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Relevance. The choice of biliary anastomosis is the main factor determining the risk of developing biliary complications after orthotopic liver transplantation. The two most common forms of biliary tract reconstruction are choledocholedochostomy (duct-to-duct anastomosis) and choledochoeunostomy (connection of the bile duct to the jejunum). The choice of biliary tract reconstruction is determined by a variety of factors, including the underlying pathology of the liver, the size of the bile ducts of the donor and recipient, previous transplantation or previous biliary tract surgery, as well as the preferences of the surgeon performing the operation. Despite the correctly chosen method of reconstruction, complications such as strictures, lithiasis, biloma, and bile leakage occur infrequently.Objective: to present a review of the literature on methods of diagnosis and treatment of biliary complications after liver transplantation.Materials and methods. The analysis of literary sources in English and Russian from 2010 to 2023 on this topic in the databases PubMed, MEDLINE, Google Scholar was carried out. The review highlights clinical studies, as well as literature reviews on similar topics with an emphasis on the treatment and diagnosis of biliary complications.Conclusion. The problem of biliary complications of liver transplantation remains relevant and unresolved to the end. Noninvasive imaging techniques for complications arising after biliary tract surgery have prospects for development. The tactics of percutaneous, endoscopic and open interventions on the biliary graft tree require further improvement.

Background. The terminal stages of chronic hepatitis C remain the main indication for liver transplantation in Russia and in the world.Aim. To retrospectively evaluate the changes in the waiting list of liver transplantation that occurred during 22 years of work of the Department for Liver Transplantation at N.V. Sklifosovsky Research Institute for Emergency Medicine in relation to patients with anti-HCV+; and to study the survival rate of anti-HCV+ after liver transplantation, and peculiarities of the course of recurrent HCV infection and virological outcomes of modern antiviral therapy.Material and methods. We analyzed the results of anti-HCV+ liver transplantations from a deceased donors (n=400) operated in the Department for Liver Transplantation at N.V. Sklifosovsky Research Institute for Emergency Medicine for 22 years. Changes in the Waiting List structure, recipient survival and antiviral therapy efficacy were studied.Results. The proportion of anti-HCV+ recipients decreased from 44.3% (period from 2007 to 2019) to 34.1% (from 2020 to 2022, p=0.0027). Survival of anti-HCV+ recipients without HCC is currently comparable to survival of non-infectious non-HCC recipients. The 5-year survival of anti-HCV+ recipients without HCC at the time of liver transplantation was 84%, and the 10-year survival was 76%. The 3and 5-year survival rates of recipients without HCC at the time of liver transplantation who had surgery before August 2016 were lower (80% and 77%, respectively) than the 3and 5-year survival rates (91%) of liver transplant recipients operated on later than this date (p=0.01). Before August 2016, recurrence of HCV infection occurred in > 90% of anti-HCV+ recipients with known HCV RNA status after liver transplantation. Spontaneous clearance of HCV RNA after liver transplantation was observed in 2.1% of cases. In recent years, the incidence of recurrent HCV infection after liver transplantation has decreased significantly (~25% in 2021–22). The use of modern direct acting antiviral regimens results in >95% viral eradication after the 1st course. The emergence of drug resistance polymorphisms in patients who have had unsuccessful experience of direct acting antiviral before liver transplantation is not an obstacle to the success of direct acting antiviral treatment after liver transplantation.Conclusion. The possibility of a rapid and safe cure for HCV infection against the backdrop of a shortage of donor organs necessitates a revision of the documents regulating organ donation, which should make organs from donors with antiHCV in the blood available for transplantation.

The work is devoted to the analysis of modern literature data and approaches in performing repeated liver transplantation. The most frequent causes of liver graft loss are PNFT, HAT, recurrent initial disease and chronic rejection. The leading indication for retransplantation in children is HAT. The one-year survival rate after retransplantation is approximately 75%. Reducing the cost of organ retransplantation and the cost-effectiveness of the procedure are controversial issues. Mathematical modeling has identified several significant recipient and donor factors affecting the outcomes of retransplantation. Despite ethical and economic considerations, retransplantation is the only option for transplant patients whose grafts have failed to engraft. The decision to retransplant should be made with some caution, with full multi-type approach in large multidisciplinary transplant centers.

Introduction. The shortage of donor organs has been and remains the basic problem of clinical transplantation and the expansion of the organ pool by using marginal donor organs has become one of its solutions. In this regard, every decision to use a "non-standard" or "non ideal" organ for transplantation should be made carefully.Aim. Demonstration of successful liver transplantation from a donor with brain death and occlusive thrombosis of the splanchnic venous system.Description. A 34-year-old donor without serious concomitant pathology was diagnosed with total portal thrombosis during liver procurement. After cold aortic perfusion, a thrombectomy from the portal vein was performed. At the “backtable” stage, an additional perfusion was made through the portal vein, the results of which confirmed the patency of the portal system. The liver graft was transplanted to a 33-year-old recipient; the postoperative period was uneventful, the patient was discharged on the 17-th postoperative day.Conclusions. Portal vein thrombosis in a donor liver is rare. A positive decision on liver transplantation from a donor with portal vein thrombosis should be based on the confirmed patency of the portal system. It is desirable that these data be supplemented by a histological examination of the donor liver. The donor organs shortage needs to expand the criteria for post-mortem organ donation. However, every decision should be made in the light of individual characteristics of the donor-recipient pair.

Fulminant liver failure is usually characterized as severe acute liver injury with encephalopathy and synthetic dysfunction (international normalized ratio [INR] ≥1.5) in a patient without cirrhosis or previous liver disease. Management of patients with acute liver failure includes ensuring that the patient is cared for appropriately, monitoring for worsening liver failure, managing complications, and providing nutritional support. Patients with acute liver failure should be treated at a liver transplant center whenever possible. Serial laboratory tests are used to monitor the course of a patient's liver failure and to monitor for complications. It is necessary to monitor the level of aminotransferases and bilirubin in serum daily. More frequent monitoring (three to four times a day) of blood coagulation parameters, complete blood count, metabolic panels, and arterial blood gases should be performed. For some causes of acute liver failure, such as acetaminophen intoxication, treatment directed at the underlying cause may prevent the need for liver transplantation and reduce mortality. Lactulose has not been shown to improve overall outcomes, and it can lead to intestinal distention, which can lead to technical difficulties during liver transplantation. Early in acute liver failure, signs and symptoms of cerebral edema may be absent or difficult to detect. Complications of cerebral edema include increased intracranial pressure and herniation of the brain stem. General measures to prevent increased intracranial pressure include minimizing stimulation, maintaining an appropriate fluid balance, and elevating the head of the patient's bed. For patients at high risk of developing cerebral edema, we also offer hypertonic saline prophylaxis (3%) with a target serum sodium level of 145 to 155 mEq/L (level 2C). High-risk patients include patients with grade IV encephalopathy, high ammonia levels (>150 µmol/L), or acute renal failure, and patients requiring vasopressor support. Approximately 40 % of patients with acute liver failure recover spontaneously with supportive care. Predictive models have been developed to help identify patients who are unlikely to recover spontaneously, as the decision to undergo liver transplant depends in part on the likelihood of spontaneous recovery of the liver. However, among those who receive a transplant, the one-year survival rate exceeds 80 %, making this treatment the treatment of choice in this difficult patient population.

The article presents the results of liver transplantation in five HIV-infected recipients with irreversible liver damage. It is shown that four of them survived in the long-term period and are observed in a stable condition, and the only death in the recipient was not related to the HIV infection. The experience in the treatment of these patients was summarized. Analysis of the first results of liver transplantation in HIV-infection in Russia shows its validity and clinical efficacy. The only lethal case is connected with the initial extremely grave condition of the recipient and his age. Two cases of surgical traumatism, lack of consistent vaccination in the preoperative period, as well as lack of patients with hepatocellular cancer, small number of observations are obvious drawbacks of our first experience and should be corrected in the future. The success of a complex and multidisciplinary program of organ transplantation in HIV infection is impossible without participation of HIV-infectionists in the transplantation team.

Liver transplantation is rightly considered the only radical treatment for terminal chronic liver diseases and patients with acute liver failure. However, despite the accumulated experience in the management of patients in this group, the level of complications development remains at a fairly high level. The success of the correction of emerging pathological conditions largely depends on the timing of their diagnosis. Since complications developing after liver transplantation most often do not have specific clinical and biochemical manifestations, the use of imaging research methods plays a key role in assessing the state of the transplanted organ at all stages of the postoperative period. Among all instrumental methods, ultrasound examination using Doppler techniques, carried out hourly directly in the intensive care unit, with an accuracy of 97 % and a specificity of up to 100 %, makes it possible to detect vascular post-transplant complications as soon as possible. Their timely correction avoids the loss of the graft. The use of dynamic observation contributes to differential diagnosis in identifying non-vascular complications at different stages of the postoperative period. The use of modern techniques greatly expands the possibilities of echography. Thus, the use of contrast enhancement not only shortens the study time, but also increases the sensitivity of Dopplerography in assessing the patency of the vascular bed, especially in patients with decreased central hemodynamics. The use of ARFI-elastography techniques in patients in the late postoperative period makes it possible to objectively assess the severity of hepatic graft fibrosis.

The implementation of the liver transplantation program at Sklifosovsky Institute of Emergency Medicine has a long history. Over the last 20 years, more than 700 patients have received high-tech medical care (transplantation) here.

Situs inversus is a rare mirror transposition of internal organs relative to the median plane. Liver transplantation in situs inversus is a serious medical challenge imposed by an abnormal arrangement of the recipient's organs.Aim. Clinical description of a successful cadaveric liver transplantation in an adult patient with situs inversus and portal vein thrombosis.Key points. A 32 years-old patient with situs inversus, chronic hepatitis B/D-induced liver cirrhosis and portal vein thrombosis had cadaveric liver transplantation, with the transplant reoriented in abdominal cavity 90° clockwise relative to the median plane. End-to-side cavocaval anastomosis was formed between the donor's retrohepatic and the recipient's main inferior vena cava, with successive portal and arterial anastomoses and complete donor liver reperfusion. A biliary reconstruction was performed with an end-to-end biliobiliary anastomosis. The surgery duration comprised 5 h 20 min, intraoperative blood loss — 2000 mL, cold ischemia time — 4 h. The patient was discharged on the 10th day after surgery in satisfactory condition.Conclusion. Situs inversus is not a contraindication to liver transplantation.

The paper reviews the milestones and prerequisites in the history of the emergence and development of xenotransplantation. The currently existing barriers (immunological, infectious, genetic, ethical, and regulatory) to the development of this organ and tissue transplantation type have been studied. Available data on theoretical research and experimental studies have been reviewed. The prospects for performing xenotransplantation in various combination of species have been assessed. The forms and variants of the xenograft rejection reaction have been described. Genetic engineering approaches to overcoming xenoimmunological incompatibility are described. An assessment is made of ways to overcome existing barriers and prospects for the further development of xenotransplantation as a scientific section of transplantology.

Worldwide, there is a trend towards an increase in the number of patients waiting for liver transplantation, despite an increase in the total number of liver transplantation operations. Solving the problem of donor organ shortage is possible through the use of organs from marginal donors: organs removed after cardiac arrest, organs with a high percentage of steatosis, organs from donors over the age of 60 years. The main reason for refusing to use them is the risk of severe complications and an unfavorable outcome of the operation. Static cold preservation today is the main method of protecting donor organs from thermal damage, which possesses rather effective protective properties. At the same time, the duration of cold preservation has a limited time interval. There is always uncertainty about the viability of the organ. Modern methods for assessing donor organs such as donor history, laboratory data, visual examination and morphology, do not reliably predict liver function after transplantation. In this regard, the development of methods for preserving the organ after removing, which do not degrade the quality of the organ or even are capable of restoring the lost functions, is relevant. The machine perfusion of the liver is one of the new concepts aimed at solving this problem. The article highlights the international experience of using the machine perfusion of the donor liver over the past 15 years. Machine perfusion is a promising trend of transplantation development, which allows reducing the shortage of donor organs and improving their quality.

Donor organ shortage stimulated an active use of donors with expanded evaluation criteria. The main evaluation method was a histological examination of liver graft biopsy specimens before (time-zero biopsy) and after reperfusion (time-1 biopsy). Severe ischemic and reperfusion injuries among recipients who received a liver graft made 20.4% and 16.6% respectively. The study showed no impact of small droplet, medium droplet, or even large droplet steatosis (less than 50%) on graft reperfusion injury.

Aim. The aim of the study was to investigate the endoscopic diagnostic and treatment techniques for biliary complications after orthotopic liver transplantation, their efficacy and safety. Material and methods. The study was based on the results of endoscopic treatment of 29 patients with biliary complications occurred after orthotopic liver transplantation in N.V. Sklifosovsky Research Institute for Emergency Medicine in the period from December 2001 to January 2017. Conclusions. The state-of-the-art methods of therapeutic endoscopy enable a successful treatment of most cases of biliary strictures and biliary-biliary anastomosis incompetence, thus achieving good long-term results using a minimally invasive methodology.

The aim of the review is to identify current possibilities of carbon dioxide laser application in microsurgical treatment of chronic laryngeal cicatricial stenoses. Currently, laser endolaryngeal surgeries are one of the main standards in surgical treatment of patients with this laryngeal pathology, including when providing high-tech assistance. Various types of lasers and methods of surgical treatment of the larynx are used. The choice of these methods is primarily determined by the opinion of the operating surgeon. The review highlights the principles of laser surgery in general, and when using carbon dioxide laser in particular. The use of micromanipulators makes it possible to combine the work of carbon dioxide laser with the operating microscope, affecting target tissues noninvasively with maximum precision. This technology makes it possible to expand the range of surgical manipulations in endolaryngeal surgeries. The main operating modes of the carbon dioxide laser, applicable for different clinical situations, such as power, impulse, laser power density (PD) are considered. In addition, the combination of a micromanipulator with an operating microscope allows the use of additional techniques aimed at preventing restenosis, such as the use of microflaps, submucosal laryngeal cicatricial tissue vaporization. The possibilities of the recurrence of cicatricial stenosis by different variants of stenting are presented. The risk of complications of this technique is not higher than in other types of larynx laser surgeries, and with proper preventive measures can be minimized. In the review, possible complications, both early and late, measures of their prophylaxis, as well as ways to eliminate their consequences are analyzed in detail.

Introduction. Despite significant progress achieved in the surgical treatment of cicatricial laryngeal stenosis and cervical trachea in recent decades, this issue appears relevant, especially among people of young and working age.Aim of the study: To develop tactics for surgical treatment of post-intubation laryngeal stenosis using a CO2-laser.Materials and methods: During the period from 2015 to 2019, surgical treatment was performed for 105 patients with post-intubation cicatricial stenosis of the larynx using microsurgical techniques and a CO2-laser, provided that the cartilage frame of the larynx was preserved, which was determined in a preoperative examination.Results and discussion: In the postoperative period, patients were monitored from 6 months to 3 years. Localization of cicatricial post-intubation laryngeal stenosis in the vestibular region is quite rare. According to the results of the study, achievement of a stable functional result was obtained in 20 (84%) of 24 patients with lesions of the vocal section of the larynx, in one case a cicatricial membrane of this section of the larynx was required to be excised after one year, and laryngoplasty with extra laryngeal access in four cases. Post-intubation stenosis of sub-folded localization is most widespread, and in our observations they amounted to 79%. The use of endolaryngeal access using a CO2-laser made it possible to achieve a good functional result in 66% of cases, reconstruction of the larynx by extra-laryngeal access was required in 33%, and laryngotracheal resection in 1%.Conclusion: It is shown that the use of a CO2-laser in the surgical treatment of chronic post-intubation laryngeal stenosis significantly expands operational capabilities due to the high accuracy and low level of damage to surrounding tissues. This method allows the formation of minimal wound surfaces by submucosal excision of scar tissue and makes it possible to cover the wound with microlosks of the mucous membrane, reducing the time of epithelization in the intervention area, which is an important prevention of repeated stenosis. In the surgical treatment of extended stenosis of the middle part of the larynx, there are prerequisites for repeated wound replacement with scar tissue, which in our observations was avoided by using endoprostheses. The defeat of the sub-follicular part of the larynx is prone to restenosis even in the absence of data for the defeat of the cartilaginous framework of the larynx.

Aim of the study: to develop a tactic of surgical treatment of cicatrical lesion of the middle larynx depending on the localization and length of stenosis.Materials and methods: from 2014 to 2019, 43 patients with cicatrical stenosis of the folded larynx underwent surgery. The average age of the patients was 39 years and ranged from 18 to 78 years. Depending on the clinical situation, patients were divided into 4 groups, in which different methods of surgical treatment were applied – removal of scars of the middle larynx using CO2-laser and additional application of keel-shaped implant (n = 21), microflaps in the area of commissure (n = 10) and intraretynoid region (n = 4), endoprosthesis covered with xenopericord (n = 8).Results: in the postoperative period endoscopic examination of the larynx was carried out in dynamics during the period up to 1 year. Patients were examined daily while in hospital, then monthly. In addition to endoscopic examination, the study of voice function was carried out by the method of determining the time of maximum fonation. The estimation of respiratory and voice rehabilitation was carried out and stable positive effect was received in 90% in the first group, 70% - in the second, 75% - in the third, 75% – in the fourth. The obtained data allow to develop an individual approach to surgical treatment of cicatrical stenosis of the larynx depending on the localization and extent of cicatrical lesion.Discussion: the optimal method of treating cicatrical lesion of the middle larynx is to create conditions that prevent the contact of wound surfaces and their separation. For this purpose, methods that are individually addressed to the main clinical situations in this problem have been developed. In addition, the use of CO2-laser in the surgical treatment of cicatrical lesions of the middle larynx significantly expands operational capabilities due to high accuracy and low level of damage to surrounding tissues.Conclusions: in case of cicatrical lesion of the middle larynx up to 4 mm in length, in the absence of a tracheostoma an effective method of restoration of respiratory and vocal function of the larynx is the use of microflaps formed by microsurgery with th e help of CO2-laser; stenoses in the area of middle larynx commissure of more than 4 mm require additional stenting for the period of epithelization of the wound surface and remodeling of the scar, which is 3–4 weeks. In the presence of a tracheostoma in patients with prolonged stenosis of the middle laryngeal commissiure, an implant coated with xenopericardium and chlorhexidine ionic-covalent immobilization, which helps to avoid inflammatory changes during the period of stenting, has proved to be a good choice.

Photodynamic diagnosis is a promising method in the treatment of laryngeal papillomatosis, which includes an assessment of the increased visual and spectrometric contrast of papillomatosis masses against the background of the introduction of the photosensitizer. We have developed a method of treatment of laryngeal papillomatosis in two stages: intraoperative diagnosis using the domestic preparation of 5-aminolevulinic acid hydrochloride and subsequent surgical treatment using a carbon dioxide laser. Using the new method, we treated 21 patients, of which 13 (61.9%) had the inter-recurrent period longer than 12 months.