[Rehabilitation program for patients with low anterior resection syndrome]. / Reabilitatsionnaya programma dlya bol'nykh rakom pryamoi kishki s sindromom nizkoi perednei rezektsii.

Surgical treatment of rectal cancer and sphincter-preserving low anterior resection results to evacuation disorders («low anterior resection syndrome¼ - LARS). There are no clinical recommendations for the treatment of patients with LARS as well as a rehabilitation program for them. OBJECTIVE: To develop a rehabilitation program for patients with low anterior resection syndrome. MATERIAL AND METHODS: The investigation was performed at 2 stages. During the first stage, 29 patients with LARS (17 (58.6%) men, mean age of the participants' 61.5±9.5 years), 12 (41.4%) women (mean age 61.2±7.8 years) were examined and received the course of conservative treatment with the use of biofeedback-therapy performed by the standard protocol. On the second stage, 17 patients (mean age 61.4±12.7 years) - 9 (52.9%) men, 8 (47.1%) women received biofeedback therapy in combination with tibial neuromodulation (TNM). Functional state of the rectum and the locking apparatus in all patients were evaluated by anorectal manometry: sphincterometry and studies of the reservoir function of the rectum before and after treatment. RESULTS: The developed complex of rehabilitation measures led to improved treatment results for patients with rectal cancer by improving the quality of life after low anterior resection, reducing the manifestations of LARS (by 47.8%). Stable positive results of treatment were maintained in 36.4% of patients, positive dynamics from the treatment according to the LARS scale decreased slightly in 54.5%, deterioration of indicators in 3-6 months after conservative rehabilitation was registered in 9.1% of cases. At the first stage maximal squeeze pressure improvement was reached in the whole cohort (p=0.047), at the second stage these trend was seen only for women for the pressure values at rest (p=0.01) and during squeeze (p=0.025). The data obtained allowed us to recommend a repeat course of treatment to 63.6% of patients. The authors modified and optimized a special complex of physical therapy for the rehabilitation of patients both in a medical institution and at home. These exercises are aimed at improving the functional state of the pelvic floor muscles and sphincter apparatus. CONCLUSION: Rehabilitation program for patients with low anterior resection syndrome should include: 1) biofeedback therapy to improve the holding function; 2) biofeedback therapy aimed at improving the reservoir function and sensitivity of the rectum to filling; 3) tibial neuromodulation. This program may help improving the contractility of the anal sphincter and reservoir function of the rectum, as well as the appearance of the urge to defecate.

[Comparative assesement of postoperative quality of life in patients with ulcerative colitis]. / Sravnitel'naya otsenka kachestva zhizni patsientov, operirovannykh po povodu yazvennogo kolita.

OBJECTIVE: To compare quality of life in patients undergoing proctocolectomy with ileal pouch procedure and ileostomy taking into account sexual function. MATERIAL AND METHODS: The comparative observational study included 138 patients with ulcerative colitis for the period 2013-2018. All patients underwent surgery with one- or two-stage formation of pelvic pouch (n=76) or ileostomy (n=62). Validated questionnaires SF-36, The International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI) were used in the study. RESULTS: Patients with pelvic pouch were significantly younger than patients with terminal ileostomy (33.7±10.9 and 44.6±14.9 years, respectively, p<0.0001). The majority of the parameters of SF-36 questionnaire were similar in both groups. Pain syndrome intensity was the only sign demonstrating the advantage of ileostomy over pelvic pouch. However, regression analysis did not confirm the effect of surgical technique on pain severity. Orgasmic function was significantly better in men with pelvic pouch compared to ileostomy. Other indicators of sexual function were similar. According to FSFI questionnaire, women with pelvic pouch also showed significantly better results than patients with permanent ileostomy. However, multivariate regression analysis revealed no significant effect of surgical technique on sexual function in men and women. At the same time, significant negative correlation between IIEF and FSFI scores and age was revealed. CONCLUSION: No significant influence of surgical technique on postoperative QOL was observed in patients with ulcerative colitis. Better sexual function in men and women with pelvic pouch are due to younger age rather type of surgery.

Short-term outcomes of a multicentre randomized clinical trial comparing D2 versus D3 lymph node dissection for colonic cancer (COLD trial).

BACKGROUND: It remains unclear whether extended lymphadenectomy provides oncological advantages in colorectal cancer. This multicentre RCT aimed to address this issue. METHODS: Patients with resectable primary colonic cancer were enrolled in four hospitals registered in the COLD trial, and randomized to D2 or D3 dissection in a 1 : 1 ratio. Data were analysed to assess the safety of D3 dissection. RESULTS: The study included the first 100 patients randomized in this ongoing trial. Ninety-nine patients were included in the intention-to-treat (ITT) analysis (43 D2, 56 D3). Ninety-two patients received the allocated treatment and were included in the per-protocol (PP) analysis: 39 of 43 in the D2 group and 53 of 56 in the D3 group. There were no deaths. The 30-day postoperative morbidity rate was 47 per cent in the D2 group and 48 per cent in the D3 group, with a risk ratio of 1·04 (95 per cent c.i. 0·68 to 1·58) (P = 0·867). There were two anastomotic leaks (5 per cent) in the D2 group and none in the D3 group. Postoperative recovery, complication and readmission rates did not differ between the groups in ITT and PP analyses. Mean lymph node yield was 26·6 and 27·8 in D2 and D3 procedures respectively. Good quality of complete mesocolic excision was more frequently noted in the D3 group (P = 0·048). Three patients in the D3 group (5 per cent) had metastases in D3 lymph nodes. D3 was never the only affected level of lymph nodes. N-positive status was more common in the D3 group (46 per cent versus 26 per cent in D2), with a risk ratio of 1·81 (95 per cent c.i. 1·01 to 3·24) (P = 0·044). CONCLUSION: D3 lymph node dissection is feasible and may be associated with better N staging. Registration number: NCT03009227 ( http://www.clinicaltrials.gov).

ANTECEDENTES: El beneficio oncológico de la linfadenectomía extendida en el cáncer colorrectal es controvertido. Este ensayo clínico aleatorizado multicéntrico tuvo como objetivo abordar esta discrepancia. MÉTODOS: Se analizaron los datos de los primeros 100 pacientes aleatorizados en un ensayo en curso para evaluar la seguridad de la disección D3. Los pacientes con cáncer de colon primario resecable incluidos en 4 hospitales participantes en el ensayo COLD, se aleatorizaron para la disección D2 y D3 en una proporción 1: 1. RESULTADOS: Se incluyeron 99 pacientes en el análisis por intención de tratamiento (intention-to-treat, ITT) (43 en D2, 56 en D3). Un total de 92 pacientes recibieron el tratamiento asignado y se incluyeron en el análisis por protocolo (per-protocol, PP): 90,7% (39 de 43) en D2, 94,6% (53 de 56) en D3. No hubo mortalidad. La morbilidad postoperatoria a los 30 días fue del 46,5% en el grupo D2 y del 48,2% en el grupo D3 con un riesgo relativo (RR) de 1,04 (i.c. del 95%: 0,68 a 1,58), P = 0,86. Hubo dos casos de fuga anastomótica (4,7%) en el grupo D2 y ninguna en D3. La recuperación postoperatoria, las complicaciones y las tasas de reingreso no difirieron entre los análisis ITT y PP. El recuento medio de ganglios linfáticos fue 26,6 y 27,8 en D2 y D3, respectivamente. Se observó una resección completa del mesorrecto de buena calidad con mayor frecuencia en el grupo D3 (P = 0,048). En el grupo D3, 3 pacientes (5,4%) tenían metástasis en los ganglios linfáticos D3. D3 nunca fue el único nivel afectado de ganglios linfáticos. El estadio pN positivo fue más frecuente en el grupo D3: 46,4% versus 25,6% en D2, con un RR para revelar enfermedad N positiva de 1,81 (i.c. del 95% 1,01 a 3,2), P = 0,04. CONCLUSIÓN: La disección de ganglios linfáticos D3 es factible y puede estar asociada con una mejor estadificación N.

[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.