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In 2023, it was 130 years since the opening of the Alexander Surgical Hospital at the Tauride Provincial Zemstvo Hospital, where many talented doctors worked. This authors present new facts about outstanding surgeon who worked in Simferopol at the turn of the 19th and 20th centuries, Alexander Fedorovich Kablukov (1857-1915). He was a founder of surgical school in the Tauride province, who first described cholecystectomy In Russian-language literature. The report covers in detail famous surgery restored thanks to pre-revolutionary sources. Excerpts from other little-known reports of surgeon related to the treatment of gallbladder and biliary diseases are also presented.

The authors present common bile duct reconstruction using the Kehr drainage.

The review is devoted to the current classifications of common bile duct malformations, authors' opinion regarding surgical approach and reconstruction of the bile ducts. The authors describe the modern modifications of bile duct reconstructions and estimate their effectiveness. PubMed database, Google Scholar and National Scientific Electronic Library eLIBRARY.ru databases were used. We analyzed the complications in children depending on various reconstructions, anatomical form, timing of reconstructive surgery and early diagnosis of this pathology.

The authors describe modern 3D technologies in hepatobiliary surgery. These approaches reduce the risk of intra- and postoperative complications. Virtual 3D reconstruction with clear visualization of parasitic cyst, adjacent vessels and bile ducts is valuable to create 3D-model of liver. This model may be applied for personalized laparoscopic approach and precise surgical intervention.

Aim: to estimate the effect of decompressive stented drainage of biliary anastomosis on incidence of biliary complications., Material and Methods: 294 patients aged from 5 months to 61 years (mean 13.8±0.81) were enrolled. They underwent liver fragments transplantation in the Department of Liver Transplantation of Petrovsky Russian Research Center of Surgery for the period from March 1997 to January 2016. Decompressive stented drainage tubes were used in 28 (9.5%) patients. Reconstruction without drainage was applied in 266 (90.5%) cases. In the group of biliobiliary reconstruction drainage was used in 18 out of 89 cases (20.2%), in the group of biliodigestive reconstruction - in 10 out of 202 cases (4.9%). Incidence of specific biliary complications was assessed., Results: There was significant direct correlation of stented drainage of biliodigestive anastomosis with various biliary complications including bile leakage (r= -0,1253; p=0.06), obturation of anastomosis (r=0.045; p=0.501), stricture of anastomosis (r= -0.0665; p=0.320), other strictures of intrahepatic bile ducts (r= -0.0291; p=0.664), hepatolithiasis (r=0.0857; p=0.199). However significant direct correation was observed between stented drainage and incidence of intrahepatic bile ducts strictures (r=0.2117; p=0.046) and anastomosis obturation (r=0.2330; p=0.028) in case of biliobiliary reconstruction. Significant correation with other biliary complications was absent (p>0.05)., Conclusion: Unconstrained stented drainage during primary biliary reconstruction is associated with increased incidence of biliary complications and should not be indicated routinely. Clear need for drainage should be determined in further investigations.

Aim: To define the role of endoscopic interventions in diagnosis and treatment of Mirizzi syndrome., Material and Methods: Results of treatment of 41 patients with Mirizzi syndrome are presented. Endoscopic transpapillary interventions including cholangiography, papillosphincterotomy lithoextraction, nazobiliary drainage were used as a first step in all cases., Results and Discussion: In 4 cases laparoscopic cholecystectomy was performed after biliary tree sanitation. In 6 advanced age patients with severe comorbidities common bile duct stenting alone was preferred. Open interventions were performed in 15 patients (36.6%) including cholecystectomy, choledocholithotomy with common bile duct drainage., Conclusion: It is shown that endoscopic transpapillary methods of diagnosis and treatment of Mirizzi syndrome provides adequate decompression and sanitation of the bile ducts in most cases and significantly reduces number of open surgical procedures.

Aim: To analyze efficacy of interventional methods via antegrade transhepatic approach in treatment of patients with strictures of biliodigestive anastomoses., Material and Methods: 24 patients aged 47.2 years were treated for the period 2002-2015. Average time from extrahepatic biliary reconstruction using transhepatic stented tubes to strictures appearance varied from 9 months to 12 years. One- and double-sided percutaneous transhepatic cholangiostomy was performed to abort biliary hypertension. Stricture recanalization was achieved using «catheter-wire» system. Antegrade dilatation of stricture was made using balloon catheter 8 mm and pressure up to 6 atm and stage exposition up to 10 minutes. Balloon repair of anastomosis was supplemented by stented outer-inner drainage of the area of stricture., Results: Restoration of patency of stricture area using antegrade interventional methods was effective in 22 patients. Recurrent stricture occurred in 2 cases within 1.5 years that required repeated biliary reconstruction including antegrade extraction of blocked uncovered stent in 1 patient. There were no major postoperative complications and deaths. Maximal recurrence-free follow-up after stent installation was 11 years.

Aim: To analyze the results of repeated reconstructions of choleresis after living related liver fragments transplantation., Material and Methods: The study included 268 recipients (145 women and 123 men) aged 5 months - 61 years (mean age 16,11 ± 14,62 years) who underwent liver fragments transplantation in the department of liver transplantation of cad. B.V. Petrovskiy Russian Research Surgery Center from 1997 to 2012. Biliary reconstructions were performed at different terms after transplantation in 37 patients (13.81%). Complications followed repeated reconstructions, the initial conditions for biliary anastomosis formation during transplantation, the results of biliary reconstructions after transplantation were analyzed., Results: In most cases despite the prevailing complications there is a combination of various biliary complications requiring biliary reconstruction. It was found that live rfragment used for transplantation, type of primary reconstruction of choler sis, number of bile ducts orifices of graft and biliary anastomoses do not demonstrate statistically significant effect on the incidence of post-transplant biliary reconstructions (p>0.05). Poor prognosis in patients with biliary complications required biliary reconstructionsis determined by the development of graft dysfunction. Early reconstruction before development of liver transplant dysfunction is necessary condition of successful treatment. In the case of graft dysfunction liver retransplantation is unique method of treatment.

Aim: To develop technique incorporating favorable aspects of gastroenterostomy in common hepatic duct anastomosis, providing bile drainage into duodenum and preventing duodenobiliary reflux., Material and Methods: It is presented developed operations for high strictures of extrahepatic bile ducts using enteric autotransplant of variable diameter., Results: Good remote postoperative results were observed in 10 survived patients. There were no recurrence of stricture, cholangitis and normal biochemical parameters were observed. It has been proved that suggested methods may be alternative to Roux-en-Y hepaticojejunostomy.

The study, which included data of 226 patients with the obstructive jaundice, proved, that the clinical presentation and laboratory tests have secondary role in diagnosing the level of the biliary block. Among diagnostic means of detecting the etiology of the obstruction were the ultrasound investigation (n=268); the magnetic resonance cholangiopanreatography (n=143); the multispiral computed tomograpth (n=119); the endoscopic retrograde cholangiopanreatography (n=187) and the transcutaneous transhepatic cholangiopanreatography (n=69). Flaws and pros of all the methods were thoroughly analyzed. The endoscopic (n=172) and transcutaneous transhepatic cholangiostomy (n=87) were used for biliary decompression. The comparative analysis of both diagnostic and treatment means allowed the creation of 3-stage algorithm. The efficacy of the last for patients with the obstructive jaundice was 96%.

Treatment results of 763 patients with acute cholecystitis were analyzed. Destructive forms of the disease was diagnosed by the ultrasound examination in all cases. Choledocholithiasis was diagnosed in 35 (4.6%), choledocholithiasis with papilla Vatery stricture was in 9 (1.2%) patients and isolated papilla Vatery stricture was registered in 5 (0.7%) patients. All patients were attempted to treat laparoscopically with the use of original "Device for antegrade papillotomy" and "Method of antegrade bipolar papillosphincterotomy". Authors state, that a final decision about the possibility of endoscopic treatment of the acute cholecystitis can be made after detection of anatomical structures of the Calo triangle. By complicated forms of the disease a one-stage laparoscopic treatment should be preferred. Endoscopic papillosphincterotomy should be performed only by the enblocked concrement of the papilla Vatery.

To describe the prognostic factors after surgical reconstruction data. were collected prospectively on 60 patients treated at the Scientific Center of Surgery named after M.Topchubashov and N5 City Hospital with major bile duct injuries and postoperative bile duct strictures between 2000 and 2009. Of the 60 patients 21 had bile duct injuries, other 39 had postoperative strictures. In 15 of 53 patients with iatrogenic injury of bile ducts trauma was recognized and repaired intraoperatively. In 22 patients was early, in 16 patients delayed recognition of bile duct injury. Most of patients had undergone a choledocho (8) or hepaticojejunostomy (33) by Roux. External drainage of bile ducts was performed in 24 patients. Of the 60 patients undergoing surgical reconstruction, 47 hud completed treatment. Of patients who had completed treatment, 82,9% were considered to have a successful outcome (24 patients excellent, 15 patients - good results) without the need for follow-up invasive, diagnostic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture-without external drainage had a better overall outcome (92,9% successful outcome) than patients with drainage of bile ducts (68,4% successful outcome). Number of stents and length of postoperative stenting also were significant predictors of outcome. Type of operation (laparoscopic or open cholecystectomy) had nd significant influence on outcome. At the same time a successful outcome, without the need for biliary stents, was obtained in 87,5% of patients after laparoscopic cholecystectomy versus 71,8% after open cholecystectomy.

Analysis of surgical treatment of 336 patients with cicatricial strictures and iatrogenic external fistulas of extrahepatic bile ducts is presented. The causes of these complications were intrasurgical injuries during cholecystectomy (n=302), resection of the stomach (n=21) and echinococcectomy (n=13). In all the cases correction of water-electrolytic balance, treatment and prophylaxis of hepatic and renal insufficiency, control of anaerobic infection were carried out before and after surgery. Restorative operations were performed in 31 (9.2%) patients, reconstructive surgeries -- in 305 (90.7%). Recurrence of the stricture required surgical intervention in 38 (11,3%) patients. Various postoperative complications were diagnosed in 119 (35.4%) patients, 26 (7.7%) patients died. The main causes of death were insufficiency of anastomotic sutures, intoxication, hepatic and renal insufficiency due to purulent cholangitis and cholangiolytic abscesses of the liver.

Results of diagnostic and therapeutic transhepatic procedures in 185 patients with portal hypertension and 292 patients with obstructive jaundice are analyzed. Optimal angles for introduction of instruments, optimal intercost and the most convenient for manipulation biliovascular structures of the liver were determined. These principles permitted to reduce the failure rate in endovasculary procedures from 10.5 to 3.8%, in endobiliary--from 13.2 to 0.97%.

Results of treatment of 233 old and elderly patients with acute cholecystitis were analysed. In 206 from them percutaneous transhepatic drainage of the gallbladder (PTDGB) was carried out under US control with creation of temporary microcholecystostoma for elimination of acute attack of cholecystitis by decompression of the biliary system, in 2 patients laparoscopic cholecystostomy was performed, and in 27 patients with choledocholithiasis and jaundice early endoscopic papillosphincterotomy was carried out. Elimination of acute attack of cholecystitis in early terms contributed much to improvement of the patients condition, to carrying out further examination and correction of concomitant diseases. After adequate premedication 189 patients were operated on early after admission (on day 2-4). The operation of choice was cholecystectomy, in 49 patients being combined with various interventions on the choledochus. Postoperative mortality rate made up 4.2%. 44 patients were not operated because of elimination of the attack by PTDGB (17) and endoscopic papillosphincterotomy (27).

The results of treatment of 138 patients with acute cholecystitis aged from 75 to 89 years are analyzed. Calculous cholecystitis was revealed in 126 patients, acalculous cholecystitis--in 12 patients. Cholelythiasis was revealed in 63 (45.6%), stricture of the large duodenal papilla (LDP)--in 13 (9.4%), combination of choledocholithiasis and stricture of LDP--in 16 (11.6%). Mechanical jaundice was revealed in 54 (39.1%) patients, purulent cholangitis--in 18 (13%). From 138 patients 113 (81.8%) underwent surgery. Urgent operations were carried out in 35 (30.9%), early operations--in 54 (47.8%), delayed operation--in 24 (21.2%) patients. Cholecystectomy was performed in 99 patients, it was supplemented with choledocholithotomy and various types of external drainage of the duct (n = 28), choledochoduodenostomy (in 40), transduodenal papillosphincterotomy (n = 6) and endoscopic papillosphincterotomy (n = 7). Cholecystostomy was carried out in 14 patients (including laparoscopic cholecystostomy, n = 5). Repeated operations were performed in 29 patients. Postoperative complications appeared in 28 (24.7%) patients. 16 patients (14.1%) died after the operation. The causes of death were hepatic functional deficiency (6), peritonitis (2), pancreatic necrosis (1), acute cardio-vascular failure (4), pulmonary artery thrombo-embolism (2), acute cerebro-vascular failure (1).

Specific morphological and functional changes in the liver in acute obturative cholecystitis have been experimentally studied in 30 dogs and clinically examined in 21 patients. No morphological substrate of liver insufficiency were found in early period of acute obturative cholecystitis. Early changes in the liver are of reactive nature and have the features of active nonspecific hepatitis. The reactions of compensation and decompensation are changing each other periodically. The intensive reactions of compensation take place in the first 2 or 3 days of disease. The reactions of compensation weaken gradually. There is no correlation between changes in the liver and in blood serum. The early surgery and laparoscopic procedures in acute obturative cholecystitis are advocated.

Bile-diverting operations in 386 patients with obstructive jaundice are analysed. It was caused by benign diseases in 202 patients (group 1) and by malignant tumors of the biliary tract and pancreas in 184 patients (group 2). Laparoscopic cholecystostomy was carried out in the first stage of treatment in each third patient. In patients of group 1 choledocholithotomy was the main operation performed for restoration of the flow of bile, it was combined with external drainage of the biliary tract in 54 patients, supplemented by transduodenal papillosphincterotomy in 30 patients, choledochoduodenostomy was carried out in 30 patients. The flow of bile was restored in group 2 patients by forming biliodigestive anastomoses. The most frequent among them were cholecystojejunostomy (38) and choledochoduodenostomy (31). Laparoscopic cholecystostomy was the most expedient operation in 61 patients with a spreading neoplastic process.

In the period from 1980 to 1990 operations were carried out on 412 patients with echinococcosis of the liver. Complicated forms were encountered in 108 patients. Rupture of the hydatid cyst into the biliary tract occurred in 72 patients. Among the patients with this complication 14 had changes of the bile ducts with the development of obstructive jaundice, 14 had a history of short-term jaundice, in 35 patients the cystobiliary fistula was discovered only during the operation. Percutaneous transhepatic and retrograde cholangiography proved to be the most informative diagnostic methods in rupture of the hydatid cyst into the biliary tract with the development of obstructive jaundice. Echinococcectomy with one-stage operative intervention on the biliary tract was conducted in 14 patients. Along with echinococcectomy, 7 underwent cholecystectomy and drainage of the common bile duct, 2 were subjected to choledochoduodenostomy, 1 to papillosphincterotomy, in 4 patients echinococcectomy was preceded by percutaneous transhepatic cholangiostomy.

The article deals with the author's views on certain aspects of the problem of reconstructive and restorative surgery of the biliary tract. Original methods are suggested for external drainage (through the inferior surface of the right hepatic lobe in the region of the gallbladder seat and through the round ligament of the liver) in formation of ++hepato-hepatico- and hepaticojejunoanastomoses. Problems of operative techniques in formation of the anastomoses are discussed. Thirty-nine operations have been carried out in the clinic in the recent decade in high strictures and traumas of the biliary tract, 25 were reconstructive and 14 restorative. Postoperative mortality was 28.2% (11 patients). Intoxication and hepatargia associated with cholangiolytic abscesses of the liver were the main causes of death.

Fifty children from one month to 14 years of age were examined and subjected to surgical treatment. Atresia of the bile ducts was diagnosed in 34 of them, hypoplasia of the bile ducts in 5, and a cyst of the choledochus in 11. Biliary atresia was managed by different variants of portoenterostomy, mostly after Kasai I, and two operations of cholecystojejunostomy were conducted in the so-called correctable type of atresia. 5 patients with biliary hypoplasia were treated by cholecystectomy, lavage of the bile ducts, and denervation of the hepatic artery. The following operations were carried out on 11 patients with a cyst of the choledochus: extirpation of the cyst with subsequent hepaticojejunostomy in 4, cystojejunostomy in 5, and cystoduodenostomy in 2 patients. Ultrasonic examination of the liver was undertaken in all 50 patients with impaired patency of the biliary tract as a screening test. Nine patients died in the postoperative period.

Seventy children with obstructive cholangopathy were examined in the clinic in the recent 15 years: 48 children had "cholangiopathy of the newborn" and 22 had a cyst of the common bile duct. A total of 44 operations were carried out: on 22 infants with cholangiopathy of the newborn and on 22 with cysts of the common bile duct. The most informative methods for the diagnosis of cholangiopathy in children are as follows: ultrasonic scanning, laparoscopy, ERCPG, aspiration biopsy of the liver, and aspiration cholangiography under control of a laparoscope. Kasai's operation is the operation of choice in obstructive cholangiopathy of the newborn. The operation of choice in cysts of the common bile duct is cystectomy with choledocho- or hepaticojejunostomy on an isolated loop after Roux.