Pathways for Optimizing the Examination and Treatment of Patients Who Underwent Colostomy Formation in Provincial Municipal Healthcare Institutions for Colonic Tumors

The dissertation is devoted to the problem of providing medical care to residents of small towns and rural localities who underwent colostomy formation in provincial municipal healthcare institutions for acute tumor-related obstructive colonic obstruction. It examines the features of diagnosis and surgical treatment of such patients in hospitals located outside regional administrative centers, as well as the possibilities of their subsequent examination and rehabilitation in specialized institutions of regional and federal rank. The work investigates organizational and technological pathways for improving treatment results, including the use of endovideosurgical technologies, mini-access, and computed tomographic colonography.

On the basis of medical-statistical data from a large agro-industrial region of the Russian Federation, the conditions of colostomy formation, the consequences of this intervention, the frequency of late postoperative complications, and the histological features of tissues in the colostomy zone are analyzed. Principles of continuity between municipal and specialized medical institutions and algorithms for staged medical care for this group of patients are developed.

Relevance of the problem

The treatment of patients with cancer of the colon and rectum is one of the pressing problems of modern abdominal surgery and oncology. The number of patients with colonic tumors is steadily increasing [26, 56, 157, 159]. Colon cancer is characteristic of industrially developed countries. It exhibits geographic and ethnic variations in occurrence. Colorectal cancer is frequently verified in the USA, Canada, and Japan, while its prevalence among the populations of India, China, and Vietnam is 10–12 times lower [242]. The problems of examination and treatment of patients with colon cancer are also relevant for Russia. If in 1960, according to data from the Oncology Research Center of the Russian Academy of Medical Sciences, 5,007 patients with newly diagnosed cancer of the colon and rectum were registered, then by 1992 the number of patients with this disease had increased more than 7-fold, amounting to 37,999 persons [61]. In 1999, more than 46 thousand new cases of colorectal cancer were detected in Russia, which exceeded by 22% the number of people who developed this pathology 10 years earlier [157]. In the structure of oncological morbidity in Russia, colon cancer occupies the third position [56, 61]. Despite the achievements in the diagnosis and treatment of colon and rectal cancer, the five-year survival rate for these tumors remains at 44.0–73.6%, while mortality exceeds 50% [152].

Among newly detected cases of malignant colonic tumors, the proportion of patients with advanced (III–IV) stages of the disease is 60–80% [104, 157]. It is precisely at the late stages of colorectal cancer that complications of the tumor process develop in most clinical observations: obstructive intestinal obstruction, tumor perforation, bleeding from the tumor, perifocal inflammatory infiltrate, and others [1, 209, 232, 244].

Particular interest attaches to the treatment of patients with colonic and rectal tumors complicated by acute obstructive colonic obstruction. At present, surgeons' views on the tactics of surgical treatment in patients with acute obstructive colonic obstruction are not unambiguous. Some authors recommend limiting the first stage to colostomy formation and postponing the radical operation to the second stage [69, 81, 193]. Other researchers, along with the relief of acute intestinal obstruction, strive toward primary resection of the bowel affected by the tumor [16, 46, 118]. A third group of authors, in treating obstructive colonic obstruction, aims at performing resections of the bowel with the tumor with simultaneous formation of an anastomosis [16, 41, 113].

The relief of obstructive intestinal obstruction is an emergency surgical intervention that is often carried out in general surgical units, frequently in provincial municipal healthcare institutions, where the conditions for performing the operation and the qualifications of the surgeons do not permit simultaneous resections with primary restoration of intestinal continuity [54, 81]. In these cases, as a rule, a colostomy is formed (with or without removal of the tumor), followed by treatment of the patients in specialized departments and centers of coloproctology [54, 81, 117].

Therefore, the study of the features of examination and treatment of residents of non-regional administrative centers who underwent colostomy for acute tumor-related obstructive colonic obstruction is of particular interest for practical healthcare and medical science.

Aim of the study: to improve the results of examination and treatment of patients who underwent colostomy formation in municipal healthcare institutions of small towns and rural localities for malignant colonic tumor complicated by obstructive colonic obstruction.

Objectives of the study

1. To analyze the results of medical care provided in municipal healthcare institutions of one of the regions of the Russian Federation for acute tumor-related obstructive colonic obstruction.

2. To assess the consequences of colostomy formation in provincial municipal healthcare institutions when providing medical care to patients with tumor-related obstructive colonic obstruction.

3. To formulate principles for the examination and treatment of patients who underwent colostomy for obstructive colonic obstruction in municipal healthcare institutions located outside regional administrative centers.

4. To identify pathways for improving the treatment results of patients in municipal healthcare institutions of small towns when they undergo colostomy formation for acute tumor-related obstructive colonic obstruction.

5. To develop an algorithm for providing medical care to patients who underwent colostomy in hospitals of small towns and rural localities for acute obstructive colonic obstruction.

Scientific novelty

The results of examination and treatment of patients who underwent colostomy for tumor-related obstructive colonic obstruction have been analyzed for the first time on the basis of medical-statistical data concerning the medical care of the population of a large agro-industrial region of the Russian Federation.

The conditions of colostomy formation in provincial municipal healthcare institutions when providing medical care to patients with acute tumor-related obstructive colonic obstruction have been studied.

Provisions of diagnostic and treatment tactics have been formulated with respect to patients who underwent colostomy for acute tumor-related obstructive colonic obstruction in municipal healthcare institutions located outside regional administrative centers.

The significance of the methodological and technological activity of specialized units of treatment-and-prophylactic institutions at the regional level in the prevention and elimination of the negative consequences of colostomy formation in municipal hospitals for patients with colorectal cancer has been demonstrated.

The possibilities of computed tomographic colonography in improving the examination of patients with colorectal cancer have been evaluated. It has been shown that performing computed tomographic colonography in patients who had previously undergone colostomy formation for acute tumor-related obstructive colonic obstruction makes it possible to substantially augment the clinical information, intraoperative data, and the findings of other special diagnostic methods with regard to the extent and resectability of the tumor process.

The complex of histological investigations carried out to assess the condition of tissues in the zone of colostomy formation, taking into account its competence, has made it possible to deepen the scientific knowledge of the etiopathogenesis of colostomy defects.

The possibilities of colostomy formation through a mini-access using the "Mini Assistant" instrument set in municipal healthcare institutions have been demonstrated in patients constituting a risk group for acute tumor-related obstructive colonic obstruction.

Organizational pathways for improving the results of treatment of patients with tumor-related obstructive colonic obstruction in the municipal formations of the region have been identified.

An algorithm has been developed for optimizing diagnostic and treatment tactics for patients with tumor-related obstructive colonic obstruction who were treated in provincial municipal healthcare institutions, with allowance for the further treatment of patients in specialized treatment-and-prophylactic institutions of federal and regional rank.

Practical significance of the work

Based on a study of data on the provision of medical care to patients with colorectal cancer in a single constituent entity of the Russian Federation, an assessment has been made of the surgical rehabilitation of patients who underwent colostomy under the conditions of provincial hospitals.

It has been shown that the number of negative consequences of colostomy formation in treatment-and-prophylactic institutions of small towns and rural settlements significantly exceeds the corresponding figure in hospitals of megacities, due to the technological imperfection of the surgical procedures performed by surgeons without adequate qualifications and to material-technical inadequacy.

Criteria for the choice of treatment-and-diagnostic tactics have been determined with respect to patients who underwent colostomy formation in municipal healthcare institutions for colonic obstructive intestinal obstruction of tumor genesis.

Basic principles have been formulated for the dispensary follow-up of patients after the relief of tumor-related obstructive colonic obstruction with colostomy formation in municipal healthcare institutions located outside regional administrative centers.

The list and sequence of the main treatment-and-diagnostic measures carried out for residents of small towns and rural localities in preparation for the elimination of the colostomy formed in provincial treatment-and-prophylactic institutions during the relief of acute tumor-related colonic obstruction have been determined.

The results of the introduction of computed tomographic colonography into the practice of examination of patients who underwent colostomy formation during the relief of acute tumor-related obstructive colonic obstruction have been evaluated.

The role of endovideosurgical technologies in the examination of patients with acute tumor-related obstructive colonic obstruction has been analyzed.

The possibilities of endovideosurgical interventions in the elimination of colostomy formed in patients during the relief of acute tumor-related obstructive colonic obstruction have been demonstrated.

Main propositions put forward for defense

1. In the relief of acute tumor-related obstructive colonic obstruction in municipal healthcare institutions located outside regional administrative centers, colostomy is the operation of choice in 87.4% of observations. The majority of patients who underwent colostomy in hospitals of small towns and rural localities subsequently have to continue examination and treatment in specialized regional and federal coloproctology centers.

2. Despite the undoubted positive value of colostomy formation in patients with acute tumor-related obstructive colonic obstruction as a life-saving operation, this surgical procedure is associated with a number of negative consequences that significantly affect the patients' quality of life in the postoperative period. In no fewer than 33.7% of cases, late postoperative complications develop in patients after colostomy.

3. The principles of providing medical care to patients who underwent the relief of acute tumor-related obstructive colonic obstruction with colostomy formation in municipal healthcare institutions should be based on: continuity in the work of medical institutions of different licensing levels, unified methodological approaches to the dispensary follow-up of patients, shared information support, and the accessibility of specialized care for each patient. Their surgical rehabilitation should be carried out in specialized institutions of regional and federal rank, where qualified specialists are available, along with appropriate equipment and possibilities for the dynamic observation of patients before and after surgery.

4. Pathways for improving the results of relief of acute tumor-related obstructive colonic obstruction with colostomy formation in municipal healthcare institutions may include: the use of endovideosurgical methods of examination of patients with intestinal obstruction of various etiologies, and the use of the "Mini Assistant" instrument set for the formation of a double-barreled decompressive colostomy in risk-group patients.

5. Pathways for improving the results of examination and treatment of patients with colostomy in specialized treatment-and-prophylactic institutions include: the use of computed tomographic colonography in the examination and the application of technologies of endovideosurgical restoration of colonic continuity after a Hartmann's procedure.

6. The provision of medical care to patients who underwent colostomy for acute tumor-related obstructive colonic obstruction in provincial municipal healthcare institutions should be carried out on the basis of a number of algorithms developed according to the staged approach to the examination and treatment of this group of patients and the continuity in the work of medical institutions of different licensing levels.

Personal participation of the author in the research

The author personally collected and analyzed the data of retrospective and prospective studies, evaluating the results of treatment of patients with acute tumor-related obstructive colonic obstruction who underwent colostomy formation. The applicant personally carried out the mathematical processing of the materials using statistical software. Since 2000, the dissertation author has directly participated in the examination of patients with colostomy and in carrying out surgical interventions on them.

Approbation of the work

The materials of the work were reported at: the VI All-Russian Scientific and Practical Conference dedicated to the 300th anniversary of Saint Petersburg and the 205th anniversary of the Military Medical Academy "Current Issues of Clinical Practice, Diagnosis, and Treatment in a Multidisciplinary Medical Institution" (Saint Petersburg, 2003); the Scientific and Practical Conference "Modern Technologies in Surgery" (Saint Petersburg, 2004); the All-Russian Scientific Conference with International Participation "Current Problems of Applied Anatomy, Operative and Clinical Surgery," dedicated to the 75th anniversary of Corresponding Member of the Russian Academy of Medical Sciences S.A. Simbirtsev; the First Congress of Ambulatory Surgeons of the Russian Federation (Saint Petersburg, 2004); the 5th All-Russian Scientific Forum "Current Problems of Surgical Diseases" (Moscow, 2004); the Scientific Conference with International Participation "Current Problems of Coloproctology," dedicated to the 40th anniversary of the State Scientific Center of Coloproctology (Moscow, 2005); the Ural Interregional Conference of Surgeons "Mini-access Surgery" (Yekaterinburg, 2005); the 2nd Congress of Military Physicians of the Medical-Prophylactic Profile of the Armed Forces of the Russian Federation (Saint Petersburg, 2006); the VIII All-Russian Scientific and Practical Conference "Current Issues of Clinical Practice, Diagnosis, and Treatment of Patients in a Multidisciplinary Medical Institution" (Saint Petersburg, 2007).

Implementation of the work

The results of the work are used in the educational process at the N.D. Monastyrsky Department of Surgery of the State Educational Institution of Additional Professional Education "Saint Petersburg Medical Academy of Postgraduate Education of the Federal Agency for Healthcare and Social Development," and have also been introduced into the practical activity of the clinics of the Saint Petersburg Medical Academy of Postgraduate Education and the surgical departments of: the State Healthcare Institution "Leningrad Regional Clinical Hospital," the Saint Petersburg State Healthcare Institution "City Aleksandrovskaya Hospital," and the Medical Center of the Federal State Unitary Enterprise "Admiralty Shipyards."

Based on the materials of the work carried out, recommendations for general practitioners entitled "Preventive, Therapeutic, and Rehabilitative Measures for Diseases of the 'Acute Abdomen' Group" (2006) have been compiled and adopted for mandatory use in the work of specialists of treatment-and-prophylactic institutions of Leningrad Oblast.

Publications

On the topic of the dissertation, 14 printed works have been published, of which three publications are in editions recommended by the Higher Attestation Commission.

Scope and structure of the dissertation

The work is set out on 282 pages of typewritten text and contains 57 tables and 32 figures. The dissertation consists of an introduction, 6 chapters, a conclusion, findings, and practical recommendations. The reference list includes 288 sources, of which 237 are Russian and 51 are foreign.