Search

The incidence of pancreatic neuroendocrine tumors has significantly increased for the last decades. Patients with multiple pancreatic neuroendocrine tumors require special attention to the diagnosis and treatment algorithms. The aim is to show possible treatment approaches for patients with multiple pancreatic neuroendocrine tumors. Materials and methods. 26 patients with multiple pancreatic neuroendocrine tumors were managed in the abdominal surgery department of Sechenov University for the last 20 years. Results. The rate of multiple tumors was 9% for sporadic tumors and 36.5% among patients with MEN-1. Sensitivity of the imaging techniques was significantly lower than in solitary insulinomas. Most patients underwent parenchymasparing procedures. Total pancreatectomy was performed only in two cases. Conclusion. Accurate imaging and identification of hormone-secreting tumors allows to offer patients parenchyma-sparing surgery and to provide more personalized approach to the treatment of patients with multiple pancreatic neuroendocrine tumors.

The lecture is dedicated to spinal dural arteriovenous fistula – infrequent disorder which not well known among wide range of neurosurgeons. The findings on etiology, clinic and treatment are presented.

In the period from 2000 to 2017, 52 children aged from 2 to 17 years, were operated for non-parasitic spleen cysts. Along with general clinical examination, the preoperative observation included enzyme immunoassay with Echinococcus diagnostics, determination of the serum level of carbohydrate antigen CA19-9, ultrasound, CT scan or MRI, spleen angiography. Evaluation of treatment results, along with clinical examination, was based on echographic monitoring using spleen mass ratio calculation technology and laboratory tests, including the study of serum immunoglobulins A, E, M, G. Depending on the location and pool of vascularization, 4 clinical and morphological variants of spleen cysts were selected - the upper, middle and lower parts of the organ, the region of the spleen's collar. Quantitative estimates of the pathological formation included small (up to 50 ml), medium (50-150 ml), large (150-300 ml) and giant (more than 300 ml) volumes of the cyst cavity. Three main minimally invasive surgical technologies are being introduced:- navigational interventions in which access to the pathological focus and therapeutic effects on the internal structures of the cyst were carried out under the control of an ultrasound image;- combined interventions with access to the pathological focus and therapeutic effect on the internal structures of the cyst under the control of an ultrasound image in combination with endovascular occlusion of the vessels of the spleen parenchyma with X-Ray control;- laparoscopic operations, including access to pathological foci and therapeutic effects on the internal structures of the cyst, provided by the endotelevision visualization. Recovery was achieved in 47 (90.4%) patients as a result of single interventions. Repeated surgeries completed with the recovery were required in 5 (9.6%) clinical observations. Subsequent follow-up with a duration of up to 3 years of disease recurrence did not show relapses. The choice of tactics of surgical treatment of children with NCC was shown to have to be based on the results of multifactorial planning, taking into account the anatomical and topographical features of the localization and growth rate of spleen cysts. The high reparative potential of the spleen in childhood determines the postoperative recovery of the organ’s morphofunctional characteristics, regardless of the volume of the cyst present. The use of quantitative parameters to estimate the mass of the spleen makes it possible to objectify the course of the postoperative period, the effectiveness of the intervention and the adequacy of the reparative regeneration processes.

The prevalence of benign tumors of the salivary glands is increasing. The complexity of the anatomical areas and the proximity of the of the facial nerve’s branches lead to frequent complications in the postoperative period. Nowadays there are several instrumental diagnostic methods for determining salivary gland tumors and among which the use of magnetic resonance imaging with contrast enhancement made it possible to estimate the exact location of neural and vascular structures in relation to the neoformation.

Aim. To reflect the main approaches and trends in neuroendocrine tumors imaging. Materials and Methods. 255 patients with hormonally active pancreatic neuroendocrine tumors were examined and operated for the period 1990–2015. There were insulinomas predominantly. Sensitivity of ultrasonography, CT, endoscopic ultrasound, arterial-stimulated blood sampling, IOUS was analyzed to reveal changes in diagnostic algorithm for this period. Results. Multiple pancreatic lesions occurred in 30%. Over the 25 years endosonography as new “gold” standard for pancreatic visualization was introduced. Indications for arterial-stimulated blood sampling were narrowed. However, this method is still actual and effective in the most difficult diagnostic situations. Conclusion . Accurate preoperative topical diagnosis allows to offer optimal, organ-sparing procedure and reduce intraoperative trauma of the pancreas and number of postoperative complications.

Ulcerative lesions of the upper digestive tract often occur in malignant obstructive jaundice due to multiple changes in the coagulation system. Emergency percutaneous arterial embolization is an effective and safe procedure to treat acute massive duodenal bleeding; it is most commonly performed via the standard transfemoral access, which can lead to complications in this area. The paper describes a clinical case of the double use of a unilateral radial access for emergency embolization of life-threatening duodenal bleeding in complications of malignant obstructive jaundice.

N.N. Burdenko surgery clinic have an experience of treatment of 342 patients with gastroenteropancreatic neuroendocrine tumors. Original algorithms of diagnosis, complex treatment and postoperative management were applied. We achieved 100% five-year survival rate after radical surgery and reduced postoperative complications 1.6 times.

Insulinoma in most cases is monohormonal orthoendocrine tumor. This fact limits its searching area by a pancreas. However the insulinoma's clinical picture can be caused by other pathology. Therefore the main task of visual the tumor but also to use all the possibilities of each method for defining type of surgery and avoiding such errors and complications, as pancreatorrhage, damage of bile or pancreatic duct, necrosis of duodenal wall, etc. On the basis of our own experience of endoscopic ultrasound for 61 patients with 66 insulinomas, we have allocated the basic variants of insulinoma ultrasound pictures: hypoechoic, heteroechoic, isoechoic tumor, and also foci without a trustworthy contour. On the basis of the analysis of our own errors we have essentially added the technique, having used multiplane pancreas scanning and biplane tumor scanning. Important points in EUS algorithm are also the following items: detecting tumor relationship to pancreatic surface, distance from the tumor to the ducts, gastrointestinal wall and vessels--for definition of possibility of the tumor enucleation; careful scanning of pancreas even after detecting one tumor--for an exception of multiple tumors, especially at MEN-I; careful scanning of a contour of the gland for an exception of parapancreatic insulinomas; estimation of vascularization not only of the detected tumor and suspicious foci, but also of all the gland--for detection of hypervascularized isoechoic tumors; revealing and the description of focal changes, especially more homoechogeneous in comparison with surrounding parenchyma-- for selection patients for examination by other methods; scanning of zones of possible metastasis. Examination of patients with organic hyperinsulinism demands combined application of two or more techniques. Use of all modern possibilities of endosonography can put this technique on one of the first places in the diagnosis of insulinomas.

Non-contrast computed tomography (CT) of the major salivary glands was made in 127 patients, which revealed 95 space-occupying lesions (88 intraglandular and 7 extraglandular ones). Pleomorphic tumors of the parotid glands are solitary, round, high-density (29.6 +/- 4.2 HU) masses with well-defined, smooth margins. Salivary cysts were characterized by the presence of a dense capsule; the density of cyst contents was 8.0 +/- 2.0 HU. Salivary lipomas had a characteristic tomographic pattern due to the presence of adipose tissue; the lipoma density was -108.3 +/- 7.8 HU. Malignant parotid tumors were characterized by the presence of higher-density masses with irregular shapes and ill-defined, indistinct margins. Benign submandibular gland tumors had no well-defined margins that separated the tumor from the gland; the density of a tumor matched that of the parenchyma; the mean tumor size was 3.6 +/- 1.3 cm; there was an increase in the sizes of the gland as compared to those of the contralateral gland, as well as a displacement of the adjacent soft tissues. Malignant submandibular gland neoplasms tumors were characterized by the presence of inhomogenous lower-density masses with irregular shapes. Enlarged paraglandular lymph nodes were observed. The sensitivity, specificity, and accuracy of native CT in diagnosing space-occupying lesions of the salivary glands were 97.6, 96.4, and 97.6%, respectively.

The authors analyzed the data of contrast-enhanced multislice spiral computed tomography (MSCT) angiography versus those of volumetric dynamic computed tomography, percutaneous and endoscopic ultrasonography, selective angiography, and arterial stimulation blood sampling in the diagnosis of sporadic insulinomas depending on the size and site of the tumor. Forty-five patients (25 women and 20 men) aged 20 to 55 years (mean age, 43.4 +/- 2.8 years) with characteristic clinical symptoms and Whipple's triad, were examined. These were found to have 45 sporadic insulinomas that were located in the head and isthmus (n = 13 (28.9%)), body (n = 19 (42.2%)), and tail (n = 13 (28.9%)). The insulinomas measured 4.0 to 10.0 mm (mean size, 6.5 +/- 2.1 mm) (n = 9), 11.0 to 20.0 mm (mean size, 13.2 +/- 2.5 mm) (n = 23), and 21.0 to 25.0 mm (mean size, 22.6 +/- 2.8 mm) (n = 13). Volumetric dynamic CT angiography increases detection rates for tumors less than 1.0 cm in size to 77.8%. It enabled insulinomas to be localized in 82.2% of cases.

The clinic obtains the experience of treatment of 245 patients with organic hyperinsulinism. The main goal of the treatment of that category of patients is an improvement of immediate results of surgical treatment which leads to the decrease in mortality level. Authors set the diagnostic and intra- and postoperative treatment algorithm, as well as the major prognostic factors of postoperative morbidity rates. The use of the algorithm allowed the 1,5 decrease in postoperative morbidity and twice decreased the lethality rate.

Experience with 150 endovascular stents and endoprostheses including ones of vertebral and carotid arteries (first experience in Russia) is analyzed. Mini-invasive surgery is indicated for patients with isolated arterial lesions (segmental stenosis, short occlusions), changed and hard for surgery parts of vascular system (renal, visceral arteries, branches of aortic arch), restenosis after traditional surgeries and also for patients with severe concomitant diseases. Rate of complications of carotid endovascular stenting was 4,3%. The follow-up ranged from 2 months to 5,5 years. There were no restenoses in the stented zone. Complete absence of complains and regress of neurological symptoms were seen in 89% patients.

Three patients were observed who had small angioma in the region of the middle nasal passage. Angioma was the cause of recurrent nasal bleeding. In one of the patients the vascular tumor was covered with massive edemous polyps for which the patient was referred for polypotomy. Introduction of computed tomography, endoscopic methods of examination allows detection and assessment of the tumor spread, selective angiography followed by embolization enables operations with minimal blood loss.

Current literature data on the clinical course, diagnosis and treatment of gastrinoma, one of the most frequent neuroendocrine tumors of the thyroid, as well as 23 cases with Zollinger-Ellison syndrome treated by the authors are analysed in detail. Peculiarities of the clinical course, difficulties of syndrome diagnosis, principles of updated topical diagnosis of gastrinoma, conservative and surgical treatments including treatment of multiple endocrine neoplasia syndrome are described.

Among 142 patients with islet cell tumor who were admitted to hospital between 1982 and 1999, 15 patients (10.6%) had malignant tumours. The mean age was 45.3 +/- 5.8 years. Islet cell tumors were located in the head and corpus of the pancreas in 26.6% and 26.6% of the patients, respectively, in the tail of the pancreas in 46.8% of the patients. The mean size of the tumor was 2.9 +/- 0.7 cm, in 6 patients (40%) liver metastases were found. US, CT and angiography which sensitivity were 72.7, 100 and 85.7%, respectively, were used for topical diagnosis of the islet cell tumors. 12 patients were operated on (15 operations) and 3 patients were treated conservatively by streptozocin. Surgical procedures included distal pancreatic resection (n = 11), enucleation of the tumor (n = 2), hepatic resection (n = 1), abdominal exploration (n = 1). In 2 patients palliative pancreatic resections were combined with transarterial embolization and devascularisation of the liver metastases and 2 patients were treated by systemic chemotherapy. To reveal malignancy before and during the operation was possible only by evaluation of distant metastases and the adjacent organs infiltration. In other cases to determine the diagnosis was possible only after planned histological identification of the resected specimens. 5-year survival rates after conservative and surgical treatment were 33% and 62.5%, respectively. In patients without distant metastases 5-year survival rate was 100%.

From 1982 to 1998 144 patients (males 31.7%, females 68.3%) with organic hyperinsulinism underwent surgery. Mean age of the patients was 44.2 +/- 4.6 years. The causes of the development of this disease were benign insulinoma (82.6%), malignant insulinoma (6.9%), beta-cells hyperplasia and microadenomatosis (4.2%). In 6.3% of the patients the origin of the disease was not established. The location of the insulinoma in the pancreatic head was detected in 33.8%, in the body--in 35.2%, in the tail--31%. The sensitivity of the used methods of topical diagnosis was the following: US--40.3%, CT--28.6%, angiography (selective celiacography and upper mesentericography)--76.9%, blood samples from the right hepatic vein after intraarterial stimulation of different parts of the pancreas by Ca with measurement of immunoreactive insulin level--87.2%, intraoperative palpation--86.5%, intraoperative US examination--100%. Preoperatively, the authors used combined angiographic examination, the sensitivity of which made up 94.9%, this study being a single one which allows to reveal the region of the lesion of the pancreas in beta-cells hyperplasy. Tumor enucleation (59 patients), distal resection of the pancreas (50), the excision of the insulinoma (25), duodenopancreatic resection (1), explorative laparotomy (9) were made. Postoperative complications rate arose in 43.6% of the patients, mortality rate--7.7%. The best results were achieved in enucleation of insulinoma and distal resection of the pancreas. The authors suggest that in preoperative diagnosis of insulinomas the preferable methods should be US-examination and combined angiographic examination. Intraoperative revision should be made with use of US examination. Depending on the intraoperative findings the preference should be given either to enucleation of insulinoma or to distal resection of the pancreas.

Method of complex angiographic examination and treatment from translumbar approach (CTLA) in patients with diffuse occlusive lesions of arterial bed was developed. 529 patients (516 males and 13 females) aged from 20 to 80 years (53.1 +/- 1.6 years) were examined and operated with the use of translumbar approach: they underwent various angiographic examinations of peripheral, visceral and coronary arteries as well as interventions on arteries. The quality of contrasting of arterial bed in CTLA was higher in comparison with results of punction translumbar aortography and intravenous digital angiography, complications rate being minimal. Application of CTLA in practice made it possible to perform practically all kinds of angiography and many invasive procedures in patients with occlusions of peripheral arteries and after reconstructive operations on vessels.

To evaluate the efficiency of computed tomography (CT) in the diagnosis of salivary neoplasms, 68 patients (50 with benign tumors of the salivary glands, 10 with theirs malignant tumors, 8 with salivary cysts) were examined. The authors revealed the high informative value of CT in the diagnosis of salivary bulky lesions. CT defined the site of a tumor, the benign or malignant pattern of its growth, the extent of tumorous invasion. The diagnostic value of CT in the diagnosis of salivary glands was as follows: its sensitivity, specificity, and accuracy were 97.0, 81.8, and 94.9%, respectively.

Computer-aided tomography (CAT) was carried out in 68 patients with tumors of the salivary glands and 45 with sialolithiasis. CAT detected the tumors and located them, showed the type of the tumor (benign or malignant) and the tumor invasion. Sensitivity of CAT in tumors of the salivary glands was 97%, specificity 81.8%, accuracy 94.9%. In sialolithiasis CAT not only detected the concrements, but helped assess the status of the gland and the adjacent structures; its sensitively, specificity and accuracy were 95.5, 100 and 98.0%, respectively.

Choice of a proper method of treatment of complicated acute pancreatitis remains indefinite. The results of treatment of 130 patients with acute destructive pancreatitis complicated with pancreatic pseudocysts have been analysed. The authors formulate individual indications to minor surgery under the ultrasound control. The classical type of surgery was used only in patients with calculous pancreatitis complicated with pseudocysts (14). In other patients various types of transcutaneous ultrasound controlled procedures were used. Pilot experience of placing cystoduodenoanastomosis under ultrasound endoscopic control is described. Letal outcomes were absent. The rate of recurrence in external drainage was 10, 5%; there were no cases of recurrence in internal drainage of pseudocysts. The period of long-term follow-up was 58 months.

Transcutaneous procedures have been performed under ultrasound control in 404 patients with mechanical jaundice, caused by tumor of the pancreas, primary liver tumor or its metastatic lesion. Cholecystostomy was performed in 40 patients, in other cases external or external-internal draining of bile with subsequent implantation of endoprosthesis for the life-long biliary duct decompression (108 endoprostheses in 98 patients) has been done. Complication have been observed in 3 (0.7%) patients. The mortality rate was 2.1%. The authors recommend this method for wide use in patients with mechanical jaundice and consider it to be a method of choice in inoperable cancer of hepato-pancreatico-duodenal zone.

Twenty-seven patients with sialolithiasis were examined using functional subtraction sialography developed by the authors. Differential diagnostic signs characterizing the degree of involvement of the salivary gland were defined. High efficacy of the method helps correctly plan the treatment strategy.

The authors have revealed dilatation of the excretory ducts of salivary glands involved in sialolithiasis and of other salivary glands in a patient. A hypothesis on the primary etiological role of ductal ectasia in the development of sialolithiasis in case some other additional factors are present is put forward. The authors recommend resorting to computer-aided tomography and functional digital subtraction sialography of the salivary glands for the diagnosis of sialolithiasis and discuss the advantages of these methods in comparison with other ones.

The authors present the results of a clinical trial of Hexabrix, a new radiopaque low osmolar agent, to be used in visceral catheterization translumbar angiography. Hexabrix was shown to reduce the frequency of side-effects by 40% as compared to triiodinated agents. The new agent causes no marked reactions in intraarterial administration even at a dose over 2 ml/kg. Hexabrix is an agent of choice to be used for patients at risk of angiographic investigation (allergy, advanced age, a severe general condition).

Functional digital subtraction sialography with a water soluble radiopaque agent (verografin) made it possible to investigate the structure and functional changes in the salivary glands of 26 patients with a minimum injury of the glands. The method permitted a decrease in a dose of the agent 4 times as compared to routine sialography; the consumption of x-ray film was decreased 5-fold. Digital processing of images helped avoid superimposing of the cranial bone components, improving the quality of images of the salivary glands. The method is indispensable during differential diagnosis, especially at early stages of diseases of the salivary glands.

The paper is concerned with some data on the quality of hemostasis after various types of angiography in 629 patients: manual hemostasis in transfemoral catheterization was used in 130 patients, mechanical fixing rubber pellets were used in 108 patients. Postmanipulation tamponade in the area of catheterization was used in 163 of 321 patients after catheterization translumbar angiography. In mechanical hemostasis, hematomas were found in 1.8%, in manual hemostasis--in 4.6%; CT and USI findings showed no hematomas after catheterizations translumbar angiography, in PTLA hematomas over 200 ml were found in 3.7%.

Based on an analysis of the angiograms of 304 patients broken down into groups by the nosological principle, a system of x-ray parameters exactly describing the normal spleen was developed. The 3 main forms of the spleen, differing significantly (P less than 0.001) in some mathematically substantiated criteria, were singled out. In analysing the angiograms of 222 patients with portal hypertension of various degree it was shown that the presence of portal hypertension including its subclinical forms can be established on the basis of a changed complex of proposed criteria. Simplified ways to calculate the area of the spleen shadow and the voluminous splenic blood flow were worked out. The data obtained can be used for a visual analysis of the angiograms as well as for computerized diagnosis of hepatic and pancreatic diseases.

Currently, our experience includes more than 40 percutaneous transhepatic cholangiographies using ultrathin Hiba needles and stiletto catheters, during which various X-ray endobiliary interventions were performed. Their standard program through the needle included cholangiography, washing of biliary tracts with physiological solution, extraction of contrast substance and bile after the study, intraductal antibiotic therapy, administration of antispasmodics.