[Fluorescence navigation and angiography with indocyanine green in stomach cancer surgery]. / Flyuorestsentnaya navigatsiya i angiografiya indotsianinom zelenym v khirurgii raka zheludka.

OBJECTIVE: To evaluate the effectiveness of intraoperative angiography and fluorescence navigation with indocyanine green in reducing the risks of intra- and postoperative complications, as well as resection quality in patients with gastric cancer. MATERIAL AND METHODS: The main group consisted of patients who underwent intraoperative angiography and fluorescence navigation with indocyanine green (n=43). The control group included patients without these procedures (n=154). Both groups did not differ in gender (p=0.937) and age (p=0.437). The lower third of the stomach was the most common tumor location in the main group (62.7% of cases), the middle and lower thirds of the stomach - in the control group (37% and 38.9% of patients, respectively). There was no between-group difference in «cT¼ grading (p>0.05). However, there were more «cN+¼ patients in the main group (14 (32.6%) versus 28 (18.4%) ones of «N0¼ category, p=0.042). Therefore, 41.9% and 13.6% of patients underwent neoadjuvant chemotherapy in both groups, respectively (<0.001). RESULTS: Intraoperative angiography and fluorescence navigation with indocyanine green does not increase mortality (p=0.631), incidence of major (CD 3-5) (p=0.436) and minor (CD 1-2) postoperative complications (p=0.177), surgery time (p=0.288), mean intraoperative blood loss (p=0.144) and length of hospital-stay (p=0.631). Fluorescence navigation with indocyanine green does not affect the number of detected «positive¼ resection margins (R1) (p=0.883) but significantly increases the number of excised lymph nodes (p<0.001). CONCLUSION: Intraoperative angiography and fluorescence navigation with indocyanine green are safe for intraoperative visualization of tumor and lymph nodes, as well as assessment of arterial blood supply. This technique is effective in traditional and minimally invasive surgeries for gastric cancer. Fluorescence navigation with indocyanine green significantly increases the number of excised lymph nodes.

[First experience of applying domestic video fluorescent equipment for visualization and blood flow evaluation of the parathyroid glands]. / Pervyi opyt primeneniya otechestvennoi videoflyuorestsentnoi ustanovki dlya vizualizatsii i otsenki krovotoka okoloshchitovidnykh zhelez.

In recent years, predictive methods for assessing the preservation of the parathyroid glands have been actively implemented. The article describes the first experience of evaluating the blood supply of the parathyroid glands by quantitative determination of the indocyanine green (ICG) accumulation index in real time in 6 patients before and after a thyroidectomy with central neck lymph node dissection for papillary thyroid cancer. Intraoperative fluorescent angiography was performed by using domestic equipment with a fluorescent module, as well as by using a domestic medication of ICG. Intraoperative values of the ICG accumulation index were compared with the levels of ionized calcium and parathyroid hormone perioperatively. No clinical manifestations of hypocalcemia were detected in the postoperative period. The obtained results showed the informativeness of the numerical assessment of the intensity of ICG fluorescence. The evaluation of the distribution (accumulation) of ICG has prospects for practical application in thyroid surgery in the formation of tactics for preserving the parathyroid glands and predicting postoperative hypoparathyreosis.

[Transaxillary minimally invasive Zenker's diverticulectomy]. / Transaksillyarnoe endovideokhirurgicheskoe udalenie divertikula Tsenkera.

We evaluated the possibility and effectiveness of transaxillary gas-free approach for minimally invasive Zenker's diverticulectomy. A 64-year-old patient with large Zenker's diverticulum (6 cm) and pathognomonic symptoms is presented. Transaxillary gas-free minimally invasive diverticulectomy was performed using an endoscopic linear stapler. Surgery time was 137 min. There were not any postoperative complications including recurrent laryngeal nerve injury. X-ray examination after 2 postoperative days revealed no signs of anastomotic leakage, so the patient was allowed to drink and consume liquid food from the 3rd day. Patient was discharged on the 7th day. Minimally invasive surgical technology ensures effective and radical transaxillary diverticulectomy in patients with Zenker's diverticulum. The advantages of this method are good and detailed exposition of surgical field, including recurrent laryngeal nerve, more precise and less invasive manipulations and better cosmetic effect. The method may be an alternative to traditional and endoscopic diverticulectomy for a certain group of patients. However, experience accumulation and further prospective studies are required.

[Initial experience of robot-assisted minimally invasive McKeown esophagectomy]. / Pervyi opyt robot-assistirovannykh subtotal'nykh rezektsii pishchevoda po McKeown.

OBJECTIVE: To report our initial experience of robot-assisted McKeown esophagectomy with stapled cervical esophagogastrostomy. MATERIAL AND METHODS: There were 5 robot-assisted McKeown esophagectomies in patients with benign end-staged and malignant diseases of the esophagus for the period from October 2019 to February 2020. RESULTS: No conversions and intraoperative complications were observed. Mean surgery time was 406±48 min, total intraoperative blood loss - 108±45 ml. Four patients had minor complications (wound infection, atelectasis, pneumothorax) that required conservative treatment. We have controlled anastomosis in 2-3 postoperative days with water-soluble contrast, none patient had an anastomotic leakage. Mean hospital-stay was 5 days. Complete (R0) resection was accomplished in all patients with malignant neoplasms. CONCLUSIONS: Our first experience showed that robot-assisted McKeown esophagectomy is a safe and feasible surgical option for esophageal diseases. Robot-assisted interventions require advanced endoscopic surgical experience.

[Simultaneous laparoscopic procedures in patients with synchronous multiple primary gastric and kidney cancer]. / Odnomomentnye laparoskopicheskie operatsii u bol'nykh s pervichno-mnozhestvennym sinkhronnym rakom zheludka i pochki.

OBJECTIVE: To evaluate an effectiveness of simultaneous laparoscopic procedures in patients with synchronous multiple primary cancer (SMPC). MATERIAL AND METHODS: We observed 3 patients (2 men and 1 woman) aged 61-78 years with synchronous multiple primary gastric and kidney cancer. Gastric tumors were localized in the lower third of the body (1) and the antrum (2), histological structure corresponded to adenocarcinoma G1 (1) and G2 (2). Kidney tumors were verified as light cell carcinoma and localized in the upper segment of the left kidney in 2 patient and right kidney in one patient. Mean dimension of tumor scheduled for resection was 4.65 cm, nephrectomy - 10.3 cm. Complexity of resection according to the RENAL scale was equal to 8 and 10. RESULTS: Three patients underwent laparoscopic Billroth-I distal gastrectomy, 2 - kidney resection and one patient - nephrectomy. Mean surgery time was 265±37 min, blood loss - 175±29 ml. There were no conversion and redo interventions within 30 days after surgery. Mean hospital-stay was 11±2 days. CONCLUSION: Minimally invasive technologies in patients with SMPC reduces blood loss, ICU- and hospital-stay. Earlier rehabilitation ensures the next stage of treatment in early postoperative period, while quality of life is better in comparison with traditional interventions.

[Laparoscopic and robot-assisted procedures in patients with gastrointestinal stromal tumors (GIST) of stomach]. / Laparoskopicheskie i robot-assistirovannye operatsii u bol'nykh gastrointestinal'noi stromal'noi opukhol'iu zheludka.

OBJECTIVE: To analyze the results of minimally invasive surgical procedures in patients with gastric GIST. MATERIAL AND METHODS: The study included 30 patients aged 52.2±9.8 years. ASA grade II (44%), III (26%) and I (23%) were predominant. Lesion of stomach body was noted in 17 (56%) patients, antrum - in 8 (27%), fundus - in 2 (7%) and cardia - in 3 (10%) patients. GIST was located on the anterior wall of stomach in 56% of patients. Exophytic growth was observed in 16 (53%) patients, endophytic - in 12 (40%), transmural growth - in 2 (7%) cases. T2 grade of tumor was noted in 67% of cases (TNM 8). All patients underwent laparoscopic or robot-assisted ('daVinci Si') partial resection of the stomach. RESULTS: Radical resection (R0) without injury of pseudocapsule of tumor was made in all patients. Laparoscopic procedures were performed in 25 (83%) patients, robot-assisted - in 5 (17%). Early postoperative complications (Clavien-Dindo II) were observed in 3 patients. Spindle cell structure of tumors (93%) with low mitotic activity (63%) prevailed. Tumor stage I was observed in 56% of patients. Patients with high mitotic tumor index (44%) were directed to targeted therapy. Recurrence and/or metastasis in long-term period were absent in 26 (87%) patients. CONCLUSION: Laparoscopic surgery for gastric GIST is safe and characterized by the absence of significant postoperative complications and long-term recurrence-free period. The use of robotic surgical system is effective and justified for anatomically difficult localization of GIST.

[Laparoscopic appendectomy for mucinous cystadenoma of the appendix]. / Laparoskopicheskaia appendéktomiia pri mutsinoznoi tsistadenome cherveobraznogo otrostka.

Treatment of acute and chronic appendicitis is still an actual problem. There are some rare courses of the disease besides well-known complications of appendicitis. Mucocele is one of the rarest forms of chronic appendicitis. Mucocele is not accompanied by clinical symptoms and diagnosed accidentally in more than 25% of cases. The most serious complication of mucocele of the appendix is malignization observed in up to 36% of cases. Ultrasound, CT and colonoscopy are the most effective methods of perioperative diagnosis. Unclear symptoms, delayed diagnosis and surgical treatment increase the risk of complications (i.e. cystadenocarcinoma).

[Treatment of reflux esophagitis in patients with cardiofundal, subtotal and total hiatal hernias]. / Lechenie refliuks-ézofagita u bol'nykh s kardiofundal'nymi, subtotal'nymi i total'nymi gryzhami pishchevogo otverstiia diafragmy.

AIM: To analyze treatment of patients with reflux esophagitis and large hiatal hernia. MATERIAL AND METHODS: There were 85 patients with reflux esophagitis and large hiatal hernia. Laparoscopic repair was performed in 33 patients, laparotomy - in 52 cases. All patients underwent fundo- or gastroplication by A.F. Chernousov, correction of large defect of hiatal orifice by cruroraphy was applied in 55 (64.7%) patients. RESULTS: Postoperative morbidity was near 10% after laparoscopic and conventional surgery despite more difficult video-assisted endoscopic technique. Complications Clavien-Dindo grade I-II were noted in 4 (12.1%) patients after laparoscopic treatment and in 6 (11.5%) patients after laparotomy. Medication was effective in all cases. Two patients with subtotal hernias had complications Clavien-Dindo grade IIIB after endoscopic surgery: recurrent hiatal hernia followed by severe reflux esophagitis and dysphagia. These complications required redo surgery. Repair of hiatal orifice is always possible without mesh reinforcement. Posterior cruroraphy is feasible and effective in all patients. Incidence of intraoperative and postoperative complications is comparable in both approaches (p<0.05). Mean hospital-stay after laparotomy was 7.3 days, after laparoscopy - 5.8 days. CONCLUSION: Endoscopic formation of antireflux cuff by A.F. Chernousov is appropriate and effective in patients with reflux esophagitis and large/giant hiatal hernias.

[Laparoscopic and robot-assisted surgery for locally advanced and generalized stomach cancer]. / Laparoskopicheskie i robot-assistirovannye operatsii pri mestno-rasprostranennom i generalizovannom rake zheludka.

AIM: To analyze the first experience of laparoscopic and robot-assisted surgery for locally advanced and generalized stomach cancer at the Burdenko Clinic of Faculty Surgery. MATERIAL AND METHODS: Since 2011 27 laparoscopic and 2 robot-assisted operations for locally advanced and generalized stomach cancer have been performed in our hospital. Mean age of patients was 62.1±10 years. There were 19 men and 10 women. RESULTS: There were 11 gastrectomies with abdominal esophageal resection and 18 Billroth I subtotal resections. Advanced surgery was made in 4 (13.7%) patients including 1 case of transverse colon resection and 3 cases of liver resection. Mean time of surgery was 260 min (180-380 min) in gastrectomy, 210 min (175-310 min) in subtotal resection. Mean intraoperative blood loss was 120 ml (50-220 ml). CONCLUSION: Minimally invasive technologies reliably reduce blood loss, rehabilitation, ICU- and hospital-stay. The quality of life after minimally invasive interventions is significantly higher compared with conventional surgery while reduced rehabilitation allows to start chemotherapy already in early postoperative period.

[Quality of life of patients with complicated reflux-esophagitis followed antireflux surgery]. / Kachestvo zhizni bol'nykh, operirovannykh po povodu refliuks-ézofagita i ego oslozhnenii.

AIM: To analyze quality of life of patients with complicated reflux-esophagitis followed antireflux surgery. MATERIAL AND METHODS: The trial enrolled 200 patients who underwent surgical treatment at the Burdenko Faculty Surgery Clinic of Sechenov First Moscow State Medical University for complicated reflux esophagitis from 2008 to 2015. Inclusion criteria were long-standing reflux esophagitis irresistible to conservative treatment, hiatal hernia with shortening of the esophagus and/or peptic stricture and/or Barrett's esophagus. Patients were divided into 2 groups according to the degree of esophagus shortening: group I - 98 patients with esophagus shortening degree I; group II - 102 patients with shortening grade II. Men/women ratio was 87(43.5%)/113(56.5%). Mean age was 56.0±13.9 years (16-83 years). We performed fundoplication in A.F. Chernousov modification in the first group and modified valvular gastroplication in the second group. All patients underwent survey within 6 months - 10 years after surgery to assess long-term outcomes. X-ray examination, upper GI endoscopy, standard laboratory tests were performed with pH-impedance and computed tomography if it was necessary. Quality of life was estimated by RAND SF-36 and GSRS (Gastrointestinal Symptom Rating Scale) questionnaires. RESULTS: SF-36 questionnaire revealed postoperative changes of physical, psychological and social values and was able to compare them with those in general population. Postoperative overall health was significantly higher in both groups compared with preoperative level and comparable with general population. GSRS questionnaire have also revealed positive changes. Overall postoperative GSRS score was 1.6±0.5 and 1.6±0.6 points in groups I and II respectively that corresponds to minor concern after surgery.

[The molecular genetic alterations in mucosa of intestines as markers of oncologic progression and estimate of effectiveness of anti-reflux operations in patients with Barrett's esophagus].

The development of disease of Barrett's esophagus is based on processes of metaplasia of epithelium of esophagus when as a result of reflux of gastric juice and bile acids the normal planocellular epithelium of esophagus is replaced by cylindrical epithelium of intestinal type. Thereupon, Barrett's esophagus is progressing up to dysplasia and adenocarcinoma of esophagus. The progression from precancerous states up to tumor is related to development of genome disorders in cells associated with malignant transformation. The genetic and epigenetic alterations conditioning tumor growth can be used as markers of prognosis of clinical course of disease. To receive possible markers of progression of Barrett's esophagus the study was organized concerning methylation of such genes-suppressors of tumor growth as MGMT, CDH1, p16/CDKN2A, DAPK, RAR-ß and RUNX3 in patients with Barrett's esophagus and adenocarcinoma of esophagus. The effectiveness of applied anti-reflux surgical treatment was evaluated too. The abnormal methylation of studied genetic panel in patients with Barrett's esophagus prior to surgical treatment was observed reliably more frequently in altered epithelium as compared with unaltered epithelium (p<0.0001), under dysplasia as compared with metaplasia (p<0.0358) and in the presence of long (>3 cm) segments of altered epithelium as compared with short (<3 cm) segments (p=0.0068). In normal epithelium, prior to operation, abnormal methylation of panel of genes was detected in 7/60 (12%) of patients. Against the background of surgical treatment number of long and short segments of altered epithelium of esophagus reliably decreased (p<0.05). At that, in short segments after operation rate of methylation increased significantly (p=0.0068). Though after operation number of patients with Barrett's esophagus and dysplasia and metaplasia decreased, the rate of abnormal methylation in the other patients increased. It is demonstrated that anti-reflux operation ameliorates condition of mucous membrane of esophagus under Barrett's esophagus. However, in cases without regression significant increasing of rate of abnormal methylation of studied panel of genes is occurred. This is a proof that abnormal methylation of system of genes is related to worse response to application of anti-reflux surgical treatment.

[Reflux esophagitis in patients with short esophagus].

Pathogenesis, pathophysiology and mechanisms of esophagus contraction by reflux esophagitis and hiatal hernia are analyzed. Modern treatment modalities of the condition are critically reviewed. Stated, that fundoplication in RSSC modification combined with selective proximal vagotomy are indicated for the treatment of esophageal contraction stage I. Valvular gastroptyxis is indicated when esophageal contraction stage II is diagnosed. Results of valvular gastroptyxis in 10 patients are analyzed. The treatment tactics should be determined by the degree of esophageal contraction, severity of inflammatory and sclerotic changes of the organ and the functional reserve of the esophageal motility.