Mikhail Vyborniy

Background: Spleen-preserving (SP) distal pancreatectomy (DP) with splenic vessels resection (SVR) (Warsaw procedure, WP) is an option for the treatment of tumors with low malignant potential. The reverse blood flow through the short gastric arteries (SGA) explains the preservation of the spleen after SVR, but leaves the source of the blood supply to the SGAs hidden. The types of blood supply to the spleen after WP and their incidence have not been previously described, nor has the significance of these types for locally advanced pancreatic head cancer (LAPHC) surgery been determined. Aim: To determine the main types of spleen blood supply after WP, and to assess the feasibility and safety of splenic artery (SA) rotation for the organ-preserving surgery of LAPHC. Methods: Retrospective analyses of demographic and perioperative data, including CT scans, overall (OS) and progression-free (PFS) survival after 71 SP DP SVR and 41 SP SVR pancreaticoduodenectomies (PD) and total pancreatectomies (TP) for LAPHC (2007–2025). Results: In 134 SP procedures, SA was resected in 115 cases (71DP, 9 TP, 3 central, and 32 PD). Indications for surgery were MCN (41), IPMN (14), CSA (3), NEN (25), SPPN (8), PHDAC (40), sarcoma (1), autoimmune (1), and calculous chronic pancreatitis (1). There were no deaths or ischemia-related splenectomies. Morbidity—31% (n23); Dindo–Clavien (D-C) > 3b-2.8%; POPF-grade B-n7 (10.6%); splenic infarctions on CT after SVR-n18 (23%), one symptomatic. CT revealed three types of arterial blood supply to the spleen after SPDP SVR: left gastric artery (LGA) type (n50, 70, 5%), gastro-epyploic arcade (GEA) type (n9, 12, 5%), and an intermediate type (n12, 17%). Spleen- and pancreas tail-preserving SVR pancreatectomies for LAPHC (n41) were accompanied by rotation of the SA to substitute resected SMA (n19) and CHA (n15) for 26 Whipples and 8TPs. There were no ischemic complications. D-C > 3–19.5%. Median OS and PFS for PDAC were 35 and 21 months for 29.5 months median follow-up. Conclusions: Despite the preservation of blood flow through all potential sources of splenic blood supply following resection of the splenic artery, the main collaterals supplying the spleen after WP are LGA branches (~90%). This knowledge, with strict adherence to the developed criteria, allows for the safe preservation of the spleen, pancreatic tail, and stomach during pancreatectomies with SA resection, including its rotation for the substitution of the SMA and CHA in LAPHC.

Background. Spleen-preserving (SP) distal pancreatectomy (DP) with splenic vessels resection (SVR) (Warsaw procedure, WP) is an option for treatment of tumors with low-malignant potential. The reverse blood flow through the short gastric arteries (SGA) explains the preservation of the spleen after SVR, but leaves the source of blood supply to the SGAs hidden. The types of blood supply to the spleen after WP and their incidence have not been previously described, nor has the significance of these types for locally advanced pancreatic head cancers (LAPHC) surgery. Aim. To determine the main types of the spleen blood supply after WP, and to assess feasibility and safety of splenic artery (SA) rotation for the organ-preserving surgery of LAPHC. Methods. Retrospective analysis of demographic and perioperative data, including CT scans analysis, overall (OS) and progression-free (PFS) survival after 71 SP DP SVR and 41 SP SVR pancreaticoduodenectomies (PD) and total pancreatectomies (TP) for LAPHC (2007-2025). Results: In 134 SP procedures, SA was resected in 115 cases (71DP, 9 TP, 3 central, 32 PD). Indications for surgery were MCN (41), IPMN (14), CSA(3), NEN(25), SPPN(8), PHDAC(40), sarcoma(1), autoimmune(1), and calculous chronic pancreatitis(1). There were no deaths and ischemia-related splenectomies. Morbidity-31%(n23), Dindo-Clavien (D-C)> 3b-2,8%, POPF grade B-n7(10.6%), splenic infarctions on CT after SVR-n18(23%), with one symptomatic. CT revealed three types of arterial blood supply to the spleen after SPDPSVR: left gastric artery(LGA) type (n50,70,5%), gastro-epyploic arcade (GEA) type(n9,12,5%), and an intermediate type(n12,17%). Spleen- and pancreas tail-preserving SVR pancreatectomies for LAPHC (n41) were accompanied by rotation of the SA to substitute resected SMA(n19) and CHA(n15) for 26 Whipples and 8TPs. There were no ischemic complications. D-C >3-19.5%. Median OS and PFS for PDAC was 35 and 21 months for 29.5 months median follow-up. Conclusion. The main collaterals supplying the spleen after WP are LGA branches (~ 90%). This knowledge with strict adherence to the developed criteria safely preserves the spleen, pancreatic tail and stomach during pancreatectomies with SA resection, including its rotation for substitution of the SMA and CHA in LAPHC.

Cell-free DNA (cfDNA) analysis-based liquid biopsy is a rapidly emerging diagnostic and prognostic tool in pancreatic ductal adenocarcinoma (PDAC). KRAS point mutations are the main biomarkers used for the detection of tumor cfDNA. However, there is another less studied yet frequent genetic alteration in this gene, namely copy number gain (CNG). The aim of this study was to evaluate the diagnostic and prognostic potential of KRAS CNG analysis in plasma and bile of patients with PDAC using ddPCR. This study included healthy volunteers (n = 69), patients with PDAC (n = 94), and other pancreatic neoplasms (OPN) (n = 17). The sensitivity and specificity of KRAS CNG compared to the control group were 16% and 100% (AUC-ROC—0.580), and compared to the OPN group, 16% and 94% (AUC-ROC—0.554), respectively. Addition of KRAS point mutations to the analysis increased the sensitivity to 65% (AUC-ROC—0.824 and 0.801, respectively). Bile exhibited an equal KRAS CNG detection rate compared to plasma (20% vs. 16%). KRAS CNG was not associated with clinical parameters, except prognosis. The probability of survival was worse in patients with KRAS CNG (HR—3.54; 95% CI: 1.55–8.12; p = 0.001). KRAS CNG in cfDNA might be a promising biomarker for both diagnostic and prognostic purposes in PDAC.

The “vein definition” for locally advanced pancreatic ductal adenocarcinoma (LA PDAC) assumes portal-to-superior mesenteric vein (PV/SMV) unreconstructability due to tumor involvement or occlusion. Radical pancreatectomies with SMV resection without PV/SMV reconstruction are scarcely discussed in the literature. Retrospective analysis of 19 radical pancreatectomies for “low” LA PDAC with SMV and all its tributaries resection without PV/SMV reconstruction has shown zero mortality; overall morbidity—56%; Dindo–Clavien—3–10.5%; R0—rate—82%; mean operative procedure time—355 ± 154 min; mean blood loss—330 ± 170 mL; delayed gastric emptying—25%; and clinically relevant postoperative pancreatic fistula—8%. In three cases, surgery was associated with superior mesenteric (n2) and common hepatic artery (n1) resection. Surgery was completed without vein reconstruction (n13) and with inferior mesenteric-to-splenic anastomosis (n6). There were no cases of liver, gastric, or intestinal ischemia. A specific complication of the SMV resection without reconstruction was 2–3 days-long intestinal edema (48%). Median overall survival was 25 months, and median progression-free survival was 18 months. All the relapses, except two, were distant. The possibility of successful SMV resection without PV/SMV reconstruction can be predicted before surgery by CT-based reconstructions. The mandatory anatomical conditions for the procedure were as follows: (1) preserved SMV-SV confluence; (2) occluded SMV for any reason (tumor or thrombus); (3) well-developed inferior mesenteric vein collaterals with dilated intestinal veins; (4) no right-sided vein collaterals; and (5) no varices in the upper abdomen. Conclusion: “Low” LA PDACs involving SMV with all its tributaries can be radically and safely resected in highly and specifically selected cases without PV/SMV reconstruction with an acceptable survival rate.

Introduction. “Vein definition” for locally advanced pancreatic ductal adenocarcinoma (LA PDAC) assumes portal-to-superior mesenteric vein (PV/SMV) unreconstructability due to tumor involvement or occlusion. Radical pancreatectomies with SMV resection without PV/SMV reconstruction are scarcely discussed in the literature. Retrospective analysis of 19 radical pancreatectomies for “low” LA PDAC with SMV and all its tributaries resection without PV/SMV reconstruction has shown zero mortality, overall morbidity – 56%, Dindo-Clavien – 3-10,5%, R0- rate – 82%, mean operative procedure time – 355±154 min, mean blood loss – 330±170 ml, delayed gastric emptying– 25%, clinically relevant postoperative pancreatic fistula – 8%. In three cases surgery was associated with superior mesenteric (n2) and common hepatic artery (n1) resection. Surgery was completed without vein reconstruction (n13) and with inferior mesenteric-to-splenic anastomosis (n6). There were no cases of liver, gastric, or intestinal ischemia. A specific complication of the SMV resection without reconstruction was 2-3 days-long intestinal edema (48%). Median overall survival – 25 months, median progression-free survival – 18 months. All the relapses, except two, were distant. The possibility of successful SMV resection without PV/SMV reconstruction can be predicted before surgery by CT-based reconstructions. The mandatory anatomical conditions for the procedure were: 1) preserved SMV-SV confluence; 2) occluded SMV for any reason (tumor or thrombus); 3) well-developed inferior mesenteric vein collaterals with dilated intestinal veins; 4) no right-sided vein collaterals, and 5) no varices in the upper abdomen. Conclusion: “Low” LA PDACs involving SMV with all its tributaries can be radically and safely resected in highly and specifically selected cases without PV/SMV reconstruction with an acceptable survival rate.

The article presents a rare clinical case both in the practice of a gynecologist and a surgeon. The cyst of the Nuck canal can be a cyst of a round ligament, localized in the inguinal canal. It is manifested by protrusion of the formation in the direction to the labia majora, clinically imitating an inguinal hernia.

The key challenge of cell-free tumor DNA (cftDNA) analysis in pancreatic ductal adenocarcinoma (PDAC) is overcoming its low detection rate, which is mainly explained by the overall scarcity of this biomarker in plasma. Obstructive jaundice is a frequent event in PDAC, which enables bile collection as a part of routine treatment. The aim of this study was to evaluate the performance of KRAS-mutated cftDNA detection-based liquid biopsy of plasma and bile in patients with pancreatic neoplasms using digital droplet PCR. The study included healthy volunteers (n = 38), patients with PDAC (n = 95, of which 20 had obstructive jaundice) and other pancreatic neoplasms (OPN) (n = 18). The sensitivity and specificity compared to the control group were 61% and 100% (AUC-ROC—0.805), and compared to the OPN group, they were 61% and 94% (AUC-ROC—0.794), respectively. Bile exhibited higher cftDNA levels than plasma (248.6 [6.743; 1068] vs. 3.26 [0; 19.225] copies/mL) and a two-fold higher detection rate (p < 0.01). Plasma cftDNA levels were associated with distant metastases, tumor size, and CA 19-9 (p < 0.05). The probability of survival was worse in patients with higher levels of cftDNA in plasma (hazard ratio—2.4; 95% CI: 1.3–4.6; p = 0.005) but not in bile (p > 0.05). Bile is a promising alternative to plasma in patients with obstructive jaundice, at least for the diagnostic purposes of liquid biopsy.

Introduction. Spigelian hernia (SH) or hernia of the Linea semilunaris is an extremely rare disease in the pediatric practice. Though it is a congenital malformation, it is revealed and treated surgically mostly at the age of over 50.Clinical observation. A 6-month-old girl was surgically treated for SH at the Ilyinskaya Hospital. The child had been followed up since her birth for terminal hydronephrosis, complicated by the rupture of renal pelvis. At the age of 4 months, because of absent functions and recurrent infection in the urinary system, the child survived nephroureterectomy. On day 4 after surgery, the patient demonstrated signs of anxiety and pain. Ultrasound examination revealed a strangulated right-sided SH. The hernia was invaginated under ultrasound control. There were no SH relapses during the dynamic follow-up. At the age of 6 months, SH laparoscopic plasty with local tissues was made. There were no complications. There were no any signs of SH relapse for the following 3 months.Conclusions. The search in the literature sources showed that for over 90-year period only 95 cases of SH in children have been described. The article also describes SH direct and indirect signs, possible complications and options for surgical treatment. Laparoscopic SH correction was performed only in 4 cases in children aged 11 months and older. The case presented by the authors is the 5th SH laparoscopic correction in the world.

Background. Oral intake of nutrients is physiological. However, some patients cannot eat per os. In this regard, there is a need to find alternative options for the introduction of nutrition. In the presence of indications for long-term enteral nutrition, gastrostomy is most preferable. Objective. Demonstration of experience with gastrostomies in adults and children in our clinic, as well as the relative simplicity and advantages of using endoscopically assisted gastrostomy with an assessment of indications and possible complications. Material and methods. From July 2019 to October 2022, 50 endoscopically assisted puncture gastrostomies were performed at Ilyinskaya Hospital, five of them in children. Results. In 97% of patients, gastrostomy tubes in the postoperative period retained their tightness, no obstruction of the canal was observed in 100% of cases. Minor complications were recorded in 8% of cases; large — 6%. Conclusion. It is necessary to give preference to endoscopically assisted puncture gastrostomy by the Push method using low-profile balloon gastrostomy tubes, which is due to low invasiveness, safety, short duration of intervention and relative ease of its implementation.

Objective. To demonstrate safe introduction of a new technology (Da Vinci robotic system) into laparoscopic bariatric practice. Material and methods. We analyzed treatment outcomes in patients with morbid obesity who underwent robot-assisted sleeve gastrectomy between 2020 and 2023. The same team of surgeons performed all operations. Evolution of technique and preparation of the operating theatre were recorded. Demographic data of patients, surgery time (docking and total surgery time), simultaneity of intervention, intraoperative and postoperative complications, as well as weight loss after 6 months were retrospectively analyzed. Results. There were 15 robot-assisted sleeve gastrectomies between 2020 and 2023. Of these, 14 patients underwent surgery without complications. One patient was diagnosed with portal vein thrombosis that required anticoagulation. Median surgery time 194 [173.5; 241] min, period between incision and docking — 35 [30; 36] min. The length of hospital-stay was 3 days. The median weight loss after 6 months was 37.5% [29.5; 51.2]. Conclusion. This study demonstrates safe introduction of a new technology to prepare the bariatric team for more complex surgical interventions in the future.