Pathways to Optimising the Preparation for Radical Treatment of Patients with Colon Cancer Complicated by Acute Obstruction

The dissertation is devoted to the optimisation of preoperative preparation of patients with colon cancer complicated by acute intestinal obstruction for radical surgical treatment. The work summarises data on the diagnostic capabilities of special methods of investigation — plain radiography, irrigoscopy, rectosigmoidoscopy, colonoscopy, laparoscopy, ultrasonography, computed tomography and magnetic resonance imaging — in obstructive colonic obstruction of tumour origin. The effectiveness of conservative, endoscopic and minimally invasive methods of decompression is assessed in relation to the dimensions of the cancerous canal and the localisation of the stricture. The dynamics of changes in the level of intoxication, indices of intra-abdominal pressure and the state of the intestinal wall are studied for various options of decompression therapy. On the basis of the results obtained, a rational programme for the application of various methods of decompression and for the intra- and postoperative correction of metabolic disturbances in this category of patients is proposed.

INTRODUCTION

Relevance of the Problem. One of the most complex issues in emergency surgery and oncology remains the treatment of colon cancer complicated by acute obstruction. Despite the introduction of modern diagnostic and therapeutic technologies into medical practice over the past 20–25 years, mortality in this pathology, according to various authors, ranges from 15 to 25 % and shows no tendency to decrease [1, 12, 138, 169, 170, 181, 182, 189, 266, 281].

In the treatment of patients with colon cancer complicated by obstruction, surgeons face the challenge not only of saving the patient's life from acute surgical pathology but also, where possible, of curing the oncological disease, which requires radical surgical interventions and combined methods of treatment [4, 8, 9].

However, in the majority of patients aged 60 years and older, alongside the severity of the disease itself there are numerous comorbidities that may themselves complicate the intra- and postoperative period and lead to fatal outcomes [74, 167, 176, 192, 225, 229, 230, 266, 281]. Therefore, the performance of radical surgical interventions increases the risk of complications and fatal outcomes; consequently, some surgeons prefer to administer conservative therapy on admission to most patients with colon cancer complicated by obstruction, reasoning that a tumour almost never causes complete luminal obstruction [141, 198, 213, 256].

According to other authors, a sustained positive effect of conservative treatment is observed in only 10–25 % of cases [2, 67, 95, 208, 127, 173, 224].

At present there is also no consensus regarding the duration of the preoperative period [204, 284].

Some authors believe that in colon cancer complicated by obstruction, conservative treatment should not be continued for more than 2–3 hours; during this time it is necessary to decompress the upper and lower intestinal segments and correct fluid and electrolyte disturbances, whereas more prolonged conservative treatment reduces the chances of a favourable surgical outcome [4, 47, 78, 80, 85, 118, 192].

According to a number of surgeons, after surgical interventions performed later than 24 hours, the number of postoperative complications and fatal outcomes is significantly higher [78, 85, 204]. Some recommend continuing preoperative preparation for 24 hours [49, 219, 222], while others allow preoperative preparation for up to 2 days [47, 114, 131, 145, 217], considering that in obstructive impairment of colonic patency the clinical and radiological semiology accumulates comparatively slowly in most cases.

The most tactically complex group remains patients in whom, against the background of conservative treatment, a temporary improvement in general condition and partial passage of stool and flatus can be achieved. This leads many surgeons to believe that decompression and infusion therapy are successful, and they continue them even during recurrent attacks of obstruction. Consequently, the favourable moment for surgical intervention is missed, and mortality and postoperative complication rates rise significantly [151, 204]. To improve the outcomes of surgical treatment in this cohort of patients, many authors propose relieving the obstruction at the first stage by conservative or minimally invasive methods, and then performing the radical surgical intervention at the second stage under maximally favourable conditions [1, 6, 276].

However, despite the clearly defined objective, the proposed solutions are rather contradictory. Some recommend starting with conservative methods of decompression; others suggest using endoscopes to apply various techniques for recanalising the cancerous canal; a third group advocates performing laparotomies at the first stage and constructing unloading proximal stomas; and a fourth group creates proximal stomas at the first stage using laparoscopic or mini-access approaches [10, 15, 65, 196, 285, 311].

Adequately performed decompression in patients with complicated colon cancer creates favourable conditions for combined treatment, which undoubtedly improves both the immediate and the long-term results of treatment.

Aim of the Study: To develop a rational programme for the use of various methods of decompression in patients with colon cancer complicated by acute obstruction.

Objectives of the Study:

1. To assess the diagnostic capabilities of the special methods used in the diagnosis of colon cancer complicated by acute obstruction, including for the selection of the most effective method of decompression.

2. To determine the dimensions of strictures in patients with colon cancer complicated by acute obstruction and their influence, as well as the influence of tumour localisation, on the effectiveness of decompression therapy.

3. To study the dynamics of changes in the level of intoxication, indices of intra-abdominal pressure and intestinal wall dimensions when using various methods of decompression therapy.

4. To investigate the possibilities of minimally invasive methods of decompression depending on stricture size in patients with colon cancer complicated by obstruction, and to refine them.

5. To refine existing minimally invasive methods of decompression in colon cancer complicated by acute obstruction.

6. To develop a rational programme for the application of various methods of decompression in patients with colon cancer complicated by acute obstruction.

Scientific Novelty of the Study:

The capabilities of modern special methods used in the diagnosis of colon cancer complicated by acute obstruction have been refined, and a rational programme for their use has been developed.

For the first time in patients with colon cancer complicated by acute obstruction, the effectiveness of conservative methods of resolving obstruction has been studied in relation to the size of the cancerous canal and the localisation of the stricture.

For the first time in patients with colon cancer complicated by acute obstruction, a comparative assessment has been made of the effectiveness of various methods of resolving obstruction using endoscopes.

Minimally invasive methods of decompression have been refined, allowing more effective decompression and detoxication therapy.

For the first time, the dynamics of changes in the intestinal wall, intra-abdominal pressure and intoxication syndrome have been studied in patients with colon cancer complicated by acute obstruction depending on the method of decompression.

A rational programme for the application of various methods of decompression in patients with colon cancer complicated by obstruction has been developed.

Practical Significance of the Work:

1. The diagnostic programme developed makes it possible to determine within a short period the duration of preoperative preparation, to select individually for each patient the necessary method of decompression, to facilitate its more successful implementation, and to determine in the preoperative period the extent of the surgical intervention and other methods of treatment.

2. The study of the dependence of the course of acute impairment of patency during decompression therapy on the size of the cancerous canal and the state of its wall allows refinement of the indications for conservative and minimally invasive methods of resolving obstruction.

3. Studies of the effectiveness of recanalisation of the cancerous canal in patients with strictures of various sizes by endoscopic methods allow refinement of the indications for their use, reduction of the number of complications, and lowering of material costs.

4. The use of the method of forced early postoperative evacuation of intestinal contents and irrigation of the intestinal lumen makes it possible to reduce the level of intoxication and the probability of inflammatory complications at an earlier stage.

5. The programme of intra- and postoperative correction of intoxication syndrome, metabolic disturbances and changes in the intestinal wall developed on the basis of the study allows optimisation of preoperative preparation for radical intervention, reduction of the number of postoperative inflammatory complications, anastomotic failure and fatal outcomes.

Statements Defended:

1. Acute obstruction in colon cancer may develop already with a stricture of less than 17 mm, but complete obturation of the intestinal lumen by the tumour does not occur in any case. In patients with a cancerous canal greater than 50 mm, necrotic changes and tumour disintegration develop in its middle part.

2. An algorithm for using the most effective methods of decompression in patients with colon cancer complicated by acute obstruction.

3. Methods for the more effective elimination of intoxication syndrome, intra-abdominal hypertension and correction of metabolic and cardiovascular disturbances in patients with targeted stomas created for colon cancer complicated by acute obstruction.

Personal Contribution of the Author

The author personally conducted the analysis of domestic and foreign literature on the topic of the dissertation. The author personally participated in the design of the dissertation research plan, the development of the computer database, the processing of medical documentation, and the statistical processing of the information obtained. The author personally took part in the diagnosis and treatment of patients with colon cancer complicated by acute obstruction and introduced the developed methods of treatment into practice.

The materials of the dissertation were reported and discussed at: a meeting of the Society of Surgeons of the Republic of Ingushetia (2010); a joint meeting of the Society of Surgeons of the Republic of North Ossetia–Alania and the Department of Hospital Surgery of the North Ossetian State Medical Academy (2010); the Research-to-Practice Conference of Surgeons and Anaesthesiologists–Resuscitators of the North Caucasus Federal District with international participation "Minimally Invasive Technologies in Surgery and Their Anaesthesiological Support" (Vladikavkaz, 2013); the Research-to-Practice Conference of Surgeons and Anaesthesiologists–Resuscitators of the North Caucasus Federal District with international participation "Minimally Invasive Technologies in Surgery and Their Anaesthesiological Support" (Vladikavkaz, 2014).

Implementation of Results

The results of the study have been implemented in the work of the Republican Clinical Hospital of Nazran, Republic of Ingushetia, and the Emergency Clinical Hospital of Vladikavkaz. The results are used in the educational and scientific process of the Department of Surgical Diseases No. 2 of the North Ossetian State Medical Academy and the Department of Surgical Diseases of the Medical Faculty of the Ingush State University.

Publications

On the topic of the dissertation, 14 scientific works have been published, of which 8 are in journals recommended by the Higher Attestation Commission of the Russian Federation.

Volume and Structure of the Dissertation

The dissertation consists of 163 pages of computer text and includes an introduction, a review of the literature, 4 chapters containing the results of original research, findings, practical recommendations and a bibliography containing 234 works by domestic and 87 works by foreign authors, illustrated with 27 tables and 14 figures.

CHAPTER 1.

(REVIEW OF THE LITERATURE)

1.1. Diagnosis in Patients with Colon Cancer Complicated by Acute Obstruction

One of the most complex issues in emergency surgery and oncology remains the treatment of colon cancer complicated by acute obstruction [78, 164, 204, 205, 206, 242, 251, 252, 257, 284, 300]. Despite the introduction of modern diagnostic and therapeutic technologies over the past 20–25 years, mortality in this pathology, according to various authors, ranges from 15 to 40 % and shows no tendency to decrease [9, 44, 78, 96, 107, 119, 121, 126, 128, 161, 164, 174, 205, 206, 212, 216].

Despite the high effectiveness of modern diagnostic methods and the distinctness of clinical signs, the diagnosis of acute obstructive impairment of colonic patency is associated with considerable difficulties [68, 78, 166, 224]. According to E.A. Erokhina and co-authors (2011), in approximately 9 % of patients hospitalised with the clinical picture of acute obstructive colonic obstruction, diagnostic errors were made that led to the development of peritonitis.

The diagnosis of intestinal obstruction must, unquestionably, be based on a thorough consideration of anamnestic data and the results of physical, radiological, endoscopic and laboratory investigations [8, 18, 47, 77, 78, 114, 144, 181, 182, 209, 281].

A competently collected history, in the opinion of N.N. Aleksandrov (1980), greatly facilitates the diagnosis not only of intestinal obstruction but also of its cause — colon cancer. For this pathology, the history is of particular importance, because the data obtained by interviewing the patient help not only to narrow the range of probable diseases and suspect the presence of a malignant tumour but also, in a number of cases, to suggest its localisation and possible complications.

Despite the availability of modern special instrumental methods for diagnosing acute colonic obstruction, in which the cause of its development is, as a rule, an advanced form of cancer, abdominal palpation remains a rather valuable method, allowing the search for the tumour to be guided. Neoplasms located in areas accessible to palpation can usually be felt. According to the observations of N.N. Aleksandrov (1980), in obstructive obstruction caused by cancer of the right half of the colon, the tumour was detected by palpation in 59 % of patients, and in cancer of the sigmoid colon in 32.1 %. According to I.A. Eryukhin and co-authors (1999), the tumour in the abdomen can be palpated in approximately every third patient admitted to the clinic with intestinal obstruction in colon cancer. L.I. Shvidler and A.L. Chekhov (2003) were able to identify a palpable tumour in 40 % of patients. S.D. Ataev and co-authors (2011) identified a palpable tumour in 62 % of patients.

In the opinion of many surgeons, digital rectal examination has not lost its significance in the diagnosis of colon cancer complicated by obstruction, since in 8–15 % of patients the tumour lies within the reach of a digital examination. At the same time, one can not only diagnose the tumour but also, by palpation, determine the size of its distal part, the degree of mobility and the diameter of the cancerous canal [4, 47, 60, 99, 104, 114, 143, 144, 205].

It should be noted that, whereas there are relatively uniform views and recommendations regarding clinical methods, there is no consensus on the use of special methods [231, 236, 261, 279, 303].

The only special diagnostic method whose use practically does not give rise to discussion in acute obstructive colonic obstruction is plain abdominal radiography [7, 18, 63, 78, 103, 144, 148, 157, 164, 228, 232, 238, 299]. Although opinions on its effectiveness differ.

Topuzov E.G. (1986, 1989), R.A. Melnikov (1987), A.S. Balalykin and co-authors (1989), V.N. Blokhin and co-authors (2005), and W.G. Cheadle et al. (1989) believe that in 25–30 % of patients radiological methods of investigation do not allow an accurate diagnosis to be established. According to B.M. Datsenko and co-authors (2005), the informative value of plain abdominal radiography does not exceed 66 %; similar data are reported by T.I. Tamm and co-authors (2011). In the opinion of M.P. Zakharash and co-authors (2009), the informative value of radiological investigation in patients with obstructive colonic obstruction is 55 %.

At the same time, the work of most surgeons attests to the high effectiveness of plain abdominal radiography [18, 19, 77, 78, 147, 164, 181, 221, 226, 281].

Olshansky A.A. and co-authors (1982) consider untimely radiological examination to be one of the main causes of diagnostic errors in acute intestinal obstruction.

In the opinion of V.Z. Totikov (1993), with the aid of plain abdominal radiography one can not only diagnose the presence of acute colonic obstruction but also, in 91–100 % of cases, approximately determine the level of tumour localisation, evaluate the effectiveness of decompression therapy and predict the dynamics of obstruction against its background.

Irrigoscopy is of particular importance for the diagnosis of colonic obstruction. According to most authors, the goal of investigation by irrigoscopy is achieved in 87.4–91.9 % [46, 47, 81, 94, 164, 188, 197, 226]. V.P. Zinevich (1985) notes a hundred-percent diagnostic effectiveness of irrigoscopy in acute colonic obstruction. In the opinion of I.A. Eryukhin and co-authors (1999), irrigoscopy must be performed in all cases of clinical suspicion of colonic obstruction. This investigation allows not only the establishment of the presence of obstruction but also the identification of its localisation.

V.Z. Totikov (1993), using irrigoscopy, determined, in addition to the presence of an obstruction in the colon and its localisation, the dimensions of the cancerous canal.

However, the question of the admissibility of radiological investigation with a contrast agent in patients with intestinal obstruction still has no unambiguous solution. N.N. Aleksandrov (1980) considers the use of this method acceptable when there is doubt about the diagnosis or when the patient exhibits symptoms of partial intestinal obstruction. According to A.I. Perevoznikov (1999), emergency irrigoscopy is ineffective in 60 % of observations, which is explained by incontinence of the barium enema and poor preparation of the colon, with up to 30 % diagnostic errors. V. Radunovic (1979) and N. Addison (1983) believe that with clear symptoms of intestinal obstruction one can operate without irrigoscopy.

Rectosigmoidoscopy is used by many surgeons in the diagnosis of colonic obstruction [4, 7, 47, 60, 104, 110, 114, 143, 182, 264, 288].

This method allows, in distal cancers of the colon, not only detection of the presence and level of the obstruction but also determination of the diameter of the stricture and an attempt at decompression [28, 62, 70, 204, 205, 206, 321]. At the same time, A.A. Balalykin (1989) considers that, when obstructive impairment of colonic patency is suspected, endoscopic examination should be performed with a colonoscope. This allows inspection of all parts of the colon, whereas with a rectoscope one can inspect only the distal parts of the sigmoid colon; consequently, this investigation is effective in only 2–15 % of patients, and in most cases colonoscopy must additionally be performed.

Endoscopic investigation is of great importance in the recognition of colon cancer complicated by obstruction [25, 40, 74, 75, 106, 147, 148, 150, 151, 178, 179, 210, 211, 217, 221, 228, 240, 244, 264, 267, 307, 321].

In the opinion of V.P. Petrov and co-authors (1984), V.I. Struchkov and co-authors (1984), L.U. Nazarov and co-authors (1986), and T.E. Brothers et al. (1987), the cause of obstruction, its level and the degree of narrowing of the cancerous canal can be identified in more than 94 % of patients. In the observations of Y.B. et al. (2011), emergency colonoscopy made it possible to establish the cause of colonic obstruction in 100 % of cases. According to B.N. Kuryazov and co-authors (2011), emergency colonoscopy was effective in 16 of 18 patients in whom it was performed to clarify the diagnosis. Colonoscopy allows, along with visualisation of the tumour, sampling of material for histological investigation, which is a necessary attribute of preoperative diagnosis [283]. In the opinion of S.G. Belov and co-authors (2000), B. Turgano-Puellas et al. (1998), and Y.B. et al. (2011), in certain cases this method may also pursue therapeutic goals, such as passing a tube proximal to the stenosing tumour for decompression and an attempt thereby to resolve the phenomena of obstruction.

Despite the high effectiveness of colonoscopy in the diagnosis of obstructive colonic obstruction, E.G. Topuzov (1989), G.V. Pakhomova (1987, 2009) and others recommend a cautious approach to this method of investigation, considering that air insufflation may lead to progression of the intestinal obstruction or perforation of the bowel. V.I. Yukhtin (1988) notes that colonoscopy at the height of intestinal obstruction is poorly tolerated by patients, and the number of diagnostic errors and unsuccessful investigations reaches 10–15 %. N.I. Korotkov (2003) considers that performing colonoscopy in the setting of acute intestinal obstruction presents considerable difficulties; moreover, the informative value of this method in acute intestinal obstruction is lower than in the chronic form.

In the opinion of I.Yu. Oleynikov and co-authors (1993), A.I. Perevoznikov (1999), A.E. Borisov and co-authors (2000), A.I. Bregel and S.B. Pinsky (2000), and K.L. Staroseltsev (2005), the laparoscopic method in the diagnosis of colon cancer complicated by obstruction is a highly effective and safe means of identifying the cause of obstruction in 88 % of cases, determining tumour localisation, the presence of invasion into adjacent organs, perifocal inflammation and comorbidities.

V.I. Petrov and O.E. Lutsevich (1982) consider that laparoscopic investigation allows detection of up to 50 % of abdominal diseases not diagnosed by traditional methods. However, in the opinion of I.A. Eryukhin and co-authors (1999), sharp distension of intestinal loops not only impedes inspection but also presents a danger because of the possibility of damage to abdominal organs. After emergency laparoscopies, according to Yu.P. Atanov (1981), mortality reaches 2 %. Consequently, when this method is used in patients with colon cancer complicated by impairment of patency, in most cases accompanied by an adhesive process around the tumour and in the abdominal cavity, the number of complications will undoubtedly be higher.

At the same time, in the opinion of A.V. Pugaev and E.E. Achkasov (2005), judgements on the diagnostic value of this method are currently contradictory, since the authors discussing the need to apply laparoscopy in acute colonic obstruction present a small number of observations.

Ultrasonographic investigation has also become widely used in the diagnosis of colon cancer and its complications. Possessing high resolving power and informativeness, ultrasound examination is an almost harmless diagnostic method [25, 33, 68, 69, 83, 94, 104, 109, 111, 122, 129, 164, 248, 270, 294, 314].

Despite the broad implementation of ultrasound in the diagnosis of colon cancer complicated by acute obstruction, to date some authors use ultrasonographic investigation only to establish the fact of obstruction, while others use it, in addition, to detect the tumour itself and metastases [68, 69, 94, 104, 109, 111, 122, 164, 204, 205, 206, 207]. Some researchers note the effectiveness of ultrasound for determining tumour size and its relation to surrounding organs and tissues, as well as the presence of a perifocal inflammatory process [41, 60, 109, 207, 214, 220]. There are reports describing the dimensions of the cancerous canal, the presence of effusion and the severity of changes in the intestinal wall [41, 60, 83, 109, 173, 207, 214, 220, 285, 286, 294].

Totikov V.Z. and co-authors (2011, 2013) used ultrasonographic investigation to predict the development of acute obstruction against the background of decompression therapy.

In the observations of M.P. Zakharash and co-authors (2009) and T.I. Tamm and co-authors (2011), the informative value of ultrasound in the diagnosis of obstructive colonic obstruction of tumour origin was 100 %, with tumour localisation identified in 70 % and 64.8 % of cases, respectively. According to B.M. Datsenko (2005), the informative value of ultrasound in the diagnosis of acute intestinal obstruction is 97 %. At the same time, in the opinion of S.Yu. Dvoynikov (2003), ultrasound as an independent method cannot solve many important problems in the diagnosis of acute colonic obstruction; consequently, its use is rational only in constant interaction with other methods of investigation.

In recent years, computed tomography has been successfully employed in the differential diagnosis of abdominal diseases [8, 42, 75, 132, 270, 276]. In the opinion of E.I. Brekhov and co-authors (2011), computed tomography is a considerably more informative method than other diagnostic techniques for determining tumour boundaries, its localisation and the degree of invasion into adjacent organs and tissues in patients with colonic obstruction.

Recently, publications have appeared in which the authors, in acute colonic obstruction, quite clearly describe not only the dimensions of the tumour itself, the presence of metastases and the relation of the tumour to surrounding organs and tissues, but also the dimensions of the tumour canal, the thickness of the tumour and intestinal walls.

The most modern method of imaging is NMR (nuclear magnetic resonance). This method makes it possible, without ionising radiation, to obtain an image of any organ or tissue of the human body and to examine it from any angle and in a new projection. Whereas with CT the image is obtained according to one parameter, an NMR image allows characterisation of tissues by five parameters.

Analysis of the literature indicates that NMR tomography is one of the most promising methods of imaging internal organs; together with its non-invasiveness, this investigation is advancing to a leading position in the diagnostic armamentarium.

However, the high cost of the equipment prevents most general clinical hospitals from having CT and NMR in their diagnostic armamentarium; consequently, in the diagnosis of colon cancer complicated by obstruction this method is used extremely rarely, and studies devoted to it are few.