[Pyloric gland adenoma - a rare tumor of the upper gastrointestinal tract with a high risk of malignancy]

BACKGROUND

Pyloric gland adenomas (PGA) are rare neoplasms of the gastrointestinal tract. According to the literature, these lesions may be underdiagnosed, and their true frequency of occurrence is underestimated.

OBJECTIVE

Clinical and morphological analysis of eight PGA cases of the upper gastrointestinal tract.

MATERIAL AND METHODS

The study included 8 cases of detection of PGA. In 7 out of 8 cases, the tumor was diagnosed by examining endoscopic biopsies, in 1 case, PGA was an accidental finding in the surgical material after proximal gastric resection.

RESULTS

6 out of 8 patients were female, the median age was 65 years (minimum 36 years and maximum 78 years). In 6 cases, PDA was localized in the stomach, in 1 - in the esophagus and in 1 - in the duodenum The size of the tumors ranged from 0.6 cm to 7.5 cm. 4 out of 6 stomach tumors appeared on the background of confirmed autoimmune gastritis, 1 - on the background of lymphocytic gastritis. 4 tumors were found in the body of the stomach, 1 - in the cardia, 1 - in the bottom of the stomach. In 2 out of 8 cases, there were signs of malignancy of the tumor with the transition to a highly differentiated adenocarcinoma. According to the results of the IHC study, the absence of a p53 mutation was noted in these cases.

CONCLUSION

PGA should be considered as neoplasms with a high risk of transformation into invasive adenocarcinoma. Increasing the recognition of PGA among pathologists and further understanding of the molecular mechanisms involved in their neoplastic transformation will improve the diagnosis and treatment of this pathology.

[Mature teratoma of the pharynx and nasal cavity in a newborn: a case report]

We present to your attention a case of mature teratoma of the pharynx and nasal cavity in a newborn, which caused severe obstruction of the upper respiratory tract and required emergency action. The article describes the diagnostic algorithm, the choice of optimal treatment tactics, which allowed rehabilitate the child in infancy.

[Laryngeal cysts in children]

Laryngeal cysts in children are relatively rare, occupying the 4-5th place in the structure of congenital malformations. The paper presents the combined experience of two Russian pediatric otorhinolaryngological clinics traditionally involved in the rehabilitation of patients with congenital and acquired pathology of the larynx.

OBJECTIVE

To analyze the features of the clinic, diagnosis and treatment of laryngeal cysts in children.

MATERIAL AND METHODS

The study included 68 children with laryngeal cysts aged from 3 days to 16 years (on average 39.5±37.0 months, Me=15.5 months). The cyst was localized in the vestibular region of the larynx in 15 (22.1%) patients, in the vocal region - in 15 (22.1%) patients, and in the sub-vocal region - in 38 (55.9%) patients. Data on the presence of a history of tracheal intubation were available in 35 (89.7%) children, including 35 (92.1%) of 38 children with a subfold cyst. 11 patients were admitted with a previously applied tracheostomy.

RESULTS

The main reasons for going to the clinic were signs of laryngeal stenosis (stridor, signs of obstruction of the upper airways) in 60.3% of patients, dysphonia - in 33.8%, and in 5.9%, the detection of a cyst became an accidental finding. To eliminate the cyst, the method of laser marsupialization was used in 10 patients, coagulatory ablation - in 2 patients, in the remaining 56 patients, decortication was performed with microinstruments, followed by laser treatment of the cyst bed. In the follow-up, children were traced from 6 months to 7 years. We did not observe a recurrence of a cyst in any case.

CONCLUSION

Currently, the lining department is the "favorite" localization of the cyst in childhood. Subclavian cysts are more common in preterm infants who need tracheal intubation. A necessary condition for radical elimination is the resection of the cyst walls.

[Application of the matrix sentence test Russian version in children]

The Russian version of the matrix sentence test (RUMatrix test) has been shown to be suitable for accurate assessment of speech intelligibility in adults.

AIM

To approve the RUMatrix for measurements in children and to evaluate its simplified version (Simplified RUMatrix).

MATERIAL AND METHODS

20 normal-hearing adults and 81 normal-hearing children aged from 5 to 10 years were involved into the study. Both versions of the test were developed by the University of Oldenburg, Germany. The tests contain syntactically homogeneous, semantically unpredictable sentences/phrases presented under the background noise. Each test list is composed of 20 sentences of 5 words for RUMatrix and of 14 speech phrases of 3 words for Simplified RUMatrix.

RESULTS

A limitation in the use of the RUMatrix test in children under 10 years of age has been revealed. Evaluation of Simplified RUMatrix test in adults confirmed the perceptual homogeneity of the test list. The results of the RUMatrix test and the Simplified RUMatrix test in children were lower than in adults; they were improving with age and reach adult values by 10 years. One training track of Simplified RUMatrix test should be carried out before the assessment.

CONCLUSION

The RUMatrix can be used for children of 10 years and older. The normative data of Simplified RUMatrix both for adults and children of the different ages have been obtained.

[Congenital laryngeal paralysis in children]

AIM

To optimize the current algorithms of diagnosis and treatment of children with congenital laryngeal paralysis.

METHOD

A retrospective study of case histories of patients with congenital laryngeal paralysis who were examined and treated at St. Petersburg State Pediatric Medical University.

RESULTS

For the period from 1995 to 2015, 30 children with various forms of congenital laryngeal paralysis were under medical supervision at the Clinic for Otorhinolaryngology at St. Petersburg State Medical University.

CONCLUSION

In cases of stage 1-2 laryngeal stenosis in children older than 3 years 6 months, the chordarythenoidotomy may be the procedure of choice. In cases of stage 2 laryngeal stenosis, in children with tracheostomy, we consider laryngotracheoplasty with the insertion of costal autograft in the back wall of the larynx at the age of 4 years as the optimal choice.

CHARGE syndrome

The article provides literature data and description of the clinical case of CHARGE syndrome with an autosomal – dominant type of inheritance in a child of 3 years and 7 months. The name of the syndrome is formed by the first letters of the characteristic congenital malformations: “C” (coloboma) – optic disc coloboma, “H” (heart defects) – cardiovascular abnormalities, “A” (atresia of choanae) – atresia or stenosis of choan, “R” (retardation of growth and development) – growth deficit, developmental delay, “G” (genital anomalies) – genital anomalies, “E” (ear abnormalities and sensorineural hearing loss) – hearing organ abnormalities. A feature of the clinical case is the early diagnosis of CHARGE syndrome, manifested by bilateral optic disc coloboma; unilateral paresis of the facial nerve; congenital heart disease (open aortic duct); retardation of growth, psychomotor and psycho-speech development; cryptorchidism; bilateral anomaly of the outer ear (short, wide, absence of the lobe and external curl), sensorineural hearing loss; bilateral renal hypopalasia, chronic kidney disease.

[The application of the screening questionnaires for the diagnostics of the central auditory processing disorders in the pediatric practice]

Identification and diagnostics of auditory processing disorders (APD) in the children continues to be a challenge. Screening tools help to decide the need for evaluation. However, none of them are used routinely in Russia, nor are there thus far auditory checklist questionnaires in the Russian language. The aim of his study was to approve Children's Auditory Performance Scale (CHAPS) and Fisher's Auditory Checklist in Russian for the children at the age of 5-10 years. The study included 52 children at the age from 5 to 11 years. All of them were native Russian speakers. Pure tone audiometry, immitancemetry, and the Simplified RuMatrix test were performed for all the children. All of them had normal hearing thresholds, speech and language development, and normal academic achievement at school. The parents filled in the CHAPS and Fisher's Auditory Checklist questionnaires in Russian. The mean value of Fisher's Auditory Checklist was 85.7 ± 9.3, the mean value of CHAPS questionnaire was equal to 0.08 ± 0.26. The results obtained with the use of the Russian language questionnaires are in excellent agreement with the test data yielded by the respective English language versions. It is recommended that the clinical assessment for APD should be performed for children with the result of the Fisher questionnaire less than 67 points and with the result of the CHAPS questionnaire less than -1 point. It is concluded that Fisher's questionnaire was more convenient for the parents to fill in.

[Transtumoral decompression in acute left-sided colonic obstruction]

AIM

To prove an effectiveness of transtumoral decompression in patients with acute malignant left-sided colonic obstruction.

MATERIAL AND METHODS

154 patients with acute left-side colonic obstruction were enrolled. Patients were divided into 4 groups. In groups 1-3 (n=120) patients underwent surgery at the moment of colonic obstruction, in 34 patients obstruction was managed with transtumoral decompression followed by radical surgery. Self-expanding metallic stents (SEMS) were used in these patients. Radical and palliative procedures at the moment of colonic obstruction are associated with high rate of postoperative complications and mortality.

RESULTS

Transtumoral decompression in malignant colonic obstruction resolves the main objectives of complicated colonic cancer management: absence of surgical trauma, endotracheal narcosis, reduced risk of abdominal infection, possible multidisciplinary assessment of patient's status and preparation for radical surgery.

[A case of sigmoid cancer occurring after uretero-sigmoid anastomosis]

Colonic neoplasia occurring in an uretero-sigmoid anastomosis is a rare case of colon cancer in the clinical practice of Russian colorectal surgeons and urologists. The article presents a case of sigmoid adenocarcinoma causing obstructive pyelonephritis.

NEW OPPORTUNITIES OF THE QUALIFYING ENDOSCOPIC DIAGNOSTICS OF PANCREAS NEOPLASMS

OBJECTIVE

the aim of study was testing and introduction in clinical practice combination of EUS with sonoelastography, fine-needle biopsy and needle-based confocal laser endomicroscopy in advanced diagnostic of pancreatic disease.

MATERIALS AND METHODS

in the period from February 2014 to December 2015, we accumulated experience of EUS-FNA in 72 patients mostly with tumor pathology of the pancreas. In 16 cases we used 19G, in 49-22G, and in 7 patients - 25G needles. In 5 patients we used COOK Echotip Procore needle. In 8 cases we performed confocal laser endomicroscopy through the 19G needle (nCLE) in 3 patients with cystic and in 5 - with solid tumors. In 20 patients, there we used.HITA-CHI-PENTAX sonoelastography was performed.

RESULTS

There were no complications in EUS-FNA. In all cases we received pathology verification of disease. nCLE results always confirmed by morphological examination of material. In elastography examination normal pancreatic tissue had a equable green-yellow color, in chronic pancreatitis on the same background there were areas of blue seal parenchyma, in the cases pancreatic adenocarcinoma it was marked predominance of blue color scale, in neuroendocrine tumors - diffuse distribution of green and blue areas. Using nCLE in patients with adenocarcinoma revealed the destruction of certain glands, polymorphic nuclei of epithelial cells, with their enlargement, deformation, loss of polarity. Appliance of Procore needle has its technical features, but allowed us to obtain more material with less bloody - due to fewer number of passes.

CONCLUSION

Thus, our study confirms the effectiveness of EUS-FNA with sonoelastography and nCLE. It defines objectives for improvement and expansion of the range for their clinical use.

[ENDOCYTOSCOPY--NEW TYPE OF ENDOSCOPIC EXAMINATION OF LOWER GASTROINTESTINAL AND RESPIRATORY TRACT]

Majority of published data describing endocytoscopic examination of upper gastrointestinal tract mucosa, but in recent publications, it is reported, that endocytoscopy is suitable for small bowel, colon, respiratory tract and even peritoneum "optical biopsy". In number of articles possibilities of celiac sprue diagnostics with endocytoscopy is discussed, but small-bowel endocytoscopy is limited, due to absence of endocytoscopes, compatible with enteroscopes. More widely endocytoscopy is used in colon, mostly in lateral-spreading adenomas diagnostics. Prof. S-E. Kudo developed endocytoscopic classification of colonic mucosa changes, used for differential diagnostics and lesion mapping, describing hyperplasia, adenomas with different grades of intraepithelial neoplasia, non-invasive and invasive cancer. Some authors reported about good possibilities of endocytoscopy in inflammatory bowel disease diagnostics. Most of data, related to respiratory tract endocytoscopic examination, focused on precancerous conditions and early pharyngeal and lung cancer, and the preliminary results are promising, but, unfortunately, for now, endocytoscopy in bronchial tree is limited, due to lack of thin endocytoscopes. According to some article data, it is possible to use endocytoscopy not only in gastrointestinal and respiratory tract, but also in optical confirmation of peritoneal tumor dissemination in gastric and ovarian cancer patients, and--in bladder mucosa examination.

[THE FIRST CLINICAL EXPERIENCE IN THE CELIAC PLEXUS BLOCKADE UNDER ENDOSCOPIC ULTRASOUND NAVIGATION IN PATIENTS WITH PANCREATIC CANCER]

OBJECTIVE

Implementation into clinical practice and getting our own data of the effectiveness of EUS-CPN in chronic pain syndrome associated with pancreatic cancer in the palliative treatment.

MATERIALS AND METHODS

In the period from October 2014 to May 2015 in P.A. Herzen Moscow Research Oncological Institute--filial FGBI "NMIRC" gained the first clinical experience in the celiac plexus blockade under endoscopic ultrasound navigation in 10 patients with pain associated with pancreatic cancer. The study group included 6 women and 4 men aged 54-83 years. In 2 of 10 cases out celiac ganglia were located and injections made in side them. In eight cases, the blockade was performed after injection into the tissue surrounding the celiac trunk. In most cases, we used standard FNA-needle with diameter 22G. Blockade performed by a combination of local anesthetic (3-4 ml of 0.5% bupivacaine) and 14-20 ml of 96% ethanol.

RESULTS

There were no complications after EUS-BCS. 9 of 10 patients (90%) had a significant (2-4 points on a visual analogue scale) reduction of pain after 1-3 days after the procedure. These patients had a significant reduction in the frequency and dosage of analgesics. Four patients required repeat of anesthesia after 2 months--the same with a marked positive effect. One patient, in spite of the double execution of EUS-CPN did not note reduction in pain intensity.

CONCLUSION

EUS-CPN procedure is highly effective, very simple and safe. It provides a high quality of life and of social adaptation oncology patients. It should be more widely used in clinical practice.

[ENDOCYTOSCOPY--NOVEL ENDOSCOPIC DIAGNOSTICS APPROACH: PRINCIPLES AND PROCEDURE]

Endocytoscopy is one of the most novel endoscopic diagnostic procedures, providing optical magnification up to 1150 times of gastrointestinal and respiratory tract mucosa. Such approach allows real-time tissue and cellular structure visualization. Endocytoscopy, along with confocal laser endomicroscopy, can be considered as "optical biopsy" in vivo. Of course, endocytoscopy currently is experimental diagnostic method, all available endocytoscopes are prototypes. According to published data, endocytoscopy can be used in precancerous conditions and early intramucosal cancer diagnostics in esophagus, stomach, colon and bronchial tree. Different types of endocytoscopes are used for examinations: some of them are baby-scopes, with fixed magnification 570-1150 times, introduced into accessory channel of the therapeutic parent-endoscope, others--are integrated type, providing scalable magnification from 80 to 380 times. As for traditional pathology ex vivo, for endocytoscopy mucosal cell nuclei stain is needed. For vital staining during endocytoscopy methylene blue, toluidine blue and crystal violet in different concentrations are more often used. In cases of squamous-cell dysplasia or cancer, it is recommended to use 1% methylene blue solution, whereas in intestinal type metaplasia, dysplastic changes and cancer (Barrett's esophagus, P. Correa precancerous cascade, colon adenomas), 1% toluidine blue is preferred. With endocytoscopy, after vital staining, we can visualize and estimate mucosa tissue and cell characteristics: papillae, crypt and gland shapes and sizes, their integrity (tissue markers); cell nuclei size and shape, polarity and nuclear dye intensity (cell markers).

[Confocal laser endomicroscopy principles and performing algorithm in gastric mucosa examination]

Accuracy of endoscopic examination in early gastric cancer and precancerous conditions diagnostics for many years depended only on quality of biopsy. That's why, risk of overlooking gastric focal carcinoma, particularly-- multiple, was relatively high. Last couple of years new endoscopic method--confocal laser endomicroscopy (CLE) was released for commercial use. This approach provides real-time information about morphology of gastric mucosa during endoscopic examination. CLE is a variation of confocal microscopy--morphologic technique, providing examination of thick specimens or live tissue. CLE system is a single-channel fluorescence microscope, used in endoscopy, where confocal probe incorporated into endoscope or mounted into accessory channel. For proper results of CLE intravenous administration of fluorescence agent is needed. In our study in P.A. Herzen Moscow Cancer Research Institute we have used 10% fluorescein sodium, due to acriflavine use is prohibited in Russian Federation. In 157 patients with suspected early gastric cancer mean time of CLE was 24 ± 3.5 min. In all cases descriptive images were acquired. Mean amount of endomicrosocpic images in one patient was as high as 162 ± 8.3.

[Early gastric cancer and precancerous conditions diagnostics with confocal laser endomicroscopy]

AIM

To develop endomicroscopic criteria of early gastric cancer and precancerous conditions

METHODS

157 suspected for early gastric cancer patients were included in our study. In all cases complex endoscopic examination (narrow-band imaging NBI-HD endoscopy, endosonography (EUS) and endoscope-based confocal laser endomicroscopy (CLE) with precise biopsy) was performed. CLE images compared to pathology data.

RESULTS

Precise criteria of intestinal metaplasia in CLE was presence of oval gray goblet cells in epithelium. Gastric adenoma with moderate dysplasia appeared on CLE images as glandular structures in mucosa surface layers. The signs of high-grade dysplastic changes in adenoma were appearing of different shape and size cells with lost polarity. Well-differentiated carcinoma featured destruction of some glands and forming dark cell clusters. Revealed criteria of poor-differentiated carcinoma was total disintegration of glandular structures. Overall accuracy of CLE in early gastric cancer and precancerous conditions diagnostics reached 95,6% (P < 0.001). Selected accuracy in different condition was: 100% in intestinal metaplasia identifying, 86.1%--in adenoma with moderate dysplasia, 96.2% in high-grade dysplasia and cancer in situ, and 100%--in poor-differentiated gastric carcinoma types).

CONCLUSION

As the result of our study we have developed precise endomicroscopic criteria of intestinal metaplasia in stomach, gastric adenoma with moderate and high-grade dysplasia and early gastric cancer--as well-differentiated, as poor-differentiated.

[Endoscopic stenting of malignant stenosis in the cervical esophagus]

OBJECTIVE

to define the optimal approach for self-expanding metal stents (SEMS) installing in the cervical esophagus in cases of malignant stenosis and to select the optimal types of stents for this tumor location.

MATERIALS

From 2004 to 2013 in P.A. Herzen Moscow Cancer Research Institute in 24 patients with cervical esophagus tumor stenosis endoscopic stenting was performed. 70% of installed stents were Choo Cervical (M.I. Tech, Korea), 13%--unspecialized Choo and Hanaro stents (M.I. Tech, Korea), and 17%--Gianturco-Z stents (Wilson-Cook, Ireland). Main contraindication for cervical esophagus stenting was location of the tumor margin less than 1 cm from the upper esophageal sphincter. In 21% of cases, endoscopic stenting was performed under combined fluoro- and endoscopic guidance, in 79%-- using only endoscopic approach.

RESULTS

Technical success of stent placement was achieved in all patients; SEMS was installed at the previously defined level. The accuracy of stenting was not depended from the type of guidance procedure. The most intensive pain was observed in cases with "not specialized" stents with diameter of 18, 20 or 22 mm. Average pain level in such patients was 4.54 points (VAS). In the subgroup with "cervical" stents average pain intensity was not exceed 3 points. Chronic pain syndrome lasts lifelong in 17% of patients.

CONCLUSION

The procedure of SEMS positioning under endoscopic guidance with individual selection of stent type allows restoring oral nutrition in patients with severe tumor stenosis of the cervical esophagus.

[Esophagoplasty in combined scarry lesions of the esophagus, laryngopharynx and the trachea in children]

The experience of plasty of the pharynx and esophagus with graft of the free small intestine segment was presented in 12 children after burn stricture by the potassium permanganate. The technical aspects of operation using methods of the reconstructive vascular surgery were described. Good short-term result was obtained in all the patients. The long-term results were investigated during 15 years. It was observed, that the graft diverticulum developed by 4-7 years in 3 patients, whom repeated operation should be performed. According to the authors, the regional plasty of the esophagus by free revasculizated small intestine graft was really effective surgical supply and could be considered as the method of choice in limited scarry lesions of the pharynx and cervical esophagus, but the method should be improved.

[The evaluation of the late results of destruction of the atrioventricular junction in patients with drug-resistant atrial fibrillation]

Atrial fibrillation is a commonly seen form of disordered cardiac rhythm. Catheter-radio frequency ablation of the atrioventricular junction was found out to be an effective approach to control heart rate in continued drug-refractory cardiac fibrillation permitting the quality of the patients' life to be improved. The best results are achievable in patients presenting with chronic cardiac fibrillation.

[Late postoperative complications of coarctation of aorta]

Main complications of the remote 2-35 years period after coarctation of the aorta repair are studied up. Of 2746 patients 2464 (89.7%) were operated upon at the age of 2-25 years old. In 841 (30.61%) of patients were determined coexistent heart diseases, more often aortic valve lesion. End-to-end anastomosis was fulfilled in 44.6% of operations and patch repair was done in 43.6%. The most frequent complication of the remote period was the aortic aneurysm-in 61 (2.2%) of cases. It occurred seven times more frequently after the patch repair (4.1%) then after anastomosis end-to-end conduction (0.6%). Late postoperative mortality equaled 1.5%. The main reasons of it were aneurysms at the site of repair--in 12 patients, aneurysms of the ascending aorta--in 4 and progressing of the coexisting heart diseases--in 10.

[Surgical correction of failures associated with corrected transposition of the main vessels]

Experience of surgical correction of failures, concomitant with corrected transposition of main vessels (CTMV) in 29 patients was summarized. For pulmonary artery (PA) stenosis demolition in 10 patients the conduits of various design were applied, for moderate left atrioventricular valve (LAVV) insufficiency--its prosthetics. Surgical treatment mortality was 20.7%. Late follow-up results of the operation was studied up in 16 (66.7%) patients. Mean period of observation constituted 3.3 years. Good result was noted in 7 patients, fair--in 9. Lowering of contractile ability of "arterial" ventriculus and the LAVV insufficiency progress were the causes of follow-up results changing for worse. Application of conventional methods of treatment do not put away the basic disorder--CTMV.