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SURGICAL TREATMENT OF COLORECTAL CANCER

SURGICAL TREATMENT OF COLORECTAL CANCER
Mereuta Ion, doctor of medicine, full professor

Rusu Porfirie, doctor of medicine, full professor

Laur Veaceslav, surgeon-proctologist oncologist

Nicolae Testemitanu State University of Medicine and Pharmacy, Moldova

Conference participant

По распространенности рак ободочной и прямой кишки, хотя и уступает первенство онкологическим заболеваниям других органов, является весьма серьезным недугом. Основным методом лечения рака толстой кишки остаётся радикальное удаление опухоли и зоны её регионального лимфогенного метастазирования.

Общие принципы хирургического лечения рака толстой кишки: радикальность, абластичность, асептичность и создание беспрепятственного отхождения кишечного содержимого, по возможности, естественным путём. Успех хирургического лечения, соблюдение его принципов в значительной степени зависит от правильной подготовки толстой кишки.

В последнее годы всё большее распространение получают местнораспрастаненные формы колоректального рака, которые требуют хирургического и комплексного лечения.

Ключевые слова: местнораспрастаненный колоректальный рак, хирургическоеи комплексное  лечение, комплексное лечение.

Even though colorectal cancer is less prevalent than various other oncological diseases of other organs it still remains a very serious affliction. Complete resection of the tumor and its zone of  lymphogenic metastasis still remains to be the main method of treatment.

Common principles of surgical treatment of colon cancer are: radicalness, ablastics, asepticism and providing safe way for gastric contents to exit, preferably in a natural way. The success of surgical treatment is largely dependent on proper preparation of the colon.

In the last years, colorectal cancer with regional extension forms requiring surgical and complex treatment, are more and more common.

Keywords: colorectal cancer with local regional extension, surgical and complex treatment, complex treatment.

 

Clinical studies are the base for promoting modern methods of treatment, introduction of new medications for clinical usage, diagnostical and therapeutic procedures. The involvement in the clinical studies is primarily based on assuring the security of the patient and him getting a complete course of treatment regardless of the group he is in.

In the last decades colorectal cancer took the leading position among other oncological diseases in Europe and USA but the mortality rate was decreased to 40% since the 90’s.

Epidemiologic investigations in most developed countries helped discover a close connection between the increase in morbidity rate with colorectal cancer and the three main factors:

  • • The increase in animal fats and proteins consumption;
  • • The decrease in consumption of dietary fibers. Excessive refinement of carbohydrates leads to the reduction of the non-absorbable cellulose, which represents a kind of absorbents for exogenous and endogenous carcinogenic substances; it also leads to increase in time it takes for substances  to pass through the intestines.
  • • The less dynamic style of living of modern individuals, which also leads to decreased passage speed throughout the intestines.

Colorectal cancer is the third in frequency both in men (663,904 cases, representing 10.0% of all malignancies) and women (571,204 cases - 9.4% of all malignancies) in the whole world.  New research of colorectal cancer (CRC) has been imposed by the continuous increase of the disease incidence both in developed countries, which have already registered high levels of prevalence, and in countries where CRC rates were not concerning before. Colorectal cancer (CRC) is nowadays one of the most frequent malignant tumors in the Western world, leading to local invasion or adhesion to surrounding organs in 5% to 20% of the patients. Such situation may demand different operative strategies and technical skills from the surgical team. In this context, a proper oncologic approach includes an en-bloc multivisceral resection of all organs and/or structures involved. Since distinction between inflammatory or neoplastic adhesions can only be achieved through pathological assessment, separation of the affected organs is not advised to prevent dissemination of malignant cells and tumor perforation. Although locally advanced colorectal lesions were considered inoperable just a couple of decades ago, more extensive procedures are nowadays the only chance for a cure, besides the actions with potentially greater operative risk. Locally advanced primary and locally advanced recurrent cancer of the colon and the rectum are surgically challenging due to clinical presumption of tumor involvement in others structures and organs. The estimated need for extensive surgical resection, often with multiviscseral en-bloc resection is crucial for preoperative surgical planning. As for the primary and the recurrent tumors, postoperative long-term survival is achievable, but only after complete R0- resection. The role of neoadjuvant and adjuvant therapy continues to be prevalent in this era of biological chemotherapies as a multimodal treatment that provides an opportunity for the technical realization of resection and improves long-term survival. Definition of locally advanced disease is necessary in order to achieve practical and theoretical clarity regarding a relatively big percentage of patients with colorectal cancer who are to be treated by a surgeon. Some patients with cancer of the colon or rectum present a different shape and extent of locally advanced primary or recurrent tumor, but in the stage of non-metastatic disease, which, despite the lack of generalization, might be resected. Unresectability criteria are variable and not clearly defined.

Purpose of research: To improve results of complex treatment of colorectal cancer with local-regional extension through the study of clinical specifics of colorectal cancer with local-regional extension, to create new methods of surgical and complex treatment

Materials and methods: The study group consisting of 86 patients.

The vast majority of patients with colorectal cancer with expansion to the adjacent organs were in the sixth decade of their life (34,9%), followed by patients in the fifth decade (29,1%). The patients were mainly female - 53.5%, compared to the male percentage of 46.5%.

Results and discussion:CC with tumor extension to adjacent organs and tissues most often (39.5%) occurred in the sigmoid  intestine, followed by the ascending portion (20.9%), hepatic angle (16.3%), cecum (13.9%), descending colon (4.7%), transverse colon and splenic angle (2.3%). Out of 86 patients, II (T3-4 NO MO) evolutionary stages of the disease were in 46.5% patients. It should be noted that in this group of patients in 33 cases out of 40 (82.5%) the evolutionary stage of the disease was classified as T4 tumor with invasion of the intestinal wall, including the serous layer, and in some cases intestinal mesentery. A group of patients with metastases in regional lymph nodes represents 53.5% cases. In most cases (51.2%) is extended as colon cancer tumor locations compared to the left colon (46.5% cases). Organs and tissues that were involved in the neoplastic process : retroperitoneal and pasranefral tissue (27.9%), smal  intestine (20.9%); abdominal wall (14%); mesocolon –(14%). Uterine annexes, uterus (8.1%), urinary bladder (4.7%) were involved in the cases of sigmoid bowel cancer tumors. In 89.5% of  cases after tumor excision, the restoration of intestine continuity did not require protective colostomy. 9 (10.5%) patients wes used  the reason for the association of intestinal occlusion was used colon resection with intestinal anastomosis with application of protective colostomy.

ICC was performed over 50 (58.1%) patients. The most common ICC were in the small intestine and colon resections-18 (20.9%) patients and abdominal wall resection-12 (13.9%) patients. In 13.9% of cases affected colon tumors invaded meso, 17.4% and 10.5% retroperitonial tissue and paranefral tissue respectively. Operations performed under such conditions were considered as typical. Overall, ICC-removal of a segment of bowel with tumors was done to 50 (58.1%) patients. In 36 (41.9%) patients with local colon cancer that spread to meso- and paranefral and retroperitoneal tissue were performed typical operations  depending on  tumor localization.

The most common colon resections ICC was combined with resection of the small intestine in 20.9%  cases. Pathomorphological study of pieces removed in surgery brought to a conclusion that tumor invasion of neighboring organs in 67.4% of cases and in 32.6% of cases the tumor adjacent organ damage proved to be of inflammatory origin.

Colorectal cancer is extremely susceptible for treatment in its early stages. That is why scientists are carrying out expositional work regarding periodical health examinations and are also developing different methods for early diagnosing of the disease.

 

References:

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  • 2. CD24 shows early upregulation and nuclear expression but is not a prognostic marker in colorectal cancer / M.A. Ahmed, A. Al-Attar, J. Kim et al. // J. Clin. Pathol. 2009. - Vol. 62, N 12. - P. 1117-22.
  • 3. Colon and rectum. In: American Joint Committee on Cancer: AJCC Cancer Staging Manual. 7th ed. NY: Springer, 2010. P. 143.
  • 4. Colorectal cancer / K. Takahashi, H. Matsumoto, T. Yamaguchi et al. // Gan to Kagaku Ryoho. 2009. Vol. 36, N 9. P. 1408-13.
  • 5. Efficacy of an endo-knife with a water-jet function (Flushknife) for endoscopic submucosal dissection of superficial colorectal neoplasms / Y. Takeuchi, N. Uedo, R. Isnihara et al. // Amer. J. Gastroenterol. 2010. Vol. 105, N2.-P. 314-22.
  • 6. Guenaga K., Atallah A.N., Castro A.A. et al. Mechanical bowel preparation for elective colorectal surgery // Cochrane Database Syst. Rev. 2009. №1. CD001944.
  • 7. Johnston P.G. Prognostic Markers of local Relapse in rectal cancer: Are we any Further forward. J.Clin. Oncol. Vol. 24, No 25, 4049-4050, 2006.
  • 8. Leung E., Ferjani A.M., Kitchen A. et al. Risk-adjusted scoring systems can predict surgeons' performance in colorectal surgery // Surgeon. 2011. N9 (1). P.3-7.
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  • 12. Rusu P. Optimizarea tratamentului chirurgical radical în cancerul colorectal ocluziv. Raport, Moldexpo 11.09.2014, Chişinău
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  • 14. Teeuwen P.H, Bremers A.J., Groenewoud J.M. et al. Predictive value of POSSUM and ACPGBI scoring in mortality and morbidity of colorectal resection: a case-control study// J. Gastrointest. Surg. 2011. N15 (2). P.294-303.
  • 15. Алиев С.А. Колоректальный рак: заболеваемость, смертность, инвалидность, некоторые факторы риска / С.А. Алиев, Э.С. Алиев // Вестник хирургии им. И.И. Грекова. 2007. № 4. С. 118-122.1.
Comments: 2

Telepneva Lyudmila Georgiyevna

Уважаемые ученые из Молдовы! Ваше сообщение очень актуально, а отмеченный в нем рост заболевания, с которым Вы довольно успешно боретесь, лишь подтверждает пессимистические прогнозы ВОЗ. По прогнозам ВОЗ, к 2020 году колоректальный рак выйдет на первое место среди заболеваний в мире, обогнав сегодняшних лидеров – сердечно-сосудистые и инфекционные заболевания. Факторами риска развития рака прямой кишки является возраст старше 45 лет, малоподвижный образ жизни, курение, нарушение режима питания, рацион с высоким содержанием жиров, пища, в основном, животного происхождения и наследственность: наличие полипов, колоректального рака у родственников. Практически во всех странах имеется высокая запущенность опухолевого процесса, что обусловлено недостатками в организации специализированной медицинской помощи. К тому же часть больных попадает в неспециализированные медицинские учреждения общего хирургического профиля, и получают неадекватное лечение. В связи с этим очень важна ранняя диагностика заболевания. В этом могут помочь величины следующих показателей пациента: фактора роста эндотелия сосудов – VEGF, эпидермального фактора роста – EGF, а также значения двух инсулиноподобных факторов роста - IGF-I и IGF-II. Причем последние два являются не только сильными стимуляторами пролиферации клеток, но и обладают антиапоптотическим действием, т. е. препятствуют элиминации измененной клетки путем апоптоза. С уважением и пожеланием всего лучшего, что есть в профессии врача и исслеователя. Телепнева Л.Г.

Hryhorenko Liubov Victorovna

Dear Ion Mereuta, Rusu Porfirie professors ! Your scientific data is very intesting, scientificaly proved and practicaly - focused. The given result was carry out on the basis of numerous diciplines - oncology, surgery, food hygiene, reabilitation etc. Your experience and majority of cases proved how dangerous should be the given pathology among the population. As i undestand the higest risk is among women population. How can you explain such epidemiology of COLORECTAL CANCER. King regards, from Hryhorenko Luibov!
Comments: 2

Telepneva Lyudmila Georgiyevna

Уважаемые ученые из Молдовы! Ваше сообщение очень актуально, а отмеченный в нем рост заболевания, с которым Вы довольно успешно боретесь, лишь подтверждает пессимистические прогнозы ВОЗ. По прогнозам ВОЗ, к 2020 году колоректальный рак выйдет на первое место среди заболеваний в мире, обогнав сегодняшних лидеров – сердечно-сосудистые и инфекционные заболевания. Факторами риска развития рака прямой кишки является возраст старше 45 лет, малоподвижный образ жизни, курение, нарушение режима питания, рацион с высоким содержанием жиров, пища, в основном, животного происхождения и наследственность: наличие полипов, колоректального рака у родственников. Практически во всех странах имеется высокая запущенность опухолевого процесса, что обусловлено недостатками в организации специализированной медицинской помощи. К тому же часть больных попадает в неспециализированные медицинские учреждения общего хирургического профиля, и получают неадекватное лечение. В связи с этим очень важна ранняя диагностика заболевания. В этом могут помочь величины следующих показателей пациента: фактора роста эндотелия сосудов – VEGF, эпидермального фактора роста – EGF, а также значения двух инсулиноподобных факторов роста - IGF-I и IGF-II. Причем последние два являются не только сильными стимуляторами пролиферации клеток, но и обладают антиапоптотическим действием, т. е. препятствуют элиминации измененной клетки путем апоптоза. С уважением и пожеланием всего лучшего, что есть в профессии врача и исслеователя. Телепнева Л.Г.

Hryhorenko Liubov Victorovna

Dear Ion Mereuta, Rusu Porfirie professors ! Your scientific data is very intesting, scientificaly proved and practicaly - focused. The given result was carry out on the basis of numerous diciplines - oncology, surgery, food hygiene, reabilitation etc. Your experience and majority of cases proved how dangerous should be the given pathology among the population. As i undestand the higest risk is among women population. How can you explain such epidemiology of COLORECTAL CANCER. King regards, from Hryhorenko Luibov!
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