Blagov, J.

Kovachev, S

Petrov, B.

Pojarliev, T.

Radionov, M.

Simeonov, A.

Zia, D. D.

English

Varna Medical University Press: Journals

SUR GI CAL TREAT MENT OF CRC IN THE SUR GERY CLINICAT THE UNI VER SITY HOS PI TAL “ST. ANNA” SO FIA IN THE FIRST DE CADE OF THE TWENTY-FIRST CEN TURYKovachev S, M. Radionov, J. Blagov, D. D. Zia, B. Petrov, A. Simeonov, T. PojarlievUMBAL “St. Anna” So fia, Clinic of gen eral and en do scopic sur geryKey words: colorectal can cer, co lon, rec tum, neo plasmINTRODUCTIONThe colorectal can cer (CRC) ranks third in in ci dence ofma lig nant neoplasms af ter lung and breast can cer.Colorectal can cer in Bul garia for the last forty years in -creased from 10.5 in 1970 up to 59.4 per 100 000 men (35.4 for co lon and 24.0 for rec tum) and 43.5 per 100 000 women (28.4 and 15.1) in 2004(1,2). This trend is ob served notonly in Bul garia but world wide, which con firms thatcolorectal can cer is a dis ease of the Pres ent Day(2,6). Lead -ing coun tries by num ber of new pa tients are North Amer -ica, Aus tra lia, New Zea land and West ern Eu rope, i.e. in -dus tri al ized coun tries. In 2002 are reg is tered more than 1mil lion new cases - 9.4% of all can cer pa tients in the world.At the same time higher rates of in crease in in ci dence is re -ported in coun tries with rapid in dus tri al iza tion, such as Ja -pan, South Ko rea and oth ers in Asian-Pa cific re gion where30-40 years ago colorectal can cer was n’t so fre quent(5,6).Table 2. LOCATIONS OF CRCLocations Count Relative shares in %Coecum 111 8,5%Colon ascendens 98 7,5%Flexura coli hepatica 42 3,2%Colon transversum 81 6,2%Flexura coli lienalis 48 3,7%Colon descendens 47 3,6%Colon sygmoideum 382 29,2%Rectum 495 38,0%PURPOSE AND TASKSThe aim of our ret ro spec tive study is to an a lyze the sur gi caltreat ment of CRC in our clinic for the pe riod 2001 - 2010.We have set tasks to an a lyze: age and gen der of pa tients;the in ci dence of dif fer ent lo ca tions; tu mor stage and time of di ag no sis; pos si bil ity for sur gery and the ra tio be tween rad -i cal and pal lia tive op er a tions; the rel a tive shares of dif fer ent types of sur gery; post op er a tive and to tal mor tal ity.MATERIALFor the pe riod 2001 – 2010 a to tal of 1304 peo ple withCRC un der went sur gery in the clinic or 109 pa tients av er -age per year. Dis tri bu tion men / women is 707:613, and theage of the pa tients ranged from 38 to 76 years (av er age ageis 68.4). Over 60 years of age were 63% of the op er ated and over 70 - 16%. Elec tive op er a tions were 1024 and the ur -gent were 280 or 27.34% (Ta ble 1).Ta ble 2 pres ents the rel a tive shares be tween the dif fer entlo ca tions of CRC in pa tients op er ated dur ing the pe riod.Tu mors in the rec tum and sygmoid co lon oc cupy a to tal of67.2 per cent, third place ranks the coecum - 8.5%, while inthe rest of the co lon were gen er ally lo cated 24.3%.Of all 1304 pa tients op er ated for CRC, in 142 (10.9%) oc -curred ad vanced pro cess (in fil tra tion of ad ja cent or gans,dis tant metastases, ileus, per fo ra tion of the tu mor with peri -to ni tis, inoperabillity, etc.).Ta ble 3 pres ents dif fer ent types of sur gery pro ce dures per -formed dur ing the pe riod.The over all mor tal ity for the pe riod 2001 - 2010 and thoseof elec tive and emer gency pa tients are pre sented in Ta ble 4.447Scripta Scientifica Medica, 2011; vol. 43 (5) Copyright © Med i cal Uni ver sity, Varna2001ã. 2002ã. 2003ã. 2004ã. 2005ã. 2006ã. 2007ã. 2008ã. 2009ã. 2010ã. TOTALElective 87 85 85 81 82 103 121 127 125 128 1024Emergency 26 23 28 34 25 36 36 24 28 20 280TOTAL 113 108 113 115 107 139 157 151 153 148 1304Table 1. DISTRIBUTION OF ELECTIVE AND EMERGENCY PATIENTS DURING THE PERIODTa ble 3. TYPES OF INTERVENTIONHemicolectomia dex. 285Resectio col. transversi 8Hemicolectomia sin. 67Resectio sygmae 211Colectomia totalis, subtotalis 50Операция по Hartmann 185RRA 193Amputatio recti 155Palliative operations 135Explorations 7TOTAL 1304Тable 4.  MORTALITYoperated deaths  relative shareTotal mortality 1304 63 4,8%Mortality byelectiveoperated1024 15 1,46%Mortality byurgent operated280 48 17,14%DISCUSSION1. Tac tics: The di ag nos tic, stag ing and pre-op er a tive pre -par ing of elec tive pa tients dur ing the pe riod was done am -bu la tory and the pa tients were ad mit ted in the clinic 24 to48 hours be fore the in ter ven tion. Neo-adjuvant ra dio- orsel dom chemo- ther apy was per formed in se lected caseswith ad vanced tu mours or low rec tal lo cal isa tion. Per oralan ti bac te rial prep a ra tion was not done, but just os motic peroral gut la vage and en e mas. Perioperative i.v. an ti bi ot icspro phy laxis was done rou tinely for 48-72 hours and just inse lected cases such ther apy. Anti-throm bo sis pro phy laxiswas done rou tinely with LMWH in doses ac cord ing to thein di vid ual score of the risk dur ing the in hos pi tal stay andwith rec om men da tion to be con tin ued up to the 30th post op -er a tive day. Anti-ul cer pro phy laxis was per formed rou -tinely with Н+ in hib i tor for 15-20 days post op er a tively.Early (up to the 48h) verticalization was per formed withelas tic belt sup port of the ab dom i nal wall. Pre dom i nantlyatraumatic and absorbable su tures and me chan i cal sta plerswere used. All the op er ated pa tients were pre sented to anoncological com mit tee and a de ci sion for the ne ces sity ofadjuvant ra dio- and chemo- ther apy was in di vid u al ized(6). 2. To tal of op er ated pa tients for CRC and cor re la tion ofelec tive and ur gent pa tients. (Fig.1): There is marked in -creas ing amount of pa tients with CRC for the last 5 years of the pe riod. Our opin ion is that this due to the fol low ingcauses: the gen er ally in creas ing in ci dence of CRC; the im -prov ing di ag nos tic and the in creas ing op er a tive ac tiv ity to -wards the dis ease. We ren der con sid er able amount of op er -ated pa tients in age over 70. We con sider that to be due tothe in creas ing av er age age of the coun try pop u la tion, but tothe im prov ing di ag nos tic and the im prov ing pro phy laxis by min i mal in va sive re mov ing of pol yps af ter the rou tinely in -tro duc ing of the en do scopic meth ods. There is marked ahigh op er a tive ac tiv ity in groups of pa tients, who were useto be con sid ered as not per spec tive in the past: these in the8th and 9th de cade of life and the group ur gent pa tients in ad -vanced age. We in ter pret that with the im prov ing po ten ti al -i ties of anesthesia, reanimation and the modern operativetechniques. 3. Lo cal isa tion of the tu mor: There is marked high con tin -gent of pa tients with tu mour lo cal isa tion in the dis tal co lonand the rec tum (67,2%), which cor re sponds to the lit er a ture data. The lo cal isa tion of CRC in the rest parts of the largebowel does not im press to rise(6,10). 4. Stages of CRC (Fig. 2): The rel a tive part of op er ated pa -tients with ad vanced CRC in 4th stage of the dis ease was29,2%. The high est ralative part (43,4%) is oc cu pied by the op er ated pa tients in 3rd clin i cal stage. 5. The anal y sis of the per formed op er a tive pro ce dures forCRC shows in ter est ing in for ma tion re gard ing to the sur gi -cal tac tics. We have marked high num ber of rad i cal in ter -448020040060080010001200elective urgentnumberFig. 1 Elective and urgent3.10%43.40%24.30%29.20%I stage ІІ stage ІІІ stage ІV stageFig. 2 Stages of tu moursven tions by ad vanced CRC – block re sec tions when in fil -tra tion of ad ja cent or gans is pre sented, as well asprocto-colectomies, to tal and sub to tal colectomies. Thepart of si mul ta neous liver re sec tions when sol i tarymetastases are pre sented is sig nif i cant also(3,7). That is due to the im prov ing po ten ti al i ties of an es the si ol ogy, re an i ma -tion and sur gi cal tech niques tak ing the ad van tages of mod -ern ap pa ra tuses, devices and consummative. The Hartmann pro ce dures per formed and of the pal lia tiveop er a tions out num bered the ur gent op er a tions. The ex pla -na tion of this is based on the fol low ing facts: Sig nif i cantlyin crease of the av er age age of pa tients and in crease of theel derly pa tients over 70 years of age, who are suf fer ing as arule of dif fer ent con com i tant dis eases. In these cases theaim was max i mal de crease of the op er a tive time and de -crease of the op er a tive trauma vol ume(4,8,9). 6. Mor tal ity: The anal y sis shows cor re spond ing to the lit er -a ture data rel a tive val ues of mor tal ity in the groups of elec -tive and ur gent op er ated pa tients. Mor tal ity rate in thegroup of ur gent op er ated pa tients cor re sponds to the lowerlev els of the lit er a ture data, but at the same time is 12 timeshigher than this in the group of elec tive op er ated pa tients.CONCLUSIONS1. The annual average of operated for CRC patients in theclinic marks stabile trend to increase. The same time aprogressive increase of the operated patients in thegroup of age over 70 is marked also.2. The di ag no sis con tin ues to be put late up in ad vancedstages of the dis ease and by com pli cated forms of CRC, de spite the in tro duc ing of new mod ern meth ods of in -ves ti ga tion in the med i cal prac tice as ultrasonography,en do scopic in ves ti ga tions, CT and MRI. The pre vail ing part of pa tients who are op er ated for CRC are in stage 3and 4. For the early di ag no sis is nec es sary ac tive searchof CRC by en do scopic in ves ti ga tions of risk groups ofthe pop u la tion like these with data for fa mil ial bur den -some and peo ple over 50 years of age. (1,2,5)3. We mark high op er a tive ac tiv ity in com pli cated CRCand op er a ble cases in 4th clin i cal stage which re sults inin creased rel a tive part of “block re sec tions”and livermetastases re sec tions. In our opin ion this is due to thefol low ing next cir cum stances: • Good po ten ti al i ties of mod ern an es the sia andre an i ma tion.• Good pre op er a tive os motic prep a ra tion of thelarge bowel and oblig a tory perioperativean ti bi ot ics pro phy laxis and post-op er a tiveantithrombotic and antiulcerative pro phy laxis.• Well ap pre ci ated op er a tive tech nique uti liz ing mod ern sur gi cal mono-, bi- andmacro-bi-po lar and ul tra sound de vices forsur gi cal cut and hemostasis, atraumaticsu tures and me chan i cal sta plers.4. The total mortality rate by the operated patients withthis gravely surgical pathology is reduced, especially by the elective operated patients, but by the operated under emergency also.REFERENCES1. “Аноректални и чревни тумори и полипи” подредакцията на В.Димитров, издателство РИК“Славяни” София 2002.2. Дамянов Д, Т. Темелков. Проблеми наколоректалната хирургия в България. Медицински университет – Варна 2001. 3. Яръмов Н, Г. Велев, К. Ангелов, М. Соколов, С.Тошев, В. Павлов. Тактика и оперативни методи за лечение на усложнения колоректален рак.Доклади ХІІІ Национален конгрес по хирургия –Изд. СУБ 2010: 473-80.4. Яръмов Н, Г. Велев, С. Тошев, М. Соколов, К.Ангелов, Б. Петров, В. Павлов. Операцията наХартман – метод на избор в условията наспешност при обтурационния дебелочревен илеус. Доклади ХІІІ Национален конгрес по хирургия –Изд. СУБ 2010: 501-5.5. Nel son H, N. Petrelli, A. Carlin et al. Guide lines 2000 for Co lon and Rec tal Can cer Sur gery. JNCI2001;93:583-96.6. Smith AJ, DK Driman, K. Spithoff, A. Hunter, RSMcleod, M. Simunovic, B. Langer. Guide line for Op ti -mi za tion of Colorectal Can cer Sur gery and Pa thol ogy. J Surg Oncol 2010; 101: 5–12.7. Nesbakken A, М. Gaard. Sur gi cal treat ment of co loncan cer. Tidsskr Nor Leageforen 2007; 127(22):2942-5.8. Ansaloni L, RE Andersson, F. Bazzoli et al.Guidelenines in the man age ment of ob struct ing can -cer of the left co lon: con sen sus con fer ence of theworld so ci ety of emer gency sur gery (WSES) andperi to neum and sur gery (PnS) so ci ety. World J Emerg Surg. 2010; 28: 5:29.9. TohmJ C, G. Chakhtoura, B. Abboud, et al. Sub to talor to tal colectomy as sur gi cal treat ment of left-sidedoc clu sive co lon can cer. J Med Liban. 2008; 56(4):198-202.10. Goldfarb M, S. Brower, SD Schwaitzberg. Min i mallyin va sive sur gery and can cer: con tro ver sies part 1.Surg Endosc. 2010; 24(2): 304–34.449Scripta Scientifica Medica, 2011; vol. 43 (5) Copyright © Med i cal Uni ver sity, Varna

Surgical treatment of CRC in the surgery clinic at the university hospital `st. Anna` Sofia in the first decade of the twenty-first century

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Surgical treatment of CRC in the surgery clinic at the university hospital `st. Anna` Sofia in the first decade of the twenty-first century

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