[UROLOGY LESSONS FOR COLORECTAL SURGEONS].

The anatomical and functional relationship of the pelvic organs is a prerequisite to the development of complications when performing surgical procedures in this anatomical region. Prevention and timely diagnosis of intraoperative injuries of both the urinary system organs and intestine, as well as well-coordinated work of urologist and colorectal surgeon team offer the opportunity to employ optimal tactics for the patient management.

[Survival rate after D3-lymphadenectomy for right-sided colic cancer: case-match study].

UNLABELLED: The aim of the study was to compare the effectiveness of D3-lymphadenectomy in compliance with «no-touch¼ principle and mesocolectomy with traditional hemicolectomy in patients with right-sided colon cancer. MATERIAL AND METHODS: It is retrospective-prospective comparative case-match study. From prospectively collected database patients with right-sided colon cancer stage I-III treated in 2009-2013 without adjuvant chemotherapy were selected. Patients who underwent conventional right-sided hemicolectomy with D2-lymphadenectomy in the regional oncologic dispensary formed the first group. The second group included patients after right-sided hemicolectomy with D3-lymphadenectomy, «no-touch¼ principle and mesocolectomy performed in academic hospital of the third level. From both groups 'case-match' patients by gender, age, stage and location of primary tumor were selected. Each group consisted of 50 patients. RESULTS: Overall and cancer-related 5-year survival was significantly higher in the second group - 80.9% vs. 56.0% (p=0.01) and 93.4% vs. 59.8% (p=0.01), respectively. CONCLUSION: D3-lymphadenectomy and mesocolectomy for right-sided colon cancer stage I-III without adjuvant chemotherapy provides significantly better overall and cancer-related 5-year survival compared with conventional right-sided hemicolectomy. Thus, D3-lymphadenectomy and mesocolectomy in compliance with «no-touch¼ principle for right-sided colon cancer is reproducible and effective in Russian conditions.

[Early complications after surgery for middle- and lower-ampullar cancer: total mesorectumectomy or "blind" preparation of rectum?].

It was performed a comparative analysis of parameters of early postoperative period in 318 patients with middle- and lower-ampullar cancer of rectum who underwent total mesorectumectomy and "blind" preparation of rectum. All patients were divided into 2 groups. The main group included 202 patients after total mesorectumectomy. The control group included 116 patients after "blind" preparation of rectum. Statistically significant differences in frequency of laparotomy wounds suppuration, urinary tract dysfunction and postoperative mortality were revealed. These complications were diagnosed more frequent in case of "blind" preparation of rectum. In the main group laparotomy wounds suppuration depended on sex (p<0.001, r=0.65), in the control group - on surgeon's experience (p=0.006, r=0.58), localization of tumor (p<0.001, r= -0.87) and type of surgery (p<0.001, r= -0.76). Urinary tract dysfunction after total mesorectumectomy depended on patient's sex (p<0.001, r=-0.77), after "blind" preparation of rectum - sex (p=0.002, r= -0.39) and performing of preoperative radiation therapy (p<0.001, r=0.46). In the main group none of the analyzed variables effected on the postoperative mortality. In the control group age (p=0.006, r=0.48), intraoperative blood loss (p=0.002, r=0.55), anastomosis failure (p=0.01, r=0.61), postoperative bleeding (p<0.001, r=0.88), early adhesive intestinal obstruction (p=0.006, r=0.77) effected on the mortality. It is considered that total mesorectumectomy in comparison with "blind" preparation of rectum decreases frequency of postoperative complications and mortality.

[Successful anaesthesia for abdominal reconstructive surgery in a myasthenia gravis patient].

This article presents a clinical case of colon disease surgical treatment in a 34-year old patient with. generalized myasthenia. Perioperative management peculiarities in these patients are clarified. Different approaches to anaesthesia choice were discussed on a case study. The importance of tactics individualization, rational drugs selection, including neuromuscular block reversal agents as well as intraoperative neuromuscular transmission monitoring.

[Expression of some biomarkers in primary colon adenocarcinomas and their lymph node metastases].

The samples of colon adenocarcinomas (CAC) and their lymph node metastases from 22 patients were studied. The expression of thymidylate synthase (TS), vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR), E-cadherin, beta-catenin, tenascin C (TN), and KAI-1/CD82 in primary CAC and their lymph node metastases was compared using an immunohistochemical method. The expression of TS, VEGF, EGFR, E-cadherin, TNC, and KAI-1 was statistically significant different in primary CAC and involved lymph nodes. Comparison of the expression of the markers in the pairs of primary CAC and metastasis revealed equal values for TNC and EFGR in 45.5 and 41% of cases, respectively; the number of coincidences in the expression of the other markers was insignificant. Determination of the expression of molecular biological markers in primary CAC and their lymph nodes may serve as a predictor of therapy response and have a prognostic value.

[Molecular markers of colorectal adrenocarcinoma progression].

Colorectal adenocarcinoma and its lymph node metastases from 72 patients and 14 control samples were studied. Expression of adhesive molecules - E-cadherin and beta-catenin, antiadhesive molecule - tenascin C and tumor metastasis suppressor KAI-1 (CD82) were studied by immunohistochemistry. The expression of E-cadherin and beta-catenin, tenascin C and KAI-1 was significantly different in adenocarcinoma and control samples. The expression of E-cadherin, tenascin C and KAI-1 was diverse in primary tumor compared to lymph node metastases. The analysis of current data showed the association of E-cadherin expression with stage of disease and depth of invasion, such as the correlation of beta-catenin nuclear expression and tenascin C expression with depth of adenocarcinoma invasion. These data may be a useful indicator of disease progression.

[The paraaortic lymphadenectomy with the lower mesenteric artery sceletonization for the sigmoid cancer treatment].

43 patients with sigmoid cancer stage I--III were operated on. The mean operative time was 206.2±73.0 min, considering the sceletonization of the lower mesenteric artery together with the paraaortic lymphadenectomy took 28±9 min. The long-term follow-up was performed in all the patients. The median follow-up time was 39.35±13.1 months. 4 patients had died, 3 of them because of the cancer progression. The paraaortic lymphadenectomy with the lower mesenteric artery sceletonization is now considered to be the method of choice in treatment of sigmoid cancer. The operation is reasonably safe considering the rate of intra- and postoperative complication rate.

[The primary tumour resection with extended D3 lymph node dissection, metastases of synchronous metastatic colorectal cancer].

The progress in colorectal cancer treatment of IV stage that was shown in last decades was mainly due to modern chemotherapy schemes and aggressive surgical approach towards distant metastatic lesions. Meanwhile less attention is paid to primary tumour treatment - the questions of necessity and volume of its resection are still open. The AIM of this study was to evaluate safety and oncologic effectiveness of primary tumour resection with D3 lymph node dissection in synchronous metastatic colorectal cancer. Patients with colorectal cancer and synchronous metastatic lesion of distant organs who underwent surgical resection of primary tumour were chosen from prospectively collected department database. The analysis of short-term and long-term results of resections with and without extended D3 lymph node dissection and prognostic factors affecting overall survival was carried out. From 2006 to 2011 total of 190 patients underwent primary tumour resection, 157 (82.6%) among them - with extended D3 lymph node dissection. Twenty one patient (11%) developed postoperative complications that required reintervention, 30-days mortality rate was 2.6%. Three-year cumulative overall survival was 37%, median survival - 22 months (25 months with extended lymph node dissection and 4 months without, p<0.001). Univariate analysis revealed following statistically significant prognostic factors improving overall survival: metastatic lesions in one distant organ, solitary haematogenous nodes, extended D3 lymph node dissection, postoperative chemotherapy, resection of metastatic lesions. Removal of primary tumour with extended lymph node dissection in metastatic colorectal cancer doesn't increase the number of postoperative complications and mortality. Performing D3 lymph node dissection favours increase of median survival and is a significant prognostic factor influencing outcomes.

[Surgical treatment of rectocele with the use of mesh implants by the obstructive defecation syndrome].

UNLABELLED: The aim of current study was to evaluate in complex the effectiveness of transvaginal mesh implants in women with obstructed defecation (OD) syndrome based on the comparison of preoperative and postoperative results of objective diagnostic tools and quality of life parameters. METHODS: from prospectively collected database of patients treated in our department those who were treated for OD by means of transvaginally placed mesh implants were chosen. The comparison of pre- and postoperative results of objective evaluation (prolapse stage according to POP-Q system, X-ray defecography - XR-DG and MRI defecography - MRI-DG) as well quality of life parameters (Wexner constipation score and validated Russian version of King's Health Questionnaire) was undertaken. Treatment effectiveness was evaluated using Сlinical Global Impression - Improvement (CGI-I) и Patient Global Impression - Improvement (PGI-I) scales. RESULTS: In 2007-2011 40 women (mean age 51.8±10.7 years) underwent transvaginal pelvic floor reconstruction with mesh implants. All of them had ≤3 stage pelvic prolapse (POP-Q) and rectocele. Preoperative XR-DG and MRI-DG helped reveal rectocele >4 cm in 85 and 43% of women respectively, 68% of patients had cystocele and 18% - genital prolapse. In 21 case mesh implants for posterior pelvic floor reinforcement were used, in other cases mesh implants for total pelvic floor repair were placed. At a mean of 19 months after the operation manual examination revealed that 90% of women had 1 stage posterior pelvic proplapse, at XR-DG and MRI-DG significant reduction of rectocele size and depth of pelvic floor descent was noted. Besides that significant decrease in mean values of Wexner constipation score and King's health questionnaire was demonstrated. Though mean values of global treatment effectiveness assessment on CGI-I and PGI-I scales didn't significantly differ (2.13±0.85 и 2.68±1.42, р=0.06), the rate of agreement between these scales measured at each single case was very low (κ-0.154), this reflects that clinician has more positive perception of disease dynamics due to treatment than the patient. When mean values of dynamics in different indexes of King's health questionnaire were compared it was demonstrated that the index of quality of life influence (3.53±0.96) was significantly higher than the indexes of OD influence (2.63±1.08) and mechanical symptoms (2.58±1.04), this suggests that while the manifestations of OD syndrome are significantly improved patient quality of life doesn't change substantially. CONCLUSIONS: XR-DG is more specific than MRI-DG in evaluating the size of rectocele and the depth of pelvic floor descent; the use of mesh implants in surgical treatment of OD syndrome results in significant reduction of rectocele and prolapse stage in 90% of patients; clinical evaluation of treatment effectiveness based on objective examination is more optimistic than subjective perception of treatment results by the patient, this indicates that anatomic correction does not always lead to quality of life improvement.

[The efficacy of the multidisciplinary approach in colorectal cancer surgery in elderly patients].

Publications of the last few years indicate a steady rise of colorectal cancer in the world. Colorectal cancer is on the second place in the structure of oncological mortality in developed countries, including Russia. The majority of colorectal cancer deaths (up to 50%) occur in elderly. The octogenarians are more likely to have comorbidities and age-specific deteriorating organ function, which could make their tolerance of surgery. To determine the short- and long-term outcomes of the multidisciplinary approach in elective colorectal surgery in patients ≥75 years of age. A review 70 octogerians who underwent colorectal cancer surgery between April 2006 and November 2010 was performed from prospectively collected database. The median age was 79 (75-95) years. Every patient was examined by multidisciplinary team before surgery. Conservative therapy was prescribed or corrected if any organ failure detected. After the period of treatment decision on their suitability for surgery was made. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates. The mean index of comorbidity was 7.3 (6-11) and 81% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM scoring model was 14.8%. All patients with comorbidities were treated conservatively during mean period of 12.2 days, nine patients (13%) required implantations of pacemakers to control heart rate in perioperative period. In 64 (91%) cases surgical resection of the colon or rectum with primary anastomosis were performed, in 6 (9%) - abdominoperineal resection of the rectum and in two cases - Hartmann's operation. Postoperative complications were noticed in 40 (57%) cases. Postoperative mortality rate (death within 30 days of surgery) was 5.7%, the 2- and 3-year overall survival rate according to Kaplan and Meier was 78.3±5.6% and 74.9±6.3% respectively. Using the multidisciplinary approach in the management of elderly allows reaching the acceptable mortality level (5.7% in comparison with predicted 14.8%) and high 2- and 3-year survival rates. This means that chronological age alone should not be contraindication to the elective curative surgery of colorectal cancer in elderly if overall assessment of the perioperative risk is possible. The study aimed to asses the intermediate and long-term results of the multidisciplinathe colorectal cancer in elderly patients. 70 patients, aged 75-95 years, were prospectively chosen to participate the study. The comorbidity Charlson index and ASA scale were used to measure the perioperative risks. The CR-POSSUM scale was used for postoperative lethality rating. The use of the above listed scales and measurements in combination with multidisciplinary conservative preaparation of patients before the operation allowed to achieve the satisfactory lethality rate of 5.7% and higher long-term survival rates after the colorectal surgery.

[The combined abdomenotranssacral access for the extralevator rectum extirpation].

Technique of the extralevator abdomenoperineal rectum extirpation with the use of the combined abdomenotranssacral access is thoroughly described in the article. The radicality of the procedure and the immediate results has been evaluated in 27 patients with the lower ampullary rectum and anal canal cancer. The average blood loss was 625±288 (300-3500) ml. The soft tissue defect was replaced with the use of unilateral rotated gluteus maximus muscle (n=21), bilateral rotated gluteus maximus muscle (n=6). Tumor-free resection line was registered by the morphological investigation of the resected tissues in 25 cases. Long-term results (13.2±3.1) (2-22 months)) were obtained in 24 patients. The obtained results of the postoperative morbidity and survival rates allow to consider the described method as a safe and appropriate surgical procedure.

[Immunity and cytokine status after surgeries on the large intestine].

The aim of our study was to examine the effect of individual schemes of multimodal analgesia on indicators of immunity and inflammation markers after operations on the colon. Patients of group 1 (n=15) received paracetamol, lornoxicam and epidural ropivacaine, 2nd group of patients (n=15)-paracetamol, epidural ropivacaine and tramadol. Comparison group (n=10) patients underwent patient controlled analgesia by promedol. Before surgery, 1st and 3rd days after surgery we examined the contents of cytokines in plasma: interleukin 12p70, interleukin 10, interleukin 6, and TNF. Before surgery and at 5-7 days after surgery indicators of cellular, fagocytal and humoral immunity were monitored. Before surgery patients with colorectal cancer revealed changes in the indices of different components of immunity, as well as an increase in pro-and anti-inflammatory cytokines compared with healthy donors. Multimodal analgesia in patients after operations on the colon is not accompanied by changes in plasma concentrations of cytokines and parameters of immune status in comparison with monoanalgesia by promedol.

[Simultaneous coronary bypass grafting and hemicolectomy].

The simultaneous surgical treatment of ischemic heart disease (coronary bypass grafting) and ascending colon cancer (right hemicolectomy) is described. Literature review showed that these simultaneous surgical heart and colon procedures are reasonable and should become a method of choice for such patients.

[Molecular-genetic analysis of clonal intratumoral heterogeneity on colorectal adenocarcinomas].

We have examined the existence of intratumoral genetic heterogeneity for LOH on chromosomes 9p21 (p16, p15, p19), 13p14 (RB1), 10q23 (PTEN), 17p (TP53), microsatellite instability and K-RAS point mutations on four different segments of sporadic colorectal cancers. The intratumoral genetic heterogenity was detected in 9/11 (81%) colorectal adenocarcinomas and morphologically validated. These results show that colorectal cancer is highly heterogeneous for these molecular markers. Furthermore, the analysis has shown the order (succession) of the appearance of these molecular anomalies during tumorigenesis on sporadic CRC, and supposed, that K-RAS point mutations, and anomalies of p16-RB1-cyclin D pathway could occur before LOH on 10q23 (PTEN) and microsatellite instability during tumor progression.

[Methodology of clinical studies in surgery].

Results of clinical studies recently became the guidelines in decision making in medicine including surgical practice. Results of each study could be used generally only if all methodological requirements are fulfilled. In this paper the principles of clinical studies design particularly in surgery and medical publications analysis are described and discussed.

[Expression of type 1 and type 2 mucins in colonic epithelial tumors].

Expression of MUC-1 and MUC-2 was investigated with immunohistochemical staining (PAP-method) in 5 cases of adenomas and in 60 cases of colorectal adenocarcinomas. The expression of MUC-1 and MUC-2 can be useful for diagnosis and prognosis in patients with colorectal carcinoma.

[Nerve-preserving operations in surgery of rectal cancer].

Forty-eight patients underwent surgery for rectal cancer. In all the patients total mesorectumectomy was combined with one of the types of nerves-preserving surgeries. Three groups were divided depending on types of this surgery: 1-- complete preservation of elements of autonomic nervous system (n=31), 2 -- partial preservation (n=16), 3 -- complete ablation (n=1). In 30 patients of group 1 normal urination recovered on postoperative day 2 to 4. In 2 patients of group 2 stable atony of urinary bladder was seen, and in 2 patients -- reflex ischuria. In patient of group 3 normal urination recovered on day 14 after surgery without vesical tenesmus. Long-term results were assessed in 1 to 12 months. No recurrences occurred. It is concluded that nerve-preserving surgeries improve functional results without loss of oncological radicalism.

[Deodorant gaskets for colostomy patients]. / Issledovanie dezodoriruiushchikh prokladok dlia bol'nykh s kolostomoi.

The results of the experiments for the objective evaluation on a model system of the protective effect of deodorant gaskets on colostomy patients are given. It has been determined that the deodorant capacity of the above gaskets is more than two times higher than that of its "washer filter" analog manufactured by the foreign "Coloplast" company.

[Aortoiliopelvic lymphadenectomy in surgical treatment of rectal cancer]. / Aortopodvzdoshno-tazovaia limfadenéktomiia v khirurgii raka priamoi kishki.

The results of aortoiliopelvic lymphadenectomy in macroscopic changes in lymphatic nodes being revealed intraoperatively in 73 patients with locally spread rectal cancer, are represented. Morphological examination of the removed tissues made it possible to reveal metastatic involvement of paraaortal and iliac lymphatic nodes in 57.3% of patients. In 36.9% of cases combined radical operations were performed. There were no lethal outcomes. Postoperative complications were detected in 37.9% of cases, among them atony of the urine bladder in 30.1% and inflammatory processes in pelvic cavity--in 8.2%. And in 9 men with normal sexual potency before the operation it resulted in impotency after surgery. 5-year survival made up 27.4% including cases with metastatic involvement of lymphatic nodes--19.3%, and without it--35.7%.