[Efficiency of tacrolimus therapy for perianal Crohn's disease]

AIM

To determine the efficacy of 0.1% tacrolimus ointment in patients with perianal Crohn's disease (CD).

SUBJECTS AND METHODS

This prospective randomized trial enrolled 20 patients with perianal CD as anal fissures and rectal fistulas. The inclusion criteria were rectovaginal or extrasphincteric fistulas and purulent leakages. A study group comprised 11 patients, including 9 with anal fissures and 2 with fistulas. A control group included 9 patients, including 8 with fissures and 1 with fistulas. The study group received systemic therapy with azathioprine 2 mg/kg/day and tacrolimus ointment 2 mg/day; the control group had systemic therapy with azathioprine 2 mg/kg/day, hormone ointment 1 mg/day, and metronidazole suppositories 250 mg/day. Control examination and perianal CD activity index (PCDAI) determination were done 6 and 12 weeks after therapy initiation.

RESULTS

At 6 weeks after beginning the study, local examination revealed the signs of anal fissure epithelialization in 5 (45.5%) of the 11 patients in the study group and in 3 (33.3%) of the 9 patients in the control one. At 12 weeks, fissure epithelialization and fistula obliteration were stated in 6 (54%) patients in the study group and in 3 (33%) of the 9 patients in the control group. At 12 weeks, PCDAI in the study and control groups was 2.00 and 4.44 scores (p = 0.01).

CONCLUSION

The findings suggest that topical 0.1% tacrolimus ointment versus antibacterial suppositories and hormone ointments is effective in treating patients with perianal CD. Topical 0.1% tacrolimus ointment therapy caused a reduction in PCDAI.

High resolution anorectal manometry. Recommendations on russian-language terminology based on interdisciplinary consensus

The aim of the paper — is to present the results of the consensus on the terminology used to describe data of high-resolution anorectal manometry.

Methods: Online survey was conducted with the help of the public platform “Google forms” with the aim to harmonize the terms, which are used to conduct high-resolution anorectal manometry (HRAM), to agree the conformity of the proposed Russian-language terms to those used in English-language literature, and their abbreviations.

Results: According to the aim, 56 specialists of different medical specialties who perform and use the results of HRAM in clinical practice and research were invited to participate in the survey. We received 45 answers from the respondents (42.2% coloproctologists, 22.2% gastroenterologists, 15.6% surgeons, 20% — representatives of other specialties). The response rate was 80.3%. According to the survey, 95.6% of respondents supported the need for harmonization of terms. Ten out of the 11 terms reached consensus level C1 (excellent), 1 term level of consistency was C2 (moderate). 90.9% of respondents (consensus level C1) were in favor of the appropriateness of using common abbreviations. However, the proposed abbreviations of the terms used in the conduct and description of the results of the HRAM can be accepted with reservations (in 10 cases out of 11 consensus level was C2).

Conclusions: The agreed in interdisciplinary consensus terms can be approved and recommended for the use in clinical practice and when research data are published in Russian-language scientific literature.

[Clinico-Pharmacological and Clinical Basis of Multiplicity of Intake of Novel Oral Anticoagulants]

In this review we present comparison of pharmacokinetics of novel oral anticoagulants (NOAC) dabigatran, rivaroxaban, apixaban, and edoxaban, principles of selection of a regimen of their dosing for phase III clinical trials in patients with atrial fibrillation. Multiplicity of administration of NOAC depends on required level of anticoagulation, ability to maintain anticoagulation for 24 hours, relationship between minimal and maximal levels of equilibrium concentrations, efficacy and safety. Once a day administration of some drugs of this group is reasonable from positions of clinical pharmacology. It can provide not only better adherence to treatment but greater safety relative to development of bleeding.

Ulcerative colitis (K51), adults

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Consensus on controversial issues of the surgery for Crohn’s disease by Delphi method

AIM: to establish the consensus on controversial issues of the surgery for Сrohn’s disease by Delphi method.

METHODS: a cross-sectional study was conducted by the Delphi method. 62 experts voted intramural and anonymous (31.03.23). 5 statements from the current edition of clinical guidelines were selected for correction by working group and further voting [2]. Based on the practical experience of the working group and literature data, 3 new statements were created also. Statements that do not reach the required level of agreement (80% or more) will be subjected to Round 2 of the Delphi method.

RESULTS: all experts took part in the anonymous voting. The panel of experts is represented by 8 different areas of practical medicine and the median of the professional experience of the respondents was 30 (12–49) years. Of the 8 statements submitted for voting, consensus (80% or more) was reached on 6 out of 8. 2 statements have been revised by working group for the distance 2nd round of the Delphi study. Consensus (more than 80%) was reached on both.

CONCLUSION: a cross-sectional study by the Delphi method provided the opinions of a panel of experts on controversial issues in the surgical treatment of Crohn’s disease. Statements that reach consensus will be included by the working group in a new edition of clinical guidelines of Crohn’s disease.

[Metal self-expanding stents for malignant obstruction of stomach outlet and duodenum]

AIM

To compare different types of self-expanding stents (partially coated or uncovered) for malignant pyloroduodenal obstruction (MPDO).

MATERIAL AND METHODS

89 MPDO patients underwent stenting at the Botkin City Hospital (Moscow) for the period 2008-2016. The causes of malignant obstruction were: stomach cancer - 53 (59.5%), pancreatic cancer - 31 (34.8%), compression by retroperitoneal lymph nodes - 3 (3.4%), duodenal cancer - 2 (2.2%). Patients were divided into two homogeneous groups. In group 1 (32 patients) partially coated stents were used, in group 2 (57 patients) - uncovered stents. Mean age was 68.3±6.2 and 64.3±5.7 years in both groups respectively; male/female ratio 18/14 in group 1, 32/25 in group 2. Length of stricture was 51±5.1 mm in group 1, 48±4.8 mm in group 2. GOOSS score in group 1: 0-8, 1-13, 2-11, 3-0, in group 2 0-14, 1-25, 2-18, 3-0 (p=0.03).

RESULTS AND DISCUSSION

Technical success was achieved in 32 patients of group 1 (100%) and in 57 patients of group 2 (100%). There were no procedure-associated complications and mortality. Clinical success was observed in 29 (90.6%) patients of group 1 and in 50 (87.7%) patients of group 2. GOOSS score of group 1: 0-8, 1-8, 2-10, 3-12, group 2: 0-3, 1-15, 2-19, 3-20. There were 3 distal dislocations of the stent within 1 - days in group 1, in group 2 dislocations were absent. Postoperative chemotherapy was prescribed in 20 (62.5%) patients of group 1 and 38 (66.7%) patients of group 2 (p=0.08). 27 patients of group 1 and 49 patients of group 2 died due to progression of the disease, others are under observation. Mean life expectancy: group 1 (18 patients - 50 days, 9 patients - 100 days, 5 patients were alive by the moment of study); group 2 (32 patients - 50 days, 100 days - 17 patients, 8 patients were alive by the moment of study). 3 patients (9.4%) in group 1 and 7 (12.3%) patients in group 2 had stent dysfunction (p=0.02). Mean period of partially covered stent function was 138±3.9 days, uncovered stent - 96±4.8 days (р=0.003).

CONCLUSION

Our study showed that time of stent function corresponds to median survival. Greater number of stent migration in group 1 is due to stent coverage, higher incidence of stent dysfunction in group 2 - due to malignant invasion.

[Prevention of venous thromboembolic complications in firearm injury]

Prevention of venous thromboembolic complications in wounded is a complex problem which has not yet been fully resolved throughout the world. Current state of venous thrombosis prevention in wounded in different countries and certain ways of its improvement are analyzed in the article.

[Surgical treatment of pancreaticoduodenal artery aneurysm combined with celiac trunk occlusion]

We report successful surgical treatment of inferior pancreaticoduodenal artery aneurysm combined with celiac trunk occlusion. Considering angioarchitectonics of the afferent and efferent arteries (significant tortuosity), possible liver ischemia during endovascular occlusion of pancreaticoduodenal artery and expected low efficiency of embolization, the patient underwent open surgery (celiac trunk replacement and resection of pancreaticoduodenal artery aneurysm). Postoperative period was uneventful. The first and subsequent postoperative controls showed an adequate function of the prosthesis and no contrast enhancement of the aneurysm. We concluded that rational surgical approach ensured optimal solution of the problem, i.e. surgical treatment of pancreaticoduodenal artery aneurysm was the most radical and functional.

Effect of ABCB1 Gene Carriage and Drug-Drug Interactions on Apixaban and Rivaroxaban Pharmacokinetics and Clinical Outcomes in Patients with Atrial Fibrillation and Deep Vein Thrombosis

Aim. To investigate the effect of ABCB1 gene carriage and interdrug interactions on apixaban pharmacokinetics and clinical outcomes in patients with atrial fibrillation and deep vein thrombosis.

Material and methods. Patients hospitalized at Yudin State Clinical Hospital participated in the study. A total of 92 patients (50 patients received apixaban and 42 – rivaroxaban) with non-valvular atrial fibrillation and deep vein thrombosis were included. Genotyping was performed by real-time polymerase chain reaction. Direct oral anticoagulants concentrations were measured using an electrospray ionization mass spectrometer in positive ionization mode.

Results. In our study we found that in patients carrying the CT+TT ABCB1 (rs4148738) C>T genotype encoding the carrier protein (P-gp), the plasma concentration of rivaroxaban was statistically significantly higher p= 0.026. In addition, we found that patients taking apixaban together with a CYP3A4/P-gp inhibitor were 3.5 times more likely to have hemorrhagic complications than those without inhibitors p = 0.004.

Conclusion. Our study revealed that the plasma concentration of rivaroxaban was higher in patients carrying the ABCB1 (rs4148738) C>T polymorphism T allele. And patients taking apixaban together with CYP3A4/P-gp inhibitor had higher risk of hemorrhagic complications in comparison with patients not taking such drugs. Further studies are needed on the influence of pharmacogenetics and pharmacokinetics on the safety and efficacy profile of apixaban and rivaroxaban, taking into account the trend of systemic approach to optimization of anticoagulant therapy of direct oral anticoagulants based on pharmacokinetic, pharmacogenetic biomarkers.

[Comparative assesement of postoperative quality of life in patients with ulcerative colitis]

OBJECTIVE

To compare quality of life in patients undergoing proctocolectomy with ileal pouch procedure and ileostomy taking into account sexual function.

MATERIAL AND METHODS

The comparative observational study included 138 patients with ulcerative colitis for the period 2013-2018. All patients underwent surgery with one- or two-stage formation of pelvic pouch (n=76) or ileostomy (n=62). Validated questionnaires SF-36, The International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI) were used in the study.

RESULTS

Patients with pelvic pouch were significantly younger than patients with terminal ileostomy (33.7±10.9 and 44.6±14.9 years, respectively, p<0.0001). The majority of the parameters of SF-36 questionnaire were similar in both groups. Pain syndrome intensity was the only sign demonstrating the advantage of ileostomy over pelvic pouch. However, regression analysis did not confirm the effect of surgical technique on pain severity. Orgasmic function was significantly better in men with pelvic pouch compared to ileostomy. Other indicators of sexual function were similar. According to FSFI questionnaire, women with pelvic pouch also showed significantly better results than patients with permanent ileostomy. However, multivariate regression analysis revealed no significant effect of surgical technique on sexual function in men and women. At the same time, significant negative correlation between IIEF and FSFI scores and age was revealed.

CONCLUSION

No significant influence of surgical technique on postoperative QOL was observed in patients with ulcerative colitis. Better sexual function in men and women with pelvic pouch are due to younger age rather type of surgery.

[Managerial and methodological aspects of emergency surgery for malignant colonic obstruction]

AIM

To determine the most feasible treatment strategy for malignant colonic obstruction.

MATERIAL AND METHODS

There were 427 patients with malignant colonic obstruction who were hospitalized for emergency indications. 30 of them were treated with medical therapy; 286 - underwent acute resection; 43 - stoma construction; 68 - stents deployment. 64 out of 427 patients underwent elective restorative/radical surgery and radio- or chemotherapy in 1-8 months. 3-year Kaplan-Meier survival was assessed.

RESULTS

Complications occurred in 58% after acute resection and in 32.6% and 8.8% after stoma and stent deployment, respectively. Postoperative mortality was significantly lower after palliative surgery (stent or stoma) compared with acute resection: 2.9%, 18.6%, 29.37%, respectively. 3-year survival was higher after elective resections compared with emergency resection group: 0,81 и 0,68 respectively.

CONCLUSION

Bridging strategy (stoma/stents) may be a valid alternative in some patients with malignant colonic obstruction due to significantly reduced postoperative mortality. Acute surgery for malignant colonic obstruction should only be carried out by appropriately trained surgeons at multi-field hospital.

[SURGICAL TREATMENT OF ULCERATIVE COLITIS. HISTORY]

The article describes the main achievements in the study of ulcerative colitis (UC) - a disease known since ancient times. «Bloody» non-epidemic diarrhea was described by Hippocrates. The first detailed description was made by K. Rokitansky in 1842. In 1875, S. Wilks and W. Mason first studied the pathomorphology of the colon in UC. The term «non-specific ulcerative colitis» was proposed by the Russian surgeon A. S. Kazachenko in 1913 at the 13th Congress of Russian surgeons. The historical excursion presents the main stages and achievements of surgical treatment of UC.

Anastomotic leak after manual circular stapled left-sided bowel surgery: analysis of technology-, disease-, and patient-related factors

BACKGROUND

Anastomotic leak rates after colorectal surgery remain high. In most left-sided colon and rectal resection surgeries, a circular stapler is utilized to create the primary bowel anastomosis. However, it remains unclear whether a relationship between circular stapler technology and anastomotic leak in left-sided colorectal surgery exists.

METHODS

A post-hoc analysis was conducted using a prospectively collected data set of patients from the 2017 European Society of Coloproctology snapshot audit who underwent elective left-sided resection (left hemicolectomy, sigmoid colectomy, or rectal resection) with a manual circular stapled anastomosis. Rates of anastomotic leak and unplanned intensive care unit stay in association with manual circular stapling were assessed. Patient-, disease-, geographical-, and surgeon-related factors as well as stapler brand were explored using multivariable regression models to identify predictors of adverse outcomes.

RESULTS

Across 3305 procedures, 8.0% of patients had an anastomotic leak and 2.1% had an unplanned intensive care unit stay. Independent predictors of anastomotic leak were male sex, minimal-access surgery converted to open surgery, and anastomosis height C11 (lower third rectum) (all P < 0.050). Independent predictors of unplanned intensive care unit stay were minimal-access surgery converted to open surgery and American Society of Anesthesiologists grade IV (all P < 0.050). Stapler device brand was not a predictor of anastomotic leak or unplanned intensive care unit stay in multivariable regression analysis. There were no differences in rates of anastomotic leak and unplanned intensive care unit stay according to stapler head diameter, geographical region, or surgeon experience.

CONCLUSION

In patients undergoing left-sided bowel anastomosis, choice of manual circular stapler, in terms of manufacturer or head diameter, is not associated with rates of anastomotic leak and unplanned intensive care unit stay.