COMPARISON OF HARTMANN'S PROCEDURE VERSUS RESECTION WITH PRIMARY ANASTOMOSIS IN MANAGEMENT OF LEFT SIDED COLON CANCER OBSTRUCTION: A PROSPECTIVE COHORT STUDY.

The aim of our prospective study is to compare and analyze the results of two treatment methods of left-sided malignant colon obstruction: Hartmann's procedure (HP) and Resection with primary anastomosis (RPA). 90 Patients with diagnosis of left-sided malignant colon obstructions were enrolled in this study. The patients were assigned into two groups: Hartmann's procedure (HP) group and Resection and Primary anastomosis group (RPA). Several clinical characteristics were determined and compared between the groups: hospital stay days, duration of the surgery, postoperative complications (during 30 days after surgery) and mortality was assessed. 37 patients were enrolled in the Hartmann's procedure (HP) group and 53 patients were enrolled in the Primary anastomosis (RPA) group and had undergone different types of colon resections with primary anastomosis. There was 1mortality in HP group and 1 in RPA group. In RPA group, there were 7 complications (13.2%). 1 intraabdominal abscess after colorectal anastomosis, which was cured with antibiotic therapy and percutaneous drainage; 5 cases of wound infections, 1- leak of colorectal anastomosis and in Hartmann's procedure group there were 8 (21.6%) complications (7 - wound infections, 1-necrosis of colostomy). But this difference is not statistically reliable (p=0.110). In stenting RPA stay were - 6 days and in HP group, it was 8 days. This difference is statistically reliable (P=0.02). In case of left-sided malignant colon obstructions, Primary anastomosis intervention should be preferred, rather than Hartmann's procedure. In the future it's needed to perform the randomized trials, which will study the long-term outcomes (recurrence of cancer, survival rate) of this treatment method.

COMPARISON OF THE PATIENT-CONTROLLED EPIDURAL AND INTRAVENOUS ANALGESIA AFTER OPEN COLORECTAL SURGERY: A RANDOMIZED CONTROLLED TRIAL.

The goal of this study was to evaluate the efficacy of two common analgesic techniques: patient-controlled epidural analgesia (PCEA) and patient-controlled intravenous analgesia (IVPCA) in patients undergoing open colorectal surgeries. 130 patients were randomized in two groups: group I - n=65 (27 males, 38 females, age range 23-75) - whose postoperative period and pain was managed with PCEA; group II - n=65 (31 male, 34 female, age range 23-75) - whose postoperative period and pain was managed with IVPCA. There were no significant differences by demographic and preoperative factors between the groups. The study demonstrates, that both analgesia techniques in colorectal surgery patients, IVPCA and PCEA, resulted in high levels of satisfaction (as reflected by a median score of 4 on the 1-5 scale), and provided effective management of postoperative pain. There were no differences in the pain scores on the postoperative visual analogue scales, analgesic requirements and satisfaction score between groups. This indicates that IVPCA and Epidural PCA are equally effective to control the postoperative pain after open colorectal surgery.

ENHANCED RECOVERY AFTER SURGERY VS TRADITIONAL CARE IN ELECTIVE COLORECTAL SURGERY: A RETROSPECTIVE COHORT STUDY.

The objective and the goal of this study was to determine how ERAS guidelines affected on hospital stay days and other complications rates in case of elective colorectal surgery in our clinic, compared to traditional care methods. First of all, all team members including surgeons, anesthetists, nurses were being trained in ERAS guidelines principals during two months and we started active implementation process after this. 87 patients, who were needed to be done colorectal surgery treatment, were actively treated according to ERAS guidelines and these patients were gathered in experimental group. At the same time, we started to collect data retrospectively from last 2 years elective colorectal surgery cases and sorted them according to preoperative, intraoperative surgical and anesthesia data, postoperative analgesia, all type of complications. 120 patients were placed in traditional care group (control group). In traditional care group open colorectal surgery was associated with long length of stay 8-10 days. High rates of surgical site infection-24.2%, readmission rate during 30 days-30.8%, PONV-44.2%, respiratory complication-6.7%, deep vein thrombosis-3.3%, urinary retention-2.5%, prolonged postoperative ileus 16.7%. We included 87 patients in ERAS care group during 2 years. In this group our study showed big reduction of hospital stay days and it was average 5 days. Compared to traditional care group incidence of respiratory complications was 0, postoperative PONV- 6.9%, postoperative ileus-5.7%, deep vein thrombosis-0, urinary retention-0, readmission rate-0, surgical site infection-3.4%.

[BREATH TEST WITH LOCALLY PRODUCED 13С-UREA (TBILISI, GEORGIA) IN DIAGNOSTICS OF HELICOBACTER PYLORI INFECTION].

Comparative assessment of results of detection of Helicobacter pylori (Hp) infection by breath tests with standard and locally produced 13С urea was done in 213 patients with gastric and duodenal pathology, including those who already were undergone the surgery. Invasive endoscopic biopsy test including rapid urease test (RUT), smear cytology and histology were also performed (tissue samples were obtained after endoscopy or surgery). RUT was carried out with the help of URE-HP test kit. Serological test for Hp antibodies was performed by IFA using kit ELISA. 13С urea breath test (UBT) was conducted for the determination of 13/12CO2 in breath samples by using of infrared spectroscope. In I group (125 patients) UBT was performed with standard 13С urea, in II group (88 patients) with locally produced 13С urea. Based on 5 different methods of Hp infection testing Hp positivity in 172 (80,8%) and Hp negativity in 41 (19,2%) patients were revealed. 13С-UBT showed the highest diagnostic value (accuracy-97,5%, sensibility-97,0%, specificity-100%) in Hp infection diagnosis. The (accuracy, sensibility and specificity of breath test with locally issued 13С urea (98,7%, 98,5% and 100% respectively) are the same as those for BT with standard 13С urea (96,7%, 96,2% and 100% respectively). These parameters are also highly credible in control of treatment efficiency (96,7%, 90,0% and 100% respectively). The correlation of index DOB‰ of breath test with results of RUT was revealed In Hp positive patients. This can serve as a marker of Hp infection rate. Preliminarily, in pre-clinical experimental study, harmless of locally issued 13С-urea from point of view of acute/sub-acute toxicity and allergy development was confirmed. The advantages (noninvasiveness, simplicity, rapidity, safety) and high diagnostic value of UBT (with both standard as well as locally produced 13С-urea) provide the opportunity to offer 13С-UBT as screening method of Hp infection diagnosis. It also should be recommended as a method of choice for controlling of Hp treatment efficiency. Taking into the consideration all above-mentioned we may recommend locally produced 13С-urea (Tbilisi, Georgia) for certification and further application.

[Benchmarking study of effectiveness of simultaneous and isolated surgeries].

Benchmarking study was conducted on effectiveness of simultaneous and isolated surgeries in practice of obstetrics and gynecology. In terms of the work, data were analyzed on the isolated and simultaneous surgeries with the patients with combined gynecological and surgical pathologies, requiring operative treatment. Man group included 254 patients with combined abnormalities, who underwent simultaneous surgeries; control group included 122 patients who underwent surgical treatment for combined diseases consecutively in two stages, in different times. Periodicity of complications in early and late post-surgical periods was evaluated, as well as risk ratio (RR) and attributable risk (AR). Simultaneous surgery is safe method of treatment of combined gynecological and surgical abnormalities. Notwithstanding extension of duration of pre-surgical examinations and post- surgical hospital stay, simultaneous operations are considered to be opportunity for being cured from several combined abnormalities within one hospitalization and anesthesia, creating positive moral and psychological background for the patients and making additional argument in favor of their conducting.

[Gynecology operations combined with hernioplasty].

Hernioplasty is one of the most widespread planned simultaneous operations in practice of obstetrics and gynecology. Rising trend of such interventions has been steadily increasing in these latter days. We have conducted 64 gynecology operations combined with hernioplasty. 5 operations were conducted in an expedited manner; 59 interventions were planned. Age of our patients ranged from 24 to 57. Duration of the surgical interventions was 129 minutes as average; duration of hospital stay days - 4±2 days, which didn't extend terms of stay at the stationary of the patients with separately conducted operations. Expressed pain syndrome was assessed with the amount of the used analgesics. Tension free hernioplasty by using reticulated polypropylene implants, on simultaneous operations, including hernioplasty combined with the gynecological components, gives good functional results and esthetic effect, excluding possibility of serious complications in the postoperative period.

[Tactics of surgical treatment of patients with complicated peptic ulcer disease].

Article presents the results of medical treatment after peptic ulcer surgery. I group--59 patients with late complications after peptic ulcer surgery and II group--16 patients with complications of peptic ulcer disease, operated in presence of absolute indications. 13C-UBT and RUT of biopsy material were used to diagnose Hp infection. Hp positive patients received antibacterial treatment. After 1 month from the end of therapy and 1 year after Hp eradication control investigations by 13C-UBT and endoscopy were performed. 77.3% of all and 84.4% of early non treated patients were Hp positive. All patients (of I and II gr.), who followed control testing after antibacterial treatment were finally detected as Hp negative. In I group, control endoscopy revealed epitelization or scarring of ulcer and reduction of inflammatory changes in gastric and duodenal mucosa in all 44 cases of eradication of Hp infection (in 2 patients with peptic ulcer of GEA ulcer relapsed in later). In II group, in 8 patients, who received antibacterial treatment additionally to surgical method, any late complications after surgery were not revealed. In other 6 Hp positive patients: 2--ulcer recurrence and 2--development of chronic gastritis of operated stomach were noted, which required the treatment of Hp infection in future. It is concluded that 1)surgery does not change Hp-status of patients and Hp infection retains in more than 80% of cases; 2) ulcer recurrence, chronic gastritis of operated stomach or its stump are associated with Hp and regress after Hp eradication; 3) progression of gastritis into atrophic remain after surgery, which increases risk of cancer development and there is possibility of its regression after antibacterial treatment of Hp infection. The recommendations were worked out: 1) perforated, bleeding or stenosing ulcer must be treated only by ulceroraphy, suturing or pyloroplasty respectively, added with subsequent Hp eradication therapy for the prevention of late complications after peptic ulcer surgery; 2) vagotomy or partial gastrectomy must be a forced intervention in cases of decompensate pylorostenosis, resistant to treatment ulcers, as ulcers non-healing or recurring after adequate conservative treatment. Subsequent verification and eradication of Hp infection are necessary.

[Indications to surgical treatment of patients with peptic ulcer disease].

The aim of this investigation is to study the influence of eradication of Helicobacter pylori (Hp) on the results of conservative treatment of patients with ulcer. The results of treatment of 216 patients with peptic ulcer disease (I gr.--152 patients with noncomplicated peptic ulcer disease and II gr.--64 patients with complications of disease) were analyzed. To diagnose Hp infection (13)C-UBT and RUT of biopsy material were used. I gr.--patients received antibacterial treatment. In II gr.: in presence of absolute indications--surgical method was used (16 patients) with additional antibacterial treatment of Hp infection after surgery and in relative indications to surgery (48 patients)--antibacterial treatment was used initially. 1 month after conservative treatment (in part of patients--1 year after Hp eradication also) (13)C-UBT were used to control Hp eradication, as endoscopy--to control ulcer healing. In I gr.: all 152 patients (97,4% of investigated, early nontreated patients with noncomplicated ulcers) were Hp positive; in II gr.--62 from 64 (96,9%). In I gr.: efficiency of primary course of eradication therapy was 91,4% and came to 99,3% after repeated treatment (in II gr.--89,1% and 100% respectively). In I gr.--in 1 patient, the resistance to antibacterial treatment was revealed and eradication of Hp infection and ulcer healing were not achieved. In II gr.--epithelization and scarring of ulcer was revealed by control endoscopy in all cases except one case of prepyloric callous ulcer (Hp was eradicated in all of them). Thus, in complicated cases of peptic ulcer disease, only in presence of absolute indications, surgery is necessity. In presence of relative indications to surgery Hp eradication therapy is indicate initially. Only in cases of resistant to treatment ulcers, as ulcers nonhealing or recurring after Hp was eradicated, must be a relative indications to surgical treatment.

[The prevalence of Helicobacter pylori infection among the Georgian population].

With aim to reveal Helicobacter pylori (Hp) infection rate among the Georgian population and to determine Hp risk groups, studies were performed in 103 practically healthy volunteers--I group and in 92 volunteers from separate professional groups (including those who had dyspeptic complaints)--II group. Noninvasive methods of Hp infection testing ((13)C - urea breath test and serological test for anti-Hp IgG and IgA antibodies) were used. In the I group, 63,1% of practically healthy volunteers, aged 31,9+/-0,86 year (9-75 ye.), was Hp positive. Average age of Hp positive individuals exceed age of Hp negative ones. Chronic Hp infection (IgG+ and IgA- combination) revealed in 75% of seropositive persons, exacerbation of Hp infection (IgG+ IgA+)--in 23,3% and acute Hp infection (IgG- IgA+)--in 1,7%. In II group: more high rates of Hp infection revealed in subgroup of surgeons (85,7%) and in subgroup of students of the military school (73,3%). Thus, epidemiological studies revealed high level of Hp infection among the Georgian population. Correlation of high risk of Hp infection with low level of life, compact of reside, low level of education and with age of inspected person were observed. Also was revealed, that medical practice with frequent contact with gastric pathology patients (having place especially in surgeons) and long-lasting compact being together of large group (having place among the students of military school), are risk-factors to Hp infection.

[Liver resection with regional chemotherapy in the cases of colorectal metastasis in the liver].

The surgical procedure is the most important in the combined treatment of the liver colorectal metastatic injury. The aim of our investigation was to determine the efficacy of liver resection together with regional chemotherapy(R/C) at solitary injury of liver. 48 patients with metastatic damage of the liver from the colorectal cancer were observed. Different degree of liver resection with R/C was performed. Outcomes of partial resection of the liver metastasis combined with primary tumor resection and 5-FU chemotherapy in the observed cases were quit satisfactory (5 year survival-14,6%).

[Strategy of treatment of patients with colorectal cancer with hepatic metastases].

Retrospective study was performed to evaluate the efficacy of combined methods of treatment in patients with colorectal cancer with hepatic metastases. 57 patients (I group - control) undergone regional chemotherapy (RC) with hepatic arterial or intraportal 5Fluorouracil (5FU). From 84 patients 48 (II group) undergone liver resection + RC (5FU), 24 (III group) - hepatic arterial embolization +RC (5FU), and 12(IV group) with multiple bilobar (<3 cm) metastases- alcoholization of metastatic nodules +RC (5FU). Overall 5-year survival for the II group was 14.8% without operative or postoperative deaths. The median survival was 19 months (range 13-27 months) and 21 months (range 15-26 months) for II and III groups respectively, which is not different from the survival rate of patients who received only RC. Although, quality of life was much better after combined treatment. Resection of colorectal liver metastases followed by regional chemotherapy can provide long-term survival in selected patients.

[Extensive hepatic resections and reconstruction of bile ducts in patients with tumors and parasitic cysts]. / Obshirnye rezektsii pecheni i rekonstruktsiia zhelchevyvodiashchikh putei pri opukholiakh i parazitarnykh kistakh.

The short-term and end results of hemihepatoectomies (36) associated with malignant (31) and benign (2) hepatic tumors and parasitic cysts (3) are presented (total right-side hemihepatectomy-7, subtotal-9, left-side hemihepatectomy-15, extended left-side hemihepatectomy-5). In 14 cases, due to considerable invasion of tumor from other sites or because of distant metastases, the liver was resected alongside with removal of primary tumor. In such patients, gastric extirpation was carried out simultaneously with resection of the esophagus and pancreas (4), colon and rectum (8) and gastropancreatoduodenal area (1). Liver resection was associated with surgical correction of biliary tracts (6). Post-operative lethality was 11.1%. The end results are quite satisfactory: out of 27 patients treated for primary (10) and secondary (17) hepatic malignancies, 15 survived 2 years, 8-4 years and more; there are 10 survivors at the time of reporting.

[Current approaches to radical surgical and combined treatment of rectal cancer]. / Sovremennye podkhody k radikal'nomu khirurgicheskomu i kombinirovannomu lecheniiu raka priamoi kishki.

The article gives an analysis of the 30 years experiences with treatment of more than 3200 patients with rectum cancer at a specialized oncological department. Postoperative lethality was 7.3%. In recent years this figure has been decreased (5.2%). The individual programs of treatment were associated with the degree of growing the tumor through the bowel wall and with the metastatic damage of the regional lymph nodes. These factors show that careful as well as extended and combined operations are justified. The advantages of combined methods of treatment and functionally saving surgical interventions have been revealed.

[Pathogenesis of colorectal cancer after resection of various segments of the large bowel]. / K voprosy o patogeneze kolorektal'nogo raka posle rezektsii razlichnykh otdelov tolstoi kishki.

The data on 120 cases of primary multiple cancer of the large bowel and 91 cases of diffuse polyposis are discussed. The development, duration and morphological features of metachronous and primary cancer arising after resection of the bowel varying in type and extent were studied. The results pointed to a high risk of cancer in such cases. The study also pointed to disturbances in the enterohepatic system and bile acid circulation as a factor of carcinogenesis in the bowel.

[The diagnostic and treatment characteristics of rectal cancer in young persons]. / Osobennosti diagnostiki i lecheniia raka priamoi kishki u lits molodogo vozrasta.

The causes of advancement and results of treatment of 191 patients (aged under 40 years) with rectal cancer seen in 1967-1987 were analysed. The peculiarities of the disease in young age were identified. Timely diagnosis and better results of treatment of rectal cancer in the young can be assured with better educational activities and mandatory rectal examination during oncological check-ups.

[The characteristics of bile acid excretion in patients with cancer of the large intestine]. / Osobennosti ékskretsii zhelchnykh kislot u bol'nykh rakom tolstoi kishki.

Marked difference in bile acids excretion (on the same diet) was observed between patients with large bowel cancer and healthy controls. The peak level of the bile acids in feces was registered in female patients 46-59 years of age suffering right-sided cancer. It is suggested that bile acid excretion in man is determined both by nutritional factors and hormonal-metabolic peculiarities of the body. High excretion of the bile acids is associated with risk for colon cancer.

[Surgical treatment of cancer of the colon and factors determining its effectiveness]. / Khirurgicheskoe lechenie raka obodochnoi kishki i faktory, opredeliaiushchie ego éffektivnost'.

The results of treatment of 1,031 patients with carcinoma of the colon by surgery from 1929 to 1985 are analysed. Postoperative mortality reduced almost three-fold in the last decades and was 4% in 1984-85. From study of the late results the authors conclude that abidance by the principles of oncological radicality is important. The recognition of patients with preneoplastic diseases and their regular active medical examination allow the results of treatment of patients with carcinoma of the colon to be improved.