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Ключевые слова: рак толстой кишки, кишечная микро биота, дисбактериоз В в е д е н и е . В настоящее время трудно недооценить роль влияния кишечной микробиоты на организм человека. С развитием технологий в области молекулярной генетики значительно изменились представления о качественном и количественном составе микроорганизмов.По современным представлениям, абсолютное большинство (89%) в составе микробиоты здорового человека занимают микроорганизмы, относящиеся к двум крупным сообществам -бак тероидам (Bacteroidetes) и фирмикутам (Fir mi cutes), каждое из которых состоит из множества родов. Бактероидыгруппа анаэробных грамотрицательных бактерий трех классов (Bacteroidetes, Flavobacteria и Sphingobacteria). Фирмикуты -преимущественно грамположительные бактерии двух основных классов -бацилл и клост ридий. К фирмикутам относятся стрептокок ки, стафилококки, лактобациллы, эн терокок ки и менее известные большинству врачей, но более многочисленные вейлонеллы, руминококки, эубактерии, пептострептококки. Самые же распространенные фирмикуты -клостридии. Установлено, что общее количество всех бифидобактерий, которые входят в семейство актиномицетов, обычно не превышает 5% от общего количества бактерий толстой кишки, а лактобацилл -не более 1%. [7] В отечественной литературе достаточно много публикаций, в которых изучались особенности микробиоты толстой кишки у больных с колоректальным раком (КРР), в том числе применительно к хирургической практике. Большинство российских исследователей для определения состава микробиоты использовали бактериологический метод. В результате практически у всех пациентов выявлены различной степени нарушения микробиоценоза кишечника в виде снижения количества лакто-и бифидобактерий и роста условно-патогенной флоры [2,[4][5][6].Несмотря на современные возможности хирургии и интенсивной медицины, небольшое число осложнений после операций, соблюдение протоколов ранней реабилитации пациентов, сохраняется определённый процент осложнений, ведущую роль в патогенезе которых играет кишечная микрофлора (абдоминальный сепсис, антибиотикоассоциированные колиты, несостоятельности кишечных анастомозов) [3,9].Предложены множество путей коррекции кишечных дисбиозов -от назначения эубиотиков и пробиотиков до фекальной трансплантации,

The main effective method of treatment for implantation metastases remains the regional treatment strategy. Systemic chemotherapy is ineffective. The standard treatment of peritoneal carcinomatosis is cytoreductive surgery with intraperitoneal chemo-hyperthermal perfusion (HIPEC), which is performed in an open, closed or laparoscopic way. In recent years a new method of intraperitoneal chemotherapy has been developed: laparoscopic aerosol intraperitoneal chemotherapy (PIPAC). An experimental study is made to compare the efficacy and safety of various methods of intraperitoneal chemotherapy.

The results of treatment of gastric cancer with peritoneal dissemination are not very comforting. The average life expectancy of patients after diagnosis is less than 6 months. Methods of systemic treatment are ineffective. The most effective strategy is regional treatment, a special place in recent years has taken intraperitoneal chemotherapy with low-dose Cisplatin and Doxorubicin administered as a pressurized aerosol (PIPAC). This article presents the analysis of the first results of treatment of patients with gastric cancer with peritoneal carcinomatosis, which was used PIPAC at conventional regimens (standard for this technique, low-dose cytostatics, exposure time and intraperitoneal pressure) and in the experimentally developed effective regimen. The developed PIPAC regimen proposed by the authors proved its safety and objectively more effective than the standard for such parameters as objective tumor response, histological response and overall survival of patients. The study will be continued to obtain statistically reliable results.

Relevance: The variability of the visceral vessels occurs from 10 to 30%. There are anatomical options in which the main arteries of the stomach depart from the aorta or superior mesenteric artery. The recommended standardized surgical technique for radical treatment of gastric cancer is defined for typical vascular anatomy. Objective: To improve the results of surgical treatment of patients with gastric cancer (GC) by optimizing the diagnostic algorithm and correcting surgical techniques. Material and Methods: The results of surgical treatment of 296 patients with gastric cancer cT1-4N1-2M0, who were treated at I.P. Pavlov First St. Petersburg State Medical University from 2012-2017. In the main group of patients (n = 176), the proposed diagnostic and treatment algorithm was applied (spiral computed tomography in the angiographic mode (SCTA) + with the discharge of the vessel participating in the blood supply to the stomach from the aorta (AO) and / or the superior mesenteric artery (SMA) extended lymph node dissection D2 + № 16a2, № 16b1). All patients were radically operated. The evaluation of the diagnostic characteristics of SCTA was performed. The results of treatment were evaluated in 108 patients of the main group. The comparison group (n = 120) consisted of patients in whom vascular anatomy was not studied. Estimated blood loss, time of operation, the frequency of perioperative complications and long-term survival. Results: In 32,9 % (n = 58) patients, variant anatomy of the visceral vessels of the upper abdominal cavity was detected. Additional arteries with typical trifurcation were found in 21,6 % (n = 38) of cases; celiac trunk bifurcation was determined in 10,2 % (n = 18) of patients; the absence of the celiac trunk and a single celiac-mesenteric trunk were found in 1,1 % (n = 2) of patients. The sensitivity of SCTA was 95,7 %, specificity 94,4 %, total accuracy 95,4 %. As a result of the applied diagnostic and treatment algorithm, the standard volume of D2 lymph node dissection was performed in 124 (70,4 %) patients during the surgical treatment of the main group of patients. Expansion of lymphadenectomy to D2 + was required in 52 (29,5 %) patients. Metastases to lymph nodes of groups № 16a2 and № 16b1 in patients who underwent extended D2 + lymph node dissection were detected in 16 (30,8 %) cases. The average blood loss in the main group was 1,95 times less and amounted to 126,5±22 ml, and in the comparison group - 246,7±34 ml (M ± m, p = 0,0276). A comparison of the average duration of the operation did not show any significant differences: in the comparison group it was 188,2 ± 16,4 minutes, while the main group was slightly lower - 172,3 ± 21,5 minutes. In the main group, the total number of complications was 14 cases (13,5 %) and was significantly lower than in the comparison group - 29 cases (25,9 %). Survival for 1-2-3 years in patients of the main group was higher than the comparison group and amounted to 92,6, 75,0, 53,7 % and 90,8, 71,8, 47,5 %, respectively. The relapsefree 1-2-3-year survival of the group of patients to whom the diagnostic and treatment algorithm was applied was also higher than in the comparison group and amounted to 90,7, 73,1, 48,1 % and 90,8, 68, 3, 44,2 %, respectively. The median survival was significantly better in the main group of patients - 31,4 months, in the comparison group - 28,5 months. Conclusions: Performing SCTA at the preoperative stage is an effective way to visualize the great vessels, allowing to plan the volume of the operation, to avoid perioperative complications. Expanding the volume of lymph node dissection to D2 + № 16a2, № 16b1 when the vessel participating in the blood supply to the stomach from the AO and / or SMA is released, as it allows to improve the long-term results of treatment of patients with gastric cancer, by increasing radical surgery.