Optimization of Surgical Tactics for Complicated Forms of Colon Cancer

The research is dedicated to the optimization of surgical treatment for complicated forms of colon cancer, which are characterized by high incidence and significant postoperative mortality. The study develops a unified tactic for choosing one-stage and two-stage operations depending on the localization and type of tumor process complications. Special attention is given to obstructing cancer of the left half of the colon, where subtotal colectomy is proposed as the operation of choice, ensuring radical tumor removal and primary intestinal restoration.

Relevance of the problem. According to numerous publications, in recent years, a steady increase in the incidence of colon cancer has been registered worldwide [27, 41, 46, 57, 81, 89, 105].

Parallel to the increase in colon cancer incidence, the frequency of its complicated forms, which constitute 60-89% [33, 35, 92, 128, 149], is increasing. Patients with colon cancer complicated by obstructive intestinal obstruction (up to 85%), perifocal inflammation (12-35%), perforation (2.1-27%), and bleeding (4-15.3%) are admitted to general surgical hospitals via emergency medical care [4, 16, 17, 31, 38, 146, 164]. In connection with this, it has become logical that surgeons of the general healthcare network have to discuss and resolve issues of complicated colon cancer.

The results of surgical treatment of patients with advanced and complicated forms of the disease continue to be extremely unsatisfactory. Overall postoperative mortality reaches 17.9-58.3% and has no tendency to decrease [52, 123, 134, 135]. The frequency of postoperative purulent-inflammatory complications during operations at the level of acute intestinal obstruction reaches 38.6-80% [15, 36, 37, 44, 111]. Extremely high mortality (26-100%) remains at the time of tumor breakdown and perforation, diastatic rupture of the colon, rupture of the perifocal abscess, accompanied by the development of diffuse purulent-fecal peritonitis [5, 9, 78, 82]. The results of treatment are significantly affected by the fact that 80% of patients admitted in an emergency order generally have stage III-IV of the tumor process [35, 47, 54, 165]. Up to 82% of patients with a complicated course of colorectal cancer are elderly and senile individuals, of whom 96% have clinically significant comorbid pathologies [2, 43, 68, 93]. These figures clearly testify to the relevance of the problem of complicated colon cancer and provide a wide scope for scientific research.

At present, indications for surgical treatment of complicated forms of colon cancer have been developed, but there is still no consensus on some individual issues, and there is no unified approach to the treatment of such complications as perforation and perifocal abscessation. In particular, there is no proper clarity in the choice of treatment tactics for left-sided localization of an obstructing tumor, as evidenced by reports of recent years [17, 31, 72, 85, 157, 163].

Up to 65% of operations for complicated colon cancer of the left half of the colon end with the creation of various types of colostomies [23, 92, 93, 111, 136]. At that time, Hartmann's operations, performed in conditions of complicated course of colon cancer, in 16.3-48.4% of observations are accompanied by the development of purulent-inflammatory complications both in the paracolostomic area and in the abdominal cavity [20, 48, 91, 150]. Permanent disability of patients with a colostomy, the need for a repeated reconstructive operation, uncontrollable act of defecation, high frequency (50.3%) of paracolostomic complications represent a complex socio-medical problem requiring further resolution [23, 36, 41, 45, 50, 89, 131, 151, 160, 167].

Given such a state of the problem, it can be stated that at the current stage of development of surgery of complicated colon cancer there are more unresolved issues than clear treatment-tactical settings regarding the timing, volume, and type of surgical interventions, indications for their performance. In connection with this, there was a need to rethink and unify the surgical tactics in favor of expanding the indications for one-stage surgical interventions with consideration for the rehabilitation of patients in the socio-occupational aspect and the corresponding quality of life, as well as revising the positions of two-stage operations in urgent situations of colon cancer. These prerequisites determined the direction of this study.

Goal of the study: improving the results of surgical treatment of complicated forms of colon cancer.

Tasks of the study:

1. to develop a unified treatment tactic for complicated forms of colon cancer taking into account the immediate results of one-stage and two-stage operations;

2. to determine and justify the indications for one-stage and two-stage operations for various complications of colon cancer;

3. to study in a comparative aspect the immediate results of the application of one-stage and two-stage operations;

4. to justify the effectiveness of subtotal colectomy for obstructing cancer of the left half of the colon.

Scientific novelty

A unified surgical tactic for complicated colon cancer has been proposed, taking into account the rehabilitation of patients in the socio-professional aspect and the corresponding quality of life.

Based on a multifactor analysis of the immediate results, indications and contraindications for the performance of one-stage and two-stage operations have been developed, and the positions of the latter in the choice of surgical tactics for complicated forms of colon cancer have been determined.

Based on a comparative assessment of the immediate results of surgical treatment of complicated forms of colon cancer, the advantage of one-stage, primary-restorative operations over two-stage interventions has been clinically justified.

In case of obstructing cancer of the left half of the colon, subtotal colectomy has been proposed, characterized by single-stage nature, oncological radicality, and the possibility of early social and occupational rehabilitation of operated patients.

Practical significance

The application in clinical practice of a unified surgical tactic based on a differentiated approach to one-stage and two-stage interventions depending on the type of complication of colon cancer improves the immediate results of surgical treatment, which is confirmed by a decrease in the frequency of postoperative complications and mortality.

Expanding the indications for the performance of one-stage operations allows substantially reducing the treatment duration of patients with complicated colon cancer, which is determined by a decrease in the length of hospital stay and a reduction in the cost of the operation compared to staged surgical treatment.

The performance of subtotal colectomy for obstructing cancer of the left half of the colon ensures one-stage radical removal of the tumor and resolution of intestinal obstruction, primary restoration of intestinal continuity, and conditions for early social and occupational rehabilitation of patients.

Main provisions for defense

The application of the developed unified surgical tactic, based on a differentiated approach to one-stage and two-stage interventions, allows improving the results of surgical treatment of complicated colon cancer.

One-stage operations provide better results of surgical treatment of complicated forms of colon cancer compared to two-stage interventions, demonstrating low rates of postoperative complications, early socio-occupational rehabilitation, corresponding quality of life of operated patients, and medico-surgical effectiveness.

In case of obstructing cancer of the left half of the colon, the operation of choice is one-stage subtotal colectomy.

Implementation of the research results

The main results of the dissertation work are applied in clinical practice of the Department of General Surgery No. 1 and the Department of Proctology and Purulent Surgery of the OOOKB, in the educational process at the Department of Surgery of the Center for Postgraduate Medical Education in the city of Osh and the Department of Surgical Diseases of the Medical Institute of Osh State University.

Publicity of the research results

The main provisions of the dissertation work were reported at the International Scientific and Practical Conference dedicated to the 125th anniversary of the National Hospital of the Ministry of Health of the Kyrgyz Republic (Bishkek, 2004); International Scientific Conference of young scientists and specialists (Bishkek, 2006); meeting of the Academic Council of the Center for Postgraduate Medical Education in Osh (Osh, 2006); surgical society of the city of Osh and Osh region (Osh, 2006); interdepartmental publicity at the Center for Postgraduate Medical Education in Osh with the participation of surgeons of the OOOKB (Osh, 2007).

Publications

10 printed works have been published on the topic of the dissertation, and 2 rationalization proposals have been received (No. 12/07 "Method of performing subtotal colectomy for obstructing tumors of the left half of the colon" and No. 13/07 "Optimization of the precise technique of a single-layer continuous suture of intestinal anastomosis" dated 02.03.2007 at KGMA).

Volume and structure of the dissertation