BACKGROUND: endoscopic submucosal dissection (ESD) is a modern effective method for patients with benign epithelial tumors and early colorectal cancer.
The use of such a technique for ESD as a submucosal tunnel (‘pocket’) – creation under a tumor creates conditions for improving the surgical specimen qualityand reducingfragmentationrate.
Aim: to study the effectiveness and safety of the tunnel method of ESD (TESD) in comparison with classical ESD (CESD) in colorectal adenomas and early colorectal cancer.
MATERIALS AND METHODS: literature search and meta-analysis were performed in accordance with the PRISMA recommendations using the PUBMED search system in the Medline electronic database without limiting publication datesin the English language literature. The systematic review included all the studies on comparison of the tunnel and classical ESD methods.
RESULTS: the analysis included 4 studies (1,422 patients, 458 in the TESD group and 961 in the CESD group). The groups were comparable in the number of adenomas (OR=1.25; 95% CI=0.87-1.79; p=0.22), adenocarcinomas (OR=0.96; 95% CI=0.49-1.87; p=0.90), in the size of neoplasms (95% CI=-6.26-1.22; p=0.19), and in the presence of submucosal fibrosis (p=0.69). There were no significant differences in intraoperative bleeding rate (OR=1.24; 95% CI=0.53-2.88; p=0.61); however, perforations occurred more often when using CESD (OR= 0.35; 95% CI=0.15-0.83; p=0.02). The CESD took significantly longer time than the TESD (OR=-19.1; 95% CI=33.89-4.45; p=0.01). The frequency of en bloc resections (OR=16.06; 95% CI=4.95-52.11; p<0.0001) and R0-resections (OR=3.28; 95% CI=1.30-8.32; p=0.01) were significantly higher in the TESD. CONCLUSION: the tunnel method of endoscopic submucosal dissection is an effective and safe alternative to the classical method. However, there is currently a lack of data for the choice of submucosal dissection method for large colorectal adenomas and early colorectal cancer, which requires further comparative studies.

AIM: evaluating the effectiveness of conservative treatment for diverticular disease complicated with first episode of acute diverticulitis. PATIENTS AND METHODS: we investigated the results of the conservative treatment of 68 patients with diverticular disease complicated with first episode of acute diverticulitis. The ages of patients range from 32 to 78. The diagnosis was made based on clinical examination, laboratory tests (markers of inflammation – CRP, faecal calprotectin) and imaging studies (irrigoscopy, colonoscopy, USG, CT, laparoscopy). In 19 of 68 patients (28%) affected segment of the colon was descending colon, in 49 (72%) patients sigmoid colon was effected.
RESULTS: all 68 patients received conservative treatment (spasmolytics, antibiotics, probiotics, anti-inflammatory, antibacterial drugs, and diet). Rifaximin was used as antibiotic (daily dose 600-1200 mg). Treatment course lasted for 7 days. We used probiotic (Enterol) to normalize colonic microflora (1 capsule 2 times a day), treatment course lasted for 7-10 days. Long-term outcome of treatment and quality of life of 54 (79,4%) patients were evaluated 2-5 years after a first episode of uncomplicated acute diverculitis. 12 (22,2%) patients underwent medical examinations, in 54 (79,4%) patients we used a questionnaire for assessment. Two scales of MOS 36-Item Short Form Health Survey (MOS SF-36) were evaluated: physical functioning and mental health. Analysis the results of the treatment showed that recurrent episodes of acute diverticulitis did not occur. The analyse of the survey results showed that the mean score of the patients were close to the results of healthy population.
CONCLUSION: pathogenetically based multicomponent conservative treatment in the first episode of acute diverticulitis can make a regression and normalize laboratory values.
The study showed that no reccurence was reported and the quality of life of the patients was similar to healthy ones after conservative treatment. It confirmes that the conservative treatment is an alternative treatment method for a first episode of uncompliated acute diverticulitis.

 

AIM: to evaluate transanal total mesorectal excision (TA TME) learning curve.
PATIENTS AND METHODS: sixty-five patients with mid- and low сT2-T4aN0-2bM0-1 rectal cancer were included.
RESULTS: mean total operating time was 272.4±50.8 (190-400) minutes and after 17 th case it has decreased. Mean operating time of transanal phase was 84.9±43.2 (40-200) minutes and after 20 th case it has also decreased. The rate of intraoperative complications was 8 (12.3%), postoperative morbidity – 25 (38.4%) cases. These indicators have decreased after 18 th and 20 th cases respectively. Conversion rate was 2 (3.0%) cases and have decreased after 6 th case. Grade 1 specimens were revealed in 9 (13.8%) cases and have decreased after 16 th case.
CONCLUSION: TA TME learning curve in high-volume colorectal unit is 16-20 cases.

AIM: to demonstrate the first results of natural orifice specimen extraction surgery (NOSES) for rectal cancer.
PATIENTS AND METHODS: in the period from June 2019 to October 2019 five NOSES for rectal cancer were performed in the hospital. The following factors were evaluated: age, gender, BMI, ASA, operation time, intraoperative blood loss, intraoperative and postoperative complications, duration of postoperative rehabilitation, need for narcotic analgesics.
RESULTS: mean age of patients was 61.2 years. Mean BMI was 25.9 kg/m2 . Mean ASA score was 2. Mean operative time was 225 minutes. Mean intraoperative blood loss was 45 ml. One intraoperative complication occurred – defect of anastomosis in the point of crossing of 3 stapler sutures. One postoperative complication occurred – postoperative ileus. Narcotic analgesics were not used. Mean duration of postoperative stay was 9.8 days. The primary results demonstrate feasibility of NOSES for rectal cancer with adequate qualification of colorectal surgeon.
CONCLUSION: NOSES is a promising technique for rectal cancer surgery. However, the further experience and randomized trials are required.

AIM: to improve the results of treatment for perianal abscess using ultrasound navigation, seton drainage of the internal fistula and subsequent minimally invasive treatment of fistula.
PATIENTS AND METHODS: seventy-two patients with perianal abscess were included in cohort retrospective study. At the first stage the abscess opening and seton under ultrasound navigation with contrast was performed. On the second stage the FiLaC procedure was performed.
RESULTS: follow-up was 8-14 weeks, 29 (53.7%) patients had subcutaneous or submucosal seton displacement, while 8 (11.1%) produced complete healing. Twenty-one (29.2%) patients required fistulectomy. In 25 (46.3%) patients, intra- and transsphincteric fistulas were detected in 18 (33.3%) and 7 (12.9%) cases, respectively. All these patients underwent laser coagulation of the fistula. After a single laser coagulation, fistula healing within 4 weeks was found in 19 (76.0%) patients. Six (24.0%) patients underwent second laser coagulation of the fistula, while healing was observed in 2 (8.0%) patients. Four (16.0%) patients after second coagulation produced recurrence and have underwent surgery (LIFT procedure or advancement flap).
CONCLUSION: perianal abscess opening with seton provides recovery in 14.8% and produces «ideal» fistula for laser ablation in 46.2% within 10-14 weeks after. Multistage minimally multistage approach provides healing and not affects anal continence in 84.0%.

AIM: to evaluate short-term results of pilonidal disease treatment using different methods: the excision of pilonidal sinus and fistula with open wound healing, the primary closure of the wound and the laser ablation (2017-2019).
PATIENTS AND METHODS: ninety patients with pilonidal disease without abscess were included in the comparative non-randomized study. The control group included 30 patients with excision and open wound healing. The first main group included 30 patients with the excision of pilonidal sinus and fistula with primary wound closure. The second main group included 30 patients with laser ablation of pilonidal sinus and fistula. The evaluation criteria included gender, age, BMI, number of previous procedures, operative time, hospital stay, postoperative pain intensity (VAS), cosmetic result (VAS), complication rate and recurrence rate.
RESULTS: all three groups were homogeneous in gender, age, BMI. The control group showed no complications (р<0.0001) and no recurrence (р<0.0001) rate but had more intensive pain (mean 5.9 points; р<0.0001) and worse cosmetic result (mean 4.4 points; р<0.0001). The group with primary wound closure (1^st main group) had the highest complication rate (23.4%; р=0.004) and recurrence rate (16.7%; р=0.02). The group with laser ablation had significantly shorter hospital stay (1.1 days; р<0.0001), good cosmetic result (mean 8.9 points; р<0.0001) and less postoperative pain (1.4 points; р<0.0001) with low recurrence rate (3.3%; p=0.32).
CONCLUSION: the laser ablation of pilonidal sinus and fistula provides less postoperative pain intensity and low recurrence rate, better cosmetic result and short hospital stay. It can be used for outpatient treatment.

AIM: to evaluate the results of submucosal laser destruction of hemorrhoids using a W-laser.
PATIENTS AND METHODS: one-hundred twenty-four patients with chronic hemorrhoids underwent submucosal W-laser destruction of hemorrhoidal piles in September 2017 – January 2019.
RESULTS: the time of the procedure was 18-22 minutes. The hospital stay was 7-10 hours. The maximal edema of the pararectal area appeared by the 3^rd days and was resolved on 13-14 days. The size of the edema depended on the volume of anesthetic. Maximal pain was observed on days 1 and 3 after surgery. The period for taking analgesics was not more than 7 days. No prolapse of hemorrhoidal piles was detected in all patients after 4 weeks postoperatively. No rectal bleeding was detected in 97.3%. The excellent result of treatment was found in 70.2%, good – in 22.6%, bad – in 7.2%.
CONCLUSION: submucosal W-laser destruction of hemorrhoidal piles showed a less pain intensity after surgery and a decrease in the complication rate, fast recovery and better quality of life.

INTRODUCTION: for the treatment of chronic anal fissure, various surgical techniques are used, the main difference between which is the method of eliminating the anal sphincter spasm. One of the most serious postoperative complications is the development of anal incontinence. To date, there are a number of methods for drug-induced relaxation of the internal sphincter, which can significantly reduce the risk of developing anal incontinence after surgery.
AIM: to evaluate the safety and effectiveness of botulinum toxin type A (BTA) and lateral subcutaneous sphincterotomy (LSS) in the treatment of chronic anal fissure with sphincter spasm.
METHODS: a systematic review and meta-analysis of 7 selected randomized clinical trials comparing the results of treatment of chronic anal fissure using BTA and LSS was performed. The results of treatment of 489 patients were analyzed with an assessment of the following indicators: the incidence of epithelization of fissures, postoperative complications, development of anal incontinence and the disease recurrence.
RESULTS: In the BTA group, the incidence of fissure epithelization is 0.88 times lower than in the LSS group (OR=0.12; CI=0.06;0.22; p<0.00001). There were no statistical differences in the rate of postoperative complications in both groups (OR=1.07; CI=0.50;2.30; p=0.85). The risk of developing postoperative anal incontinence is 0.86 times lower in the BTA group than in the LSS group (OR=0.14; CI=0.03;0.64; p=0.01). The risk of relapse after lateral subcutaneous sphincterotomy is 6.06 times lower than when using botulinum toxin type A (OR=6.06; CI=3.52;10.42; p<0.00001).
CONCLUSION The use of botulinum toxin type A in the treatment of chronic anal fissure reduces the risk of developing postoperative anal incontinence, but this method is significantly inferior to lateral subcutaneous sphincterotomy in terms of the rate of chronic anal fissure epithelization.