[Fluorescence angiography in colorectal surgery]. / Rol' fluorestsentnoi angiografii pri formirovanii kolorektal'nogo anastomoza.

OBJECTIVE: To evaluate the impact of indocyanine green fluorescence angiography on the incidence of colorectal anastomotic leakage. MATERIAL AND METHODS: We summarized the results of non-comparative and randomized clinical trials, as well as meta-analyses. RESULTS: Indocyanine green fluorescence angiography changes the anastomosis site in 10% of patients due to inadequate blood supply to intestinal wall at the initially scheduled level. This method can decrease the incidence of «low¼ colorectal anastomosis leakage. CONCLUSION: Routine intraoperative fluorescence angiography with indocyanine green can become a standard method for prevention of colorectal anastomotic leakage.

[Results of total mesorectal excision and transanal endoscopic microsurgery for rectal adenocarcinoma with submucosal invasion]. / Rezul'taty total'noi mezorektumektomii i transanal'noi endomikrokhirurgii pri adenokartsinomakh pryamoi kishki s invaziei v podslizistyi sloi.

OBJECTIVE: To analyze early and long-term outcomes after total mesorectal excision (TME) and transanal endoscopic microsurgery (TEM) in patients with T1 rectal cancer. MATERIAL AND METHODS: A retrospective non-randomized comparative study included 2 groups of patients: group 1 - total mesorectal excision, group 2 - transanal endoscopic microsurgery. In the second group, total mesorectal excision was proposed for patients with tumor invasion depth pT1sm3 and/or lymphovascular invasion and/or low differentiation. If total mesorectal excision was performed as a salvage surgery, the patient was excluded from further analysis. RESULTS: There were 156 patients with rectal adenocarcinoma pT1 between October 2011 and August 2019 (102 cases - TEM, 54 cases - TME). We excluded 10 patients from the TEM group due to salvage surgery. Duration of TEM was 40.0 (34; 50) min, TME - 139 (120; 180) min (p=0.00001). Postoperative hospital-stay was also significantly less in the TEM group (7 (6; 9) vs. 10 (7; 11) days, p=0.00001). Six (6.5%) patients in the TEM group and 1 (1.8%) patient in the TME group developed a local recurrence in pelvic cavity (p=0.1). There were no distant metastases. Disease-free 3-year survival was 92% after TEM and 96% after TME (p=0.058). CONCLUSION: Transanal endoscopic microsurgery is a relatively safe alternative to total mesorectal excision for early rectal cancer.

[Prevention of colorectal anastomotic leakage using its reinforcement (results of the randomized study)]. / Profilaktika nesostoyatel'nosti kolorektal'nogo anastomoza putem ego ukrepleniya (rezul'taty randomizirovannogo issledovaniya).

OBJECTIVE: To reduce the incidence of postoperative complications via reinforcement of colorectal anastomosis. MATERIAL AND METHODS: A randomized prospective study included 115 patients. In the main group (n=60), anterior resections were followed by reinforcement of colorectal anastomosis via suturing the muscular and serous layers at 2, 4, 6, 8, 10, 12 o'clock. In case of low anterior resection, all layers of intestinal wall were transanally sutured at the above-mentioned points. Reinforcement was not performed in the control group (n=55). RESULTS: In the main group, overall incidence of anastomotic leakage was 8.3% (5/60), in the control group - 25.5% (14/55) (p=0.01). We also analyzed the subgroups of anastomoses with high and low risk of leakage. In case of transabdominal reinforcement, incidence of anastomotic leakage was 11% (2/18) in the main group and 0% (0/14) in the control group (p=0.6). Transanal reinforcement was followed by anastomotic leakage in 7% (3/42) of patients in the main group and 34% (14/41) of patients in the control group (p=0.005). CONCLUSION: Reinforcement of colorectal instrumental anastomosis by additional sutures reduces the incidence of postoperative complications associated with anastomotic leakage.

[Risk factors associated with non-closure of defunctioning stoma in patients with rectal cancer: univariate and multivariate analysis]. / Faktory riska, vliyayushchie na otkaz ot likvidatsii preventivnoi stomy u bol'nykh rakom pryamoi kishki: uni- i mul'tivariantnyi analizy.

OBJECTIVE: To identify the risk factors associated with non-closure of defunctioning stoma in patients with rectal cancer. MATERIAL AND METHODS: A retrospective analysis included patients who underwent surgical treatment at the Ryzhikh National Medical Research Centre of Coloproctology for the period from March 2017 to August 2019. Inclusion criterion was anterior or low anterior resection followed by anastomosis and preventive stoma. Univariate and multivariate analysis enrolled 28 factors for identifying the risk factors of non-closure of defunctioning stoma. RESULTS: There were 246 patients with rectal cancer. Intraoperative fluorescence angiography was applied in 145 cases to assess blood supply within the anastomosis and reduce the risk of anastomotic leakage. According to multivariate analysis, only two factors had significant influence on non-closure of preventive stoma - any grade of anastomotic leakage (OR 6.5; 95% CI 2.2-18.8, p=0.001) and rectal cancer stage IV (OR 7.2; 95% CI 1.9-27.6, p=0.004). CONCLUSION: According to our data, permanent stoma is observed in 15% of patients.

[Reinforcement of staple line of colorectal anastomosis for leakage prevention: a systematic review and metaanalysis]. / Rol' ukrepleniia kolorektal'nogo anastomoza dlia profilaktiki ego nesostoiatel'nosti: sistematicheskii obzor literatury i metaanaliz.

OBJECTIVE: To evaluate the influence of reinforcement of staple line of colorectal anastomosis on the incidence of leakage. MATERIAL AND METHODS: A systematic review was performed in accordance with the PRISMA recommendations. Statistical analysis was carried out in the Review Manager 5.3 software. RESULTS: This trial included four original articles published in 2011-2018. There were 493 patients. Reinforcement of anastomosis was made in 232 (47%) cases, colorectal anastomosis was not reinforced in 261 (53%) patients. Anastomotic leakage rate was 5.6 and 11.1% in both groups, respectively (OR 0.55, CI 0.13-2.33; p=0.42). Transabdominal reinforcement reduced leakage rate by 10.2% (OR 0.18, CI 0.06-0.55; p=0.002) while transanal reinforcement was ineffective (OR 1.66, CI 0.38-7.19; p=0,5). Incidence of preventive stoma was similar (OR 0.3, CI 0.07-1.22; p=0.09), but it was possible to abandon preventive stoma in 18% of cases after anastomotic reinforcement. CONCLUSION: A small number of studies dedicated to anastomosis reinforcement resulted controversial data.

[Risk factors of regional lymph node metastases in pT1 colorectal cancer]. / Faktory riska porazheniia regionarnykh limfaticheskikh uzlov pri rake priamoi kishki rT1.

AIM: To identify risk factors of lymph node metastases in patients with pT1 rectal cancer. MATERIAL AND METHODS: There were 43 patients aged 62.3±11.3 years with pT1 rectal cancer who underwent mesorectal excision in 2012 - 2018. There were 34 (64%) females and 19 (36%) males. RESULTS: Histological examination revealed SM1-2 in 22/43 (51%) cases, SM3 - in 21/43 (49%) cases. Lymph node metastases were identified in specimens with submucosal invasion: SM3 - in 8/21 (38.1%) cases and SM1-2 - in 3/22 (13.6%) cases (p=0.08). Logistic regression confirmed lymphovascular invasion (p=0.005) and mucosal and/or poorly differentiated carcinoma (p=0.014) as independent predictors of lymph node metastases. CONCLUSION: Lymphovascular invasion and poorly differentiated carcinoma are indications for transabdominal mesorectal excision.

[Risk factors of postoperative complications in patients with synchronous colorectal cancer liver metastases]. / Faktory, assotsiirovannye s razvitiem posleoperatsionnykh oslozhnenii u bol'nykh s sinkhronnymi metastazami kolorektal'nogo raka v pecheni.

AIM: Univariate and multivariate analysis of various risk factors and morbidity in patients with synchronous colorectal cancer (CRC) liver metastases. MATERIAL AND METHODS: Prospective data of 173 patients with synchronous CRC liver metastases have been analyzed from January 2013 to February 2017 at the Ryzhikh State Coloproctology Research Center. RESULTS: In multivariate analysis significant risk factors of morbidity were age ≤61 years, the largest liver metastasis ≥ 2.1 cm (odds ratio (OR) 2.99; 95% CI 1.4-6.5), number of liver metastases >1 (OR 2.5; 95% CI 1.1-5.5), bilobar liver injury (OR 2.5; 95% CI 1.3-4.8), blood loss (OR 1.001; 95% CI 1.0001-1.002). Model for prediction of complications was constructed (AUC 0.79). CONCLUSION: Simultaneous surgery is not risk factor of complications. Probability of complications is increased in advanced tumor and consequently more traumatic surgery. Predictive model is useful for prognosis of complications and describes surgical experience of State Coloproctology Research Center.

[Meta-analysis of management of colorectal anastomotic leakage]. / Meta-analiz metodov lecheniia nesostoiatel'nosti kolorektal'nogo anastomoza.

AIM: To identify the most effective management of colorectal anastomosis failure via analysis of available literature sources. RESULTS: Systematic review included 20 original trials. Effectiveness of redo interventions for colorectal anastomosis failure including open, laparoscopic, minimally invasive techniques (transanal drainage, endoscopic vacuum therapy, endoscopic drainage) was described. Anastomotic failure rate was 6.5%. Medication was effective in 57% (95% CI 34-77%) of cases. Redo open surgery was applied in 43% (95% CI 23-66%) of patients. Postoperative mortality was 21-27%. Redo laparoscopic procedure was performed in 61% (95% CI 50-70%) of cases for anastomotic failure after previous laparoscopy, incidence of conversion was 12% (95% CI 4-28%). Transanal drainage was effective in 85% (95% CI 61-94%) of cases, endoscopic vacuum therapy - in 82% (95% CI 74-87%), healing of anastomosis without need for colostomy was achieved in 16% (95% CI 9-26%) of cases. Endoscopic clipping for colorectal anastomotic defect was effective in 73.3-77% of cases. CONCLUSION: Redo surgery for anastomotic failure is associated with advanced mortality and need for permanent colostomy. Laparoscopic approach reduces incidence of complications after redo surgery and followed by better functional outcomes. Minimally invasive procedures are advisable for colorectal anastomosis failure without need for redo surgery. However, effectiveness of these methods is controversial due to few reports and no comparative trials.

[Prevention of colorectal anastomotic leakage by using of intraoperative fluorescent angiography: prospective trial data]. / Primenenie intraoperatsionnoi fliuorestsentnoi angiografii v kachestve metoda profilaktiki nesostoiatel'nosti kolorektal'nogo anastomoza: rezul'taty prospektivnogo issledovaniia.

AIM: To evaluate the effect of intraoperative fluorescent angiography on the incidence of colorectal anastomosis failure. MATERIAL AND METHODS: Prospective, non-comparative study included 52 patients with rectal or sigmoid cancer who underwent surgery with stapled colorectal anastomosis. Intraoperative fluorescent angiography with indocyanine green was performed to determine colon perfusion. All patients underwent proctography with water-soluble contrast agent in 6-8 days after surgery in order to determine anastomotic leakage. RESULTS: Fluorescent angiography was followed by changed volume of proximal colectomy in 14 (27%) patients due to inadequate blood supply of intestinal wall at previous surgical level. Additionally, 1-5 cm of intestinal wall were excised. Postoperative anastomotic leakage occurred in 3 (5.8%) patients. CONCLUSION: Fluorescent angiography with indocyanine green is accompanied by reduced incidence of anastomotic failure in colorectal suregry.

Risk factors for postoperative ileus after colorectal cancer surgery.

AIM: To assess the rate and independent risk factors of postoperative ileus (POI) after colorectal cancer surgery. METHODS: Three hundred consecutive patients underwent colorectal surgery for cancer at the State Scientific Centre of coloproctology, Moscow, Russia, between November 2015 and August 2016. POI was diagnosed as an absence of intestinal function for 72 hours or more after operation and confirmed by plain radiography. Uni- and multivariate logistic regression of the tumour-, patient- and treatment-related factors was performed. All patients had epidural catheters with multimodal analgesia. RESULTS: Thirty-nine patients (13%) had postoperative ileus. The variables associated with this condition in univariate analysis were age < 64 y.o. (p = 0.02), male gender (p = 0.02), BMI ≥ 25 kg/m2 (p = 0.02), moderate drinking (p = 0.02), heavier drinking (p < 0.0001), opioids (p = 0.02), history of abdominal operation (p = 0.003), firm, extensive adhesions as a result of previous surgery (p = 0.005), multivisceral resection (p = 0.009), blood loss ≥ 150 mL (p = 0.006), haemotransfusion (p = 0.01) and open approach (p = 0.006). In the multivariate logistic regression, BMI ≥ 26 kg/m2 (p = 0.008), opioids (p = 0.04) history of abdominal operation (p = 0.04) and adhesions (p = 0.03) were identified as independent risk factors. CONCLUSION: Postoperative ileus is a common complication in colorectal surgery. The results of our study suggest at least two surgeon-dependent risk factors, i.e., open approach and opioids in the postoperative period. This article is protected by copyright. All rights reserved.

Side-to-end vs. straight stapled colorectal anastomosis after low anterior resection: results of randomized clinical trial.

AIM: The aim of this study is to compare surgical, functional, physiologic outcomes and QOL after low anterior resection (LAR) with andside-to-end or straight colorectal anastomosis. METHOD: Between 2012 and 2015, 86 patients with mid and low rectal tumors were enrolled into randomized trial. Wexner score, number of defecations, use of antidiarrheal medicine or laxatives, enemas, pads, episodes of nocturnal incontinence, and urgency were recorded. The Fecal Incontinence Quality of Life (FIQL) scale was used for assessment of QOL. Anal manometry and volumetric examination were performed. RESULTS: Six patients were excluded from the study. There was no mortality. The morbidity rate was 6 (14.6 %) for side-to-end vs. 8 (20.0 %) for straight anastomosis (p = 0.57). The median Wexner score was 5 vs. 6 (p = 0.033), 4 vs. 5 (p = 0.006), and 2 vs. 3 (p = 0.1) at 1, 3, and 6 months after stoma reversal, respectively. Side-to-end anastomosis resulted in a fewer mean numbers of bowel movements per day at the same check points of follow-up: 5.8 ± 0.14 vs. 6.4 ± 0.15 (p = 0.006), 3.7 ± 0.1 vs. 4.2 ± 0.1 (p = 0.003), and 2.5 ± 0.1 vs. 3.0 ± 0.10 (p = 0.0002), correspondingly. Maximal tolerated volume was higher for side-to-end anastomosis at 3 and 6 months of follow-up: 152.0 vs. 137.8 cm(3) (p = 0.002) and 180.5 vs. 167.0 cm(3) (p = 0.006), respectively. Better FIQL score was found at 1 and 3 months in the side-to-end group. CONCLUSION: Better functional outcomes and QOL were observed in a short period after stoma closure, but at 6 months of follow-up, the only benefit of side-to-end anastomosis was a lower number of bowel movements.

[Early Rectal Cancer: Can Transanal Endoscopic Microsurgery (TEM) Become the Standard Treatment?]

Aim: Transanal endoscopic microsurgery (TEM) is a main treatment technique for rectal adenomas, but can also be used for selected malignant tumors. This study presents TEM experience. Methods: The study enrolled patients with rectal adenomas, and selected adenocarcinomas. Preoperative work-up included: digital rectal examination, rectoscopy with biopsy, colonoscopy, EUS, pelvic MRI. Results: Three hundred and thirty patients [mean age of 61,4±10 (33­88)] underwent TEM. The mean size ± SD of tumors was 3.2±1.2 cm (0.6­10.0). Mean distance from anal verge was 6.7±2.6 cm (2.0­14.0). Preoperative biopsy revealed: adenoma ­ 263/330 (79,7%), adenocarcinoma ­ 67/330 (20,3%). The median operating time was 40 (15­220) min. Tumor-free margins were obtained in all operative specimens. In 5/330 (1.5%) cases tumors were fragmented. The morbidity rate was 19/330 (5.7%). Pathological investigation revealed: adenoma in 192/330 (58.1%) cases, adenocarcinoma stage Tis, T1, T2 and T3 in 138/330 (41.9%). Median follow-up lasted for 24 (1­57) months. Five patients (2.0%) with adenoma and four patients (5.2%) with adenocarcinoma had local recurrence. Conclusion: Transanal endoscopic microsurgery for rectal adenomas and selected malignant tumors is associated with low morbidity and low recurrents rates.

[SIDE-TO-END ANASTOMOSIS IN LOW ANTERIOR RECTAL RESECTION].

The authors have launched a prospective randomized study aimed to make a comparison of functional results of formation of straight coloanal (control group) and side-to end (main group) anastomosis in case of low anterior rectal resection since 2012. Each group consisted of 40 patients undergoing operation concerning uncomplicated rectal cancer of medium-ampullar section of rectum. It was noted that patients of the main group had lower stool frequency in postoperative period. A function of the interior sphincter was less damaged and the rate of compliance of rectum was high.

[Possibilities of transanal endoscopic microsurgery: the experience of 202 operations].

Transanal endoscopic microsurgery (TEM/TEO) is a standard treatment for rectal adenomas but can also be used for selected malignant tumors. Rectal adenomas, selected adenocarcinomas and carcinoids were chosen for operations. Preoperative work-up included: digital rectal examination, rectoscopy with biopsy, colonoscopy, EUS, pelvic CT (MRI). Two hundred and two patients [mean age of 62.4 ± 10.3 (33-86)] had TEO. The mean size ± SD of tumors was 3.2 ± 1.4 cm (0.6-8.0). Mean distance from anal verge and dental line was 7.1 ± 2.4 cm (2.5-14.0) and 4.6 ± 2.6 cm (0.5-12.0), respectively. Preoperative biopsy revealed: adenoma--156/202 (77.2%), adenocarcinoma--39/202 (19.3%) and carcinoid--7/202 (3.5%). The median operating time was 40 (20-180) min. Tumor-free margins were obtained in 200/202 (99%) operative specimens, 2/202 (1.0%) cases tumors were fragmented. Morbidity was 7/202 (3.5%). Pathological investigation revealed: adenoma in 109/202 (54.0%) cases, adenocarcinoma stage Tis, T1, T2 and T3 in 86/202 (42.5%), carcinoid in 5/202 (2.5%), neurilemoma in 1/202 (0.5%), neurofibroma in 1/202 (0.5%). One hundred and two patients had follow-up (95%). Median follow-up at 20 (1-41) months; 3/192 patients with adenocarcinoma, 1/192 patient with adenoma and 1/192 patient with carcinoid had local recurrence. Thus, transanal endoscopic microsurgery for rectal adenomas and selected malignant tumors is associated with low morbidity and low recurrents rates.

[Effect of intraoperative intrapelvic chemotherapy with hyperthermia on the incidence of rectal cancer recurrences].

Often due to a severe somatic condition of the patient, the presence of perifocal inflammation, anemia, age, it is not possible to perform neoadjuvant chemoradiotherapy for rectal cancer. To improve cancer treatment outcomes in these patients intraoperative intrapelvic chemotherapy with hyperthermia is used at the Centre. In the present study there included 120 patients with rectal cancer at stage T3-4N0-2M0, while 60 patients underwent intraoperative intrapelvic chemotherapy with hyperthermia (cisplatin at a dose of 150 mg, the time of the procedure--60 minutes, the temperature of the perfusate--44-45 degrees C). Conducting of intraoperative intrapelvic chemotherapy with hyperthermia allowed reducing the frequency of local recurrence in 2 times from 16.7% to 8.3% and increasing a 3-year overall survival by 10%--from 63% to 73%, which shows intraoperative intrapelvic chemotherapy with hyperthermia as an effective method in the prevention of local recurrences.

[Is the localization of the tumor in intra-peritoneal part of the rectum contraindication to transanal endoscopic microsurgery].

Transanal endoscopic microsurgery (TEM) is the method used in cases of benign tumors at the early stages of rectal cancer. The tumor localization in peritonized part of the rectum indicates a limiting level for removal of the neoplasm. TEM was performed on 137 patients. The mean age was 63.8 ± 9.8 years and the number of women consisted of 65.7%. Neoplasms were located in the upper ampullar rectum and a potential possibility of connection with the peritoneal cavity was noted in 12 (8.7%) patients, but during TEM it was only in 5 cases. There wasn't any conversion to a peritoneal surgery. The wound closures were carried out from the side of the rectum lumen and all the operations were finished with the control laparoscopy and formation of sigmostoma. The stomas were closed in 3 patients on fifth- sixth weeks. A connection with the peritoneal cavity during TEM isn't critical event in the case of wound closure through surgical rectoscope and it doesn't lead to the conversion to radical operation.

[Decrease of the number of involved lymph nodes after preoperative chemoradiotherapy in rectal carcinoma].

The total of 296 T3-4NO-2 Federal Coloproctology Science Center colon cancer patients received treatment since 2004 to 2011, 165 patients (main group) also received treatment (pre- and postoperative irradiation, surgery, adjuvant chemotherapy) in P.A.Herzen State Clinical Research Center for Oncology. The control group (131 patients) received only surgery with adjuvant chemotherapy. Based on our results, prolonged chemoradiotherapy leads to statistically significant decrease of regional mesorectal lymph nodes metastases, the decrease is most evident in N1 stage patients group (1-3 lymph nodes metastases). However, the number of diagnosed involved lymph nodes also depends on the depth of tumor penetration and the timing between chemoradiotherapy and surgery. The most important prognostic criterion is not the state of involved lymph nodes, but their number.

[Rationale for intraoperative intrapelvic chemotherapy in combination with hyperthermia in the treatment of rectal cancer].

Neoadjuvant treatment should not be given to grave cases of rectal cancer with concomitant perifocal inflammation, anemia and advanced age. To improve results, intraoperative intrapelvic chemotherapy in combination with hyperthermia was carried out at the Center's Clinic. Pre-clinical studies involved working out optimal cryo-temporal regimens to maximize cytotoxic effects of drugs and hyperthermia as well as establishing systemic influence of local hyperthermia and chemotherapy on the intraoperative intrapelvic one. Our optimal cryo-temporal regimens and intraoperative intrapelvic chemotherapy proved highly effective.