Technical considerations depending on the level of vascular ligation in laparoscopic rectal resection.

AIM: In addition to ischemia there is also anastomotic ends tension proven to be a risk factor for anastomotic leak. HT vascular ligation is accepted as a rule, in attempt to achieve tension-free anastomosis. LT is a preferred option, based on the more accurate preservation of proximal intestinal segment microperfusion and lower risk of damage to the hypogastric plexus. The aim of this study is evaluation of comparative indicators in high tie (HT) and low tie (LT) laparoscopic rectal resections. METHODS: A prospective nonrandomized comparative cohort study of patients in our department with cancer of the rectum in clinical stage I-III, operated on in laparoscopic approach over a 6-years period. RESULTS: For the period 2015-2020, a number of 208 laparoscopic surgeries have been done for rectal cancer. Patients were divided into three groups-group A with HT vascular ligation 116 pts. (69%), group B-53 pts. (25%), underwent low ligation-LT and group C-39pts. (19%) low tie plus lymph node dissection of the apical LN group (LT-appic LND). The distribution was made without randomization, based on the operators' expertise. Anastomotic leaks were 3.8% in group A, 3.0% in group B and 2.9% in group C (p > 0.05) with no significance difference. There is no significant difference in the number of lymph nodes obtained in group A and group B, while in group C the number of the harvested lymph nodes was higher (p < 0.05). The indicators for intestinal / defecation dysfunction, as well as for urinary/sexual dysfunction, according to our data, are significantly more favorable in patients with LT, in contrast to the other two groups. CONCLUSION: HT vascular ligation attempts to achieve tension-free anastomosis and more harvested lymph nodes. However, LT could be a preferred option, based on the lack of significant evidence for a difference in specific oncological survival and due to more accurate preservation of proximal intestinal segment microperfusion to prevent anastomosis dehiscence, also for its lower risk of damage to the hypogastric plexus. Splenic flexure mobilization provides elongation of the proximal intestinal segment, but has no proven effect on anastomotic leakage incidence. It increases surgical duration and is in fact necessary in up to 30% of the cases. At the present moment there is no precise data whether LT has an advantage in terms of prevention of autonomic nervous and urogenital dysfunction. New prospective randomized and highly probative studies are needed to standardize the procedures in specific clinical situations.

[Novelties in the Treatment of Colorectal Diseases - An Echo from the 10-th ESCP Congress].

Treatment of colorectal pathology stands continuous development. One of the promotional leaders of the new therapeutic approaches is the European Society of Coloproctology (ESCP). The annual congress of the organization held in Dublin, Ireland and it unites the elite of European Community countries. The most advanced scientific knowledge of the diseases of the colon and rectum, anal canal and perineum was presented.

LAPAROSCOPIC TREATMENT OF RECTAL CANCER.

There is an established standard for the surgical treatment of rectal neoplasms. Every conventional operation can be performed by means of laparoscopy, if the complex approach to the disease and classical oncological principles are observed. Depending on the height of tumor, surgical operations, different in tactical and technical terms, are performed. The correct preoperative staging, planning, and securing of resources guarantee the favorable outcome of therapy. The main advantages are the less postoperative pain and briefer hospital stay. The better visualization of pelvic organs and routine use of high-energy sources reduce the blood loss and potential complications. With a view to ensure modern treatment of this major group of patients, the input of the required resources, for turning into one of the routine methods of rectal cancer treatment, is a necessity. ABBREVIATIONS USED: LAR (laparoscopic anterior resection), LLAR (low laparoscopic anterior resection), LIsRR (laparoscopic intersphincteric resection of the rectum), TME (total mesorectal excision), TATME (transanal total mesorectal excision), LER (laparoscopic extirpation of the rectum), IMA (inferior mesenteric artery), and IMV (inferior mesenteric vein).

PRIMARY RETROPERITONEAL EXTRA-ORGAN TUMORS (PRET) - SURGICAL TACTICS.

INTRODUCTION: Retroperitoneal tumors, in general, are rare tumors which histopathological characteristics and biological behavior can be considered as benign or malignant. They originate from various tissue elements located in the retroperitoneal space. They often cover Anatomical structures of varying importance - mainly retroperitoneal vessels and organs, which determines the type of surgery - radical or palliative. They are composed of adipose tissue, vascular elements, smooth and striated muscle, neural elements germline structures. There are three main types of retroperitoneal tumors: mesodermal, neurogenic and teratosarcomas. As mentioned above each can be either benign and malignant. In most cases there are no specific symptoms except general weakness, heaviness in the abdomen, loss of appetite, progressive weight loss, headache and fever. The pain is most often located in the lumbosacral area. The tumor can also cause disturbances in urination. In patients with advanced stage can be observed significantly symmetrical or asymmetrical tumor growth in the abdominal area. The most commonly used techniques for the diagnosis of the disease are X-ray, CT-scan and MRI. MATERIAL AND METHODS: Retrospective study involving 112 cases operated in the clinic for 14-years period (2000-2014) - 101 patients, 11 of them were operated on twice in a different time interval on the occasion of relapsed malignant process. RESULTS: Out of all operated cases, 42% are males (47 cases) and 58% - women (65 cases). In most cases (72% - 81 cases) tumors are malignant. All patients were treated surgically. There were followed up a total of 89 patients over a period of 3 months to 8 years (96 months) as of the studied malignant cases 3 year survival was observed in 21 patients, and one patient has survived 96 months after total extirpation of fibrosarcoma. Early postoperative mortality (till 20th postoperative day) was registered in 3 patients - 2.67% of all operated cases. DISCUSSION: About 80% of primary retroperitoneal extra-organ tumors are generally malignant. People of all ages are affected equally and no statistically significant difference in the number of men and women is detected. There are many theories about the emergence of retroperitoneal tumors, but currently none of them has not been fully proven. Treatment depends on the type of the lesion. Surgery is the main approach and it should be applied to both benign and malignant lesions. In the case of malignancy other methods than surgical are chemo- and radiotherapy but they are less effective.

A Meta-Analysis of Quality of Life, Estimated by Questionnaires of the European Organization for Research and Treatment of Cancer (EORTC) after Rectal Cancer Surgery.

BACKGROUND: Rectal carcinoma is one of the most common cancers on a global scale. Although there were major improvements in its treatment during the last two decades, surgery is still the only curative method. However, is often complicated and can cause disorder of different aspects of the patients self-perception of health. The aim of this study is performing ofa meta-analysis for evaluation and comparison of the quality of liferesults after rectal cancer treatment. METHODS: Search of relevant articles, which were published between 2000 and 2015, was performed. The outcomes of abdominoperineal resection and anterior resection were analyzed with the EORTC's quality of life measuring instruments - quality-of-life questionnaire C30 (QLQ-C30)and quality-of-life questionnaire CR38 (QLQ-CR38). The assessment score, appropriate for the survey, was established at least one year after radical surgery. The Statistical Package for Social Sciences (SPSS) package of IBM Statistics, version 19 was used for the statistical analyses. RESULTS: 13 studies, published between 2001 and 2015, have been presented in this meta-analysis. Data from 1805 patients,with a mean age of 64.7 years, have been included. When comparing Miles extirpation and sphincter-sparing operations,statistical significance was detected for the following variables:social functioning (74.6 ± 8.5 vs. 83.4 ± 8.6, P = 0.045),constipation (11 ± 8.4 vs. 22.6 ± 8.3, P = 0.032), and body image (67.9 ± 14 vs. 82.5 ± 9.1, P= 0.01). CONCLUSION: Preservation of the sphincter is a better treatment option that should be carefully considered. Dependently registered differences, our conviction for the rectal cancer care concern needs individualization of the approach in this surgery.It is essential that the policy of avoidance of abdominoperineal resection (APR) cannot currently be justified on the grounds of quality-of-life (QoL) results alone.

Epigenetic alterations in patients with type 2 diabetes mellitus.

Epigenetic changes, in particular DNA methylation processes, play a role in the pathogenesis and progression of type 2 diabetes mellitus (T2DM) linking genetic and environmental factors. To clarify this role, we have analyzed in patients with different duration of T2DM: (i) expression levels of methyl-CpG-binding domain protein 2 (MBD2) as marker of DNA methylation, and ii) methylation changes in 22 genes connected to cellular stress and toxicity. We have analyzed MBD2 mRNA expression levels in16 patients and 12 controls and the methylation status of stress and toxicity genes in four DNA pools: (i) controls; (ii) newly-diagnosed T2DM patients; (iii) patients with T2DM duration of <5 years and (iv) of >5 years. The MBD2 expression levels were 10.4-times increased on average in T2DM patients compared to controls. Consistent increase in DNA methylation fraction with the increase in T2DM duration was observed in Prdx2 and SCARA3 genes, connected to oxidative stress protection and in BRCA1 and Tp53 tumor-suppressor genes. In conclusion, increased MBD2 expression in patients indicated general dysregulation of DNA methylation in T2DM. The elevated methylation of Prdx2 and SCARA3 genes suggests disturbance in oxidative stress protection in T2DM. The increased methylation of BRCA1 and Tp53 genes unraveled an epigenetic cause for T2DM related increase in cancer risk.

Peutz-Jeghers syndrome--a rare case and a literature review.

The Peutz-Jeghers syndrome is inherited condition, characterized by hamartomatous gastrointestinal polyposis and with mucocutaneous pigmentation. We have experienced a case with typical clinical features, diagnosed before complication's development. In order to prevent cancer setting it is recommended to perform aggressive screening and high-technological procedures.

Quality of life aspects in patients operated for low rectal cancer.

Neoplasms of the rectum represent a common therapeutic problem, with plenty of different possible operative decisions for low-situated tumor cases. Some unfavorable consequences of these surgical approaches seriously affect the patient's life. From the surgical point of view, sparing the sphincter can be considered as achievement of the desired result. This seldom matches what the operated people expect before and experience after the treatment. The necessity of critical assessment of the used operative techniques arises with the rectal cancer surgery development. Despite their undeniable attractiveness, sphincter- sparing operations (SSO) are not accompanied with the awaited result in every case. A need of feedback mechanism arises to control vacillation from saving sphincter by all means to the tremendous number of abdominoperineal excisions (APE). With the introduction of the integral psychometric term "Quality of Life" (QoL) a possibility for a dynamic control over the obtained results was created. This control is realized by a set of instruments. These tools help measure objectively the results taken, as well as their practical use aiming to optimize our treatment policy. Recognition of their modifications and principles could be a step forward for the best interpretation.

[Methodology of quality of life assessment with EORTC questionnaires of operated for rectum carcinoma patients. Prognostic factors].

The integral psychometric term quality of life illustrates the subjective sensation of the received results. The instruments developed by EORTC contribute to its dynamic objectification and optimization, by applying the adequate practice. For patients with rectal carcinoma this marker is expected to have a prediction value, like other markers that determine the progress of the disease.

[Modification of the transverse coloplasy pouch--experience with this feasible technique in different types of low rectum resections].

The increased number of sphincter-spared patients after low rectal resection requires an up-to-date approach, aiming at better functional results. The authors modify into practice the transverse coloplasy pouch, with a longitudinal seromuscular incision, mucosal liberalization and transverse suture. They describe their experience with this feasible technique in different types of low rectum resections. The conception of the technique is with increased neorectal volume to avoid some unpleasant consequences of this surgery, without changing the oncological effectiveness. The modification with a single-layer suture facilitates the technique, has some advantages and does not worsen the desired effect.

[Complex results of investigating the quality of life after rectal surgery].

INTRODUCTION: The recent development of rectal surgery is related to the possibility of avoiding permanent stoma formation, which is presumably believed to be the main factor that decreases quality of life. Despite the modern views of the disease, the adequacy of complex treatment and the technical improvements, low anastomoses often result in poor bowel function. The subjective perception of health is changed for these patients. There arises the question of adequacy of operative approach. The aim of our investigation was analysis of the present QoL data of patients treated in the Specialized Oncology Hospital of Veliko Tarnovo. MATERIALS AND METHODS: The quality of life of 173 patients was examined with the help of EORTC questionnaires QLQ C30 and QLQ C38. The comparison is between a group with high anterior resection (N1 = 50-28.9%), a group with low sphincter-sparing operation (N2 = 59-34.3%) and primary extirpated patients (N3 = 53-30.8%). They were questioned preoperatively, in an early and late aspect, as well as before prophylactic stoma closure. RESULTS: The high resected patients present the best QoL values. Performing the extirpation leads to significant preoperative drop and a good adaptation afterwards. Their indexes are not much different from anterior resection group. Compared with the low technique group considerable improvement as regards the scales social functioning and global health status (P < 0.05) was observed. This group has high values of general and specific symptomology (pain, constipation, diarrhea, dyspnoea, financial difficulties, defecational problems and sexual dysfunction) generating low QoL. Their recovery is prolongated in relation with the drop of the modules before the prophylactic stoma closure. CONCLUSION: The best health perception available after treating the rectum carcinoma is for high located tumors. We recon that for patients with extirpation techniques and primary stoma formation there is no objective data of QoL decrease. In comparison, the group with low rectal resections had to undergo another operative intervention, and there were some specific complications and following poor function reducing quality of life. The requirement for very precise selection of patients must be fulfilled.

[Quality of life in rectum cancer surgery].

With the rectal cancer surgery development arise the necessity of critical assessment of the operative techniques used. Although its undeniable attractiveness, the sphincter-sparing operations are not in every case accompanied with the desired effect. With the introduction of the integral psychometric term "quality of life" a possibility for a dynamic control over the obtained results was created. This control is realized by a set of instruments. These instruments help to objective the results measurement, as well as their practical use aiming to optimize our treatment policy.