[Treatment of primary malignant melanoma of the esophagus]. / Lechenie pervichnoi melanomy pishchevoda.

OBJECTIVE: To present treatment of primary esophageal melanoma in a young patient, as well as review of modern data on this issue. MATERIAL AND METHODS: We describe the results of treatment of a patient with primary melanoma of the esophagus. PubMed, SCOPUS, and elibrary databases were used for the review. RESULTS: We present a rare case of primary esophageal melanoma and variant of radical surgical treatment. The review is devoted to historical information about this nosology, statistical data, options for diagnosis and treatment. CONCLUSION: Such a rare clinical case is of great scientific interest due to the rarity of this disease. In our opinion, a certain register of orphan malignant tumors is necessary for diagnosis and treatment of various rare malignancies.

[One-stage reconstructive jejunogastroplasty after previous multiple abdominal surgeries for left-sided diaphragm rupture complicated by gastric incarceration and necrosis]. / Odnomomentnaya rekonstruktivnaya eyunogastroplastika u bol'nogo posle mnozhestvennykh operatsii na bryushnoi polosti po povodu razryva levogo kupola diafragmy s ushchemleniem i nekrozom zheludka.

Acute gastric necrosis is a rare event requiring organ resection. Delayed reconstruction is advisable in patients with peritonitis and sepsis. The most common complication of gastrectomy with reconstruction is failure of esophagojejunostomy and duodenal stump. In case of severe esophagojejunostomy failure, appropriate surgical approach and timing of reconstructive stage should be analyzed. We report one-stage reconstructive surgery in a patient with multiple fistulas after previous gastrectomy. Surgery included reconstructive jejunogastroplasty with jejunal graft interposition. The patient underwent previous several unsuccessful reconstructive procedures complicated by failure of esophagojejunostomy and duodenal stump with external intestinal, duodenal and esophageal fistulas. Nutritional insufficiency, water and electrolyte disorders due to significant loss of proteins and intestinal juice through the drain tubes deteriorated clinical status. Surgical procedures finished reconstruction, provided closure of multiple fistulas and stomas and restored physiological duodenal passage.

[Non-occlusive mesenteric ischemia in reconstructive digestive tract surgery]. / Neokklyuzionnaya mezenterial'naya ishemiya v rekonstruktivnoi khirurgii organov zheludochno-kishechnogo trakta.

OBJECTIVE: To analyze the mechanisms of non-occlusive mesenteric ischemia (NOMI) after digestive tract surgery. MATERIAL AND METHODS: NOMI occurred in 10 (0.4%) patients after reconstructive digestive tract surgery between 2015 and 2021. There were 4 women and 6 men aged 29-92 years (67 [60; 71]). Patients differed from each other in the nature of baseline disease and surgical approach. All patients underwent standardized surgical interventions. There were no intraoperative complications. RESULTS: Median of surgery time was 372.5 (246.25; 548.75) min, blood loss - 450 (200; 725) ml. These parameters conformed to the type of surgery. There were no specific clinical signs of NOMI. Lactic acidosis (>4 mmol/L) occurred in 7 patients after 1-3 postoperative days. In 6 patients, fulminant NOMI developed after 1-2 postoperative days with subsequent multiple organ failure syndrome and septic shock. All patients underwent emergency redo surgery. Multivisceral gastrointestinal necrosis occurred in 5 patients, gastric conduit necrosis - 3, colon necrosis - 1, gastric stump necrosis - 1 patient. Mortality rate was 80%. Two patients survived. CONCLUSION: NOMI manifested as a septic shock in 60% of patients that was due to fulminant development of multivisceral necrosis after 1-2 postoperative days. Timely diagnosis of reversible NOMI in these cases was impossible. Extensive visceral necrosis in early postoperative period is probably associated with intraoperative critical ischemia of digestive organs.

[Redo reconstruction of the digestive tract after gastric surgery]. / Povtornye rekonstruktsii pishchevaritel'nogo trakta posle operatsii na zheludke.

OBJECTIVE: To formulate the concept of physiological reconstruction of the digestive tract during redo gastric surgery. MATERIAL AND METHODS: There were 52 patients who underwent redo gastric surgery after previous resections, drainage and antireflux procedures in 2011-2017 at the Vishnevsky National Research Surgical Center. Redo resection of the stomach with Billroth-1 and Hofmeister reconstructions were performed in 5 (9.6%) and 1 patient (1.9%), respectively. Roux-en-Y reconstruction was performed in 4 (7.7%) patients after gastric remnant extirpation. Jejunogastroplasty was used in 30 (57.7%) patients. A segment of the transverse colon as the reconstructive material was used in 2 (3.8%) patients, left colon - in 8 (15.4%) after esophagectomy. One (1.9%) patient underwent extirpation of 'small' stomach and thoracic esophagus after previous gastric bypass. Gastric remnant was used as an isoperistaltic tube for subtotal esophagoplasty. Reconstruction was not possible in only 1 (1.9%) patient after advanced visceral resection for recurrent cancer within esophagojejunostomy due to deficit of visceral material. RESULTS: Postoperative complications were observed in 5 (9.6%) patients. Partial failure of esophagojejunostomy and duodenojejunostomy occurred in 2 (3.8%) and 1 patient (1.9%), respectively. Colon transplant necrosis was noted in 1 (1.9%) patient that required resection followed by colo- and esophagostomy nutrition. One patient died on the 1st postoperative day from progressive multiple organ failure. At the end of the study, 44 (86.2%) out of 51 patients were under follow-up. Good results were revealed in 26 (59.9%) patients, satisfactory outcomes - in 12 (27.4%) patients. Redo surgery was not effective in only 6 (13.7%) patients. CONCLUSION: Evaluation of our results demonstrates complete alleviation of pathological postoperative syndromes after gastric surgery in the majority of patients. Therefore, redo surgery with gastroplasty and restoration of duodenal passage are advisable.

[Endoscopic treatment of esophageal anastomotic leakage using vacuum-assisted closure system]. / Éndoskopicheskoe lechenie nesostoiatel'nosti pishchevodnykh anastomozov s ispol'zovaniem vakuumno-aspiratsionnoi sistemy.

OBJECTIVE: To analyze the effectiveness of vacuum-assisted closure system for esophageal anastomotic leakage. MATERIAL AND METHODS: There were 10 patients with upper gastrointestinal anastomotic leakage who were treated at our institution in 2015-2018. Vacuum aspiration system was applied in all cases. RESULTS: Esophageal wall defect was successfully closed in 9 out of 10 patients after 2-4 courses and the system was eliminated in 11 days on the average. Localized cavity with granulation tissue developed in 1 patient after 5 courses and the system was also eliminated. CONCLUSION: Endoscopic vacuum-assisted therapy is an innovative, minimally invasive, economically profitable and successful method for anastomotic leakage. This procedure should be taken into consideration and widely used in multi-field hospitals.

[Intraoperative fluid therapy during esophagectomy followed by repair]. / Intraoperatsionnaia infuzionnaia terapiia pri ézofagéktomii s odnomomentnoi plastikoi pishchevoda.

AIM: To optimize fluid therapy in transhiatal eshophagectomy by using of goal-oriented infusion therapy based on stroke volume variation. MATERIAL AND METHODS: Our trial enrolled 30 patients who underwent transhiatal esophagectomy followed by repair for the period 2011-2014. Patients were divided into 2 groups. The first group (LT) included 16 patients with liberal fluid therapy. The second group (GDT) consisted of 14 patients in whom goal-oriented fluid therapy was performed. Goal-oriented fluid therapy was implemented via stroke volume variation (SVV). RESULTS: Infusion rate was 6.7 ml/kg/h and 11.5 ml/kg/h in the main and control groups, respectively. Morbidity rate was 28.6% (n=4) and 62.5% (n=10) in the main and control groups respectively. Clavien-Dindo IV complications were lung atelectasis (n=2, 14%), pneumonia (n=1, 7%). Hydrothorax required puncture was noted in 1 (7%) case. Acute respiratory failure as complication IVa was in 1 (9%) patient. In the control group complications were registered in 10 (62.5%) patients. Complications I-II degree included lung atelectasis (n=4, 25%), cervical anastomosis failure (n=1, 6%); complications IVa were observed in 8 cases (50%). It was significant respiratory failure with reduced PO2/FiO2<300. Patients of the main group required less time for postoperative mechanical ventilation (120 [90-300] vs. 315 [215-810] min (p=0.02) and ICU-stay (0.83 [0.7-0.8] vs. 1.75 [1.25-2.75] (p=0.0022).

[Jejunogastroplasty as an alternative method of gastrointestinal tract reconstruction after gastrectomy].

AIM: To prove the surgical safety and functional efficiency of jejunogastroplasty with duodenal passage preservation as an alternative method of gastrointestinal tract reconstruction after gastrectomy. MATERIAL AND METHODS: It was analyzed the results of treatment of 60 patients who underwent gastrectomy for stomach cancer for the period from September 2009 to May 2013. Two congeneric groups by 30 patients who underwent Roux-en-Y reconstruction (control group) and jejunogastroplasty (comparison group) were prospectively compared. RESULTS: Immediate results did not significantly differ in the both groups. Blood loss was 528±61.0 and 507±71.2 ml, incidence of complications--20.0 and 6.7%, frequency of esophagostomy failure--3.3% and 0, postoperative mortality rate--3.3% and 0, duration of postoperative hospital-stay--12.4±1.3 and 10.9±1.2 days respectively (p<0.05). In remote postoperative period the number of patients with stable body mass index or its positive changes was 52.9 and 81.8% in control and main groups, with dumping syndrome--47.1 and 9.1%, with diarrhea--35.3 and 4.5% respectively (p<0.05). Index of good state of health in main group was 68.2%, in control group--17.6% (p<0.05). In authors' opinion safety and physiological efficiency of jejunogastroplasty allow you considering its priority for primary reconstruction after gastrectomy and alternativeness to Roux-en-Y technique.

[Completion of esophagoplasty by means of transplant's remobilization].

Experience in completion of esophagoplasty by means of old transplant's remobilization in 54 patients is analyzed. Primary esophagoplasty in 52 patients was performed for burn stricture, 1 -- for traumatic stricture, 1 -- cancer of the esophagus. In 26 patients the cause of incomplete esophagoplasty was deficient length, in 11 -- necrosis, in 8 -- doubtful viability of transplant, in 7 -- insufficiency of esophageal anastomosis, in 2 -- prolonged obliteration of it. Total remobilization was performed in 41 patients, partial -- in 13. Thirty-six colic, 17 intestinal and 1 gastric transplants were used repeatedly. Esophagoplasty was completed in 50 patients, in 42 of them by one stage. In the rest 4 patients delayed pharyngoplasty was performed in the ENT clinic. One (1.8%) patient died in hospital due to insufficiency of proximal anastomosis and phlegmon of the thorax. Long-term result was studied in 40 patients: it was good in 25 patients, satisfactory -- in 12, bad -- in 3 patients.

[Experience in repeated esophagoplasty].

Experience in repeated esophagoplasty in 58 patients is analyzed. Fifty-four patients of them had reoperation because of incomplete plastic reconstruction, 4 patients -- because of artificial esophagus (cancer, papillomatosis, trauma) diseases. Primary esophagoplasty in 47 patients was performed due to burn stricture of the esophagus, in 9 -- due to cancer of the cardia and esophagus, in 1 -- due to peptic stricture, and in 1 -- due to leiomyoma of the esophagus. The causes of unsuccessful esophagoplasty were the following: necrosis of the transplant (28 patients), extensive obliteration of cervical anastomosis (6), insufficiency of intrapleural anastomosis (4), initially short length of the transplant (4), doubtful vitality of the transplant (1 patient). Subtotal repeated reconstruction of the esophagus was performed in 34 patients, total -- in 21, segmental (with a fragment of the intestine on a long vascular pedicle) -- in 3 patients. Left half of the colon was used as new material in 38 patients, small intestine -- in 12, ileocolon -- in 4, stomach -- in 3 patients. Repeated restrosternal esophagoplasty with left half of the colon was performed most often (27 patients). Reconstruction was completed in 55 patients. Complications were seen in 19 patients. There were no cases of hospital lethality. Long-term results were followed up in 49 patients, stricture of cervical anastomosis has diagnosed in 17 of them. Result of repeated esophagoplasty was good in 26 patients, satisfactory -- in 19, poor -- in 4 patients.

[Local esophagoplasty in patients with burn strictures of the esophagus]. / Mestnaia ézopfagoplastika u bol'nykh s ozhogovymi strikturami pishchevoda.

Local plastic reconstruction of short burn strictures of the esophagus (SBSE) was performed in 14 patients aged from 22 to 37 years, 9 were men, 5--women. Decreased body mass was revealed in all the patients, mass deficit over 20% was in 4 (28.6%) of them. SBSE located in the upper third of the esophagus in 9 (64.3%) patients, in middle third--in 5 (35.7%). Local esophagoplasty was performed from cervical approach in 9 (64.3%) patients, from right-sided thoracotomy--in 5 (35.7%). Dissection of SBSE with 3/4 anastomosis was performed in 5 (35.7%) patients; circulatory resection of esophageal stricture with end-to-end anastomosis--in 7 (50.0%); detour side-to-side anastomosis without stricture resection--in 2 (14.3%). There was no hospital lethality. Postoperative complications were seen in 14.2% cases. Long-term results were good in 10 (71.4%) patients, satisfactory (strictures of anastomosis)--in 3 (21.4%), unsatisfactory--in 1 (7.2%). Local esophagoplasty is indicated for patients with SBSE when bouginage and dilatation of stenosis are not effective.

[Surgical policy for patients with prolonged esophageal burn strictures]. / Lechebnaia taktika i vybor khirurgicheskogo lecheniia bol'nykh s protiazhennymi ozhogovymi strikturami pishchevoda.

Concept of early radical surgical treatment of prolonged esophageal burn strictures (PEBS) is presented. From 1980 to 2000 one-stage esophagoplasty was performed in 503 (62.0%) of 811 patients with PEBS. Bouginage was effective in 17.2% patients. Extirpation of the esophagus with posteriormediastinal plastic repair was performed in 119 patients. Mean age of patients was 48 years, mean anamnesis time--11 years. 13 (10.9%) patients had total PEBS. Combined burn of the stomach was revealed in 25 (21.0%), of the pharynx--in 4 (3.4%) patients. Isoperistaltic gastric tube was used in 102 (85.7%) patients, whole stomach--in 1 (0.8%), left half of the large intestine (antiperistaltic)--in 16 (13.4%) patients. Esophagectomy was performed transiatally in 114 (95.8%), from three approaches (+ right-sided thoracotomy)--in 5 (4.2%) patients. Transplant on the neck was connected with esophagus in 106 (89.1%) patients, with the pharynx--in 13 (10.9%). Combined operations were performed in 14 (11.8%) patients. Intraoperative complications were in 6 (5.0%), postoperative--in 39 (33.0%) patients. Insufficiency of cervical anastomosis was seen in 16 (13.4%), paresis of recurrent nerve--in 4 (3.4%) patients. Hospital lethality was 3.4% (4 patients). Good and satisfactory long-term results of esophagoplasty were achieved in 97 (97.0%) patients. PEBS is the indication for transhiatal extirpation of the esophagus with its one-stage plastic repair with gastric tube (or large intestine) during first 6 months after burn.

[50 years after ante-thoracic esophagoplasty]. / 50 let posle antetorakal'noi ézofagoplastiki.

Fifty years after antethoracic esophagoplasty the patient's quality of life was rather satisfactory.

[Radical surgical treatment of Barrett's esophagus]. / Radikal'noe khirurgicheskoe lechenie pishchevoda Barretta.

In the light of modern scientific knowledge, pathogenesis of Barrette's esophagus (BE) is presented as an integral neoplastic process. Indications to operation and policy of radical surgical treatment in BE, including in combined esophageal diseases (burn and peptic strictures, reflux esophagitis, short esophagus) were developed. From 1990 to 2000 radical operations were performed in 14 patients (11 males, 3 females) with BE. Mean age was 54.1 years. About 80% patients had clinical signs of reflux esophagitis at the moment of hospitalization. In all the patients the diagnosis of BE was verified in microscopic examination of operative material. 4 patients with cylindrical metaplasia associated with ulcers and esophageal peptic strictures were operated, 3 patients--with epithelium dysplasia, 7 patients--with adenocarcinoma. All the patients underwent extirpation of thoracic portion of esophagus with one-stage plasty with isoperistaltic gastric tube, supplemented with mediastinal and abdominal lymphodissection in cancer. Affection of the regional lymph nodes was revealed in 43% patients with esophageal adenocarcinoma. 50% patients had complications in postoperative period. There were no cases of hospital lethality. The expansion of indications for early surgical treatment of BE at the stage of meta-, and dysplasia, before adenocarcinoma development, is thought valid.