Aim. To analyse the surgical aspects of performing a split liver transplantation in patients with end-stage liver disease.

Key findings. Split liver transplantation (SLT) is a technique allowing two functional grafts to be obtained from one deceased donor to simultaneously save the lives of two recipients. The global clinical experience of SLT application currently comprises more than three decades. Criteria necessary for successful SLT were developed, based both on assessment of graft quality (age and anthropometric characteristics of the donor, laboratory parameters, ultrasound data, length of stay in intensive care, as well as macroscopic intraoperative assessment of the liver), and on the selection of recipients (primarily in accordance with the height-weight characteristics and the use of the GRWR [graftto-recipient weight ratio]). The use of these criteria allows the results to be achieved comparable to other types of liver transplantation (a whole liver from a deceased donor or liver fragments of an intravital donor). However, issues involved with of the optimal choice of surgical techniques remain to be solved, which include such key aspects as the anatomical method of separation (left lateral section and extended right lobe; anatomical left and right lobes of the liver), an optimal method of separation (ex situ or in situ) and others. The issues of logistics of the SLT application, including the principles of allocation of transplants, also remain significant. Ethical aspects are equally important, since, theoretically, the widespread introduction of the SLT technique may increase the risk of graft loss. The immediate and long-term SLT results require further study, which makes it possible to form a more objective opinion on the effectiveness of the technique.

Conclusion. SLT shows good results both in the near and in the remote period. The key aspects of SLT performing are a deep understanding of the variant anatomy of the liver and a high level of knowledge of liver resection surgery. The active use of SLT allows the pool of donor organs to be increased, which is of great importance under the conditions of their permanent lack. 

Aim. To generalize and present current data on the development of approaches to hemorrhoidectomy, as well as to analyse the function of the rectal closing apparatus after surgery.

Key findings. The haemorrhoid disease is one of the most common human diseases and the most common reason for visiting a coloproctologist. In Russia, the prevalence of haemorrhoids amounts to 130–145 people per 1,000 adult population, with its proportion in the structure of colon diseases varying from 34 to 41 %. Minimally invasive methods for treating such conditions have been shown to be effective in patients with 1–3 stage haemorrhoids. However, these methods have shown little value at stage 4 hemorrhoids, largely because they fail to affect all parts of the disease pathogenesis. Thus, hemorrhoidectomy remains to be the “gold standard” for stage 4 hemorrhoids treatment, which is aimed at eliminating the three main vascular collectors. Hemorrhoidectomy is accompanied by the risk of stricture and postoperative anal sphincter failure. In this regard, it is necessary to assess the functional state of the rectal closing apparatus after hemorrhoidectomy. Improving hemorrhoidectomy, for example, by the use of an ultrasonic scalpel, allows the hemorrhoidectomy to be performed without additional sewing of vessels and coagulation, and the injury of the anal sphincter to be minimized.

Conclusion. The possibility of injuring the anal sphincter is a serious problem in anal surgery. Anal sphincter incontinence is a serious illness that exacerbates the patients’ social life. Unfortunately, the issue of anal sphincter incontinence after hemorrhoidectomy is under-investigated, resulting in few rehabilitation programs. 

Aim. To evaluate the E-cadherin content in the blood plasma of individuals with suffering from both gastroesophageal reflux disease (GERD) and GERD combined with obstructive sleep apnea/hypopnea syndrome (OSAHS).

Materials and methods. 120 patients with GERD and/or OSAHS were examined. All the patients underwent esophagogastroduodenoscopy with the biopsy of the lower third of the esophagus in order to perform GERD morphological verification. The diagnostics of respiratory disorders during sleeping was performed using computer pulse oximetry. Group 1 (n = 29) consisted of GERD patients, group 2 (n = 35) of patients with GERD in combination with OSAHS, group 3 (n = 30) of patients with OSAHS, group 4 (n = 26) was the comparison group. The concentration of E-cadherin in the blood plasma was determined using enzyme immunoassay.

Results. There were no statistically significant differences in the plasma level of the N-terminal E-cadherin fragment between GERD patients and the comparison group (0.207 (0.128; 0.295) and 0.128 (0.067; 0.281) ng/ml, respectively, p = 0.082). However, the patients with erosive esophagitis were characterized by a higher content of E-cadherin in the blood plasma than those of the comparison group (0.284 (0.176; 0.858) and 0.128 (0.067; 0.281) ng/ml,  respectively, p = 0.03). In patients with GERD and OSAHS, statistically significantly higher plasma concentrations of E-cadherin were observed as compared to GERD patients (0.379 (0.277; 0.538) and 0.2007 (0.128; 0.295) ng/ml,  respectively, p = 0.017). A positive dependence of E-cadherin concentration in the blood plasma on the apnea/hypopnea index was found (r = 0.43, p <0.05).

Conclusions. OSAHS negatively affects the state of histoarchitecture of the esophageal mucosa of GERD patients, as evidenced by an increase in N-terminal E-cadherin in the blood plasma and may indicate a loss of E-cadherin in the esophageal mucosa with the development of an impaired function of tight junctions. 

Aim. To improve the results of surgical treatment of patients with esophageal diverticulum of various localization using intraoperative intraluminal endoscopy.

Materials and Methods: The Department of Surgery of the Esophagus and Stomach, the Petrovsky National Research Centre of Surgery, has accumulated a large experience in treating diverticulosis patients. Thus, during the 2010–2018 period, 74 patients with esophageal diverticula of various localization were operated. Out of them, 56 (75.7 %), 10 (13.5 %) and 8 (10.8 %) patients underwent surgical treatment with respect to faringo-esophageal, bifurcation and epiphrenic diverticula, respectively. The patients were divided into two groups: 31 people (41.9 %) in the main group underwent diverticulectomy with intraoperative intraluminal endoscopic assistance (IVEA), while 43 (58.1 %) people in the control group underwent diverticulectomy without IVEA. Intraoperatively, at the stage of discovering diverticulum, the endoscopist applied transillumination and air insufflation in the cavity of the diverticulum, followed by controlling the mobilization of diverticulum. At the resection stage, the completeness of the surgical removal was controlled, along with the absence of esophageal lumen narrowing after sewing the neck of the diverticulum using a linear stapler.

Results. The average duration of the operation in patients with Zenker’s diverticula and those in the control group was 45.5 ± 8.8 min and 73.8 ± 12.7 min (p < 0.05), respectively. In patients with the diverticula of the middle and lower third of the esophagus, the average surgery duration was equal to 120.3 ± 11.2 min and 150.5 ± 17.3 (p <0.05) min in the main and control groups, respectively. Radiological examination 2–3 days after surgery revealed no complications in the main group. In the control group, 2 (4.7 %) patients showed a small leakage of the contrast agent outside the esophagus (stopped conservatively). Signs of mild dysphagia when taking solid foods were detected in 1 (2.4 %) patient of the control group. This condition was associated with excessive ingress of the esophageal wall into the apparatus suture, which led to a slight narrowing of its lumen. No patients with dysphagia in the postoperative period were recorded in the main group.

Conclusion: The combination of surgical treatment of esophageal diverticula with IVEA allows the duration of surgery to be optimized, deformation of the esophageal lumen to be avoided, possible complications to be minimized, thereby improving the results of surgical treatment. 

Aim. To identify the relationship between rhythm disturbances, including ventricular tachycardia (VT), and the small intestinal bowel bacterial overgrowth syndrome in chronic heart failure (CHF) with left ventricular systolic dysfunction.

Materials and methods. The study included 60 patients with CHF with systolic dysfunction of the left ventricle (left ventricular ejection fraction less than 50 %). Conventional biochemical and hematological tests , ECG and echocardiography were performed. The level of the N-terminal fragment of the brain natriuretic peptide (NT-proBNP) and nonspecific inflammatory markers (C-reactive protein (CRP), fibrinogen, leukocytes, lymphocytes, neutrophil to lymphocyte ratio) were studied. Lactulose hydrogen breath test was fulfiled to detect the small intestinal bowel bacterial overgrowth syndrome (SIBOS). In the presence of complaints of palpitation and interruptions in the heart work or other indications, Holter ECG monitoring was performed. The control group consisted of 20 patients comparable to the main group by sex, age and major diseases in the absence of CHF and SIBOS.

Results. The prevalence of SIBOS among patients with CHF significantly exceeded its prevalence in the group of patients without CHF (SIBOS was detected in 25 of 60 patients with CHF (42 %) and in 2 of 22 patients without CHF (9 %); p = 0.0034). The small bowel bacterial overgrowth syndrome with CHF did not have a significant impact on the functional class and the indicators of clinical and biochemical analysis of blood as well as on echocardiographic data and the number of supraventricular and ventricular extrasystoles. However, in patients with SIBOS, higher CRP values were observed (median and interquartile range: 3.6 (2.5; 4.1) vs 2.15 (0.4; 5.1); p = 0.041). In addition, among patients with CHF and a positive SIBOS test, ventricular tachycardia was significantly more common (in 45 % of patients with SIBOS and in 10.71 % of patients without SIBOS; p = 0.01555). The presence of SIBOS increased the risk of VT in patients with CHF (OR = 6.818, 95 % CI: 1.542 - 30.153; P = 0.011)). The development of VT in patients with SIBOS was associated rather with systemic inflammation than with the severity of CHF characterized by high NTproBNP numbers, while in the absence of SIBOS the opposite trend was noted.

Conclusion. The development of VT in patients with SIBOS is associated rather with systemic inflammation rather than with the severity of CHF. SIBOS can be considered as an additional risk factor in the development of systemic inflammation and ventricular tachycardia in patients with CHF. 

Aim.  To study features of localization of the DNA-ase I and endonuclease-G proapoptotic proteases in the pancreas in chronic pancreatitis (CP).

Materials and methods. Histological pancreas preparations from 60 patients with various CP forms were studied: group I — 10 patients with obstructive CP; group II — 21 patients with calcific CP; group III — 13 patients with fibroparenchymal CP; group IV — 16 patients with CP complicated by pseudocyst. Pancreas biopsies were obtained during planned organ operations, as well as using a fine-needle biopsy under ultrasound control. Tissue material was fixed in Bowen medium. Microscopic tissue sections were prepared and subsequently stained with hematoxylin-eosin and by Mallory-Slinchenko. Immunohistochemical typing of proapoptotic proteases was performed according to the indirect avidin-streptavidin-peroxidase reaction (“Elite”, USA) using rabbit antibodies to DNA-I and endonuclease-G (“Chemicon”, USA, 1: 500 dilution — 1: 2000, incubation 12:00, + 4 °С).

Results. Patients in all the groups demonstrated signs of chronic inflammation, with 31.7 % of cases showing signs of its exacerbation. Atrophic changes were found in most patients (96.7 %). No significant differences were observed with regard to the severity and frequency of fibrosis of various degrees in the groups: mild, moderate, severe and full fibrosis was detected in 6.7 %, 20.0 %, 16.7 % and 56.6 %, respectively. The study of the localization of proapoptotic nucleases in the structures of the pancreas showed proapoptotic nucleases of DNA-ase I to be exclusively located in the cytoplasm of pancreatic acinar cells. At all stages of CP fibrosis, single acinar cells with translocation of the nuclease from the cytoplasm into the cell nucleus were found in the lobes of the pancreas. Endonuclease-G was found in large numbers in the cytoplasm of pancreatic islets, with it lower number being detected in the cytoplasm of the epithelial cells of the ducts.

Conclusions. In CP, proapoptotic proteases of DNase I and endonuclease G are expressed in the cytoplasm of cells located in different pancreas zones. Thus, DNase I is expressed in the cytoplasm of acinar cells, while endonuclease G is most typical for insular cells and those in the epithelium of the ducts. This proves the existence of various apoptosis mechanisms in the exo- and endocrine portions of the pancreas. 

The problem of non-invasive monitoring of the liver condition is particularly relevant in liver transplantation among young children. Transforming growth factor beta 1 (TGF-β1) is a pleiotropic cytokine with a profibrogenic and immunosuppressive effect that can have a definite effect on the liver transplant functioning.

Aim. To determine the diagnostic efficacy of TGF-β1 in blood when assessing the risk of developing graft dysfunction in liver recipient children.

Materials and methods. 95 children aged 3 to 73 months with liver cirrhosis of various etiologies were surveyed. All the patients underwent liver transplantation (LT) from a living related donor. The TGF-β1 concentration in plasma was determined using ELISA on average 3 ± 2 days prior to liver transplantation and in the early post-transplant period.

Results. The level of TGF-β1 in the blood of children with liver cirrhosis was lower than in healthy children (p = 0.001). LT was accompanied by an increase in the TGF-β1 content in the blood of recipients (p = 0.001). The incidence of graft dysfunction in the early postoperative period correlated with the pre-transplantation level of TGF-β1 (r = 0.40, p = 0.00), which was lower in recipients with developed graft dysfunction than in patients without dysfunction (1.7 ± 1.3 ng/ml versus 6.7 ± 5.3 ng/ml, p = 0.001). The analysis of the test diagnostic efficiency showed that the area under the ROC curve (AUC) was 0.85 ± 0.05, 95 % CI 0.75–0.94, the sensitivity of the method was 83 %, its specificity was 77 %. When the marker value was less than the threshold (2.2 ng/ml), the relative risk of developing graft dysfunction was 11.4 ± 0.7, 95 % CI 2.7-48.7. The accuracy of the method, the positive predictive value and the negative predictive value of the results were 78, 83 and 77 %, respectively.

Conclusion. The level of TGF-β1 in the blood of liver recipient children before transplantation below 2.2 ng/ml increases the risk of developing graft dysfunction in the early postoperative period 11-fold. Measuring the TGF-β1 level in the blood prior to liver transplantation makes it possible to identify recipients with 85 % chance of developing a graft dysfunction. 

Aim.  To study muscular (brachial and radial arteries) and elastic (aorta) regional arterial stiffness in IBD patients in comparison with those without IBD, as well as to establish the relationship between arterial stiffness and the characteristics of the IBD course (the duration of illness, severity of attack, activity of systemic inflammation).

Materials and methods. The study included 21 IBD patients and 30 patients in the comparison group. The values of regional aortic and muscular arterial stiffness were measured by applanation tonometry. The carotid–femoral pulse wave velocity (cfPWV) and the carotid-radial pulse wave velocity (crPWV) were determined. The laboratory research plan included the analysis of complete blood count, biochemical parameters, fibrinogen and a high sensitivity  C-reactive protein (hsCRP).

Results. crPWV, similar to cfPWV, was not significantly different between the groups. At the same time, the proportion of individuals with an increase in the cfPWV of more than 10 m/s was higher in the group of IBD patients. However, these differences did not reach the level of statistical significance. According to the results of the correlation analysis, the increase in cfPWV was associated with an increase in patient age (r = 0.564; p = 0.01), the duration of IBD history (r = 0.628; p = 0.003), fasting plasma glucose (r = 0.367; p = 0.034) and GFR decrease (r = -0.482; p = 0.031). The crPWV also directly correlated with the IBD duration (r = 0.630; p = 0.003). According to the results of the regression analysis, an increase in the IBD duration by 1 year is associated with an increase in cfPWV by 0.205 m/s, i.e. the increase in the IBD duration by 5 years is associated with an increase in the cfPWV of approximately 1 m/s.

Conclusion. In IBD patients, the duration of the disease directly correlated with an increase in cfPWV and crPWV. The increase in the IBD duration by 1 year was associated with an increase in cfPWV by 0.205 m/s. The muscular and elastic regional arterial stiffness was not statistically significantly different between IBD patients and the comparison group. 

Aim. To assess the prevalence of erosive-ulcerative lesions of the gastric mucosa, as well as the frequency of Helicobacter pylori infection in patients with ulcerative colitis.

Materials and methods. The study included 70 patients with ulcerative colitis. All patients, along with the standard examination using esophagogastroduodenoscopy, were diagnosed with regard to H. pylori infection: all 70 patients received a rapid urease test (RUT), 24 patients (34.3 %) had H. pylori DNA analyzed in feces, and 46 patients (65.7 %) had 13C labeled urea breath test. The study of H. pylori infection with RUT was carried out in 111 patients without inflammatory bowel disease, who formed the control group.

Results. Endoscopic examination of patients with ulcerative colitis revealed inflammatory and erosive changes in the gastric mucosa. In 7.1 % of cases (5 out of 70 people), the erosion of the body stomach was detected, in 40.0 % of patients (28 out of 70) – erosion of the antrum. No effect of previous steroid therapy, as well as the high activity of ulcerative colitis on the frequency of the stomach erosive lesions (respectively, p = 0.433; p = 0.158) was detected. H. pylori infection was found in patients with ulcerative colitis significantly less frequently than in the control group (respectively, in 52.9 % (37 people out of 70) and 71.2 % of cases (79 people out of 111); p = 0.012). No relationship was found between H.pylori infection and the severity of the exacerbation of the underlying disease (p = 0.157).

Conclusion. In patients with ulcerative colitis, erosive changes frequently found in the stomach do not correlate with the activity of the underlying disease. H. pylori infection is less common in patients with ulcerative colitis than in individuals not suffering from inflammatory bowel disease.