[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.

[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.

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.

[Intersphincteric resection for stage I-III low rectal cancer is an oncologically safe alternative to extralevator abdomino-perineal rectal resection]. / Intersfinkternaia rezektsiia pri nizhneampuliarnom rake priamoi kishki I-III stadii iavliaetsia onkologicheski bezopasnoi al'ternativoi ékstralevatornoi ékstirpatsii priamoi kishki.

AIM: To compare oncologic efficiency of intersphincteric resections and extralevator abdominoperineal excisions in surgical treatment of low rectal cancer. METHODS: Between 2006 and 2015 in Department of colorectal and pelvic floor surgery (Russian scientific center of surgery n.a. acad. B.V. Petrovsky) and in Clinic of Colorectal and Minimally invasive surgery (Sechenov First Moscow State Medical University) 40 consecutive patients underwent intersphincteric resection (ISR) and 31 underwent extralevator abdominoperineal excision (EAPE). All patients had low rectal cancer staged I-III within 5 cm from the anal verge. RESULTS: Circular resection margin >1 mm was achieved in 95% and 84% of patients after ISR and EAPR correspondingly (p=0.002), negative distal resection margin was achieved in 95% of ISR patients. In ISR group mean distance from the lower tumor edge to the distal resection margin was 1,17±0,78 cm. Colo-anal anastomosis leak rate was 17%. The 3-year disease-free survival in ISR group was 97%, 5-year disease-free survival was 93%. The 5-year disease-free survival in stage III for ISR group was 71,4%. In 98% of ISR patients complete restoration of bowel continuity was performed.

[Survival rate after D3-lymphadenectomy for right-sided colic cancer: case-match study].

UNLABELLED: The aim of the study was to compare the effectiveness of D3-lymphadenectomy in compliance with «no-touch¼ principle and mesocolectomy with traditional hemicolectomy in patients with right-sided colon cancer. MATERIAL AND METHODS: It is retrospective-prospective comparative case-match study. From prospectively collected database patients with right-sided colon cancer stage I-III treated in 2009-2013 without adjuvant chemotherapy were selected. Patients who underwent conventional right-sided hemicolectomy with D2-lymphadenectomy in the regional oncologic dispensary formed the first group. The second group included patients after right-sided hemicolectomy with D3-lymphadenectomy, «no-touch¼ principle and mesocolectomy performed in academic hospital of the third level. From both groups 'case-match' patients by gender, age, stage and location of primary tumor were selected. Each group consisted of 50 patients. RESULTS: Overall and cancer-related 5-year survival was significantly higher in the second group - 80.9% vs. 56.0% (p=0.01) and 93.4% vs. 59.8% (p=0.01), respectively. CONCLUSION: D3-lymphadenectomy and mesocolectomy for right-sided colon cancer stage I-III without adjuvant chemotherapy provides significantly better overall and cancer-related 5-year survival compared with conventional right-sided hemicolectomy. Thus, D3-lymphadenectomy and mesocolectomy in compliance with «no-touch¼ principle for right-sided colon cancer is reproducible and effective in Russian conditions.

[Early complications after surgery for middle- and lower-ampullar cancer: total mesorectumectomy or "blind" preparation of rectum?].

It was performed a comparative analysis of parameters of early postoperative period in 318 patients with middle- and lower-ampullar cancer of rectum who underwent total mesorectumectomy and "blind" preparation of rectum. All patients were divided into 2 groups. The main group included 202 patients after total mesorectumectomy. The control group included 116 patients after "blind" preparation of rectum. Statistically significant differences in frequency of laparotomy wounds suppuration, urinary tract dysfunction and postoperative mortality were revealed. These complications were diagnosed more frequent in case of "blind" preparation of rectum. In the main group laparotomy wounds suppuration depended on sex (p<0.001, r=0.65), in the control group - on surgeon's experience (p=0.006, r=0.58), localization of tumor (p<0.001, r= -0.87) and type of surgery (p<0.001, r= -0.76). Urinary tract dysfunction after total mesorectumectomy depended on patient's sex (p<0.001, r=-0.77), after "blind" preparation of rectum - sex (p=0.002, r= -0.39) and performing of preoperative radiation therapy (p<0.001, r=0.46). In the main group none of the analyzed variables effected on the postoperative mortality. In the control group age (p=0.006, r=0.48), intraoperative blood loss (p=0.002, r=0.55), anastomosis failure (p=0.01, r=0.61), postoperative bleeding (p<0.001, r=0.88), early adhesive intestinal obstruction (p=0.006, r=0.77) effected on the mortality. It is considered that total mesorectumectomy in comparison with "blind" preparation of rectum decreases frequency of postoperative complications and mortality.

[The primary tumour resection with extended D3 lymph node dissection, metastases of synchronous metastatic colorectal cancer].

The progress in colorectal cancer treatment of IV stage that was shown in last decades was mainly due to modern chemotherapy schemes and aggressive surgical approach towards distant metastatic lesions. Meanwhile less attention is paid to primary tumour treatment - the questions of necessity and volume of its resection are still open. The AIM of this study was to evaluate safety and oncologic effectiveness of primary tumour resection with D3 lymph node dissection in synchronous metastatic colorectal cancer. Patients with colorectal cancer and synchronous metastatic lesion of distant organs who underwent surgical resection of primary tumour were chosen from prospectively collected department database. The analysis of short-term and long-term results of resections with and without extended D3 lymph node dissection and prognostic factors affecting overall survival was carried out. From 2006 to 2011 total of 190 patients underwent primary tumour resection, 157 (82.6%) among them - with extended D3 lymph node dissection. Twenty one patient (11%) developed postoperative complications that required reintervention, 30-days mortality rate was 2.6%. Three-year cumulative overall survival was 37%, median survival - 22 months (25 months with extended lymph node dissection and 4 months without, p<0.001). Univariate analysis revealed following statistically significant prognostic factors improving overall survival: metastatic lesions in one distant organ, solitary haematogenous nodes, extended D3 lymph node dissection, postoperative chemotherapy, resection of metastatic lesions. Removal of primary tumour with extended lymph node dissection in metastatic colorectal cancer doesn't increase the number of postoperative complications and mortality. Performing D3 lymph node dissection favours increase of median survival and is a significant prognostic factor influencing outcomes.