ORIGINAL ARTICLES
Aim: to analyze the diagnostic value of the digital rectal examination, colonoscopy, MRI and ERUS for detecting occult adenocarcinoma in rectal adenomas.
Patients and methods: the study included 100 patients with newly identified epithelial rectal neoplasms, which undergone transanal endoscopic microsurgery from December 2019 to December 2020. All the patients underwent digital rectal examination, colonoscopy, ERUS with sonoelastography, and pelvic MRI. The diagnostics value of this methods was estimated with determination of sensitivity and specificity.
Results: the study included 67 (67%) females and 33 (33%) males. The mean age of the patients was 64.4 ± 10.7 years. The median distance from the tumor to the anal verge was 6.0 ± 2.9 cm. The sensitivity of the digital rectal examination in the occult malignancy verification was 0.44 (95% CI 0.24–0.65), specificity — 0.93 (95% CI 0.85–0.97). The sensitivity of the colonoscopy — 0.56 (95% CI 0.34–0.75), the specificity — 0.84 (95% CI 0.73–0.91). The sensitivity of MRI — 0.40 (95% CI 0.21–0.61), specificity — 0.89 (95% CI 0.80–0.95). The sensitivity of ERUS was 0.48 (95% CI 0.27–0.68), the specificity — 0.73 (95% CI 0.61–0.82). Pair wise comparison of diagnostic methods revealed the absence of significant differences in their diagnostic value (p > 0.05).
Conclusion: at least one of diagnostic methods allows to verify the presence of malignant transformation in 100% of cases. So, only combination of diagnostic methods can help to choose the optimal treatment option.
Aim: to evaluate the effect of the lymphadenectomy (LD) level on the quality of life (QoL) in patients who underwent laparoscopic colon resection for colon cancer.
Patients and methods: the study included 86 patients who underwent surgery for colon cancer from January 2018 to August 2020. The patients were randomized in 2 groups: the main group — with D3 lymphadenectomy — 41 patients and the control group — with D2 — 45 patients. Two validated QoL questionnaires (QLQ-C30 v. 3.0, QLQ-CR29 v. 2.1) of the European Organization for Research and Treatment of Cancer (EORTC) were applied by the patients on the day before the surgery and on the 30th day after the surgery and were used for the further analysis.
Results: there were no significant differences between the groups in gender, age, weight, height, BMI, assessment of functional and physical status according to the ASA and ECOG scales, incidence of comorbidities, tumor site, type and volume surgical of procedures. Regardless of the level of lymphadenectomy, the significant improvement in QoL after surgery was obtained (pQoLD3 = 0.005, pQoLD2 = 0.023) in both groups. The significant increase in the incidence of diarrhea by 2.65 times was detected after laparoscopic right hemicolectomies with extended lymphadenectomy (p = 0.042). Also, there was a significant 2.45 fold increase in the risk of developing erectile dysfunction (ED) after D3 lymphadenectomy in the patients who underwent laparoscopic resections of the left colon in the early postoperative period (p = 0.031).
Conclusion: the analysis of physical, social functioning and symptomatic scales has established that in patients who underwent colon resection for cancer of the left colon erectile dysfunction occurred to a greater extent after D3 LD, whereas diarrhea was more likely to develop after resection of the right colon with D3 LD than with D2 LD.
Aim: to compare the early and long-term results of endoscopic mucosal resection (EMR) and conventional polypectomy for benign epithelial colon neoplasms
Patients and methods: the retrospective study included 344 patients with histologically verified adenomas of the size of up to 40 mm in the colon, who underwent EMR or conventional polypectomy. Mucosectomy (EMR) was performed in 207 patients, while conventional polypectomy was performed in 137.
Results: there were no significant differences in the postoperative morbidity rates between the methods (OR = 1.8; 95% CI = 0.7–4.8, p = 0.3). Fragmentation significantly more often occurred in the group of conventional polypectomy (OR = 3.5; 95% CI = 2.3–5.5, p = 0.001, especially when the size of the neoplasm was over 1 cm (OR = 3.1; 95% CI = 1.1–8.9 = 0.037). Recurrence occurred in 19/173 (10.9%) in 12 (8.3%) patients of the EMR group. In the polypectomy group, recurrence developed in 22 (23.1%) patients, in 24/108 (22.2%) cases at the site of the postoperative scar. It was found that the adenoma recurrence in the area of endoscopic excision occurs significantly more often after conventional polypectomy (OR = 2.3; 95% CI = 1.2–4.4; p = 0.016).
Conclusion: EMR and conventional polypectomy both are the safe methods with low morbidity rates. However, the EMR is the preferred method of endoscopic excision for adenomas larger than 1 cm due to the fact that it allows for deeper and more complete resection of the tissue than conventional polypectomy.
Aim: to improve the results of fistula treatment, to evaluate the effectiveness of the combined use of LIFT and FiLaC techniques.
Patients and methods: the study included 35 patients with transsphincter fistulas of cryptopglandular etiology involved more than 1/3 of the sphincter. All patients underwent surgery with laser energy (the laser conductor speed is 1 mm per second, the wavelength is 1470 nm, the radiation output is 13 W) after the LIFT procedure.
Results: the primary healing rate was 28/35 (80,0%). The patients who failed the combined procedure (cases of prolonged healing more than 3 months) underwent a second procedure ReFiLaC, which led to the closure of fistula in 2 of 3 patients. A median follow-up period was 10,2 months. No incontinence to solid and liquid stools was detected.
Conclusion: preliminary results of the study permits to assess the potential of the combined low-invasive approach for anal fistulas as positive.
Aim: to evaluate prognostic factors in colorectal cancer.
Material and methods: published data (publications in PubMed, Scopus, eLIBRARY databases) and own results of treatment of 47 patients with T2-4N0-2M0 colon cancer in 2017–2018. The following prognostic factors were studied: metastasis in regional lymph nodes, tumor site, CEA level, KRAS and BRAF mutation status, microsatellite instability, MUSASHI2, p53, VEGF.
Results: a correlation between tumor progression and the status of regional lymph nodes demonstrated significant differences (p = 0.038): in N0, the risk of progression was 3.8%, in N1 — 14.9%, in N2 — 43.6%. Statistical processing of the results did not reveal significant differences between groups of patients without and with cancer generalization by their age, gender, tumor site, type of lymph node dissection, T stage, differentiation of adenocarcinoma, levels of CEA, mutations of KRAS, MSI, p53, MUSASHI2, VEGF. We used these prognostic factors to determine biological features of the tumor, its aggressiveness and treatment approaches.
Conclusions: the status of regional lymph nodes remains the main factor in determining the prognosis of a colon tumor and in the medical therapy appointment. Molecular genetic factors are currently of great importance for determining tactics in personalized medical treatment.
Aim: to identify the risk factors for conversion of endoscopic submucosal dissection to abdominal surgery.
Patients and methods: the prospective cohort study included 405 patients: 166 (40.9%) males and 239 (59.1%) females. The median age was 66 (59; 72) years old; the patients underwent endoscopic submucosal dissection of colorectal epithelial neoplasms.
Results: the median size of the removed neoplasms was 3.0 (2.4; 4) cm, tumor was removed en bloc in 324/363 (89.2%) cases; and R0 resection margins were detected in 218/324 (67.3%) cases. Significant risk factors for conversion were: the tumor size ≥ 3.2 cm (OR 2.9, 95% CI 1.2–7.1, p = 0.017), lifting ≤ 3 mm (OR 41, 95% CI 15–105, p = 0.000002) and the tumor vascular pattern IIIa according Sano’s capillary pattern classification (OR 4.0, 95% CI 1.3–11.9, p = 0.013).
Conclusion: endoscopic submucosal dissection is a safe way to remove colorectal neoplasms. However, the presence of conversion risk factors can influence the outcome of endoscopic treatment.
Aim: to develop a conservative rehabilitation program for patients with severe symptoms of LARS.
Patients and methods: since January 2019, 50 patients after low anterior resection were included in the study. The main group included 25 patients who underwent biofeedback therapy and tibial neuromodulation in 3–6 months after surgery. Functional results before and after treatment were evaluated by anorectal manometry. The control group included 25 patients, according to the Propensity score matching.
Results: the median score on the LARS scale, in the main group was 41.0 ± 2.8 points, in the control — 38 ± 4. With sphincterometry, the median pressure at rest before treatment was 30.0 ± 7.8, with a voluntary contraction of 140.6 ± 56.0 mm Hg. After the conservative treatment, patients in the main group had significantly better results: the median score on the LARS scale decreased from 41 ± 2.8 to 17 ± 8 points (p < 0.0001), the median pressure after treatment increased from 30.0 ± 7.8 to 36.0 ± 8.0 (p = 0.004), with a voluntary contraction from 140.6 ± 56.0 to 157.5 ± 53.2 mmHg (p = 0.008). Comparing the results of the questionnaire of the main group with the control group after the stoma closure and after 12 months, it turned out that in the main group there was a significant decrease in the severity of LARS: 17.0 ± 8.0 scores vs. 35.0 ± 4.5 (p = 0.0003), which shows an improvement in the tone and contractility of the sphincter after conservative treatment.
Conclusion: comprehensive biofeedback therapy and tibial neuromodulation improves the functional results of patients with severe LARS.
Background: endoscopic electroexcision is the standard technique for the removal of colorectal polyps. However, it is associated with the postoperative morbidity. In order to reduce the incidence of complications, “cold” excision seems to be an alternative option.
Aim: to improve the results of endoscopic treatment for patients with colorectal polyps.
Patients and methods: from September 2019 to September 2020, 160 patients ≥ 18 years old (80 in each group), who underwent endoscopic removal of colorectal polyps ≤ 10 mm in size by cold excision (132 lesions) and traditional polypectomy (129 lesions), were included in a prospective randomized trial. All removed specimens were studied histologically with an assessment of the resection margins (R0/R1). The analysis of the postoperative complications after endoscopic polypectomy and the incidence of Rx resection after removal of polyps by both techniques was done.
Results: the compared groups were homogenous in the number of patients, gender, age, and comobridities. There were no significant differences in the number of removed polyps, their site and the type according to endoscopic classifications. The operation time was significantly higher in the conventional polypectomy group compared with the “cold” one (p = 0.0001). There were no significant differences in the intraoperative complications rate between the two groups (p = 0.06). There were no postoperative complications in the “cold” group. In the control group postoperative complications occurred after 12 out of 129 polyps removal (p = 0.001). The univariate analysis showed that a risk factor for the development of postoperative complications after conventional polypectomy is the lack of submucosal lifting (OR: 15.3, 95% CI: 1.9-125.6, p = 0.01). Histopathology of the removed specimens showed that in both groups most of the procedures were considered as R0 resections (54% in the main group, 56.4% in the control group, p = 0.8). The polyp size ≤ 4 mm identified as a risk factor for R1, Rx resection (OR: 2.4, 95% CI: 1.3–4.7, p = 0.007).
Conclusion: “cold” polypectomy is an effective and safe method and may be recommended as an alternative technique for the removal of non-pedunculated colorectal polyps ≤ 10 mm.
REVIEW
In the literature review, the problem of colorectal anastomosis leakage is considered with an emphasis on the role and capabilities of radiology, including methodological features, diagnostic effectiveness and characteristic manifestations at various times after surgery, also controversial and unresolved issues of the use of various methods of radiation research are noted.
Peutz-Jeghers syndrome (PJS) is an extremely rare autosomal dominant hereditary disease characterized by the growth of hamartomatous polyps in the gastrointestinal tract, mucocutaneous pigmented macules and an increased risk of malignant neoplasms of various localizations. In most cases the development of PJS is associated with the presence of a mutation in the STK11 gene, but not all patients have this mutation. This review presents the historical aspects of the first data on PJS, considers the clinical manifestations of the disease, current diagnostic methods, as well as recent knowledge about the genetic causes, about the risk of malignant neoplasms in patients with PJS, existing guidelines for screening and treatment of patients with PJS. However, the presence of a number of unresolved issues in genetics, monitoring and treatment indicates the need for further research.
ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ
Aim: to analyze the structure and changes of colorectal cancer (CRC) epidemiology in the Ulyanovsk region in 2005–2019 according to the regional cancer register.
Materials and methods: the study is based on statistical data on the primary detection of CRC in the districts of the Ulyanovsk region (form No. 7) in 2005–2019. Standardized rates of morbidity and mortality were evaluated. Data on the number, gender and age of the regional population were obtained in Ulyanovsk State Statistics Service.
Results: the incidence of CRC in the region increased by 1.51 times over the analyzed period (from 31.12 to 49.58 per 100 thousand people). From the total number of newly diagnosed CRC in 2019, the urban population was 25%, and the rural population — 75%. The incidence rates in the districts of the region were assessed. The highest morbidity in males was detected at the age of 60–64 years old, and it was 1.58 times higher than in females. In the adult population under 30 years old, only few cases of colorectal cancer were detected. The main histological type of tumors was adenocarcinoma. Poorly differentiated tumors accounted for about 3%. The highest age-standardized rates for rectal tumors were 10.1 and 12.8 per 100 thousand people in 2005 and 2019, respectively; for the recto sigmoid tumors — 0.9 and 2.3 per 100 thousand people; and for the anal cancer — 0.4 cases per 100 thousand people in 2019. The male/female ratio of deaths from CRC in 2019 was 1.005:1.000.
Conclusion: there has been a trend to an increase in the incidence of colorectal cancer among the Ulyanovsk region population in the period from 2005 to 2019. We identified some areas of the region that significantly differ in the incidence of colorectal cancer.
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