The results are extended and combined operations for rectal cancer
Science Articles / / August 12, 2017
GATAULLIN IG Aglullin IR, EM Gannoshenko
main criterion for characterizing the results of surgical treatment of colorectal cancer, is the duration of life of patients and survival rates.This is one of the most important issues that are closely related to the diagnosis, treatment, rehabilitation and dispensary observation.
complex analysis of prognostic factors of tumor showed that the 5-year survival rate of patients with colorectal cancer depends on the presence of regional metastases, which according to various authors, regional metastases are detected from 20 to 40% of patients with colorectal cancer.Given such a high frequency of metastatic colorectal cancer, in order to improve operations radicalism was proposed, in addition to the removal of lymph nodes, together with its own fascia of the rectum, producing an extended lymphadenectomy, ieremove the lymph nodes of the iliac and obturator groups (J. Saner, N. Bacon, 1952).The volume of transactions expanded in two directions, up - by ligation
We analyzed 485 cases of colorectal cancer in patients treated in clinical oncology dispensary of the republic of Tatarstan.The frequency of tumor lesions of various departments of the rectum has been uneven.The most common were amazed nizhneampulyarny and anal departments (44.3%) ,null, further sredneampulyarny (31.5%), less frequently observed damage verhneampulyarnogo rectosigmoid and rectum (24.1%).
All patients were operated radically.The nature of surgical interventions depended on the location of the tumor, its location, the presence of regional metastases, tumor complications, functional status of the patients.In general, in operations for direct contact colon cancer marked predominance sfinkterosohranyayuschih operations (52.6%) over the extirpation direct kishki- (42.1%).The majority of patients after surgery Hartmann later, at different periods (from 3 months to 2 years), were performed reconstructive surgery.
Histological examination of tumors removed in most cases (95.6%) were adenocarcinoma of varying degrees of differentiation.
study of anatomical types of colorectal tumors showed slight predominance of exophytic growth forms (51.45%).Mixed (peptic) form was detected in 36.1%, endophytic - in 12.5% of patients.A morphological study of the remote during surgery preparations noted the predominance of common forms of cancer (stage TK and T4) were observed respectively in 22.7% and 65.2% of patients.Regional metastases were found in 32.7% of the operated patients.
studying metastasis of colorectal cancer, we found no strict regularity in the sequence of its stages.In particular, when tumors medium - and rectum verhneampulyarnogo metastases were observed during the sigmoid artery (9.4% and 14.3% of cases).But when cancer is in the Upper ampullar and rectosigmoid departments in 19% of cases showed metastasis along the internal iliac vessels.In cancer of the anal and rectum nizhneampulyarnogo in 7.7% of patients had metastases at the mouth nizhnebryzheechnoy artery.
According to research by prof.Ibatullina IA, the allocation of segments of the lymphatic system allows to prove the laws of lymphatic metastasis.The study of the structure of the lymphatic vessels and thoracic duct indicates that the normal valve device prevents retrograde lymph flow, and therefore, a retrograde metastasis.Aimfogennye metastases directed generally in the cranial direction.However, the presence of anastomoses between the two lying next segment provides 10-15% of cases of retrograde metastasis and occurrence of metastases in the parietal group of lymph nodes.Given the above, the classical radical surgery used in various localizations of cancer of the rectum (perineal bryushno- hysterectomy, abdominal-anal resection, intra-abdominal resection), will be radical enough, because it does not provide for the removal of all phases of metastatic lymphatic metastasis of tumors.Increase radicalism operations can only supplement of its component extended aorto-iliac-pelvic lymphadenectomy with high ligation nizhnebryzheechnoy artery in her place of origin of the aorta.
But at the moment we do not have sufficiently reliable pre - and intraoperative diagnostic methods metastatic lesion of regional lymph collectors.
Based on the literature data and our own studies, we developed the indications for advanced operations for rectal cancer.The main of them is the presence of morphologically confirmed during the operations of regional metastases in any of metastasis collectors.In the absence of visible lesions of the lymph nodes, we consider it appropriate to supplement the radical operation extended lymphadenectomy in the following cases:
- When the tumor in the anal and rectum nizhneampulyarnom.
- When tumors sprouting all layers or beyond the bowel wall (stage TK and T4).
- When endophytic type of tumor growth.
- In poorly differentiated and mucinous adenocarcinomas.
- When the tumor size of more than 5 square meters.cm.
All these data can be obtained as in the preoperative endoscopic, morphological and ultrasound studies, and during surgery.If you have any of these parameters probability of regional metastasis increased significantly.
main criterion for characterizing the results of surgical treatment of colorectal cancer, is the duration of life of patients and survival rates.This is one of the most important issues that are closely related to the diagnosis, treatment, rehabilitation and dispensary observation.To increase the radicalism of surgical interventions in clinic widely use extended aorto-iliac-pelvic lymphadenectomy as a component of operations on the rectum and krupnofraktsionnoe preoperative irradiation (a single dose of 5-6 Gy, 20-24 Gy total).
evaluation of treatment outcomes was conducted in -x 3 groups of patients with rectal cancer:
- group - 164 people, which made the classic radical surgery.
- group - 207 people who underwent surgery only a component of the extended lymphadenectomy (extended operations).
- group - 94 people, which made krupnofraktsionnoe exposure before performing advanced operations.
When analyzing the immediate results of the treatment in all three groups of patients the number of complications was not significantly different.They were, respectively, 20.2%, 23.7% and 25.1%.The mortality rate was 3.5%.The main cause of death was postoperative peritonitis (57.2%).The study of long-term results of treatment of patients in group I showed that in the presence of regional metastases 5-year survival rate was 9.1%, significantly lower than in the absence of metastases (39.5%).In group II, 5 years and more than lived 26.3% of patients with regional metastases and 42.9% without.The study results of the combined treatment (III group) showed that 5-year survival of patients with regional metastases was 34.2% and 56.7% without regional metastases.
Extended operation in the presence of regional metastases increases 5-year survival rate of 17.2% (from 9.1% to 26.3%).Effectiveness of combined treatment on (surgical dressing has increased both in the presence reginarnyh metastases (from 9.15 to 34.2%) and without them (from 39.5 to 56,7%).
important problem is in onkoproktologiilocally advanced rectal cancer, which is diagnosed in 40-50% of patients. of these, radical surgery is exposed to only one in three patients. The main cause of failure in surgical treatment of these patients is the spread of tumor to the surrounding tissue.
method of choice in locally advanced rectal cancera combined operation with the removal of one of the primary tumor block with adjacent organs
Our clinical material includes 56 patients who underwent combined surgery in locally advanced rectal cancer
most often involved in the process bodies of female sexual sphere -.. 18 patients, 7 patients- posterior wall of the bladder, y - 8 jejunum.In 2 cases it was resected internal iliac Vienna and one prostate gland.
To assess the degree of tumor spread to adjacent organs all patients underwent a comprehensive examination of the abdomen and pelvic organs, including fibrocolonoscopy, X-rays of the colon and bladder, and intracavitary transabdominal ultrasound, cystoscopy, CT.The final decision on the feasibility and appropriateness of the combined operation took after the reversible mobilization of tumor conglomerate.
analysis of the immediate results of 36 combined operations (without evisceration) showed that the postoperative period was complicated in 12 patients (33%).The vast majority of complications were purulent-inflammatory.The mortality rate was 5.5% (2 patients).
In cases where the tumor affected pelvic organs form a single tumor conglomerate and radicalism can not be achieved only part of their resection, the only possible radical intervention is the evisceration of the pelvic organs.
This operation in the classic version involves complete removal of the pelvic organs with the formation of colonies - and urethral terostom on the anterior abdominal wall.Improving immediate and long-term results of treatment of these patients is largely dependent on surgical rehabilitation, that is, the simultaneous restoration of the continuity of the urinary tract and bowel.
evisceration pelvic about locally advanced rectal cancer was performed in 20 patients.In the preoperative period in 12 patients was carried out radiotherapy, in other cases, it refrained from in connection with the complications of tumor growth (vesico-intestinal fistula, bleeding).After removal of the pelvic reconstructive phase was carried out by bringing down proximal colon through the anal canal and cystoplasty.We used the 2 options of forming an artificial bladder - ileocecal segment of the colon and the isolated segment of ileum.Postoperative complications were observed in more than 50% of patients, including leading-pyo were vospaltelnye and urological.Postoperative mortality was 15% (3 patients).Indicators of three and five-year survival rate of patients were respectively 51.4% and 30.6%.The average life expectancy was 30.7 months.
perform radical surgery for colorectal cancer in patients prevents existing liver metastases, which occur in 20-30% of cases.The widespread introduction of liver resection for metastatic prevent its severe intraoperative complications and postoperative mortality high.
In our clinic since 1997 in colorectal cancer patients with liver metastases performed, along with the removal of the primary tumor - 4 hemihepatectomy left-handed, right-hemihepatectomy 2, 3 bisegmentektomii, 4 segmentectomy, 4 atypical marginal resection of a total of 17 interventions in the liver.Perioperative morbidity and mortality has not been in these patients.We attribute these favorable outcomes with the use of special technology, consisting in:
- adequate surgical access using the 4 retractors RAC 10
- use of intraoperative ultrasound
- the application of ultrasonic surgical aspirator Cusa 200
- use of argon coagulator
- application "Tachocomb "to cover the wound surface.
Thus, the widespread adoption of the clinic expanded and combined surgical interventions, including evisceration of the pelvic organs, the use of new technologies in the treatment process increases the number of resectable patients previously considered inoperable, improve the immediate and long-term results of treatment of colorectal cancer.