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Koloproktologia

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Vol 18, No 2(68) (2019)
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LEADING ARTICLE

7-20 1485
Abstract

AIM: transanal endomicrosurgery (TEM) is the standard for organ-preserving treatment of patients with large adenomas and early rectal cancer. The advantage of TEM in comparison with other transanal methods of treatment of rectal tumors is the low frequency of R1 resections and fragmentation, which procudes a low level of local recurrences. Endoscopic submucosal dissection (ESD) is a new technology for superficial rectum tumors. This systematic review and meta-analysis compared safety and efficacy of ESD vs TEM for large adenoma and early colorectal cancer.

PATIENTS AND METHODS: a literature search and meta-analysis of the data was carried out in accordance with the English-language Medline database without restrictions on the publication date (end December 18, 2018) according to keywords: «endoscopic submucosal dissection», «esd», «endoscopic dissection», «tem», «tamis», «transanal endoscopic microsurgery», «transanal resection», «teo», «transanal endoscopic microsurgical excision». The systematic review includes all papers on the comparison of TEM and ESD for large adenomas and early rectal cancer. Statistical data processing was performed using Review Manager 5.3.

RESULTS: four retrospective comparative studies were included in the analysis (215 patients). Groups were homogenous in the number of tumors (Odds ratio [OR]=1,19; 95% confidence interval [CI] 0.23-6.16) and size (p=0.55). The intraoperative morbidity included bleeding (p=0.54) and rectal perforation (p=0.32) was homogenous as well. The operation time in the ESD group was significantly longer by 32 minutes than TEM (OR=32.5;95% CI 17,7-47.4; p<0.0001). Postoperative stay was higher than in 1.6 times after TEM (OR=16.1; 95% CI 1.5-30.1; p=0.03). The antibiotics use after surgery was not significantly different in both groups (p=0.33). The en-bloc resections (p=0.66) and the rate of R1 resections (p=0.74) were not significantly different in both groups. The local recurrence rate was homogenous (p=0.95).

CONCLUSIONS: the ESD and TEM procedures are safe and effective techniques for local excision of adenomas and early colorectal cancer, but a randomized study is needed to prove the results.

ORIGINAL ARTICLES

21-26 1224
Abstract

AIM: to evaluate the effecacy of laser submucosal destruction using a radial light guide in patients with chronic hemorrhoids (stages II and III).

PATIENTS AND METHODS: the study included 65 patients with chronic hemorrhoids, 20% had stage II and 80% – stage III by Goligher classification. Laser submucosal destruction of hemorrhoidal piles has been performed in all patients. The following criteria of assessment were used: pain intensity by visual analogue pain (VAS) scale, the morbidity rate and the time complete wounds healing. Criteria for late results assessment was the severity of the main symptoms of hemorrhoidal disease like piles prolapse, bleeding, thrombosis and anal itching.

RESULTS: in 54 (83.1%) patients the postoperative period was uneventful. Postoperative pain syndrome was 3±2 points on VAS scale. Minor postoperative complications were detected in 11 (16.9%) patients. No recurrent hemorrhoids occurred in follow-up.

CONCLUSION: laser submucosal destruction is a good alternative for HAL-RAR and STARR procedure for hemorrhoidal disease, when the rubber band ligation and sclerotherapy were ineffective but the time for classical hemorrhoidectomy has not yet come.

27-32 2734
Abstract

AIM: to evaluate the efficacy, safety and drug tolerance of «Colokit» for bowel cleansing before colonoscopy.

PATIENTS AND METHODS: an open prospective non-randomised study of the quality of bowel cleansing was carried out in 30 patients (17 females, aged 26-72 years), who underwent diagnostic colonoscopy after using «Сolokit» (Mayoly Spindler, France) using two different regimes (recommended and alternative).

RESULTS: the quality of the bowel cleansing was significantly better in patients after «Colokit» use in recommended regime vs alternative regime. No difference in subjective assessment of patients’ comfort during bowel preparation was found in both regimes. CONCLUSION: the «Colokit» agent provides good preparation and patients’ comfort and can be recommended for the bowel cleansing before colonoscopy.

33-48 911
Abstract

AIM: to assess results of endoscopic submucosal dissection (ESD) for colon neoplasms due to lesion site.

PATIENTS AND METHODS: One-hundred thirteen patients (66 females, aged 65,7±11,0 years) with colon neoplasms which underwent ESD for one year (January 2017 – January 2018) were included in the study. All patients were divided in two groups depending on lesion site. The first group included patients with lesions in caecum, ascending colon and proximal third of tranverse colon, the second group – other colon parts and intraperitoneal part of the rectum. All patients underwent preoperative tests including colonoscopy, gastroscopy and transabdominal ultrasound. ESD included lesion marking, injection, circular incision and dissection. The results obtained were analyzed statistically using Graph Pad 7 for Mac. RESULTS: the 1st group included 61 (54.0%) patients and the 2nd – 52 (46.0%). Laterally spreading tumors (LST) were detected more often in the 1st group (56 patients of the 1st group vs 38 – in the 2nd, p=0.03). The lesion size in the 1st group was 31±13 (7-80) mm and 29±11 (8-76) in the 2nd one (p=0.3). Conversion from ESD to resection occurred in 9 (8.0%) patients, in 5 patients of the 1st group and in 4 – the 2nd one (p=1.0). The only reason for conversion was unfavorable lesion lifting (≤2 mm).

Most of the lesions were removed en bloc, specimen fragmentation after ESD occurred in 10 (9.6%) patients: in 5 (9.0%) in the 1st group and in 5 (10.4%) in the 2nd (р=1.0). Intraoperative complications during ESD in the 1st group occurred in 2 (3.5%) cases and in 2 (4.1%) – in the 2nd (р=1.0). Postoperative complications were detected in 2 (1.9%) patients. Histopathology showed adenocarcinoma in 9 (8.0%) patients. Two (1.7%) patients produced local recurrence. CONCLUSION: ESD is a safe method removal of colon ademonas. The intra- and postoperative complications rate is 3.5% and 1.9% for the 1st and the 2nd group. Local recurrences occurred in 2,04%. Unfavorable lesion lifting (≤2 mm) in right colon is a risk factor for specimen fragmentation or conversion.

49-54 12427
Abstract

AIM: to improve treatment results of adults with colon malformations and fixation abnormalities.

PATIENTS AND METHODS: retrospective observational study included 157 adults with colon malformations and fixation abnormalities.

RESULT: bioelectric excitability in colon malformations and fixation anomalies is typical due to stage of the disease and localization. It was found that disease progress is followed by the inhibition of bio-potentials and intestinal wall atrophy and atony. Sixty-nine (43.9%) patients had the compensated constipation. In 88 (56.1%) patients with sub- and decompensation have met indications for surgery. Seventy-two (45.9%) of them underwent surgery by open and laparoscopic approach. The type of the procedure depended on the type of abnormality. Postoperative complications occurred in 5 (6.9%) patients with mortality rate 1.4%. Better quality of life was detected in operated patients than of those, who refused surgery.

CONCLUSION: multimodal diagnostics with precise evaluation of the motor-evacuation function of the colon in patients with colon malformations and fixation abnormalities, assessment of conservative treatment, the determination of the type of surgery allows to improve functional results and quality of life.

55-68 839
Abstract

AIM: to assess the feasibility and safety of laparoscopic elective colon resections for diverticular disease.

PATIENTS AND METHODS: a retrospective non-randomized study included 38 patients with elective colon resection for diverticular disease. Twentysix underwent laparoscopic resections (main group), 12 – open resections (controls). The indications for surgery were: chronic diverticulitis, pericolic abdominal mass, external and internal colon fistulas and stricture of the colon. RESULTS: operation time was the same in the control group (167.1±73.3 vs 129.9±43.7 min,p=0.06). Thirty-three (86.8%) resections were performed with a colorectal anastomosis and 5 (13.2%) obstructive resections of the sigmoid colon. In the main group, the inferior mesenteric artery (IMA) was divided at the origin in 4 (15.4%) cases, in the control group – in 6 (50%) (p=0.045). The anastomotic leakage in the main group was in 3 (11.5%) patients, in the control group – in 1 (8.3%)(p=1.0). The postoperative period was significantly shorter in the main group compared with the controls(9.3±2.8 vs 13.4±5.1 days, p=0.003). After laparoscopic procedures, narcotic analgesics were used in 3 (11.5%) cases, after conventional – in 8 (66.7%) (p=0.001).

CONCLUSION: laparoscopic approach is comparable to the conventional onein operative timeand postoperative morbidity. Laparoscopic approach is associated with a significantly less postoperative pain syndrome and a shorter postoperative period, more often allows to preserve the IMA as well.

69-74 821
Abstract

AIM: to clarify surgeon’s preferences for the conservative treatment of chronic hemorrhoids.

MATERIALS AND METHODS: an anonymous survey included 102 surgeons with an experience in chronic hemorrhoids treatment. RESULTS: an analysis of survey revealed surgeon’s preferences for local and systemic drugs for the treatment of chronic hemorrhoids. The surgeons reported more than 30 different drugs for the local treatment of hemorrhoids. Most specialists consider it necessary to prescribe systemic phlebotonics. The drug «Detralex» was most often used.

CONCLUSION: a majority of surgeons use effective drugs for the treatment of chronic hemorrhoids. In any cases relative shortage of knowledge about discussed problem was revealed.

75-81 846
Abstract

AIM: to assess efficacy of FiLaC technology for extrasphincteric fistulas.

PATIENTS AND METHODS: the retrospective cohort study included 56 patients with extrasphincteric fistulas of Grade III and IV. All patients underwent a modified FiLaC procedure, which consisted of excision of the fistula tract, preservation of the fistula tract inside anal canal with its laser exposure by water-absorbing Biolitec laser power of 13W and energy density of 100 J/cm. Internal fistula opening was closed with a Z-shaped absorbable suture.

RESULTS: after fistula tract excision up to the anal canal we failed to insert laser probe to the internal fistulous opening in 6 (10.7%) patients due to scars. Thirty-nine (78.0%) 50 patients, who underwent FiLaC procedure were under observation with median follow-up of 27 months. Twenty (51.3%) patients had fistulas of Grade III with the recurrence occurred in 7 (35.0%) patients. Among 19 (48.7%) patients with fistulas Grade IV the recurrence was detected in all cases.

CONCLUSION: FiLaC procedure is effective only for extrasphincteric fistulas Grade III.

CLINICAL OBSERVATIONS

82-89 12581
Abstract

Atypical hemolytic uremic syndrome (aHUS) is a rare life-threatening condition caused by uncontrolled complement activation due to mutations in the alternative pathway of complement components. aHUS is characterized by microangiopathic hemolytic anemia, thrombocytopenia, acute renal failure and affecting multiple organ systems. Extra-renal manifestations of aHUS take place in 20% of patients including involvement of the central nervous system, cardiovascular system, lungs, skin and gastrointestinal tract. This case report describes a severe course of atypical hemolytic uremic syndrome in a 21-year-old female, developed ischemic colitis.

90-96 564
Abstract
A rare clinical observation of spontaneous intestinal perforation into the free abdominal cavity in teenager with complicated Crohn's disease during steroids therapy is presented. The experience of exclusive enteral nutrition and the results of the first stricturoplasty in children are demonstrated.

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