[Primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in left colonic and rectal cancer resections - the first Russian experience]. / Pervichno-zabryushinnyi dostup dlya sosudosberegayushchei limfodissektsii v lechenii raka levoi poloviny obodochnoi i pryamoi kishki ­ pervyi rossiiskii opyt.

OBJECTIVE: To develop and describe a technique of primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in the left colon and rectal cancer surgery; to evaluate the short-term results of the first series of patients treated with a new minimally invasive method. MATERIAL AND METHODS: The first 10 patients with adenocarcinoma of the left colon and rectum, who underwent surgical treatment using the retroperitoneal approach with vessel-sparing D3 lymph node dissection, were included in the study. The primary retroperitoneal approach involved mobilization of the left side of the colon, D3 lymph node dissection with skeletonization of inferior mesenteric artery (IMA) and selective ligation of afferent vessels from retroperitoneal space using SILS access system at the first steps of surgery. Intersection of visceral and parietal peritoneum, as well as intersection of mesentery within the bowel resection borders was performed laparoscopically. Surgical specimen was removed through retroperitoneal access incision. RESULTS: Duration of retroperitoneal stage with lymph node dissection was 100 min (70.0-115.0). There were 28.5 (22-37) regional lymph nodes removed during vessel-sparing D3 lymph node dissection with IMA skeletalization, 3 (1-4) metastatic regional lymph nodes and 3.5 (2-5) apical nodes. In 4 out of 10 patients, we damaged visceral peritoneum during retroperitoneal dissection. Two patients developed Clavien-Dindo grade 1-2 complications. Mean postoperative hospital stay was 8 days (5-12). CONCLUSION: We developed retroperitoneal vessel-sparing D3 lymph node dissection for the treatment of left colon and rectal cancer. Initial results demonstrated safety and feasibility of this approach.

[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.

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.

[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.

[Sacral resection in surgical treatment of locally advanced primary and recurrent rectal and anal cancer: short-term outcomes]. / Rezektsiia kresttsa pri khirurgicheskom lechenii mestno-rasprostranennogo pervichnogo i reditsivnogo raka priamoi kishki i anal'nogo kanala: neposredstvennye rezul'taty.

AIM: To assess safety of rectum removal with distal sacral resection. MATERIAL AND METHODS: The short-term results of surgical treatment of primary and recurrent locally advanced rectal and anal cancer with sacral fixation have been analyzed. 32 patients underwent combined operations with sacral resection at the level of S2-S5. In 12 patients only one point of tumor fixation (F1) was revealed, 10 patients had two points of fixation (F2), three patients had three fixation points (F3) and in 7 cases the tumor was fixed to four points (F4) of fixation to different pelvic structures. RESULTS AND DISCUSSION: Mean intraoperative blood loss and surgery time was 551±81 ml and 320±20 min in cases of sacral fixation only that was significantly lower compared with F2 cases - 1278±551 ml and 433±45 min, F3 cases - 2200±600 ml and 620±88 min, F4 cases - 2157±512.5 ml and 519±52,3 min, respectively (р<0.05). Complications requiring surgical intervention occurred in 9% patients (n=3). Among 23 patients with intact bladder and ureters urinary disorders occurred in 42% (n=10). Resection margin was negative along posterior surface of the specimen in all cases. CONCLUSION: Advanced surgery with distal sacral resection is advisable for radical removal of locally advanced and recurrent rectal and anal canal cancer fixed to the sacrum with negative resection margin. These operations are feasible in specialized centers and should be performed by specially trained oncological or colorectal surgeon.

[Functional results of digestive tract reconstruction after gastrectomy]. / Funktsional'nye rezul'taty rekonstruktsii pishchevaritel'nogo trakta posle gastréktomii (s kommentariem).

AIM: To substantiate and to prove the advantages of the new method of gastroplasty in comparison with traditional loop reconstruction of digestive tract after gastrectomy. MATERIAL AND METHODS: It was performed prospective comparative study of surgical treatment of 431 patients with gastric cancer who underwent gastrectomy with different variants of digestive tract reconstruction. The main group (146 patients) consisted of patients in whom original technique including establishment of food reservoir in initial jejunal part during reconstruction was applied. The control group consisted of patients with traditional loop reconstruction of the digestive tract (285 patients). RESULTS: Early dumping syndrome (within 1 year) was diagnosed in 9 (13.2%) patients of the main group and 16 (21.6%) patients of the control group. Mild and moderate degrees of this syndrome were observed in 7 (77.8%) and 10 (62.5%), 2 (22.2%) and 4 (25.0%) patients in the main and control groups respectively. Severe dumping syndrome occurred in 2 (12.5%) patients only in the control group. Late dumping syndrome was revealed in 7 (10.3%) and 11 (14.9%) patients, respectively. Body mass index was 18.7±0.8 and 17.4±0.6 (p<0.05), respectively. After 2 years early dumping syndrome was diagnosed in 6 (14.3%) and 10 (21.3%) patients, mild degree in 5 (83.3%) and 5 (50.0%) patients; moderate degree in 1 (16.7%) and 3 (30.0%). Severe dumping syndrome was confirmed in 2 (20.0%) patients from the control group. Late dumping syndrome occurred in 4 (9.5%) and 7 (14.9%), respectively. Body mass index was 21.2±0.7 and 19.0±0.9 (p<0.05), respectively. After 3 years, early dumping syndrome in mild form was diagnosed in 2 (10.5%) cases and late syndromy in 1 (5.3%) patient of the main group. There were 5 (21.7%) patients with the syndrome in the control group including mild and moderate severity in 3 (60.0%) and 2 (40.0%) patients respectively. Late dumping syndrome occurred in 3 (13.0%) patients. Body mass index was 21.9±1.0 and 19.7±0.6 respectively. CONCLUSION: Food reservoir in the initial part of jejunum after gastrectomy creates better conditions for the normalization of metabolic exchange resulting early functional digestive adaptation, especially in long-term period.

[Prevention of reflux-esophagitis after gastrectomy].

It is presented the results of gastrectomy in 431 patients with varying reconstructive-reparative stage. Patients were divided into two comparable groups. The main group consisted of 146 patients who underwent developed technique with food reservoir performing after gastrectomy. Control group included 285 patients after conventional digestive tract reconstruction. It was concluded that 30.4% of patients have entero-esophageal reflux, in 21.7% and 8.7% of patients endoscopic and morphological signs of reflux-esophagitis were observed respectively. Suggested technique creates gas bubble providing obturator mechanism and decreasing the frequency of entero-esophageal reflux to 26.3% and reflux-esophagitis to 5.3%. It proves advantage of suggested method of gastroplasty for prevention of reflux-esophagitis in comparison with traditional digestive tract reconstruction after gastrectomy.

[Spleen-preserving D2 lymphodissection in gastrectomy]. / Splenosokhrannaya limfodissektsiya D2 pri gastrektomii.

AIM: To analyze immediate and remote results of surgical treatment of 480 patients with gastric cancer who underwent total gastrectomy. MATERIAL AND METHODS: The study group included 371 patients who had spleen-preserving D2 lymphodissection during gastrectomy and control group consisted of 109 patients after D2 lymphodissection with splenectomy. Duration of surgery was 183.7±33.8 and 184.1±30.9 min in study and control groups respectively (p=0.72), blood loss - 330.2±33.7 and 351.8±28.8 ml (p=0.0001), incidence of postoperative complications - 6.7% (25 cases) and 4.6% (5 cases) respectively (p=0.5), mortality rate - 2.7% and 0.9% respectively (p=0.46). Number of excised regional lymph nodes of groups 10 and 11 was in most patients of the study group - 5.8 and 5.5 (p=0.92). Metastases in splenic hilus lymph nodes were diagnosed in 28 (7.5%) and 9 (8.2%) patients of the study and control groups respectively (p=0.30), metastases in lymph nodes along splenic vessels - in 24 (6.5%) and 7 (6.4%) patients respectively (p=0.90). RESULTS: 5-year survival in the study group was 40.3±3.0%, average life expectancy - 3.4±3.3 years, in the control groups - 33.1±5.6% and 2.7±2.5 years respectively. It was concluded that spleen-preserving D2 lymphodissection decreases incidence of postoperative complications and has similar drastic nature as standard lymphodissection with splenectomy.