Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_1073_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

22 Мб

Скачать

☆

<<< < Предыдущая 13 14 15 16 17 18 19 20 21 22 23 2425 / 5025 26 27 28 29 30 31 32 33 34 35 36 37 > Следующая >>>

19 Colorectal Cancer Management in Older Adults: Use of Geriatric Assessment…

https://t.me/medicina_free

Quality

evidence

Low

associated with long-term

outcome and

perioperative morbidity

- geriatric sum score is

- intermediate or high risk

data

associated with

scores were associated with

lower perioperative OS

- sum scores were

Low

identify patients at higher

risk for postoperative

complications

- frailty screening can

postoperative

complications

with G8 under 15 and/or

4GMST less than 1m/s

- higher complication rate

Moderate

alter the treatment plan in

colorectal cancer

- geriatric consultation can

impairments

− 93% had geriatric

− 69% were referred for

High

increase the number of

- geriatric interventions

‘more intensive

treatment option’

interventions included

older CRC patients

medication changes,

completing adjuvant

chemotherapy and can

improve mobility and

nutritional therapy, and

physiotherapy

- more interventional

illness burden.

patients completed

chemotherapy than control

- QoL and morbidity

improved in

interventional patients

decreased in

- burden of disease

227

interventional patients

assessment

- geriatric risk factor

undergoing elective

colorectal cancer surgery

Study design Patients Measure Results Conclusion

Retrospective 550 patients over age 70

Study

Souwer

[10]

-G8 score

-4MGST score

of age undergoing elective

colorectal cancer surgery

Retrospective 149 patients over 69years

Bessems

[11]

-geriatric consultation

168 patients over 59years

of age with colorectal

cancer referred for

Prospective

cohort

Verweij

[12]

-CGA-based intervention - Most common

geriatric consultation

adjuvant or rst-line

− 142 patients receiving

Randomized

phase III trial

Lund

[13]

palliative chemotherapy

under 14 were

randomized to CGA-

based interventions or

- patients with G8 score

standard care

228

https://t.me/medicina_free

J. L. Roberson and N. M. Saur

Personal View

The multidimensional CGA, typically performed by geriatricians, is the gold standard for assessing frailty and can provide important insight and treatment guidance in the perioperative setting in patients with colorectal cancer. However, as a limited resource, only a minority of surgeons are able to collaborate with geriatricians [14,

15]. Therefore, it is imperative that surgeons familiarized themselves with the com-

ponents of a CGA and collaborate with geriatricians whenever possible. The main domains of a CGA, for surgeons’ reference, are functional assessment, cognitive assessment, evaluation of comorbidities, and nutrition assessment.

At the crux of creating a treatment plan for an older adult with colorectal cancer, however, is aligning patient goals with possible outcomes. While maintaining independence and a desire to die at home are common health priorities among seniors, both medical and surgical interventions can result in complications requiring further invasive procedures, ICU admissions, or hasten an in-hospital death [16]. Therefore, in the elective, outpatient setting, the provider should elicit a patient’s goals of care and identify factors that inuence their quality of life through the process of shared decision making [17]. A variety of communication aids have been developed for elective surgery that help with information exchange and mutual decision making. Specically, one question prompt list (QPL) encourages discussions to cover three main areas: (1) Should I have surgery? (2) What should I expect if everything goals well? And (3) What happens if things go wrong? [18] These types of questions change the focus of the ofce visits from specic technical details to instead patient goals and possible outcomes and, combined with the overall clinical assessment, can help guide towards treatment for oncologic cure versus palliation.

To assist surgeons in this endeavor, the American College of Surgeons (ACS) Geriatric Surgery Task Force has launched the Geriatric Surgery Verication Program. The goal of this program is to support all hospitals, regardless of size and/ or resources, in caring for older adults with surgical diagnoses. The ACS has identied four phases of care of special importance, acknowledging that the ultimate goal is to preserve functional independence and prioritize quality of life: (1) goals of care and decision making, (2) cognitive function and prevention of delirium, (3) maintenance of function and mobility, and (4) nutrition and hydration optimization [19].

Looking forward and outside of the outpatient encounter, inpatient geriatric comanagement for surgical patients has been shown to decrease perioperative complications. Specically, within vascular surgery, prospectively enrolled patients with an inpatient surgical procedure were compared in a pre-post fashion following implementation of formal comanagement. The post-group saw a signicant reduction in hospital-acquired geriatric syndromes such as delirium as well as cardiac and infective complications [20].

With an aging population, it is the responsibility of the surgeon to be comfortable caring for older adults, crafting care plans congruent with a patient’s goals, and consulting with geriatricians. If proceeding with surgery, there are a variety of assessments and interventions that can ultimately improve perioperative outcomes and assist the patient in achieving their health goals.

19 Colorectal Cancer Management in Older Adults: Use of Geriatric Assessment…

https://t.me/medicina_free

229

References

1. Siegel RL, Miller KD, Fedewa SA, etal. Colorectal cancer statistics, 2017. CA Cancer J Clin. 2017;67:177–93.

2. Walter LC, Covinsky KE.Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285:2750–6.

3. Saur NM, Montroni I, Shahrokni A, Kunitake H, Potenti FM, Goodacre RC, Davis BR, Carli F.Care of the geriatric colorectal surgical patient and framework for creating a geriatric program: a compendium from the 2019 American society of colon and rectal surgeons annual meeting. Dis Colon Rectum. 2020;63(11):1489–95. https://doi.org/10.1097/DCR.0000000000001793. PMID: 32947418; PMCID: PMC7547896

4. Shahrokni A, Alexander K. The age of talking about age alone is over. Ann Surg Oncol. 2019;26:12–4.

5. Lawler M, Selby P, Aapro MS, Duffy S.Ageism in cancer care. BMJ. 2014;348:g1614.

6. Aparicio T, Canouï-Poitrine F, Caillet P, François E, Cudennec T, Carola E, Albrand G, Bouvier AM, Petri C, Couturier B, Phelip JM, Bengrine-Lefevre L, Paillaud E.Treatment guidelines of metastatic colorectal cancer in older patients from the French Society of Geriatric Oncology (SoFOG). Dig Liver Dis. 2020;52(5):493–505. https://doi.org/10.1016/j.dld.2019.12.145. Epub 2020 Feb 3

7. Antonio M, Saldaña J, Carmona-Bayonas A, Navarro V, Tebé C, Nadal M, Formiga F, Salazar R, Borràs JM. Geriatric assessment predicts survival and competing mortality in elderly patients with early colorectal cancer: can it help in adjuvant therapy decision-making? Oncologist. 2017;22(8):934–43. https://doi.org/10.1634/theoncologist.2016- 0462. Epub 2017 May 9. PMID: 28487465; PMCID: PMC5553962

8. Li M, Schulte N, Elting F, Winkler EC, Hetjens S, Berger AK, Zschäbitz S, Hofmann J, Hofmann J, Hilbertz L, Kuhn M, Khakzar C, Jesenofsky R, Betge J, Zhan T, Belle S, Ebert MP, Härtel N.Sequential geriatric assessment in older patients with colorectal cancer during chemotherapy: subgroup analysis of a prospective, multicenter study EpiReal 75. Oncol Res Treat. 2022;45(11):670–80. https://doi.org/10.1159/000525101. Epub 2022 Jun 8

9. Decoster L, Vanacker L, Kenis C, Prenen H, Van Cutsem E, Van Der Auwera J, Van Eetvelde E, Van Puyvelde K, Flamaing J, Milisen K, Lobelle JP, De Grève J, Wildiers H.Relevance of geriatric assessment in older patients with colorectal cancer. Clin Colorectal Cancer. 2017;16(3):e221–9. https://doi.org/10.1016/j.clcc.2016.07.010. Epub 2016 Aug 8

10. Souwer ETD, Hultink D, Bastiaannet E, Hamaker ME, Schiphorst A, Pronk A, van der Bol JM, Steup WH, Dekker JWT, Portielje JEA, van den Bos F.The prognostic value of a geriatric risk score for older patients with colorectal cancer. Ann Surg Oncol. 2019;26(1):71–8.

https://doi.org/10.1245/s10434- 018- 6867- x. Epub 2018 Oct 25. PMID: 30362061; PMCID:

PMC6338720

11. Bessems SAM, Konsten JLM, Vogelaar JFJ, Csepán-Magyar R, Maas HAAM, van de Wouw YAJ, Janssen-Heijnen MLG.Frailty screening by Geriatric-8 and 4-meter gait speed test is feasible and predicts postoperative complications in elderly colorectal cancer patients. J Geriatr Oncol. 2021;12(4):592–8. https://doi.org/10.1016/j.jgo.2020.10.012. Epub 2020 Nov 4

12. Verweij NM, Souwer ETD, Schiphorst AHW, Maas HA, Portielje JEA, Pronk A, van den Bos F, Hamaker ME. The effect of a geriatric evaluation on treatment decisions for older patients with colorectal cancer. Int J Color Dis. 2017;32(11):1625–9. https://doi.org/10.1007/

s00384- 017- 2883- 8. Epub 2017 Sep 20

13. Lund CM, Vistisen KK, Olsen AP, Bardal P, Schultz M, Dolin TG, Rønholt F, Johansen JS, Nielsen DL.The effect of geriatric intervention in frail older patients receiving chemotherapy for colorectal cancer: a randomised trial (GERICO). Br J Cancer. 2021;124(12):1949–58.

https://doi.org/10.1038/s41416- 021- 01367- 0. Epub 2021 Apr 7. PMID: 33828260; PMCID:

PMC8185087

14. Korc-Grodzicki B, Holmes HM, Shahrokni A.Geriatric assessment for oncologists. Cancer Biol Med. 2015;12:261–74.

230

https://t.me/medicina_free

15. Kottek A, Bates T, Spetz MJ.The roles and value of geriatricians in healthcare teams: a landscape analysis. UCSF Health Workforce Research Center on Long-Term Care; 2017. Accessed 15 Oct 2019. https://healthworkforce.ucsf.edu/sites/healthworkforce.ucsf.edu/les/REPORT_

Geriatricians_Lit_FINAL.pdf.

16. Ballou JH, Brasel KJ.Palliative care and geriatric surgery. Clin Geriatr Med. 2019;35(1):35–44.

https://doi.org/10.1016/j.cger.2018.08.004. Epub 2018 Sep 28

17. Kon AA, Davidson JE, Morrison W, etal. Shared decision making in ICUs: an American college of critical care medicine and American Thoracic Society policy statement. Crit Care Med. 2016;44(1):188–201.

18. Steffens NM, Tucholka JL, Nabozny MJ, Schmick AE, Brasel KJ, Schwarze ML.Engaging patients, health care professionals, and community members to improve preoperative decision making for older adults facing high-risk surgery. JAMA Surg. 2016;151(10):938–45. https://

doi.org/10.1001/jamasurg.2016.1308. PMID: 27368074; PMCID: PMC5071104

19. Ma M, Zhang L, Rosenthal R, Finlayson E, Russell MM.The American College of surgeons geriatric surgery verication program and the practicing colorectal surgeon. Semin Colon Rectal Surg. 2020;31(4):100779. https://doi.org/10.1016/j.scrs.2020.100779. Epub 2020 Oct

2. PMID: 33041604; PMCID: PMC7531280

20. Thillainadesan J, Aitken SJ, Monaro SR, Cullen JS, Kerdic R, Hilmer SN, Naganathan V. Geriatric comanagement of older vascular surgery inpatients reduces hospital-acquired geriatric syndromes. J Am Med Dir Assoc. 2022;23(4):589–595.e6. https://doi.org/10.1016/j.

jamda.2021.09.037. Epub 2021 Oct 29

J. L. Roberson and N. M. Saur

Colon Cancer intheSplenic Flexure:

https://t.me/medicina_free

Which Operation?

HimaniBhatt andKellieMathis

Introduction

Adenocarcinoma of the colon is the fourth most common cancer worldwide, and tumor location within the splenic exure is rare, occurring in less than 10% of cases. Splenic exure cancers (SFC) have been anatomically dened as cancers located within 10cm in either direction from the left upper quadrant maximal bend of the colon or alternatively as a cancer located between the distal 1/3 of the transverse colon and the proximal 1/3 of the descending colon [1–3]. Embryologically, the splenic exure is located between the nal portion of the midgut and the starting portion of the hindgut, and it is supplied by both superior mesenteric and inferior mesenteric arteries. This dual vasculature and lymphatic drainage has led to uncertainty about the most appropriate extent of resection for SFCs. Understanding the complex anatomy and embryology of the splenic exure is important to determine the optimal surgical approach for a SFC [3].

SFCs have a less favorable prognosis compared to other colon locations, often present at an advanced stage, have a high metastatic potential, have a high incidence of bowel obstruction, and are associated with a higher rate of lymph node positivity [4, 5]. The reason for these poor outcomes is not entirely understood. Multiple operations have been described for SFC including extended right hemicolectomy with an ileocolic anastomosis (and sometimes referred to as subtotal colectomy), left hemicolectomy with a colorectal anastomosis, segmental colectomy with a colocolonic anastomosis, and a total colectomy with an ileorectal anastomosis. The

H. Bhatt · K. Mathis (*) Department of Surgery, Mayo Clinic, Rochester, MN, USA e-mail: Bhatt.himani@mayo.edu; Mathis.kellie@mayo.edu

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery, Difcult Decisions in Surgery: An Evidence-Based Approach,

https://doi.org/10.1007/978-3-031-42303-1_20

231

232

https://t.me/medicina_free

H. Bhatt and K. Mathis

literature is limited on consensus for the best approach to treat SFCs and consists of only retrospective and heterogenous data from single institutions, making generalizable recommendations difcult. In this chapter we aim to provide a thorough literature review to collate an evidence-based optimal surgical approach for SFC resection.

Methods

An extensive literature review of several databases was conducted on May 18, 2022. The databases included: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & amp; Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Controlled vocabulary supplemented with keywords like: “left colic exure”, “splenic exure“, “transverse colon”, “Adenomatous polyposis”, “Familial polyposis”, “colorectal or bowel* or colon*”, “left colic exure”, “splenic exure“, “transverse colon”, “cancer* or neoplasm* or tumor* or tumour* or carcinoma* or adenocarcinoma* or carcinogenes*”, “extended right colectomy*”, “extended right hemicolectomy*”, “extended right hemi-colectomy*”, “right extended colectomy*”, “right extended hemicolectomy*”, “right extended hemi-colectomy*”, “left colectomy*”, “left hemicolectomy*”, “left hemicolectomy*”. Directed searches of the references from the primary articles were also performed to look for additional relevant articles. Results from observational studies and metanalyses were found. We found that all the relevant observational studies were already incorporated in the metanalyses and thus, we only included these meta-analyses in this review. Search was limited to: [1] Articles only in English, [2] Articles published in last 5years [3] Articles related to splenic exure cancer resection, and [4] Full text articles. See PICO information in Table20.1. The Final 3 Metanalysis studies were reviewed in detail and their results are presented in the Table20.2.

Table 20.1 PICO table

Patient population Patients with

splenic exure cancer

Intervention Comparators

Extended right/ subtotal colectomy

Left/segmental colectomy

Outcomes Perioperative outcome, overall

survival, disease free survival

20 Colon Cancer intheSplenic Flexure: Which Operation?

https://t.me/medicina_free

Study

Quality

Total

number

Low

patients ERH LH STC SC Outcomes

956 353 361 242 No difference between

ERH, LH and SC in

terms of postoperative

morbidity and mortality,

Low

lymph node yield and

cancer survival.

for the curative

resection of splenic

2734 596 928 109 928 SC, LH, ERH and STC

Low

exure tumors provide

similar survival.

569 132 437 No difference in ERH

233

or LC

Table 20.2 Summary of 3 Metanalyses Included in this Review

Number of

Studies

7 retrospective

Type of

study

Systematic

Year Country Timeline

2020 UK 1946 to

Author

Hajibandeh

studies

review and

meta-

2020

etal.

analysis

10 retrospective

studies

Network

meta-

August

Wang etal. 2021 China up to

analysis

2020

12 retrospective

studies (6

comparative, 6

case series)

Systematic

review and

meta-

analysis

2016

2017 France 1990 to

Martınez-Pe

rez etal.

ERH Extended right hemicolectomy LH Left hemicolectomy SC Segmental colectomy, STC Subtotal colectomy

234

https://t.me/medicina_free

H. Bhatt and K. Mathis

Results

Extensive literature review yielded 3 meta-analysis studies that matched our search criteria. We found no prospective or randomized control trials published to date. The studies included in the meta-analysis were all retrospective in nature leaving us with low quality evidence.

This study included a total of 3264 non-overlapping subjects, but variable numbers of patients were included in each individual comparison.

Intra-Operative Outcomes

The intra-operative outcomes of interest include operative time, margin status, success of the anastomosis, the number of lymph nodes harvested, and minimally invasive surgery (MIS) use.

Extended Right Hemicolectomy vs Left Hemicolectomy

When comparing extended right hemicolectomy with left hemicolectomy, Hajibandeh etal., found no difference in operative times, rate of R0 resection, or the proportion of patients who had more than 12 LNs harvested. They did report that ERH resulted in a higher number of total lymph nodes harvested as compared to LH [xed effects model: MD 3.52, 95% CI 2.14, 4.89; P<0.00001; low heterogeneity (I2=43%); high GRADE certainty of evidence] [6]. Wang etal., reported a higher rate of primary anastomosis in the ERH group compared to the LH group [7].

Martinez Perez etal., found no differences in LN retrieval, R0 resection between ERH and LH [8].

Extended Right Hemicolectomy vs Segmental Colectomy

Hajibandeh etal., found no difference in rate of R0 resection, total number of LNs harvested, or the proportion of patients who had more than 12 LNs harvested. Operative times were signicantly longer in the ERH group compared to segmental colectomy [6]Wang etal., found a higher rate of ileus in the ERH group compared to segmental colectomy (OR=4.2, 95% CI 1.3–18.0, P=0.019: low heterogeneity (I2=14.8%) [7].

Segmental Colectomy vs Left Hemicolectomy

In the ACS NSQIP study, there were no differences in the proportion of patients with <12 LNs. 73% of all cases were done with an MIS technique. Patients in the segmental colectomy group had shorter operative times compared to left hemicolectomy [2].

20 Colon Cancer intheSplenic Flexure: Which Operation?

https://t.me/medicina_free

235

Direct Comparison of4 Techniques: Subtotal Colectomy, Extended Right Hemicolectomy, Left Hemicolectomy andSegmental Colectomy

Wang etal., reported no difference in rate of minimally invasive technology use or proportion of patients with >12 LNs harvested [7].

Post-Operative Outcomes/Morbidity

The postoperative outcomes reported include postoperative mortality, total complication rate, severe complication rate, anastomotic leak, ileus, need for reoperation, and length of hospital stay.

Extended Right Hemicolectomy Versus Left Hemicolectomy

Hajibandeh etal., found no statistical difference in total postoperative complications [xed effects model: OR 1.16, 95% CI 0.83, 1.63; P=0.37; low heterogeneity (I2=0%); high GRADE certainty of evidence], severe complications [xed effects model: OR 0.69, 95% CI 0.43, 1.12; P=0.13; low heterogeneity (I2=28%); high GRADE certainty of evidence], wound infection [xed effect model: OR 0.63, 95% CI _0.14, 2.80; P=0.55; low heterogeneity (I2=0%); low GRADE certainty of evidence], pancreatic stula [xed effects model: OR 1.00, 95% CI 0.06, 16.85; P = 1.00; very low GRADE certainty of evidence], and intra-abdominal abscess [xed effects model: OR 2.08, 95% CI 0.18, 24.41; P= 0.56; very low GRADE certainty of evidence]. They also found no difference in anastomotic leak rates, mortality, ileus, need for reoperation and length of hospital stay [6]. Martinez Perez etal., found no differences in operative times, anastomotic leaks, postop complications [8].

Extended Right Hemicolectomy vs Segmental Colectomy

Hajibandeh etal., found no statistical difference in total postoperative complications, anastomotic leak, severe complications, mortality, need for reoperation, or length of hospital stay. They did report a higher rate of postoperative ileus in in the ERH group compared to segmental colectomy [6].

Segmental Colectomy vs Left Hemicolectomy

Hajibandeh etal., found no statistical difference in total postoperative complications, anastomotic leak, severe complications, mortality, need for reoperation, or length of hospital stay [6]. In the ACS-NSQIP study, there was no difference in major morbidity rates [2].

Direct Comparison of4 Techniques: Subtotal Colectomy, Extended Right Hemicolectomy, Left Hemicolectomy andSegmental Colectomy

Wang, etal. reported no difference in need for reoperation, anastomotic leak, or mortality [7].

236

https://t.me/medicina_free

H. Bhatt and K. Mathis

Laparoscopic Techniques (all Operations Combined) Versus Open Technique

Martinez Perez found no difference in postoperative complication rates comparing patients undergoing MIS surgery versus open surgery. The time to tolerance of an oral diet and the length of hospital stay both favored the laparoscopic group [8].

Survival Outcomes

All studies showed no differences in overall survival or disease-free survival among all comparisons. Survival outcomes were reported as 5year outcomes in Hajibandeh etal., and Wang et al., studies [6, 7]. Wang etal., also reported no differences in local recurrence rates or distant recurrence rates [7].

Recommendation

After an in-depth review of the surgical literature for management of splenic exure adenocarcinoma, there is no consensus for a “best” operation. All operations, including extended right hemicolectomy, left hemicolectomy, segmental colectomy, and subtotal colectomy, have similar post-operative outcomes and no differences in long-term oncologic outcomes. Two surveys about surgeons’ choice regarding SFC resection approach yielded different outcomes, where one favored ERH at 63% [9] and the other favored SC for 70% [10]. Therefore, the surgical care of each patient with splenic exure adenocarcinoma should be individualized.

A principle of colon cancer surgery is to base the extent of resection on the lymphovascular drainage of the region where the tumor is located [11]. This is where some of the uncertainty stems from with splenic exure cancers as the lymphovascular drainage is not clear cut and predictable. Advocates of the ERH believe that lymph nodes along the middle colic proper should be removed in addition to those around the left colics while advocates of left hemicolectomy or segmental colectomy believe that left colic lymph node excision is sufcient. A clinical trial by Vasey etal., was conducted on 30 patients to assess the lymphatic drainage of SFC using scintigraphic mapping intraoperatively. It demonstrated that lymphatic ow was usually directed towards the left colic pedicle (96% of patients) followed by the left branch of the middle colic and the inferior mesenteric artery [12]. Watanabe etal., injected peritumoral indocyanine green at the time of laparoscopy for splenic exure adenocarcinoma and found that the left colic basin was dominant in most and one patient had ow along the left branch of the middle colic [13]. Additionally, there was uorescence along the inferior mesenteric vein in multiple patients [12,

13]. Both left hemicolectomy and segmental colectomy ligate the left branch of the

middle colic and the left colic vessels, so either operation would allow sufcient lymph node resection in the vast majority.

A signicant number of patients with SFCs will present with obstruction and require urgent operations. In these cases, there may be signicant dilation of the

<<< < Предыдущая 13 14 15 16 17 18 19 20 21 22 23 2425 / 5025 26 27 28 29 30 31 32 33 34 35 36 37 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202622 Мб0Книга_1068_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202622 Мб0Книга_1069_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202632 Мб0Книга_107_библиотеки_им_акад_М_И_Перельмана.epub
#
31.08.202622 Мб0Книга_1071_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202622 Мб0Книга_1072_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202622 Мб0Книга_1073_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202622 Мб0Книга_1074_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202622 Мб0Книга_1075_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202622 Мб0Книга_1077_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202622 Мб0Книга_1078_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_108_библиотеки_им_акад_М_И_Перельмана.pdf