[ICG angiography in prevention of colorectal anastomotic leakage]. / Rol' ICG-angiografii v profilaktike nesostoyatel'nosti kolorektal'nykh anastomozov.

OBJECTIVE: To evaluate the effectiveness of indocyanine green fluorescence angiography in assessment of colorectal anastomosis perfusion. MATERIAL AND METHODS: A prospective single-center non-randomized comparative study included 85 patients with rectum and sigmoid colon cancer between September 2019 and March 2023. In the main group (n=41), we intraoperatively injected indocyanine green (ICG) IV to assess perfusion in the near infrared spectrum. In the control group (n=44), the same interventions were performed without ICG. RESULTS: In the main group, anterior resection of the rectum was performed in 23 (56.1%) patients with neoplasms of distal sigmoid colon and rectosigmoid tumors. Low anterior resection was performed in 18 (43.9%) cases. In the control group, the same procedures were carried out in 24 (54.5%) and 20 (45.5%) patients, respectively. After mobilization of the colon and ICG injection, we corrected resection line in 4 cases. As soon as anastomosis was formed and blood supply was controlled by ICG fluorescence angiography, we performed a water-bubble test to detect anastomotic leakage. Positive tests were detected in 4 (9.8%) and 5 (11.4%) patients of both groups, respectively. Postoperative complications occurred in 10 (24.4%) and 11 (27.3%) patients, respectively (p=0.94). Anastomosis failure was found in 1 and 7 patients, respectively. Anastomotic leakage grade «B¼ was significantly more common in the control group (2.4 and 13.6%, respectively, p=0.06). Anastomotic leaks were absent in all 4 patients who underwent resection level adjustment after intraoperative ICG angiography. CONCLUSION: Fluorescent luminescence will qualitatively improve intraoperative diagnosis of hypoperfusion of resection edges. Undoubtedly, this will reduce the incidence of colorectal anastomotic leaks caused by ischemia of large bowel wall.

[Comprehensive rehabilitation of immune-mediated adverse events in cancer patients receiving checkpoint inhibitor therapy]. / Kompleksnaya reabilitatsiya immunooposredovannykh nezhelatel'nykh yavlenii u patsientov so zlokachestvennymi opukholyami, poluchayushchikh terapiyu ingibitorami kontrol'nykh tochek.

OBJECTIVE: To evaluate adverse events and clinical effectiveness of complex rehabilitation programs in patients with malignant tumors receiving checkpoint inhibitor therapy. MATERIAL AND METHODS: The study included 144 cancer patients who received immunotherapy for the period from 2019 to 2021. Group 1 consisted of 72 patients who received a comprehensive rehabilitation program including physical therapy, diet therapy, psychotherapy, general magnetotherapy. Patients of the second (control) group (n=72) did not receive rehabilitation procedures. Effectiveness of treatment was evaluated according to RECIST 1.1 criteria, safety of treatment - according to CTCAE criteria (version 5.0, 2017). To assess the quality of life (QoL), the Russian version of the EORTC QLQ-C30 questionnaire was used. RESULTS: Mean follow-up period in the first group was 4.5 months, in the control group - 5 months. Disease progression was observed in 35 (48.6%) patients of the main group and 32 (44.4%) patients of the control group. Two (2.8%) patients in the control group demonstrated complete response to therapy. Partial response was established in both groups in 13 patients (18.1%). Stabilization of disease was detected in 24 (33.3%) and 25 (34.7%) patients, respectively. Adverse events were registered in 54 (75.0%) and 60 (83.3%) patients, respectively. Adverse events grade III-IV occurred in 9.7% and 11.1% of patients, respectively. CONCLUSION. I: Mmunotherapy combined with comprehensive rehabilitation program confirms high effectiveness of these drugs. We observed good tolerability of rehabilitation procedures that do not deteriorate the course of the underlying disease. However, there are certain important issues, in particular influence of rehabilitation procedures on tolerability of immunotherapy in patients with cancer.

[Modern approaches to the rehabilitation of patients with chronic paraproctitis in the early postoperative period]. / Sovremennye podkhody k reabilitatsii bol'nykh khronicheskim paraproktitom v rannem posleoperatsionnom periode.

Along with the classical methods of surgical treatment of rectal fistulas, new minimally invasive technologies have appeared using video endoscopic support for processing the fistulous tract and closing the internal fistula opening, intrasphincter ligation of the fistulous tract LIFT, however, they do not exclude relapses in the late postoperative period. The FiLaC (Fistula Laser Closure) laser technology based on the use of a radial flexible laser light guide, which does not cause damage to the anal canal mucosa, pain in the postoperative period, rectal postoperative bleeding and strictures, is quite promising in the further development of outpatient minimally invasive surgery for anal fistulas. anal canal. However, even with this technique, complications and relapses were observed in 10-12% of cases, which dictates the need to develop not only a patient-oriented approach to the surgical treatment of patients with chronic paraproctitis, but also to develop postoperative rehabilitation programs in the early postoperative period. OBJECTIVE: To study the effect of complex rehabilitation programs used in the early postoperative period on the efficacy of the therapy in patients with pararectal fistulas. MATERIAL AND METHODS: The study included 90 patients with chronic paraproctitis, (the average age was 43±3.4 years, the average duration of the disease was 5.1±1.5 years), who underwent a surgery using the modified FiLac technology. The patients were divided into 3 groups (30 patients in each group) depending on the rehabilitation method used during the postoperative period (2 days after the surgery): 1st group underwent a 4-component rehabilitation complex (intravenous ozone therapy, rectal laser therapy, recto-tibialmyostimulation of the pelvic floor muscles and biofeedback therapy); 2nd group underwent a 2-component rehabilitation complex (intravenous ozone therapy and rectal laser therapy); 3rd group has received a standard medical complex, which served as a background in 1st group and 2nd group. Therapeutic efficacy was assessed according to the assessment of pain syndrome (on the VAS scale), the results of anal sphincterometry (the Peritron 9600 device), the incidence of postoperative complications and relapses at different follow-up periods (up to 5 years). RESULTS: A comparative analysis of the nature of the course of the postoperative period, depending on the type of postoperative rehabilitation was carried out. In multiple comparisons using the parametric ANOVA method, it was found that there were statistically significant differences between the 1st group and the 3rd group in terms of pain intensity, duration of pain, the timing of wound healing, the frequency of complications, and the timing of return to work. The results in the 2nd group were slightly lower than in the 1st group, but they also differed significantly from the data of the 3rd group. During the analysis of the early and late p/o complications and relapses in patients with chronic paraproctitis after surgery the most significant were obtained from the 1st group (only 1 case of early p/o complications and relapse within 1 to 5 years), while in the 3rd group there were 2 (6.6%) cases of early p/o complications, 2 cases (6.6%) of relapses within a period of up to 1 year and 6 (20%) cases in the period from 1 to 5 years. In patients of the 2nd group, results close to the results of the 1st group were obtained: 2 (6.6%), 2 (6.6%) and 3 (9.9%) cases respectively. CONCLUSION: The use of expanded rehabilitation complexes among the patients with chronic paraproctitis in the early postoperative period after surgery, including intravenous ozone therapy, rectal laser therapy, recto-tibialmyostimulation and bifidobac therapy, made it possible to significantly improve therapeutic efficacy, which was confirmed by faster pain relief, fewer early and late p/o complications. The data obtained indicate the need for the use of rehabilitation programs in the early postoperative period for the treatment and prevention of complications after surgery.

[Modern surgical technologies in the treatment of patients with chronic paraproctitis]. / Sovremennye khirurgicheskie tekhnologii v lechenii bol'nykh khronicheskim paraproktitom.

The development of minimally invasive surgical technologies in the treatment of chronic paraproctitis is a promising young trend in coloproctology. Increasingly, in clinical practice, coloproctologists use laser technologies in the outpatient treatment of extra- and transsphincteric pararectal fistulas, in particular, laser technology FiLaC (Fistula Laser Closure). OBJECTIVE: Conducting a comparative retrospective and prospective cohort study of immediate and long-term results of treatment of complicated transsphincteric and extrasphincteric fistulas using the developed modified FiLaC technology with the «traditional¼ FiLaC technology, and standard excision of the fistulous tract with plasty of the internal fistula opening with a full-thickness flap of the rectal wall. MATERIAL AND METHODS: The study included 270 patients with trans- and extrasphincter pararectal fistulas, which were divided into three groups. In group 1 (n=90) the traditional FiLaC technology was used for the treatment of fistulas, in group 2 (n=90) the modified FiLaC technology was used, providing for the opening of purulent streaks and laser coagulation (FiLaC) of the intrasphincter part of the fistula with a Biolitec laser, 12 W, 100 J/cm, in group 3 (n=90), excision of the fistula tract with plastic surgery of the internal fistula opening with a full-thickness flap of the rectal wall was used. RESULTS: The results of treatment in patients of the three groups were monitored for 19-36 months. after surgery (median 31 months). The analysis of the results showed that in group 2 (modified FiLaC technology) healing of fistulas occurred faster (7.3±0.5 weeks versus 12.6±0.7 weeks) compared to group 3 (excision of the fistula with plasty of the internal fistula opening). The indicators of sphincterometry in the long-term period in patients of the 2nd group were restored in relation to the initial ones, and in the th group 3 they were reduced compared to the initial values. Postoperative complications were most common in patients of group 3 (32.2%), and least often in patients of group 2 - 8.9%. At the same time, late postoperative complications were most common (24.4%) in patients of group 1. None of the patients in group 2 had late postoperative complications, while 11.1% of postoperative complications were recorded in group 3. In patients who underwent excision of the AC (group 3), relapses were most common: early - 15.6%, late - in 21.1%. The least frequent relapses were observed in patients who underwent modified FiLaC technology (Group 2): 6.7% - early relapses and 11.1% - late relapses. CONCLUSION: The use of the modified FiLaC technology in the treatment of trans- and extrasphincteric fistulas of the rectum made it possible to minimize postoperative complications, fully preserve the function of anal holding, and achieve healing of fistulas in 82.5% of cases with a median follow-up of 31 months.

[Regenerative effect of comprehensive physiotherapeutic programs in the early postoperative period in patients with chronic paraproctitis]. / Regenerativnyi effekt primeneniya kompleksnykh fizioterapevticheskikh programm v rannem posleoperatsionnom periode u bol'nykh khronicheskim paraproktitom.

The modern lifestyle is often associated with low physical activity and blood stasis in the pelvic organs, which leads to increased incidence of proctological diseases, and increasingly in people of young working age. Chronic paraproctitis is the third most common proctological disorder that requires surgical treatment. The disease occurs commonly in the age group of 30-50 years, predominantly in men, which determines its socio-economic significance. It indicates the urgent need for advanced comprehensive physiotherapeutic programs for early rehabilitation of patients after surgery for chronic paraproctitis, and the application of new diagnostic technologies for assessment of surgery effectiveness and postoperative changes to provide adequate and effective medical rehabilitation. One of the main goals in the early postoperative period is the acceleration of adequate scar formation and reduction of the postoperative wound healing time; therefore, it seems reasonable to assess regeneration processes using transrectal ultrasound examination and sonoelastography of the scar tissue, which have great potential for use in coloproctology. OBJECTIVE: To study the role of the medical rehabilitation program in the early postoperative period on the adequate scar formation and postoperative wound healing processes (by transrectal ultrasound investigation and scar tissue sonoelastography) as well as postoperative complications rate and long-term (up to 12 months) treatment outcomes in patients with chronic paraproctitis. MATERIAL AND METHODS: The study included 60 patients 20-69 years with chronic pararectal fistulas (ICD-10: K60.4). The patients were assigned into two groups. The control group consisted of 30 patients who received standard of care in the early postoperative period, including analgesics, local antibacterial ointments (Levomekol, etc.), and rectal suppositories (Relief Pro, etc.). The main group also consisted of 30 patients who received standard of care and a 5-day comprehensive physiotherapeutic program starting the second day after the surgery. Effectiveness was assessed by complex transrectal ultrasound investigation with color Doppler mapping, Doppler sonography, and sonoelastography at various post-surgery time points. RESULTS: The higher efficacy of the rehabilitation program, including intravenous ozone therapy, rectal laser therapy, recto-tibial myostimulation, and biofeedback therapy in the early postoperative period, versus the standard of care, was shown. CONCLUSION: The introduction of rehabilitation program including intravenous ozone therapy, rectal laser therapy, recto-tibial myostimulation, and biofeedback therapy in the early postoperative period significantly reduced the average postoperative wound healing time by accelerating the formation of an adequate scar (according to transrectal ultrasound investigation and scar tissue sonoelastography) and the incidence of postoperative complications and improved the long-term treatment outcomes (up to 12 months) in patients with chronic paraproctitis.

[Impact of comorbid chronic heart failure with preserved left ventricular ejection fraction on the management of elderly cancer patients before and after total resections]. / Otsenka vliyaniya komorbidnoi khronicheskoi serdechnoi nedostatochnosti s sokhrannoi fraktsiei vybrosa levogo zheludochka na vedenie pozhilykh onkologicheskikh patsientov do i posle radikal'nykh operativnykh vmeshatel'stv.

OBJECTIVE: To determine the predictors of safe enhanced recovery after surgery in elderly cancer patients with comorbid chronic heart failure (CHF) and preserved left ventricular ejection fraction (LVEF). MATERIAL AND METHODS: There were 75 patients over 65 years old (mean 73.6±5.6 years) with cancer of abdominal and pelvic organs and comorbid cardiovascular diseases for the period from January 2018 to July 2020. All patients underwent total resections with enhanced postoperative recovery at the Petrovsky National Research Centre of Surgery. RESULTS: CHF with preserved LVEF was diagnosed in 42 (56%) patients (NYHA class I - 20 patients, class II - 19 patients, class III - 3 patients). ACE/ARA/neprilysin inhibitors were described in 74.7% of patients, beta-blockers - 70.7%, calcium channel blockers - 37.3%, diuretic therapy - 21.3%, antithrombotic therapy - 62.7%, statins - 54.7%, antiarrhythmic therapy - 12%. Preoperative correction of cardiac therapy was required in 60% of patients. Mean LVEF was 58.5±6.8%, pulmonary artery systolic pressure - 29±7.8 mm Hg, impairment of local myocardial contractility was observed in 6.7% of patients. Serum NT-proBNP level was 534.5±63.9 pg/ml, LDL-C - 3.3±1.1 mmol/l, GFR - 65.95±17.1 ml/min/1.73m2, glycated hemoglobin 6.37±0.67%. Perioperative risk of cardiovascular complications within 30-day postoperative period was assessed using the Revised Cardiac Risk Index (RCRI) score (6% in 59 patients, 10.1% in 11 patients, and 15% in 5 patients). Incidence of cardiovascular complications in early postoperative period was 4%, postoperative 30-day mortality rate - 1.3%. CONCLUSION: Our small study of surgical treatment of elderly cancer patients with comorbid CHF with preserved LVEF demonstrates the need for a personalized assessment of preoperative clinical and instrumental data to optimize cardiac therapy and perioperative monitoring. Multidisciplinary approach reduces perioperative mortality and cardiovascular morbidity from 7.2% to 4%.

[Metastasis of the right colon mucinous adenocarcinoma to aortocaval and retropancreatic space: case report and literature review]. / Metastaz slizeobrazuyushchei adenokartsinomy pravoi poloviny obodochnoi kishki v aortokaval'noe i retropankreaticheskoe prostranstvo: obzor literatury i redkoe klinicheskoe nablyudenie.

Metastases of the right colon cancer to extra-regional lymph nodes are rarely observed. Available literature data cannot be a reliable guide to choose the optimal treatment strategy. Indeed, excision of extra-regional lymph nodes is a rare experience and its results are poorly represented. According to our clinical experience, surgical intervention following comprehensive examination may be radical in patients with right colon cancer if distant metastases are absent. Resection of extra-regional lymph nodes can be safely performed in these cases. We report a patient with the right colon cancer and lesion of extra-regional lymph nodes behind the pancreatic head, paracaval and paraaortic space, hepatoduodenal ligament. Standard laparoscopic right-sided hemicolectomy with D-3 lymph node dissection was accompanied by resection of a conglomerate of nodal metastases behind the pancreatic head and superficial resection of the pancreas. Extra-regional lymph node excision is a reasonable option for colon mucinous adenocarcinoma stage I-III. However, comprehensive preoperative examination is required. Technical difficulty of extra-regional lymph node excision it is not the reason for limitation of surgical intervention. However, safe and total resection requires an adequate surgical approach.

[Multi-component multi-stage treatment of a patient with infection of thoracic aorta prosthesis, deep sternal wound infection and soft tissue deficit of the chest]. / Mnogokomponentnoe, mnogoetapnoe lechenie patsientki s infektsiei proteza vsei grudnoi aorty, osteomielitom grudiny i defitsitom myagkikh tkanei grudnoi kletki.

We report a comorbid patient after redo Frozen Elephant Trunk procedure followed by recurrent infection of thoracic aortic prosthesis, deep sternal wound infection and extensive soft tissue defect. Closure with skin-muscle thoracodorsal flap and graft-sparing technique with omentoplasty is an alternative to total graft replacement for thoracic aortic graft infection in comorbid patients with concomitant extensive defect of the chest wall or recurrent infection in early postoperative period.

[Endoscopic harvesting of internal mammary artery for coronary artery bypass grafting]. / Éndoskopicheskoe vydelenie vnutrennei grudnoi arterii iz mini-torakotomii pri mammarno-koronarnom shuntirovanii.

Endoscopic harvesting of internal mammary artery for minimally invasive coronary artery bypass surgery seems to be highly justified and expedient. Technical features of this procedure are reviewed in the article. There are certain advantages of this method including ligation of proximal branches, reduced surgical trauma, better cosmetic results and enhanced postoperative rehabilitation.

[The role of lymphadenectomy for treatment of colorectal liver metastases with regional lymph nodes involvement]. / Rol' limfadenéktomii v lechenii metastaticheskogo kolorektal'nogo raka pecheni s porazheniem regionarnykh limfaticheskikh uzlov.

Liver resection remains the method of choice for treatment of colorectal liver metastases with good long-term results. Regional lymph nodes involvement is significant negative prognostic factor. Moreover, it has been considered as a contraindication for liver resection for a long time. The role of lymphadenectomy remains controversial. Current state of this problem is reviewed in the article. Liver regional lymph nodes involvement takes place in 10-20% of cases. PET/CT is the most sensitive method of preoperative diagnosis. Involvement of liver regional lymph nodes is currently not absolute contraindication for liver resection. Routine lymphadenectomy does not make sense, and, perhaps, is justified only within scientific trials for more accurate disease staging. Indications for lymphadenectomy are suspicious changes of lymph nodes revealed by preoperative visualization methods or by intraoperative exploration. Modern chemotherapy regimens allow to reconsider the prognostic importance of liver regional lymph node metastases and to extend indications for liver resections.

[Isolated pancreatic metastases of renal cell carcinoma]. / Izolirovannye metastazy pochechno-kletochnogo raka v podzheludochnuiu zhelezu.

AIM: To present own experience of surgical treatment of isolated pancreatic metastases of renal cell carcinoma. MATERIAL AND METHODS: There are 3 cases of pancreatic metastases of renal cell carcinoma. They were diagnosed in women aged 55, 66 and 67 years in 9, 11 and 23 years after nephrectomy respectively. RESULTS: The tumors were placed in head (60 mm), body (10 and 5 mm) and tail (30 mm) of the pancreas. There were 2 distal pancreatectomy with splenectomy and 1 pancreatoduodenectomy. All patients are alive within 39, 49 and 8 months after surgery respectively. One woman has been diagnosed pulmonary metastases after 19 months. 20-month sunitinib administration contributes to regression of the disease. There was no recurrent disease in other two patients. CONCLUSION: Isolated pancreatic metastases of renal cell carcinoma can occur in decades after nephrectomy. Therefore, lifelong follow-up is necessary. Pancreatectomy for focal lesion is associated with good long-term outcome.

[Radiofrequency ablation in combined treatment of metastatic colorectal liver cancer]. / Radiochastotnaya ablyatsiya v kombinirovannom lechenii metastaticheskogo kolorektal'nogo raka pecheni.

AIM: To study surgical and oncological outcomes in patients with metastatic colorectal liver cancer who underwent radiofrequency ablation in the structure of combined approach. MATERIAL AND METHODS: It is a prospective analysis of treatment of 76 patients with metastatic colorectal liver cancer who underwent RFA for the period 2004-2013. Overall survival was analyzed using univariate and multivariate analysis. RESULTS: According to univariate analysis overall 5-year survival is negatively determined by following factors: primary localization of the tumor in rectum (36.2% and 7.2%; p=0.021); bilobed metastatic liver disease (35.9% and 15.4%; p=0.068); metastases dimensions over 5 cm (27.4% and 0%, p=0.091); augmentation of CAE levels over 4 norms (26.7% and 11.4%, p=0.09); RFA as a component of two-stage liver surgery (23.3% and 26.0%, p=0.09). CONCLUSION: RFA is an effective method of local antineoplastic effect for metastatic colorectal cancer. Dimensions of coagulated metastases, volume of metastatic lesion, carcinoembryonic antigen level, ablation as a component of two-stage surgery affect long-term survival after RFA.

The role of prognostic models in metastatic colorectal liver cancer surgery.

INTRODUCTION: Patients with metastatic colorectal liver cancer differ from each other by some characteristics which affect on the prognosis of disease. Long-term results and, consequently, the prognosis depend on not one but group of factors which may be incorporated into mathematical models allowing to classify patients according to their risk of recurrence or prognosis of survival. AIM: To calculate survival in patients with metastatic colorectal liver cancer and to evaluate the most popular models of 3- and 5-year survival rate prognosis after liver resection. MATERIAL AND METHODS: We analyzed the results of treatment of 342 patients with metastatic colorectal cancer who underwent different resections since 1991 to 2014. The effectiveness of prognostic models was estimated according to the most popular scales that were developed based on groups of more than 200 patients. RESULTS: Long-term results were followed in 312 (91.2%) patients. Median life in the total group of patients was 24 months in 3-, 5- and 10-year survival of 56.3%, 36.1% and 18.1% respectively. The most accurate stratification of patients into groups was obtained using preoperative Rees scale for 5-year and 3-year survival (C-statistics - 0.73 and 0.69, respectively). Analysis of Iwatsuki and Fong scales for 5-year survival prediction (C-statistics - 0.68 and 0.62) and postoperative Rees scale for 3-year survival (C-statistics - 0.63) also showed relatively good results. None of models showed C-statistics level over 0.8. CONCLUSION: Stratification of patients according to prognostic scales should not affect on monitoring of patients with high risk of recurrence and poor prognosis of survival.