В данном разделе указаны критерии оценки клинической значимости применения дорогостоящей противоопухолевой лекарственной терапии в соответствии со шкалой, разработанной экспертной группой (с м. стр. 7). В тексте они обозначены, как магнитуда клинической значимости (МКЗ).

Цель. Анализ ранних и поздних сосудистых осложнений (тромбозы, кровотечения), их причин и тактики лечения у больных после ПДР, в том числе с сосудистой реконструкцией. Материалы и методы. Проведен ретроспективный анализ технических особенностей операции и послеоперационного периода у 595 пациентов, которым в период с 2006 по 2020 гг была выполнена панкреатодуоденальная резекция. Резекции магистральных сосудов в ходе операции выполнены у 180 (30,3%) пациентов. Оценивали характер, количество и тяжесть развившихся после операции осложнений. К раним сосудистым осложнением относили внутрибрюшные кровотечения или тромбозы магистральных сосудов, диагностированные в первые 24 часа после оперативного вмешательства. Поздним, как правило аррозивным, кровотечением являлось внутрибрюшное кровотечение, возникшее позже 24 часов после оперативного лечения. К несостоятельности панкреатодигестивного анастомоза относили панкреатическую фистулу типа В или С согласно рекомендациям ISGPF (2016). Летальным исходом считали неблагоприятный исход в течение 30 суток или в период госпитализации. Результаты. Реконструкции магистральных венозных коллекторов в ходе ПДР как стандартная опция выполнена у 180 пациентов из 595, что составило 30,3%. Тромбозы зоны реконструкции выявлены у 17 больных (9,4%). Ранний тромбоз наступил у 10 (5,6%). Диагностированные ранние венозные тромбозы протекали с яркой клинической симптоматикой, что позволило их своевременно выявить. Активная хирургическая тактика позволила успешно выполнить тромбэктомию у трех пациентов и привело к выздоровлению. У 2 пациентов реконструкция оказалась безуспешной, в том числе в одном случае ввиду значимой портальной гипертензии на фоне химиотерапевтического гепатоза. Консервативное лечение у 5 пациентов успеха не имело. Летальные исходы наступили у 7 человек, которым не удалось восстановить кровоток по воротной вене. По-видимому, некоторые ранние тромбозы не проявлялись клинически и не были диагностированы, как и поздние тромбозы магистральных сосудов после их реконструкции протекали бессимптомно и были, как правило, диагностической находкой у 7 пациентов. Внутрибрюшные кровотечения в первые сутки диагностированы и своевременно успешно купированы у трех пациентов (0,5%). Поздние фатальные аррозивные кровотечения развились у 17 (30,1%) из 55 пациентов с панкреатической фистулой. Лечение аррозивных кровотечений малоэффективно, основное внимание уделяли профилактике формирования панкреатической фистулы. Все пациенты с диагностированной панкреатической фистулой по тактике ее лечения были разделены на 2 группы (1 группа – 296 пациентов, вторая – 299). Различия тактики лечения панкреатической фистулы заключались в применении во второй группе пациентов активной аспирации отделяемого фистулы. Группы пациентов не имели достоверных демографических и операционных различий друг от друга. В первой группе без применения активной аспирации количество фистул класса В было – 8 (2,7%), класса С – 26 (8,8%), во второй группе количество свищей класса В составило 9 (3%), в то же время, количество тяжелых фистул класса С достоверно снизилось до 12 (4%) (p= 1, Хи2 – 0,051 и p= 0.027, Хи2 – 4,892 соответственно). В первой группе количество поздних кровотечений было 14 (4,7%), во второй – 3 (1%) (p= 0,006, Хи2 – 7,442). Общая летальность в группах снизилась с 5,7% до 1,7% (разница статистически достоверна p= 0.016, Хи2 - 5.827). Заключение. Резекции и реконструкции магистральных вен портальной системы при их инвазии в ходе ПДР выполнена у 30,3 % пациентов. Нами выделены ранние и поздние сосудистые осложнения (тромбозы и кровотечения), что позволяет четко определить тактику их лечения. Из диагностированных 17 тромбозов среди 180 реконструкций магистральных вен ранний симптомный тромбоз наступил у 10 (5,6%). Наиболее эффективной была успешная экстренная (менее 12 часов) реваскуляризация, которую удалось выполнить у 3 пациентов. Две безуспешные тромбэктомии, как и консервативное лечение у 5 пациентов привели к летальному исходу. Бессимптомный тромбоз у 7 пациентов был выявлен при контрольных исследованиях. Доля ранних внутрибрюшных кровотечений была незначительна (0,5%) и, как правило, была обусловлена предсуществующей коагулопатией. Поздние аррозивные кровотечения диагностированы у 17 пациентов, как результат панкреатической фистулы. Хирургическая остановка кровотечения оказалась эффективной у 3 пациентов. Профилактика развития и активное лечение панкреатической фистулы позволила достоверно снизить их число и, как следствие, частоту кровотечений с 14 (4,7%) в первой группе до 3 (1%) во второй группе с активной тактикой. При этом летальность уменьшилась с 5,7% до 1,7%. Предложенный протокол профилактики лечения сосудистых осложнений у больных перенесших ПДР показал свою эффективность. При развитии несостоятельности панкреатодигестивных анастомозов, с целью профилактики аррозивных кровотечений, целесообразно использовать активную аспирацию. Для профилактики поздних аррозивных кровотечений, при эффективном лечении хирургических осложнений необходимо выполнить компьютерную томографию брюшной полости с контрастным усилением через 20-30 дней после последнего оперативного вмешательства с целью выявления аневризматических расширений висцеральных артерий.

MEETING DATE: July 7, 2023ITEMS ON THE AGENDA:1. The role of the adjuvant atezolizumab plus bevacizumab in patients with hepatocellular carcinoma (HCC) at high risk of recurrence following surgical resection or ablation. Profile of the patient who will benefit the most from this therapy.2. To evaluate the prospects for therapeutic options for patients with early HCC in Russia.Liver cancer remains a public health concern globally, with an increasing trend in the number of incident cases worldwide. Early, precise diagnosis and timely treatment contribute to the improvement in overall and relapse-free survival. It is important that the entire arsenal of local treatments (resection, ablation and liver transplantation) can be applied in cases when HCC is detected at a very early and early stage of the disease. Tumour recurrence after surgical treatment or ablation is a complex and underexplored problem in the treatment of patients with HCC. Many factors that can predict the risk of relapse after surgical treatment have been described: tumour size >5 cm, >3 foci, micro- or macrovascular (Vp1-2) invasion, poor degree of tumour differentiation (G3-4). Our advisory board tried to identify the most important risk factors for early relapse, and to determine the role and impact of the results of the first positive clinical trial focused on the issue of early HCC, IMbrave050: a phase 3 trial of adjuvant atezolizumab + bevacizumab vs active surveillance in patients with HCC at high risk of disease recurrence following resection or ablatio.

Chronic pancreatitis (CP) is a quite common disease with an annual incidence of up to 30 new cases per 100,000 persons in Russia, and 9.6 cases per 100,000 persons abroad. Idiopathic pancreatitis associated with genetic mutations ranks second in frequency. When conservative therapy is ineffective, surgical intervention is considered. Total pancreatectomy reduces pain, but leads to pancreatogenic diabetes mellitus. In case of hereditary pancreatitis caused by mutations in the PRSS1, CFTR, SPINK1 genes, pancreatectomy becomes advisable, including for prevention of pancreatic cancer. Isolation of Langerhans islets from the excised pancreas and their autotransplantation (total pancreatectomy with islet autotransplantation, TPIAT) provides additional treatment options. Such surgical interventions are not performed in Russia as of yet. The aim of the study was to assess the effectiveness of total pancreatectomy followed by restoration of glucose tolerance in treatment of patients with chronic genetically determined pain pancreatitis. Materials and Methods:Two patients with chronic pain pancreatitis with the SPINK1 and PRSS1 genetic mutations were examined and underwent surgical total pancreatectomy. Islets were isolated from the excised glands and implanted into the liver. Postoperative followup included an assessment of quality of life and pain intensity based on questionnaires, as well as determination of the glycemic level. Results:Following total pancreatoduodenectomy and autotransplantation, a significant decrease in pain and an improvement in quality of life were noted. Transplanted islets' function was reduced, due to their insufficient number, which required administration of exogenous insulin. Conclusion:The described experience demonstrates the TPIAT effectiveness in treatment of chronic pancreatitis, which can become a basis for further research and introduction of the technique into domestic clinical practice.

Background: Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disease characterized by insulin deficiency due β-cell destruction and following hyperglycaemia. Specific markers of T1DM are pancreatic islet-targeting autoantibodies that are found months to years before symptom onset, and can be used to identify individuals who are at risk of developing T1DM. Aim: The study is aimed at the review of current knowledge of diabetes-related autoantibodies as biomarkers of T1DM. Materials and methods : Foreign and national clinical studies on this topic were included. PubMed, Medline and ­eLibrary were searched. Results: Modern ideas about known diabetes-specific autoantibodies as markers of autoimmune inflammation of β-cells of the pancreas were discussed. The analysis of their independent diagnostic value in predicting the occurrence of T1DM were carried out. Conclusion: There is no unified concept in the literature on this issue. Current data on autoantibodies in T1DM show a ­significant individual variability in the timing, dynamic changes and autoantibody composition in T1DM progression.

The review addresses the main methods for assessing the function and regenerative potential of the liver. They include both the traditional methods, commonly used in clinical practice, and the latest promising techniques suitable for the analysis of cellular and tissue pathology and having a proven diagnostic value. It is known that the dynamics of liver regeneration is reflected in the metabolic status of liver cells, their morphology, and the molecular rearrangement. Therefore, by looking at these parameters we will be able to assess the regenerative potential of the liver as a whole. At present, the most promising method is represented by multiphoton microscopy able to generate the second harmonic; there are also such techniques as coherent anti-stokes Raman spectroscopy (CARS), stimulated Raman scattering (SRS) microscopy, and fluorescence lifetime imaging microscopy (FLIM). In addition, a number of options for analyzing metabolic and structural changes are provided by mass spectrometry, in particular time-of-flight secondary ion mass spectrometry (ToF-SIMS). Studies using these methods with in vivo models and with human biopsy samples demonstrate their relevance in biomedical research and in clinical practice alike.

The article summarizes the available information on the domestic and foreign literature on the impact of urologic diseases on the dental status of patients. A detailed analysis of the dependence of the specific sources of diseases of the oral mucosa of renal function. Presented convincing evidence of the high prevalence of kidney disease in the world, which makes this pathology is not only medical but also social problems. Refined features revealed by visual examination of patients with kidney disease. Described the complaint most often imposed nephrology patients on dental examination, and the mechanism of their development of the study of various authors. The peculiarities of diseases of the oral mucosa in patients with chronic renal failure. The possible causes of the occurrence, as well as the relationship with the stage of kidney disease.

In the article on the example of patients with chronic kidney disease shows the relationship between the level of oral health and quality of life. For this case study conducted using a special questionnaire "Profile effect of oral health." Found a significant reduction in dental parameters of quality of life of these patients in all components: physical, psychological and social. The results are compared with the values in the control group, where even in the background of relative overall health dental diseases affect the quality of life. In patients undergoing hemodialysis the paramount importance in reducing the quality of life has a psychological component, and in patients without somatic pathology physical. Comparative analysis of quality of life index on scales showed the maximum reduction in the study group on the scale of "psychological problems", and in the control group on a scale of "physical discomfort." The findings suggest that quality of life depends on the characteristics of the dental status of patients, due to the general state of health. The results of the survey on quality of life can be added to the objective analysis of clinical data on the state of dental health.

There have been studied the results of surgical treatment of 42 patients with chronic pancreatitis, complicated with obstructive jaundice, with the assessment of life quality with the help of the Russian version of questionnaire MOS-SF-36. Herewith 25 patients had pancreaticoduodenal resection, and 17 patients Berne variant of isolated duodenum-preserving resection of head of pancreas. It has been proved that duodenum-preserving resection of head of pancreas has better results than pancreaticoduodenal resection, but the last one has its advantages in cases of duodenal obstruction and is done with patients of more severe conditions.

There have been analyzed the results of surgical treatment of 128 patients with metastases of colorectal cancer in the liver operated in the Privolzhsky district medical center of Federal Medico-Biologic agency of Russia (Nizhny Novgorod). There has been carried out the comparative assessment of the results processed by means of international register LiverMetSurvey (www.livermetsurvey.org) with collective data of the project published. All main aspects were compared. Age, primary tumour localization, the number, size and localization of hepatic metastases, the presence of associated pathologies, as well as the volume of surgeries performed in the compared groups had differences representing the work of Regional Hepatology Centre. The main difference was in postoperative survival of such patients: according to International register, two-year survival amounts to 76%, and in our centre 57%. The obtained results of the analysis show the approaches to the treatment of this difficult group of patients in the Privolzhsky district medical center correspond to the international protocol...

114 liver resections in patients with the colorectal metastases were performed within the period of 2005-2010. 52 patients (48,14%) with bilobar mulpiple metastatic liver lesion were operated. In 11 patients liver resection was supplemented with metastases destruction by the device developed on the basis of local impact of ultrahigh frequencies energy. The reliable differences were not revealed while studying and comparison of the survival rate of patients after performed operations in monolobar and bilobar metastatic liver lesion. With that the survival term of the operated patient was amounted to 22,8 months. Some variants of one stage and two stages surgical treatment were suggested.

We have designed a new instrument for termoablation of colorectal metastases in the liver based on the use of high frequency energy. In order to assess the efficieny of the device, experiments on large laboratory animals were performed and the affected zone was investigated using light and electron microscopy. In the clinical practice, analyses of compound effects of microwaves on the liver metastasis in 19 colorectal cancer patients demonstrated the effectiveness of our method. Microscopic and ultrastructural investigation of the removed tissue revealed particular features of destruction of liver metastases resulting from local application of microwave energy. 10 patients with bilateral liver metastases underwent two-step surgical treatment with the use of the microwave method. Assessment of the performance of the microwave method during the second step of the operation showed that in 9 cases of 10 the metastases in the liver were destroyed.

The traditional technique of puncture drainage of biliary ducts while diagnostics and treatment of obstructive jaundice of tumorous genesis needs in expensive X-ray-surgical equipments and accompanies with high radiation-absorbed dose for the personnel and patient. The alternative offered is the drainage method under ultrasonic control with following rontgenological cholangiographic investigation.