Radical Surgical Treatment Research Articles

Progress of immune checkpoint inhibitors in the treatment of advanced hepatocellular carcinoma.

Among primary liver cancers, hepatocellular carcinoma is the most common pathological type. Its onset is insidious, and most patients have no obvious discomfort in the early stage, so it is found late, and the opportunity for surgical radical treatment is lost, resulting in a poor prognosis. With the introduction of molecular-targeted drugs represented by sorafenib, patients with middle- and late-stage liver cancer have regained the light of day. However, their therapeutic efficacy is relatively low due to the limited target of drug action, toxic side effects, and other reasons. At this time, the emergence of immunotherapy represented by immune checkpoint inhibitors (ICIs) well breaks this embarrassing situation, which mainly achieves the anti-tumor purpose by improving the tumor immune microenvironment. Currently, ICI monotherapy, as well as combination therapy, has been widely used in the clinic, further prolonging the survival of patients with advanced hepatocellular carcinoma. This article reviews the development of monotherapy and combination therapy for ICIs in advanced hepatocellular carcinoma and the latest research progress.

ENDOSCOPIC TREATMENT FOR EARLY COLORECTAL CANCER

Relevance: In recent years, significant breakthroughs have occurred in the endoscopic treatment of cancerous and precancerous lesions of the gastrointestinal tract. Endoscopic mucosal resection (EMR) is a simple and effective method of treating most benign gastrointestinal tract lesions. However, with the introduction of endoscopic submucosal dissection (ESD) and full-thickness endoscopic resection (EFTR), the volume of lesions subject to endoscopic treatment has significantly expanded even in the colon. Currently, these methods are regularly used not only for the treatment of benign tumors but also for complex resection of early stages of colorectal cancer. For the first time in Kazakhstan, the presented article analyzed the cases of endoscopic removal of epithelial formations of the large intestine performed at an oncological clinic from 2020 to 2023.
 The aim was to evaluate the use of endoscopic treatment of early colorectal cancer.
 Methods: The article presents a retrospective analysis of 68 cases of endoscopic removal of epithelial formations of the colon performed from 2020 to 2023 at the Center of Expert Endoscopy and Interventional Radiology of the National Scientific Cancer Center (Astana, Kazakhstan).
 Results: In 2020-2023, 68 endoscopic extractions of colon tumors were performed, including 25 outpatient and 43 inpatient manipulations. Out of 43 inpatient cases, endoscopic dissection in the submucosal layer was performed in 9 cases, and endoscopic mucosal resection of tumors of the large intestine was performed in 34 cases. Morphologically, we found hyperplastic polyps in 11 cases, lipomas in 2 cases, tubulovillous adenomas with mild dysplasia – 43 cases, tubulovillous adenomas with severe dysplasia – 11 cases, carcinoma in situ – 3 cases, and adenocarcinoma with invasion – 3 cases.
 Conclusion: When detecting benign neoplasms with dysplasia and early colorectal cancer, minimally invasive technologies (EMR, ESD, EFTR) should be the first preferred treatment method and only if they cannot be performed and there is a high risk of invasion into the underlying layers, and therefore, if endoscopic treatment is not radical, clinicians should choose surgical radical treatment. Patients should be informed about the availability of the latest methods of local treatment in the Republic through the financing of the Compulsory Medical Insurance Fund (CMIF).

The role of non-invasive preoperative imaging techniques in predicting the risk of pancreatic fistula development in pancreaticoduodenal tumours

Background. In pancreaticoduodenal tumours, pancreaticoduodenectomy (PDE) is a radical surgical intervention. The most important stage of the operation is the pancreaticojejunoanastomosis (PEA), the admissibility of which depends on many factors: the degree of fibrous changes in the pancreatic parenchyma, the degree of mechanical jaundice, and the operating surgeon’s technique. Identification of factors that reflect changes in the structure of the pancreatic parenchyma and its ductal system, which are important predictors in predicting the risk of developing pancreatic fistula (PF) after PDE, is of great scientific importance. Purpose. Evaluation of changes in the structure of the pancreatic parenchyma and its ductal system using non-invasive preoperative imaging methods in predicting the risk of pancreatic fistula development during pancreaticoduodenectomy. Materials and Methods. This study included 302 patients who underwent pancreaticoduodenectomy. Mechanical jaundice was detected in 246 (81.5%) patients, 56 (18.5%) patients had no jaundice, the age of patients ranged from 31 to 77 years, 178 (58.9%) were men and 124 (41.1%) were women. Ultrasound elastography and multidetector computed tomography were used for preoperative non-invasive visualisation of the degree of changes in the pancreatic parenchyma and its ductal system. The following parameters of visualisation of the pancreatic parenchyma with an assessment of the anatomical features of the isthmus and the duct of Wirsung were identified: diameter and cross-sectional area of the duct of Wirsung (at the level of the isthmus), width and thickness of the pancreas (at the level of the isthmus), cross-sectional area of the pancreatic isthmus (without the area of the duct of Wirsung), native density, and stiffness of the pancreatic parenchyma. Results and discussion. The ROC analysis of the parameters for assessing the state of the parenchyma of the pancreas and the duct of Wirsung obtained from computed tomography made it possible to determine the validity of these indicators in predicting the risk of developing PF. According to the results of the ROC analysis, the following indicators were identified as markers of moderate risk of developing PF: the diameter of the duct of Wirsung is less than 4 mm, the cross-sectional area of the duct of Wirsung is less than 0.23 cm2 , the thickness of the isthmus of the pancreas is greater than 15 mm, the width of the isthmus of the pancreas is greater than 19 mm, the cross-sectional area of the isthmus of the pancreas (without the area of the duct of Wirsung) is greater than 3 cm2 , and the native density is greater than 24 HU. To assess the high risk of developing PF, the use of ROC analysis allowed us to establish the high quality of diagnostic models for such computed tomography parameters as the diameter of the duct of Wirsung – the area under the ROC curve is 0.965, the cross-sectional area of the duct of Wirsung – AUC is 0.894, the cross-sectional area of the isthmus of the pancreas (without the area of the duct of Wirsung) – AUC is 0.873, the width of the isthmus of the pancreas – the area under the ROC curve is 0.859, the native density – AUC is 0.844. Determination of the parameter of stiffness of the pancreatic parenchyma by shear wave elastography in predicting high and moderate risk of developing PF also corresponded to the high quality of the diagnostic model. Conclusions. The use of non-invasive imaging methods allows changes in the structure of the pancreatic parenchyma, anatomical features of the pancreatic isthmus and the duct of Wirsung to be detected at the preoperative stage, the risk of developing a pancreatic fistula to be predicted and the number of complications during pancreaticoduodenectomy to be reduced.

Postoperative complications for complicated malignant tumours of the stomach

Objective — to determine the frequency and structure of postoperative complications for malignant tumours of the stomach accompanied by gastrointestinal bleeding. Materials and methods. The study analysed the treatment outcomes of 101 patients with a malignant tumour of the stomach complicated by bleeding (84 cases), perforation (6 cases), or stenosis (19 cases, with 8 of them having both stenosis and bleeding). These patients underwent inpatient treatment at the Kyiv City Centre for Gastrointestinal Bleeding and the Kyiv City Clinical Hospital of Emergency Medical Help between 2015 and 2020. Out of the patients, 78 (77.2%) had histologically confirmed cancer, 11 (10.9%) had GIST, and 12 (11.9%) had malignant lymphoma. Results. During the peak period of ongoing and recurrent bleeding, 5 (6%) patients required emergency surgery, including 2 (40%) radical and 3 (60%) non‑radical procedures. After proper preoperative preparation and a comprehensive follow‑up assessment, 58 (57.4%) patients underwent radical surgical interventions for stomach cancer complicated by acute gastrointestinal bleeding in the early delayed period. In the early postoperative period, 4 (15.4%) patients experienced complications after 26 radical gastrectomies combined with jejunogastroplasty. In the delayed period, early postoperative complications occurred in 9 (28.1%) patients after 32 radical gastric resections. The total postoperative mortality after emergency surgical interventions was 20.0%. The total postoperative mortality in the early‑term period was 5.7% (5 patients out of 88), which is 3.5% less compared to emergency operations (the difference is statistically significant, p ≤0.05). Conclusions. When urgent surgical interventions are carried out at the peak of ongoing and recurrent bleeding, the mortality rate from postoperative complications is 3.5 times higher than when operations are performed in the early delayed period after adequate preparation and comprehensive patient monitoring. The death rate after radical operations is 2.1 times lower than that after palliative and symptomatic operations. As the operations conducted during the peak bleeding period are associated with high postoperative mortality, we believe that they pose a high risk to patients with malignant tumours of the stomach.

ENDOSCOPIC TREATMENT FOR EARLY COLORECTAL CANCER

Relevance: In recent years, significant breakthroughs have occurred in the endoscopic treatment of cancerous and precancerous lesions
 of the gastrointestinal tract. Endoscopic mucosal resection (EMR) is a simple and effective method of treating most benign gastrointestinal
 tract lesions. However, with the introduction of endoscopic submucosal dissection (ESD) and full-thickness endoscopic resection (EFTR), the
 ЛЕЧЕНИЕ
 38 Онкология и Радиология Казахстана, №4 (70) 2023
 volume of lesions subject to endoscopic treatment has significantly expanded even in the colon. Currently, these methods are regularly used
 not only for the treatment of benign tumors but also for complex resection of early stages of colorectal cancer. For the first time in Kazakhstan,
 the presented article analyzed the cases of endoscopic removal of epithelial formations of the large intestine performed at an oncological clinic
 from 2020 to 2023.
 The aim was to evaluate the use of endoscopic treatment of early colorectal cancer.
 Methods: The article presents a retrospective analysis of 68 cases of endoscopic removal of epithelial formations of the colon performed from
 2020 to 2023 at the Center of Expert Endoscopy and Interventional Radiology of the National Scientific Cancer Center (Astana, Kazakhstan).
 Results: In 2020-2023, 68 endoscopic extractions of colon tumors were performed, including 25 outpatient and 43 inpatient manipulations.
 Out of 43 inpatient cases, endoscopic dissection in the submucosal layer was performed in 9 cases, and endoscopic mucosal resection of tumors
 of the large intestine was performed in 34 cases. Morphologically, we found hyperplastic polyps in 11 cases, lipomas in 2 cases, tubulovillous
 adenomas with mild dysplasia – 43 cases, tubulovillous adenomas with severe dysplasia – 11 cases, carcinoma in situ – 3 cases, and adenocarcinoma with invasion – 3 cases.
 Conclusion: When detecting benign neoplasms with dysplasia and early colorectal cancer, minimally invasive technologies (EMR, ESD,
 EFTR) should be the first preferred treatment method and only if they cannot be performed and there is a high risk of invasion into the underlying layers, and therefore, if endoscopic treatment is not radical, clinicians should choose surgical radical treatment. Patients should
 be informed about the availability of the latest methods of local treatment in the Republic through the financing of the Compulsory Medical
 Insurance Fund (CMIF)

The unsolved problem of musculoskeletal hydatid disease: two case reports

BackgroundHydatidosis is a parasitic infection caused by Echinococcus granulosus and humans are usually an accidental intermediate host. Involvement of the musculoskeletal system is reported to occur in 0.5% to 4% of the cases.Case presentationWe present our experience with two cases of musculoskeletal hydatidosis in black African patients that required orthopaedic surgical intervention. A 51-year-old black African female presented with right hip hydatid disease and a 37-year-old black African female presented with the disease affecting the left shoulder. Both patients presented with joint pain and reduced range of motion. The patient with involvement of the shoulder had a background history of human immunodeficiency virus, this was not present with the other patient. Diagnostic work-up confirmed peri-articular hydatid disease and both patients were surgically managed with arthroplasty. Post-operative complications encountered include hardware loosening from bone lysis and hardware failure.DiscussionThe medical literature describes a limited number of cases of peri-articular musculoskeletal hydatid disease. Patients are often subjected to many investigations, prolonged treatment periods and multiple surgeries. Concurrent use of medical and surgical treatment is advocated however, the choice of surgery is individualised.ConclusionHydatid disease must always feature in the differential diagnosis of multiple lytic bone lesions and radical surgical intervention may be required from the outset.

A differentiated approach to the selection of pancreaticojejunostomy during pancreatoduodenectomy

Background. Pancreatoduodenectomy is a radical surgical intervention in case of neoplasms of the pancreatoduodenal zone, which is accompanied by frequent postoperative complications. The critical point of the reconstructive stage of pancreatoduodenectomy is pancreaticojejunostomy (PES), which dictates the importance of improving the techniques of its repair and drainage, as well as the development of a differentiated approach to the choice of PES. The aim of the study: to evaluate the effectiveness of a differentiated approach to the choice of PES technique when performing pancreatoduodenectomy. Materials and methods. The study included 302 patients who underwent pancreatoduodenectomy for pancreatic neoplasms. The age of patients varied from 31 to 77 years, there were 178 (58.9 %) men, and 124 (41.1 %) women. In the comparison group (154 patients), a standard diagnostic and treatment algorithm was used with the choice of PES technique taking into account the intraoperative evaluation of the degree of the pancreatic parenchyma density and the assessment of the ductal system (surgeon’s experience and intuition). In the main group (148 patients), an improved diagnostic and treatment algorithm was used, which included non-invasive preoperative methods of visualization of changes in the pancreatic parenchyma, anatomical features of its isthmus and ductal system, as well as the use of developed methods for repair and drainage of the PES. Results. In the main group, the applied differentiated approach to the selection of PES consisted in the fact that at the preoperative stage, the degree of risk of developing pancreatic fistula (PF) was predicted: in 66 (44.6 %) patients, a low risk was detected, in 42 (28.4 %) — a moderate risk, 40 (27.0 %) people had a high risk. Identification of patients with a high risk of developing PF made it possible to carry out the necessary medical measures not only in the operating room, but also in the pre-operative stage, which affected a decrease in the frequency of severe forms of PF. Specifically, in the compari­son group, type B was noted 2.5 times (χ2 = 3.94; p = 0.047) and type C — 6.4 times (p = 0.034 according to Fisher’s exact test) more often than in the main group. This became the basis for the development of PES techniques with plastic covering of the anastomotic zone and improvement of PES drainage techniques with simultaneous drainage of the biliodigestive anastomosis. The developed differentiated approach to the choice of PES method based on the preoperative assessment of the risk of PF made it possible to reduce the frequency of its development, especially severe forms (types B and C) from 16.2 % of cases in the comparison group to 5.4 % in main group (χ2 = 8.01; p = 0.005). Mortality due to pancreatic fistula in the main group was 0.7 %, in the comparison group — 4.8 % (p = 0.034, Fisher’s exact test). Conclusions. Carrying out a preoperative non-invasive assessment of the degree of changes in the pancreatic parenchyma and the state of the duct of Wirsung by means of fibroelastography and computer tomography made it possible to develop a differentiated approach to the choice of PES technique, taking into account the prediction of the risk of PF in the postoperative period (sensitivity — 90.5 %, specificity — 81, 8 %, diagnostic accuracy — 86.1 %). The use of the developed methods with a falciform ligament wrap and cholangiodrainage to drain PES in soft pancreas made it possible to reduce in half the frequency of PF development (p < 0.05), which led to a decrease in mortality by almost 7 times (p < 0.05).

Functional or radical surgical treatment of laryngeal chondrosarcoma, analysis of survival and prognostic factors: A REFCOR and NetSarc-ResOs multicenter study of 74 cases

IntroductionLaryngeal chondrosarcoma (LCS) is a rare tumor of slow evolution whose treatment is poorly codified. For a long time, a radical treatment by total laryngectomy (TL) was proposed. More recent studies tend to propose a conservative surgical approach of the larynx. The objective of this study was to compare the overall survival (OS) of total laryngectomized patients (TL+) versus non-laryngectomized patients (TL-). The secondary objectives were to analyse the reoperation free survival (RFS), the total laryngectomy free survival (TLFS) and to identify the preoperative factors leading surgeons to propose TL. Materials and methodsA retrospective analysis of prospectively collected incident cases from the REFCOR and NetSarc-ResOs multicenter databases between March 1997 and June 2021 was conducted. A propensity score matching analysis was performed to compare the OS of TL+ and TL-patients. Results74 patients were included. After propensity score, the 5-year OS of TL+ and TL-patients was comparable (100 %, p = 1). The 5-year RFS rate was 69.2 % (95 % CI [57.5–83.4]) and the 5-year TLFS was 61.7 % (95 % CI [50.4–75.5]). Cricoid involvement greater than 50 % (HR 3.58; IC 95 % [1.61–7.92] p < 0.001), an ASA score of 3 or 4 (HR 5.07; IC 95 % [1.64–15.67] p = 0.009) and involvement of several cartilages (HR 5.26; IC 95 % [1.17–23.6] p = 0.04) are prognostic factors for TL. Dyspnea caused by the tumour is a prognostic factor for reoperation (HR 2.59; IC 95 % [1.04–6.45] p = 0.03). ConclusionThese results demonstrate that conservative treatment should be considered as first-line treatment for laryngeal chondrosarcoma.

PERSONALIZED APPROACH TO THE CHOICE OF BILIARY DRAINAGE TACTICS IN PATIENTS WITH TUMOR-INDUCED MECHANICAL JAUNDICE

Mechanical jaundice resulting from the tumor-induced obstruction of bile ducts is usually the first and quite severe complication of malignant neoplasms of the organs of the hepatopancreatoduodenal zone. Radical treatment for this condition, as reported by various sources, remains below 20-25%. Therefore, the imperative is to select the most effective minimally invasive biliary drainage method to alleviate biliary tract pressure and address the issue of mechanical jaundice. This approach serves both as a preparatory step for potential radical surgical intervention and as a definitive method for palliative treatment in this patient category.&#x0D; The aim of this work is to develop an optimal algorithm for diagnosis and treatment of patients with tumor-induced mechanical jaundice, which will increase the effectiveness of primary surgical intervention and reduce the number of complications and mortality for this category of patients.&#x0D; The investigation focused on examining the results of diagnostic and surgical interventions in 108 patients with tumor-induced mechanical jaundice. These patients underwent biliary drainage operations in surgical hospitals between 2017 and 2023. Analysis of the surgical outcomes revealed that endoscopic drainage and percutaneous transhepatic drainage exhibited similar effectiveness in I and II levels of biliary obstruction. However, endoscopic drainage demonstrated lower complication rates and improved quality of life for patients, establishing it as the preferred method. For level III blockages, percutaneous transhepatic drainage is recommended.&#x0D; The implementation of a diagnostic and treatment algorithm, which considers the level of biliary block, the severity of mechanical jaundice, and the tumor process stage, enables the selection of the most effective minimally invasive biliary drainage method. This approach contributes to a reduction in postoperative mortality.

The Role of Imaging of Lymphatic System to Prevent Cancer Related Lymphedema.

Lymphedema is a progressive chronic condition affecting approximately 250 million people worldwide, a number that is currently underestimated. In Western countries, the most common form of lymphedema of the extremities is cancer-related and less radical surgical intervention is the main option to prevent it. Standardized protocols in the areas of diagnosis, staging and treatment are strongly required to address this issue. The aim of this study is to review the main diagnostic methods, comparing new emerging procedures to lymphoscintigraphy, considered as the golden standard to date. The roles of Magnetic Resonance Lymphangiography (MRL) or indocyanine green ICG lymphography are particularly reviewed in order to evaluate diagnostic accuracy, potential associations with lymphoscintigraphy, and future directions guided by AI protocols. The use of imaging to treat lymphedema has benefited from new techniques in the area of lymphatic vessels anatomy; these perspectives have become of value in many clinical scenarios to prevent cancer-related lymphedema.

Solitary metastasis of colorectal cancer in the left adrenal gland 4 years after surgery on the primary tumor. Case report

Colorectal cancer (CRC) is one of the most common oncological diseases. On average, in 20–25% of cases after radical surgical treatment of CRC, the progression of the disease in the form of metachronous metastases in the liver and lungs, as the most common localization of CRC metastases, is noted in patients. With the advent of new drug treatment strategies for CRC, there is an increase in overall survival, as a result of which CRC metastases in the adrenal glands have become more common than previously thought, and the number of published reports of cases of CRC metastasis in the adrenal glands has increased. In this article, we report a rare clinical observation of metachronous solitary metastasis of CRC to the left adrenal gland 4 years after radical surgical treatment of the primary tumor: the patient underwent radical left-sided adrenalectomy. The period of observation of the patient without signs of progression and relapse of the disease is 6 months (at the time of publication).

Endoscopic stenting of a tumor of the rectosigmoid junction

Annotation. Obturational obstruction of the large intestine of tumor genesis belongs to acute surgical pathology and the issue of operative tactics in this case is extremely important in emergency surgery. The current trend in the treatment of complicated colorectal cancer is to carry out radical surgical interventions with the formation of primary anastomoses and compliance with basic oncological principles. However, carrying out such interventions under adverse conditions, including neglected oncological processes, the presence of severe concomitant pathologies, late hospitalization, instability and uncompensated indicators of the patient's homeostasis, leads to a high risk of developing various postoperative complications and postoperative mortality. Therefore, the use of endoscopic methods of restoring the patency of the large intestine with the help of stents is becoming widely used. Endoscopic colonic stenting is one of the modern, promising methods of treatment for patients with intestinal obstruction. It is characterized by minimal invasiveness, and a significantly lower frequency of post-surgery complications and mortality. According to the recommendations of the European Society of Gastrointestinal Endoscopy, colonic stenting is used for patients with clinical symptoms and radiological signs of tumor obstruction of the colon without signs of perforation; installation of a stent for compensation of homeostasis systems, for comprehensive preoperative preparation (if necessary, with the use of chemotherapy or X-ray therapy). The article presents the results of our own clinical observation of an endoscopic colonic stenting case as a method of symptomatic treatment of colonic obstruction in a patient with colorectal cancer and severe concomitant diseases. We analyzed the peculiarities of using colonic stents and determined the importance of mastering this method for proctologists and oncoproctologists.

Hyponatremia as a Marker for Predicting Surgical Intervention in Necrotizing Enterocolitis: A Retrospective Cohort Study

IntroductionTo investigate the predictive value of plasma sodium at the onset of necrotizing enterocolitis (NEC) diagnosis in distinguishing surgical NEC from medical NEC. MethodsA retrospective review of all NEC neonates treated at our hospital between 2008 and 2022. Patients were divided into two groups based on treatment methods: surgical intervention and medical treatment. Patient demographics, laboratory parameters, and outcomes were all documented. The values of laboratory parameters were collected at the onset of NEC and after treatment. To identify potential predictors of surgical NEC, multivariate logistic regression analyses were used. The receiver operating characteristic curve was applied to determine predictive factors. ResultsSurgical treatment was performed in 111 infants (44.6%), and medical treatment in 138 cases (55.4%). Of 249 infants with NEC, 22 patients exhibited Bell stage I, 91 infants had Bell stage II, and 136 patients displayed Bell stage III. We discovered that white blood cell (WBC), C-reactive protein (CRP), fibrinogen, and sodium were independent predictors of NEC receiving surgery based on the results of the multivariate logistic regression analysis. Hyponatremia was found in 122 of the 249 patients (49%). At the onset of NEC diagnosis, hyponatremia was found in 83.8% of surgical intervention group and in 21.0% of medical treatment group (P < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value for WBC, CRP, fibrinogen, and sodium were calculated. The cutoff values were determined using receiver operating characteristic analysis. The area under the curve of hyponatremia for surgical intervention was 0.875, with 84% sensitivity, 80% specificity, 77% positive predictive value, and 86% negative predictive value, which had a greater specificity (0.80) for predicting surgical intervention than WBC (0.67), CRP (0.50), and fibrinogen (0.70). ConclusionsWhen a surgical evaluation is necessary, hyponatremia can effectively distinguish surgical NEC from medical NEC. It could be used as a predictive marker to guide parental counseling for surgical intervention and rapid transfer of patients to tertiary centers when they have a surgical condition.

Radical Surgical Treatment of Idiopathic Tracheal Stenosis. A Clinical Observation

Introduction. Idiopathic cicatricial tracheal stenosis (ICTS) comprises a rare and dangerous disease of unknown etiology. Its morphological substrate consists in the formation of circular fibrotic stenosis, usually at the level of the cricoid cartilage and the first two С-shaped rings of the trachea. The first cases of the disease were described by Brandenburg only in 1972. Progression of the disease is slow, right up to severe respiratory failure and asphyxia. Treatment methods for idiopathic cicatricial tracheal stenosis include both endoscopic and open surgical techniques. However, endoscopic treatment fails to produce the desired effect. Materials and methods. The authors of the present paper performed tracheo-laryngeal resection as a radical method for treating idiopathic tracheal stenosis in a 54-year-old patient against the background of prolonged unsuccessful endoscopic treatment. The follow-up period accounted for 45 days. Examinations in the postoperative period showed complete epithelialization of the anastomosis line without inflammation. Results and discussion. Idiopathic cicatricial tracheal stenosis is considered to be a dangerous disease without significant causes of development. However, it is claimed to be a potentially curable disease, though its treatment is a difficult task. Some authors report satisfactory results of endoscopic treatment of ICTS, but most publications on this issue consider a single tracheo-laryngeal resection with anastomosis as the most optimal method of treatment, thereby correlating with the results of the present study. Conclusion. The present observation characterizes the peculiarity and possibility of radical treatment of ICTS, since the endoscopic method of treatment produces only a temporary effect. Small number of observations and lack of a coherent pathogenetic theory necessitate further research into this problem.

The impact of selection bias in the treatment for ruptured anterior communicating artery aneurysms: different results or different patients?

BackgroundAnterior communicating artery is one of the most frequent locations for the development of intracranial aneurysm. The availability and advances of different treatments modalities allows for case-specific selection, but potentially impacts our ability to assess equipoise among them. ObjectiveInvestigate and compare clinical and morphological variables among surgical and endovascular treatment groups with ruptured anterior communicating artery aneurysms. MethodsData from patients from a single university hospital treated for ruptured anterior communicating aneurysms after multidisciplinary discussion in a period from January 2009 to January 2020 were retrospectively reviewed. Demographics, clinical status, aneurysm morphologic features and in-hospital complications were registered for each treatment (endovascular coiling vs. microsurgical clipping). Clinical assessment was made from outpatient evaluation at 1-year follow-up. ResultsA total of 119 patients was obtained adding surgical (n = 80) and endovascular (n = 39) treatment groups. No significant changes between groups were detected regarding gender, age of treatment or other risk factors. Global complication rate (p = 0.335, p = 0.225, p = 0.428) and clinical outcome (p = 0.802) was similar among both groups. Univariate and multivariate analysis revealed statistically significant differences between endovascular and surgical treatment groups regarding dome orientation (p = 0.011), aneurysm height (p < 0.001) and maximum diameter (p < 0.001), aspect-ratio (p < 0.001), dome-to-neck ratio (p < 0.001) and dome diameter (p = 0.014). ConclusionsDespite similar clinical outcomes and rate of complications, morphological differences highlight the presence of a selection bias and high heterogeneity, which hampers inferential analysis when comparing both techniques.

Clinical analysis of 102 cases of pediatric vocal fold nodules

Objective:To evaluate the impact of vocal fold nodules on the quality of life of children, and to compare the efficacy between conservative management（voice hygiene education, etc.） and laryngeal microsurgery. Methods:A retrospective study was performed on 102 children with vocal fold nodules, who received treatment in Children's Hospital of Fudan University during the period from January 2020 to December 2022. According to the regime, the patients were divided into conservative management group and surgical treatment group; Cases are divided into pre-school age group （2-5 years old） and school-age group （6-12 years old） based on age. The pediatric voice-related quality of life （pVRQOL） was used to evaluate the impact of vocal fold nodules on the quality of life of children and differences in efficacy between two treatment regimens. Results:The pVRQOL scores of vocal fold nodule grades 1, 2, and 3 were 91.58±8.17, 78.87±12.49, 72.50±12.08, respectively. There were statistical differences between grade 1 and grade 2, and between grade 2 and grade 3. There were statistical differences between grade 1 grade 2, grade 2 and grade 3 （P<0.001）, suggesting that the higher the rating of vocal cord nodules, the lower the pVRQOL score of patients was. The pVRQOL score of the school-age group was 69.83±11.11, which is lower than that of the preschool group（87.59±8.63）, and the difference was statistically significant （P=0.042）. Vocal fold nodules had a significant impact on the pVRQOL score of school-age children. In the conservative management group, the pVRQOL scores before and after treatment were 83.99±12.66 and 87.26±9.58, respectively, and there was significant difference between the two groups（P=0.046）. Indirect voice therapy such as voice hygiene education could improve children's pVRQOL scores and was more effective for school-age children（P<0.001）. The microsurgical treatment had a more significant improvement in the pVRQOL score of children. Conclusion:The higher the rating of vocal fold nodules, the greater the impact on the quality of life of patients. Vocal fold nodules had a greater impact on the quality of life of school-age children than that of preschool children. Voice hygiene education could improve the quality of life of children, which was more evident in the school-age group. Compared with voice hygiene therapy, laryngeal microsurgery had a more significant effect on improving the pVRQOL score of patients. It is recommended to undergo laryngeal microsurgery for the treatment of vocal fold nodules for the requirement of improving the quality of life related to voice. During the 6-month follow-up period after surgery in this study, the short-term efficacy of laryngeal microsurgery in treating vocal cord nodules in children is clear, but the long-term efficacy needs further research.

Comparative study of conservative treatment and lymphaticovenular anastomosis with compression therapy for early-stage breast cancer-related lymphoedema

This single-centre retrospective cohort study aimed to clarify the superiority of treatment by comparing the outcomes of lymphaticovenular anastomosis with compression therapy and conservative treatment centred on compression therapy in the early stage of breast cancer-related lymphoedema. Data were collected from all patients treated for breast cancer-related lymphoedema between January 2015 and December 2022. The patients were classified into conservative treatment and surgical treatment groups. The upper extremity lymphoedema index value was calculated, based on five circumference values of the upper extremity and body mass index, to compare the 6-, 12-, 18- and 24-month outcomes between the groups. Of 101 patients with breast cancer-related lymphoedema, 81 (conservative treatment: 52; surgical treatment: 29) were included in the analysis. The therapeutic effect was significantly higher in the surgical treatment group than in the conservative treatment group, when comparing the rate of change in oedema at 6 (-6.6%±7.3% vs. 0.9%±7.5%; p<0.001), 12 (-7.3%±6.2% vs. 2.9%±8.6%; p<0.001), 18 (-7.6%±8.0% vs. 3.9%± 9.2%; p<0.001) and 24 (-5.6%±6.0% vs. 4.4%±10.7%; p<0.001) months. The incidence of cellulitis increased in the conservative treatment group (from 9.6% to 15.4%), whereas it was suppressed in the surgical treatment group (from 13.8% to 0%). Conservative treatment centred on compression therapy increased oedema over time; however, lymphaticovenular anastomosis with compression therapy effectively reduced oedema.

A case report of surgical complications in a patient with ulcerative colitis

Rapidly rising prevalence of ulcerative colitis in developed countries among young population compels the medical community to pay attention not only to the problems of early diagnosis and therapy of this disease, but also to preventing the development of complications, that may lead to disability. This article reviews a clinical case of the development of surgical complications in a patient with a long-term active course of ulcerative colitis, who has been also suffering from autoimmune hepatitis and primary sclerosing cholangitis for 20 years. The prolonged active course of the disease and total damage to the colon, association with primary sclerosing cholangitis, as well as the patient’s low adherence to therapy were risk factors for the development of adenocarcinoma of the ascending colon, which required radical surgical treatment. The formation of adhesive disease and multiple abdominal abscesses can be noted as long-term complications, which led to the repeated use of invasive methods of treatment. Over the next few months, the patient experienced 2 more episodes of local purulent complications that required surgical treatment due to the ineffectiveness of antibiotic therapy. All episodes of purulent complications were accompanied by progressive leukopenia due to prolonged use of immunosuppressive drugs. In our opinion, in patients with ulcerative colitis who take cytostatic agents for a long time, special attention should be paid to monitoring and correcting leukopenia, as well as preventing the development of purulent complications.

Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia.

To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI). This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs). In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27). Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy. Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.

Impact of cervical intraepithelial neoplasia and treatment on IVF/ICSI outcomes.

Does treatment selection for cervical lesions affect the outcome of IVF/ICSI? There was no difference in pregnancy outcome between treated and untreated groups, or between different types of IVF/ICSI treatment. Human papillomavirus (HPV) infection and HPV-induced cervical lesions are associated with decreased fertility, and cervical intraepithelial neoplasia (CIN) treatment may increase the risk of adverse pregnancy outcomes. Between 2018 and 2020, 190 women with infertility who had abnormal HPV screening or cytology results prior to IVF/ICSI, and were diagnosed with CIN2/CIN3 by colposcopy biopsy at a tertiary hospital, were enrolled in a retrospective cohort study with follow-up until 31 December 2021. Patients with infertility who were diagnosed with CIN2/CIN3 by colposcopy biopsy were divided into the treatment and expectant management groups. The treatment group was divided into two intervention subgroups: the ablative therapy group and the surgical treatment group. The baseline data, number of oocytes retrieved, and rates of fertilization, high-quality embryos, positive serum HCG, clinical pregnancy, abortion, live birth, and cumulative pregnancy were compared among groups. Among the 190 patients included in the study, 152 were diagnosed with CIN2, and 38 patients had CIN3. There was no significant difference in the baseline data between the treatment and expectant groups. The time from confirmed lesions to the onset of gonadotrophin administration in the surgical treatment group was significantly longer than in the ablative therapy group and the expectant group (P = 0.007 and P = 0.024, respectively). For the treatment and expectant groups, respectively, the average number of oocytes retrieved (12.95 ± 8.77; 13.32 ± 9.16), fertilization rate (71.01 ± 23.86; 64.84 ± 26.24), and high-quality embryo rate (48.93 ± 30.72; 55.17 ± 34.13) did not differ, and no differences were detected between the different treatment subgroups. There were no differences among groups in rates of HCG positivity, clinical pregnancy, miscarriage, live birth, or cumulative pregnancy. The live birth rate in the surgical treatment group was slightly higher than that in the expectant groups (77.78% versus 66.67%), but the difference was not statistically significant. The 3-year cumulative pregnancy rates in the surgical treatment and expectant groups were 58.19% and 64.00%, respectively. This is a retrospective study, which by nature can include selection bias, and the number of cases in the expectant group was <30, which may result in a false-negative result owing to the small sample size. For patients with CIN2/CIN3, the treatment of cervical lesions does not affect the outcome of IVF/ICSI. Patients with CIN2 can enroll for IVF/ICSI cycles, with close follow-up to prevent the progression of cervical lesions, in order to avoid further delay in starting ART. For patients with CIN3, ovulation induction and embryo cryopreservation can be initiated as soon as possible after cervical lesions are treated, and frozen-thawed embryo transfer can be carried out 9-12 months later. This work was funded by the Key Clinical Projects of the Peking University Third Hospital (to Y.W., BYSYZD2021014). The authors declare no conflicts of interest. N/A.