[Diagnostic and conservative treatment nuances in patients with obstructive jaundice: in the wake of Russian consensus].

The research was performed at the Loginov Moscow Clinical Scientific Center. It is based on Russian obstructive jaundice (OJ) consensus results, considered at the 45th annual Central Research Institute of Gastroenterology Scientific session Oncological issues in the gastroenterologist practice (1 March 2019). The article objective is to note the diagnostic and conservative treatment current issues in patients with OJ. The increase in the number of patients with OJ of different etiology provides problem actuality. In a large number of cases, medical treatment is delayed due to inadequate diagnostic and management, while correct patients routing today can be provided regardless of medical institution level. In this article the examination steps and conservative treatment role in patients with biliary obstruction management are presented.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]. / Rossiiskii konsensus po aktual'nym voprosam diagnostiki i lecheniya sindroma mekhanicheskoi zheltukhi.

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

[Recommendations for the Protocol of functional examination of the anorectal zone and disorders classification: the International Anorectal Physiology Working Group consensus and Russian real-world practice].

This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. Aim to provide information about methods of diagnosis and new classification of functional anorectal disorders to a wide range of specialists general practitioners, therapists, gastroenterologists, coloproctologists all who face the manifestations of these diseases in everyday practice and determine the diagnostic and therapeutic algorithm. Current paper provides agreed statements of IAPWG Consensus and comments (in italics) of Russian experts on real-world practice, mainly on methodology of examination. These comments in no way intended to detract from the provisions agreed by the international group of experts. We hope that these comments will help to improve the quality of examination based on the systematization of local experience with the use of the methods discussed and the results obtained. Key recommendations: the International Anorectal Physiology Working Group protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.

[Comparative assessment of the expression of Muc 2, Muc 5AC, and Muc 6 in serrated neoplasms of the colon]. / Sravnitel'naia otsenka ékspressii Muc 2, Muc 5AC i Muc 6 v zubchatykh novoobrazovaniiakh tolstoi kishki.

In the course of the serrated pathway of carcinogenesis, there are changes in the expression of mucins with a characteristic immunophenotypic sign, such as a late loss of intestinal differentiation and an increase in gastric differentiation. OBJECTIVE: To comparatively assess the expression of Muc 2, Muc 5AC, and Muc 6 in hyperplastic polyps (HPs), sessile serrated adenomas (SSAs) and traditional serrated adenomas (TSAs) of the colon for determination of their role in differential diagnosis. MATERIAL AND METHODS: Sixty-five serrated masses from 52 patients were examined. Among them, there were 26 SSAs, 26 HPs, and 13 TSAs. A histological examination was done using hematoxylin and eosin staining; periodic acid-Schiff reaction in combination with alcian blue, as well as immunohistochemistry with anti-Muc 2, anti-Muc 5AC, and anti-Muc 6 antibodies were used. Genetic testing of the specimens for KRAS and BRAF mutations was also carried out. RESULTS: All the serrated neoplasms of the colon exhibited a pronounced expression of Muc 2. A marked Muc 6 expression in the dilated crypt bases was found in 76.9% of SSAs, while no reaction was seen in 92.3% of HPs and in 100% of TSAs. SSAs were characterized by an intense Muc 5AC expression in the whole length of the crypts and in the surface epithelium in contrast with HPs and TSAs, where the expression of the marker was focal. Comparison of the response of the markers and the presence of gene mutations identified that the SSAs with BRAF mutation intensely expressed along the length of the crypt for Muc 5AC and Muc 6; and the TSAs with KRAS mutation had a moderate focal Muc 5AC expression in the crypt bases in 100% of cases. CONCLUSION: For differential diagnosis of the types of serrated adenomas of the colon, it is useful for a pathologist to apply the immunohistochemical markers Muc 2, Muc 5AC, and Muc 6 in his/her practice.

[All-Russian Consensus on Diagnosis and Treatment of Celiac Disease in Children and Adults]. / Vserossiiskii konsensus po diagnostike i lecheniyu tseliakii u detei i vzroslykh.

The paper presents the All-Russian consensus on the diagnosis and treatment of celiac disease in children and adults, which has been elaborated by leading experts, such as gastroenterologists and pediatricians of Russia on the basis of the existing Russian and international guidelines. The consensus approved at the 42nd Annual Scientific Session of the Central Research Institute of Gastroenterology on Principles of Evidence-Based Medicine into Clinical Practice (March 2-3, 2016). The consensus is intended for practitioners engaged in the management and treatment of patients with celiac disease. Evidence for the main provisions of the consensus was sought in electronic databases. In making recommendations, the main source was the publications included in the Cochrane Library, EMBASE, MEDLINE, and PubMed. The search depth was 10 years. Recommendations in the preliminary version were reviewed by independent experts. Voting was done by the Delphic polling system.

[Endoscopic pancreatic stenting in pancreatic fistulas management]. / Endoskopicheskoe transpapillyarnoe pankreaticheskoe stentirovanie v lechenii svishchei podzheludochnoi zhelezy (s kommentariem A.G. Krigera).

AIM: To present 18-year experience of endoscopic transpapillary stenting in patients with pancreatic fistula. MATERIAL AND METHODS: The study included 48 patients with pancreatic fistula resistant to conservative management. Pancreatic stenting was successful in 32 (66.7%) patients. In 30 (93.8%) of them stenting appeared as the final stage of pancreatic fistula treatment. RESULTS: Inclidence of complications after endoscopic treatment was 4.2%. We evaluated long-term results in 23 cases within 8-184 months. There were good results in 21 (91.3%) cases and satisfactory - in 2 (8.7%) cases. We had not unsatisfactory results in our experience.

Engineering Approach to Identifying Patients with Colon Tumors on the Basis of Electrophotonic Imaging Technique Data.

BACKGROUND: Colonic neoplasms are quite a serious problem today. Screening methods play an important role in diagnosing the disease. Colorectal cancer screening is a complex undertaking, having various options, which require a lot of efforts both from the doctor and from the patient, including the use of sedatives and the necessity of the presence of an assistant for some procedures such as colonoscopy. This is why it is very important to find a method by which one can make a diagnosis quickly, easily, and painlessly. METHODS: The ability to identify patients with tumors of the colon using the Electrophotonic Imaging (EPI) technique, as well as using it for differential diagnosis of tumors of the colon by their morphology, size and quantity was investigated. Selection of the most significant parameters of the EPI-graphy for the separation of the control group and the group of patients with tumors of the colon was developed. 137 people were studied with the EPI camera, with ages ranging from 16 to 86 years, including 49 males and 88 females. Based on the results of the colonoscopy and histological findings all subjects were divided into 2 groups: control group of 55 people, 9 males, 46 females; and patients with tumors (benign or malignant) of the colon - 82 people; 40 males and 42 females. Then all subjects were divided into smaller groups based on morphology, size, number of tumors and localization. RESULTS: Based on the identified indicators decision rules to determine the patients with tumors of the colon were constructed. The specificity of the resulting function was 80.0% and sensitivity 75.6%. Decision rule was built as well with logistic regression. The specificity of the resulting function was 78.2% and sensitivity 90.0%. The accuracy of this approach was higher than using discriminant analysis. CONCLUSIONS: The results of this study have proven the ability to identify patients with tumors of the colon using EPI technology, as well as use it for differential diagnosis of tumors of the colon by their morphology, size and quantity. EPI testing is non-invasive, takes less than five minutes, and equipment is relatively cheap and accessible in mass production. This opens up good prospects for further research for implementation as a first step of the screening process. This paper presents the pilot study developing methodological approach to the GDV data processing. That is why we tried different methods of data processing. At the same time we do not pretend to develop a diagnostic method - sample size is too small for this, and other cancer types were not studied. Further research is needed.

[Surgical treatment of patients with gastrointestinal stromal tumor of the stomach]. / Operativnoe lechenie bol'nykh s gastrointestinal'noi stromal'noi opukhol'yu zheludka (s kommentariem).

AIM: to evaluate objectively the effectiveness of currently used diagnostic and curative approaches to gastrointestinal stromal tumors (GIST). MATERIAL AND METHODS: Early and remote results of treatment of 49 patients with gastric GISTs were presented. Herewith in 20 (40.8%) patients the disease was complicated by gastrointestinal bleeding. 43 (87.7%) of 49 patients with gastric GIST were operated. Conventional surgery was performed in 24 (55.8%) cases, laparoscopic interventions - in 12 (28%) cases, endoscopic endoluminal - in 7 (16.2%). 6 (14.2%) patients were not operated. RESULTS: Intraoperative complications were observed in 2 (4.65%) patients. In postoperative period complications occurred also in 2 (4.65%) patients. In long-term postoperative period tumoral process progression was observed in 3 (8.3%) patients. Recurrence was diagnosed in 2 (5.6%) patients.

[Combination of endoscopic methods in diagnostics and surgical treatment of perforative duodenal ulcer].

AIM: To present the results of perforative duodenal ulcer surgical management using combination of endoscopic methods. MATERIAL AND METHODS: The study included 279 patients with perforative duodenal ulcer who were operated for the period from 1996 to 2012. Diagnostics and medical tactics were based on developed in our clinic algorithm that includes use of both esophagogastroduodenoscopy and laparoscopy. CONCLUSION: Presented technique confirmed correct diagnosis, defined medical tactics and choice of surgery in 100% of cases. 67 patients had contraindications for laparoscopic suturing and underwent conventional operations. Herewith postoperative complications and death were observed in 25 (37.3%) and 9 (13.4%) patients respectively. Laparoscopic suturing was performed in 212 patients. Complications were diagnosed in 19 (8.9%) cases including 8 (3.7%) intraoperative and 11 (5.2%) postoperative. Deaths were absent.

[Laparoscopic diagnosis and treatment of acute early adhesive intestinal obstruction].

AIM: To estimate the role of emergency laparoscopic interventions in diagnosis and treatment of acute early adhesive intestinal obstruction. MATERIAL AND METHODS: It is presented the results of diagnostic and curative laparoscopic interventions in 58 patients with suspected acute early adhesive intestinal obstruction after abdominal surgery. Complex clinical-instrumental, non-invasive diagnosis does not always reveal this complication in early postoperative period. Diagnostic laparoscopy was the most informative method to assess state of abdominal cavity, to establish and characterize acute early adhesive intestinal obstruction, to determine following treatment and choice of surgery in all patients. RESULTS: Diagnosis of intestinal obstruction was not confirmed in 15 (25.9%) patients based laparoscopic checkup. Acute early adhesive intestinal obstruction was established in 43 (74.1%) patients. Small intestine injuries were observed in 2 (4.5%) cases during laparoscopy. Contraindications to laparoscopic treatment of obstruction were determined in 18 (41.9%) patients in whom conventional operations were performed with complications and death in 7 (38.8%) and 3 (16.6%) cases respectively. Curative laparoscopy was applied in 23 (53.4%) patients with successful resolving of intestinal obstruction and complications in 19 (82.7%) and 4 (17.4%) cases respectively.

[Laparoscopic diagnosis and treatment of early adhesive small bowel obstruction after gynecological surgery].

It is presented the results of diagnostic and curative laparoscopic interventions in 33 patients with acute early adhesive small bowel obstruction. Ileus developed after surgical treatment (laparotomy) of different gynecological diseases. Laparoscopy appeared as the most informative diagnostic method to confirm diagnosis in all patients, to estimate state of abdominal cavity and small pelvis organs what can help to determine method of surgical treatment. Contraindications for laparoscopic surgery were identified in 12 (36.4%) patients and conversion to laparotomy was applied in this group. Postoperative complications were diagnosed in 1 (8.3%) patient. 2 (16.6%) patients died. Early adhesive ileus was resolved laparoscopically in 21 (63.6%) of 33 patients. Recurrent acute early adhesive ileus was detected in 1 (4.7%) patient.

[Diagnosis and immediate results of treatment of patients with non-epithelial tumors of upper gastrointestinal tract].

We presented an experience of treatment of 225 patients with non-epithelial tumors of upper gastrointestinal tract. Complicated disease's course was observed in 24% of cases. Tactical approaches are discussed depending on localization, dimensions and nature of tumor growth. Also indications for minimally invasive operations are defined. It was operated 102 (45.3%) of above-mentioned patients. Conventional surgical interventions were performed in 49 (48.0%) cases, laparoscopic operations - in 11 (10.8%) observations, endoscopic techniques using flexible endoscope - in 42 (41.2%) patients. One hundred and twenty-three (54.7%) patients were under dynamic observation. Technical features of the performed operations are described in the article. Complications were diagnosed in 8 patients including intraoperative in 3 cases and postoperative in 5 cases. Postoperative mortality was 2.0% (2 of 102 died). Overall mortality was 1.3% (3 of 225 patients died). Gastrointestinal stromal tumor (38) and leiomyoma (29) were the most frequent findings among removed tumors.

[COLON CAPSULE ENDOSCOPY IN CLINICAL EXPERIENCE].

AIM: Is to evaluate technical aspects and feasibility of colon capsule endoscopy (CCE) in the daily clinical practice. MATERIALS AND METHODS: From I.2014 to VIII.2014 we performed 36 (97.3%) CCE from 37 patients (m-19, f-17, mean age 43.9 ± 14.2 years, range 22-72). RESULTS: Total CCE was performed in 33 (89.2%) patients. In all patients we were able to register anatomy and to evaluate the lumen and the wall of large bowel; to explore and identify mucosal abnormality as well as epithelial lesions. CONCLUSION: The article demonstrates our own experience of colon capsule endoscopy (n = 36); the principal possibilities to evaluate colon anatomy and to detect wide range of abnormality.

[APPLICATION OF HD-VIDEOENDOSCOPY, MAGNIFYING ENDOSCOPY AND NARROW BAND IMAGING TECHNIQUE FOR THE DIFFERENTIAL DIAGNOSIS OF BENIGN AND NEOPLASTIC EPITHELIAL LESIONS IN THE STOMACH. THE POTENTIAL OF THE COMPUTER-AIDED ANALYSIS].

An endoscopic diagnosis of superficial epithelial neoplastic gastric lesions and early gastric cancer is the challenge of medicine today. It remains at a low level without the use of modern endoscopic technologies such as HDTV and magnifying endoscopy, narrow band imaging (NBI) and similar image-enhanced endoscopic methods, which provide the visualization of microsurface and microvascular pattern. There are a few endoscopic classifications of microsurface and microvascular patterns to distinguish benign and neoplastic superficial gastric epithelial lesions. However, the most effective classifications are based on the intuitive analysis of regularity of surface or/and vascular pattern or heterogeneity of vessels shape and thickness. They are complex for understanding and learning to inexperienced specialists. In this study, we performed expert and computer analysis of 104 HDTV and magnifying NBI endoscopic images of benign and neoplastic gastric lesions in parallel. The images were described for 7 clinical and 23 endoscopic parameters, including 12 qualitative parameters of microsurface and microvascular patterns by the expert evaluation. After statistical analysis, the significant parameters were defined, and the decision rule for the differential diagnosis of benign and malignant lesions were composed. An accuracy of the decision rule was 95.8% for selection of benign lesions and 81.8% for epithelial neoplasia. We performed the computer-aided image analysis using a method "bag of visual words" to distinguish endoscopic images based on irregular vascular pattern as the most significant parameter in expert image analysis and we have shown the accuracy 73-78% for this method. We plan to use this method for independent computer-aided analysis of endoscopic images for differentiation of benign and neoplastic epithelial gastric lesions and creating the clinical decision support system for endoscopy.

[RADICAL ENDOSCOPIC REMOVAL OF ADENOMA OF THE MAJOR DUODENAL PAPILLA WITH SUCCESSFUL INTRAOPERATIVE CORRECTION OF COMPLICATIONS].

We introduce one of the successful clinical observations of a radical endoscopic removal of adenoma of the major duodenal papilla with severe dysplasia, as well as intraoperative correction of complications, jet bleeding and retroduodenal perforation, which occurred during this operation.

[Possibilities and limitations of retrograde transpapillary stenting of the main pancreatic duct in the treatment of chronic pancreatitis and its complications].

UNLABELLED: For the last years the role of endoscopic pancreatic stenting in the treatment of chronic pancreatitis and its complica- tions has significantly increased. MATERIALS AND METHODS: In the clinic of abdominal surgery and endoscopy of Pirogov RNRMU based on the University Hospital 31 for the period from 01.1998 to 01.2014 Wirsung duct occlusion, which developed on the background of CP was the cause of performing of 215 endoscopic procedures in 95 patients: 34 (35.8%) women and 61 (64.2%) men. Mean age 49.8 ± 11.7 years. Study group consisted of 52 (54.7%) patients with strictures of MPD and 43 (45.3%) with pancreatic fistulas. We tried to perform pancreatic stenting in all the cases, as a method of treatment of pathological changes in the pancreatic ductal system. RESULTS: Endoscopic stenting was successfully performed in 64 cases (67.4%), while in 45 (70.3%) cases, this intervention was the definitive method of treatment. Temporary Wirsung duct stenting was performed in 19 (29.7%) cases in which endoscopic retrograde step interven- tions were training to perform surgery. It is significant that the main causes of the technical impossibility of pancreatic stenting was the complete dissociation of Wirsung duct (8), distal localization of occlusive lesions (13), presence of severe angulation in stenotic changes (20) and the length of the scar stricture of the MPD more than 1 cm (17) and particularly a combination of several factors. Clinically significant complications after endoscopic interventions in our study occurred in 6 (2.8%) cases. Lethal outcome occurred in one patient (0.5%). CONCLUSION: According to the results of our study pancreatic stenting was technically feasible in 67.4% of all cases. At the same time, endoscopic correction, if the possibility of its technical implementation, may be the final method of treatment in 70.3% cases. In this endoscopic pancreatic stenting has a low complication rate (2.8%) and mortality (0.5%). The main reasons for the failures and limitations of endoscopic stage treatment is a combination of factors: complete dissociation of the MPD, distal location of the Wirsung duct strictures with severe angulation in this area and a large length of strictures.

[Torsion and necrosis of epiploic appendices of the large bowel].

The features of the clinical symptoms was studied, the possibility of laparoscopy in modern diagnosis and treatment of epiploic appendices torsion and necrosis of the large bowel was assessed in the article. It was done the retrospective analysis of the medical records of 87 patients with a diagnosis of epiploic appendices torsion and necrosis of the large bowel. The patients had laparoscopic operations in our hospital in the period from January 1995 to December 2012. The clinical picture, laboratory and instrumental datas in cases of epiploic appendices torsion and necrosis were scarce and nonspecific. An abdominal pain preferentially localized in the lower divisions was the main symptom (97.7%). The instrumental methods did not allow to diagnose the torsion and necrosis of epiploic appendices in the majority of cases and all these techniques were used for the differential diagnosis with other diseases. The assumption of the presence of appendices torsion and necrosis occured just in 34.5% of cases before the operation. Diagnosis of epiploic appendices torsion and necrosis present significant difficulties on prehospital and preoperative stages. The diagnostic laparoscopy is the method of choice in unclear situations and it allows to diagnose the torsion and necrosis of epiploic appendices in 96.6% of cases. Successful surgical treatment by using laparoscopic approach is possible in 90.8% of cases.

[Laparoscopy as a method of final diagnosis of acute adhesive small bowel obstruction in a previously unoperated patients].

The article presents the use of laparoscopic interventions in 38 patients with Acute Adhesive Small Bowel Obstruction (AASBO) in patients without previous history of abdominal surgery. Clinical, radiological and ultrasound patterns of disease are analyzed. The use of laparoscopy has proved itself the most effective and relatively safe diagnostic procedure. In 14 (36.8%) patients convertion to laparotomy was made due to contraindications for laparoscopy. In 24 (63.2%) patients laparosopic adhesyolisis was performed and AASBO subsequently treated with complications rate of 4.2%.