[Indocyanine green in delayed esophageal reconstruction after previous extirpation]. / Primenenie indotsianina zelenogo pri otsrochennoi plastike pishchevoda tolstoi kishkoi posle ego ekstirpatsii.

Advanced chemo- and radiotherapy makes it possible to expand the cohort of patients who can undergo surgical treatment for esophageal cancer. Optimization of perioperative approach, diagnosis and modern options for complications reduced early postoperative mortality after esophagectomy. Conduit ischemia with failure of esophageal-gastric or esophageal-intestinal anastomosis is one of the most serious complications. To minimize the risk of anastomotic leakage and graft necrosis in these patients, various methods of intraoperative assessment of graft viability are being investigated. Near-infrared fluorescence imaging with indocyanine green is valuable for real time assessment of graft perfusion. To date, fluorescence imaging is analyzed regarding perfusion of the gastric stalk after esophagectomy. However, there are still few or no data on this method for analysis of colonic conduit perfusion. The absence of plastic material for gastrointestinal reconstruction is the most dangerous moment in case of ischemia and necrosis of colonic graft. We present our first case of delayed retrosternal esophageal repair using intraoperative indocyanine green fluorescence imaging for assessment of conduit perfusion.

[Predictive model for additional intraoperative placement of chest drainage after thoracoscopic lobectomy]. / Prognosticheskaya model' dlya dopolnitel'noi intraoperatsionnoi ustanovki plevral'nogo drenazha pri torakoskopicheskoi lobektomii.

OBJECTIVE: To create a prognostic model determining the risk of tension pneumothorax and the need for intraoperative installation of additional drainage after thoracoscopic lobectomy. MATERIAL AND METHODS: A retrospective multiple-center study included patients who underwent thoracoscopic lobectomy for lung cancer between 2016 and 2022. One drainage tube was used after surgery in all cases. We synthesized data to expand patient selection using the Riley method and machine learning algorithm. In total, treatment outcomes in 1458 patients were analyzed. After identifying significant factors, we performed binary logistic regression analysis using backward stepwise inclusion of variables in accordance with the Akaike information criterion. After validating the model using the Bootstrap method (400 iterations) and original data set, we created a nomogram determining scoring characteristics, linear predictors and risk of postoperative tension pneumothorax. RESULTS: The incidence of tension pneumothorax was 4.53% (n=66). The most significant variables associated with pneumothorax and the need for additional pleural drainage were adhesions, intraoperative lung suturing, unclear interlobar groove, enlarged intrapulmonary lymph nodes and chronic obstructive pulmonary disease (p<0.001). The model's C-index was 0.957, mean absolute calibration error - 0.6%, calibration curve slope - 0.959. A score of 26 indicated a 95% risk of postoperative pneumothorax. CONCLUSION: We developed a prognostic model for tension pneumothorax after thoracoscopic lobectomy. Nomogram makes it possible to make a decision on intraoperative installation of additional pleural drainage tube and prevent complications associated with postoperative lung collapse.

[Intraoperative and early surgical complications after VATS lobectomy]. / Intraoperatsionnye i rannie khirurgicheskie oslozhneniya pri torakoskopicheskikh lobektomiyakh.

OBJECTIVE: To improve the results of thoracoscopic anatomic lung resections (lobectomy) via reducing the incidence of intraoperative and early surgical complications. MATERIAL AND METHODS: The study enrolled 479 patients who underwent thoracoscopic lobectomy. We determined the main criteria of complications: injury of vascular structures with severe bleeding, damage of the bronchi and adjacent organs. RESULTS: Potentially life-threatening conditions requiring additional surgical manipulations (bleeding in 35 patients, bronchial trauma in 3 patients) were diagnosed in 7.9% (38/479) of cases. Vascular injury with severe bleeding occurred in 7.3% of patients (n=35). Three patients had bronchial trauma (7.9%). We stopped bleeding without thoracotomy in 48.5% (17/35) of patients. In 51.5% (18/35) of cases, emergency thoracotomy was performed. CONCLUSION: The problem of safety is still urgent despite widespread thoracoscopy in lung resections. Knowledge of the factors contributing to complications and working out appropriate algorithm of actions are of great importance.

[Diagnostic clinical algorithm for mediastinal tumors]. / Klinicheskii algoritm diagnostikii i lecheniya opukholei sredosteniya.

OBJECTIVE: To optimize therapeutic and tactical algorithm in patients with mediastinal tumors. MATERIAL AND METHODS: The study included 300 patients with mediastinal tumors examined and treated in the Thoracic Surgery Department of the Hertzen Moscow Cancer Research Center between 2008 and 2019. Patients were stratified into 2 groups. The diagnostic group consisted of 160 patients including 80 ones after 89 ultrasound-assisted transthoracic biopsies and 80 patients after open biopsy through parasternal mediastinotomy. The treatment group consisted of 140 patients who underwent 145 resections of mediastinal tumors. We analyzed the results of diagnosis and treatment in both groups, mistakes, risk factors of non-informative biopsies and complicated course of the postoperative period. Subsequently, a clinical algorithm was developed. Its effectiveness in 50 patients was compared with 90 patients who constituted the historical control group. RESULTS: The final histological diagnosis after transthoracic ultrasound-assisted biopsy of the mediastinum was established in 71 out of 89 cases (80%). Informative value of ultrasound-assisted biopsy for thymic tumors was 100%, for metastatic mediastinal lesions - 92%. Repeated ultrasound-assisted biopsies were performed in 7 (9%) patients that made it possible to establish the final diagnosis in 5 (71%) cases. In the parasternal mediastinotomy group, the final correct histological diagnosis was made in 79 out of 80 (99%) patients. Analyzing thoracoscopic approach and traditional sternotomy or thoracotomy, we found surgery time decrease from 187 (150-215) to 140 (122-165) min (p<0.01), blood loss from 300 (200-350) to 50 (35-150) ml (p<0.01), postoperative hospital-day from 12 (9-14.5) to 7 (6-8) days (p<0.01). Mean dimension of tumor was 5 (4-6) cm in the thoracoscopy group and 7.5 (6-10) cm in the open surgery group (p<0.01). Postoperative complications occurred in 19 (13%) patients, mortality rate was 2.8%. Multivariate analysis revealed superior vena cava syndrome (OR=5.1, 95% CI=1.246-21.343; p=0.024) and invasion of the right pleural cavity (OR 4.2, 95% CI 1.12-7.69; p=0.006) as the most significant predictors of postoperative complications. The proposed algorithms made it possible to reduce the incidence of non-informative biopsy from 12% to 0% (p<0.05), misdiagnosis from 9% to 1% (p<0.05), exploratory surgeries from 23% to 0% (p<0.05). CONCLUSION: The developed algorithm is valuable to avoid the errors and improve the results of diagnosis and treatment of patients with mediastinal tumors.

[Surgical treatment of retroperitoneal neurogenic tumors in children]. / Khirurgicheskoe lechenie detei s neirogennymi opukholyami zabryushinnogo prostranstva.

OBJECTIVE: To evaluate feasibility and advantages of laparoscopic access in children with retroperitoneal neurogenic tumors. MATERIAL AND METHODS: A comparative analysis of postoperative results was performed in 2 groups of patients with retroperitoneal neurogenic tumors without IDRF risk factors. Different surgical approaches were applied. The main group (laparoscopic access) consisted of 18 patients. The control group included 22 patients after laparotomy. We compared the following variables: surgery time, blood loss, postoperative need for analgesics, intraoperative and postoperative complications, timing of postoperative enteral feeding, postoperative hospital-stay and regional recurrence rate. RESULTS: Duration of laparoscopic and open surgery was similar (80.5 vs. 86.5 min, p>0.05). Intraoperative blood loss was significantly lower in the laparoscopy group (10 vs. 17 ml/kg, p<0.05). Two patients required conversion of laparoscopic approach. In laparotomy group, massive intraoperative bleeding occurred in 1 patient. Early postoperative period was more favorable in the main group compared to the control group. There were no local and metastatic recurrences in delayed postoperative period after laparoscopic surgery. One (4.5%) patient had metastatic recurrence after laparotomy. There were no regional recurrences in this group. CONCLUSION: Laparoscopic resection of neurogenic retroperitoneal tumors in children is feasible if great vessels are not involved in neoplastic process. Open surgery is preferable in patients with invasion of great vessels.

[Rethymectomy in patients with myasthenia gravis and recurrent thymoma]. / Retimektomiya u bol'nykh miasteniei i retsidivom opukholi vilochkovoi zhelezy.

OBJECTIVE: To analyze efficacy and safety of rethymectomy in patients with pathology of thymus. MATERIAL AND METHODS: Nine patients (2 males and 7 females) underwent rethymectomy in the thoracic surgery department of the Hertzen Research Institute of Oncology for the period from March 2009 to December 2019. Initial thymectomy for myasthenia gravis was performed in 6 patients, for thymoma without myasthenia - in 3 patients. Age of patients varied from 27 to 75 years (median 42.8 years). Myasthenia manifested at the age of 25-61 years (median 29.2 years). Period between manifestation and thymectomy varied from 6 to 24 months (median 12.6 months). MGFA grade IIIa was in 1 patient, grade IIIb - in 1, grade IVa - in 1, grade IVb - in 2, grade V - in 1 patient. Rethymectomy was performed via sternotomy in 4 cases, through thoracoscopy - in 5 patients. RESULTS: Postoperative complications occurred in 2 (22.2%) patients. Biopsy revealed residual thymic tissue in all patients. Median follow-up after rethymectomy was 30.2 months (range 12-132 months). Complete stable remission was achieved in 3 (50.0%) patients, remission - in 2 cases, partial remission - in 1 patient. Median dose of steroids before rethymectomy was 40 mg (range 16-96 mg), median dose after rethymectomy - 8 mg (range 0-24 mg). Differences were significant (p=0.04). All patients operated on for thymoma or recurrence are alive within 12-124 months after rethymectomy. CONCLUSION: Rethymectomy is a safe and effective treatment option for patients with refractory myasthenia gravis (especially in case of detected residual thymic tissue) or recurrent thymoma. Radical surgery for recurrent thymoma ensures favorable survival.

[Liver transplantation for hepatoblastoma in children]. / Transplantatsiya pecheni pri gepatoblastome u detei.

OBJECTIVE: To improve the outcomes in children with hepatoblastoma. MATERIAL AND METHODS: There were 160 children with focal liver lesions who underwent surgery at the department of liver transplantation in 2008-2019. Patients with malignant tumors made up 77% (n=123). Hepatoblastoma (HB) prevailed (86%, n=106). Liver transplantation was performed in 19 (18%) patients with HB. Median follow-up after transplantation was 24.3 months by December 2019. Follow-up period did not exceed 4 years in more than 2/3 of patients. RESULTS: Overall and disease-free 10-year survival was 87.1% and 82.7%, respectively. Similar values were observed after resections (91.1% and 86.6%). At the same time, actuarial 4-year survival after liver transplantation for HB was 68%. CONCLUSION: Improvement of treatment outcomes may be achieved through multidisciplinary interaction ensuring timely drug therapy and liver transplantation.

[Solitary fibrous tumor of pleura (symptoms, diagnosis, treatment)]. / Solitarnaya fibroznaya opukhol' plevry (klinika, diagnostika, lechenie).

OBJECTIVE: Optimization of diagnosis and treatment of patients with solitary fibrous tumor of pleura, analysis of overall survival and disease-free survival, predictors of recurrence. MATERIAL AND METHODS: There were 66 patients with solitary fibrous tumor of pleura (26 men and 40 women) aged 57.6 years (range 26-80 years). Asymptomatic course was found in 29 (44%) patients, various symptoms - in 37 (56%) patients. Thoracotomy was applied in 36 patients, thoracoscopy - in 30 patients. Immunohistochemical examination included analysis of definition of Stat6 expression. RESULTS: Benign variant of SFT was diagnosed in 50 (75.7%) patients, malignant variant - in 16 (24.3%) patients. STAT6 expression was observed in all cases. Postoperative morbidity was 9%, mortality - 1.6%. Recurrence was diagnosed in 2 (4%) patients with benign variant of disease and in 5 (31.2%) patients with malignant variant (2 of them died from progression of disease). Progression-free survival was 89.4%, overall survival - 95.4%. Predictors of recurrence are tumor dimension over 10 cm, necrosis and/or hemorrhagic component of tumor, mitotic count of at least four per 10 high-power fields. CONCLUSION. S: Olitary fibrous tumor of pleura is a rare mesenchymal fibroblastic neoplasm growing from submesothelial layer. Differential and preoperative morphological diagnosis of SFT is difficult and demands a special immunohistochemical examination with analysis of Stat 6 expression. Surgery is preferred for tumor de novo and recurrent neoplasm.

[Resection of retroperitoneal leiomyosarcoma followed by replacement of cavarenal segment of inferior vena cava]. / Udalenie zabryushinnoi leiomiosarkomy s rezektsiei i protezirovaniem kavarenal'nogo segmenta nizhnei poloi veny Klinicheskoe nablyudenie.

The authors reported a rare clinical case of successful surgical treatment of young female with retroperitoneal leiomyosarcoma followed by lesion of the cavarenal segment of inferior vena cava, left renal vein. Clinical and morphological features of disease, postoperative outcomes and prognostic factors in patients with retroperitoneal leiomyosarcoma are discussed.

[Segmentectomy in patients with primary pulmonary malignancies]. / Segmentéktomiia pri pervichnykh zlokachestvennykh opukholiakh legkikh.

OBJECTIVE: To analyze immediate and long-term results of anatomical resections for lung cancer with subsequent comparison of the results of segmentectomy and lobectomy in patients with peripheral NSCLC stage IA1-2. MATERIAL AND METHODS: There were 52 sublobular anatomical resections of the lung for peripheral non-small cell carcinoma and carcinoid T1a-bN0M0, IA1-2 stage. 3D-CT reconstruction with separation of bronchial and vascular structures was used to schedule complex segmentectomy. We retrospectively analyzed 200 patients with cT1a-bN0M0 peripheral non-small cell lung cancer (NSCLC) and tumor dimension ≤2 cm who underwent lobectomy (n=148) and segmentectomy (n=52). Mortality, morbidity and overall 5-year survival were compared in two propensity score matched groups (46 pairs, segmentectomy vs. lobectomy). RESULTS: There was no mortality in both groups. Morbidity was similar after segmentectomy and lobectomy (8.69 and 6.52%; p=0.32). 3D-CT with separation of bronchial and vascular structures enabled surgeons to perform atypical segmentectomies and VATS procedures more often (from 13.5 to 31.3%; p>0.05 and from 11.5 to 50.0%; p<0.05). Five-year survival was 82 and 86% (p=0.652) after segmentectomy and lobectomy, respectively. CONCLUSION: Postoperative results and long-term outcome after segmentectomy and lobectomy are comparable in patients with NSCLC cT1a-bN0M0, stage IA1-2. Segmentectomy is advisable surgery in patients with low pulmonary capacity and severe comorbidities.

[Lymphatic malformation of cervical-supraclavicular area with large mediastinal component]. / Limfaticheskaia mal'formatsiia sheino-nadkliuchichnoi oblasti s mediastinal'nym komponentom bol'shikh razmerov.

Lymphatic malformation (LM) is a benign neoplasm that consists of abnormally formed lymphatic vessels and cavities. The incidence of LM is 6% among all benign tumors. Mediastinal localization is extremely rare, only case reports in adults are described. Clinical observation of 42-year-old patient with LM of cervical-supraclavicular area and large mediastinal component communicating with thoracic lymphatic duct is presented. The first stage was thoracoscopic clipping of thoracic lymphatic duct, the second one - radical surgery through combined cervico-sterno-thoracotomy.

[Regional and peripheral blockades for prevention of chronic post-thoracotomy pain syndrome in oncosurgical practice]. / Primenenie regionarnykh i perifericheskikh blokad dlia profilaktiki khronicheskogo posttorakotomicheskogo bolevogo sindroma v onkokhirurgicheskoi praktike.

AIM: To compare an effectiveness of thoracic epidural anesthesia/analgesia, paravertebral and intercostal blockades in prevention of chronic post-thoracotomy pain syndrome (CPTPS) in oncosurgery. MATERIAL AND METHODS: There were 300 patients who underwent open surgery including lobectomy or pneumonectomy. Patients were randomized into 3 groups depending on type of anesthesia: TEA (n=100) - combined general and epidural anesthesia; PVB (n=50) - combined general and paravertebral anesthesia; ICB (n=50) - general anesthesia was supplemented by intercostal blockade after removal of the drug. RESULTS: CPTPS incidence was 34 and 40% in 6 months postoperatively after PVB and ICB, respectively (p>0.05). In TEA group this value was significantly lower compared with ICB group (23%, p<0.05). CONCLUSION: TEA contributes to significant reduction of CPTPS incidence, while paravertebral blockade does not affect the frequency of this complication.

[Surgery for non-small cell lung carcinoma after previous chemoradiotherapy alone]. / Operatsii u bol'nykh nemelkokletochnym rakom legkogo posle samostoyatel'noi khimioluchevoi terapii.

AIM: To investigate early and remote results of surgery in patients with recurrent non-small cell lung carcinoma (NSCLC) after previous chemoradiotherapy alone. MATERIAL AND METHODS: The retrospective study included 14 NSCLC patients (10 men and 4 women, mean age 52.6 years) who were operated in thoracic department for the period June 2008 - December 2013. Histologically squamous cell carcinoma prevailed (64.3%). Prior to surgery stage IIB was diagnosed in 2 patients, IIIA in 11 and IIIB in 1 patient. The dose of radiotherapy ranged from 45 to 70 Gr (median 58Gr). The average number of chemotherapy cycles was 3.8 per patient. Pneumonectomy was performed in all patients except one who underwent left-sided lower lobectomy. In all cases bronchial stump was covered by vascularized muscle flap (intercostal, latissimus dorsi). Postoperative complications were classified by TMM system (Thoracic Morbidity and Mortality System). RESULTS: Postoperative complications were observed in 7 (50.0%) patients including level II in 2 cases, IIIA in 1 case, IVA in 3 patients and V (death) in 1 (7.1%) patient. Postoperative stages of lung cancer were IB in 2 cases, IIA in 1, IIB in 5, IIIA in 4 and IIIB in 2 patients. Overall 1, 2 and 3-year survival rate was 89.1%, 82.0% and 48.0% respectively (median 35.0 months). Recurrence-free survival was 84.2%, 72.0% and 24.8%, respectively (median 28.0 months). Overall and recurrence-free 5-year survival rate was 10.8%. CONCLUSION: «Salvage¼ surgery may be recommended as individual approach in patients with reccurent lung cancer after previous chemoradiotherapy.

[ENDOCYTOSCOPY--NOVEL ENDOSCOPIC DIAGNOSTICS APPROACH: PRINCIPLES AND PROCEDURE].

Endocytoscopy is one of the most novel endoscopic diagnostic procedures, providing optical magnification up to 1150 times of gastrointestinal and respiratory tract mucosa. Such approach allows real-time tissue and cellular structure visualization. Endocytoscopy, along with confocal laser endomicroscopy, can be considered as "optical biopsy" in vivo. Of course, endocytoscopy currently is experimental diagnostic method, all available endocytoscopes are prototypes. According to published data, endocytoscopy can be used in precancerous conditions and early intramucosal cancer diagnostics in esophagus, stomach, colon and bronchial tree. Different types of endocytoscopes are used for examinations: some of them are baby-scopes, with fixed magnification 570-1150 times, introduced into accessory channel of the therapeutic parent-endoscope, others--are integrated type, providing scalable magnification from 80 to 380 times. As for traditional pathology ex vivo, for endocytoscopy mucosal cell nuclei stain is needed. For vital staining during endocytoscopy methylene blue, toluidine blue and crystal violet in different concentrations are more often used. In cases of squamous-cell dysplasia or cancer, it is recommended to use 1% methylene blue solution, whereas in intestinal type metaplasia, dysplastic changes and cancer (Barrett's esophagus, P. Correa precancerous cascade, colon adenomas), 1% toluidine blue is preferred. With endocytoscopy, after vital staining, we can visualize and estimate mucosa tissue and cell characteristics: papillae, crypt and gland shapes and sizes, their integrity (tissue markers); cell nuclei size and shape, polarity and nuclear dye intensity (cell markers).

[ENDOCYTOSCOPY--NEW TYPE OF ENDOSCOPIC EXAMINATION OF LOWER GASTROINTESTINAL AND RESPIRATORY TRACT].

Majority of published data describing endocytoscopic examination of upper gastrointestinal tract mucosa, but in recent publications, it is reported, that endocytoscopy is suitable for small bowel, colon, respiratory tract and even peritoneum "optical biopsy". In number of articles possibilities of celiac sprue diagnostics with endocytoscopy is discussed, but small-bowel endocytoscopy is limited, due to absence of endocytoscopes, compatible with enteroscopes. More widely endocytoscopy is used in colon, mostly in lateral-spreading adenomas diagnostics. Prof. S-E. Kudo developed endocytoscopic classification of colonic mucosa changes, used for differential diagnostics and lesion mapping, describing hyperplasia, adenomas with different grades of intraepithelial neoplasia, non-invasive and invasive cancer. Some authors reported about good possibilities of endocytoscopy in inflammatory bowel disease diagnostics. Most of data, related to respiratory tract endocytoscopic examination, focused on precancerous conditions and early pharyngeal and lung cancer, and the preliminary results are promising, but, unfortunately, for now, endocytoscopy in bronchial tree is limited, due to lack of thin endocytoscopes. According to some article data, it is possible to use endocytoscopy not only in gastrointestinal and respiratory tract, but also in optical confirmation of peritoneal tumor dissemination in gastric and ovarian cancer patients, and--in bladder mucosa examination.

[Lung-preserving surgical treatment of patients with bronchial carcinoid].

Isolated bronchus resection for central cancer was performed in 25 patients including preoperative bronchoscopic removal of exophytic tumor in 20 (80%) observations in thoracic department of P. Gertsen Moscow Research Cancer Institute. According to morphological study typical carcinoid was diagnosed in 23 (92%) patients, atypical - in 2 (8%) cases. All patients underwent conventional mediastinal lymphadenectomy. Postoperative complications after bronchus resection developed in 6 (33.3%) patients. There were no deaths. Overall 5- and 10-year survival was 100% and 96% respectively. The authors consider that by strict indications combination of endoscopic removal with isolated bronchus resection preserves all pulmonary parenchyma without prejudice for surgical radicalism.

Analysis of patterns formed by two-component diffusion limited aggregation.

We consider diffusion limited aggregation of particles of two different kinds. It is assumed that a particle of one kind may adhere only to another particle of the same kind. The particles aggregate on a linear substrate which consists of periodically or randomly placed particles of different kinds. We analyze the influence of initial patterns on the structure of growing clusters. It is shown that at small distances from the substrate, the cluster structures repeat initial patterns. However, starting from a critical distance the initial periodicity is abruptly lost, and the particle distribution tends to a random one. An approach describing the evolution of the number of branches is proposed. Our calculations show that the initial pattern can be detected only at the distance which is not larger than approximately one and a half of the characteristic pattern size.

Comparative enzyme immunoassay of matrix metalloproteinases-2, -7, -9 and their tissue inhibitor-2 in tumors and plasma of patients with gastric cancer.

The content of matrix metalloproteinases (MMP) -2, -7, and -9 was significantly higher in tumors in comparison with the adjacent histologically intact gastric mucosa in 80, 70, and 72% patients with gastric cancer, respectively, the increase in the level of MMP tissue inhibitor-2 (TIMP-2) detected in 61% tumors was insignificant. Only plasma level of MMP-7 was elevated in primary patients in comparison with the control and positively correlated with the expression of this protein in the tumor. The concentration of MMP-7 was maximum in the blood of patients with tumor invasion in lymph vessels. These data suggest MMP-7 as a possible serological marker of gastric cancer.

Analysis of NM23 protein and components of plasminogen activation system in tumors of patients with stomach cancer with consideration for disease clinical picture and morphology.

Immunohistochemical analysis of the expression and distribution of nm23 protein and biochemical analysis of the main components of plasminogen activation system in tumors were carried out in stomach cancer patients. The data indicate that the expression of nm23 protein in malignant epithelial gastric tumors is heterogeneous, characterized by cytoplasmic and nuclear immunoreactivity. Reduced expression of the marker is more typical of poorly or undifferentiated tumors. The expression of nm23 protein positively correlated with tPA level (r(s)=0.4; p=0.01) and did not correlate with the content of uPA and PAI-1 in tumors. High PAI-1 values in tumors (>0.5 ng/mg protein) significantly correlated with lower 3-year overall survival of stomach cancer patients. These data confirm the role of the studied proteins in invasion and metastases of malignant tumors and suggest a relationship between changes in the expression of nm23 protein and mechanisms of stomach cancer progress.