Algorithms for selecting the extent of colonic resection in patients with visceroptosis

The dissertation is devoted to the surgical treatment of visceroptosis complicated by chronic colonic stasis. The author analyses the unsatisfactory outcomes of existing operative procedures and the associated high recurrence rate, caused by the absence of uniform criteria for assessing impaired motor-evacuatory function of the colon and of a consensus on the choice of resection extent. The work presents the results of a comprehensive clinical, endoscopic, radiological, radioisotope and morphological examination of patients, as well as an analysis of immediate and remote outcomes of various surgical interventions performed in the Republic of Sakha (Yakutia). On the basis of the data obtained, the author refined the clinical criteria for assessing the degree of impaired motor-evacuatory function of the colon and developed algorithms for selecting the extent of colonic resection according to the degree of compensation of chronic colonic stasis.

Visceroptosis complicated by chronic colonic stasis is one of the widespread diseases in the structure of colonic pathology. According to data from different authors, chronic colonic stasis (CCS) affects 30–40 % of the adult working-age population, with women suffering more often than men [49, 70, 88, 94, 101]. It has been reliably established that among the population over 60 years of age, the number of those suffering from constipation of varying degrees of severity increases, reaching 60 % [98, 127]. In the Republic of Sakha (Yakutia), a high prevalence of visceroptosis is noted, which allows it to be regarded as a regional pathology [49, 94].

Despite the numerous studies, the issues of surgical treatment remain controversial to this day, and the number of recurrences after surgical correction, according to a number of authors, reaches 27.3–45.9 % [18, 70, 101, 142, 146, 160, 167]. The causes of unsatisfactory results are both the imperfection of the criteria for assessing the impairment of the motor-evacuatory function of the colon and the absence of a consensus on the choice of the extent of colonic resection [65, 88, 89]. In this regard, some authors believe that the extent of the operative intervention should be no less than a subtotal resection of the colon [83, 87, 111, 116, 137, 149, 150, 151], while others propose various extents of isolated colonic resections [97, 99], or left-sided hemicolectomy [49, 94].

All of the above testifies to the relevance of the problem of surgical treatment of visceroptosis complicated by CCS and to the necessity of its further study.

Aim of the study: to improve the results of surgical treatment of chronic colonic stasis in visceroptosis.

Objectives of the study:

1. to study the clinical signs of decompensation of the motor-evacuatory function of the colon in patients with visceroptosis;

2. to carry out an analysis of remote results of various methods of surgical treatment of CCS in patients with visceroptosis;

3. to develop an algorithm for selecting the extent of colonic resection in patients with visceroptosis.

Scientific novelty: as a result of the comprehensive study of surgical treatment of patients with visceroptosis complicated by chronic colonic stasis, for the first time:

1. the clinical criteria for assessing the degree of impairment of the motor-evacuatory function of the colon have been refined;

2. the algorithms for diagnosis and selection of the extent of colonic resection in the complex surgical treatment of visceroptosis have been refined.

Statements submitted for defence:

1. in patients with visceroptosis, the clinical indicator of CCS decompensation is the absence of independent stool;

2. the method that allows one to reliably identify the degree of decompensation of the motor-evacuatory function of the colon is radioisotope dynamic scintigraphy using 99mTc-brommesida;

3. in cases of decompensation of CCS, the extent of the operative intervention should be no less than a subtotal resection of the colon, while in cases of subcompensation, resection of the left flank of the colon with bilateral colopexy is effective.

Practical significance: refined algorithms for diagnosis and selection of the extent of operative intervention are proposed, allowing improvement of the results of surgical treatment of chronic colonic stasis in patients with visceroptosis.

The work was carried out at the Department of Hospital Surgery of the Medical Faculty of the Medical Institute of Yakutsk State University. I consider it my duty to express deep gratitude and appreciation to my teacher, the supervisor of the candidate dissertation, the Head of the Department of Hospital Surgery of the Medical Institute of YSU, Doctor of Medical Sciences L. V. Tobokhov, for the opportunity to carry out this work and for the invaluable assistance and support provided during its preparation. I express my gratitude to the staff of the Department of Hospital Surgery of the Medical Institute of YSU and to the team of Surgical Unit No. 2 of RB No. 1 — MTsM, who participated in the development and introduction into clinical practice of the algorithms for selecting the extent of colonic resection and the complex surgical correction of visceroptosis.