Rectal Reconstruction after Total Mesorectumectomy: Functional Outcomes and Quality of Life

Background. The study aims to compare the functional outcomes and quality of life in patients having variant rectal reconstruction procedures after low anterior resection for cancer.Materials and methods. A prospective randomised controlled trial enrolled 90 patients who underwent total mesorectumectomy with formation of J-pouch (J-P), side-to-end (STE) or end-to-end (ETE) anastomoses.Results and discussion. We analysed 22 J-P, 30 STE and 38 ETE patients. For technical reasons, 26.6 % J-Ps were remodelled to other anastomoses. The neorectal sensory threshold, first and permanent defecation urges and maximal tolerated volume were higher in J-P at months 3–6–12 postoperatively.Severe low anterior resection syndrome events at post-surgery month 6 were significantly more frequent in the ETE vs. J-P and STE cohorts (21, 0 and 3.3 %, respectively, p < 0.05). Stool frequency was significantly lower in J-P vs. STE and ETE at months 3–6–12. Wexner score was 3, 5, 6 at month 6 (p < 0.05) and 0, 1, 1 at month 12 for J-P, STE and ETE, respectively (p > 0.05). Evacuatory dysfunction was present at month 6 in 59.1 J-P, 33.3 STE and 21.1 % ETE.Quality of life (FIQL) in J-P and STE was significantly higher vs. ETE anastomoses in the Lifestyle (3.21, 3.22 and 3.03, respectively, p < 0.05) and Coping (3.29, 3.21 and 2.95, respectively, p < 0.05) scales to month 12 postoperatively.Conclusion. The J-pouch formation after low anterior resection ameliorates anal continence at months 3–6 post-surgery, reduces low anterior resection syndrome and improves quality of life (FIQL). The ease of implementation and irrelevance of evacuatory dysfunction in side-to-end anastomosis make it a superior choice over end-to-end surgery

Иринотекан в лечении колоректального рака. Обзор литературы

In 1998, oncologists got a brand new antitumor drug – irinotecan. It’s been already 18 years since its approval for second-line polychemotherapy of metastatic colorectal cancer. Indications for irinotecan use were significantly expanded since that time; it is now used in combination with other therapeutic agents for first- or second-line treatment of metastatic colorectal cancer, in combination with targeted drugs or separately; there are some studies assessing the use of irinotecan in neoadjuvant therapy. The article describes the history and modern schemes of irinotecan administration in treatment of colorectal cancer.С 1998 г. в арсенале онкологов появился принципиально новый противоопухолевый агент – иринотекан. С момента его одобрения в качестве препарата для проведения 2-й линии полихимиотерапии метастатического колоректального рака прошло уже 18 лет. За это время к применению иринотекана появилось большое количество показаний, его используют в различных сочетаниях с другими препаратами в качестве 1-й и 2-й линий терапии метастатического колоректального рака, в сочетании с таргетными препаратами и без, ведется ряд исследований по изучению работы препарата в неоадъювантном режиме. В статье рассматриваются история и современные схемы применения иринотекана в лечении колоректального рака

Оптимизация хирургической тактики лечения локализованных форм рака толстой кишки (обзор литературы)

Malignant tumors have long occupied a special place in medicine and many researchers in different areas focused their attention on these disorders. Particular attention should be paid to gastrointestinal tumors with colon cancer being the most common among them. Moreover, the incidence of colon cancer is constantly growing.Despite the extensive experience in surgical treatment for colon cancer, we are still in search for new optimal methods that can increase overall and relapse-free survival without increasing the incidence of intra- and post-operative complications that are always associated with the volume of surgery.Recently, there has been a stable trend towards organ-sparing techniques. Segmental resections have become widely used in patients with localized cancer of the left colon and are now considered as an alternative to traditional left hemicolectomy. These two techniques demonstrated no significant differences in long-term outcomes. Then segmental resections became widely used in patients with localized tumors of the right colon and middle third of the transverse colon. These surgeries demonstrated their efficacy and good long-term outcomes.As for caecal cancer, the literature on this subject is too scant to make any conclusions about the rationality and feasibility of ileocecal resections. This implies that the utility of the method and its potential implications should be evaluated in further studies, including prospective ones that will compare both short-term and long-term outcomes. This literature review analyzes anatomical and physiological characteristics of right and left colon tumors, outlines generally accepted standards of lymphadenectomy, and summarizes the information on novel surgical techniques for colorectal cancer.Злокачественные новообразования на протяжении многих десятилетий занимают особое место в медицине, фокусируя на себе внимание исследователей разных специальностей. Самое пристальное внимание стоит уделить опухолям желудочно-кишечного тракта, среди которых рак ободочной кишки стабильно занимает 1-е место, имея тенденцию к ежегодному росту показателя заболеваемости.Несмотря на многолетний накопленный опыт хирургического лечения злокачественных новообразований толстой кишки, сохраняется необходимость поиска новых оптимальных методов лечения, способных повысить показатели общей и безрецидивной выживаемости, при этом учитывая вероятность осложнений, возникающих в интра- и послеоперационном периоде, которые неизменно связаны с объемом выполняемых оперативных вмешательств.Со временем в клинической практике хирургов наметилась тенденция к выбору органосохраняющих методик. Сегментарные резекции нашли широкое применение при локализованных формах рака левого изгиба ободочной кишки, став альтернативой общепринятой методике левосторонней гемиколэктомии. Опыт их применения не показал статистически значимых различий в отношении отдаленных онкологических результатов. Впоследствии сегментарные резекции начали активно проводиться при локализованных формах рака правого изгиба и средней трети поперечной ободочной кишки, доказывая свою целесообразность и демонстрируя отсутствие статистически значимых различий в долгосрочных исходах лечения.Что касается рака слепой кишки, то представленных на сегодняшний день данных литературы и описанных научных исследований недостаточно, чтобы уверенно говорить о рациональности и обоснованности широкого применения илеоцекальных резекций. Из чего следует, что возможность использования, а также потенциальная область приложения данной методики требуют дальнейшего изучения, в том числе в рамках проспективных исследований, с последующим сравнительным анализом как непосредственных, так и отдаленных результатов лечения. В представленном обзоре литературы были проанализированы анатомо-физиологические особенности правосторонней и левосторонней локализации опухолей ободочной кишки, изложены общепринятые стандарты лимфаденэктомии и обобщены данные о результатах применения современных методик оперативного лечения колоректального рака

Результаты трансанальной мезоректумэктомии при раке прямой кишки

Objective: comparative analysis of specific perioperative features and pathological characteristics of the removed sample after laparoscopic total mesorectumectomy (Lap-TME) and transanal total mesorectumectomy (Ta-TME).Materials and methods. A prospective non-randomized controlled study was carried out from November 2013 until September 2016. Patients with сТ1–4aN0–2M0 cancer of low- or medium-ampullar section of rectum were enrolled.Results. 55 and 54 patients were included in the Ta-TME and Lap-TME groups respectively. Duration of surgery was 285 min (Ta-TME group) and 260 min (Lap-TME group); median volume of blood loss was less than 100 ml; duration of hospital stay after surgery was 7 days in both groups. 1 (1.8 %) patient from Ta-TME group and 3 (5.6 %) patients from the control group had conversion to open surgery (р = 0.223). Transanal removal of the sample was done in 53.7 % of the cases in Ta-TME group and 25.5 % of the cases in Lap-TME group (p = 0.008). Complications were registered in 27,3 and 24,1 % of the patients respectively (р = 0,436). 90.9 % of the patients from Ta-TME group had Grade 2–3 quality of mesorectumectomy, while in Lap-TME group this parameter was 85.2 % (p = 0.266). Circumferential resection margin damage was observed in 7.3 % of cases from Ta-TME group and 9.3 % of cases from Lap-TME group (p = 0.488).Conclusion. Ta-TME does not worsen short-term oncological results. Further randomized studies are required to identify those patients who would benefit from bottoms up mesorectumectomy.Цель исследования – провести сравнительный анализ периоперационных особенностей и патоморфологических характеристик удаленного препарата после лапароскопической тотальной мезоректумэктомии (Лап-ТМЭ) и трансанальной тотальной мезоректумэктомии (Та-ТМЭ).Материалы и методы. С ноября 2013 г. по сентябрь 2016 г. было проведено проспективное нерандомизированное контролируемое исследование, в которое были включены пациенты с диагнозом рака нижне- или среднеампулярного отдела прямой кишки сТ1–4aN0–2M0.Результаты. В группы Та-ТМЭ и Лап-ТМЭ вошли 55 и 54 пациента соответственно. Продолжительность операции составила 285 (Та-ТМЭ) и 260 мин (Лап-ТМЭ), медиана объема кровопотери – менее 100 мл, длительность пребывания в стационаре после операции – 7 койко-дней в обеих группах. В группе Та-ТМЭ зарегистрирована 1 (1,8 %) конверсия в открытую операцию и 3 (5,6 %) – в контрольной группе (р = 0,223). Трансанальное извлечение препарата выполнено в 53,7 % наблюдений в группе Та-ТМЭ против 25,5 % в группеЛап-ТМЭ (p = 0,008). Осложнения отмечены у 27,3 и 24,1 % пациентов соответственно (р = 0,436). Качество мезоректумэктомии в группе Та-ТМЭ оценено как Grade 2–3 в 90,9 % случаев, в группе Лап-ТМЭ этот показатель составил 85,2 % (p = 0,266). Поражение циркулярной границы резекции в группе Та-ТМЭ выявлено у 7,3 % больных, в то время как в группе Лап-ТМЭ – у 9,3 % (p = 0,488).Выводы. Та-ТМЭ не ухудшает непосредственные онкологические результаты. Требуются дальнейшие рандомизированные исследования для выявления когорты пациентов, которые получают наибольшее преимущество от применения мезоректумэктомии «снизу вверх»

The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS)

Objective: To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. Summary Background Data: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. Methods: Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee. Results: Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee. Conclusions: The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies

The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS)

Objective: To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. Summary Background Data: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. Methods: Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee. Results: Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee. Conclusions: The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies.</p

Прогнозирование панкреатической фистулы после панкреатодуоденальной резекции с помощью компьютерной томографии

Aim. To reveal and evaluate opportunities of preoperative computer tomography (CT) for pancreatic fistula (PF) prediction after pancreatoduodenectomy.Materials and methods. In 2005 International Study Group on Pancreatic Fistula (ISGPF) developed grading criteria for PF, including asymptomatic biochemical (Grade A), that could be treated conservatively, and clinically relevant (Grade B, Grade C), with consecutive active surgical treatment. For now ISGPF definition of PF is widely accepted. We review the literature since 2005 for original articles in English describing quantitive assessment of the pancreatic parenchyma using CT with histological validation. Low sample trials (&lt;10 cases) were excluded.Results. Three original publications met the inclusion criteria. Fatty and fibrosis infiltration of the pancreatic parenchyma assessed by preoperative CT revealed statistically significant correlation with PF rate.Conclusion. Preoperative CT offers accurate prediction opportunities for postoperative pancreatic fistula and may help caregivers to set up protocols for a strict and early detection of warning clinical signs, to tailor the clinical management of different risk classes, or to select high-risk patients who might be excluded from surgical resection. This would also improve patient selection for relevant research protocols and facilitate a more definitive assessment of collected data related to surgical outcomes, across different institutions and surgeons, and even among different surgeries, in either single-institution or multi-center trials that involve pancreatic surgery.Цель исследования: выявить и оценить возможности прогнозирования панкреатической фистулы после панкреатодуоденальной резекции на основании данных предоперационной компьютерной томографии (КТ).Материал и методы. В 2005 г. Международная рабочая группа по изучению панкреатических фистул (International Study Group on Pancreatic Fistula, ISGPF) разработала критерии градации панкреатических фистул на бессимптомные биохимические (Grade A) и клинически значимые (Grade B и С), требующие терапевтической (Grade A) или хирургической коррекции (Grade B и С). Данная классификация стала общепринятой и широко используется. Проведен анализ литературы, при котором учитывались только оригинальные англоязычные публикации после 2005 г, которые описывали возможности предоперационной количественной оценки плотности поджелудочной железы (ПЖ) с помощью КТ, а данные КТ сопоставлялись с результатами гистологического исследования ткани ПЖ. Работы с малыми выборками (&lt;10 пациентов) были исключены из анализа.Результаты. Критериям включения соответствовали 3 статьи, описывающие возможности КТ для оценки степени фиброза и жировой инфильтрации паренхимы ПЖ, в качестве факторов риска панкреатической фистулы. Выявлена статистически достоверная зависимость данных показателей и риска панкреатической фистулы.Заключение. Современные возможности Кт позволяют объективно судить о риске развития панкреатической фистулы и предоставляют хирургам возможность подобрать наиболее подходящую периоперационную тактику ведения пациента. Прогнозирование риска панкреатической фистулы и формирование гомогенных групп для клинических исследований позволят получать более достоверные результаты при анализе данных даже из разных источников, что, несомненно, повысит качество проводимых исследований

Laparoscopic extralevator abdominoperineal extirpation of the rectum: long-term results

Objective: comparative assessment of long-term oncological results of laparoscopic extralevator and traditional abdominal-perineal resection (APR).Materials and methods. The analysis of immediate and long-term oncological results of treatment of 92 patients who underwent traditional laparoscopic and extralevator APR for low rectal cancer. Inclusion criteria were tumors of the lower ampullar rectum, excluding the performance of sphincter-sparing surgical interventions, and patients’ age up to 75 years. Exclusion criteria: distant metastases, histologically confirmed squamous cell carcinoma. Analysis of immediate and long-term results was carried out.Results. The main group included patients who underwent extralevator APR (n = 62), patients in the control group (n = 30) underwent traditional APR. There were no significant differences in the type of neoadjuvant and adjuvant treatment in the comparison groups (p &gt;0.05). In the group of patients operated on in the volume of extralevator APR, 42 received neoadjuvant chemoradiotherapy versus 19 patients in the group of traditional APR, there was no statistically significant difference (p = 0.21). In the extralevator APR group, perineal plastic surgery was performed significantly more often than in the traditional APR group (p = 0.001). When evaluating the immediate results, there was a statistically significant difference in the total number of complications between the study groups, such complications as bladder dysfunction following after surgery, inflammatory pelvic disease in the perineal wound, perineal hernia occurred significantly more often in the traditional APR group than in the extralevator APR group (p &gt;0.05). In terms of overall and disease-free survival, the groups differed statistically significantly: 5-year overall survival in the main group was 90 % versus 62.5 % in the control group (p = 0.03), 5-year disease-free survival in the main group was 98.5 % versus 65 % in the control group, respectively (p = 0.01).Conclusions. Extralevator APR of the rectum is the most radical surgical intervention than with the traditional APR technique due to the lower risk of a positive circumferention resection margin, therefore, reducing the incidence of local recurrence, and as a result, improving overall and disease-free survival rates compared to the traditional technique

Primary rectal melanoma (a case report)

Primary rectal melanoma is a rare malignant tumor with an aggressive course and poor prognosis. The article describes a clinical observation demonstrating the successful comprehensive treatment of primary rectal melanoma. A patient with a complicated course of rectal melanoma, stage IV of the first stage was performed by surgical treatment with removal of the external intestine according to the Hartmann type with removal of the uterine appendages from both sides of the en-block, and resection of the left pelvic plexus. In the postoperative period, the patient underwent chemoembolization of the liver with combined immunotherapy. The patient is alive two years after the operation; there is no evidence for local recurrence and progression of the disease

Semiotics and the role of transrectal ultrasound in rectal cancer staging

Transrectal ultrasound (TRUS) is inexpensive and simple method for examining the rectum and surrounding tissues. In particular it is used to preoperatively assess stage, in patients with rectal cancer. By using TRUS is possible to analyze the neoplasm extent, depth of tumor invasion into the layers of the colon wall, the mesorectal lymph node involvement and the circumferential resection margin. This method is comparable to an expensive magnetic resonance imaging scan, and if done correctly could even exceed it. The correct diagnosis, especially in the early stages of the disease, plays an important role in choosing surgical treatment in future. However, to interpret the results, you must be familiar with the anatomy of the rectum and anal canal, as well as follow the simple rules for the preparation and implementation of TRUS. If you follow all the rules, you can answer the question about the possibility of performing organ-preserving surgery and compliance with cancer radicalism