[Proctectomy for low rectal cancer with restoration of sphincter, levator and reservoir in perineal part of intestine].

AIM: To develop surgery of proctectomy with total mesorectectomy, internal and deep external sphincter resection with bringing down of intestine and formation of sphincter, levator and reservoir in its perineal part. MATERIAL AND METHODS: Nine patients aged 38-74 years with low-ampullar rectal adenocarcinoma placed in 8-25 mm from anus underwent proctectomy with total mesorectectomy, internal and deep external sphincter resection and bringing down. There were 4, 1, 3 and 1 patients with T2N0M0, T2N1M0, T3N0M1 and T4N2M1 stages respectively. Simultaneous atypical liver resection was performed in 2 cases. In perineal part of intestine sphincter, levator and reservoir were created using smooth muscle cuff, fixed sero-muscular flap and transversely sutured submucosa respectively. Morphological features of sphincter, levator and reservoir were experimentally studied using histostereometry in dogs. RESULTS: Recurrence-free follow-up from 3 to 9 years was observed in 5 patients (T2N0-1M0). Faecal continence according to Wexner score scale was 11±1.

[Proctectomy and sphincterolevatoroplasty in cancer of the inferioampular part of rectum with involvement of the anal canal].

Proctectomy with total mesorectumectomy, resection of the interior sphincter, deep parts of the external sphincter and bringing down were fulfilled according to an original authors' method in 7 patients aged from 38 to 78 years for cancer of the inferioampular part of the rectum with tumor located within the limits 8-35 mm from the anus (T3N1MO (n=1), T3NOM1 (n=1), T4N2M1 (n=1). Six months after operation conscious urge to defecation 1-2 times a day and containment of stools were noted and a year later it was possible to ignore urges during 15-30 min. In 5 patients T3NOM0--T3N1M0 relapse-free period for 3-5 years was noted.

[Modeling of rectal ampulla and rectosigmoid sphincter mechanism in anterior resections of various level].

Original technologies of modeling of rectal ampulla and rectosigmoid sphincter mechanism have been developed for improvement of short- and long-term results after anterior resection of the rectum. The study group consisted of patients after upper resection (n=54) where rectosigmoid mechanism was formed as valve flap on 4-5 cm distally to anastomosis with recovery of pelvic peritoneum at this level, and of the patients after lower resection (n=47) where modeling of rectal ampulla and rectosigmoid mechanism was performed with serosomyotomy of intestinal portion between sphincter and anastomosis. The control group consisted of patients with direct anastomoses at the distance of 6-12 cm (n=12) and 5-1 cm from the anus. 4-6 months later the ampulla-shaped dilatation of intestinal portion after serosomyotomy and formation of functionally active sphincter mechanism were detected in patients of the study group. Developed technologies reduced the number of patients with multi-moment evacuation and incapable to hold the stool for 15 min.

[Modification of rehabilitation stage after inter-sphincter resection of the rectum].

Endoscopic ultrasonic examination for diagnosis of malignant tumors of a lower-ampullar part of the rectum determined indications to inter-sphincter resection consisting in total mesorectumectomy, resection of the rectum and internal sphincter. The method of creation of a globe-shape reservoir with artificial muscular sphincter was developed. Fourteen patients underwent surgery, the follow-up was up to 3,5 years. It is demonstrated that a globe-shape extensible reservoir and autonomic bloching function of muscular sphincter are the main conditions of repair of defecation functions in long-term period after inter-sphincter resection.

[Surgical creation of a reservoir-colostomy with reflex evacuation]. / Sposob formirovaniia rezervuarnouderzhivaiushchei kolostomy s reflektornym oporozheniem.

The authors consider that the problem of social rehabilitation of "colostomized" patients consists in an involuntary and sudden character of evacuation from the ostomy due to the absence of normal imperative urge to defecation. For this purpose a method of reservoir-retaining colostomy modulating the appearance of urge to defecation was worked out in experiments and used in clinic in 17 patients. Preconditions for the appearance of the urge were regular sensations due to mediated distention of the parietal peritoneum after filling the reservoir-retaining volume. The subjective sensations preceding the evacuation from the colostomy appeared 10-20 minutes before defecation and were felt as discomfort and abdominal cramping towards of the external end of the colostomy in 15 (88.2%) and as elements of intestinal colic in 2 (11.8%) patients. So, 9 (53%) patients managed to sufficiently control the evacuation from the ostomy and not to use the pouch. Five patients (29.4%) demonstrated the ability to restrain defecation for 10-15 minutes by straining the anterior abdominal wall muscles when the urge appeared. Evacuation from the ostomy was reiterative (2-4 times), once or twice a day, rarely 3-4 times a day and lasted from 15 till 60 minutes.

[Reservoir ileorectal anastomosis]. / Rezervuarnyi ileorektal'nyi anastomoz.

It was established in experimental and clinical studies that creation of reservoir ileorectal anastomosis by standard methods is accompanied by hypotonia, lining deformation and transformation of mucosa: of terminal part of the ileum under the influence of "aggressive" rectal contents. Development of a great number of secretory elements and loss of basic part of resorption structures of small intestine mucosa are accompanied by chronic postcolectomic diarrhea. Method of creation of reservoir ileorectal anastomosis with areflux mechanism was developed for correction of these disorders. Results of experimental studies on 33 dogs and 5 clinical cases demonstrate that the areflux mechanism coordinates motor-evacuatory intestinal function after colectomy and impedes development of specific pathomorphologic changes of mucosa of reservoir ileorectal anastomosis. This is the main condition for repair of fecoformation in patients in remote period after colectomy.