[Full-wall semi-circular mobilization of posterior wall of the lower ampullar rectum for complex recurrent anorectal fistula]. / Polnostennaya polutsirkulyarnaya mobilizatsiya zadnei stenki nizhneampulyarnogo otdela pryamoi kishki kak metod lecheniya slozhnykh retsidivnykh anorektal'nykh svishchei.

OBJECTIVE: To describe a new technique for closure of sphincter complex defects after excision of recurrent high rectal fistulas and compare with other traditional techniques. MATERIAL AND METHODS: We retrospectively analyzed patients operated on for recurrent posterior rectal fistula. All patients underwent fistulectomy and one of the methods for defect closure after excision of the fistula: sphincter suturing, muco-muscular flap or full-wall semicircular mobilization of the lower ampullar rectum. The last method implemented the principle of inter-sphincter resection in rectal cancer. We developed this method as an alternative to muco-muscular flap in patients with fibrosis of anal canal to form a full-thickness well-vascularized flap without tissue tension. RESULTS: Between 2019 and 2021, 6 patients underwent fistulectomy with sphincter suturing, 5 patients - closure with muco-muscular flap, 3 males underwent full-wall semicircular mobilization of the lower ampullar rectum. There was a tendency to better continence after a year (1 (0, 1.5), 1 (0, 1.5) and 3 (1, 3) points, respectively). Postoperative follow-up period was 12.5 (10, 15), 12 (9, 15) and 16 (12, 19) months, respectively. None patient had signs of recurrence throughout the follow-up period. CONCLUSION: Original technique can be considered as an alternative to standard approaches in patients with high recurrent posterior anorectal fistulas, when traditional displaced endorectal flap is ineffective or impossible due to excessive scarring and anatomical changes in the anal canal.

[Surgeon's role in CT-based preoperative determination of inferior mesenteric artery anatomy in colorectal cancer treatment]. / Rol' khirurga v opredelenii anatomii nizhnei bryzheechnoi arterii po dannym komp'yuternoi tomografii pri lechenii kolorektal'nogo raka.

BACKGROUND: The inferior mesenteric artery (IMA) is a blood vessel of great importance in left colon and rectal cancer surgery. We aimed to determine the role of surgeons in computed tomography (CT) based vascular anatomy interpretation. METHOD: Patients with left colon and rectal cancer treated surgically with D3 lymph node dissection and selective vascular ligation were included in this study. All patients (n=250) underwent preoperative CT with intravenous contrast. The IMA anatomy was schematically depicted by surgeon based on CT interpretation. Intraoperatively anatomy was defined by skeletonisation of the IMA. All patients had segmental resection with selective vascular ligation. The concurrence of prospectively obtained results were evaluated by intraclass correlation and Kendall's tau-b test. Misinterpretation of IMA anatomy was analysed by CT-specialist. RESULTS: The preoperative and intraoperative IMA anatomy features were correctly interpreted in 237 cases (in 94.8%) within skeletonisation extent, which is supported by high level of agreement and concordance of preoperative data regards to intraoperative findings (K=0.926; p<0.001; CC=0.912; p<0.001). As a result of the CT-based evaluation of the IMA, E, K, and H types of branching patterns were proposed. IMV position was mistakenly identified in 2.6% of cases. CONCLUSION: Surgeons are able to evaluate the IMA anatomy accurately with CT and use it in routine preoperative planning. The E, K, and H branching types may be used when defining approach to skeletonisation and level of vascular ligation.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

[E.coli bacterial suspension in the treatment of hemorrhoids]. / Vozmozhnosti ispol'zovaniya preparatov suspenzii kul'tury bakterii E.coli v lechenii gemorroya v svete sovremennykh kontseptsii.

Hemorrhoidal disease is the most common proctologic disease and the search for new treatment methods, as well as an in-depth understanding of the mechanisms underlying effects of well-known agents on disease pathogenesis still remain relevant. There have been long recognized the effects of the E.coli bacterial culture suspension (BCS) as a therapeutic means eliciting decreased exudation during inflammation, wound healing, tissue regeneration, and stimulated immunity. Here, based on recent findings related to innate and adaptive immune cells, we set out to present mechanisms accounting for some effects coupled to commensal bacteria, particularly inactivated E.coli BCS, which are important for understanding pathogenesis-related action of drug Posterisan and Posterisan forte, and outline their broad application in therapy of hemorrhoids. Based on the analysis, it was concluded that such effects are mediated via multi-pronged and complementary interactions between diverse human receptors expressed in the anorectal region cells and microbial components: NOD ligands, metabolites, enzymes, heat shock proteins and nucleic acids, which lead to production of pro-inflammatory cytokines by anodermal colonocytes, innate and adaptive immune cells, neurons in the submucosal plexus covered by transitional zone epithelium, and hemorrhoid plexus endothelium. Based on current concepts, it may be plausible that E.coli BCS-derived biologically active components contained in drug Posterisan are capable of exerting both positive local and systemic effects, which extend our understanding and substantiate its use in hemorrhoidal disease. The effectiveness of using Posterisan and Posterisan forte is corroborated by their indications in real-life clinical practice, both as a conservative therapy as well as after surgical interventions.

Systematic review of failure of nonoperative management in complicated sigmoid diverticulitis with abscess.

PURPOSE: The aim of this systematic review was to determine the rates of failure following nonoperative management for acute sigmoid diverticulitis complicated by abscess. METHODS: Pubmed and Medline were systematically searched by two independent researchers. Studies reporting outcomes of nonoperative management of diverticulitis with abscess revealed on CT scan were included. The endpoint of the study was failure of nonoperative management which included relapse and recurrence. Relapse was defined as development of additional complications such as peritonitis or obstruction that required urgent surgery during index admission or readmission within 30 days. Recurrence was defined as development of symptoms after an asymptomatic period of 30-90 days following nonoperative management. Nonoperative management included nil per os, intravenous fluids and antibiotics, CT-guided percutaneous drainage, and/or total parenteral nutrition. RESULTS: Twenty-four of 844 studies yielded by literature search totaling 12,601 patients were eligible for inclusion. Pooled relapse rate was 18.9%. The pooled rate of recurrence of acute diverticulitis was found to be 25.5%. 60.9% of recurrences were complicated diverticulitis. Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared with pericolic abscess (51% vs. 18%; p = 0.0001). CONCLUSION: The rate of failure of nonoperative management was 44.4%. The rate of relapse at 30 days following nonoperative management was at 18.9%. Distant abscesses were associated with significantly increased rates of relapse compared with pericolic abscesses. The rate of recurrence following nonoperative management was 25.5% at the mean follow-up of 38 months.

[Choice of optimal treatment strategy for acute perianal thrombosis. Results of online survey]. / Vybor metoda lecheniia ostrogo perianal'nogo tromboza. Rezul'taty oprosa vrachei.

OBJECTIVE: To study the factors influencing the physicians' choice of treatment strategy in patients with acute perianal thrombosis. MATERIAL AND METHODS: A survey was conducted among 124 Russian colorectal surgeons. RESULTS: This survey showed that the choice of treatment strategy varies between private and state clinics. Conservative approach is preferred in government clinics (p=0.024). The time factor is more important for professionals. Hemorrhoidectomy is preferred in private clinicians, thrombectomy - in public clinics. The majority of physicians note that pregnancy significantly affects choice of treatment tactics. The most important factors to refuse surgery are pregnancy (r=0.796), age over 70 years (r=0.655), duration of thrombosis over 4 days (r=0.791). Large thrombosed node (2-3 cm), severe pain syndrome (r=0.858) and duration of disease less than 3 days (r=0.901) determine preferable surgical approach. CONCLUSION: The choice of treatment of acute perianal thrombosis depends on not only duration of disease, severity of pain syndrome, age and pregnancy, but also on the type of the hospital. Conservative treatment is preferable in the majority of national state hospitals. Moreover, most surgeons prefer less aggressive treatment options in the state clinics. Further research is needed to determine any important factors limiting more effective surgical treatment besides pain and patient's attitude toward the disease.

Natural orifice specimen extraction (NOSE) surgery with rectal eversion and total extra-abdominal resection.

BACKGROUND: Natural orifice specimen extraction (NOSE)surgery is gaining popularity among colorectal surgeons. The technical aspects of this new procedure are still debated and many variations have been presented in the last decade. METHODS: We propose a new variation of transanal NOSE after robotic and laparoscopic LAR consisting of rectal eversion by using a special rod after laparoscopic TME. Eversion makes it possible to perform resection and placement of the anvil extracorporeally. We included a video demonstration of the technique. Clinical Patient Grading Assessment Scale was calculated 1 month after stoma closure and the Low Anterior Resection Syndrome (LARS )score was calculated preoperatively and 1 month after stoma closure. RESULTS: Seven female patients with rectal cancer, all with normal BMI, underwent laparoscopic (n = 5) or robotic (n = 2) TME with rectal eversion. No intraoperative and postoperative complications were reported. One month after stoma closure, the median Clinical Patient Grading Assessment Scale was 5 (range 3-7), which means "a good deal better". The median LARS score was 14 (IQR 14-19,5) preoperatively and 19 (IQR 19-21,5) 1 month after stoma closure. CONCLUSIONS: This variation of NOSE surgery was safe and effective in our patient population.

[Selective approach for splenic flexure mobilization in total mesorectal excision followed by low colorectal anastomoses]. / Selektivnyi podkhod k mobilizatsii selezenochnogo izgiba pri formirovanii nizkikh kolorektal'nykh anastozomov posle total'noi mezorektuméktomii.

AIM: To evaluate the results of selective approach for splenic flexure mobilization (SFM) after total mesorectal excision with low colorectal anastomoses. MATERIAL AND METHODS: Clinical data were obtained from the multicenter RCT database comparing ileostomy and colostomy in patients with rectal cancer who underwent total mesorectal excision from 2012 to 2017. Our clinic policy is performing paraaortic lymph node dissection with 'low' inferior mesenteric artery ligation, left colic artery preservation and use of sigmoid colon for colorectal anastomosis. SFM was used only in cases of inability to apply above-mentioned procedure (selective approach for SFM). RESULTS: SFM was performed in 15 (13%) out of 115 patients. The most frequent reasons for SFM were sigmoid colon diverticulosis, impaired blood supply or inadequate length of sigmoid colon. There were no differences in intraoperative and postoperative complications between TME without SFM and TME with SFM. CONCLUSION: Selective SFM in TME followed by advanced paraaortic lymph node dissection and left colic artery preservation is safe and may be considered as a viable option to routine SFM in rectal cancer surgery.

[A case of sigmoid cancer occurring after uretero-sigmoid anastomosis].

Colonic neoplasia occurring in an uretero-sigmoid anastomosis is a rare case of colon cancer in the clinical practice of Russian colorectal surgeons and urologists. The article presents a case of sigmoid adenocarcinoma causing obstructive pyelonephritis.

Laparoscopic technique of modified extraperitoneal (retrotransversalis) end colostomy for abdominoperineal excision.

AIM: To describe the technique of a modified extraperitoneal retrotransversalis end colostomy as part of a laparoscopic abdominoperineal excision (APR). METHOD: The colostomy site is preoperatively chosen and used intra-operatively for a trocar. After the rectum has been mobilized the descending colon is freed. The peritoneal margin is gently grasped and the parietal peritoneum and extraperitoneal together with the transversalis fascia are separated from the transverse abdominal muscle fibres upwards for 3-4 cm aiming at the trocar site to form the extraperitoneal retrotransversalis canal. The stoma site trocar is partially withdrawn and its head is turned laterally until its tip is positioned in the layer between the abdominal wall muscles and underlying transversalis and extraperitoneal fascia together with the parietal peritoneum. The CO2 source can be attached so that the gas helps to separate the layers, after which the colostomy trephine is formed at the site of the trocar, the grasper is inserted to gently deliver the blunt end of the descending colon through the canal and the end colostomy is formed in a usual way. RESULTS: No procedure-specific complications were noted in 39 patients who had laparoscopic APR with extraperitoneal retrotransversalis end colostomy from 2009 to 2016. In 23 patients who survived for 3.7 ± 1.7 years after surgery there were no clinical or CT signs of parastomal hernia or prolapse. CONCLUSION: This single-institution retrospective case series demonstrates that laparoscopic extraperitoneal retrotransversalis end colostomy is feasible, safe and effective in preventing parastomal hernias and stomal prolapse.