Pelvic floor disorders (PFD) represents a significant social and economic problem involving about 25% of women older than 60 years with a 13% lifetime risk of undergoing surgery for PFD. Optimal management is impossible without comprehensive assessment of pelvic floor and multimodal approach. A combination of ultrasonic methods has several advantages (low cost, wide accessibility and availability, office procedure performed by clinicians, intraoperative technique, relatively time consuming, good compliance) and should be performed as first-line assessment in PFD.

INTRODUCTION: there are no studies comparing laparoscopic, open, and transanal mesorectal excision for rectal cancer.

AIM: to compare quality of total mesorectal excision (TME) according to the P. Quirke protocol, to assess circular resection margins (CRM), to assess distal resection margins (DRM) and perioperative morbidity.

PATIENTS AND METHODS: prospective study was performed to compare the effectiveness of different methods of TME.

RESULTS: eighty-eight patients were included in the study, 29 – in the laparoscopic (LA TME) group, 29 – in the open TME group, 30 – in the transanal (TA TME) group. The groups were comparable in clinical, demographic and tumor parameters. There was no significant difference between LA TME, open TME and TA TME in quality of mesorectal excision (p=0.67). There was also no significant difference in rates of positive CRM and positive DRM (p=0.38). No significant difference was obtained between intraoperative and postoperative complications rates (p=0.38; p=0.45). CONCLUSION: all three methods of TME showed the same results for quality, circular and distal resection margins and perioperative morbidity.

AIM: to evaluate high-definition colonoscopy (HD-WLE) using chromoendoscopy for dysplasia in the longstanding ulcerative colitis (UC).

PATIENTS AND METHODS: a cohort prospective study included 140 patients (aged 29-79 years old) with a long course of UC (6-44 years) in time of endoscopic remission with good quality of bowel cleansing. A white-light endoscopy was performed using high-definition colonoscopies (HD-WLE). Chromoendoscopy (0.4% solution of indigo carmine), targeted biopsy, and histological analysis were performed.

RESULTS: HD-WLE revealed 34 lesions with endoscopic signs of dysplasia in 27 (19.3%) patients: in 20 patients – 1 (74.1%) lesion, in 7 patients 2 (25.9%). In 22 patients (64.7%) lesions were more than 1 cm.
Chromoendoscopy confirmed the signs of dysplasia in 100.0% of cases (88.2% – low grade dysplasia).
Histologically, low-grade dysplasia was detected in 58.8% of cases, undetected dysplasia – in 20.6%, sporadic adenomas – in 20.6%.
The effectiveness of endoscopic diagnosis for detecting dysplasia was 74%. A comparative analysis of the endoscopic signs of dysplasia and sporadic adenomas showed the absence of significant differences.

CONCLUSION: the additional chromoendoscopy during HD-WLE colonoscopy with targeted biopsy does not lead to increase of colorectal epithelial dysplasia detection in UC.
The experience of endoscopist should be considered when making decision which type of endoscopy for dysplasia detection in UC is needed.

AIM: to reveal risk factors of complications after ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC).

PATIENTS AND METHODS: from September 2011 by July 2018, 144 patients, who underwent IPAA surgery for UC were included in the study. Univariate and multivariate analyses were performed to reveal the risk factors for complication of IPAA, such as pouchitis, cuffitis, pouch fistulas, anastomotic stricture, pouch leakage, bleeding from IPAA, incontinence and small bowel obstruction (SBO).

RESULTS: multivariate regression analysis showed that left-sided UC (OR=12,5, 95% CI 1,7-92, p=0,01), patient's age ≤33 years (OR=5,7, 95% CI 1,54-21,3, p=0,009) and hormone-free period before the IPAA ≤10 months (OR=6,86, 95% CI 1,49-31,56, p=0,01) were associated with cuffitis. The fibrotic changes/wound infection in the anal canal (OR=5,02, 95% CI 1,02-24,69, p=0,04) and albumin <35 g/l (OR=8,11, 95% CI 2,12-30,99, p=0,002) were associated with fistulas. Time between IPAA formation and preventive ileostomy closure >5,6 months was associated with SBO (OR=2,82, 95% CI 1,01-8,31, p=0,0495). Steroid therapy at the time of IPAA surgery was associated with pouch leakage (OR=15,62, 95% CI 2,09116,64, p=0,007). Hand-sewn IPAA (OR=42,54, 95% CI 3,51-516,43, p=0,003) were associated with incontinence. Ulcerative defects in the distal part of the rectum according to transrectal ultrasound were associated with anastomotic stricture (OR=10,46, 95% CI 1,52-71,75, p=0,017). There were no statistically significant risk factors for pouchitis and IPAA bleeding.

CONCLUSION: determination of the risk factors for complications of IPAA is a crucial clinical issue for patients with UC. We identified several factors associated with increased risk of complications after pouch formation. Nevertheless, it seems promising to continue the study in order to create the mathematical model that predicts the development of a specific pouch-related complication and determines a group of patients with UC in whom the formation of IPAA is not recommended due to high risk of complications and impaired quality of life.

AIM: evaluation of the effectiveness of the enhanced recovery protocol for stoma reversal procedures.

PATIENTS AND METHODS: a single-center retrospective analysis of stoma reversal surgery in 130 ostomy patients in 2012-18 was performed. From 2012 to 2015, 56 (43.1%) patients were treated before the implementation of the Enhanced Recovery After Surgery (ERAS) protocol in clinical practice, 74(56.9%) patients were treated in accordance with the principles of fast-track.

RESULTS: the introduction into clinical practice of the ERAS protocol reduced postoperative complications from 8.5% to 5.4% (p=0.002) and the hospital stay from 16,3±9,4 to 11,4±4,2 days (p=0.003).

CONCLUSION: the fast-track strategy is an effective way to improve the results of stoma reversal procedures.

AIM: to assess the safety of endoscopic piecemeal mucosal resection (EPMR) of large epithelial colorectal lesions and to identify risk factors for tumor recurrence.

PATIENTS AND METHODS: results of EPMR were evaluated in retrospective study, which was carried out in five regional endoscopic centers. The criterion for inclusion in the study was benign colorectal lesion of 20 mm and larger.

RESULTS: we found that complications of EPMR occurred in 13% of cases. In 9.2% it was intraoperative bleeding, which was stopped endoscopically. Postoperative bleeding was detected in 1.2% of patients, perforation – in 2.4%. Tumor recurrence developed in 12%. We have revealed a direct correlation between tumor recurrence and intraoperative bleeding (p=0.013) and a size of lesion >4 cm (p=0.012); the inverse correlation between the tumor recurrence and the fullness of the lifting during the removal (p=0.008) and the male gender of the patient (p=0.043).

CONCLUSION: significant risk factors of tumor recurrence after endoscopic piecemeal resection of large benign colorectal neoplasia were identified before the procedure (gender and tumor size) and intraoperatively (completeness of lifting and the intraoperative bleeding).

AIM: to assess the efficacy of botulinum toxin type A for chronic anal fissure.

PATIENTS AND METHODS: the study included 80 patients randomized by random number generation in 2 groups. Forty patients underwent fissure excision in combination with injections of botulinum toxin type A into the internal sphincter (main group) and 40 – in combination with pneumatic balloon dilatation of the anal sphincter (control group).

RESULTS: there were no statistically significant differences in the intensity of postoperative pain after defecation and during the day between the groups, p=0.45 and p=0.39, respectively. The groups were comparable in the complications such as perianal skin hematomas (p=0.84), external hemorrhoid thrombosis (p=0.1), urinary retention (p=0.46), long-term non-healing wounds (p=0.76). Transitory weakening of the anal sphincter was significantly more often in the control group. On day 30, the transitory anal incontinence in the main group was detected in 6 (21%), in the control group – in 18 (75%) patients, p=0.0002. On day 60, the weakness of the anal sphincter remained in the main group in 3 (10.7%), in the control group – in 10 (41%) patients, p=0.02.

CONCLUSION: botulinum toxin type A and pneumatic balloon dilatation have equal effectiveness in the treatment of chronic anal fissure. The use of botulinum toxin type A can reduce the incidence of transitory weakening of the anal sphincter function in patients with chronic anal fissure.

AIM: to assess the effectiveness of micronized purified flavonoid fraction (MPFF) in conservative treatment for chronic hemorrhoids according to high-resolution anoscopy (HRA).

PATIENTS AND METHODS: the study included 192 patients with chronic hemorrhoids, stage III. The general recommendation for all patients was dietary fibers for soft stools. The main group included 96 patients treated with MPFF for 2 months, 96 controls used dietary fibers only. The treatment effectiveness was evaluated due to high-resolution anoscopy data and clinical manifestation of the disease. The calculation of the drug intake compliance was carried out as well.

RESULTS: patients of the main group showed significant clinical improvement after treatment in prolapse correction (66% vs 27%; p=0.001), in pain intensity decrease (5 times vs 1.5 times; p=0.03), in bleeding incidence (4 times vs 1.5 times; p=0.001). HRA showed significant reduction of inflammation (from type 2 to type 1) in main group in 50% and 20% in controls (p=0.02). Compliance with the MPFF in main group 1 was 74%, the total compliance of dietary fiber intake in both groups was 66.3%.

CONCLUSIONS: combination of MPFF with dietary fiber intake significantly reduces clinical manifestations of chronic hemorrhoids stage III and HRA shows significant reduction of inflammation in hemorrhoid piles in these cases.

MutYH-associated polyposis (MAP) is hereditary syndrome with autosomal recessive inheritance, caused by biallelic mutation in MutYH gene and characterized by presence of multiple (20 and more) polyps in the bowel and increased life-time risk of colorectal cancer. At the same time finding 2 heterozygous mutations in MutYH gene (by Sanger method) doesn`t mean the diagnosis of MAP because of need to confirm their biallelic location. This case-report demonstrates difficulties in diagnostic of MAP caused by inability to investigate parent DNA samples and our options for solution of this problem.

Pelvic floor descent syndrome (PFDS) affects multiparous and postmenopausal women. According to epidemiological studies in postmenopausal women, more than 50% suffer from severe symptoms of PFDS, which significantly reduce the quality of life. The high prevalence of pelvic floor pathology increases the need for multimodal diagnosis and treatment. The pelvic floor is a unique anatomical and functional structure and malfunction of this system may lead to many different static and functional disorders. There are a lot of methods of medical imaging modalities for PFDS (X-ray defecography, perineal ultrasound, MR defecography). MRI defecography allows to visualize in detail all three parts of the pelvis, including soft tissues and supporting structures; to evaluate structural and functional pelvic abnormalities in a single study. The range of normal mobility of the pelvic floor and pelvic organs on MRI defecography is still required.