Aim: To assess the efficiency of preemptive analgesia with Ketoprofen 10 mg 2 hours before procedure per os with spinal anesthesia to decrease postoperative pain and the amount of used analgesics.
Methods: Patients of our clinic who meet the following inclusion criteria are included: they must be diagnosed with anorectal disease and planned anorectal procedure. After signing the consent all participants are randomly divided into 2 groups: the first one gets a tablet with 10 mg Ketoprofen, the second one gets a tablet containing starch per os 2 hours before surgery (72 participants per arm). Patients of both arms receive spinal anesthesia and undergo open hemorrhoidectomy. Following the procedure the primary and secondary outcomes are evaluated: opioid administration intake, the pain at rest and during defecation, duration and frequency of other analgesics intake, readmission rate, overall quality of life, time from the procedure to returning to work and the complications rate.
Discussion: Multimodality pain management has been shown to improve pain control and decrease opioid intake in patients after anorectal surgery in several studies. Gabapentin can be considered as an alternative approach to pain control as NSAIDs have limitative adverse effects. Systemic admission of ketorolac with local anesthetics also showed significant efficacy in patients undergoing anorectal surgery. We hope to prove the efficacy of multimodal analgesia including preemptive one for patients undergoing anorectal procedure that will help to hold postoperative pain level no more than 3-4 points on VAS with minimal consumption of opioid analgesics.

Background: Anorectal fistula is a benign disease with an average prevalence of 1.69/10,000 population. The disease significantly reduces the life quality and has a tendency to relapse. Repeated surgical treatment can lead to anal sphincter impairment. Paraproctitis is the main anorectal fistulas cause. However, there are also iatrogenic traumatic fistulas that occur after various anorectal surgical interventions.
Clinical case: A 44-year old female patient applied to the MSU University clinic in March 2020 with perineal wound with permanent purulent discharge. During examination perianal soft tissue defect was determined, the external fistula opening (40x25x25cm) was visualized at the wound bottom, the internal fistula opening (2x3mm) was visualized at 12h of the clock dial. The perianal area is deformed due to scarring. In 2016 the patient underwent surgical «rectocele elimination, posterior colporaphy, levatoroplasty, plastic surgery of the anterior rectal wall». Obstructive defecation syndrome developed during postoperative period, and repeated surgical treatment was performed – anterior anosfincterolevatoroplasty, Milligan-Morgan hemorrhoidectomy.On the 9th day, there was a «perianal soft tissue rupture» with bleeding and «local anterior rectal wall damage in the suprasphincter zone». Then «the rectal defect suturing» was performed. The perineal wound was left open. The patient was reoperated in 3 months due to a rectovaginal fistula with no effect. A fistulectomy was performed at the Moscow State University Medical Center with the removal of the anal canal defect by mucosal-submucosal flap. The surgical wound heals by secondary tension.
Conclusion: The current studies describe a small number of cases of anorectal fistulas secondary to anorectal surgery. At the same time, there is no data on the further surgical management of such patients. It is important to present the iatrogenic anorectal fistulas cases, not only to analyze the fistula cause, but also to describe the surgical treatment method and its efficacy.

The disadvantage of bipolar and holmium enucleation in transurethral surgery of benign prostatic hyperplasia (BPH) is the frequent postoperative urination disorders. To increase the effectiveness of surgical treatment, a modification of the surgical technique is necessary.
Objective: to compare the perioperative results of endosurgical treatment of large sized BPH using transurethral bipolar (TUEB), laser (HoLEP) and modified laser prostate enucleation (HoLEP-M) methods.
Patients and methods: A randomized prospective study was conducted according to the results of surgical treatment of 1104 patients with BPH with a volume of 80 to 350 cm3, divided by methods of endoscopic enucleation of the prostate. A mod-ification of the HoLEP technique was to optimize access to the surgical site with the designation of new anatomical landmarks.
Results: Comparison of surgical methods showed their equivalence in the volume of removed tissue, the low frequency of hemorrhagic and infectious complications, the dynamics of urological indicators in the delayed period. TUEB has the least parameters for the time of surgical intervention (98.2 ± 2.24 min.), the vol-ume of blood loss (65.5 ± 1.83 ml), the terms of postoperative catheterization of the bladder (2.0 ± 0.32 days), and the days of hospitalization (3.2 ± 0.40 days). The safety of laser methods is higher than TUEB, during which 3.1% of closed perforations of the prostatic capsule and bladder were observed (versus 0.8-1.5% with laser methods). Modification of the HoLEP technique allows reducing the frequency of late dysuric disorders by 2-3 times, urinary incontinence by 3.4-4 times, cicatricial complications by 1.7-2 times.
Conclusion: Bipolar and laser methods of transurethral enucleation of the prostate of large sizes are comparable by criteria of complete removal of prostatic tissue, effectiveness and tolerability in patients with thrombohemorrhagic risk. In terms of the frequency of intraoperative injuries, the safety of laser methods is higher due to the reduced penetrating ability of laser energy. Modification of surgical access to the prostate preserves the prostatic urethra as much as possible and is a promising measure for the prevention of late obstructive and functional complications of transurethral interventions.

Despite all the achievements of modern surgery, the number of postoperative infectious complications in the world remains high. Their occurrence leads to a longer period of patients’ hospitalization, requires the use of additional medical and diagnostic measures, which ultimately leads to higher treatment costs and significant financial losses in the health care system. Therefore, it is important to identify postoperative complications at an early stage, even before the development of pronounced clinical symptoms, and to predict their possible development in a certain category of patients. For these purposes, scientists try to use various laboratory markers. In this paper, we analyzed both well-known indicators of the inflammatory response, such as: C-reactive protein, albumin, their ratio, procalcitonin and interleukin-6, and relatively new parameters that research teams are trying to apply for these purposes: neutrophil granularity intensity and neutrophil reactivity intensity, pancreatic stone protein and pancreatitis-associated protein. We tried to collect the most complete information available at the moment, evaluate the opinions of researchers, identify contradictions in their works and try to explain their cause. As a result, it turned out that even the markers of inflammation known for many years are not absolutely specific for postoperative infectious complications. We concluded that most of the laboratory parameters described in this article can be used to some extent in the early diagnosis of postoperative infectious complications, but if we want to obtain more complete information in this area of knowledge, it is necessary to conduct new largescale studies.

Introduction. Boerhaave syndrome is a rare, difficult to diagnose and formidable disease with a high mortality rate. For the treatment of this pathology, many variants of interventions have been proposed. Some surgeons prefer to use a thoracotomic access, others – a laparotomic transhiatal one. In the domestic literature there are scant observations of usement of minimally invasive technologies.
Clinical observation. The patient was admitted to the surgical department for emergency indications. In the admission department spontaneous left side hydropneumothorax was diagnosted. Drainage of the left pleural cavity was performed. On the second day, a spontaneous rupture of the esophagus was diagnosed. Video-laparotranschiatal drainage of the posterior mediastinum, drainage of the left subhepatic space, Maydl jejunostomy was performed. In the postoperative period, intensive conservative therapy was carried out, massive lavage of the mediastinum and the left pleural cavity with antiseptic solutions. For a long time, there was a large drainage debit. Because of treatment the dynamics were positive. On the 45th day the drainage of the pleural cavity was removed. By the 66th day complete healing of the esophageal defect and removal of the mediastinal drainage.
Discussion. Due to the difficulties in diagnosis, a spontaneous rupture of the esophagus was detected a day later. The applied surgical access and technique allowed to provide adequate drainage and sanitation of the posterior mediastinum and left pleural cavity. The subsequent tactics of managing the patient ensured his recovery. The trauma of the video-laparotranschiatal access is less, in comparison with open surgical interventions. We consider the experience of using video endoscopic technologies for Boerhaave syndrome positive and promising.

Introduction: Hirschsprung's disease (HD) is a relatively rare condition, in which the intermuscular (Auerbach) and submucosal (Meissner) plexus are absent in the colon wall at various lengths. In the literature, HD is described mainly in relation to the pediatric surgery area of interests because up to 90% of cases of this disease are detected before the age of 5 years 6. However, in some patients, the symptoms of the disease are not severe, so patients survive to adulthood without an established diagnosis.
Clinical case: we demonstrate our experience of surgical treatment of Hirschsprung's disease in a 18-year-old patient.
Conclusion: Although Hirschsprung's disease is in most cases a disease of childhood, it is necessary to keep in mind its typical symptoms when an adult patient complains of constipation. Proper diagnosis and correctly selected surgical treatment can not only eliminate symptoms and improve quality of life, but also reduce the likelihood of serious complications.