and specificity of forceps biopsy were slightly higher than in brush: 82.4 % and 75.0 % vs 73.3 % and 66.7 % (p >0,05).Conclusions. Antegrade percutaneous transhepatic biliary biopsy is safe for both brush and forceps techniques. However, forceps biopsy has higher sensitivity and specificity in the diagnosis Klatskin tumor and better possibility of determining the degree of malignancy differentiation.

The aim of the study was to show new promising possibilities of direct perfusion test for the transplanted liver.Materials and methods. We have performed 246 liver transplantations (1998–2020). Since 2015 arterial complications were detected in 24 (23%) patients after 105 transplantations complicated by liver hypoperfusion: splenic artery steal syndrome (n = 8), hepatic artery thrombosis (n = 7), combination of hepatic artery stenosis and steal syndrome (n = 6), hepatic artery stenosis (n = 3). Endovascular interventions were performed in these cases for revascularization. Direct perfusion test was performed in 8 patients.Results. The liver perfusion index increased from 0.27 (0.13–0.45) to 0.62 (0.33–0.89) after endovascular procedures. Sufficient perfusion was ≥0.65.Conclusion. Direct liver perfusion test makes possible to identify and objectify graft blood supply, timely and adequate correction, and reduces the risk of developing biliary ischemic complications.

The review presents an analysis of the literature and our own data on the use of intra-arterial chemotherapy in pancreatic cancer. It is concluded that transcatheter arterial administration of cytostatics is a relatively safe and effective method of treatment. Combination of celiac axis infusion with arterial chemoembolization, as well as infusion with radiotherapy increase the survival. Neoand adjuvant arterial chemotherapy improves the results of pancreatic surgery. The use of new locoregional chemotherapy regimens is promising and requires further study.

A young female patient who developed anastomotic biliary stricture following an orthotopic liver transplantation was observed. A self-expandable metallic stent was placed to correct the stricture. At the 8th month of her repeat pregnancy, the stent broke asymptomatically into half. Fortunately, the second childbirth, like the first one, had no complications. Eighteen months later, due to obstruction of fragments by sludge and gallstones, re-stenting was performed with a coated biliary stent. Four years and five months later, recurrent jaundice occurred due to occlusion of the second stent. This was addressed by surgical removal of both stents. Two years after surgery, the bile ducts remain completely patent. We found only two cases in literature on a similar extremely rare biliary stenting complication. It has been suggested that stent deformation may be related to pregnancy. The feasibility of using stenting in benign biliary strictures in some clinical situations is discussed.

OBJECTIVE was to evaluate the results of transcatheter arterial chemoembolization (TACE) in the treatment of patients with hepatocellular carcinoma (HCC) on advanced liver cirrhosis (LC) and intermediate stage (B) according to BCLC classification (Barcelona Clinic Liver Cancer classification).METHODS AND MATERIALS. We evaluated results of TACE in 54 patients. Of them, 12 (22 %) had stage A of cirrhosis and 42 (78 %) – stage B of cirrhosis according to the Child-Pugh score. Nine (17 %) patients matched stage A4 and 45 (83 %) – stage В according to BCLC classification. The TACEs was performed according to the conventional practice with using Lipiodol + gelfoam (n=40) and with a drug-eluting beads (n=14) from 1 to 16 (average 6) times. The Doxorubicin was used as a first-line therapy in all cases.RESULTS. After TACE, two patients died of liver failure (3.7 %). According to the m-RECIST, complete response to treatment was observed in 9 (16.5 %), partial response – in 13 (24 %), stabilization – in 19 (35.5 %) and progression – in 13 (24 %) patients. At present, 22 (41 %) patients are alive for 1 to 51 (average 16.2) months. 32 patients (59 %) died between 2 to 62 months: 13 (24 %) – from HCC progression, 19 (35 %) – from liver failure. The 1– 2–3-year survival rate was 75–44–15 %; only one patient survived > 5 years. The median survival rate was (22.0±3.0) months, overall survival rate according to Kaplan – Meier was 26 months.CONCLUSION. TACE is a relatively safe and effective treatment in patients with HCC on advanced LC and intermediate stage (B).

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.

Objective: classical methods of determining arterial blood supply of the graft following orthotopic liver transplantation (OLT) reflect the presence of blood flow in the trunk and large branches of the A. hepatica, without the characteristic of completeness of blood filling of peripheral sections, which is very important for objective evaluation of function. The aim of this study is to establish the diagnostic value of a direct perfusion study (IFlow) of the graft. Materials and methods. From 1998 to 2019, 245 OLTs were conducted. From 2015 to 2019, arterial changes were detected in 24 (23%) patients after 104 OLTs. A perfusion study was performed in 9 patients with suspected arterial graft failure. According to the IFlow study, liver hypoperfusion due to stenosis and/or splenic steal syndrome was detected in 8 cases and became an indication for therapeutic intervention. Results. Hepatic stenting and/or splenic artery embolization was performed to improve arterial blood supply to the liver. Endovascular procedures performed restored the perfusion index from 0.24 (0.01–0.89) to 0.61 (0.35–0.98). Conclusion. Absence of ultrasound and multispiral computed tomography signs of arterial complications does not rule out the need for perfusion angiography. Perfusion angiography allows to objectify the angiography data and perform corrective intervention in good time.

Objective : to study liver transplantation (LT) outcomes in cirrhotic patients with hepatocellular carcinoma (HCC), who underwent transcatheter hepatic arterial chemoembolization (THACE). Materials and methods. From January 1998 to April 2020, we performed 245 orthotopic liver transplantation (OLTs) in 229 patients of which 25 (10.2%) had HCC in cirrhosis. In 9 (36%) patients, LT was performed without neoadjuvant therapy (Group 1). Group 2 consisted of 16 (66%) patients who underwent 49 THACE cycles before LT. 10 (62.5%) patients fell within the Milan criteria, while 6 (37.5%) were outside. According to the BCLC (Barcelona Clinic Liver Cancer) classification, 10 patients had A 1 –A 4 stage, while 6 were in B stage. In 11 (68.5%) of 16 patients, increased serum alpha-fetoprotein (AFP) concentrations from 20 to 2463 (on average 493.8) ng/mL was revealed before treatment. In performing THACE, both the classical method (with lipiodol and hemostatic sponge) and the method with drug-eluting beads were performed 1 to 7 (on average 3) times. Doxorubicin was used in all cases. Results . Group 2 recorded a 100% technical success. There were no complications. We performed radiofrequency ablation (RFA) in three patients as an adjunct. In two patients, we performed laparoscopic RFA-assisted atypical liver resection, and in one – sequential resection and RFA. Under the m-Recist criteria, complete response was observed in 6 (37.5%), partial response in 7 (43.75%), and stabilization in 3 (18.75%) patients. Change in AFP concentrations were as follows: in 5 out of 11 patients with increased concentrations, we were able to reduce their AFP concentrations to the reference values, their long-term outcomes are comparable to those of Group 1. Four patients showed a 13–84% decrease; a directly proportional relationship between the degree of AFP decrease and the time to tumor progression was revealed. In 2 patients, there were 42% and 320% increase in AFP concentrations, the time to tumor progression was 3 and 1 month, both did not live up to 12 months. Among 9 (56%) of the living 16 patients, a maximum of 156 months and a minimum of 4 months (60.2 average) have elapsed since the surgery. Two of these nine have tumor progression (cases 4 and 14). Seven (44%) patients died within 9 to 54 months. The 1, 3, 5-year actuarial survival rates were 93, 50, 32%, two patients lived more than 10 years. The average life expectancy was 28.0 ± 3.0 months. Conclusion . Serum AFP concentration is an important prognostic factor influencing the long-term outcomes of LT. Good biological response to THACE can be a positive predictor; LT outcomes in these patients are comparable to those in patients who meet the Milan criteria. A decrease in AFP concentrations by less than 50% after neoadjuvant THACE is an unfavorable factor, and its increase is extremely adverse.

Objective. To study effectiveness of intra-arterial chemotherapy in patients with locally advanced and metastatic pancreatic cancer.Material and methods. There were 329 patients who underwent regional chemotherapy in 2000 – 2015 (infusion through celiac trunk – 167, chemoembolization of gastroduodenal artery – 52, combination of these methods – 72, combined chemo-radiotherapy – 38). Locally advanced unresectable pancreatic cancer with arterial invasion (T4 grade) was observed in 198 (60.2%) patients, liver metastases (stage IV) – in 131 (39.8%) patients. Chemoembolization or chemoradiation therapy was performed for patients without distant metastases.Results. The best results for unresectable pancreatic cancer were obtained in 160 patients after chemoembolization combined with infusion. Partial response was obtained in 24.1% of cases compared with 8.9% and 13.4% of cases after infusion or chemoembolization alone. Mean life expectancy was 15.5 months compared with 14.6 and 10.6 months, respectively. Median of life expectancy was 15.6 months compared with 11.7 and 10.8 months, respectively. At the same time, progression of disease was observed in the majority of 131 patients with metastatic cancer. Partial response was noted only in 2.3% of patients only after chemoinfusion. Survival and median survival after chemoinfusion and combination of chemoembolization with chemoinfusion were similar (10.1 (8.3) and 10.9 (7.5) months). Chemoradiotherapy in 4 patients with initially unresectable pancreatic cancer resulted reduction of tumor dimension by 28% (24–32%). Therefore, radical operations were performed later. One-year survival was achieved in 20 (58.8%) out of 34 patients with unresectable pancreatic cancer. Mean life expectancy was 15.4 months (median 13.8 months).Conclusion. Intra-arterial chemotherapy is effective treatment in patients with pancreatic cancer stage III and IV. Combination of celiac axis infusion with arterial embolization, as well as infusion with radiotherapy resulted the best survival. Certain advantage of chemoinfusion was found for liver metastases. The use of new chemotherapy modes for intra-arterial infusion requires further study.

Aim. To estimate the effectiveness of intraarterial chemotherapy in treatment of patients with unresectable colorectal liver metastases resistant to systemic chemotherapy. Materials and methods. Between 2011 and 2018, 64 patients were treated. Previously performed 3–35 cycles of systemic chemotherapy was assessed as ineffective in 58 and discontinued in 6 patients because of grade III–IV toxicity. The most effective cytostatics previously used in systemic chemotherapy was used for intraarterial therapy. In the absence of effective drugs, monotherapy with Mitomycin C was done. For hypovascular metastases hepatic arterial infusion was performed using 4–6 g 5-fluorouracil, 15–20 mg Mitomycin C, 150–200 mg Oxaliplatin or 160–200 mg Irinotecan per cycle. For hypervascular metastases was used oily chemoembolization included selective infusion of suspension consisted of Lipiodol with Mitomycin C 10–20 mg or Irinotecan 160–200 mg or Doxorubicin 50–80 mg followed by occlusion of feeding arteries with gelfoam. Combination TACE + HAI was performed in anatomical variants of hepatic artery. Results. We performed 238 cycles of intraarterial chemotherapy (from 2 to 16, average 3,7 per patient). There were no major complications and mortality. Progression-free survival after the intraarterial chemotherapy was 11.7 months. The median survival from the start of first cycle of systemic chemotherapy was 22 mo. in group patients with synchronous and 23 mo. with metachronous metastases. Conclusion . Preliminary results show promising intraarterial chemotherapy for treatment of patients with chemoresistant colorectal liver metastases. The application of the method makes it possible to reduced tumor growth for one year after interruption of systemic chemotherapy.

OBJECTIVe. The article is devoted to the study of the safety and the effectiveness of the arterial chemoembolization in patients with locally advanced pancreatic cancer. MATERIAL AND METHODS. Between 2000 and 2015, 52 patients with unresectable locally advanced cancer of the pancreatic head without remote meastases T3-4n0-1M0 were treated with chemoembolization of the gastroduodenal artery. 109 cycles of chemoembolization (from 1 to 7, average 2) were performed. RESULTS. Manifestations of postembolization syndrome were stopped within 24 hours with conservative therapy. chemotherapeutic toxicity of I degree was observed in 44 (85 %) patients, gastrointestinal toxicity of II–III degree – in 8 (15 %). clinical effect such as increased body mass and reduction of pain was achieved after performing two cycles in the majority of patients: 90 and 71 %, respectively. The average life expectancy of the entire group was 9.9, median of 6.7 months. however, these figures were higher in14 patients received three or more cycles: 14.4 and 9.6 months. oily chemoembolization of the arteries of the pancreas is a relatively safe method of treatment in patients with inoperable cancer of the pancreas head. Performing of the multiple cycles increases patient survival.

The paper describes a case of the rare complication of orthotopic liver transplantation - steal syndrome successfully controlled by interventional radiology techniques.

Presented the case of a combined approach preparation of 47 years old patient with primary biliary cirrhosis for orthotopic liver transplantation (OLT) and arterial flow insufficiency correction after surgery. The patient was under waiting list for OLT due liver cirrhosis progression. The patient underwent Intraportal infusion of autologous bone marrow mononuclear cells (MNC) which is allowed temporary stabilized the cirrhotic transformation. The transjugular intrahepatic portosystemic shunt (TIPS) procedure performed due to portal hypertension progression with episodes of bleeding from the esophageal and gastric varices, that allowed to receive organ donor and OLT. At 6 months after OLT the patient had clinical signs of a jaundice caused by splenic artery steal syndrome which was corrected by endovascular intervention: splenic artery trunk embolization.

Objective: to assess the first results of transjugular intrahepatic portocaval shunting (TIPS) as a technique for preventing portal hypertension complications in patients in the period of waiting for a donor liver.Subjects and methods. TIPS was performed in 6 patients on the list of waiting for orthotopic liver transplantation (OLT). The indications for TIPS were current (n=1) or high-risk recurrent hemorrhages from the esophageal varices and stomach (n=4) and diuretic-resistant ascitis (n=1).Results. TIPS was successfully carried out in all the patients. The portovenous gradient was reduced by 2—3 times (to 9—12 mm Hg). A further follow-up revealed recurrent varicose hemorrhage or ascitis in none patients. Doppler study indicated that the shunt showed a good function. OLT was successfully made in 3 patients 2, 8, and 19 months after TIPS; one female patient had been waiting for OLT for 5 months; 2 patients died from sepsis and hepatic failure following 1 and 5 months, respectively.Conclusion. The first results suggest that in patients with hepatic cirrhosis complicated with portal hypertension, TIPS can be regarded as a safety bridge while waiting for a donor liver.

The paper describes a case of the rare complication of orthotopic liver transplantation - steal syndrome successfully controlled by interventional radiology techniques.

The objective was of the study to evaluate the role of preoperative x-ray endovascular interventions – transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) – for improvement of resectability of colorectal liver metastases.Material and methods. Between 1997 and 2017, we treated 11 patients who simultaneously had large-volume (60–70 %) of right liver lobe colorectal metastases and small future remnant liver. The treatment was started from 1–4 cycles of TACE to reduce or stabilize the rapid growth of the tumor. In case of good effect, we performed PVE and then we performed liver resection.Results. There were no major complications of TACE or PVE. After 1–4 cycles of TACE, the volume of metastases showed partial decrease or stabilization. The following PVE allowed to increase the future remnant volume of the left liver lobe up to a safe 40–45 %. Right – sided hemihepatectomy was performed in 6 patients and extended right-sided hemihepatectomy in 5 patients. There were no postoperative mortality or severe complications. At present, 4 patients are alive without recurrence during 1.5–8 years, and 4 other patients received endovascular treatment for local recurrence are alive during 1.5–5 years. The 3 patients died from tumor progression during 13–30 months. CONCLUSION. In patients with simultaneously extensive for resection volume of right liver lobe metastases and small left liver lobe, the primary treatment with TACE is reasonable. Only after the documentation of tumor decrease or stabilization, it is necessary to determine the timing of PVE and following major liver resection. This order of treatment procedures allows to improve resectability in cases with extensive, large-volume, rapidly grown malignant liver lesions.