[The noncomplicated colon cancer treatment].

531 patients with non-complicated and non-metastatic colon cancer were operated on during 1995-2008 years. Surgery was radical in all cases. Various types of surgical treatment of the colon cancer, postoperative complications and lethality were analyzed. Open methods reported a 1,6% complications rate and lethality rate was 0,4%. Whereas, laparoscopically operated patients showed the complication rate of 3,6% and lethality was 1,2%. Overall 5-year survival was 91,7% for T1-3N0M0; 75,6% for T4N0M0 and 55,3% for T1-4N1-2M0 stages.

[Is subtotal resection of the colon actual for ulcerative colitis in the century of ileal reservoirs?].

The authors describe results of surgical treatment of 112 patients operated for a severe resistant form of ulcerative colitis (UC). In 26 (23.2%) of observations the operations were performed for complications, in 65 (58%)--for hormone-resistent, and in 21 (18.8%)--for hormone-dependent forms of UC. In 80 (71.4%) cases subtotal resection of the colon with ileo- and sigmostomies was fulfilled, in 26 (23.2%) a single stage ablation of all large intestine was fulfilled with the formation of permanent ileostomy and in 5 (5.4%) of observations the first step was finished with the formation of a reconstructive-plastic reservoir anastomosis. The number of complications in the nearest postoperative period was in 12.8% of patients, lethality was 2.3%. The development of a strict strategy of treatment for severe forms of the disease including the present-day using conservative and surgical methods of treatment depending on the individual character of each patient with UC made it possible to minimize the number of postoperative complications and decrease lethality and also to restore anal defecation with good functional results in 30.1% of operated patients.

[Proctectomy with external sphincter preservation: long-term functional results].

52 patients with the lower ampullary rectal cancer with tumor localization on the dentate line level had been operated with the use of the originally developed reconstructive technique, permitting preservation of the external anal sphincter elements and, consequently, partial continence. Colonic rectal pouch and smooth muscle cuff were performed during the neorectum and neoanus plasty. A protective stoma was performed in all cases. Contractive activity of saved elements of EAS improved with a course of time and squeezing anal pressure increased as well. Consequent continence improvement occurred during the first year after the stoma closure, biofeed-back therapy provided faster rehabilitation. The achieved long-term functional results (73,4% actuarial 5-year disease-free survival) prove the oncological efficacy of the method on the strict assumption of indications observance. Thus, proctectomy with partial external anal sphincter preservation allows to avoid permanent colostomy and provides a satisfactory quality of life of the operated patients.

[Results of surgical treatment of residual and recurrent anal tumors].

Radio- or chemotherapy is a modern standard of anal cancer treatment. Recurrence or partial remission rate after radiochemotherapy achieves 20-40%. The study is aimed to evaluate the role of abdominoperineal resection in the treatment of residual and recurrent anal cancer. 120 patients (aged from 30 to 81 (59+/-11) years, men:women ratio--1:9) were prospectively studied in the period of 1995 to 2007. The TNM distribution was as follows: T1-2N0M0--66(55.0%), T3-4N0M0--18(15.0%), T1-2N1-3M0--15(12.5%) and T3-4N1-3M0--21(17.5%) patients. The radiotherapy delivered in a dose range of 55-65 Gy was used alone or in combination with chemotherapy with 5-fluoruracil, mitomycin C or Xeloda. The complete tumor regression after radiotherapy/radiochemotherapy was achieved in 74(61.1%) of 120 patients with cancer-specific survival rate of 81.7%. Partial tumor regression was registered in 46 of 120 patients. The abdominoperineal resection was performed in 39(84.8%) of patients with the residual tumor. Thus, surgical treatment allowed secondary local tumor control in 76.9% of patients with the 5-year survival rates of 69.0%. The median survival time for the non-operated patients, including those, received an extra course of radiotherapy, was 19 months. The locoregional tumor relapse was diagnosed in 10(13.74%) of 74 patients with the complete tumor regression. The use of abdominoperineal resection allowed the secondary local tumor control and 5 year survival. Thus, abdominoperineal resection remains the method of choice in the treatment of residual and recurrent anal tumors.

[Proctectomy with external sphincter elements' preservation in surgery of low-ampullary rectal cancer].

Operational technique for the rectum tumors, localized at the level of dentate line, developed in the State center of coloproctology, allows preservation of external anal sphincter elements and thus, partial preservation of defecation control. Technique is described and proved, preliminary treatment results of 42 patients are analysed. The operation is oncologically effective (local recurrence rate 4,8%). Preservation of external sphincter elements has a high functional value in complex with "neorectum" and "neosphincter". A majority of operated patients can keep the stool, 80% of able-bodied patients continued their professional activities.

[The hand-assisted laparoscopic resections of colon's left parts].

Authors have an experience of 88 hand-assisted laparoscopic procedures. Results of 32 hand-assisted resections of colon's left parts are analyzed. The special original sealing device was used for making of pneumoperitoneum during laparoscopic procedures. The study group consisted of 19 female and 13 male patients. Mean age was 60.0 +/- 9.8 years (42-76 ys). Overweight was seen at 23 (72%) patients, 12 of them had obesity of I-III stage. Previous abdominal operations have been performed at 11 (34.4%) patients. Mean time of surgery was 181 +/- 53 min, operative bleeding--92 +/- 65 ml, no intraoperative complications occurred. Length of minilaparotomy was 7.3 +/- 0.8 cm. Poltoperative complications were seen at 4 (12.5%) cases, there were no lethal outcomes. Mean hospital stay was 9.8 +/- 3.5 bed-days.

[The clinicomorphological characterization of segmental lesion in ulcerous colitis].

The authors analyzed the clinical picture in 18 patients with distal lesion of the colon and an inflammatory focus in the cecum (segmentary lesion), and five patients with distal lesion of the colon revealed with endoscopy and pathomorphological signs of inflammation in visually intact cecum. The analysis shows that in a range of cases the extent of lesion in ulcerous colitis (UC) cannot be determined correctly with colonoscopy. An apparent segmentary character of lesion (inflammation in the distal colon and an inflammatory focus in the cecum) is an additional criterion of unfavorable prognosis of transformation into disseminated UC forms. Such patients need application of the same treatment regimens as in patients with disseminated UC forms.

[Modification of Svenson's biopsy of rectal wall in diagnosis of malformations of intramural nervous system in adults].

Thirty-five autopsied specimens of rectum's distal part and anal canal part were studied. It was revealed that length of physiological hypogangliosis zone ranged from 7.5 to 50.0 mm (mean 24.4+/-10.9 mm). With regard to this wide range the modification of transanal Svenson's biopsy of rectal wall was proposed for diagnosis of malformations of intramural nervous system of the colon. The method was used in 21 patients with megacolon. The results demonstrate accuracy and safety of this diagnostic method.

[Nerve-preserving operations in surgery of rectal cancer].

Forty-eight patients underwent surgery for rectal cancer. In all the patients total mesorectumectomy was combined with one of the types of nerves-preserving surgeries. Three groups were divided depending on types of this surgery: 1-- complete preservation of elements of autonomic nervous system (n=31), 2 -- partial preservation (n=16), 3 -- complete ablation (n=1). In 30 patients of group 1 normal urination recovered on postoperative day 2 to 4. In 2 patients of group 2 stable atony of urinary bladder was seen, and in 2 patients -- reflex ischuria. In patient of group 3 normal urination recovered on day 14 after surgery without vesical tenesmus. Long-term results were assessed in 1 to 12 months. No recurrences occurred. It is concluded that nerve-preserving surgeries improve functional results without loss of oncological radicalism.

[Surgical treatment of hormone-resistant form of nonspecific ulcerative colitis]. / Khirurgicheskoe lechenie gormonorezistentnoi formy nespetsificheskogo iazvennogo kolita.

From 1990 to 2002 seventy-nine patients with hormone-resistant form of nonspecific ulcerative colitis (NUC) underwent surgery. There were 37 men, 42 women, mean age was 34.4 +/- 3.8 years. Severe form of NUC was in all the patients, total lesion of the colon was in 60.8% cases, subtotal - in 25.3%, and right-sided - in 13.9%. Acute disease was seen in 21 (26.6%) patients, chronic recurrent - in 42 (53.2%), chronic continuous - in 16 (20.2%). Complex intensive treatment including glucocorticoids (prednisolon 2 mg/kg/day) was used in all the patients. Criteria of efficacy were clinical, laboratory and instrumental data (rate of stool, hemodynamics, hyperthermia, pain syndrome, hemoglobin, level of leukocytes and albumin, results of endoscopy and roentgenoscopy). Absence of positive results during 3 weeks was regarded as inefficacy of therapy and indication for surgery. Subtotal resection of the colon with ileostoma or sygmostoma was performed in 68 patients. Detection of resistance to hormones before development of NUC's intestinal complications (intestinal bleeding, toxic dilatation and perforation of colon) permitted to improve results of surgery: number of postoperative complications reduced from 60 to 8 - 9%, lethality - from 21 to 4.6%.

[Prognosis of epidermoid anal carcinoma regression after conservative treatment]. / Prognoz regressii opukholi pri konservativnoi terapii épidermoidnogo raka anal'nogo kanala.

The prospective study was concerned with definition of the clinical and therapeutic factors behind poor response of anal cancer to radio- (RT) or chemoradiotherapy (CRT). Out of 64 female and 8 male patients at the mean age of 57 (33-81), thirty six had split-course of 60-65 Gy (RT), twenty--60-65 Gy, 5-FU and mitomycin C (CRT) and eighteen--up to 55-65 Gy (1.5 Gy--session 1, 1.0 Gy--session 2) (hyper-fractionated RT) plus 5-FU, for squamous cell anal carcinoma. There was no endorectal ultrasound evidence of perirectal lymph node involvement (uN0): T1-2uN-M0 (n=46), T3-4uN0M0 (n=11), uN1 or N2-3 (groin or endorectal ultrasound: T1-2uN-M0 (n=46), T3-4uN0M0 (n=11), uN1 or N2-3 (groin metastases) were detected in 7 patients: T1-2uN1-2M0 (n=7), T3-4N1-3M0 (n=10). Endorectal ultrasound staging (ERUS) used a linear 7.5 MHz transducer. The uTNM system was devised on the basis of tumor invasion parameters. There were no tumors confined to the subendothelial layer of the anal canal (uT1); 24 (32.4%) tumors were confined to the internal anal sphincter (uT2); 19 (25.7%) invaded the external anal sphincter (uT3) and 31 (41.9%)--levator ani (uT4). All carcinomas T4 (n=9) corresponded to the uT4 category. Only T-stage and tumor invasion (uT) proved significant prognostic variables. Complete response of T1-2 was 79.2%, T3-4--33.3% (p=0.0003); uT2--95.8%, uT3--68.4%, and uT4--41.9% (except T4) (p=0.0001). In multivariate logistic analysis, uT alone appeared an independent variable (p=0.015). ERUS uTNM staging is more effective in prognosis for RT and CRT and, therefore, should be recommended for preliminary management of epidermoid anal carcinoma.

[Transanal endoscopic surgical method of removing rectal tumors]. / Transanal'nyi éndokhirurgicheskii metod udaleniia opukholei priamoi kishki.

Experience in endosurgical removal of rectal tumors in 96 patients is presented. Performed from 1999, open non-gas method and closed method of transanal endomicrosurgery (TEM) have reduced rate of adenoma recurrences to 8.8%. Development of the open method increased it accessibility for hospitals using endoscopic techniques.

[Laparoscopic surgery of rectal cancer (comparative results of laparoscopic and open abdominal resection)]. / Laparoskopicheskie operatsii u bol'nykh rakom priamoi kishki (sravnitel'nye rezul'taty laparoskopicheskikh i otkrytykh perednikh rezektsii).

Attempt to perform surgery with laparoscopic technologies was taken in 80 (50.6%) from 158 patients with cancer of the rectum. Surgery was finished only with laparoscopy in 64 (80.0%) cases, conversion to open operation was necessary in 16 (20.0%). Open anterior surgery was performed in 78 patients. Patients after laparoscopic operations required less narcotic analgesics (63.3 +/- 1.5 and 105.0 +/- 2.2 mg, respectively) and demonstrated earlier restoration of peristalsis (31.7 +/- 1.2 hours and 59.4 +/- 1.7 hours, respectively). Rate of complications after laparoscopic surgeries was 9.4%, after open--25.6%. Three-year survival after laparoscopic anterior resection was 91.7%, after open--84.6%. Survival of patients depends of depth of invasion into intestinal loop and lesion of lymphatic nodes, irrespective of surgical method.

[Laparoscopic rectum repair]. / Laparoskopicheskaia rektopeksiia.

A reliable and simple method of allograft fixation in laparoscopic posterior-loop rectopexy (LPR) was developed. The study was carried out on 40 cadavers, peak effort of separation of the net fixed to the sacrum by various methods was evaluated. Effort of separation in fixation of the net by sutures was 10.1 +/- 2.12 kg, in fixation by hernial stapler--1.13 +/- 0.36 kg, stapler "Pro-Tack"--6.38 +/- 1.85 kg, in fixation of the net by the new device--8.9 +/- 0.75 kg. From 1995 till 1999 LPR was performed with the new device in 15 patients, the open posterior-loop rectopexy (OPR) with fixation of the net by non-absorbable sutures--in 16 patients. In LPR intraoperative blood flow was twice as small (146.0 +/- 79.2 ml) as in OPR (275.6 +/- 76.9 ml). Mean time of LPR was 183.1 +/- 69.8 min, OPR--211.3 +/- 57.9 min. Relief of pain after LPR enabled with reduction of narcotic analgetics requirement (58.3 +/- 1.5 mg). Mean dose of narcotic analgetics after OPR was 93.2 +/- 1.4 mg. The proposed method of allograft fixation and device for it realization are effective and meet all requirements.

[Ambulatory surgical interventions in patients with proctological diseases]. / Ambulatornye khirurgicheskie vmeshatel'stva u bol'nykh proktologicheskimi zabolevaniiami.

The results of 629 operations for the most frequent proctological diseases (hemorrhoid, anal scissure, rectal fistula, acute paraproctitis) were analyzed. 134 operations were performed in outpatient clinic, 225--in one-day hospital and 270 (control group)--in coloproctology department. The place of operation did not influence postoperative period and temporary disability time. The mean stay of patient in outpatient department and hospital surgical unit was 3.8 and 324 hours, respectively. Since the second day after operation in specialized department it is possible to perform therapeutic manipulations outpatient in coloproctology room without negative sequences for patient's health. Cost of the ambulatory operation constituted 28.4% of hospital stay for patients with similar interventions. Surgical treatment of the above diseases could be performed in outpatients setfing in more than 50% patients. The bed resources must be used for patients who need long-term and intensive treatment in specialized department.

[Determination of colon resection limits in diverticulosis]. / Opredelenie granits rezektsii obodochnoi kishki pri divertikuleze.

Results of surgical treatment of 112 patients with colon diverticulosis are analyzed. It is established that during operation it is necessary to perform such scope of resection which permits to create anastomosis between colon parts without their discoordination. The risk of complications from anastomosis decreases to 3.7%. The creation of anastomosis with significant discoordination leads to high risk of its insufficiency. It is desirable to resect the colon's parts with moderate discoordination. When the extension of of resection margins due to parts with moderate discoordination is dangerous, it is possible to create the anastomosis with ileo- or colostoma. In this case the risk of inflammatory complications remains, but conservative treatment of these complications in the conditions of feces efflux is effective.

[Short- and long-term results of sphincter preserving operations with creation of colonic J-reservoir]. / Blizhaishie i otdalennye rezul'taty sfinkterosokhraniaiushchikh operatsii s formiorovaniem tolstokishechnogo J-obraznogo rezervuara.

The aim of this study was to evaluate short- and long-term results of sphincter preserving operations with forming a colonic J-reservoir. This study examined the results of the treatment of 63 patients with medioampullary carcinoma of the rectum. Sphincter preserving operations with forming a reservoiroanal anastomosis were made in 34 patients (test group), 29 patients had sphincter preserving operations with forming coloanal and supraanal colorectal anastomoses (control group). In the test group complications were observed in 6 (17.6%) patients and in the control group in 6 (20.7%) patients (p = 0.3962). The defecation frequency in the test group 3 months after the operation was 1.87 +/- (1-3) time a day, in the control group even through 12 months--3.0 +/- 1.5 times a day (p = 0.0001). In terms up to 6 months tenesmus, imperative desire to defecate and defecation's multistage more often disturbed the patients of the control group (p = 0.0005). The function of the faeces continence was satisfactory in both the patients' groups, however in the control group the events of the anal incontinence of I-II degree (p > 0.05) occurred more often. The negative aspect of the colonic reservoir's forming is frequent change of the evacuation function with constipation, however, the differences were statistically insignificant (p > 0.05). Creation of a colonic reservoir doesn't increase lethality and postoperative complications rate, allows to reduce clinical manifestations of a "low anterior resection" syndrome.