Scripta v41 2009 3 by Boris Sakakushev

Medical University Prof. Dr. Paraskev Stoyanov VARNA, Bulgaria

Scripta Scientifica Medica Vol. 41 (3), 2009 PAPERS FROM XITH NATIONAL CONFERENCE OF COLOPROCTOLOGY

pp. 213-316

SCRIPTA SCIENTIFICA MEDICA An official publication of Medical University "Prof. Dr. Paraskev Stoyanov", Varna Editor-in-Chief: Prof. Anelia Klissarova, MD, PhD, DSc Rector of Medical University of Varna e-mail: klisarova@mu-varna.bg Co-Editor-in-Chief: Assoc. Prof. Rossen Madjov, MD, PhD, DSc Vice Rector of Medical University of Varna e-mail: madjov@mu-varna.bg

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Scripta Scientifica Medica, 2009; vol. 41 (3)

CONTENTS Sakakushev B., B. Hadzhiev, B. Boev, B. Atanasov, V. Petkov - COLORECTAL ANASTOMOTIC LEAK - UNEXPECTED FATAL DISASTER OR A PREDICTABLE CONTROLLED PROBABILITY? A 2009 UPDATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Veltchev L. - COLORECTAL PRIMARY AND COLORECTAL LIVER METASTASES-NEW APPROACHES FOR MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Hadzhiev B. - MODERN METHODS OF OCCLUSIVE TREATMENT OF ANORECTAL FISTULA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Sakakushev B., B. Hadzhiev, B. Boev, B. Atanasov, V. Petkov - FAST-TRACK COLORECTAL CANCER SURGERY - PRESENT AND FUTURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Chernopolsky P., P. Arnaudov, K. Georgiev, V. Bozhkov, T. Ivanov, R. Madjov ABDOMINAL TUBERCULOSIS REPORT OF 5 PATIENTS AND LITERATURE REVIEW . . . . . . . . . . . . . 241 Áëàãîâ É., È. Ãðèãîðîâ, Î. Òîìîâ, Ò. Ïîæàðëèåâ - ÕÈÐÓÐÃÈ×ÍÀ ÒÀÊÒÈÊÀ ÏÐÈ ßÒÐÎÃÅÍÍÈ ÍÀÐÀÍßÂÀÍÈß ÍÀ ÊÎËÎÍÀ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Ñòîéêîâ Ä., Þ. Ïåòêîâ, Ñ. Ñòðàøèëîâ, È. Äåêîâà - ×ÅÐÍÎÄÐÎÁÍÈ ÌÅÒÀÑÒÀÇÈ ÂÚÇÌÎÆÍÎÑÒÈ ÇÀ ËÅ×ÅÍÈÅ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Ïåòêîâ Þ., Ä. Ñòîéêîâ, È. Äåêîâà - ÓÑËÎÆÍÅÍÈß ÍÀ ÊÎËÎÐÅÊÒÀËÍÈß ÊÀÐÖÈÍÎÌ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Áëàãîâ É., Ä. Çèÿ, Ì. Ðàäèîíîâ, È. Ñå÷àíîâ, Ò. Ïîæàðëèåâ - ÎÁÅÌ ÍÀ ÕÈÐÓÐÃÈ×ÍÀÒÀ ÐÅÇÅÊÖÈß È ÈÇÕÎÄ ÎÒ ËÅ×ÅÍÈÅÒÎ ÏÐÈ ÁÎËÍÈ Ñ ËÎÊÀËÍÎ ÀÂÀÍÑÈÐÀË ÏÚÐÂÈ×ÅÍ ÊÎËÎÐÅÊÒÀËÅÍ ÊÀÐÖÈÍÎÌ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Ïîïîâ Â., À. Ïúðâîâ Í. Êîâà÷åâ, Ä. Ðàäåíîâñêè, Â. Ñòîÿíîâ - ÑÓÁÒÎÒÀËÍÀÒÀ ÊÎËÅÊÒÎÌÈß - ÏÐÅÄÏÎ×ÈÒÀÍ ÌÅÒÎÄ ÏÐÈ ËÅÂÎÑÒÐÀÍÅÍ ÄÅÁÅËÎ×ÐÅÂÅÍ ÈËÅÓÑ . . . . . . . . 261 Ãåîðãèåâ Â., Â. Äèìèòðîâ - ÈÍÒÐÀÎÏÅÐÀÒÈÂÍÎ ÌÀÐÊÈÐÀÍÅ ÍÀ ÑÅÍÒÈÍÅËÍÈ ÂÚÇËÈ Ñ ÐÀÄÈÎÍÓÊËÈÄÈ ÏÐÈ ÊÀÐÖÈÍÎÌ ÍÀ ÊÎËÎÍÀ - ÎÏÈÑÀÍÈÅ ÍÀ ÌÅÒÎÄÀ È ÏÚÐÂÎÍÀ×ÀËÍÈ ÐÅÇÓËÒÀÒÈ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Áëèçíàøêè È., Ã. Êîòàøåâ, Ä. Àòàíàñîâ, Å. Äèìàíîâà - ÕÈÐÓÐÃÈ×ÍÎ ËÅ×ÅÍÈÅ ÏÐÈ ÄÈÂÅÐÒÈÊÓËÎÇÀ ÍÀ ÊÎËÎÍÀ - ÏÅÒ ÃÎÄÈØÅÍ ÎÏÈÒ, ÏÎÊÀÇÀÍÈß, ÐÅÇÓËÒÀÒÈ, ÈÇÂÎÄÈ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Ñòåôàíîâ Ò., Ö. Ãóíåâ, Â. ×àêúðîâ, Ê. Ìóðäæåâ, Ç. Ìèëåñêè - ÏÎÂÅÄÅÍÈÅ ÏÐÈ ÎÁÒÓÐÀÖÈÎÍÅÍ ÈËÅÓÑ ÏÐÈ×ÈÍÅÍ ÎÒ ÊÎËÎÐÅÊÒÀËÅÍ ÐÀÊ ÇÀ 5 ÃÎÄÈØÅÍ ÏÅÐÈÎÄ /2003-2008/ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 ABSTRACTS FROM XITH NATIONAL CONFERENCE OF COLOPROCTOLOGY . . . . . . . . . . . . . . . . . . . 276 AUTHOR'S INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 PERMUTERM SUBJECT INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314 INSTRUCTIONS TO AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

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Scripta Scientifica Medica, 2009; vol. 41 (3), pp 219-224

COLORECTAL ANASTOMOTIC LEAK - UNEXPECTED FATAL DISASTER OR A PREDICTABLE CONTROLLED PROBABILITY? A 2009 UPDATE Sakakushev B., B. Hadzhiev, B. Boev, B. Atanasov, V. Petkov Medical University, University Hospital "St. George" Plovdiv, Bulgaria, Clinic of General Surgery with Coloproctology ABSTRACT Despite improvements in surgical technique, anastomotic leakage/AL/ after colorectal cancer surgery/CRCS/ continues to be a major clinical problem with high mortality and morbidity, hospital resources and costs and worse oncological prognosis. Assessing risk factors, early clinical signs and symptoms of an AL using modern diagnostics earlier either only conservative or most oftenly operative treatment must be performed. We studied retrospectively for 12 years period /1998 to 2008/ 404 patients with CRC who underwent primary resections and anastomoses. Patient related variables supposed to act as risk factors for anastomosis leakage like gender, age, comorbid disease, ASA score, site of tumor, bowel preparation, timing and mode of operation and drainage were thoroughly analyzed. Type of different operation was compared in relation to leak occurrence as well as morbidity and mortality rates. AL was considered to be present when described atrelaparotomy or endoscopy, or when post-operative computerized tomography scan showed the presence of air or fluid collections or an infiltrate surrounding the anastomosis. Leaks occurred between the 5th and the 15th postoperative days, with the onset of abscess, peritonitis or systemic sepsis. There were 10 AL /2.5%/ related more to rectum (4) and sigma(2) resection/anastomosis. AL in the early stage of localized peritonitis, with minor defect are oversewed and drained or reresection with proximal diverting stoma performed. I advanced diffuse peritonitis either obstructive resection or exteriorization has been applied. Thorough analysis of risk factors is extensively discussed and conclusions on improving rates and outcome of AL after CRCS are outlined.

Key words: Anastomosis leakage /AL/, Colorectal Cancer Surgery /CRCS/ INTRODUCTION Despite improvements in surgical technique, anastomotic leakage/AL/ after colorectal cancer surgery/CRCS/ continues to be a major clinical problem (1,2,3). It is feared and dreaded complication associated with early and long-term morbidity and mortality, prolonged postoperative length of stay and considerable demand for hospital resources and costs (4,5,6). Anastomotic dehiscence occurs more commonly in rectal anastomoses than in anastomoses of the other parts of the alimentary tract. Due to technical diffi culties in accessing this area and its easily compromised blood supply (7). The reported leak rate varies between 1% and 39% depending on the definition of a leak, and type of resection, although experienced colorectal surgeons often quote 3% to 6% as an acceptable overall leakage rate (1,3,4,5,8,9). The incidence of clinically significant leakage after low anterior resection (LAR) varies between 3% and 21%,but is thought to average 10%. Or lower when patients are operated by a high-volume surgeon (7,9). Postoperative mortality rates following an anastomotic leak may be as high as 39% (1,4,7).

Identifying a leak as early as possible can reduce the morbidity and mortality rates and improve outcomes (1). There is no uniformly accepted definition of an AL in the literature, because more than 56 different definitions were describedIn 1991, the United Kingdom Surgical Infection Study Group proposed the definition as a "leak of luminal contents from a surgical join between two hollow viscera." (4). AL is defined as the breakdown of a colonic anastomosis associated with an intraabdominalcollection identified either by contrast radiographs before a subsequent operation or by the surgeon at the time of a subsequent operation (10). A clinical AL was described as the presence of luminal contents through a drain or wound site or abscess cavity causing inflammation (ie, fever, leukocytosis, or fecal discharge (6) or a clinically apparent leakage sign (such as emission of gas pus or feces from thre pelvic drain or peritonitis) or extravasation of an endoluminaly administered water soliable contrast medium according to computed tomography early postoperatively (11). Free AL is featured by free perforation and associated peritonitis, while contained AL are with presence of localized findings on contrast radiographs and lack of peritonitis (10). Risk factors can be categorized as patient-specific, intraoperative, and specific for low rectal anastomosis /Table 1/ (4,9).

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Sakakushev B., B. Hadzhiev, B. Boev ...

AIM Table 1. Modified categorization of risk factors for AL.

Patient factors

Malnutrition, BMI, advanced age Steroids, statins Tobacco and alchohol use, Leukocytosis, ASA score, Cardiovascular disease, Diabetes Diverticulitis

Disease related factors

Type of neoadjuvant therapy Radio- or chemotherapy or a combination

Operative and Surgeon related factors

Urgent vs elective operation Mechanical bowel preparation Perioperative blood transfusion Low anastomosis > 7sm from anus Peritonitis, Ileus Worsen blood supply to anastomosis Anastomosis configuration Surgeon or assistant Operative time >2 hours, night hours

Specific factors for low anastomosis

Male Obesity

The aim of this retrospective study was to identify the mode of presentation of patients with a clinical AL following CRCS in order to facilitate early diagnosis and treatment.

Table 2 Patient variables and tumor localization in AL after CRCS Characteristic

Leak

No leak

67.5/50 -91/

59.2/41-89/

Gender M/F

7/3

209/185

ASA score

I:1, II:4,III:4,IV:1

I:3,II:110,III:185,IV:96

Age

Co-morbid disease > 1

Site of CRC No of Patients

394

Ca coeci

Ca colonis ascendens

Ca flexura hepatica

Ca colonis transversi

Ca flexura lienalis

Ca colonis descendens

Ca sigmatis

Ca rectosigmoidalis

Ca recti

Multiple Ca

Urgent vs. elective

Urgent 6, Elective 4

Urgent 41 Elective 353

Stapled vs handsewn

Stapled 4, Handsewn 6

Stapled 108, Hadsewn 286

Prophilactic drainage

394

Yes 4, No 6

Yes 353 No 41

352

Mechanical bowel preparation Operative time > 2 hours

220

Colorectal anastomotic leak - unexpected fatal disaster or ...

RESULTS

DISCUSSION

Mean age of the patients with AL was 67.5 years /50-91/, while those with no leak were 59.2/41-89/. Al was observed in 7 men and 3 women. AL occurred in ASA I -1, ASA II -4, ASA III - 4 Ă¨ ASA IV -1 patients. More than 1 comorbid disease like diabetes, cardiovascular or pulmonary disease was present in all 10 patients with AL. Leakage of anastomosis was clinically registered in 1 patient with cancer of ascending colon, 1 of the hepatic flexura,, 2 of the transverse colon, 2 of the sigma and 4 of the rectum /Table 3/. AL appeared in 6 urgent and 4 elective operations; 4 anastomoses with AL were stapled, 6 -handsewn. In all cases of AL operative time was more than 2 hours. Mechanical bowel preparation was done in 4 patients with leakage, in 6 -it was not performed. All of the patients with anastomosis leakage did have intraabdominal drain. Table 3. Types of resections and anastomoses performed for CRC included in the study

Operation Type

Leak

No leak

Right Hemicolectomy

119

Transverse Colon Resection

Left Hemicolectomy

Sygma Resection

107

Anterior Rectum Resection

101

Subtotal Colectomy

404

Total

The following postoperative complications have been registered: wound infection - 76 /18.8%/, bronchopneumonia 2 /0.5%/, embolia - 2 /0.5%/, anastomosis dehiscence - 10 /2.5%/, eventrations - 3 /0.7%/, postoperative ileus - 8 /1.2%/, postoperative hemorrhage - 4 /1.0%/, pneumothorax - 1 /0.2%/. Readmission rate was 3.5% (14) and lethality -4.5% (18). AL was considered to be present when described at relaparotomy or endoscopy, or when post-operative computerized tomography scan showed the presence of air or fluid collections or an infiltrate surrounding the anastomosis. Leaks occurred between the 5th and the 15th postoperative days, with the onset of abscess, peritonitis or systemic sepsis. Traditional late signs and symptoms of a leak include fever, elevated white blood cell count (WBC), gas or faecal discharge from the incisional wound, vagina or drain tract, and peritonitis /Table 4/. Three of the patients with AL reoperated died -2 from severe sepsis and one polyorgan insufficiency. Mean hospital stay for AL patients was was -25.6 days (14 -19).

Many risk factors have been attributed to anastomotic leakage (4). The major surgical factors that influence the likelihood of anastomotic leakage are tension-free anastomosis and sufficient blood supply; other possible factors include age, sex, preoperative medical disease, obesity, chemoradiotherapy /CRT/, bowel obstruction, tumor location, and pelvic drainage, level of anastomosis, TME (8,11). Obesity is a risk factor, because of tension and ischemia caused by a short, thick mesentery /4/. BMI higher than 30 increase the risk for developing leakage almost three-fold (9). Tobacco and alcohol use are risk factors for anastomotic leaks mainly by causing tissue hypoxia, which compromises healing. (4,7). Comorbid conditions, such as diabetes mellitus, hypertension, and cardiac disease all represent conditions that affect ASA status and can cause impaired circulation at the microcirculation required for a healthy anastomosis (4). Steroid and statins use is considered a risk factor for anastomotic leak (4). Preoperative CRT of only two fields with high doses per fraction and a small interval between fractions leads to higher anastomotic leakage rate than four-field RT (4,7). Male sex is considered a risk factor for leakage, due to the narrow male pelvis which makes low anastomoses technically more demanding as a result of poor visualization during dissection (4,7). In our patients with leakage 7 were men, while only three -women. Hypoalbuminemia or low prealbumin levels places a patient at higher risk for anastomotic leaks. Albumin value lower than 30 g/dl and recent weight loss of more than 5 kg are risk factors for leakage (4,7). Perioperative blood transfusions induce immunosuppression predisposing to various postoperative infections, therefore increasing the risk of anastomotic leakage (7). Patients with leakage had a significantly lower collagenI/III ratio and higher expression of metalloproteasis than patients without leakage (7). Bevacizumab, a monoclonal antibody, targeting the vascular endothelial growth factor receptor can cause perforation due to arterial microthromboembolic disease leading to bowel ischemia (4). The incidence of leakage is increased during celecoxib /cyclo-oxygenase inhibitor/ for postoperative analgesia use (12). Patients with leakage had lower tissue oxygen saturation at the anastomosis site than patients without anastomotic leakage. Ligation of the inferior mesenteric artery at its origin (high ligation) may severely compromise the blood supply of the sigmoid colon, because the division is proximal to the origin of the left colic artery. The peritonealization of the pelvis and the extraperitoneal positioning of the anastomosis reduces the occurrence of peritonitis after anastomotic leakage (7). We have always tried to extraperitonize low rectal anastomosis .The global clinical risk assessment of anastomotic leakage by the operating surgeon has low predictive value for anastomotic leakage and underestimates the risk of anastomotic leakage (3). Du-

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Sakakushev B., B. Hadzhiev, B. Boev ...

ration of operations more than 2-4 hours has higher leak rate, associated with more difficult resections and anastomoses. All of our AL appered after operation lasting more than 2 hours. Tissue ischemia at the site of the anastomosis is frequently cited and implicated as a cause for anastomotic breakdown. Laser Doppler scans before and after mobilizing, dividing, and anastomosing the colon show a 32% reduction in colonic tissue perfusion 2 cm proximal to the anastomotic site and a 51% decrease at the anastomotic site. Location of the vascular ligation has no impact on colonic perfusion, but location of the resection is vital to tissue oxygenation. Proximal lumen of the bowel must always be inspected. If the mucosa is pink then the blood supply is adequate. Relying on merely looking at the serosal surface is fraught with pitfalls, as the serosa might be viable but the mucosa is not (4). The leakage rate after resection of the transverse colon is remarkably high, possibly by the involvement of the watershed area at the splenic flexure and Griffithsâ&#x20AC;&#x2122; critical point (insufficient marginal artery at splenic flexure) contribute to this high leakage rate (9). Omental wraps around colonic anastomoses were not justified (4). Our policy is to mobilize the splenic flexure always when we suspect tension of the colorectal anastomosis. Patients operated upon after-hours had more than a twofold increased risk of anastomotic leakage significantly more anastomoses were constructed by residents after-hours (95%) decreased technical performance of the operating team has contributed to a higher leakage rate at night. Medical errors to occur more often at night. In addition, physicians appear to be less proficient at night, which leads to more errors at night than during daytime. Decreased non-technical skills of the operating team at night, like teamwork- and management skills and situational awareness, contribute to higher leakage rates. Situational awareness (SA), defined as the ability of the surgeon to observe, understand and predict events in the operating room (OR), appears to be closely related to technical error rates (9). Although we have not analyzed the urgent operations at night we believe that resections and anastomoses performed at night even by an experienced surgeon are disadvantageous and bare a risk for AL. Surgeons experiencing leak rates that exceed 3.0% should probably undergo peer review. clearly articulated definition for colonic anastomotic leaks and their expected rates from which we can benchmark surgeon performance (10). A diagnostic test which measures microperfusion before and after creation of an anastomosis like visible light spectroscopy and multispectral fluorescence imaging techniques to evaluate realtime microperfusion in gastrointestinal surgery will be most suitable (3). The issue of routine drainage of colonic anastomoses has been a topic of controversy for years. Those championing the use of these drains believe they play a role in evacuating perianastomotic fluid collections, lessening the incidence of abscess formation and serving as an early warning marker for anastomotic dehiscence (4). The rationale behind the placement of a drain after LAR is to promote ade222

quate drainage of the pelvis and prevent the formation of a hematoma, which may become infected and result in a pelvic abscess, which in turn can erode the anastomosis. The pelvic drain serves as â&#x20AC;&#x153;an eyeâ&#x20AC;? into the pelvis, often allowing for early recognition of otherwise silent leakage of feces, pus, or air (7). It also makes conservative treatment of a leakage feasible by creating a tract that can turn into a fecal fi stula during the postoperative period. the need for surgical reintervention after leakage was signifi cantly lower for patients with pre-existing pelvic drainage than for patients without drainage (3,13). Although prophylactic drainage (PD) is associated with AL, suggesting that it is a risk factor /9/. It may assist in its management (7). We have always routinely used presacral tube drain, after extraperitonizing the low colorectal anastomosis, thus when AL appear, it drains the perirectal extraperitoneal splittage, preventing from peritonitis. Given the wide array of results in the literature that has examined the use of a bowel prep, mechanical preparation is recommended to minimize contamination (4), although some state that bowel preparation is not necessary even after TME for rectal cancer (7). In elective CRCS since 3 years we have started a protocol based study avoiding mechanical bowel preparation. There is strong evidence that rates are equal from a multicenter, randomized, prospective trial comparing handsewn to stapled anastomosis in elective and emergent colorectal operations not a statistically significant difference even with low anastomoses (4). The lower-lying anastomoses require more stapling devices. The learning curve for the stapling devices has not been fully evaluated, but it is thought to be less steep than that for manually constructed anastomosis (7). AL in our stapled anastomoses were 4, while in hand sewn they were 6. We perform stapled colorectal anastomoses since 1993 and having much experience both with circular and linear stapler colorectal anastomoses recommend them as superior to handsewn, not only for low anterior rectum resection. Leak rates of 7% above the peritoneal reflection are compared with 18% 5 cm from the anal verge (4,7). From a study of 1014 stapled anastomoses AL above 7 sm from the anal verge was 1%, while below 7 sm It was 7.7% (11). From 10 CRCS leaks we have had 4 after low rectal resections and 2 after sigma resections, which implies that low rectum resections are more amendable to AL. A defunctioning stoma decreases clinical anastomotic leak rate and reoperation rate and is recommended after low anterior resection for rectal cancer (14). Proximal diversion does not prevent leaks, but lessens the dreaded sequelae should a clinical leak occur, even in higher-risk patients. Stomas are not without inherent complications of their own, such as necrosis, retraction, prolapse, and disuse stricture of a distal anastomosis (4). The argument against the use of protective stomas is overtreatment. reconstruction is an additional operation (7). We have never performed primary diverting stoma in our 404 CRC primary resections and anastomoses.

Colorectal anastomotic leak - unexpected fatal disaster or ...

A method of reducing the potential for anastomotic leak is intraoperative testing of the integrity of the anastomosis with isotonic sodium chloride solution, povidone-iodine, or air insufflation of the anastomosis. However, others suggest that the results of leak testing may influence the decision to perform additional exploratory surgery in a patient in critical condition. Because the knowledge of a sound anastomosis at intraoperative testing provides a false sense of anastomotic integrity untested anastomoses have twice the rate of postoperative clinical leaks compared with those that were tested. An airtight anastomosis at intraoperative testing is a reliable indicator of anastomotic integrity (7). AL are detected from 3 to 45 days postoperatively. When leaks occur clinically, the median postoperative day of diagnosis is 7 days; when made radiographically the median postoperative day of leakage is 16 (4). Diagnosing leaks relies on the clinical picture and radiographic findings. The earliest predictors of an anastomotic leak are respiratory and neurological in nature (1). Prompt an early work-up to rule out the development of an anastomotic leak and reduce morbidity and mortality associated with this complication. Tracking resource utilization and outcomes in the setting of a prospective study with standardized cardiac, respiratory and neurological preoperative assessmentand monitoring helps to identify and treat leaks earlier. Computed tomography (CT) is the most readily available imaging tool for diagnosis of postoperative lower gastrointestinal tract (LGIT) leak. CT studies on patients shortly after abdominal surgery are not definitive. A negative CT study does not rule out LGIT leak. Clinically based decision making and exploratory relaparotomy still do play a role in those patients withsuspicion for LGIT leak (15). Patients with anastomotic leaks most often require volume resuscitation and should all be started on broad spectrum antibiotics. Once an anastomotic leak has been recognized, management should be individualized to accommodate patientâ&#x20AC;&#x2122;s needs (4). Patients with contained leaks tend to be treated with percutaneous drainage, whereas the patients with free leaks tend to be treated surgically with emergent reexploration, takedown of the anastomosis and creation of an end stoma, or a proximal diversion via a loop ileostomy (10,16). Available strategies include observation and bowel rest, percutaneous drainage, colonic stenting, and surgical revision, diversion, or drainage. With a small degree of contamination, right-sided colonic leaks can often be reanastomosed and drained. With more extensive contamination, resection with ileostomy and mucous fistula or creation of a Hartmanâ&#x20AC;&#x2122;s pouch should be used (4,6). Management of left-colon leaks depends on the level of the anastomosis. Intraperitoneal leaks should be resected with the ends brought out as ostomies, if possible. Extremely low anastomotic leaks should be extensively drained with proximal complete diversion with either an ileostomy or colostomy. Newer approaches use endostents and transanal endoscopic vacuum devices (4).

From 4019 colorectal resections and primary anastomoses /1992 -2004 / with 58 AL /largest series of symptomatic leaks in the literature/ Damrauer and aut. suggest that the differences between free and contained leaks may be a result of wishful thinking more than of actual clinical outcomes (10). Contained leaks tended to have the same signs and symptoms as free leaks. Although they were more likely to have been subjected to attempts at nonoperative treatment, this modality failed in almost all patients with contained leaks, and these patients subsequently required surgical intervention (10). When AL is in the early stage of localized peritonitis, with minor defect we oversew and drain it,.or do reresection with proximal diverting stoma. In advanced diffuse peritonitis we perform either obstructive resection or exteriorization. Tumor cells present in the colonic lumen after resection that can implant and grow in the remaining colorectal segment. anastomotic leak is independently associated with worse longterm outcomes. Iintraluminal tumor cells that are normally inconsequential after a colon resection may implant after a leak. A third option is these patients might have decreased immune function from morbidity associated with a leak (4). AL have significantly poorer long-term survival (11). Preventing AL is offered by various types of nonabsorbable, semiabsorbable, and absorbable material to buttress staple lines to strengthen anastomoses (6); intraluminal tubes such as the SBS tube (absorbable) and the Coloshield (permanent); endo-sponge device (5) sealing colon anastomoses with fibrin, but there is little evidence to support its widespread use currently (4). Table 4. Basic signs and symptoms of AL

Clinical signs

Pain, peritonitis, feculent or purulent discharge

Biochemical markers

Fever, achycardia, leucocitosis

Radiological studies

Fluid collection

Intraoperative findings

Gross enteric spillage Anastomotic disruption

Currently available risk estimating systems have one or more limitations associated with lack of specificity to operation type, size of sample (reliability), range of outcomes predicted, and appreciation of hospital effects. The ACS colorectal risk calculator allows surgeons to preoperatively provide patients with detailed information about their personal risks of overall morbidity, serious morbidity, and mortality (17). Sequelae of colon and rectal anastomotic leaks are substantial. Mortality rates range from 0% to 32% (14,18).

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Sakakushev B., B. Hadzhiev, B. Boev ... Table 5. Current status of risk factors for anastomosis leakage in CRCS

Facts

Obscurity

Fiction

Risk Factors Male sex Smoking, alchohol Malnutrition Hight of anastomosis Splenic Fl mobilization BMI >30kgm2 After hours operation Protective measures J-pouch

Collagen type Enzyme expression Long RT plus ChT Blood trahsfussion

Tumor stage Stapled or hand-sewn anastomosis Short sheme RT Omentoplasty Extraperitoneal anastomosis Bowel preparation

Protective stoma

Pelvic drains

10.

CONCLUSION 11.

Because of the substantial morbidity and mortality associated with delayed recognition, detection and investigation of an anastomotic leak, it is imperative to diagnose and treat this complication as early as possible. Treatment of a colonic anastomotic leak must then be individualized to the location and sequelae of the leak. Treatments range from nonoperative percutaneous drainage to surgical revision or resection of the anastomosis. Although there is ongoing research into new technological methods to prevent anastomotic leaks, no currently available methods have been widely accepted. Now in the ongoing 2009 AL after CRCS, though a major surgical problem with medical and social impact on quality of surgical care and patient life, has lowered its rate to the acceptable 3% in specialized centers, mainly due to surgeons experience and technical proficiency, modern diagnostics and risk assessment, turning out from an embarrassing fatal disaster in the past to a predictable probability today and hope in the future.

REFERENCES 1.

Bel lows Ă&#x2018;., Webber H., Albo et aut. Early predictors of anastomotic leaks after colectomy Tech Coloproctol (2009) 13:41-47 Chapuis P., Sinclair G., Dent O., Anastomotic leakage after resection of colorectal cancer generates prodigious use of hospitakl resources. ANZ Journal of Surgery Volume 79 Issue s1, p A13 - A13 Karliczek A, Harlaar N, Zeebregts C et aut. Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis (2009) 24:569-576 Kingham T, Pachter H. Colonic Anastomotic Leak: Risk Factors,Diagnosis, and Treatment. J Am Coll Surg. 2009 Feb;208(2):269-78.

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Koperen P, Henegouwen M, Rosman C et aut.The Dutch multicenter experience of the Endo-Sponge treatmentfor anastomotic leakage after colorectal surgery. Surg Endosc (2009) 23:1379-1383. Ricciardi R, Rob erts P, Marcello P et aut. Anastomotic Leak Testing After Colorectal Resection. Arch Surg. 2009;144(5):407-411 Taflampas P, Christodulakis M, Tsiftsis D.Anastomotic Leakage After Low Anterior Resection for Rectal Cancer: Facts, Obscurity, and Fiction. Surg Today (2009) 39:183-188 Cong Z, Fu C, Han-tao et aut. Wang Influencing Factors of Symptomatic Anastomotic Leakage After Anterior Resection of the Rectum for Cancer World J Surg (2009) 33:1292-1297 Komen N, Dijk J, Lalmahomed Z. After-hours colorectal surgery: a risk factor for anastomotic leakage. Int J Colorectal Dis (2009) 24:789-795 Damrauer S, Bordeianou L, Berger D, Contained Anastomotic Leaks After Colorectal Surgery Arch Surg. 2009;144(4):333-338 Jung S., Yu C., Choi P., et aut. Risk factors and oncologic impact of Anstomotic leakage after rectal cancer surgery. Dis colon & rectum,2008, vol 51, p 902-908. Holte K, Andersen J, Jakobsen DH, Kehlet H. Cyclo-oxygenase 2 inhibitors and the risk of anastomotic leakage after fast-track colonic surgery. British Journal of Surgery, 96 (6), 650-654 (May 2009) Tsujinaka S., Kawamura Y Konishi F. et aut. Pelvic Drainage for Anterior resection revised : Use of drains in anastomotik leaks. ANZ Journal of Surgery, Volume 78, Number 6, June 2008 , pp. 461-465(5) Tan S,Tang L, Shi L, Eu K. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer.British Journal of Surgery, Volume 96, Number 5, May 2009, pp. 462-472(11) Khoury W, Ben-Yehuda A, Ben-Haim M et aut. Abdominal Computed Tomography for Diagnosing Postoperative Lower Gastrointestinal Tract Leaks. J Gastrointest Surg Gedik E, SĂśylemez K, Girgin S et aut. Relaparotomies: Why is Mortality Higher? Eur J Trauma. Emerg Surg 2009 Co hen M., Bilimoria K., Ko C., Hall B. Development of an American College of Surgeons National Surgery Quality Improvement Program: Morbidity and Mortality Risk Calculator for Colorectal Surgery Journal of the American College of Surgeons, Volume 208, Issue 6, June 2009, p 1009-1016 Phitayakorn R., Delaney C., Reynolds H et aut. Standartized algorhytms for management of anastomotic leaks and related abdominal and pelvic abscess after colorectal surgery. World J Surg, 2008 Jun;32(6):1147

Scripta Scientifica Medica, 2009; vol. 41 (3), pp 225-229

COLORECTAL PRIMARY AND COLORECTAL LIVER METASTASES-NEW APPROACHES FOR MANAGEMENT Veltchev L. Department of Surgical Oncology, MD Anderson Cancer Center, Texas Medical Center, Houston SUMMARY Improved imaging and more effective neoadjuvant chemotherapy have contributed to improved surgical outcomes following resections. The use of either oxaliplatin and, or irinotecan (respectively Folfox and Folfiri) have improved responses, progression free survival, and up to 30% of patients with unresectable disease became potentially curable following treatment with 5FU and oxaliplatinum. Consequently many patients with extensive disease at pre-operative imaging undergo neoadjuvant chemotherapy in an attempt to dawn stage the disease for subsequent surgery. Injury to normal liver tissue following systematic chemotherapy is well recognized. SOS (Sinusoidal obstructive syndrome) described by Rubbia -Brand and al. found that SOS was associated with chemotherapy for colorectal tumor and metastases in patients treated with oxaliplatinum and the liver became congested and friable with increased risk of bleeding at surgery, if more than 90 days (JN Vauthey). PVE (portal vein embolization) in selected patients is life safest manipulation in patients wit synchronous and methachronous colorectal metastases.Exceptinal regenerative capability of liver parenchyma after programmed obstruction, combined with pre- and post PVE liver volumetrie by Standardized method created in MD Anderson CC is new point of management for major liver resection, principally in two stage liver resection for multiple CR mets. The last decade in West clinics was observed change in management to patients with colorectal primary and synchronous liver metastases. What is new from Houston?

The colorectal cancer is in third place in world and presents important health problem. Between 15% and 25% of the patients have in the time of diagnosis liver metastases (synchronous) and another 20%-25% developed later (methachronous). In 30%-50% of patients with either synchronous or metachronous liver metastases, the liver is the only site of metastatic disease. The most frequent cause for death is liver failure and insufficiency. Liver resection currently represents the only potentially curative therapeutic option for hepatic colorectal metastasis (CRLM), and 5-year survival rates of 35%-58% have been reported. Traditionally, primary tumor stage, preoperative carcinoembryonic antigen (CEA) level, hepatic tumor size, number of hepatic metastases, time from primary tumor treatment to diagnosis of hepatic metastases and presence of extrahepatic disease has been reported to be independent predictors of survival after resection. Tree directions of CRLM treatment in last decade became important for patients with untreated before disease:

I. Neoadjuvant chemotherapy Surgical resection of hepatic metastases is the standard of care for resectable disease, with recent single and multicenter studies reporting up to a 58% 5-year survival rate (1,2). Traditionally administered postoperatively, systemic chemotherapy has increasingly been used in the preoperative setting before liver resection because of several theoretical

advantages. These include the potential to downsize tumor(s) preoperatively, to increase curative resection rates, and to convert some patients from having unresectable to resectable disease. Use of preoperative therapy in patients at high risk for recurrence may assist in identifying responders so that therapy can be tailored postoperatively based on preoperative response. In addition, patients with multiple tumors who progress on preoperative chemotherapy and who, therefore, may not benefit from resection can be spared nontherapeutic surgery (3). Introduction of Irinotecan, an inhibitor of topoisomerasa I, and Oxaliplatin, new class platinum derivate without nephrotoxicity, in association with traditional 5 FU (5 Fluorouracil)-LV(Leucovorin) named Folfiri and Folfox, rise the number of percentage of radiologic response in 40-50% in patients. The recent study show that another class biologic medicamentation Cetuximab, an epidermal growth factor receptor antagonist and Bevacizumab (Avastin), a monoclonal antibody against vascular endothelium growth factor in combination with Folfiri and Folfox have improved effect of response from CRLM of 65-80%. Controversially, many authors report of unlike effect of neoadjuvant chemotherapy: New chemotherapy regimens for CRM, such as FU plus irinotecan or oxaliplatin, have response rates up to 56 % (4) but there have been reported cases of severe

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Veltchev L.

histopathologic changes in the resected liver of patients treated with these regimens. Rubbia-Brandt et al (5) reported an increased rate of sinusoidal dilation in patients who had received chemotherapy, most of whom (78%) had received preoperative oxaliplatin. Vauthey JN et al (6) (MD Anderson Cancer Center) in his study report the association of irinotecan with steatohepatitis and subsequent postoperative mortality after hepatic surgery. Although steatohepatitis is generally a benign condition, but the presence of steatohepatitis has been associated with an increased risk of liver disease and liver failure in some patients. Steatohepatitis of the liver may cause defective cell proliferation through alterations of the nuclear factor-kappa B pathway, which is crucial for the priming phase of liver regeneration.

Conclusion However, the effect of prolonged chemotherapy deserves further investigation because the current study included mostly patients presenting with resectable disease (82.3%) and the median durations of treatment with oxaliplatin and irinotecan were only 12 and 16 weeks, respectively. Preoperative chemotherapy can induce regimen specific histopathologic hepatic changes. In the case of oxaliplatin, the chemotherapy-associated liver injury was not associated with an increased risk of perioperative morbidity or mortality. In contrast, steatohepatitis was associated with irinotecan and with an increased perioperative risk of death, especially in patients undergoing a major resection combined with radiofrequency ablation. Some have recommended liver biopsy to evaluate for steatosis or steatohepatitis. Rather, laparoscopy before laparotomy in patients with preoperative imaging studies that suggest steatosis should be considered to directly evaluate the liver. The extent of resection and type of chemotherapy regimen should be carefully considered and individualized, including a consideration for BMI and related comorbid factors. In patients who require major hepatic surgery and have proven hepatic injury, preoperative portal vein embolization may be considered based on prior experience with major hepatectomy in cirrhosis, although the specific indications for this approach remain to be defined.

II. Liver regeneration, Portal vein embolization and Preoperative liver volumetrie. Development of a new technique in medical science offers decrease of the morbidity and mortality among patients who are candidate for major liver resection. PVE, an interventional radiological manipulation who redirects portal blood flow to the intended liver remnant to induce hypertrophy and to help to prevent postoperative complications, associated with liver failure. Patients who have liver disease in addition to liver tumors and undergo resection of more then 60% of the liver’s functional mass and patients with a normal liver who have more than 75%-80% of the

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functional liver mass are considered at higher risk for postoperative liver complications (6). In 1990, M. Macauchi et al (7) reported the first use of preoperative PVE performed solely to induce left liver hypertrophy before major hepatic resection in patients with hilar cholangiocarcinoma. The ability of the liver to regenerate after injury or resection is the basis for preparation for major hepatectomy in a patient with an anticipated small liver remnant. Despite its considerable metabolic load, the liver is essentially a quiescent organ in terms of hepatocyte replication, with only 0, 0012% -0, 01% of hepatocytes undergoing motosis at any time (8). This low cell turnover in the healthy liver can be activated by toxic injury or surgical resection which stimulates sudden, massive hepatocyte proliferation resulting in recovery of the functional liver mass within 2 weeks after the loss of as much as two thirds of the liver. The regenerative response is typically mediated by the proliferation of surviving hepatocytes within the acinar architecture of the remnant liver.The moleculare and cellular events during regeneration result from growth factor (GF) stimulation in response to injury. In regenerating liver hepatocyte GF, transforming GF-a and epidermal GF are positive stimulus for hepaticyte replication. They induce release of cytokines, including tumor necrotic factor- a (TNF-a) and Interleukin-6 (IL-6), and activate immediate response genes that ready the hepatocyte for cell cycle progression. Insulin is synergic (comitogenic) with hepatocyte GF, which explain the slower regeneration rates seen in patients with diabetes. Importanly, extrahepatic factors are transported primarily from the gut via the portal vein (PV) and not by the hepatic artery (9). Compared with replication after resection, the peak replication after PVE is delayed approximately 3-4 days, suggesting that the hypertrophy stimulus generated by hepatocyte removal is stronger than the stimulus produced by apoptosis seen after PVE.Regeneration observed in the diseased liver ( i.e., cirrhotic) has a lover capacity to regenerate than the healthy liver. Explication can be the diminished capacity of hepatocytes to respond to hepatotropic factors or because parenchymal damage such as fibrosis leads to slower portal blood flow rates. PVE is safe, with acomplication rate in the range of 5%-8%. PVE has been shown to increase the size of the FLR from 8% to 16%, depending on the extent of the underlying liver disease Non cirrhotic livers in humans regenerate fastest, at rates of 12-21 cm3/d at 2 weeks, 11 cm3/d at 4 weeks, and 6 cm3/d at 32 days after PVE (9,10). The rational to use PVE preoperatively was to: · Minimize the abrupt increase in portal pressure at resection that can lead to hepatocellular damage to the FLR · Dissociate portal pressure-induced hepatocellular damage from direct trauma to the FLR during physical manipulation of the liver at the time of surgery · improve overall tolerance to major resection by increasing hepatic mass before resection to reduce the risk of post-resection metabolic change. Observed

Colorectal primary and colorectal liver metastases-new approaches for ...

changes in hepatic functionally test are minor and they generally peak at levels less three times baseline levels 1-3 days after PVE and return to normal within 7-10 days regardless to used embolic agent (10). Side effects are minor or absent and infrequent: fever and pain, nausea and vomiting. Experimental studies reveal that hepatocytes undergoes apoptosis( i.e. programmed cell dead ) and not necrosis after portal venous occlusion which explains the absence of significant systemic symptoms. Contraindications to PVE include: dilated biliary ducts of FLR, presense of untreatable coagulopathy, moderat portal hypertention and renal insufficiency in dialyzed patients.In presense of portal neoplastic invasion the portal flow is already diverted and no need of embolyzation. Measurement of FLR: computer tomography (CT) with volumetryis essential for planning hepatic resection (10) (MD Anderson Cancer Center). Tree-dimensional CT volumetric measurement are acquired by outlining the hepatic segmental contours and calculating the volumes from surface measurements from each slice. The CT is performed with intravenous contrast agent administration in several phases to demarcate the vascular landmarks of the hepatic segments. CT is used to directly measure the FLR, which is by definition disease-free. The total liver volume is estimated (total estimated liver volume;TELV) by a formula (TELV= -794,41+1,267.28 x BSA (body surface area); r2=0.454; derived from the close association between liver size and patient size based on body weight and BSA.The FLR/TELV ratio is calculated to provide a volumetric estimated of function of the FLR. From this method of calculation, called standardized FLR measurement, a correlation between the anticipated liver remnant and operative outcome has been established. CT image is obtained immediately before PVE and 3-4 weeks after PVE to asses the degree of FLR hypertrophy. For the patients with cirrhosis proposed functional test to assess liver function.Makauchi et al (11) propose indocyamine green retention test to determine the extension of resection in cirrhotic patients. The guideline prompting PVE in patients with cirrhosis has been set at a standardized FLR volume of less than 40%. Technique: to ensure adequate hypertrophy, embolization of portal branches must be complete as possible so that recanalization of the occluded portal system is minimized. The entire portal tree to be resected must be occluded to avoid the development of intrahepatic portoportal collaterals that may limit regeneration. PVE can be performed by three approaches: the transhepatic contralateral, i.e. portal access via the FLR, transhepatic ipsilateral via the respectable part of liver (Fig.1) and intraoperative transileocolic venous approaches. The choice of method depends of the preferences of the operator, on the type of planed hepatic resection, on embolization extend and embolizing agent. The aim is to occlude completely the portal branches of the portion of hepatic parenchyma that is going to be resected; If right hepatectomy is planned, segments V-VIII are embolized. According to the anatomy and variation of the portal vein branch it is necessary to be

embolized segment IV if case of the right extended hepatectomy. Complete embolization of him guaranty maximal effect of procedure and adequate hypertrophy of FLR preoperatively.

Fig.1 Percutaneous transhepatic embolization of the right portal vein plus the left portal vein branch to segment IV

In percutaneus transhepatic procedure may observed the technical complications: subcapsular hematoma, hemoperitoneum, hemobilia, pseudoanevrism, arteriovenous fistula, arterioportal shunts, transition liver failure, pneumothorax and sepsis (12). PVE is validated technique to increase the volume and function of the liver remnant before resection of liver tumors. The technique increases the safety of major resection in patients with liver disease and extends the option of resection to patients with multiple hepatic metastasis and limited parenchymal sparing from metastatic disease. Results: PVE has clearly been shown to enable safer resection with acceptable oncologic outcome in properly selected patients with otherwise normal livers. In patients with CRLMs extended right hepatectomy-resection of right liver plus segment IV and /or I (extended right hepatectomy or less often, the left liver plus segments V,VIII, and/or I(extended left hepatectomy). Nagino et al. (13) proved that PVE of the right liver extended to segment IV provide a statistically significant FLR volume gain. Patients considered to have unresectable tumors as a result of inadequate liver volume at presentation could undergo complete resection after PVE, with an associated 5 years overall survival rate of 29%. Timing of resection: planned the day for operation is usually 2-4 weeks after PVE and depends of results of control CT and hepatic volumetry. Conclusions: PVE is a validated technique to increase the volume and function of the liver remnant before resection of bile duct cancer. The technique increases the safety of major resection in patients with hilar CRLMs.Currently recommended thresholds prompting consideration of preoperative PVE are an FLR/TELV ratio no greater than 20% for patients with an otherwise normal liver and an FLR/TELV ratio less than 40% for patients with underlying liver disease.

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III. Major hepatic resection, two stage resections and margin line. Which first: colorectal primary or colorectal liver metastases? In patients with synchronous colorectal liver metastases, an approach reversing the traditional therapeutic order - i.e. starting with chemotherapy first, doing the liver surgery second, and performing the colorectal surgery last - is theoretically appealing as it avoids the risk of metastatic progression during treatment of the primary tumor (14). Two stage resections In patients with multiple colorectal liver metastases in both sides of the liver, a two-stage hepatectomy may be the best therapeutic approach (15). Specifically, a two-stage hepatectomy approach may be the only potentially curative therapeutic approach in those patients with extensive bilateral colorectal liver metastases that cannot be resected with or without ablation in a single procedure while sparing an adequate FLR. Initial experience with the two-stage hepatectomy procedure without PVE was associated with a relatively high incidence of liver failure resulting from insufficient functional volume of the FLR and high mortality (9%-15%) (16). More recently, two-stage hepatectomy combined with PVE was reported with no operative mortality and acceptable morbidity. Because of concern that nodules in the FLR after PVE may progress more rapidly than those in the nontumoral remnant hepatic parenchyma (17), metastases in the FLR (usually the left bilateral sectors) are usually resected in the first stage. PVE is then performed, if indicated, and the liver is allowed to hypertrophy for 3-4 weeks. Another advantage of performing a limited resection in the first stage is the preservation of a maximal amount of liver parenchyma that will hypertrophy after PVE to become the FLR. The components of the two stages should, however, be individualized, depending on the distribution of the tumor, liver volume, and other needed procedures. Similarly, as an alternative to PVE, portal vein ligation can sometimes be performed during the first-stage resection (18). In the absence of any significant tumor progression, an extended hepatectomy (usually involving the right hemiliver) is performed as the second stage.

Margin lines Surgical margin status has long been held as an important criterion for resectability and continues to be so. Cady et al. reported that a surgical margin <1 cm was associated with a significantly shorter disease-free survival duration. Many centers adopted the "1 cm rule" as a minimal margin to obtain at the time of hepatic resection. They have suggested that an anticipated surgical margin <1 cm is an absolute or relative contraindication to surgery. The status of the surgical margin has been shown to be important in long-term outcomes following resection of colorectal liver metastases. Multiple studies (19,20) have shown that a negative resection margin decreases local recurrence rates and improves survival. Complete removal of all macroscopic

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disease with negative microscopic resection margins is a very strong determinant of long-term outcome in all studies. In a study by Altendorf-Hofmann and Scheele (21), the median survival time of patients who underwent an R1 or R2 resection was only 14 months, compared with 44 months for those patients who underwent an R0 resection. Pawlik et al. (19) (MD Anderson Cancer Center) reported on 557 patients in whom the influence of surgical margin status on survival and site of recurrence following curative hepatic resection was specificallyevaluated. In that study, patients were classified according to the width of the resection margin, defined as the shortest distance from the edge of the tumor to the line of transection. A positive margin was defined as the presence of exposed tumor along the line of transection detected by histologic examination, and margin recurrence was defined as evidence of new tumor involving the parenchymal transaction line. On final pathologic analysis, margin status was positive in 45 patients and negative by 1-4 mm in 129, 5-9 mm in 85, and at least 1.0 cm in 298. Among the 45 patients with a positive margin, the diagnosis of positive margin was made postoperatively in 34 patients and intraoperatively in 11 patients. Of the patients who recurred, only 21 patients, or 4%, developed a recurrence at the site of the surgical margin. Among these 21 patients, only four had the surgical margin as the sole site of recurrence. With regard to factors predictive of pattern of recurrence, patients with a positive surgical margin had a higher overall recurrence rate, 51%, compared with about 40% for patients with a negative surgical margin. However, patients with a negative margin, regardless of the margin width, had similar overall recurrence rates. Only a positive surgical margin was associated with surgical margin recurrence. The 5-year survival rate was 17% for patients with a positive margin, compared with 64% for patients with a negative surgical margin. The width of the surgical margin did not significantly affect survival in patients with negative margins. That is, no significant difference in survival was seen in patients with a negative surgical margin, regardless of the width of the margin. Furthermore, on multivariate analysis, margin status was not a significant predictor of survival.

ConclusionS 1. Neoadjuvant chemotherapy with Folfiri and Folfox has high response rate in patients with colorectal cancer and colorectal liver metastases. The rate of response is predictor factor for radical treatment and long-term outcome. It can initiate liver complications such SOS, steatohepatitis and liver damage. This limited us of neoadjuvant chemo treatment to 4-5 courses before surgery. In advanced tumors 3 year survival with effective chemotherapy present 9%. 2. Liver parenchyma can regenerate and introduction of PVE and CT liver volumetry permit in selected patients to be included in bias for radical treatment. 3. Use of new safest radiological techniques changes the algorithm of standard treatment for primary colorectal cancer and synchronous liver metastases. Dependent of

Colorectal primary and colorectal liver metastases-new approaches for ...

chemotherapy effects, the two stage procedure has become new paradigm for "unresectable" before patients. 4. The number, size and extra hepatic disease are not now absolute contraindications for surgical treatment. Dawnstaging is new criteria for radicality. 5. Positive surgical margin line is not predictor factors in neoadjuvant chemotherapy responders.Long-terme survival and recurrence in responders with R0 and R1 is the some rate.

REFERENCES Abdalla EK, Vauthey JN, Ellis LM, et al: Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ ablation for colorectal liver metastases. Ann Surg 239:818-825, 2004 2. Pawlik TM, Scoggins CR, Zorzi D, et al: Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases. Ann Sur, 241:715-724, 2005 3. Allen PJ, Kemeny N, Jarnagin W, et al: Importance of response to neoadjuvant chemotherapy in patients undergoing resection of synchronous colorectal liver metastases. J Gastrointest Surg 7:109-117, 2003 4. Tournigand C, An dre T, Achille E, et al: FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: A randomized GERCOR study. J Clin Oncol 22:229-237, 2004 5. Rubbia-Brandt L, Audard V, Sartoretti P, et al: Severe hepatic sinusoidal obstruction associated with oxaliplatin-based chemotherapy in patients with metastatic colorectal cancer. Ann Oncol 15: 460-466, 2004 6. Vauthey JN, Chaoui A,Do KA, et al.Standartized measurement of the future liver remnant prior to extended liver resection : methodology and clinical associations. Surgery 2000; 127:512-519. 7. Macauchi M,Thai BL,Takayasu K, et al.Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma-a preliminary report.Surgery1990;107:521-527. 8. Koniaris LG,McKillop IH, Schwartz SI, Zimmers TA.Liver regeneration.JAm Coll Surg 2003;197:634-659. 9. Machalopoulos GK, Zarnegar R. Hepatocyte growth factor.Hepatology 1992; 15:149-155. 10. Madoff DC, Hicks ME, Vauthey JN, et al.Transhepatic portal vein embolization: anatomy,

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indications, and technical considerations.Radiographics 2002; 22:1063-1076 Makuuchi M,Kosuge T, Takayama T, et al.Surgery for small liver cancers. Semin. Surg Oncol 1993;9:298-304. Kodama Y, Shimizu T, Miyamoto N, Myyasaka K.Complications of percutaneus transhepatic portal vein embolization. J Vasc Inter Radiol 2002; 13: 1233-1237. Nagino M, Nimura Y, Kamiya J, et al.Right or left trisegment portal vein embolization before hepatic trisegmentectomy for hilar bile duct carcinoma.Surgery 1995;117:677-681. Mentha G, Roth AD, Terraz S, Giostra E, Gervaz P, Andres A, Mo rel P, Rubbia-Brandt L, Majno PE.Liver first approach in the treatment of colorectal cancer with synchronous liver metastases. Bis muth H, Adam R, Levi F et al. Resection of nonresectable liver metastases from colorectal cancer after neoadjuvant chemotherapy. Ann Surg 1996;224:509 -520; discussion 520-522. Jaeck D, Oussoultzoglou E, Rosso E et al. A two-stage hepatectomy procedurecombined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases. Ann Surg 2004;240:1037-1049; discussion 1049-1051. Elias D, De Baere T, Roche A et al. During liver regeneration following right portal embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma. Br J Surg 1999; 86:784 -788. Lorenzo Capussotti, MD; Andrea Muratore, MD; Filippo Baracchi, MD; Ber nard Lelong, MD;Alessandro Ferrero, MD; Daniele Regge, MD; Jean Rob ert Delpero, MD Portal Vein Ligation as an Efficient Method of Increasing the Future Liver Remnant Volume in the Surgical Treatment of Colorectal Metastases.Arch Surg 2008;143:978-982. Pawlik TM, Scoggins CR, ZorziD et al. Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases.Ann Surg 2005; 241:715-722; discussion 722-724. Fong Y, Co hen AM, Fortner JG et al. Liver resection for colorectal metastases. J Clin Oncol 1997; 15:938 -946. Altendorf-Hofmann A, Scheele J. A critical review of the major indicators of prognosis after resection of hepatic metastases from colorectal carcinoma. Surg Oncol Clin N Am 2003;12:165-192, xi.

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MODERN METHODS OF OCCLUSIVE TREATMENT OF ANORECTAL FISTULA Hadzhiev B. Medical University, University Hospital St. George, Clinic of General Surgery with Coloproctology ABSTRACT The occlusive treatment of anorectal fistula(ARF) is a modern method of application of different new biomaterials. We report a initial experience and results of treatment with fibringlue Òissucol® and Surgisis® AFP™ Anal Fistula Plug. For a period 2004 - 2008 in our clinic have been treated 37 patients with ARF, 32 males and 5 females, 47,2 years on average. From the very 37 patients, 34 have been treated with fibrin sealant Tissucol® and 3 with Surgisis® AFP™. When applying fibrin glue Tissucol® we have registered a rate of success in 73,53% (25/34), while in Surgisis® AFP™ Anal Fistula Plug success has been 100% (3/3). The application of these methods is easy and simple technique, which preserves unchainged the anatomy of anorectal region, having very good short and long term results.

Key words: Fistula-in-ano, Anal fistula, Fibrin glue, Fibri sealant, Fistula anal plug INTRODUCTION The idea of closing a fistula tract by occlusive treatment as a plain and attractive procedure has existed for a long time. The attempts however have been accompanied with failure (7). That approach began to change in the last 10-15 years with the development of new biotechnologies and fabrication of appropriate biomaterials, respectively. This includes different biological glues for sealing the fistula tracts and/or specially fabricated collagen plug. The fibrin glue was tested broadly in almost all fields of surgery, because of its easy and simple local application (13,14). Agreement based on clear, evident data determining the necessity of its application in anorectal fistula surgery is still not achieved. The idea of closing the fistula tract with a collagen plug from porous structure of Surgisis®, representing a lyophilized porcine submucosa with resilient and protective properties when implanted, have been realized in the recent years. The procedure is based on the principles of the "scaffold" theory of sprouting inside the matrix (scaffold). In this case the fibroblast cells invade and remain inside the structure of Surgisis®, forming a native tissue (1,10,16). Presently four alternative procedures to fistolotomia are available for clinical cases with relatively higher anorectal fistulas (ARF) and the primary one is the ligature approach or loose form of "seton" technique. Second are the plastic methods of closing the internal fistula opening and partial fistulectomia by advancement mucous flap techniques that are effective in nearly two thirds of the clinical cases and require frequently multiple attempts of closing. Their safetiness in terms of anal continence is not absolute, particularly regarding the rectal mucous flap. The other two less aggressive and rather conservative methods of surgical

treatment that can be presented as occlusive treatment of anorectal fistulas are fibrin glue (9,15,17) and the newest technique of collagen anal fistula plug (AFP) (4,8). The treatment with fibrin glue is really safe, but its efficiency is limited to 50-70% of the clinical cases. The new technique with Surgisis® AFPTM Anal Fistula Plug A is a method of direct closure of the primary fistula tract of ARF, with a partial drainage through the external secondary fistula opening. Biological fibrin glues are the most frequently used in surgery and especially in occlusive closure of ARF. Previously two forms of fibrin glue were recognized - autologue glue made from patient's own blood and commercially available glues made from human's blood products and from calf apoprotein. Presently, commercial fibrin glues are the most available and frequently used. Applied into the fistula tract the fibrin glue caused formation of blood clot that stimulates migration, proliferation and activation of fibroblasts, serving as a matrix for the invading cells. The clot is degradated for 7-14 hours and collagen fiber synthesis from the infiltrated fibroblasts begins allowing later cicatrisation of fistula tract (2,5,12). Surgisis® AFP™ (Cook Surgical Inc, Indiana, USA) became the first surgical device for direct occlusive treatment of ARF. This is a relatively long conical-shaped device made from lyophilized porcine submucosa. In the beginning the authors of the method used a self-made plug (SMP) in the form of a hand-screwed funnel prepared from a sheath of treated xenotransplantat (4 x 7 cm) Surgisis® ES (Cook Surgical Inc, USA) and later Surgisis® AFP™ Anal Fistula Plug was used. Presently, a commercially designed 9.5 cm long, cone-shaped device made from four folded layers Surgisis® ES. The biological Surgisis® 231

Hadzhiev B.

AFP™ Anal Fistula Plug is a biodegradable xenotransplantant, which does not trigger foreign body reaction or infiltration of giant cells but only offers the scaffold for ingrowth of host cells for tissue repair. It is experimentally proven and verified in practice that the plug can be used also in a relatively "infected" surgical field. It is placed in the primary fistula tract through the internal fistula opening, where it serves as a biological prosthesis for native cellular proliferation and regeneration, with consequential free and reliable closure of the fistula tract. Some surgeons already have used Surgisis® AFP™ for more than four years and according to the retrospective studies the results are quite satisfactory (4,8).

AIM To study the modern occlusive treatment with fibringlue Òissucol® and Surgisis® AFP™ Anal Fistula Plug and its effectiveness in short and longterm prospective.

external opening to the internal opening and Tussucol medium was injected inwards from the external opening (14). In 2008 3 patients with cryptoglandular anal fistulas were operated and follow up after application of original collagen Surgisis® AFP™ Anal Fistula Plug. Spinal anesthesia and gynecological position of the patient were preferred for the operation. The fistula tract was carefully identified with standard fistula probe and hydrogen peroxide solution was instilled through the external opening for cleaning. The plug was placed in a saline solution to soften and then using a suture through its thin end is tied to the end of the probe drawn through the fistula tract and adapted to its shape. The redundant parts of the plug were cut to the level of the two openings. The plug was the fixed with 8-shaped suture to the internal opening, which tightly closed with that suture. At the level of the external opening the plug was loosely fixed to the skin to allow fluid drainage. In none of the patients close of the fistula tract had been done previously. The mean length of the ARF was 4.5 cm (3.5-6.0 cm) (Fig.2).

MATERIAL AND METHODS Thirty seven patients (32 males and 5 females) of mean age 47.2 years have been treated in the clinic for ARF from 2004 to 2008. Of those 34 patients were treated with fibrin glue Tissucol® and 3 patients with Surgisis® AFP™ Anal Fistula Plug (Fig. 1).

Fig. 2. Types of ARF treated with Fibrin Glue or Anal Fistula Plug Fig. 1. Distribution of patients according to length of anorectal fistula

Patien ts with complicated fistulas and those with specific case history were excluded from the study. The patients underwent standard preparation with cleansing of the large bowel. Neither prophylactic nor therapeutic administration of antibiotics was used. Under general or spinal anesthesia the fistulas were examined and probed, their external and internal openings were defined and the fistula tract was carefully cleaned, washed out and filled with entirely with fibrin glue (Tissucol®, Baxter). The mean period of hospital stay in the clinic was 3.7 days. Control follow-up outpatient examinations were done after one week, 1, 3 and 6 months. After a careful curettage of the fistula tract and following lavage a flexible catheter was inserted through the

232

The follow-up periods were after a week, 1, 3, 6 months. Healing was achieved in 100% (3/3). The hospital stay in AFP treatment was 2.3 days.

RESULTS AND DISCUSSION The results from the use of fibrin glue for treatment of ARF in our study showed 73.53% success (25/34). The final results were worse in Patients with recurrent fistulas (50% success, 2/4). None of our patients experienced postoperative problems with anal continence or another complications requiring additional treatment. The results of fibrin glue treatment vary according to most of the authors (9,14,16). The length of the fistula tract is a tract is a disputable prognostic factor. In most of the studies the efficiency

Modern methods of occlusive treatment of anorectal fistula

is best in longer fistula tracts (14) while in less studies the opposite correlation is observed (13). The other factors, causing failure in application of the fibrin glue are Crohn disease HIV positive patients (16). Closure of the primary internal opening with additional suture (1,10) and/or supplementation of antibiotics to the glue mixture (13,17) do not allow improvement of the results. Most of the authors agree with the statement that loner follow-up with control examinations is necessary for proper evaluation of the method (3,6,11,20). This type of of treatment is directed with priority to the risky ARF with higher location and/or in patients with possible occurrence and development of anal incontinence. In simple and low ARF, which are most frequent, fistulotomia is the method of choice. In these only 50% of ARF treated with fibrin glue heal at 100% compared with those treated with fistulotomia. In the risk group ARF patients fibrin glue would be more efficient compared with the conventional treatment (63%:13%) (9). The number of our patients teated with Surgisis® AFP™ Anal Fistula Plug is too small for definite conclusions with statistical significance of the results. It is particularly important defining the recurrence of the disease as a true relapse or as continuation of the same disease, as well as the criteria of healing. It is considered that anal fistula is cured when three is no more secretion in the perianal area or local swelling and the fistula trat are constantly closed. It should be undelined that clear plain secretion can be observed abot 2-3 weeks after implantation of the fistula plug and that does not indicate recurrence of the disease (4,8). In one clinical case we observed slight serous secretion from the external opening for 6 days and that was not considered a relapse. True relapse is present in case of periodical secretion from open fistula tract. That is observed within 10 weeks and is a results of the restoring the lumen of the primary fistula tract.

10.

11.

12.

13.

14. 15.

CONCLUSION We think that fibrin glue Surgisis® AFP™ Anal Fistula Plug Physiological are safe and physiological methos for occlusive treatment of ARF, with very good success and sufficient efficiency in patients. Of course, more extensive studies of the problem are needed, for to allow more precisely evaluation of the method.

REFERENCES 1.

Abel ME, Chiu YS, Rus sell TR. Autologous fibrin glue in the treatment of rectovaginal and complex fistulas. Dis Colon Rectum, 1993,36(5):447-9 Aitola P, Hiltunen KM, Matikainen M Fibrin glue in perianal fistulas-a pilot study. Ann Chir Gynaecol, 1999,88(2):124-7 Bu chanan GN, Bartram CI, Phillips RK. Efficacy of fibrin sealant in the management of complex

16.

17.

18.

19.

20.

anal fistula: a prospective trial. Dis Colon Rectum, 2003, 46(9): 1167-74 Cham pagne BJ, O'Connor LM, Fer gu son M. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum, 2006,49(12): 1817-21 Chan KM, Lau CW, Lai KK. Preliminary results of using a commercial fibrin sealant in the treatment of fistula-in-ano. J R Coll Surg Edinb, 2002, 47(1): 407-10 Gisbertz SS, Sosef MN, Festen S. Treatment of fistulas in ano with fibrin glue. Digestive surgery, 2005, 22 (1-2): 91-4 Hjortrup A, Moesgaard F, Kjaergard J. Fibrin adhesive in the treatment of perineal fistulas. Dis Colon Rectum, 1991, 34(2): 752-4 John son EK, Gaw JU, Armstrong DN. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum, 2006,49(3): 371-6 Lindsey I, Smilgin-Humphreys MM, Cunningham C, et al. A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula. Dis Colon Rectum, 2002,45(12): 1608-15 Loungnarath R, Dietz DW, Mutch MG. Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum, 2004,47(4): 432-6 Maralcan G, Baskonus I, Aybasti N. The use of fibrin glue in the treatment of fistula-in-ano: a prospective study. Surgery today, 2006,36(2): 166-70 Park JJ, Cintron JR, Orsay CP. Repair of chronic anorectal fistulae using commercial fibrin sealant. Arch Surg, 2000,135(2): 166-9 Patrlj L, Kocman B, Martinac M. Fibrin glue-antibiotic mixture in the treatment of anal fistulae: experience with 69 cases. Digestive surgery, 2000, 17(1): 77-80 Pigot F. Closure of an anal fistula with biologic glue. J Chir, Paris, 2003, 140(5): 286 8 Senejoux À, Des sequelles fonctionnelles aux alternatives a la fistulotomie. Dis Colon Rectum, 2007, 27 (1): 93-99 Sentovich SM. Fibrin glue for anal fistulas: longterm results. Dis Colon Rectum, 2003, 46(4): 498-502 Singer M, Cintron J, Nel son R. Treatment of fistulas-in-ano with fibrin sealant in combination with intraadhesive antibiotics and/or surgical closure of the internal fistula opening. Dis Colon Rectum, 2005,48(4): 799-808 van Koperen PJ, D'Hoore A, Wolthuis AM, Bemelman WA et al. Anal fistula plug for closure of difficult anorectal fistula: a prospective study. Dis Colon Rectum, 2007, 50(12):2168-72. Zawadzki A, Starck M. Collagen plugs--new treatment of complex anal fistulas. Experiences from a Swedish center. Lakartidningen, 2008,105(20):1489-91. Zmora O, Neufeld D, Ziv Y. Prospective, multicenter evaluation of highly concentrated fibrin glue in the treatment of complex cryptogenic perianal fistulas. Dis Colon Rectum, 2005, 48(12): 2167-72

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Scripta Scientifica Medica, 2009; vol. 41 (3), pp 235-239

FAST-TRACK COLORECTAL CANCER SURGERY PRESENT AND FUTURE Sakakushev B., B. Hadzhiev, B. Boev, B. Atanasov, V. Petkov Medical University, University Hospital â&#x20AC;&#x153;St. Georgeâ&#x20AC;? - Plovdiv, Bulgaria Clinic of General Surgery with Coloproctology ABSTRACT The traditional perioperative approach in CRC surgery has been changed with the introduction of perioperative multimodal rehabilitation /so called fast track (FT) rehabilitation or enhanced recovery after surgery/ERAS/. FT surgery program aims to reduce the stress response to surgery, operative morbidity, hasten return of organ function and hence accelerate recovery following major surgery. The aim of our study was to find out elements and patient variables coinciding with modern ERAS programs and to compare outcomes of both traditional surgical care strategies and those containing FT surgery elements. We have studied retrospectively all 748 cases of colorectal cancer operated in our clinic between 1998 and 2008 and analyzed 404 of them with only resections and anastomoses for FT elements in the pre- intra- and postoperative course using a modified protocol with 19 interventions and dividing the study period into two parts -prior and post 2003. Our retrospective observation sowed lower postoperative stay in sigma resections, right and left hemicolectomies in the more recent period where elements of FT surgery have been present. Soe of these patients did have lower morbidity and mortality rates, faster recovery at low readmission rates compared with the patients treated traditionally. Unfortunately adherence to surgical dogma, traditionalism and lack of implementation and following of a strict FT surgery protocol did not allow us to perform more extensive, and protocol specified study. Even these scanty and low evidenced data have encouraged a group of surgeons to recently start a prospective randomized protocol based research on major elective and urgent visceral surgery operations convinced in FT surgery advantages.

Key words: fast track surgery /FT/, enhanced recovery after surgery /ERAS/, colorectal cancer /CRC INTRODUCTION With improved life expectancy and high incidence of colorectal cancer among the elderly the need for safe surgery is increasing (1). Patients undergoing major colorectal surgery have complication rate of 15% to 20%, prolonging postoperative hospital stay by 6 to 10 days and overloading health care systems with significant financial burden (2,3,4). In 1995 Bardram and later Kehlet et al. were the first to divert from the traditional perioperative approach and to introduce perioperative multimodal rehabilitation /so called fast track (FT) rehabilitation or enhanced recovery after surgery/ERAS/ in a detailed specific protocol (1,3). ERAS collection of strategies aim to reduce the stress response to surgery, reduce operative morbidity, hasten return of organ function and hence accelerate recovery following major surgery (5). The basic mechanism for an increased perioperaive risk in patients with perioperative organ dysfunction is the surgical stress response, associated with the operation, resulting in increasing demands on the already impaired organs (6) ERAS programs although quite diverse can be classified by the interventions.included

in the protocol as preoperative, intraoperative, or postoperative (4) /Table 1/. For a study to be qualified as having an ERAS intervention it should include at least five of the elements in Table 1, one of each coming from the preoperative, peri-operative and postoperative periods (7). It is a strategy combined in a structured pathway, allowing the surgical and anaesthetic teams to decrease the physical insult and aid recovery enabling earlier discharge. FT programmes being taken up now worldwide are rapidly developing in colonic and rectal surgery. Fast-track programmes reduce the length of hospital stay in several ways but, for colorectal surgery, many of these are targeted at maintaining normal gut physiology. Although many authors advocate and recommend FT colorectal oncological surgery as better, safe and feasible (4,8,10,11,12) results of multicentre trials in US and Europe show low acceptance by surgeons and even patients (3,8,13).

AIM The aim of our study was to find out elements and patient variables coinciding with these of modern ERAS programs 235

Sakakushev B., B. Hadzhiev, B. Boev, ...

and to compare outcomes of both traditional surgical care strategies and those containing FT surgery elements. Table 1. Modified protocol of core package elements in ERAS for colorectal Cancer patients /1,5,7,8,9/ ERAS /FT/ Elements & Interventions

Preoperative

1. Education, counselling, assessment 2. Short fasting period - carbohydrate load (2 hours to surgery) 3. No mechanical bowel preparation, no pre- and pro-biotic 4. No premedication

5. No intravenous fluid overload /restriction / optimisation / 6. Perioperative hyperoxia 7. Normothermia /active prevention of hypothermia / Intraoperative 8. Tailored optimal anesthesia 9. Minimally invasive incisions /transverse, laparoscopic / 10. No routine use of nasogastric /NG/ tubes 11. No routine use of peritoneal drains 12. Enforced mobilisation - walking from day 1 13. Early removal of urinary catheters /drains and lines/ 14. Immediate oral intake/liquids/ and solid food from day 1 15. No systemic opoid use - balanced, Postoperative multimodal analgesia 16. Standard laxatives or pro-kinetics 17. Routine anti-emetic 18. DVT prophylaxis 19. Discharge criteria - able to eat, drink, flatus passage, satisfactory home support, oral analgesia

MATERIALS AND METHODS We studied retrospectively all cases of resections and anastomoses for colorectal cancer in our clinic, from 1998 to 2008. For 12 years period 748 patients have been operated in our clinic for different localizations of colorectal cancer /Table 2/, performing 16 types of operations demonstrated on Table 3. We have formally separated our research into two consecutive periods - 1998 -2002 and 2003 -2008, because of the gradual, but persistent changes in perioperative strategies for CRC surgery after 2003, in terms of shortened preoperative stay, routine ASA score preoperative risk assessment, avoidance of preoperative antibiotic bowel preparation, avoidance of routine use in sigma resection, selected reducing of preoperative intravenous fluid overload for elective surgery, early removal of urinary catheter and NG tube on 1 - 2 postoperative day and last but not least early mobilization in and out of bed and early oral intake of liquids and solids on day 1-2-3. For the whole study period we have routinely used DVT prophylaxis, selective morphine analgesia, usually once on the night of operation, pro-kinetics on 1-3 postoperative day and strict fulfillment of discharge criteria for the patient -ability to eat, drink, 236

flatus passage, satisfactory home support, oral analgesia. Only resections and anastomoses without stoma were included in the study. Table 4 shows 6 different types of primary resections and anastomoses performed for elective or emergent cases of colorectal cancer. Table 2. Distribution of patients according to CRC site Site of CRC

ยน of Patients

Percentage %

Ca coeci

6.95

Ca colonis ascendens

7.75

Ca flexura lienalis

4.54

Ca colonis transversi

4.4

Ca flexura hepatica

4.28

Ca colonis descendens

3.34

Ca sigmatis

152

20.3

Ca rectosigmoidalis

4.4

Ca recti

323

43.18

0.8

748

100

Multiple Ca Total

Table 3. Types of all operations performed for CRC Operation Type

ยน of Patients

Percentage %

Expl. Laparotomy

2.9

Right Hemicolectomy

121

16.2

Transverse Colon Resection

3.2

Left Hemicolectomy

5.7

Sigma Resection

109

14.6

Anterior Rectum Resection

105

14.0

Miles' rectum extirpation

163

21.8

Transversostomy

4.0

Sygmostomy

7.9

Hartman's' procedure

5.9

Ileostomy

0.8

Ileotransversostomy

1.9

Transversosygmostomy

0.5

Subtotal Colectomy

0.3

Ileosygmostomy

0.3

748

100

Cecostomy

Total

Fast-track colorectal cancer surgery - present and future

The main outcomes of interest in our analysis were: 1. Short-term morbidity including anastomotic leak, complications other than anastomotic leak, and general postoperative complications (bowel obstruction/ stricture, prolonged ileus, abscess formation, wound infection, urogenital infection, and pulmonary embolism) 2. Length of primary postoperative hospital stay expressed as days in the hospital after surgery 3. Readmission rate expressed as percentage 4. Mortality expressed as percentage Table 4. Types of operations performed for CRC included in the study

The first break from traditional care is the omission of bowel preparation. A dehydrated patient results in a dehyTable 5. Postoperative Complications & Mortality in CRC resections Complication Type

¹ of Patients/404/

Percentage %

Wound infection

18.8

Bronchopneumonia

0.5

Embolia

0.5

Anastomosis dehiscence

2.5

Eventrations

0.7

Postoperative ileus

1.2

Operation Type

¹ of Patients

Percentage %

Right Hemicolectomy

121

30.3

Postoperative hemorrhage

1.0

Transverse Colon Resection

6.0

Pneumothorax

0.2

Left Hemicolectomy

10.7

Readmission rate

3.5

Sygma Resection

109

27.2

Lethality

4.5

Anterior Rectum Resection

105

26.3

0.5

404

100.0

Subtotal Colectomy Total

RESULTS Mean age of the patients was 60.7 years /41 -91/, ratio men 216/53.5%/: women 188/ 46.5%/ was 1.15:1. Most of the subjects did have more than one co-morbid disease, which together with advanced age explained the relatively high risk - ASA I -4, ASA II -114, ASA III - 189 è ASA IV -97. The following postoperative complications have been registered: wound infection - 76 /18.8%/, bronchopneumonia -2 /0.5%/, embolia -2 /0.5%/, anastomosis dehiscence -10 /2.5%/, eventrations -3 /0.7%/, postoperative ileus -8 /1.2%/, postoperative hemorrhage -4 /1.0%/, pneumothorax -1 /0.2%/. Readmission rate was 3.5% (14) and lethality -4.5% (18). Mean hospital stay was -21.7 days. /7 -89/. In the second study period/2003 -2008 / postoperative stay for sigma resection cases was 10.6 (7-52) and for right and left haemicolectomies, free of complications - 14.5(8 -63).

DISCUSSION ERAS has questioned the traditions and dogmas of perioperative care. It has integrated evidence-based knowledge to optimize perioperative care for elective surgical patients based on modifications of surgical and anaesthetic practice and nutritional aspects.

drated bowel, and there is no evidence that bowel preparation is of any benefit. To decrease dehydration, preoperative feeding with glucose-containing fluids is allowed up to two hours before surgery, thus maintaining gut function for as long as is possible. Premedication is of less importance with the advent of modern anaesthetic techniques and drugs. The problem of giving benzodiazepines -the most common premed -is that their half-life is considerably longer than that of newer volatiles or propofol, rendering the patient sleepy and unable to sit up in bed, and therefore unable to breathe as deeply or drink as normal. Minimising the need for systemic morphine (and its many debilitating side effects) by epidural anaesthesia maintains gut peristalsis throughout surgery because of the sympathetic blockade from the epidural, thereby also helping gut homeostasis (2). Intraoperative hyperoxia reduces small vessel hypoxia, decreasing infection and anastomotic leak rates and resumption to a full diet. Normothermia by active air warming and fluid routes maintains the patient’s core and peripheral temperature as close to normal as possible, maintaining immune function (14), preserving normal blood coagulation and preventing hypothermia and myocardial ischaemia. Intravenous fluids given intraoperatively prevent secondary dehydration, minimise renal impairment and cognitive dysfunction, as well as surgical complications. The concept of fluid-restrictive regimens in preventing gut oedema from fluid overload may be counter-productive, and there is evidence that more fluid (especially synthetic colloids) given appropriately under Doppler control can further reduce the length of stay by two days. Some studies cite evidence that restrictive fluid regimens are advantageous, but closer examination shows these ‘restricted’ regimens used different

237

Sakakushev B., B. Hadzhiev, B. Boev, ...

fluids (usually colloids) to suggest the appearance of less fluid (2,15). While postoperatively the anaesthetic team works to achieve physiological equilibrium, the surgeon minimizes trauma and surgical insult by using transverse incisions or newer laparoscopic approaches, dissection within anatomical planes using a power source to avoid blood loss, avoidance of drains and nasogastric tubes wherever possible, removal of urinary catheters as soon as possible, thus enabling early mobilisation (16). This is aided in the immediate postoperative period, as the anaesthetist has rendered the patient comfortable, nausea-free, alert and awake, and as a result able to take diet and mobilise on the night of operation (2). The effectiveness of an ERAS program depends on changing patients’ expectations for their hospital stay. Encouraging them to expect a reduced stay, with a shorter, complication-free recovery, is easily accepted. Additionally, a full explanation of each part of the process, backed up with clear, easy-to-understand written material, helps to manage patients’ expectations. Short hospital stay, low complication rate and fast recovery of FT surgery allows efficient use of hospital beds and reducing hospital costs (17). Our data sowed almost equal sex occurrence /men:women ratio - 1.15:1/. Mean age of the patients with CRC resections was 60.7 years /41-91/. Most of the subjects did have more than one co-morbid disease, having relatively high risk ASA I -4, ASA II -114, ASA III - 189 è ASA IV -97. The registered postoperative complications in CRC resections and anastomoses were almost equal as these in non resected patients : wound infection - 76 /18.8%/, bronchopneumonia -2 /0.5%/, embolia -2 /0.5%/, anastomosis dehiscence -10 /2.5%/, eventrations -3 /0.7%/, postoperative ileus -8 /1.2%/, postoperative hemorrhage -4 /1.0%/, pneumothorax -1 /0.2%/. The older the age the higher ASA score and rate of complications registered. Readmission rate was 3.5%/14/ and lethality -4.5%/18 /. Mean hospital stay was -21.7 days/7 -89/. In the second study period/2003 -2008 / postoperative stay for sigma resection cases was 10.6 /7-52/ and for right and left haemicolectomies, free of complications - 14.5 /8-63/. Sigma resections and both right and left hemicolectomies in the period 2003 -2008 with shorter postoperative stay did have lower complication rate. The lack of randomization and strict adherence to a protocol of FT interventions in the period 2003 -2008, does not afford as to draw statistically and clinically significant conclusions on the results of implementation of several FT surgery parameters. The modified protocol with 19 FT surgery interventions is in action now for a recently started prospective randomized trial in our clinic on elective and emergency visceral surgery. Despite these encouraging results from a large number of studies, fast-track protocols are not adopted widely in daily clinical practice due to long-standing medical traditions and dogma, low compliance, leading to collaboration and communication difficulty among the different disciplines required to run the protocol and reduced reimbursement to 238

the hospital (3). The multidisciplinary teams, comprising surgeons, anesthesiologists, and nursing staff all require additional training and management in order to carry out respective fast-track roles (3,8). Significant organizational and structural preliminary work is needed for the consistent implementation of such a complex program (2,17). Another reason for not implementing a whole protocol is that not all of the fast-track elements are of equal importance and centers around the world have adopted and incorporated various features of an enhanced recovery program in their traditional care plans, such as no routine use of nasogastric tubes, early postoperative feeding, and mobilization, in an effort to modernize them. Although the individual studies showed that ERAS programs were associated with shorter primary and total hospital length of stay, we cannot provide further evidence for these outcomes. Our study does indicate, that implementing elements of ERAS programs are associated with reduced total complications. The impact of ERAS programmes may extend beyond the commonly reported short term outcomes and ERAS may accelerate overall recovery and return to normal function (18,19).

CONCLUSIONS Surgeons should continually refine their knowledge of disease processes, mature their technical skills and become adept at anticipating the clinical course of their patients to minimize the potential for complications. The multidisciplinary approach of ERAS programs requires further refinement to provide its ultimate goal - the stress, pain, and risk- free operation. Cooperation between all the involved health care professionals is the only way of implementation to achieve the necessary structural and organizational changes which have to be addressed to achieve complete protocol compliance. There is evidence to suggest that ERAS programs are better and safe than traditional perioperative care, but a larger randomized controlled trial is necessary with more rigorous methodology to more clearly define components for ERAS programs as well as assess more clinically relevant endpoints.

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Fast-track colorectal cancer surgery - present and future 4.

Eskicioglu G., Forbes S., Aarts A., Enhanced Recovery after Surgery (ERAS) Programs for Patients Having Colorectal Surgery: A Meta-analysis of Randomized Trials J Gastrointest Surg, May 2009, p 1-9. 5. Zargar-Shoshtari K., Con nolly, A., Is rael L., Hill A. Fast-Track Surgery May Reduce Complications Following Major Colonic Surgery. Dis. Colon Rectum Vol.51: 1633-1640 (2008) 6. Kehlet H. Evidence-based Surgical Care and the evolution of Fast-track Surgery. Ann Sur g248/2/;189-198 7. Wal ter C., Collin J. Dumville D.Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Disease, 11, 344-353 8. Braumann C., Guenther N., W endling P et aut. Multimodal Perioperative Rehabilitation in Elective Conventional Resection of Colonic Cancer: Results from the German Multicenter Quality Assurance Program ‘Fast-Track Colon II’ Dig Surg 2009; Vol. 26, No. 2, 2009 :123-129 9. Jottard K., Berlo C., Jeuken L., Dejong C. Changes in Outcome during Implementation of a Fast-Track Colonic Surgery Project in a University-Affiliated General Teaching Hospital. Dig Surg 2008;25:335-338 10. Wind J, Polle SW, Fung Kon Jin P et aut Systematic review of enhanced recovery programmes in colonic surgery Br J Surg. 2006 Jul;93(7):800-9. Enhanced Recovery after Surgery (ERAS) 11. GroupSchwenk W., Neudecker J., Raue W. Fast-track” rehabilitation after rectal cancer resection Int J Colorectal Dis (2006) 21: 547-553 12. Ham mer J., Harling H., Wille-Jørgensen P. Implementation of the scientific evidence into daily practice- example from fast-track colonic cancer surgery. Colorectal Dis. 2008 Jul;10(6):593-8

13. Hasenberg T., Keese M., Langle F. Fast-track’ colonic surgery in Austria and Germany -results from the survey on patterns in current perioperative practice. Colorectal Disease, 11, 162-167 14. Wichmann MW, Eben R, Angele MK, Brandenburg F, Goetz AE, Jauch KW. Fast-track rehabilitation in elective colorectal surgery patients: a prospective clinical and immunological single-centre study. ANZ J Surg. 2007 Jul;77(7):502-715. 15. Aguilar-Nascimento J., Breno A., Diniz N et aut. Clinical Benefits After the Implementation of a Protocol of Restricted Perioperative Intravenous Crystalloid Fluids in Major Abdominal Operations. World J Surg (2009) 33:925-930 16. Kahokehr A., Sammour T., Sahakian V. Predictors of day stay after colonic surgery in a structured multi-modal care program. ANZ Journal of Surgery Volume 79 Issue s1, Pages A15 - A16 17. Delaney CP, Fazio VW , Senagore AJ, Rob in son B, Halverson AL, Remzi FH. ‘Fast track’ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery Br J Surg. 2001 Nov;88(11):1533-8 18. Zargar Shoshtari K.,. Paddison J., Booth R and. Hill A. A prospective study on the Iinfluence of a Fast-track Pprogram on Ppostoperative Fatigue and Functional Recovery After Major Colonic Surgery... ANZ Journal of Surgery Volume 79 Issue s1, Pages A12 - A1219. 19. Liu Z, Wang XD, Li L Perioperative fast track programs enhance the postoperative recovery after rectal carcinoma resection Zhonghua Wei Chang Wai Ke Za Zhi. 2008 Nov;11(6):551-3.

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ABDOMINAL TUBERCULOSIS REPORT OF 5 PATIENTS AND LITERATURE REVIEW Chernopolsky P., P. Arnaudov, K. Georgiev, V. Bozhkov, T. Ivanov, R. Madjov Second Department of Surgery, UMHAT "St.Marina" - Varna, Medical University - Varna Each year, tuberculosis (TB) results in the death of 3 million people globally. In 2000-2020 - 200 million people will become sick, and 35 million will die from TB, if control is not strengthened. Tuberculosis is still common in the developing world, so common that it must be considered in the differential diagnosis of a majority of the surgical presentations. The disease is a diagnostic enigma and the management is still controversial. Surgical treatments, both radical and conservative, are being advocated. With the development of modern antitubercular drugs, the surgical management is with a view to overcome the deleterious effects of the disease, like obstruction, perforation and disorganization of the tissues.

Key words: abdominal tuberculosis, bowel obstruction, lymph nodes Tuberculosis can involve any part of the gastrointestinal tract and is the sixth most frequent site of extra-pulmonary involvement. Tuberculosis bacteria (Mycobacterium tuberculosis) reach the gastrointestinal tract via haematogenous spread, ingestion of infected sputum, or direct spread from infected contiguous lymph nodes and fallopian tubes. The gross pathology is characterized by transverse ulcers, fibrosis, thickening and stricturing of the bowel wall, enlarged mesenteric lymph nodes, omental thickening and peritoneal tubercles.

tion. 4 of the patients were discharged with normal postoperative period. The 62 year old male died on the second postoperative day due to toxaemia and shock. The other patients were followed up for a period of 2 months to 1 year. All of the patients were in good health and free from symptoms. Table 1.

Patient

Diagnosis at admission

Operative procedure

Outcome

Intestinal obstruction

Laparotomy Intestinal resection Primary anastomosis

Normal postoperative period Discharged

PATIENTS AND METHODS We report about 5 patients admitted in the Second Department of surgery as emergency cases between 2001 and 2009 (table 1). Diagnosis in all of the cases was confirmed surgically and patohystologically. In 3 of these clinical diagnosis was other than tuberculosis on clinical evidence. 2 were female and 3 male at age from 24 to 62 years. Three of them present with a signs and symptoms of peritonitis, one with bowel obstruction and one with bleeding per rectum and palpable abdominal mass. The most serious case was a 62 year old man with clinic of peritonitis due to multiple intestinal perforations, more than 72 hours after the initial complaints. These patients were investigated with physical exams, laboratory tests, abdominal ultrasound scan, X-rays and CT scan. An emergent surgical intervention was performed in all of the patients - intestinal resection with primary anastomosis in that with the bowel obstruction (28 year old female), right hemicolectomy in the patient with the bleeding (29 year old male), intestinal resection and coecostomy in the patient with multiple intestinal perforations (32 year old male), lavage and drainage in the patient with the peritoneal tuberculosis (24 year old female), intestinal resection and ileostomy in the most severe case (62 year old male). All the cases were put on antitubercular drugs after the opera-

28 year old female

Normal 29 year old Palpable Right postoperative male abdominal mass hemicolectomy period Discharged Peritonitis diffusa 32 year old (multiple male intestinal perforations)

Intestinal resection Coecostomy

Normal postoperative period Discharged

24 year old female

Laparotomy Lavage Drainage

Normal postoperative period Discharged

Laparotomy Intestinal resection Ileostomy

Death on the second postoperative day with symptoms of multiorgan failure

Peritonitis

Peritonitis totalis >72h 62 year old (multiple male intestinal perforations)

241

Chernopolsky P., P. Arnaudov, K. Georgiev ...

The histological findings of abdominal tuberculosis presented in the intestinal lesions, lymph nodes and peritoneum - a tuberculous granulomas with central caseation necrosis, Langhans epithelioid cells, lymphocytes, lymph nodes with caseous-productive tuberculosis.

DISCUSSION According to World Health Organization (WHO) nearly one-third of the world's population is under the risk of acquiring tuberculosis (TB) and more than 30 million deaths occurred due to tuberculosis every year. Abdominal tuberculosis accounts for nearly 2% of TB cases world-wide. TB can involve any part of the gastrointestinal tract from mouth to anus, the peritoneum and the pancreatobiliary system. It can have a varied presentation, frequently mimicking other abdominal diseases. Autopsies conducted on patients with pulmonary tuberculosis before the era of effective antitubercular drugs revealed intestinal involvement in 55-90% cases. TB of the gastrointestinal tract is the sixth most frequent form of extra-pulmonary site after lymphatic, genitourinary, bone and joint, military and meningeal tuberculosis. The postulated mechanisms by which the tubercule bacilli reach the gastrointestinal tract are: hematogenous spread from the primary lung focus, with later reactivation; ingestion of bacilli in sputum from active pulmonary focus; direct spread from adjacent organs and through lymph channels from infected nodes. The most common site of involvement is the ileocaecal region, possibly because of the increased physiological stasis, increased rate of fluid and electrolyte absorption, minimal digestive activity and an abundance of lymphoid tissue at this site. In Bhansali's series, including 196 patients with gastrointestinal tuberculosis, ileum was involved in 102 and caecum in 100 patients. Of the 300 patients in a study ileocaecal involvement was present in 162. Peritoneal involvement may occur from spread from lymph nodes, intestinal lesions or from tubercular salpingitis in women. Abdominal lymph nodal and peritoneal tuberculosis may occur without gastrointestinal involvement in about one third of the cases. Tuberculous granulomas are initially formed in the mucosa or the Peyer's patches. These granulomas are of variable size and characteristically tend to be confluent, in contrast to those in Crohn's disease. Granulomas are often seen just beneath the ulcer bed, mainly in the submucosal layer. Tubercular ulcers are relatively superficial and usually do not penetrate beyond the muscularis. These ulcers are usually transversely oriented in contrast to Crohn's disease, where the ulcers are longitudinal or serpiginous. Cicatrical healing of these ulcers results in strictures. Occlusive arterial changes may produce ischemia and contribute to the development of strictures. Endarteritis also accounts for the rarity of massive bleeding in cases of intestinal tuberculosis. Angiograms of patients with strictures had occlusions of the vessels, while ulcerated lesions had hypervascularity. Mesenteric lymph nodes may be enlarged matted and may 242

caseate. Characteristic granulomas may be seen only in the mesenteric lymph nodes, especially common in patients who have taken antitubercular therapy for some time. The reverse - the presence of granulomas in the intestine and no granulomas in the draining lymph node is rare. The ileocaecal angle is distorted and often obtuse, because both sides of the ileocaecal valve are usually involved leading to incompetence of the valve, another point of distinction from Crohn's disease. Hoon et al. classified the gross morphological appearance of the involved bowel into ulcerative, ulcerohyperplastic and hyperplastic varieties. Ulcerative form has been found more often in malnourished adults, while hyperplastic in relatively well nourished adults. Peritoneal tuberculosis occurs in 3 forms - wet type with ascitis; encysted type with a localized abdominal swelling; and fibrotic type with abdominal masses composed of mesenteric and omental thickening, with matted bowel loops. Abdominal tuberculosis is predominantly a disease of young adults. Two-thirds of the patients are 21-40 year old (in our series only one over 60 years) and the sex incidence is equal (in our series 2 females and 3 males). The clinical presentation of abdominal tuberculosis can be acute, chronic or acute on chronic. The duration of symptoms vary from 2 days in acute case to 15 years in a chronic case. In large series duration is between 3 weeks and 3 years. Most patients have constitutional symptoms of fever (40-70%), pain (85-90%), diarrhoea (11-20%), constipation, alternating constipation and diarrhea, weight loss (40-90%), vomiting (50-60%), malaise. Pain can be either colicky due to luminal compromise, or dull and continuous when the mesenteric lymph nodes are involved. Table 2 Presenting complaints Abdominal pain Weight loss Fever/night sweats Loss of appetite Bowel disturbance Other (cough, weakness, abnormal liver function tests)

Percent % 88 87 55 69 69 22

Abdominal tuberculosis should be considered for patients who present with non-specific abdominal complaints and weight loss over a long period. There is no procedure, which can be considered as golden standard in diagnosis of abdominal tuberculosis.The differential diagnosis of TB includes many diseases of gastrointestinal tract with similar clinical presentation - Crohnâ&#x20AC;&#x2122;s disease, carcinoma, yersiniosis, amebiasis etc. Laboratory tests have only limited value. Elevated ESR, anaemia and raised C-reactive protein are the most consistent laboratory findings. The differential and total leucocyte counts do not reveal any abnormality. Mantoux test is positive in 42% of cases. At ultrasound scan and computer tomography can reveal a local-

Abdominal tuberculosis report of 5 patients and literature review

ized ascites, calcified lymph nodes, splenomegaly and abdominal mass. Often a laparoscopy is performed, because of the inadequate diagnostic value of other methods. All patients should receive conventional antitubercular therapy for at least 6 months including rifampicin, isoniazid, pyrazinamide and ethambutol. The surgical treatment has gone through three phases: 1. Bypassing the stenosed segment by enteroenterostomy or by ileotransverse colostomy was practiced when effective antitubercular drugs were unavailable and resectional surgery was considered hazardous in the presence of active disease. This practice produced blind loop syndrome, fistulae and recurrent obstruction in the remaining segments. 2. With the advent of antitubercular drugs, more radical procedures like right hemicolectomy with or without extensive removal of the draining lymph node and wide bowel resection became popular. 3. Modern surgical techniques -the patients are subjected to operative treatment under the following criteria: 1. perforation; 2. intestinal obstruction; 3. palpable abdominal mass; 4. enlarged abdominal lymph nodes, general weakness and low grade fever.

SUMMARY Abdominal tuberculosis is defined as infection of the peritoneum, hollow or solid abdominal organs with Mycobacterium tuberculi. The peritoneum and the ileocaecal region are the most likely sites of infection and are involved in the majority of the cases by hematogenous spread or through swallowing of infected sputum from primary pulmonary tuberculosis. The clinical presentation tends to be non-specific with abdominal pain and general complaints and the differential diagnosis will often include inflammatory bowel disease, malignancy or some other infection. The first country to eliminate tuberculosis will be the one which regards the disease as a serious problem, right to the end.

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Anand BS. Distinguishing Crohns disease from intestinal tuberculosis. Natl Med J India 1989; 2 : 170-5. Kapoor VK. Abdominal tuberculosis. Postgrad Med J 1998;74 : 459-6. Katariya RN, Sood S, Rao PG, Rao Plng . Stricturoplasty for tubercular strictures of the GI Tract. Br J Surg 1977; 64 : 496-8. Anonymous. The challenge of tuberculosis. Lancet 1994; 34 : 277-9. Joshi MJ. The surgical management of intestinal tuberculosis - a conservative approach. Indian J Gastroentrol 1991; 10 : 270-30. Chen Ym, Lee DY, Perng PR. Abdominal tuberculosis in Taiwan a report from veterans, general hospital, Taipei. Tuber Lung Dis 1995;76:35-8. Manohar A, Simjee AE, Hafejee AA, Pettegell KE. Symptoms and investigative finding in 145 patient with tuberculose peritonitis diagnosed by peritonoscopy and biopsy over a 5 years period. Gut 1990;31:1130-2. Perkins MD, Conde MB, Mar tins M, Kritski AL. Serologic diagnosis of tuberculosis using a simple commercial. Chest. 2003;123:107-12. Apaydin B. Paksoy M, Bilir M, Zengin K, Saribeyoglu K, Taskin M. Value of diagnostic laparoscopy in tuberculous peritonitis. Eur J Surg 1999;165:158. Sheer TA, Coyle WJ. Gastrointestinal tuberculosis.Curr Gastroentrerol Rep2003;5:273 Sandikci MU, Colakoglus, Ergun Y, Unal S, Akkiz H, Sandikci S, et al . presentation and role of peritonescopy in the diagnosis of tuberculous peritonitis. J Gastroenterol Hepatol 1992;7:298-301. Jorge AD. Peritoneal tuberculous. Endoscopy 1984;16:102. Badaoui E, Berney T, Kai ser L, Mentha G, Mo rel P. Surgicalpresentation of abdominal tuberculosis: a protean disease. Hepato-Gastroenterology 2000;47:751-5 Inadomi JM, Kapur S, Kinkhabwala M, Cello JP. The laparoscopicevaluation of ascites. Gastrointest Endosc Clin N Am 2001;11:79-91 Tison C, de Kerviler B, Kahn X, Joubert M, Le Borgne J. Videolaparoscopic diagnosis and follow-up of a peritoneal tuberculosis. AnnChirurg 2000;125:776-8

Tandon HD, Prakash A. Pathology of intestinal tuberculosis and its distinction from Crohnâ&#x20AC;&#x2122;s disease. Gut 1972; 13 :260-9.

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ÕÈÐÓÐÃÈ×ÍÀ ÒÀÊÒÈÊÀ ÏÐÈ ßÒÐÎÃÅÍÍÈ ÍÀÐÀÍßÂÀÍÈß ÍÀ ÊÎËÎÍÀ Áëàãîâ É., È. Ãðèãîðîâ, Î. Òîìîâ, Ò. Ïîæàðëèåâ ÓÌÁÀË "Ñâåòà Àííà" Ñîôèÿ ÐÅÇÞÌÅ Öåëòà íà òîâà ðåòðîñïåêòèâíî 5 ãîäèøíî ïðîó÷âàíå å äà ñå óñòàíîâÿò ÷åñòîòàòà íà ïåðôîðàöèèòå íà êîëîíà ñëåä êîëîíîñêîïèÿ, òÿõíàòà åòèîëîãèÿ è îïòèìèçèðàíå íà òåðàïåâòè÷íàòà òàêòèêà. Çà ïåðèîäà 2004ã.-2008ã. èçâúðøèõìå îáùî 3595 êîëîíîñêîïèè, êàòî 1553 îò òÿõ òåðàïåâòè÷íè. Â ÊÎÅÕ îïåðèðàõìå âñè÷êèòå 8 (0.22%) ïàöèåíòà ñ ÿòðîãåííà ïåðôîðàöèÿ íà êîëîíà. Øåñò îò òÿõ èíòåðâåíèðàõìå äî 8-èÿ ÷àñ. Ïðè òðèìà áîëíè èçâúðøèõìå ïúðâè÷íà ñóòóðà ñ ïðîòåêòèâíà êîëîñòîìà, ïðè äâàìà ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà, ïðè äâàìà áå èçâåäåíà ñòîìà íà ìÿñòîòî íà ïåðôîðàöèÿòà, ïðè åäèí áîëåí ðåçåêöèÿ íà ñèãìàòà ïî ìåòîäà íà Hartman. Åêçèòóñ ëåòàëèñ èìàõìå ïðè åäèí ïàöèåíò. Ñúîáðàçÿâàíåòî ñ ðèñêîâèòå ôàêòîðè îò ñòðàíà íà ïàöèåíòà è ïîâèøàâàíåòî íà êâàëèôèêàöèÿòà íà åêèïèòå èçâúðøâàùè èçñëåäâàíåòî ìîãàò äà äîâåäàò äî íàìàëÿâàíå íà ÷åñòîòàòà íà òåçè óñëîæíåíèÿ. Ñïåøíîòî îïåðàòèâíî ëå÷åíèå å ìåòîä íà èçáîð ïðè òåçè áîëíè. Ñóòóðàòà èëè ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà ñå ïðåïîðú÷âà ïðè ïàöèåíòè îïåðèðàíè â ïúðâèòå ÷àñîâå ñëåä ïåðôîðàöèÿòà ïðè îòñúñòâèå íà êîíòàìèíàöèÿ íà êîðåìíàòà êóõèíà.

Êëþ÷îâè äóìè: êîëîíîñêîïèÿ, ÿòðîãåííè ëåçèè, ïåðôîðàöèÿ íà êîëîíà Åäíè îò íàé-÷åñòèòå ïðè÷èíè çà ÿòðîãåííè íàðàíÿâàíèÿ íà êîëîíà ñà êîëîíîñêîïñêèòå äèàãíîñòè÷íè è òåðàïåâòè÷íè ìàíèïóëàöèè. ×åñòè óñëîæíåíèÿ ïðè êîëîíîñêîïèÿ ñà êúðâåíåòî è ïåðôîðàöèèòå íà äåáåëîòî ÷åðâî. ×åñòîòàòà íà ïåðôîðàöèèòå íà êîëîíà ïî ëèòåðàòóðíè äàííè âàðèðà îò 0.03 - 0.8% ïðè äèàãíîñòè÷íèòå äî 0.15 - 3% ïðè òåðàïåâòè÷íèòå êîëîíîñêîïèè (1,2,3,4,5,6,7,8). Â ìàòåðèàë çà 5 ãîäèíè ïðåäñòàâÿìå ÷åñòîòàòà íà ïåðôîðàöèèòå íà êîëîíà ñëåä êîëîíîñêîïèÿ è òåðàïåâòè÷íèÿ ïîäõîä.

ÌÀÒÅÐÈÀË È ÌÅÒÎÄÈ Çà ïåðèîäà 2004-2008ã.âêëþ÷èòåëíî â ðåòðîñïåêòèâíî ïðîó÷âàíå âêëþ÷èõìå âñè÷êè ïàöèåíòè ëåêóâàíè â ÊÎÅÕ ñ ÿòðîãåííà ïåðôîðàöèÿ íà êîëîíà ñëåä êîëîíîñêîïèè èçâúðøåíè â ÓÌÁÀË "Ñâåòà Àííà". Îò áîëíèòå îáðàáîòèõìå ñëåäíèòå äàííè: âúçðàñò, ïîë, àíàìíåçà, êëèíè÷íà êàðòèíà, âðåìå îò ïåðôîðàöèÿòà äî îïåðàòèâíîòî ëå÷åíèå, ëîêàëèçàöèÿ, ðåíòãåíîëîãè÷íè íàõîäêè, èçïîëçâàíà ñåäàöèÿ è àíàëãåçèÿ, òåðàïåâòè÷íî ïîâåäåíèå, óñëîæíåíèÿ è ñìúðòíîñò. Çà ñåäàöèÿ è îáåçáîëÿâàíå ïðè ïðîâåäåíèòå êîëîíîñêîïèè íàé-÷åñòî ñà èçïîëçâàíè Ìidazolam è Ðropofol. Ïðåäâàðèòåëíî ïî÷èñòâàíå íà êîëîíà å ïðîâåäåíî ïðè 100% îò ïàöèåíòèòå ñ ïåðôîðàöèÿ.Ïðè äâàìà îò áîëíèòå ïî÷èñòâàíåòî å áèëî íåçàäîâîëèòåëíî.

ÐÅÇÓËÒÀÒÈ Çà ïåðèîäà â ÓÌÁÀË "Ñâåòà Àííà" èçâúðøèõìå îáùî 3595 êîëîíîñêîïèè, êàòî îò òÿõ 1553 áÿõà òåðàïåâòè÷íè. Òàáëèöà 1. Âèä êîëîíîñêîïèÿ è áðîé áîëíè. Ïðîöåäóðè ïî ãîäèíè

2004

2005

2006

2007

2008 Îáùî

Äèàãíîñòè÷íà êîëîíîñêîïèÿ

240

383

449

596

374

2042

Òåðàïåâòè÷íà êîëîíîñêîïèÿ

122

196

233

341

661

1553

Îáùî

362

579

682

937

1035

3595

Ïåðôîðàöèÿ íà êîëîíà ïðè êîëîíîñêîïèÿ èìàõìå ïðè 8 /0.22%/ ïàöèåíòè. Â 6 îò ñëó÷àèòå ñ ïåðôîðàöèÿ, êîëîíîñêîïèÿòà å ïðîâåäåíà ïðè ñåäèðàíå è îáåçáîëÿâàíå íà áîëíèòå. Ëåçèÿòà å óñòàíîâåíà îò åíäîñêîïèñòà â 88,6% îò äèàãíîñòè÷íèòå êîëîíîñêîïèè è â 16,6% îò òåðàïåâòè÷íèòå. Íàé-÷åñòèòå ïðè÷èíè çà ïåðôîðàöèÿòà áÿõà: - ÷èñòî ìåõàíè÷íà (÷ðåç äèðåêòíî òðàâìèðàíå ñ êðàÿ íà êîëîíîñêîïà) - 5 áîëíè,

245

Áëàãîâ É., È. Ãðèãîðîâ, Î. Òîìîâ...

áàðîòðàâìà (âñëåäñòâèå ïðåêàëåíî ðàçäóâàíå íà ÷åðâîòî ñ ãàç) -1 áîëåí,

Âñè÷êèòå ïàöèåíòè ëåêóâàõìå â ñïåøåí ïîðÿäúê, êàòî øåñò îò ïàöèåíòèòå îïåðèðàõìå äî 8-èÿ ÷àñ. Ïðè 4ìà áîëíè íàìåðèõìå ïåðôîðàöèÿ íà ê.ñèãìîèäåóì, ïðè 2ìà íà ê.òðàíçâåðçóì, ïðè 1 íà ðåêòóì è ïðè 1 íà ê.àñöåíäåíñ. Ïðè 3ìà ïàöèåíòè èçâúðøèõìå ïúðâè÷íà ñóòóðà ñ ïðîòåêòèâíà êîëîñòîìà, ïðè 2ìà ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà, ïðè 2ìà èçâåäîõìå ñòîìà íà ìÿñòîòî íà ïåðôîðàöèÿòà,à ïðè åäèí ïàöèåíò ðåçåêöèðàõìå ñèãìàòà ïî ìåòîäà íà Hartmann. Åäíà ïàöèåíòêà íà 88ã. íàïðàâè äåõèñöåíöèÿ íà îïåðàòèâíàòà ðàíà è áå îïåðèðàíà ïîâòîðíî,êàòî åäíà ñåäìèöà ïî-êúñíî ïî÷èíà ñëåäñòâèå íà ðèòúìíè íàðóøåíèÿ. Â òàáë. 2 ïîêàçâàìå ïàöèåíòè, íàðàíÿâàíèÿ, âèä îïåðàöèÿ è óñëîæíåíèÿ.

ÎÁÑÚÆÄÀÍÅ

Ôèã 1. Ëîêàëèçàöèÿ íà ÿòðîãåííèòå ïðåðôîðàöèè íà êîëîíà.

- âòîðè÷íà òðàâìà ñëåä ïîëèïåêòîìèÿ - 2ìà áîëíè. Ïåðôîðàòèâíèòå ëåçèè âàðèðàõà îò ðàçêúñâàíå íà ½ îò ëóìåíà íà êîëîíà äî ïúëíîòî ìó ïðåêúñâàíå è

ßòðîãåííèòå ïåðôîðàöèè íà äåáåëîòî ÷åðâî ñëåä êîëîíîñêîïèÿ ñà ñðàâíèòåëíî ðåäêè óñëîæíåíèÿ. Ïðåäâèä ìàñîâîòî íàâëèçàíå íà êîëîíîñêîïèèòå â ìåäèöèíñêàòà ïðàêòèêà è íàé-âå÷å òåðàïåâòè÷íèòå êîëîíîñêîïñêè ìàíèïóëàöèè àáñîëþòíèÿò áðîé íà òåçè óñëîæíåíèÿ íàðàñòâà çíà÷èòåëíî â ïîñëåäíèòå ãîäèíè (6).

Òàáë. 2. Ïàöèåíòè, ëîêàëèçàöèÿ íà íàðàíÿâàíåòî, âèä îïåðàöèÿ, óñëîæíåíèÿ. Áðîé

Ïîë

Ãîäèíè

Îïåð.èíòåðâåíöèÿ

Äèàãíîçà

Âèä îïåðàöèÿ

Óñëîæíåíèÿ

<8÷

Perforatio sigmae

Laparoscopia.Sutura sigmae.Cîecostomia

<8÷

Ca rectiT4N1M1.Perf.recti

Sutura recti.Sigmostomia

2÷

Perf.col.transversi

Transversostoma

>24÷

Perf.col.transversi.St.post polypectomiam

Transversostomia

<8÷

Perf.col.asc.St.post polypectomiam

Hemicolectomia dex.

<8÷

Ca coeciT4N0M0.Perforatio sigmae

Hemicolectomia dex. Sutura sigmae

<8÷

Perforatio sigmae

Sutura sigmae. Transversostomia

4÷

Perforatio sigmae

Resectio sigmae a m.Hartmann

Dehistentio vulneris.Exitus letalis

íàðàíÿâàíåòî ìó íà îùå äâå äî òðè ìåñòà. Çà òîçè ïåðèîä â Êëèíèêàòà ïî îáùà è åíäîñêîïñêà õèðóðãèÿ îïåðèðàõìå âñè÷êèòå 8 ïàöèåíòà - 6 ìúæå è 2 æåíè, íà âúçðàñò îò 62ã. äî 88ã. Êàòî äîìèíèðàùè ñèìïòîìè óñòàíîâèõìå êîðåìíàòà áîëêà è ïåðèòîíåàëíîòî äðàçíåíå. Ïðè âñè÷êè ïàöèåíòè ðåíòãåíîëîãè÷íî áå îòêðèò ñâîáîäåí ãàç â êîðåìíàòà êóõèíà. Ïðè åäíà ïàöèåíòêà óñòàíîâèõìå ïîäêîæåí åìôèçåì.

246

Íàé-÷åñòèòå ñèìïòîìè ñà êîðåìíà áîëêà 66% è ïîâèøåíà òåìïåðàòóðà 24% (9). Â íÿêîè ñëó÷àè òå ìîãàò äà ëèïñâàò. Íàõîäêèòå îò îáèêíîâåíèòå ðåíòãåíîâè ñíèìêè ìîãàò äà ïîêàæàò ñâîáîäåí ãàç â êîðåìíàòà êóõèíà (íà íèâîòî îêîëî êîëîíà) èëè ñúáèðàíå íà ãàç â ðåòðîïåðèòîíåàëíîòî ïðîñòðàíñòâo (7). Ïðè ïåðôîðàöèè íà ðåêòóìà èëè íà ðåêòîñèãìîèäàëíî íèâî ãàç ìîæå äà ïðîíèêíå êúì psoas ìóñêóëèòå, ìåäèàñòèíóìà è ïîäêîæèåòî. Àêî ïðè

Õèðóðãè÷íà òàêòèêà ïðè ÿòðîãåííè íàðàíÿâàíèÿ íà êîëîíà

íàòèâíàòà ðåíòãåíîãðàôèÿ íå ñå âèæäà ïåðôîðàöèÿ, òîãàâà êîìïþòúðíàòà òîìîãðàôèÿ ìîæå äà ïîäïîìîãíå äèàãíîçàòà ÷ðåç îòêðèâàíå íà ñâîáîäåí ãàç, ìèêðîïåðôîðàöèè èëè íàëè÷èå íà àáñöåñ. Îòñúñòâèåòî íà ãàç èçâúí êîëîíà íå èçêëþ÷âà äèàãíîçàòà ïåðôîðàöèÿ (4). Ãîëÿìî çíà÷åíèå çà âúçíèêâàíåòî èì èìà íàëè÷èåòî íà ðèñêîâè ôàêòîðè ñúáùàâàíè îò ðàçëè÷íè àâòîðè è âêëþ÷âàùè âúçïàëèòåëíà àêòèâíîñò, ïðåäøåñòâàùî òàçîâî îáëú÷âàíå, íàëè÷èåòî íà äèâåðòèêóëè è ïðåäøåñòâàùà êîðåìíà îïåðàöèÿ (14). Ñïîðåä íàñ êúì òÿõ áè ìîãëî äà ñå äîáàâè è îïèòà íà åêèïà,âúïðåêè ÷å ñïîðåä íÿêîè àâòîðè òî íå å îïðåäåëÿùî (13). Ìåõàíèçìà íà ïåðôîðàöèèòå ïðè äèàãíîñòè÷íà êîëîíîñêîïèÿ ìîæå äà áúäå ìåõàíè÷åí èëè â ðåçóëòàò íà áàðîòðàâìà (5). Ëåçèÿòà â ñòåíàòà íà êîëîíà, ïðè÷èíåíà îò âúðõà íà åíäîñêîïà ñå äúëæè íàé-÷åñòî íà íåàäåêâàòíî áîðàâåíå ñ àïàðàòà, ñúçäàâàíåòî íà àëôà áðèìêà è ïðîíèêâàíåòî íà åíäîñêîïà ïðåç ìóêîçàòà è èçâúí ëóìåíà (15). Ãðåøêè ïðè ðàçïîçíàâàíåòî íà ëóìåíà íà äèâåðòèêóëà îò òîçè íà êîëîíà, ìíîæåñòâî ñðàñòâàíèÿ ïîðàäè ïðåäøåñòâàùà õèðóðãè÷íà èíòåðâåíöèÿ, íàëè÷èåòî íà äîëèõîñèãìà è ïî-ãîëÿìàòà ÷åñòîòà íà äèâåðòèêóëè â îáëàñòòà íà ñèãìàòà, ïðàâÿò òîçè ñåãìåíò ïî-ïîäàòëèâ íà íàðàíÿâàíèÿ (15). Ïåðôîðàöèÿòà ñëåä áàðîòðàâìà íàïðèìåð â ðåçóëòàò íà ïðåêîìåðíî ðàçäóâàíå ñ ãàç, ïðîâîêèðà ïî-âèñîêà ÷åñòîòà íà ïåðôîðàöèèòå â îáëàñòòà íà öåêóìà Òîâà ìîæå äà ñå ñëó÷è è â îáëàñòòà íà ñèãìàòà, òúé êàòî ôëåêñóðàòà íà êîëîíà ìîæå äà áëàãîïðèÿòñòâà ñúçäàâàíåòî íà ñåãìåíò ñ âèñîêî íàïðåæåíèå ïî âðåìå íà ðàçäóâàíåòî íà ÷åðâîòî ñ ãàç. Íàé-âåðîÿòíî òîâà å ñòàíàëî ïðè äâàìà îò íàøèòå ñëó÷àè, â êîèòî ïåðôîðàöèÿòà å áèëà âñëåäñòâèå íà áàðîòðàâìà. Åäíèÿ áîëåí áåøå ñ ïðåäõîäíà êîðåìíà îïåðàöèÿ äîâåëà äî òåæêè àäõåçèè ïî õîäà íà äåáåëîòî ÷åðâî, à äðóãèÿ áå ñ ïðèäðóæàâàùà àêðåòíà åïèãàñòðàëíà õåðíèÿ ñúäúðæàùà êîëîí òðàíñâåðçóì. Ïåðôîðàöèèòå ñëåä òåðàïåâòè÷íà êîëîíîñêîïèÿ ìîãàò äà âúçíèêíàò ïî ìåõàíèçìè ñõîäíè ñ òåçè ïðè äèàãíîñòè÷íèòå êîëîíîñêîïèè,êàòî êúì òÿõ ñå äîáàâÿò è òåçè ñëåä áèîïñèè, ïîëèïåêòîìèè, èçïîëçâàíå íà åëåêòðîêàóòåð èëè èçïîëçâàíå íà àðãîí-òåðàïèÿ ïðè ëå÷åíèå íà àðòåðèî-âåíîçíè ìàëôîðìàöèè (8,14). Íàøèÿò îïèò è òîçè íà äðóãè àâòîðè ñ òîçè âèä ïåðôîðàöèè ïîêàçâà, ÷å òå ñà ñúñ çíà÷èòåëíî ïî-ìàëúê ðàçìåð â ñðàâíåíèå ñ ïåðôîðàöèèòå, ïðîâîêèðàíè îò âúðõà íà êîëîíîñêîïà è îáèêíîâåíî ñå îòêðèâàò ïî-êúñíî (14). Èçïîëçâàíåòî íà àíåñòåòèöè íå ïîâèøàâà ðèñêà îò ïåðôîðàöèÿ è íå å ñúïðîâîäåíî îò ñåðèîçíè óñëîæíåíèÿ (16). Íèå íå óñòàíîâèõìå ðàçëèêè â äèàãíîñòè÷íîòî çàáàâÿíå ïðè èçïîëçâàíå íà ñåäàòèâíè è àíàëãåçèðàùè ìåäèêàìåíòè ïî âðåìå íà ïðîöåäóðàòà. Ñòåïåíòà íà ñåäèðàíå è îáåçáîëÿâàíå îáà÷å îñòàâà ñïîðåí âúïðîñ.

Êîíñåðâàòèâíèÿò ïîäõîä ïðè ïàöèåíòè ñ ïåðôîðàöèÿ íà êîëîíà ñëåä êîëîíîñêîïèÿ å ïðîòèâîðå÷èâ è íåóñïåõúò íà êîíñåðâàòèâíîòî ëå÷åíèå, êîåòî íàëàãà ïî-êúñíà ëàïàðîòîìèÿ â íÿêîè ñåðèè äîñòèãà ïðèáëèçèòåëíî èëè íàä 50% îò ñëó÷àèòå (14). Ïåðôîðàöèèòå ïðè òåðàïåâòè÷íèòå êîëîíîñêîïèè ñà ïîíÿêîãà ñ ïî-ìàëêè è çàìúðñÿâàíåòî íà êîðåìíàòà êóõèíà å ìèíèìàëíî (8). Ñëåäîâàòåëíî àêî ïîäãîòâèì êîëîíà àäåêâàòíî è ñå óâåðèì â îïòèìàëíî äîáðîòî îáùî ñúñòîÿíèå íà ïàöèåíòà, òîãàâà âåðîÿòíî òîçè âèä ïåðôîðàöèè ùå îòãîâîðÿò çàäîâîëèòåëíî íà êîíñåðâàòèâíîòî ëå÷åíèå. Âúçìîæíîñòèòå çà êîíñåðâàòèâíî òðåòèðàíå ñå óâåëè÷àâàò ñ ïîñòàâÿíåòî íà êëèïîâå íåïîñðåäñòâåíî ñëåä ëåçèÿòà ïî âðåìå íà ñàìàòà êîëîíîñêîïèÿ (10). Ïî ëèòåðàòóðíè äàííè íåîïåðàòèâíîòî êîíñåðâàòèâíî ëå÷åíèå å âúçìîæíî ïðè ñòðîãî ñåëåêòèðàíè ïàöèåíòè, ïðè êîèòî íå ñå óñòàíîâÿâà ñâîáîäåí ãàç â êîðåìíàòà êóõèíà è íÿìàò êëèíèêà íà äèôóçåí ïåðèòîíèò (10,11). Íèå ïðåïîðú÷âàìå íåçàáàâíà îïåðàöèÿ ïðè âñè÷êè îñòàíàëè ñëó÷àè âúç îñíîâà íà ôàêòà, ÷å íåóñïåõúò íà êîíñåðâàòèâíîòî ëå÷åíèå óâåëè÷àâà âúçïàëåíèåòî, äàâà âúçìîæíîñò çà ðàçâèòèå íà ïúëçÿù ïåðèòîíèò, êàòî ïî òîçè íà÷èí óâåëè÷àâà ïîñòîïåðàòèâíàòà çàáîëåâàåìîñò è ñìúðòíîñò. Âèäúò íà õèðóðãè÷íàòà èíòåðâåíöèÿ çàâèñè îò ãîëåìèíàòà íà ëåçèÿòà, ñòåïåíòà íà çàìúðñÿâàíå, ñúïúòñòâàùàòà ïàòîëîãèÿ íà êîëîíà è îáùîòî ñúñòîÿíèå íà ïàöèåíòà. Íèå ñìÿòàìå, ÷å ïðè ïàöèåíòè ñ ðàííî îòêðèòè ïåðôîðàöèè è íèñêà ñòåïåí íà ôåêàëíà êîíòàìèíàöèÿ ìîæå äà ñå íàïðàâè ñóòóðà íà ïåðôîðàöèÿòà èëè ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà ñ/áåç ïðîòåêòèâíà ñòîìà. Ïðè ïàöèåíòèòå ñ ãîëÿìà ôåêàëíà êîíòàìèíàöèÿ, ìíîæåñòâî ïðèäðóæàâàùè çàáîëÿâàíèÿ èëè õåìîäèíàìè÷íà íåñòàáèëíîñò ñòîìàòà îñòàâà íàäåæäíà àëòåðíàòèâà (14). Ñëåäîïåðàòèâíàòà ñìúðòíîñò ïî ëèòåðàòóðíè äàííè âàðèðà ì/ó 0-50%, êàòî ñå âëèÿå ðÿçêî îò ñòàòóñà íà ïàöèåíòà (3,11,12).

ÈÇÂÎÄÈ Ñúîáðàçÿâàíåòî ñ ðèñêîâèòå ôàêòîðè îò ñòðàíà íà ïàöèåíòà è ïîâèøàâàíåòî êâàëèôèêàöèÿòà íà åêèïèòå èçâúðøâàùè èçñëåäâàíåòî ìîãàò äà äîâåäàò äî íàìàëÿâàíå íà ÷åñòîòàòà íà òåçè óñëîæíåíèÿ. Ñïåøíîòî îïåðàòèâíî ëå÷åíèå å ìåòîä íà èçáîð ïðè òåçè áîëíè. Ïúðâè÷íà ñóòóðàòà èëè ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà ñå ïðåïîðú÷âà ïðè ïàöèåíòè îïåðèðàíè â ïúðâèòå ÷àñîâå ñëåä ïåðôîðàöèÿòà ïðè îòñúñòâèå íà êîíòàìèíàöèÿ íà êîðåìíàòà êóõèíà.

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management of iatrogenic colon perforations, The American journal of surgery ISSN 0002-9610 CODEN AJSUAB Kang HY, Kang HW, Kim SG, Kim JS, Park KJ, Jung HC, Song IS.:Incidence and management of colonoscopic perforations in Korea. Digestion. 2008;78(4):218-23. Epub 2009 Jan 13. PMID: 19142003 [PubMed - indexed for MEDLINE Farley DR, Bannon MP, Zietlow SP, Pem ber ton JH, Ilstrup DM: Management of colonoscopic perforations.Mayo Clin Proc. 1997 Aug; 72(8): 729-33. PMID: 9276600 [PubMed - indexed for MEDLINE] M. T. García Martínez, A. Ruano Poblador, L. Galán Raposo, A. M. Gay Fernández: Perforation after colonoscopy: Our 16-year experience , Revista Esanola de Enfermedates digestivas,1130-0108/2007/99/10/588-592 Wexner SD, Garbus JE, Sing JJ, SAGES Coloscopic Study Outcomes Group. A prospective analysis of 13580 colonoscopies. Reevaluation of credentialing guidelines. Surg Endosc 2001; 15: 251-61. Coob WS, Heniford T, Sigmon LB, Hasan R, Simms C, Kercher KW, et al. Colonoscopic perforations: Incidence, management and outcomes. Am Surg 2004; 70: 750-7. Livstone EM, Kerstein MD. Serosal tears following colonoscopic. Arch Surg 1976; 111: 88. Martínez J, Casellas JA, Aparicio JR, Garmendia M, Amorós A. Seguridad de la administración de propofol por el personal de launidad de endoscopia digestiva. Gastroenterol Hepatol 2007; 30:105-9.

Scripta Scientifica Medica, 2009; vol. 41 (3), pp 249-251

×ÅÐÍÎÄÐÎÁÍÈ ÌÅÒÀÑÒÀÇÈ - ÂÚÇÌÎÆÍÎÑÒÈ ÇÀ ËÅ×ÅÍÈÅ Ñòîéêîâ Ä., Þ. Ïåòêîâ, Ñ. Ñòðàøèëîâ, È. Äåêîâà Âèñöåðàëíà õèðóðãèÿ - ÓÌÁÀË - Ïëåâåí Ïðîáëåìúò ñ ÷åðíîäðîáíèòå ìåòàñòàçè ïðè òóìîðèòå íà õðàíîñìèëàòåëíèÿ òðàêò äîñêîðî ñå ñìÿòàøå çà íåðåøèì. Ïîÿâàòà èì ñå ñâúðçâàøå ñ äèñåìèíàöèÿ íà îñíîâíîòî çàáîëÿâàíå, êîÿòî áåøå èíêóðàáèëíà. Ïðåç âòîðàòà ïîëîâèíà íà ìèíàëèÿ âåê ñå ïîÿâèõà ñúîáùåíèÿ çà ðàçëè÷íè ìåòîäè íà òðåòèðàíå íà ÷åðíîäðîáíè ìåòàñòàçè ñ ïðîìåíëèâ óñïåõ. Íèå ùå ñå ñïðåì íà äâà îò òÿõ: ìåòàñòàçåêòîìèÿ è ðàäèî-òåðìîàáëàöèÿ. Ïîñëåäíèÿò ñå èçïîëçâà ïðè íåðåçåêòàáèëíè ÷åðíîäðîáíè ëåçèè. Âèñîêî÷åñòîòíà ðàäèî-òåðìî àáëàöèÿ. Òÿ èìà çà öåë ïîâèøàâàíå òåìïåðàòóðàòà â òóìîðíîòî îãíèùå, êîåòî äà ïðåäèçâèêà äåñòðóêöèÿòà ìó. Òîçè åôåêò ñå ïîñòèãà ÷ðåç ïðåìèíàâàíåòî íà âèñîêî-÷åñòîòíè òîêîâå /îêîëî 480êÍz/ ìåæäó åëåêòðîäèòå ïîñòàâåíè â ïàòîëîãè÷íàòà òúêàí. Äîêàçàíî å, ÷å ïîâèøåíèåòî íà òåëåñíàòà òåìïåðàòóðà íàä 420Ñ âîäè äî íàðóøåíèÿ â áèîõèìè÷íèòå ïðîöåñè, à ïîâèøåíèåòî íàä 450Ñ çà íÿêîëêî ÷àñà âîäè äî íåîáðàòèìî êëåòú÷íî óâðåæäàíå. Òåìïåðàòóðà â ãðàíèöèòå íà 50-550Ñ âîäè äî íåêðîçà ñàìî çà 4-6 ìèí. Òåìïåðàòóðà â ãðàíèöèòå 60-1000Ñ âîäè äî íåîáðàòèìî óâðåæäàíå íà ìèòîõîíäðèàëíèòå åíçèìè â êëåòêèòå, à òåìïåðàòóðà 100-1100Ñ äî èçïàðåíèå íà òúêàíèòå è êàðáîíèçàöèÿ. Ðàäèî-òåðìîàáëàöèÿòà âîäè äî ïîâèøåíèå íà ëîêàëíàòà òåìïåðàòóðà â òóìîðà â ãðàíèöèòå íà 50-1000Ñ çà ïîâå÷å îò 10 ìèíóòè /10-30/. Ïðè áèïîëÿðíàòà ìîíîåëåêòðîäíà òåðìîàáëàöèÿ òåìïåðàòóðàòà ñå ïîâèøàâà åôåêòèâíî â ðàäèóñ 1.6 ñì îò öåíòúðà ñ èãëàòà (3,10) /ôèã.1/. Òîâà íàëàãà èçïîëçâàíå íà äðóãè âàðèàíòè ïðè ëåçèè íàä 3 ñì.

Ôèã.1. Áèïîëÿðíà òåðìîàáëàöèÿ

Îñíîâíèòå âúçìîæíîñòèòå ñà íÿêîëêî: 1. Ïîâèøàâàíå âðåìåòî íà åêñïîçèöèÿòà äî 30 è ïîâå÷å ìèíóòè è ñúùåâðåìåííî óâåëè÷àâàíå ìîùíîñòòà îò 50 äî íàä 150 Watts. Âúçìîæíîñòèòå òóê ñà äà ñå óâåëè÷è ðàäèóñúò íà àáëàöèÿ äî 1.5-2ñì, êîåòî îçíà÷àâà åôåêòèâíîñò ïðè ÷åðíîäðîáíè ìåòàñòàçè ñ äèàìåòúð 3-4ñì. 2. Ïîâèøàâàíå åëåêòðîïðîâîäèìîñòòà íà òúêàíèòå ÷ðåç èíæåêòèðàíå íà 38.5% NaCl â òóìîðíîòî îãíèùå, ïðè êîåòî ìîæå äà ñå óâåëè÷è ïëîùòà íà àáëàöèÿòà äî 6.5 ñì â ðàäèóñ îò åëåêòðîäà (4,7). 3. Èçïîëçâàíå íà ìóëòèïîëÿðíà òåðìîàáëàöèÿ ñ äâà èëè òðè áèïîëÿðíè åëåêòðîäà, êîåòî ïîçâîëÿâà äåñòðóêöèÿ íà òóìîðè è ìåòàñòàçè ñ äèàìåòúð 6-7 ñì. (1,8) /ôèã.2/. 4. Êîìáèíèðàíå íà õèìèîòåðàïèÿ ñ ðàäèî-òåðìî àáëàöèÿ (doxorubicin i.v. - 30 ìèí ïðåäè òåðìîàáëàöèÿòà èëè ëèïîçîìåí äîêñîðóáèöèí 24÷. ïðåäè òåðìîàáëàöèÿòà), êîåòî óâåëè÷àâà ðàäèóñà íà äåñòðóêöèÿ ñ 2-3 ìì (9).

Ïîêàçàíèÿ çà ðàäèî-òåðìîàáëàöèÿ 1. Ïúðâè÷íè ÷åðíîäðîáíè òóìîðè. 2. Ìåòàñòàòè÷íè ëåçèè íà ÷åðåí äðîá. 3. Òóìîðè íà áúáðåêà /ñîëèòàðíè èëè äâóñòðàííè è ðåöèäèâíè ëåçèè/. 4. Àäðåíàëíè òóìîðè. 5. Òóìîðè íà ìëå÷íàòà æëåçà /ïðåäîïåðàòèâíî ïðè ìàëêè òóìîðè äî 1.5ñì/. 6. Òóìîðè íà áåëèÿ äðîá /íåîïåðàáèëíè áîëíè ñ ìíîæåñòâåíè ìåòàñòàçè/. 7. Òóìîðè íà ìîçúêà.

Ôèã.2 Ìóëòèïîëÿðíà òåðìîàáëàöèÿ 249

Ñòîéêîâ Ä., Þ. Ïåòêîâ, Ñ. Ñòðàøèëîâ...

8. Òóìîðè íà êîñòèòå. 9. Òóìîðè íà íåðâèòå ñúñ ñèëíè íåâðàëãè÷íè áîëêè. 10. Ïàíêðåàòè÷íè òóìîðè. 11. Ëèåíàëíè ìåòàñòàçè. 12. Ïðîñòàòíè òóìîðè ïðè ïàöèåíòè ñ âèñîê îïåðàòèâåí ðèñê. 13. Òóìîðè íà ìàòêàòà. 14. Ìåêîòúêàííè òóìîðè. 15. Ìåòàñòàòè÷íè ëèìôíè âúçëè. Åôåêòà îò òåðìîàáëàöèÿòà ñå îò÷èòà ÷ðåç ñðàâíÿâàíå íà ÊÒ íåïîñðåäñòâåíî ñëåä ïðîöåäóðàòà è òðè ìåñåöà ïî-êúñíî.

Óñëîæíåíèÿ ñëåä òåðìîàáëàöèÿ (2,6): 1. Ãðèïîïîäîáåí ñèíäðîì - ñóáôåáðèëíà òåìïåðàòóðà, ñúíëèâîñò è ïîòåíå, êîèòî îòçâó÷àâàò îáèêíîâåíî íà ïåòèÿ äåí. 2. Êîëàòåðàëíè ñúäîâè óâðåæäàíèÿ. 3. ×åðíîäðîáíè õåìàòîìè è àáñöåñè. 4. Íàðàñòâàùà ÷åðíîäðîáíà íåäîñòàòú÷íîñò. 5. Õåìîðàãèÿ.

åäíîâðåìåííî íà 5 ìåòàñòàçè - 3 â äåñåí ëîá è 2 â ëÿâ ëîá, ïðè äðóã íà 4, ïðè äâàìà íà 3 è åäèí ñ äâå öåíòðàëíî ðàçïîëîæåíè òàêèâà. Ïðåõîäåí ñóáôåáðèëèòåò å íàáëþäàâàí ïðè äâàìà îò ïàöèåíòèòå äî 4-6òè ñëåäîïåðàòèâåí äåí. Ïîñëåäíèÿò îòçâó÷à áåç äîïúëíèòåëíî ëå÷åíèå. Ïðè ïàöèåíòà ñ äâåòå ìåòàñòàçè, åäíàòà áå ðàçïîëîæåíà öåíòðàëíî ñ ðàçìåðè äî 6-7 ñì. è áåøå äîâåëà äî ïúëíà îêëóçèÿ íà d.hepaticus dex. Ïúðâî ñå íàïðàâè òðàíñ òóìîðåí äðåíàæ, à ñëåä òîâà òåðìîàáëàöèÿ. Â ñëåäîïåðàòèâíèÿ ïåðèîä íà òîçè áîëåí ñå îò÷åòå ñïàäàíå íà ñåðóìíîòî íèâî íà òîòàëíèÿ áèëèðóáèí îò 560 äî 160-180 íà 4-5 äåí, ñëåä êîåòî íàñòúïè îòíîâî ïîâèøåíèå íà áèëèðóáèíà äî èçõîäíèòå ñòîéíîñòè, âúïðåêè íàëè÷èåòî íà èäåàëíà ïðîõîäèìîñò â æëú÷íèòå ïúòèùà íà ñëåäîïåðàòèâíèòå õîëàíãèîãðàôèè. Ñìÿòàìå, ÷å òîâà ñå äúëæè íà èðåâåðçèáèëíà ÷åðíîäðîáíà íåäîñòàòú÷íîñò â ðåçóëòàò íà óâðåäèòå îò íåîïëàñòè÷íèÿ ïðîöåñ è ïîñëåäâàùàòà òåðìîàáëàöèÿ.

ÌÀÒÅÐÈÀË È ÌÅÒÎÄÈ Â êëèíèêàòà ïî Âèñöåðàëíà õèðóðãèÿ íà ÓÌÁÀË Ïëåâåí ðàçïîëàãàìå ñ òåðìîàáëàòîð, óëòðàçâóêîâ ñêàëïåë è äþçà îò ìåñåö þëè íà 2008ã. Çà ïåðèîäà äî êðàÿ íà 2008 ã. ñìå íàïðàâèëè îòâîðåíà òåðìîàáëàöèÿ íà 5-ìà ïàöèåíòè ñ îáùî 17 ÷åðíîäðîáíè ìåòàñòàçè îò äåáåëî÷ðåâíè òóìîðè. Ïðè âñè÷êè òÿõ ñå ïðåäïðèåìàøå ñúîòâåòíàòà òàêòèêà çà èçïîëçâàíå íà áðîÿ íà åëåêòðîäèòå, ðàçñòîÿíèåòî ìåæäó òÿõ, êîëè÷åñòâîòî íà ïðåäàäåíàòà åíåðãèÿ è âðåìåòðàåíåòî íà ïîäàâàíåòî è ñúîáðàçíî ãîëåìèíàòà íà ìåòàñòàòè÷íîòî îãíèùå (òàáë. 1). Òàáë. 1

ÐàçñòîÿÃîëåìèía Áðîé íà íèå íà åëåêòðîäè ìåæäó ìåòàñòàçàòà - òå åëåêòðîäèòå

ÏðîäúëÏðèëîæå- æèòåëíà íîñò íà åíåðãèÿ àáëàöèÿòà

äî 2 ñì.

15 kJ

13 ìèí.

2-3 ñì.

1,0 ñì.

15-35 kJ

9-20 ìèí.

3-4 ñì.

2,0 ñì.

35-70 kJ

11-21 ìèí.

4-5 ñì.

2,5 ñì.

70-130 kJ 21-40 ìèí.

5-6 ñì.

3,0 ñì.

130-225 kJ 40-68 ìèí.

Ïðè èíòðàõåïàòàëíî ðàçïîëîæåíèòå îãíèùà ñìå èçïîëçâàëè èíòðàîïåðàòèâíà åõîãðàôèÿ, ñ ïîìîùà íà êîÿòî ñìå öåíòðèðàëè òî÷íî ðàçïîëîæåíèåòî íà èãëèòå (5). Ïðè åäèí å íàïðàâåíà àáëàöèÿ

250

Ôèãóðà 3

Âúâ âñè÷êè ñëó÷àè, êîãàòî áåøå âúçìîæíà ðåçåêöèÿ íèå ïðèáÿãâàõìå äî íåÿ. Ïðè äâàìà áîëíè ñìå íàïðàâèëè ëåâîñòðàííà ëîáåêòîìèÿ, ïðè åäèí ðåçåêöèÿ íà ²V ñåãìåíò ïî ïîâîä íà êàðöèíîì íà æëú÷íèÿ ìåõóð. Ïðè îñòàíàëèòå ÷åòèðè ïàöèåíòè ïðåäïðèåõìå ìåòàñòàçåêòîìèÿ. Äåáåëî÷ðåâíà ðåçåêöèÿ ñ ìåòàñòàçåêòîìèÿ íà åäèí åòàï å îñúùåñòâåíà ïðè òðèìà ïàöèåíòè, êàòî îïåðàöèÿòà

×åðíîäðîáíè ìåòàñòàçè - âúçìîæíîñòè çà ëå÷åíèå

âúðõó ÷åðíèÿ äðîá ïðåäõîæäà äåáåëî÷ðåâíàòà ðåçåêöèÿ (11,12) /ôèã. 3 è 4/.

Ôèãóðà 4

Ñëåä ïîÿâèëèòå ñå ïóáëèêàöèè îò íåìñêè àâòîðè çà ðåçåêöèÿ â ãðàíèöèòå íà åäèí ìèëèìåòúð îò âèäèìèòå ãðàíèöè íà ìåòàñòàçàòà è òî ïðè ãîëåìè ñåðèè áîëíè, íèå âå÷å íå ñúáëþäàâàìå òî÷íî åäíîñàíòèìåòðîâàòà ãðàíèöà.

ÈÇÂÎÄÈ 1. ×åðíîäðîáíèòå ìåòàñòàçè îòäàâíà âå÷å íå ñå ñâúðçâàò ñ èíêóðàáèëíîñò íà ïàöèåíòà. 2. Ïðè ãîëÿìà ÷àñò îò ÷åðíîäðîáíèòå ëåçèè å âúçìîæíà ðåçåêöèÿ, êàòî íèå ñìå ïðèâúðæåíèöè íà èêîíîìè÷íàòà ìíîãîåòàïíà ðåçåêöèÿ. 3. Òåðìîàáëàöèÿ ñå ïðàâè ïðè áîëíè ñ èíîïåðàáèëíè ìåòàñòàçè. Ìåòîäúò å ñ ìàëúê ïðîöåíò óñëîæíåíèÿ, à ìîæå äà äîâåäå äî óäúëæàâàíå íà æèâîòà ïîíå ñ åäíà ãîäèíà êàòî ïðè 22% îò ïàöèåíòèòå ìîæå äà ñå äîñòèãíå è 5 ãîäèøíà ïðåæèâÿåìîñò.

ÁÈÁËÈÎÃÐÀÔÈß 1.

Laeseke PF, Sampson LA, Haemmerich D, et al. Multiple-electrode radiofrequency ablation cre-

ates confluent areas of necrosis: in vivo porcine liver results. Radiology 2006;241 : 116-124. 2. Curley SA, Marra P, Beaty K, Ellis LM, Vauthey JN, Abdalla EK, et al. Early and late complications after radiofrequency ablation of malignant liver tumors in 608 patients. Ann Surg 2004;239:450-8. 3. Gillams AR. Radiofrequency ablation in the management of liver tumours. European Journal of Surgical Oncology 2003; 29(1):9-16. 4. Lee JM, Han JK, Kim SH, et al. A comparative experimental study of the in-vitro efficiency of hypertonic saline-enhanced hepatic bipolar and monopolar radiofrequency ablation. Korean J Radiol 2003;4:163-169. 5. Goldberg SN, Charboneau JW, Dodd GD, 3rd, et al. Image-guided tumor ablation: proposal for standardization of terms and reporting criteria. Radiology 2003; 228:335-345 6. Mulier S, Mulier P, Ni Y, et al. Complications of radiofrequency coagulationof liver tumors. Br J Surg. 2002;89:1206-1222. 7. Goldberg SN, Ahmed M, Ga zelle GS, et al. Radio-frequency thermal ablation with NaCl solution injection: effect of electrical conductivity on tissue heating and coagulation-phantom and porcine liver study. Radiology 2001;219:157-165. 8. Haemmerich D, Staelin ST, Tungjitkusolmun S, Lee FT Jr, Mahvi DM, Web ster JG. Hepatic bipolar radio-frequency ablation between separated multi-prong electrodes. IEEE Trans Biomed Eng 2001; 48:1145 -1152 9. Goldberg SN, Saldinger PF, Ga zelle GS, et al. Percutaneous tumor ablation: increased coagulation necrosis with combined radiofrequency and percutaneous doxorubicin injection (abstr). AJR Am J Roentgenol 2000; 174:34. 10. Curley SA, Izzo F, Delrio P, et al. Radiofrequency ablation of unresectable primary and metastatic hepatic malignancies. Ann Surg. 1999;230:1-8. 11. Sugarbaker PH. Surgical management of metastatic cancer in the liver. Ann Ital Chir. 1996;67:773-782. 12. Fong Y, Blumgart LH, Co hen AM. Surgical treatment of colorectal metastases to the liver. CA Cancer J Clin. 1995;45:50-62.

251

Scripta Scientifica Medica, 2009; vol. 41 (3), pp 253-256

ÓÑËÎÆÍÅÍÈß ÍÀ ÊÎËÎÐÅÊÒÀËÍÈß ÊÀÐÖÈÍÎÌ Ïåòêîâ Þ., Ä. Ñòîéêîâ, È. Äåêîâà Îòäåëåíèå ïî êîðåìíà õèðóðãèÿ. Êëèíèêà ïî õèðóðãè÷íè áîëåñòè, ÓÌÁÀË "Ä-ð Ãåîðãè Ñòðàíñêè" ÅÀÄ - Ïëåâåí Êîëîðåêòàëíèÿò íàðöèíîì å åäíî îò íàé-çíà÷èìèòå çëîêà÷åñòâåíâåíè çàáîëÿâàíèÿ ïîðàäè áúðçî íàðàñòâàùàòà ÷åñòîòà, ðàçøèðÿâàíå íà âúçðàñòîâàòà ãðàíèöà è ìíîãîîáðàçíàòà ëå÷åáíà òàêòèêà. Äèñêðåòíîòî êëèíè÷íî ïðîòè÷àíå íà çàáîëÿâàíåòî è êúñíî ïîòúðñåíàòà ìåäèöèíñêà ïîìîù ñà ïðè÷èíà çà îòêðèâàíåòî ìó â íàïðåäíàë ñòàäèè, êîãàòî ôîðìàöèÿòà å îáõâàíàëà ñúñåäíèòå îðãàíè ñ èëè áåç ìåòàñòàçè, èëè å äîâåëî äî óñëîæíåíèÿ. Êîëîðåêòàëíèÿò êàðöèíîì çàåìà ïúðâî ìÿñòî ìåæäó òóìîðèòå íà ñòîìàøíî-÷ðåâíèÿ òðàêò. Ïî äàííè íà Íàöèîíàëíèÿ ðàêîâ ðåãèñòúð, çàáîëåâàåìîñòòà ñå å ïîâèøèëà äî 39.7 íà 100 000 íàñåëåíèå. Ïîñëåäíèòå ãîäèíè ñå íàáëþäàâà çíà÷èòåëíî ïîäîáðåíèå â îíêîëîãè÷íèòå è ôóíêöèîíàëíè ðåçóëòàòè ñëåä õèðóðãè÷åñêîòî ëå÷åíèå, êîåòî å ðåçóëòàò îò âúâåæäàíå â ïðàêòèêàòà íà àíòèáèîòè÷íà ïðîôèëàêòèêà, ïðåîïåðàòèâíà àíòèêîàãóëàíòíà òåðàïèÿ è ñòàíäàðòèçèðàíè îïåðàòèâíè òåõíèêè.

ÖÅË

Óñëîæíåííèòå ôîðìè, ñà 92 (46,47%) îò âñè÷êèòå áîëíè îïåðèðàíè çà ÊÐÊ. Ïî÷èíàëèòå ïàöèåíòè ïðåç òîçè ïåðèîä ñà 295, êîåòî å 4,43% îò âñè÷êè îïåðèðàíè áîëíè. Îò îïåðèðàíèòå çà óñëîæíåíèÿ íà êîëîðåêòàëíèÿ êàðöèíîì ñà ïî÷èíàëè 15 (16,30%) ïàöèåíòà. Âúçðàñòîâèÿò äèàïàçîí íà îïåðèðàíèòå áîëíè ñ óñëîæíåíèÿ íà ÊÐÊ âàðèðà îò 28 ãîä. äî 91 ãîä., êàòî îñíîâíàòà ÷àñò 79 (85,87%) ñà â èíòåðâàëà 51 - 90 ãîä. Ïðîó÷âàíåòî å ðåòðîñïåêòèâíî. Îñíîâíèòå èçòî÷íèöè çà èíôîðìàöèÿ ñà èñòîðèèòå íà çàáîëÿâàíå, îïåðàòèâíèòå æóðíàëè è ïðîòîêîëèòå îò îáäóêöèÿ íà ïî÷èíàëèòå ïàöèåíòè. Ïðàâè âïå÷àòëåíèå, ÷å äâå îò ëîêàëèçàöèèòå íà ÊÐÊ ñà

Äà áúäàò ïðîó÷åíè è àíàëèçèðàíè, ïîêàçàíèÿòà è ðåçóëòàòèòå ïðè áîëíè îïåðèðàíè ñ óñëîæíåíèÿ íà êîëîðåêòàëíèÿ êàðöèíîì çà ïåðèîä îò 5 ãîäèíè.

ÌÀÒÅÐÈÀË È ÌÅÒÎÄÈ Ïàöèåíòèòå ëåêóâàíè â ÎÊÂÕ íà Êëèíèêàòà ïî õèðóðãèÿ íà ÓÌÁÀË "Ä-ð Ãåîðãè Ñòðàíñêè"-ÅÀÄÏëåâåí çà ïåðèîäà 2004-2008 ãîä. ñà 8266. Ïðåç òîçè ïåðèîä ñà èçâúðøåíè 6662 (80,60%) îïåðàòèâíè

Òàáë. 1. Âúçðàñòîâî ðàçïðåäåëåíèå íà áîëíèòå îïåðèðàíè çà óñëîæíåíèÿ íà ÊÐÊ è ëåòàëèòåò Âúçðàñò ïî ãîäèíè

ìúæå

æåíè

îáùî

Åêçèòóñ ìúæå

Åêçèòóñ æåíè

îáùî

21-30

2,17%

31-40

2,17%

41-50

8,70%

51-60

16,30%

61-70

19,56%

26,67%

71-80

35,87%

53,33%

81-90

14,13%

20,00%

Íàä 90

1,09%

Oáùî

100%

èíòåðâåíöèè. Îïåðèðàíè çà äåáåëî÷ðåâíè çàáîëÿâàíèÿ â ïëàíîâ è ñïåøåí ïîðÿäúê ñà 244 (3,66%) ïàöèåíòà, îò òÿõ çà êîëîðåêòàëåí êàðöèíîì 198 (2,97%).

ñ íàé-âèñîê ïðîöåíò: íà êîëîí ñèãìîèäåóì 70 (35,35%) è ðåêòóì 48 (24,24%). Ñëåäâàùèòå ïî ÷åñòîòà

253

Ïåòêîâ Þ., Ä. Ñòîéêîâ, È. Äåêîâà

ëîêàëèçàöèè ñà: öüîêóì, êîëîí àñöåíäåíñ è êîëîí äåñöåíäåíñ. Òåæåñòòà íà çàáîëÿâàíåòî ïðåöåíÿâàõìå ñïîðåä êëèíè÷íîòî ñúñòîÿíèå, èçñëåäâàíå íà êðúâíèòå è áèîõèìè÷íèòå ïîêàçàòåëè, óðèíà, ïóëñ, RR, ÖÂÍ, îáðàçíè èçñëåäâàíèÿ (åõîãðàôèÿ, ôèáðîêîëîíîñíîïèÿ, èðèãîãðàôèÿ, àêñèàëíà êîìïþòúðíà òîìîãðàôèÿ è ßÌÐ). Òàáë. 2 .Ðàçïðåäåëåíèå íà ïàöèåíòèòå ïî âèäà íà ëîêàëèçàöèÿòà íà ÊÐÊ. Àíàòîìè÷íà ëîêàëèçàöèÿ íà ÊÐÊ

áðîé

Öüîêóì

7,59%

Êîëîí àñöåíäåíñ

8,08%

Ôëåêñóðà êîëè õåïàòèêà

5,05%

Êîëîí òðàíñâåðçóì

6,06%

Ôëåêñóðà êîëè ëèåíàëèñ

6,06%

Êîëîí äåñöåíäåíñ

7,58%

Êîëîí ñèãìóèäåóì

35,35%

Ðåêòóì

24,24%

Îáùî:

198

100%

Ëå÷åíèåòî íà áîëíèòå ñ óñëîæíåíèÿ íà ÊÐÊ ïðîòå÷å íà ÷åòèðè åòàïà: - ïðåäîïåðàòèâíà ïîäãîòîâêà - îïåðàòèâíî ëå÷åíèå çà îòñòðàíÿâàíå íà ïðè÷èíèòå - êîíñåðâàòèâíî ëå÷åíèå (àíòèáèîòè÷íà òåðàïèÿ, âëèâàíèÿ íà âîäíî-ñîëåâè ðàçòâîðè,áåëòú÷íè ðàçòâîðè,êðúâ è êðúâíè ïðîäóêòè, ìåäèêàìåíòè çà ïîäúðæàíå íà ñúðäå÷íàòà, áåëîäðîáíàòà è áúáðå÷íàòà ôóíêöèè) - èíòåíçèâíî ëå÷åíèå ñðåùó âòîðè÷íè óñëîæíåíèÿ.

Òàáë. 3. Âèäîâå óñëîæíåíèÿ íà ÊÐÊ. Âèä óñëîæíåíèå

Ìúæå

Æåíè

Îáùî

Îáòóðèðàù ÊÐÊ

Êúðâÿù ÊÐÊ

Ïåðôîðèðàë ÊÐÊ ñ ïåðèòîíèò

Ïåðôîðèðàë ÊÐÊ â ðåòðîïåðèòîí åóìà ñ àáñöåñ

Îáùî

Òàáë. 4. Âèäîâå îïåðàòèâíè èíòåðâåíöèè. Âèäîâå îïåðàöèè

Íåóñëîæíåíè ÊÐÊ

Óñëîæíåíè ÊÐÊ

îáùî

Äÿñíà õåìèêîëåêòîìèÿ

Ðåçåêöèÿ íà êîëîí òðàíñâåðçóì

Ëÿâà õåìèêîëåêòîìèÿ

Ðåçåêöèÿ íà ñèãìà ïî Õàðòìàí

Ñèãìîñòîìèÿ /òèï äâóöåâêà/

Ïðåäíà ðåçåêöèÿ íà ðåêòóìà

Àìïóòàöèÿ íà ðåêòóìà ïî Ìàéëñ

Èëåî- òðàíñâåðçî àíàñòîìîçà + öüîêîñòîìèÿ

Òðàíñâåðçîñòîìèÿ

Êðèîäåñòðóêöèÿ

106

198

Öüîêîñòîìèÿ Ðåçåêöèÿ íà ñèãìà + Ò-Ò àíàñòîìîçà

Oáùî

254

Óñëîæíåíèÿ íà êîëîðåêòàëíèÿ êàðöèíîì

Ñëåä îòâàðÿíå íà êîðåìíàòà êóõèíà ñìå èçâúðøâàëè ðåâèçèÿ, ñïàçâàéêè îïðåäåëåíè ïðèíöèïè: Òàáë. 5 Áðîé íà ëàâàæèòå íà áîëíè ñ ÂËÏË. Ëàâàæè (áðîé)

Áîëíè

Ïî÷èíàëè

àñïèðàöèÿ è èçòîïÿâàíå íà êîðåìíàòà êóõèíà (ïðè íàëè÷èå íà ïåðèòîíèò êàòî ðåçóëòàò îò ïåðôîðàöèÿ íà ÊÐÊ ) - îáñòîéíà ðåâèçèÿ íà êîðåìíàòà êóõèíà è îðãàíèòå - óòî÷íÿâàíå ëîêàëèçàöèÿòà íà ÊÐÊ - èçáîð íà îïåðàòèâíàòà èíòåðâåíöèÿ (ðàäèêàëíà èëè ïàëèåòèâíà) - èíòðàîïåðàòèâåí ïåðèòîíåàëåí ëàâàæ - äðåíèðàíå íà êîðåìíàòà êóõèíà - çàòâàðÿíå íà êîðåìíàòà ñòåíà èëè ïîäãîòîâêà çà ëå÷åíèå ïîä ëàïàðîñòîìà. Îáèêíîâåííî áîëíè ñ óñëîæíåíèÿ íà ÊÐÊ ñå îïåðèðàò ïî ñïåøíîñò è èçáîðà íà îïåðàòèâíàòà òàêòèêà è çàâúðøâàíåòî íà îïåðàòèâíàòà èíòåðâåíöèÿ ïðåöåíÿâàõìå ñïîðåä: èíòîêñèêàöèÿòà íà îðãàíèçìà, âèäà óñëîæíåíèå íà ÊÐÊ, íàëè÷èå è õàðàêòåð íà ïðèäðóæàâàùèòå çàáîëÿâàíèÿ. Ïðè âñåêè áîëåí èíäèâèäóàëíî èçáèðàõìå âèäà è îáåìà íà îïåðàòèâíàòà èíòåðâåíöèÿ â çàâèñèìîñò îò ëîêàëèçàöèÿòà è ñòàäèÿò íà ðàêîâèÿò ïðîöåñ. Ïðîâåæäàõìå ïåðèîïåðàòèâíà àíòèáèîòè÷íà ïðîôèëàêòèêà. Èçïîëçâàíè ñà Ceftriaxon 2g i.v. , 2 ÷àñà ïðåäè îïåðàöèÿòà èëè êîìáèíàöèÿ îò 2 g Ceftriaxon + Metronidazol 1000 mg, êîÿòî â ïîâå÷åòî ñëó÷àé å ïðåìèíàâàëà â ëå÷åáíà, â çàâèñèìîñò îò ïðîäúëæèòåëíîñòòà è õîäà íà îïåðàòèâíàòà èíòåðâåíöèÿ. Âñè÷êè îïåðèðàíè áîëíè ïðîôèëàêòèðàõìå ñ Í-2 áëîêåðè, èíõèáèòîðè íà ïðîòîííàòà ïîìïà è íèñêîìîëåêóëÿðåí õåïàðèí.

ïåðôîðàöèÿ íà ÊÐÊ è ïåðèòîíèò ñìå ïðèëîæèëè ïðè 15 ïàöèåíòà. Ñ òîòàëåí ïåðèòîíèò ñà áèëè 4-ìà ïàöèåíòè, ñ äèôóçåí - 8 è ñ ëîêàëåí - 3. Ëàïàðîñòîìèÿòà å ìåòîä, êîéòî íè äàâà âúçìîæíîñò äà êîíòðîëèðàìå ñúñòîÿíèåòî è âúçïàëåíèåòî, ïîäïîìàãà ðååêñïëîðàöèÿòà, îñèãóðÿâà åôåêòèâåí äðåíàæ, ðåäóöèðà ïî-âèñîêîòî àáäîìèíàëíî íàëÿãàíå è îñèãóðÿâà ñâîåâðåìåííà õèðóðãè÷íà íàìåñà çà íàñòúïèëèòå óñëîæíåíèÿ. Áðîÿò íà ëàâàæèòå ñå îïðåäåëÿ îò êîðåìíèÿ ñòàòóñ íà ïàöèåíòèòå. Îò îïåðèðàíèòå 92 ïàöèåíòè ñ óñëîæíåíèå íà ÊÐÊ ïî ñïåøíîñò, ðàäèêàëíè îïåðàòèâíè èíòåðâåíöèè ñà èçâúðøåíè íà 59 (64,13%) à íà 33 (35,87%) ñà íàïðàâåíè ïàëèàòèâíè îïåðàöèè. Íàé-÷åñòèòå ñëåäîïåðàòèâíè õèðóðãè÷íè óñëîæíåíèÿ ñà ðàíåâèòå èíôåêöèè (16 ñëó÷àÿ 17,39%) è èíñóôèöèåíöèÿ íà àíàñòîìîçèòå (11 ñëó÷àÿ 11,96%). Ïðè èíñóôèöèåíöèèòå ñå íàëîæè äà ñå èçâúðøè ðåîïåðàöèè, êàòî 2-ìà ïàöèåíòà ñå îñòàâèõà íà ÂËÏË. Ïî÷èíàëèòå ñëåä îïåðàöèèòå ïàöèåíòè ñà âúâ âúçðàçñòîâèÿ èíòåðâàë ìåæäó 61 -90 ãîäèíè. Â ïúðâèòå äâå äåíîíîùèÿ ñà ïî÷èíàëè 6ìà ïàöèåíòè ñ íåïðåîäîëÿí èíòîêñèêàöèîíåí ñèíäðîì, îò òÿõ 4ìà îïåðèðàíè ïî ïîâîä ïåðôîðèðàë ÊÐÊ. Îñòàíàëèòå 9 ïàöèåíòà ñà ïî÷èíàëè ñ êàðòèíàòà íà áåëîäðîáåí òðîìáîåìáîëèçúì, ñúðäå÷íî-ñúäîâà íåäîñòàòú÷íîñò è çàñòîéíè ïíåâìîíèè.

ÈÇÂÎÄÈ 1. ÊÐÊ å çàáîëÿâÿíå, êîåòî íàðàñòâà â îòíîøåíèå 2,33:1 (198 : 85) ñïðÿìî ïðåäèøíèÿ ïåðèîä îò 5 ãîäèíè (2000 -2004) . 2. Ïàöèåíòèòå â íàïðåäíàëà âúçðàñò ìåæäó 71 -80 ãîäèíè ñà îñíîâíîòà ãðóïà ñ âèñîê îïåðàòèâåí ðèñê, ïîðàäè ïðèäðóæàâàùèòå çàáîëÿâàíèÿ, êîèòî èãðàÿò çíà÷èòåëíà ðîëÿ çà ñëåäîïåðàòèââíèòå óñëîæíåíèÿ è ëåòàëèòåò. 3. Çàáîëåâàåìîñòòà ñðåä ìëàäàòà âúçðàñò ÷óâñòâèòåëíî íàðàñòâà. 4. Íàé-÷åñòî óñëîæíåíèå ïðè ÊÐÊ å îáòóðàöèÿòà íà ëóìåíà, ò.êàòî íàé-÷åñòàòà ëîêàëèçàöèÿ íà êàðöèíîìà çàñÿãà ñèãìà è ðåêòóì. 5. Ëàïàðîñòîìèÿòà å ìåòîä íà èçáîð ïðè ïàöèåíòè ñ óñëîæíåíèÿ è îò ðèñêîâèòå ãðóïè.

ÎÁÑÚÆÄÀÍÅ Íàé çàñåãíàòàòà âúçðàñòîâà ãðóïà îò ÊÐÊ å 71-80 ãîä. ïîñëåäâàíà îò ïàöèåíòèòå íà âúçðàñò 61-70 ãîä. è 51-60 ãîä. Ëåòàëèòåòúò ñúùî å â íàé-âèñîê ïðîöåíò â ãðàíèöàòà 71-80 ãîäèíè. Ïðè÷èíèòå çà òîâà ñà ïðèäðóæàâàùèòå áåëîäðîáíè, ñúðäå÷íî-ñúäîâè, áúáðå÷íè è äðóãè çàáîëÿâàíèÿ. Îáòóðèðàùèÿò ÊÐÊ å íà âîäåùî ìÿñòî îò óñëîæíåíèÿòà, ïîñëåäâàí îò ïåðôîðàöèÿ ñ ïåðèòîíèò. ÂËÏË êàòî ìåòîä çà èçáîð ïðè çàâúðøâàíå íà îïåðàòèâíàòà èíòåðâåíöèÿ ïðè îïåðèðàíèòå áîëíè ñ

ËÈÒÅÐÀÒÓÐÀ 1.

Colon and Rectal Cancer Home Page - National Cancer Institute Information about colon and rectal cancer treatment, prevention, genetics, causes, screening, statistics and other topics from the National Cancer ... Colorectal cancer - Wikipedia, the free encyclopedia Colorectal cancer, also called colon cancer or large bowel cancer, includes cancerous growths in the colon, rectum and appendix. ...

255

Ïåòêîâ Þ., Ä. Ñòîéêîâ, È. Äåêîâà 3.

Colon cancer - MayoClinic.com, Colon cancer Comprehensive overview covers signs, symptoms and treatment of colon and rectal cancers. Ðàê íà äåáåëîòî ÷åðâî Ëå÷åíèå - Íàöèîíàëåí èíñòèòóò Ðàê, Åêñïåðò-ïðåãëåäàíè îáîáùåíà èíôîðìàöèÿ çà ëå÷åíèå íà ðàê íà äåáåëîòî ÷åðâî. Cancer - Colorectal Cancer, CDC promotes colorectal cancer (cancer of the colon and rectum) prevention by building partnerships, encouraging screening, supporting education and ... Êîëîðåêòàëíèÿ ðàê íîâèíè îò Ìåäèöèíñêè Íîâèíè Äíåñ, Ïîñëåäíèòå êîëîðåêòàëíèÿ ðàê íîâèíàðñêè çàãëàâèÿ, ïóáëèêóâàíè åæåäíåâíî Guideline No. 67: Management of colorectal cancer [Management of colorectal cancer SIGN Guideline

256

67] ... Follow up of patients treated for colorectal cancer, Palliative care and the management of symptoms. Colorectal cancer info; Colon cancer prevention CCSIF Colorectal Cancer (CRC) is the second most deadly form of cancer, second to lung cancer. The Colorectal Cancer Screening Initiative Foundation website to Ðàê íà äåáåëîòî ÷åðâî - ñèìïòîìè, äèàãíîñòèêà, ëå÷åíèå íà ðàê íà äåáåëîòî ÷åðâî - NY... Òàêèâà ðàê å ïîíÿêîãà ïî-íàòàòúê “êîëîðåêòàëíèÿ ðàê...Ñïîðåä àìåðèêàíñêàòà ðàêà îáùåñòâî, êîëîðåêòàëíèÿ ðàê å åäíà îò âîäåùèòå ïðè÷èíè çà...

Scripta Scientifica Medica, 2009; vol. 41 (3), pp 257-260

ÎÁÅÌ ÍÀ ÕÈÐÓÐÃÈ×ÍÀÒÀ ÐÅÇÅÊÖÈß È ÈÇÕÎÄ ÎÒ ËÅ×ÅÍÈÅÒÎ ÏÐÈ ÁÎËÍÈ Ñ ËÎÊÀËÍÎ ÀÂÀÍÑÈÐÀË ÏÚÐÂÈ×ÅÍ ÊÎËÎÐÅÊÒÀËÅÍ ÊÀÐÖÈÍÎÌ Áëàãîâ É., Ä. Çèÿ, Ì. Ðàäèîíîâ, È. Ñå÷àíîâ, Ò. Ïîæàðëèåâ Êëèíèêà ïî îáùà è åíäîñêîïñêà õèðóðãèÿ, ÓÌÁÀË "Ñâ. Àííà" Ñîôèÿ ÐÅÇÞÌÅ Óâîä: Ïðè ëîêàëíî àâàíñèðàëèÿ êîëîðåêòàëåí êàðöèíîì íàáëþäàâàìå òóìîðíà èíôèëòðàöèÿ â ïðèëåæàùè îðãàíè è ñòðóêòóðè. Â ïîâå÷åòî ñëó÷àè åäèíñòâåíàòà âúçìîæíîñò å en bloc ðåçåêöèÿ. Íàøàòà öåë áå äà ïðîó÷èì óñëîæíåíèÿòà, ñìúðòíîñòòà è ïðåæèâÿåìîñòòà ñëåä îïåðàòèâíà èíòåðâåíöèÿ ïî ïîâîä êîëîðåêòàëåí êàðöèíîì. Ìåòîäè: Áÿõà ïðîó÷åíè 113 ñëó÷àÿ íà ïàöèåíòè ñ ëîêàëíî àâàíñèðàë êîëîðåêòàëåí êàðöèíîì çà ïåðèîäà 1999-2008 ã. îò îáùî 1232 îïåðèðàíè ïî ïîâîä êîëîðåêòàëåí êàðöèíîì. Ðåçóëòàòè: Íèå èçâúðøèõìå en bloc ðåçåêöèè â 56.6% îò ñëó÷àèòå, ñòàíäàðòíè ðåçåêöèè â 26.5%, ïàëèàòèâíè îïåðàöèè â 14.2% è åêñïëîðàòèâíè ëàïàðîòîìèè â 2.7% îò ñëó÷àèòå. Êàòî ðàííè óñëîæíåíèÿ îò÷åòîõìå èíñóôèöèåíöèÿ íà àíàñòîìîçàòà ïðè 3-ìà áîëíè, ñóïóðàöèÿ - ïðè 6, äåõèñöåíöèÿ - ïðè 3 è ñëåäîïåðàòèâíî êúðâåíå ïðè 1 áîëåí. Ïåðèîïåðàòèâíàòà ñìúðòíîñò áåøå 7.1%. Åäíîãîäèøíà ïðåæèâÿåìîñò óñòàíîâèõìå ïðè 86 áîëíè (76.1% ), à 5-ãîäèøíà ïðè 28 (24.8%). Çàêëþ÷åíèå: Âúïðåêè íÿêîè õèðóðãè÷íè è òåðàïåâòè÷íè ïðîáëåìè, ìóëòèâèñöåðàëíèòå ðåçåêöèè ñà íàé-äîáðàòà îïöèÿ çà ïàöèåíòè ñ ëîêàëíî àâàíñèðàë êîëîðåêòàëåí êàðöèíîì. Íàøåòî ìíåíèå å, ÷å ðàçïðîñòðàíåíèåòî íà òóìîðà è èíôèëòðàöèÿòà íà ñúñåäíè îðãàíè è ñòðóêòóðè íå å êîíòðàèíäèêàöèÿ çà îïåðàòèâíî ëå÷åíèå.

Êëþ÷îâè äóìè: ëîêàëíî àâàíñèðàë êîëîðåêòàëåí êàðöèíîì, óñëîæíåíèÿ, êîëîðåêòàëåí êàðöèíîì Êîëîðåêòàëíèÿò êàðöèíîì (ÊÐÊ) å åäèí îò íàé-÷åñòî ñðåùàíèòå çëîêà÷åñâåíè òóìîðè, çàåìàù òðåòî ìÿñòî â ÷îâåøêîòî òÿëî (1). Ïðèáëèçèòåëíî 5-15% îò ïúðâè÷íèÿò êîëîðåêòàëåí êàðöèíîì ïðîðàñòâà â ñúñåäíè îðãàíè áåç äà èìà äàëå÷íè ìåòàñòàçè (2,3,10,17). Ïîíàñòîÿùåì çà ëîêàëíî àâàíñèðàëèòå òóìîðè (ËÀÒ) ñïîðåä National Cancer Institute (3) è American Society of Colon Rectal Surgeons (2,4) êàòî "guideline" å ïðèåòà ìóëòèâèñöåðàëíàòà ðåçåêöèÿ ñ àäõåðåíòíèòå ñòðóêòóðè en bloc. Â ìàòåðèàë çà 10 ãîäèíè ïðåäñòàâÿìå íàøèÿ îïèò ñ ëîêàëíî àâàíñèðàëèÿ ÊÐÊ, ïðåæèâÿåìîñò, óñëîæíåíèÿ è ñìúðòíîñò ïðè òîçè âèä òóìîðè.

ÌÀÒÅÐÈÀË È ÌÅÒÎÄÈ Ïðåç ïåðèîäà îò 10 ãîäèíè (1999ã.-2008ã). â ÊÎÅÕ ïðè ÓÌÁÀË "Ñâ. Àííà"- Ñîôèÿ îïåðèðàõìå 1232 áîëíè ñ ÊÐÊ. Îò òÿõ 113 (9,24%) áîëíè áÿõà ñ ëîêàëíî àâàíñèðàë êàðöèíîì. Íà âñè÷êè áîëíè ïðè ïîñòúïâàíåòî âçèìàìå ñòàíäàðòíè êðúâíè èçñëåäâàíèÿ, èçâúðøâàìå ðåêòàëíî òóøå, ÓÇÄ íà êîðåì è ãðàôèÿ íà áÿë äðîá. Ïðè ñïåøíî îïåðèðàíèòå áîëíè êàòî ñòàíäàðòíà ïðîöåäóðà ïðàâèì èðèãîãðàôèÿ ïî ñïåøíîñò.

Íà ïëàíîâèòå áîëíè îñúùåñòâÿâàìå è ÔÊÑ ñ áèîïñèÿ. Ïðè ñúìíåíèÿ çà àíãàæèðàíå íà ñúñåäíè ñòðóêòóðè è îðãàíè íàçíà÷àâàìå ñúîòâåòíî öèñòîñêîïèè, ÔÃÑ è ÊÀÒ. Ïðè ÷àñò îò ïàöèåíòèòå ñ ðåêòàëåí êàðöèíîì å íàïðàâåí è òðèèçìåðåí óëòðàçâóê. Âñè÷êè ïàöèåíòè ñ íàëè÷íè ÷åðíîäðîáíè ìåòàñòàçè è ïàöèåíòèòå ñ N3 ëèìôåí ñòàòóñ èçêëþ÷èõìå îò èçñëåäâàíåòî. Íèå ñúáðàõìå è îáðàáîòèõìå ñëåäíèòå ïðîìåíëèâè: ïîë, âúçðàñò, àäþâàíòíà òåðàïèÿ, âèä îïåðàòèâíà èíòåðâåíöèÿ, óñëîæíåíèÿ, ñìúðòíîñò, ïðåæèâÿåìîñò. ÊÐÊ ãî ðàçãëåæäàìå â òðè ïîäãðóïè: äåñåí êîëîí (ïðîêñèìàëíî îò ëèåíàëíàòà ôëåêñóðà), ëÿâ êîëîí (äèñòàëíî îò ëèåíàëíàòà ôëåêñóðà) è ðåêòóì. Ïðåõîäà ñèãìà-ðåêòóì êàðöèíîìè ãè âêëþ÷âàìå êúì ðåêòàëíèòå ïîðàäè àíàòîìè÷íàòà èì âðúçêà è õèðóðãè÷íî ëå÷åíèå. Â en bloc ðåçåêöèè îò÷èòàìå âñè÷êè áîëíè, ïðè êîèòî å îòñòðàíåí òóìîðà çàåäíî ñ àíãàæèðàíèòå ñòðóêòóðè è îðãàíè, ïðè ñòàíäàðòíèòå ðåçåêöèè å îòñòðàíåí òóìîðà ñ àäõåçèîëèçà íà ïðèëåæàùè òúêàíè è îðãàíè. Êàòî ïàëèàòèâíè îïåðàöèè îòáåëÿçâàìå òåçè, ïðè êîèòî òóìîðà íå å îòñòðàíåí, à å èçâúðøåíà îáõîäíà àíàñòîìîçà èëè å èçâåäåíà ñòîìà. Â ïåðèîïåðàòèâíà ñìúðòíîñò âêëþ÷âàìå ñìúðòíîñòòà äî 30-òè ñëåäîïåðàòèâåí äåí.

257

Áëàãîâ É., Ä. Çèÿ, Ì. Ðàäèîíîâ...

Äàííèòå áÿõà îáðàáîòåíè ñòàòèñòè÷åñêè ñ ïîìîùòà íà àëòåðíàòèâíèÿ àíàëèç. Ñòàòèñòè÷åñêà äîñòîâåðíîñò íà ðàçëèêèòå ìåæäó ïðîöåíòè áåøå îöåíÿâàíà ïîñðåäñòâîì êðèòåðèÿ íà çíà÷èìîñò t (ñðàâíÿâàíå íà ïîêàçàòåëè çà îòíîñèòåëåí äÿë) ïðè óñòàíîâåíà ñòîéíîñò íà óðîâåíà íà çíà÷èìîñò íà íóëåâàòà õèïîòåçà P<0.05. Ïîðàäè ìàëêèÿ áðîé íà ñúïîñòàâÿíèòå âåëè÷èíè, ðåçóëòàòèòå òðÿáâà äà ñå ïðèåìàò ñ èçâåñòíà äîçà ðåçåðâèðàíîñò. Òàáë.1 Ïàöèåíòè, ëîêàëèçàöèÿ è âðåìå íà õèðóðãè÷íà íàìåñà Ëîêàëèçàöèÿ

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Ñïåøíî Ïëàíîâî Îáù áðîé îïåðèðàíè îïåðèðàíè

Äåñåí êîëîí Ëÿâ êîëîí

1:1.2

Ðåêòóì

áîëíè, èíñóôèöèåíöèè - ïðè 3, äåõèñöåíöèè - ïðè 3, ïîñòîïåðàòèâíî êúðâåíå - ïðè 1 áîëåí). Åäíîãîäèøíà ïðåæèâÿåìîñò óñòàíîâèõìå ïðè 86 áîëíè (76.1%), à 5 ãîä. ïðåæèâÿåìîñò ïðè 28 (24.8%). Ðåçóëòàòèòå ïðåäñòàâÿìå â òàáë. 2.

ÎÁÑÚÆÄÀÍÅ Õèðóðãè÷íàòà ðåçåêöèÿ îñòàâà ìåòîä íà èçáîð ïðè ëîêàëíî àâàíñèðàëèÿ ÊÐÊ (11). Íàé-÷åñòèòå îðãàíè êúì êîèòî ïðîðàñòâà êàðöèíîìà íà äåáåëîòî ÷åðâî ñà òúíêè ÷åðâà, ñòîìàõ, äóîäåíóì, ïàíêðåàñ, ïèêî÷åí ìåõóð è ðåïðîäóêòèâíèòå îðãàíè ïðè æåíàòà. Ïîñëåäíè ïðîó÷âàíèÿ ïîä÷åðòàâàò, ÷å ïðàâèëíîòî ëå÷åíèå íà òåçè ëîêàëíî àâàíñèðàëè òóìîðè å ìóëòèâèñöåðàëíàòà ðåçåêöèÿ, ïðè êîÿòî ïúðâè÷íèÿ êàðöèíîì è ñòðóêòóðèòå êúì êîèòî å ïðîðàñòíàë ñå ðåçåöèðàò en bloc (15,16,17,18). Â 40-84% îò àäõåçèèòå ìåæäó òóìîðà è ñúñåäíèòå îðãàíè

Òàáë.2 Ïàöèåíòè, âèä õèðóðãèÿ, óñëîæíåíèÿ, ñìúðòíîñò

Âèä îïåð.èíòåðâåíöèÿ En-bloc Äåñåí êîëîí Ëÿâ êîëîí Ðåêòóì Ñòàíäàðíà ðåçåêöèÿ Äåñåí êîëîí Ëÿâ êîëîí Ðåêòóì Ïàëèàòèâíè îïåðàöèè Äåñåí êîëîí Ëÿâ êîëîí Ðåêòóì Åêñïëîðàòèâíè îïåðàöèè Äåñåí êîëîí Ëÿâ êîëîí Ðåêòóì Îáùî

Áðîé áîëíè

óñëîæíåíèÿ

ñìúðòíîñò

1 1 1

113

13 (11.5%)

8 (7.1%)

64 (56.6%) 15 30 19 30 (26.5%) 12 12 6 16 (14.2%) 1 8 7 3 (2.7%)

ÐÅÇÓËÒÀÒÈ Îò âñè÷êè 113 áîëíè ïî ñïåøíîñò îïåðèðàõìå 24, à ïëàíîâî 89. Ðàçïðåäåëåíèåòî ìúæå/æåíè å 54:59 (ïðèáëèçèòåëíî 1:1,2), êàòî âúçðàñòòà íà ïàöèåíòèòå âàðèðà îò 38 äî 84 ãîäèíè. Ïðè 29 îò ñëó÷àèòå òóìîðúò áå ëîêàëèçèðàí â äåñíèÿ êîëîí, ïðè 51 â ëåâèÿ êîëîí è 33 â ðåêòóìà. Â 13 îò ñëó÷àèòå óñòàíîâèõìå óñëîæåíèÿ, ñâúðçàíè ïðÿêî ñ îïåðàòèâíàòà èíòåðâåíöèÿ (ñóïóðàöèè - ïðè 6 258

ñà ìàëèãíåíè (3,10,11,22). Â ñëó÷àèòå êîãàòî íå å áèëà èçâúðøåíà en bloc ðåçåêöèÿ, à òóìîðúò å áèë îòïðåïàðàí îò îêîëíèòå îðãàíè è ðåçåöèðàí, ïðîöåíòà íà ðåöèäèâè å ïî-âèñîê (10,15). Â 35% îò ñëó÷àèòå íà ëîêàëíî àâàíñèðàë ÊÐÊ ïðè êîèòî íå å èçâúðøåíà en bloc ðåçåêöèÿ ðåöèäèâèòå è ñìúðòíîñòòà ñà ïî-âèñîêè ñïðÿìî îñòàíàëèòå 65% ïðè êîèòî å èçâúðøåíà en bloc ðåçåêöèÿ (15). Êîíöåïöèÿòà íà ìóëòèâèñöåðàëíàòà ðåçåêöèÿ å ïîñòèãàíåòî íà R0 ðåçåêöèÿ, ÷ðåç íàìàëÿâàíå íà âúçìîæíîñòòà çà ëîêàëíè ðåöèäèâè îò

Îáåì íà õèðóðãè÷íàòà ðåçåêöèÿ è èçõîä îò ëå÷åíèåòî ïðè áîëíè ñ ëîêàëíî àâàíñèðàë ...

77% íà 36% è ïîäîáðÿâàíå íà 5 ãîäèøíàòà ïðåæèâÿåìîñò äî 43% (10,11,17,18,22). Èçõîäà îò ëå÷åíèåòî íà ËÀÒ çàâèñè ãëàâíî îò äâà ôàêòîðà - åäèíèÿò å ñâúðçàí ïðÿêî ñ îáùèÿ ñòàòóñ è âúçðàñòòà íà ïàöèåíòà, à äðóãèÿ ñ ëîêàëíàòà íàõîäêà. È ìàêàð ÷å, øàíñîâåòå ïðè ìëàäè ïàöèåíòè ñ ïî-ëåêà ëîêàëíà íàõîäêà ñà ïî-äîáðè, òî íàïðåäíàëàòà âúçðàñò íå òðÿáâà äà áúäå ñàìà ïî ñåáå ñè êîíòðàèíäèêàöèÿ çà ìóëòèâèñöåðàëíà ðåçåêöèÿ. Íàñòîÿùè ñúîáùåíèÿ äåìîíñòðèðàò îòëè÷íè ðåçóëòàòè ïðè ñåëåêòèðàíè âúçðàñòíè ïàöèåíòè ñ ËÀÒ è en bloc ðåçåêöèè (6,7). Âúïðåêè ïî-âèñîêàòà ïðåæèâÿåìîñò ïðè en bloc ðåçåêöèèòå, ìîðáèäíîñòòà ïðè òÿõ å ïî-âèñîêà ñïðÿìî ñòàíäàðòíàòà ðåçåêöèÿ, ïîðàäè ïî-ãîëåìèÿ îáåì íà îïåðàöèÿòà, íî íèâîòî íà ïåðèîïåðàòèâíàòà ñìúðòíîñò å åäíà è ñúùà (10,11,16,17,19,20,22). Â íàøèÿ ìàòåðèàë ïàöèåíòèòå ñ en bloc ðåçåêöèÿ â ñðàâíåíèå ñ ïàëèàòèâíî îïåðèðàíèòå íÿìàò ïî-âèñîê ïðîöåíò ñëåäîïåðàòèâíè óñëîæíåíèÿ (10.9% : 25%, P>0.05 ) è ïåðèîïåðàòèâíà ñìúðòíîñò (6.2% : 12.5%, Ð>0.05). Íèå îò÷èòàìå ïî-âèñîêà ïåðèîïåðàòèâíà ñìúðòíîñò íà ïàöèåíòèòå ñ en bloc ñïðÿìî áîëíèòå ñúñ ñòàíäàðòíà ðåçåêöèÿ (6.2% : 3.3%, P>0.05), íî ñòàòèñòè÷åñêè òîâà å áåç çíà÷åíèå. Ïðè ïàöèåíòè ñ ëîêàëèçàöèÿ íà òóìîðà â äåñåí êîëîí ïðîöåíòà íà èçâúðøåíèòå en bloc ðåçåêöèè å ïî-ìàëúê â ñðàâíåíèå ñ òóìîðèòå ëîêàëèçèðàíè â ëåâèÿ êîëîí è ðåêòóì. Òîâà ñå îáÿñíÿâà ñ ôàêòà, ÷å ïðè ËÀÒ íà äåñíèÿ êîëîí ïîñòèãàíåòî íà ÷èñòè ðåçåêöèîííè ëèíèè å òðóäíî ïîðàäè áëèçîñòòà íà îðãàíè êàòî ÷åðåí äðîá, áèëèàðíà ñèñòåìà, ãëàâà è òÿëî íà ïàíêðåàñ, ñòîìàõ è èíôèëòðèðàíåòî èì. Ðåçóëòàòèòå îò íÿêîëêî ïðîó÷âàíèÿ ïîêàçâàò, ÷å ïðè èíâàçèÿ â ãëàâàòà íà ïàíêðåàñà en bloc äóîäåíîïàíêðåàòè÷íàòà ðåçåêöèÿ ïîäîáðÿâà îáùàòà ïðåæèâÿåìîñò (8,9,21). Òðÿáâà äà ñå îòáåëåæè, ÷å âúïðåêè ñúâðåìåííèòå âúçìîæíîñòè íà ÊÀÒ è ßÌÐ âñå îùå íå ìîæåì äà ãîâîðèì çà íàäåæäíî îöåíÿâàíå íà íîäàëíèÿ ñòàòóñ íà ïàöèåíòèòå. Àíãàæèðàíåòî íà ëèìôíèòå âúçëè ïðè âñåêè ïàöèåíò ìîæå äà áúäå àêóðàòíî îïðåäåëåíî åäèíñòâåíî è ñàìî îò ïàòîëîãà. Ïðîó÷âàíèÿ ïîêàçâàò, ÷å ÷åñòîòàòà íà ìóëòèâèñöåðàëíèòå ðåçåêöèè ïðè ïàöèåíòè ñ íåìåòàñòàòè÷íè ëèìôíè âúçëè å ïî-ãîëÿìà â ñðàâíåíèå ñúñ ñëó÷àèòå ïðè êîèòî èìà ìåòàñòàòè÷íè ëèìôíè âúçëè (15). Ñúùåâðåìåííî 5 ãîäèøíàòà ïðåæèâÿåìîñò ïðè ïàöèåíòè ñ ëèìôíè ìåòàñòàçè ñå äâèæè ìåæäó 0% è 11% â ñðàâíåíèå ñ òåçè áåç ëèìôíè ìåòàñòàçè, êîÿòî å ìåæäó 37% è 76% (1,5,13,14,16). Ðåêòàëíèòå êàðöèíîìè îáèêíîâåíî ïðè ïðîðàñòâàíå àíãàæèðàò ïèêî÷íèÿ ìåõóð è ãåíèòàëèèòå ïðè æåíèòå, êàòî äîðçàëíî ìîæå äà áúäå âúâëå÷åí è ñàêðóìà. Àãðåñèâíàòà èì áèîëîãèÿ â ñðàâíåíèå ñ îñòàíàëèòå êîëîí êàðöèíîìè ñå èçðàçÿâà è â ïî-ðàííîòî èì ìåòàñòàçèðàíå â ëèìôíèòå âúçëè, ïåðèíåâðàëíà è ïåðèâàñêóëàðíà èíâàçèÿ. Âúïðîñà çà ïðåäïðèåìàíå ïðè íóæäà íà çàäíà èëè òîòàëíà åêçàíòåðàöèÿ å ïîñòèãàíåòî íà R0 ðåçåêöèÿ. È âúïðåêè, ÷å ñàìàòà îïåðàòèâíà èíòåðâåíöèÿ ñå ïîíàñÿ ñðàâíèòåëíî äîáðå,

òî ïðîöåíòà íà àñîöèèðàíèòå ñëåäîïåðàòèâíè óñëîæíåíèÿ îñòàâà ñðàâíèòåëíî âèñîê. Òå âêëþ÷âàò èíòðààáäîìèíàëíè àáñöåñè, ÷ðåâíè ôèñòóëè, èëåîóðåòåðàëíè ôèñòóëè è ñòåíîçè, ñåïñèñ (12,16). Ñëó÷àèòå íà ìóëòèâèñöåðàëíà ðåçåêöèÿ ïðè áîëíè, êîèòî ñà ïîëó÷èëè íåîàäþâàíòíà òåðàïèÿ ïî ïîâîä ðåêòàëåí êàðöèíîì ñà ïî-ìàëêî â ñðàâíåíèå ñ òåçè êîèòî íå ñà áèëè îáëú÷åíè ïðåäîïåðàòèâíî. Ïî âðåìå íà ðàáîòàòà ñè îòáåëÿçàõìå ñëåäíèòå âàæíè îáñòîÿòåëñòâà. Äàííèòå, êîèòî îáðàáîòâàõìå áÿõà ïî çàïèñ è îïèñàíèå íà îïåðàòèâíèòå åêèïè. Èíäèâèäóàëíàòà ïðåöåíêà âúâ âñåêè êîíêðåòåí ñëó÷àé îñòàâà ìíîãî âàæíà îòíîñíî èíâàçèÿòà íà òóìîðà, íàëè÷èåòî íà àäõåçèè êúì îêîëíèòå ñòðóêòóðè è äàëè òå ñà îöåíÿâàíè êàòî ìàëèãíåíè. Â òîçè ñìèñúë îïèòúò íà åêèïèòå èìà ïðÿêî îòíîøåíèå êúì îáåìà íà ïðåäñòîÿùàòà îïåðàòèâíà èíòåðâåíöèÿ è êà÷åñòâîòî íà èçâúðøåíàòà ðàáîòà. Â íÿêîè ñëó÷àè ïðè èçâúðøâàíèòå en bloc ðåçåêöèè ëèïñâàò èçñëåäâàíè ðåçåêöèîííè ëèíèè. Ïðîñëåäÿâàéêè ïàöèåíòèòå ÷åñòî ñå ãóáè âðúçêàòà ñ îïåðèðàùèÿ åêèï, òúé êàòî ñëåä èçïèñâàíåòî èì òå ñå íàñî÷âàò çà ïðîñëåäÿâàíå êúì îíêîëîãè÷íèòå äèñïàíñåðè.

ÇÀÊËÞ×ÅÍÈÅ Àäõåçèèòå êúì ñúñåäíèòå îðãàíè ïðè ËÀÒ íå áè òðÿáâàëî äà ñå îòäåëÿò, òúé êàòî â ïî-ãîëÿì ïðîöåíò ñà ìàëèãíåíè. Íèå ñìÿòàìå, ÷å òîçè âèä ëîêàëíî àâàíñèðàëè òóìîðè òðÿáâà äà ñå òðåòèðàò àãðåñèâíî ÷ðåç ìóëòèâèñöåðàëíè ðåçåêöèè. Ñëåäîïåðàòèâíèòå óñëîæíåíèÿ è ïåðèîïåðàòèâíàòà ñìúðòíîñò ñà ñðàâíèìè ïðè òåçè ñúñ ñòàíäàðòíî ðåçåöèðàíèòå áîëíè. Ïðàâèëíàòà ïðåöåíòêà è ðåøåíèåòî çà âèäà íà îïåðàòèâíàòà èíòåðâåíöèÿ îïðåäåëÿ è ïî-íàòàòúøíàòà ñúäáà íà òàçè ïîïóëàöèÿ ïàöèåíòè.

ÊÍÈÃÎÏÈÑ 1.

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Scripta Scientifica Medica, 2009; vol. 41 (3), pp 261-265

ÑÓÁÒÎÒÀËÍÀÒÀ ÊÎËÅÊÒÎÌÈß - ÏÐÅÄÏÎ×ÈÒÀÍ ÌÅÒÎÄ ÏÐÈ ËÅÂÎÑÒÐÀÍÅÍ ÄÅÁÅËÎ×ÐÅÂÅÍ ÈËÅÓÑ Ïîïîâ Â., À. Ïúðâîâ Í. Êîâà÷åâ, Ä. Ðàäåíîâñêè, Â. Ñòîÿíîâ Ñåêöèÿ ïî ñïåøíà õèðóðãèÿ, IV-òà õèðóðãè÷åñêà êëèíèêà, ÌÁÀËÑÌ "Í.È.Ïèðîãîâ" Õèðóðãè÷íîòî ëå÷åíèå íà îáñòðóêòèâíèÿ èëåóñ íà ëåâèÿ êîëîí (ÎÈËÊ) ïðîäúëæàâà äà áúäå ïðåäèçâèêàòåëñòâî çà õèðóðãà. Ïðè÷èíàòà çàòîâà ñå êðèå â ðàçëè÷íèòå âàðèàíòè çà ðåøàâàíå íà èëåóñíîòî ñúñòîÿíèå. Íàé-ðàçïðîñòðàíåíèÿò ìåòîä å äâóåòàïíàòà îïåðàöèÿ ñ ïðåêúñâàíå íà ÷ðåâíèÿ ïàñàæ, èçâåæäàíå íà ïðîòèâîåñòåñòâåí àíóñ è çàäúíâàíå íà äèñòàëíèÿ ÷óêàí èëè ò.íàð. îïåðàöèÿ ïî ìåòîäà íà Hartmann. Ïðåç ïîñëåäíèòå ãîäèíè âñå ïîâå÷å õèðóðçè ñå ñòðåìÿò êúì èçâúðøâàíå íà åäíîåòàïíè îïåðàöèè ïðè ëåâîñòðàííà îáñòðóêöèÿ êàòî åäèíèÿ âàðèàíò å ÷àñòè÷íà ðåçåêöèÿ è ïúðâè÷íà àíàñòîìîçà ñëåä on table èðèãàöèÿ íà ÷åðâîòî èëè íàáèðàùàòà âñå ïî-ãîëÿìà ïîïóëÿðíîñò ñóáòîòàëíà êîëåêòîìèÿ (ÑÊ). Â íàñòîÿùèÿò äîêëàä ñå ïðàâè ðåòðîñïåêòèâåí àíàëèç íà îïåðèðàíèòå ïî ñïåøíîñò áîëíè ñ äåáåëî÷ðåâåí èëåóñ (ÄÈ) â Ñåêöèÿòà ïî ñïåøíà õèðóðãèÿ â ÌÁÀËÑÌ "Í.È.Ïèðîãîâ" çà ïåðèîä îò òðè ãîäèíè 2006-2008ã. Çà òîçè ïåðèîä ñà îïåðèðàíè îáùî 402 áîëíè êàòî ìúæåòå ñà áèëè ïðåîáëàäàâàùè 58%. Ñïîðåä ëîêàëèçàöèÿòà íà îáñòðóêòèâíèÿ ïðîöåñ ïàöèåíòèòå ñå ðàçïðåäåëÿò â äâå ãîëåìè ãðóïè êàêòî ñëåäâà: - 254(64,2%) - ñ ëåâîñòðàííà ëîêàëèçàöèÿ, ñëåä flexura coli lienalis - 148(36,8%) - ñ äåñíîñòðàííà ëîêàëèçàöèÿ,äî colon transversum. Îáùèÿò áðîé ïî÷èíàëè å áèë 68(22,2) è å ïî-âèñîê îò ïîäîáíè ïðîó÷âàíèÿ â ëèòåðàòóðàòà (Deen at al), íî òðÿáâà äà ñå èìà ïðåäâèä, ÷å â íàñòîÿùàòà ñåðèÿ ñà âêëþ÷åíè ñàìî îïåðèðàíè ïî ñïåøíîñò áîëíè. Íàé-÷åñòî ïðèëàãàíèòå îïåðàöèè ñà áèëè: äâóåòàïíàòà ïî ìåòîäà íà Hartmann 86(28,1) è ñóáòîòàëíàòà êîëåêòîìèÿ - 52(17,02). Ïðåç ïîñëåäíèòå ãîäèíè çíà÷èòåëíî ñå ðàçøèðèõà ïîêàçàíèÿòà çà ÑÊ ïî ñïåøíîñò è äîáðèòå ñëåäîïåðàòèâíè ðåçóëòàòè ïðåâúðíàõà òîçè ìåòîä â ïðåäïî÷èòàí ïðè ëå÷åíèåòî íà îáñòðóêòèâíèÿ èëåóñ íà ëåâèÿ êîëîí.

Ëå÷åíèåòî íà ëåâîñòðàííàòà äåáåëî÷ðåâíà îáñòðóêöèÿ âñå îùå å õèðóðãè÷åñêî ïðåäèçâèêàòåëñòâî. Èëåóñúò ïðè÷èíåí îò êîëîðåêòàëåí êàðöèîì å çàáîëÿâàíå ñ ìíîãî âèñîê ìîðòàëèòåò îò 15-20%. Òî èçèñêâà ñåðèîçíè òåîðåòè÷åñêè ïîçíàíèÿ çà ïðîöåñèòå íàñòúïâàùè â îðãàíèçìà ïðè èëåóñíî ñúñòîÿíèå îò åäíà ñòðàíà è ìíîãî äîáðà ïðàêòè÷åñêà è îïåðàòèâíà ïîäãîòîâêà íåîáõîäèìè ïðè èçâúðøâàíåòî íà òåçè ñïåøíè îïåðàöèè. Äîêàòî îïåðàòèâíàòà òàêòèêà ïðè äåñíîñòðàíà ëîêàëèçàöèÿ íà ïðîöåñà å ÿñíà è íÿìà ñïîðíè ìîìåíòè,ïðè ëåâîñòðàííàòà âàðèàíòèòå ñà íÿêîëêî è íå âèíàãè ñà òî÷íî îïðåäåëåíè êðèòåðèèòå çà ïðèëàãàíåòî íà âñåêè åäèí îò òÿõ. Êàòî äÿñíà ñå îïðåäåëÿ ëîêàëèçàöèÿ íà ïðîöåñà ïðîêñèìàëíî îò ëèåíàëíàòà ôëåêñóðà,à êàòî ëÿâà-ðàçïîëîæåíèå íà îáñòðóêöèÿòà äèñòàëíî îò íåÿ. Â ñâåòîâåí ìàùàá ñå íàëàãàò âñå ïîâå÷å åäíîåòàïíèòå ïðîöåäóðè êàòî ìåòîä íà èçáîð è òîâà å îáÿñíèìî îò ãëåäíà òî÷êà íà èêîíîìè÷åñêà îáîñíîâêà è êîìôîðòà çà ïàöèåíòà. Ïðè äÿñíà ëîêàëèçàöèÿ íà èëåóñíèÿ ïðîöåñ ìåòîä íà èçáîð å äÿñíàòà õåìèêîëåêòîìèÿ êàòî âèäà íà àíàñòîìîçàòà ñå îïðåäåëÿ îò ðàçëèêàòà â ëóìåíèòå íà ÷åðâàòà è ïðåäïî÷èòàíèÿòà è îïèòà íà õèðóðãà. Ïðè ëÿâà ëîêàëèçàöèÿ âàðèàíòèòå ñà íÿêîëêî:

ÄÂÓÅÒÀÏÍÈ 1. ðåçåêöèÿ íà çàñåãíàòèÿ ó÷àñòúê ñ èçâåæäàíå íà åäíîñòâîëîâ èëè äâóñòâîëîâ ïðîòèâîåñòåñòâåí àíóñ òîâà ñà ò.íàð.ìîäèôèöèðàíè îïåðàöèè ïî Hartmann è Mikulicz. 2. èçâåæäàíå ñàìî íà îòáðåìåíÿâàùà ñòîìà ïðîêñèìàëíî îò ñòåñíåíèåòî 3. ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà è ïðîêñèìàëíà ïðîòåêòèâíà ñòîìà. 4. ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà áåç ïðîòåêòèâíà ñòîìà 5. ïîñòàâÿíå íà åíäîëóìåíåí ñàìîðàçãúâàù ñòåíò è íà âòîðè åòàï îïåðàöèÿ

ÅÄÍÎÅÒÀÏÍÈ 1. ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà ñëåä on table ëàâàæ íà êîëîíà 2. ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà áåç ëàâàæ, à ñàìî ñ äåêîìïðåñèÿ. 3. ñóáòîòàëíà êîëåêòîìèÿ (ÑÊ) ñ ïúðâè÷íà èëåî-ðåêòî èëè èëåî-ñèãìîàíàñòîìîçà. Èçáîðúò íà õèðóðãà çàâèñè îò ìíîæåñòâî ôàêòîðè: - îáùî ñúñòîÿíèå íà áîëíèÿ - âúçðàñò - ïðèäðóæàâàùè áîëåñòè

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Ïîïîâ Â., À. Ïúðâîâ Í. Êîâà÷åâ...

ñòåïåíòà íà èëåóñà è îñîáåíî ñúñòîÿíèåòî íà ïðîêñèìàëíèÿ êîëîí - íàëè÷èå íà ïåðèòîíèò - ðàçïðîñòðàíåíèå íà òóìîðíèÿ ïðîöåñ - ñïîñîáíîñòòà íà õèðóðãè÷íèÿ åêèï äà ïðåöåíÿâà ïðàâèëíî ñúñòîÿíèåòî è äà èçïúëíè ñúîòâåòíàòà îïåðàöèÿ Íàé-òðóäíî è îòãîâîðíî å äà ñå âçåìå ðåøåíèå êîãà äà ñå èçâúðøè ñóáòîòàëíà ðåçåêöèÿ íà êîëîíà. Òàçè îïåðàöèÿ å â ïî-ãîëÿìà èëè ïî-ìàëêà ñòåïåí îñàêàòÿâàùà èíòåðâåíöèÿ è ïîðàäè òàçè ïðè÷èíà ðåøåíèåòî çà íåÿ òðÿáâà äà ñå âçåìå îò îïèòåí õèðóðã èëè åêèï,êîéòî å íàÿñíî ñ ïîêàçàíèÿòà çà òàçè îïåðàöèÿ è å ñïîñîáåí äà ÿ èçâúðøè. Ïðîäúëæèòåëíîñòòà íà èíòåðâåíöèÿòà å ïî-ãîëÿìà îò åòàïíèòå îïåðàöèè, à îñâåí òîâà èìà è íå ìàëúê ðèñê îò èíñóôèöèåíöèÿ íà àíàñòîìîçàòà. Â ñëåäîïåðàòèâíèÿ ïåðèîä ÷åñòîòàòà íà äåôåêàöèèòå å îò 3-6, íî ñïîðåä ìíîãî ïðîó÷âàíèÿ ñïàäà äî 2 ñëåä ñðåäíî 60 äíè. Òîâà ñà íÿêîè îò íåäîñòàòúöèòå íà òîçè ïîäõîä,íî îò äðóãà ñòðàíà íå ñà ìàëêî è íåãîâèòå ïðåèìóùåñòâà. Îñíîâíîòî ïðåäèìñòâî íà ìåòîäà å åäíîåòàïíàòà èíòåðâåíöèÿ - îòñòðàíÿâà ñå íàâåäíúæ öÿëîòî ïðîìåíåíî äåáåëî ÷åðâî. Ïðè òåæúê èëåóñ è êîìïåòåíòíà Áàóõèíîâà êëàïà ëóìåíà å èçïúëíåí ñ òå÷íî, âèñîêî òîêñè÷íî ñúäúðæèìî,à ìóêîçàòà îò äðóãà ãëåäíà òî÷êà å àòðîôè÷íà è ñ ïîâèøåí ïåðìåàáèëèòåò âîäåù äî ðèñê îò áàêòåðèàëíà òðàíñëîêàöèÿ è íàâëèçàíå íà òîêñè÷íè ïðîäóêòè â ñèñòåìíîòî êðúâîîáðàùåíèå. Ïîä âúïðîñ îñòàâà âúçìîæíîñòòà äà ñå âúçñòàíîâè íîðìàëíàòà ìîòîðèêà è æèçíåíîñò íà óâðåäåíîòî ÷åðâî, äîðè è ñëåä ïðåäëàãàíèÿ ìåòîä íà âúòðåëóìåíåí ëàâàæ. Ãîëÿìà å âåðîÿòíîñòòà êîëîíà äà ñå ïðåâúðíå â òîêñè÷åí ìåãàêîëîí ïîðàäè ïðîäúëæàâàùîòî ïîñòúïâàíå íà òúíêî÷ðåâíî ñúäúðæèìî â ïàðåòè÷íîòî äåáåëî ÷åðâî. Çàäåéñòâà ñå ïîðî÷íèÿ êðúã èëåóñ - ïåðèòîíèò, êîéòî ñå ÿâÿâà íàé-÷åñòàòà ïðè÷èíà çà ëåòàëåí èçõîä ïðè íàïðåäíàëèòå ôîðìè íà îáòóðàöèîíåí èëåóñ íà ëåâèÿ êîëîí. Ñïîðåä Pichlmayr ïúðâè÷íàòà ðåçåêöèÿ ïðè ñëó÷àè íà ëåâîñòðàííà îáñòðóêöèÿ òðÿáâà äà ñå ðàçãëåæäà êàòî ëîãè÷íî ðàçâèòèå íà âå÷å óòâúðäåíàòà òàêòèêà ïðè îáòóðàöèîííè êàðöèíîìè íà äåñíèÿ êîëîí. Çà ïúðâè ïúò å ïðèëîæåíà îò Hughes ïðåç 1966ã., à å óòâúðäåíà â ïðàêòèêàòà îò èçâåñòíèÿ êîëîïðîêòîëîã Goligher 15ã. ïî-êúñíî êàòî òîé äîêàçâà íåéíèòå ïðåèìóùåñòâà è ÿ ïðåïîðú÷âà êàòî "ñìåëà è àòðàêòèâíà ïðîöåäóðà". Ñïîðåä Runkel ñóáòîòàëíàòà êîëåêòîìèÿ ñ ïîñëåäâàùà èëåî-ñèãìî àíàñòîìîçà å èíäèöèðàíà ïðè ëå÷åíèåòî íà êîìáèíàöèÿ îò ëåâîñòðàííà îáñòðóêöèÿ è ïðîêñèìàëíà ïåðôîðàöèÿ. Ñïîðåä ñáîðíè ñòàòèñòè÷åñêè äàííè íà ãîðíèòå àâòîðè ìîðòàëèòåòà ñëåä òàçè èíòåðâåíöèÿ å 9,41%. Pisanu.A et al. ñ÷èòàò, ÷å ìîæå äà ñå ïðèëàãà ïúðâè÷íà àíàñòîìîçà ñëåä èíòðàîïåðàòèâåí ëàâàæ ïðè îáñòðóêòèâåí êàðöèíîì íà ñèãìàòà, êîãàòî íÿìà èçìåíåíèÿ íà ïðîêñèìàëíîòî ÷åðâî. Ñóáòîòàëíà 262

êîëåêòîìèÿ å ïðèëàãàíà â ñëó÷àé íà ìàñèâíî äèëàòèðàí êîëîí ñ èñõåìè÷íè ëåçèè èëè ëàöåðàöèè ïî ñåðîçàòà ïðè ïàöèåíòè ñúñ çàïàçåíà àíàëíà êîíòèíåíöèÿ. Ìíîãî å âàæåí è îïèòà íà õèðóðãà - ïðè íåäîñòàòú÷åí òàêúâ ìåòîä íà èçáîð îñòàâà ïðîêñèìàëíàòà îòáðåìåíÿâàùà êîëîñòîìèÿ îñîáåíî çà ïàöèåíòè ñ ìíîãî ëîøà ïðîãíîçà. Holzer B et al. ñà ïðèâúðæåíèöè íà êîíöåïöèÿòà çà ðàçëè÷íà òàêòèêà ñïîðåä ëîêàëèçàöèÿòà, îáùîòî ñúñòîÿíèå è òóìîðíèÿ ñòàäèé. Â ñëó÷àé íà çíà÷èòåëíî óâðåæäàíå íà äåáåëîòî ÷åðâî ñå ïðåïîðú÷âà äâóåòàïíà ïðîöåäóðà ñ ïúðâè÷íà ðåçåêöèÿ è êîëîñòîìèÿ è âòîðè÷íà - çà çàòâàðÿíå íà ñòîìàòà èëè êàòî àëòåðíàòèâà - ñóáòîòàëíàòà êîëåêòîìèÿ ïðè ïàöèåíòè, êîèòî ñà â äîáðî îáùî ñúñòîÿíèå. Ìíîãî èíòåðåñíî ðåòðîñïåêòèâíî ïðîó÷âàíå ïðàâè êîëåêòèâ íà÷åëî ñ Lee YM et al.îò Queen Mary Hospital â Hong Kong. Öåëòà íà òîâà ïðîó÷âàíå å áèëà äà ñå ñðàâíÿò îïåðàòèâíèòå ðåçóëòàòè ïðè ïàöèåíòè, íà êîèòî ñà ïðèëîæåíè ñïåøíè îïåðàöèè çà äåñíîñòðàííà è ëåâîñòðàííà îáñòðóêöèÿ îò ïúðâè÷íè êîëîðåêòàëíè êàðöèíîìè. Çà 8 ãîäèøåí ïåðèîä ñà âêëþ÷åíè 243 áîëíè êàòî 107 ñà áèëè ñ îáñòðóêöèÿ ïðîêñèìàëíî îò ëèåíàëíàòà ôëåêñóðà, à 136 - äèñòàëíî îò íåÿ. Ïúðâè÷íà ðåçåêöèÿ å èçâúðøåíà ïðè 91,8% îò ñëó÷àèòå. Îáùèÿò ìîðòàëèòåò å áèë 9,4%, ÷åñòîòàòà íà èíñóôèöèåíöèè å áèëà 6,1%. Òîâà ïðîó÷âàíå å ïîêàçàëî, ÷å ïúðâè÷íàòà ðåçåêöèÿ ñ àíàñòîìîçà ïðè ëåâîñòðàííà îáñòðóêöèÿ íå å ïî-ðèñêîâà îò ïúðâè÷íàòà àíàñòîìîçà ïðè äÿñíà îáñòðóêöèÿ, îñâåí ïðè ñëó÷àèòå íà õåìîäèíàìè÷íî íåñòàáèëíè ïàöèåíòè èëè êîãàòî ñúñòîÿíèåòî íà ÷åðâîòî íå å îïòèìàëíî çà ïúðâè÷íà àíàñòîìîçà. Naraynsingh V. et al. ïðåïîðú÷âàò äðóã ìåòîä çà ïúðâè÷íà àíàñòîìîçà ñëåä äåêîìïðåñèÿ íà ïðîêñèìàëíîòî äåáåëî ÷åðâî áåç èçâúðøâàíå íà îðòîãðàäåí èëè ðåòðîãðàäåí ëàâàæ. Òå ñ÷èòàò, ÷å äåêîìïðåñèÿòà å íàïúëíî äîñòàòú÷íà çà íàìàëÿâàíå íà íàëÿãàíåòî â ÷åðâîòî,ïîäîáðÿâà êðúâîñíàáäÿâàíåòî ìó è îáëåê÷àâà çàòâàðÿíåòî íà êîðåìíàòà ñòåíà êàòî ïðîôèëàêòèðà ðàçâèòèå íà compartement syndrome. Ïîëó÷åíèòå ðåçóëòàòè ñà îêóðàæèòåëíè - 1 èíñóôèöèåíöèÿ îò 58 ïîñëåäîâàòåëíè îïåðàöèè è 1 ëåòàëåí ñëó÷àé îò ìèîêàðäåí èíôàðêò. Ðàçáèðà ñå íåîáõîäèìè ñà ïðîñïåêòèâíè ðàíäîìèçèðàíè ïðîó÷âàíèÿ ñðàâíÿâàùè äâàòà ìåòîäà - ñ âúòðåëóìåíåí ëàâàæ è ñàìî ñ äåêîìïðåñèÿ, çà äà ñå èçëåçå ñ êðàéíî ñòàíîâèùå. Èíòåðåñíî ïðîó÷âàíå ñà íàïðàâèëè A.Goyal et M.Schein îò Áðóêëèíñêàòà áîëíèöà â Íþ Éîðê. Òå ñà èçïðàòèëè àíêåòíè ëèñòîâå íà 500 ñëó÷àéíî ïîäáðàíè õèðóðçè ÷ëåíîâå íà Àñîöèàöèÿòà íà õèðóðçèòå íà õðàíîñìèëàòåëíàòà ñèñòåìà, êàòî ñà ïîèñêàëè îò òÿõ äà ïîñî÷àò ïðèëàãàíèÿ ìåòîä ïðè îñòðà ëåâîñòðàííà ïàòîëîãèÿ íà äåáåëîòî ÷åðâî. Îñíîâíèÿò âúïðîñ å áèë: êàêâà å òàêòèêàòà ïðè áîëíè ñ íèñúê è âèñîê ðèñê è ëåâîñòðàííà îáñòðóêöèÿ èëè ïåðôîðàöèÿ. Îòãîâîð ñà äàëè 43% îò ëåêàðèòå êàòî 1/2 ïðèëàãàò åäíîåòàïíà ðåçåêöèÿ ñ àíàñòîìîçà ïðè ïàöèåíòè ñ íèñúê ðèñê è

Ñóáòîòàëíàòà êîëåêòîìèÿ - ïðåäïî÷èòàí ìåòîä ...

ëÿâà îáñòðóêöèÿ è 1/3 - ïðè íàëè÷íà ïåðôîðàöèÿ.Ïðè áîëíè ñ âèñîê ðèñê ïîâå÷åòî ïðåäïî÷èòàò âñå îùå äâóåòàïíèòå ïðîöåäóðè - 88% ñà çà Hartmann, à 7% îòáðåìåíÿâàùà êîëîñòîìà.

ÌÀÒÅÐÈÀË È ÌÅÒÎÄÈ Òàáë.1. Îáùî îïåðèðàíè áîëíè çà ïåðèîäà 2006-2008ã. è ðàçïðåäåëåíèå ñïîðåä ëîêàëèçàöèÿòà. 2006ã.

2007ã.

2008ã.

161

121

120

Äåñåí êîëîí

60 (37,26)

39(32,2)

49(40,8)

Ëÿâ êîëîí

101(62,74)

82(67,8)

71(59,2)

Îáùî îïåðèðàíè

Äåñåí êîëîí Ëÿâ êîëîí

2006ã.

2007ã.

2008ã.

12(20)

6(15,4)

4(8,16)

30(29,7)

20(24,4)

16(22,5)

Òàáë.3. Ëîêàëèçàöèÿ íà òóìîðíèÿ ïðîöåñ â äåñíèÿ êîëîí 2006ã.

2007ã.

2008ã.

Coecum

22(36,66)

13(33,33)

16(32,65)

Flexura hepatica

26(43,33)

15(38,46)

24(48,97)

12(20)

11(28,20)

9(18,36)

Transversum

Òàáë.4. Ëîêàëèçàöèÿ íà ïðîöåñà â ëåâèÿ êîëîí. 2006ã.

2007ã.

2008ã.

16(15,84)

15(18,29)

9(12,32)

8(7,92)

9(10,97)

10(13,69)

Sigma

57(56,43)

45(54,87)

41(56,16)

Rectosigma

14(13,86)

8(9,75)

11(15,06)

6(5,94)

5(6,09)

2(2,73)

Flexura leinalis Descendens

Rectum

Òàáë.5. Âèäîâå îïåðàòèâíè èíòåðâåíöèè.

À/ ÅÄÍÎÅÒÀÏÍÈ

Òàáë.2. Ìîðòàëèòåò çà ïåðèîäà 2006-2008ã.

Îáùî ïî÷èíàëè

Ïðåç ïîñëåäíèòå òðè ãîäèíè 2006-2008ã. â Ñåêöèÿòà ïî ñïåøíà õèðóðãèÿ êúì ÌÁÀËÑÌ "Í.È.Ïèðîãîâ" ñà áèëè îïåðèðàíè 402 áîëíè ñ äåáåëî÷ðåâåí èëåóñ. Îò òÿõ 148(36,8%) ñà áèëè ñ ëîêàëèçàöèÿ íà îáñòðóêöèÿòà ïðîêñèìàëíî îò ëèåíàëíàòà ôëåêñóðà, à 254(64,2%) - ñ ëîêàëèçàöèÿ äèñòàëíî îò ñúùàòà. Èçïîëçâàíèÿò ìåòîä å áèë ðåòðîñïåêòèâåí àíàëèç, à öåëòà - äà ñå îïðåäåëè îïòèìàëíàòà îïåðàòèâíà òàêòèêà ïðè ðàçëè÷íèòå âàðèàíòè íà äåáåëî÷ðåâåí èëåóñ íà ëåâèÿ êîëîí.

2006ã.

2007ã.

2008ã.

8(20)

15(31,25)

7(21,21)

Resection cum anstomosis

13(32,5)

9(18,75)

7(21,21)

Colectomia subtot.

19(47,5)

24(50)

19(57,57)

2006ã.

2007ã.

2008ã.

Hartmann

47(81,03)

27(75)

41(89,13)

Mikulicz

6(10,34)

8(22,22)

3(6,52)

Colostoma

5(8,62)

1(2,77)

2(4,34)

Hemicolectomia sinistra

Á/ ÄÂÓÅÒÀÏÍÈ

Òàáë.6. Ñúîòíîøåíèå åäíîåòàïíè êúì äâóåòàïíè 2006ã.

2007ã.

2008ã.

Åäíîåòàïíè

40(40,81)

48(57,14)

33(42,85)

Äâóåòàïíè

58(59,19)

36(42,86)

44(57,15)

Òàáë.7. Ìîðòàëèòåò ñëåä åäíîåòàïíè îïåðàöèè íà ëåâèÿ êîëîí 2006ã.

2007ã.

2008ã.

Hemicolectom ia.sin

8 - 2(25)

15 - 3(20)

7 - 1(14,28)

Resectio cum anast.

13 - 2(15,38)

9 -íÿìà ïî÷èíàëè

7 -íÿìà ïî÷èíàëè

Colectomia subtotal

19 - 6(31,57) 24 - 8(33,33)

19 - 5(26,5)

263

Ïîïîâ Â., À. Ïúðâîâ Í. Êîâà÷åâ...

Àêî ñå íàïðàâè àíàëèç íà ãîðíèòå ïîêàçàòåëè ñå âèæäà, ÷å ïðè íàä 60% îò ñëó÷àèòå íà äåáåëî÷ðåâåí èëåóñ ïðè÷èíàòà çà îáñòðóêöèÿ å áèëà ëîêàëèçðàíà äèñòàëíî îò ëèåíàëíàòà ôëåêñóðà. Ìîðòàëèòåòúò ñëåä îïåðàöèè Òàáë.8. Ìîðòàëèòåò ñëåä äâóåòàïíè îïåðàöèè 2006ã. Hartmann

2007ã.

2008ã.

47 - 12(25,53) 27 - 6(22,22) 41 - 10(24,39)

Mikulicz

6 - 3(50)

8 - 1(12,5)

3 - íÿìà ïî÷èíàëè

Colostoma

5 - 2(40)

1 - íÿìà ïî÷èíàëè

2 - íÿìà ïî÷èíàëè

ïî ïîâîä ëåâîñòðàííà îáòóðàöèÿ ñúùî å ñèãíèôèêàíòíî ïî-âèñîê îò òîçè ñëåä îïåðàöèè íà äåñíèÿ êîëîí. Äîêàòî ìåòîäà íà èçáîð ïðè äåñåí èëåóñ å äÿñíàòà õåìèêîëåêòîìèÿ, òî ïðè ëÿâà ëîêàëèçàöèÿ âàðèàíòèòå ñà íÿêîëêî è îñíîâíèÿ âúïðîñ,êîéòî ñòîè ïðåä õèðóðãà å äàëè äà èçáåðå åäíîåòàïíà èëè äâóåòàïíà ïðîöåäóðà. Â ðàçãëåäàíèÿ òðèãîäèøåí ìàòåðèàë íà Ñåêöèÿòà ïî ñïåøíà õèðóðãèÿ ïðåèìóùåñòâîòî å íà ñòðàíàòà íà äâóåòàïíèòå ìåòîäè ,îò êîèòî â íàä 80% îò ñëó÷àèòå å áèëà ïðèëàãàíà îïåðàöèÿòà ïî òèïà íà Hartmann. Ìîðòàëèòåòúò ñëåä òîçè ïîäõîä ñå äâèæè îêîëî 24% è å ñúïîñòàâèì ñ ìîðòàëèòåòà ñëåä åäíîåòàïíè îïåðàöèè. Îò åäíîåòàïíèòå âàðèàíòè íàé-÷åñòî å ïðèëàãàíà ñóáòîòàëíàòà êîëåêòîìèÿ - ñðåäíî ïðè íàä 50% îò ñëó÷àèòå êàòî å áèëà ïðåäïî÷èòàí ìåòîä ïðè íàïðåäíàëè èëåóñè ñ ïðîìåíè íà ïðîêñèìàëíîòî ÷åðâî. Ïðàâè âïå÷àòëåíèå âèñîêèÿ ìîðòàëèòåò ñëåä òàçè îïåðàöèÿ äîñòèãàù îêîëî 30%. Åäíà îò ïðè÷èíèòå çà òîçè âèñîê ïðîöåíò å êîíòèíãåíòà îò áîëíè âúðõó êîèòî ñå ïðèëàãà - â ãîëÿìàòà ñè ÷àñò òîâà ñà ïàöèåíòè íàä 75ã. â òåæêî îáùî ñúñòîÿíèå ñ ìíîãî ïðèäðóæàâàùè çàáîëÿâàíèÿ è ñ ãîëÿìà äàâíîñò íà çàáîëÿâàíåòî. Áîëøèíñòâîòî îò ïàöèåíòèòå ñà ñ òåæêè ìåòàáîëèòíè îòêëîíåíèÿ è ïîñòúïâàò ïðåç íîùòà èëè ïðåç ïî÷èâíèòå äíè,êîåòî íàëàãà äà ñå îïåðèðàò ïðåç íîùòà ñëåä êðàòêà ïðåäîïåðàòèâíà ïîäãîòîâêà,ìíîãî ÷åñòî áåç ÿñíà ïðåäâàðèòåëíà äèàãíîçà è íå âèíàãè îò îïèòíè õèðóðçè. Âñè÷êè òåçè ïðåäïîñòàâêè îïðåäåëÿò èçêëþ÷èòåëíàòà âàæíîñò íà èçáîðà íà ïîäõîäÿùà îïåðàòèâíà òàêòèêà çà êðàéíèÿ èçõîä êàòî íå òðÿáâà äà ñå îìàëîâàæàâà ðîëÿòà íà îïåðàòèâíàòà òåõíèêà è îïèòà íà îïåðàòîðà. Îñíîâíèÿò âúïðîñ, êîéòî ñòîè ïðåä õèðóðãà å êîãà äà ñå ïðèëîæè åäíîåòàïíà ïðîöåäóðà è êîãà å çà ïðåäïî÷èòàíå äâóåòàïíàòà. Àêî ñå ïðèåìå, ÷å ïðè àíàëîãè÷íè ñúñòîÿíèÿ íà íàïðåäíàë äåáåëî÷ðåâåí èëåóñ ñóáòîòàëíàòà êîëåêòîìèÿ (ÑÊ) å àëòåðíàòèâà íà îïåðàöèÿòà ïî òèïà íà Hartmann å ðåäíî äà ñìå íàÿñíî ñ ïðåäèìñòâàòà íà åäèíèÿ ìåòîä ñïðÿìî äðóãèÿ. Ïðåäèìñòâàòà íà ÑÊ ñà:

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ñëåäîïåðàòèâíèÿò ïåðèîä ïðîòè÷à ïî-ëåêî ïîðàäè ëèïñàòà íà ïàðåòè÷íî äåáåëî ÷åðâî - ëèïñâà ïðîòèâîåñòåñòâåí àíóñ íàëàãàù ñúîòâåòíè ãðèæè è íåîáõîäèìîñò îò ñëåäâàùà îïåðàöèÿ çà âúçñòàíîâÿâàíåòî ìó - ïî-ãîëÿì ðàäèêàëèòåò êàòî ñå ïðåäîòâðàòÿâà ïîÿâàòà íà íîâà äåáåëî÷ðåâíà íåîïëàçìà. - ïî-êðàòúê ñëåäîïåðàòèâåí ïðåñòîé - ïî-ðåäêè óñëîæíåíèÿ îò ñòðàíà íà îïåðàòèâíàòà ðàíà Îñíîâíèÿò àðãóìåíò ñðåùó òàçè ïðîöåäóðà å, ÷å ÑÊ å ãîëÿìà ïî îáåì è òåæåñò èíòåðâåíöèÿ, êîÿòî ñå ïðèëàãà ïðè âúçðàñòíè è óâðåäåíè áîëíè. Òîâà ìîæå â ãîëÿìà ñòåïåí äà ñå êîðèãèðà ñ àäåêâàòíà ïðåäîïåðàòèâíà ïîäãîòîâêà,ïîäõîäÿùà ùàäÿùà àíåñòåçèÿ,îïèòåí õèðóðãè÷åí åêèï è ïðåöèçíî âîäåíå íà ñëåäîïåðàòèâíèÿ ïåðèîä. Âîäåùàòà èíäèêàöèÿ çà èçâúðøâàíå íà ÑÊ å íàïðåäíàë ëåâîñòðàíåí äåáåëî÷ðåâåí èëåóñ ñ ïðîêñèìàëíî îò ïðåïÿòñòâèåòî äèëàòèðàíî ÷åðâî è ðàçêúñâàíèÿ ïî ñåðîçàòà èëè ïåðôîðàöèÿ - íàé-÷åñòî â îáëàñòòà íà öåêóìà. Îïòèìàëíîòî ñúñòîÿíèå å ïðè êîìïåòåíòíà Áàóõèíîâà êëàïà, òúé êàòî òîãàâà ñúñòîÿíèåòî íà òúíêîòî ÷åðâî å îïòèìàëíî çà àíàñòîìîçà ñ ìíîãî ÷åñòî êîëàáèðàëîòî è ñõîäíî ïî ðàçìåð äåáåëî ÷åðâî äèñòàëíî îò ïðåïÿòñâèåòî. Çà ïðåäïî÷èòàíå å èëåî-ñèãìî èëè èëåî-ðåêòî àíàñòîìîçàòà äà ñå èçâúðøâà ïî òèïà òåðìèíîòåðìèíàëíà, íî ïðè ãîëÿìà ðàçëèêà â ëóìåíèòå å ïîêàçàíà è äðóã òèï àíàñòîìîçà. Ïðè ÑÊ ñå îòñòðàíÿâà öÿëîòî äåáåëî ÷åðâî,êîåòî âîäè äî âëîøàâàíå íà ðåçîðáöèÿòà íà òå÷íîñòè,èçâúðøâàùà ñå â äÿñíàòà ïîëîâèíà íà êîëîíà.Òîâà âîäè äî ãîëåìè çàãóáè â ñëåäîïåðàòèâíèÿ ïåðèîä è íàëàãà ïðåöèçíî áàëàíñèðàíå ñ ïîäõîäÿùè âîäíî-åëåêòðîëèòíè è êîëîèäíè ðàçòâîðè. ×åñòîòàòà íà èçõîæäàíèÿòà â ðàííèÿ ñëåäîïåðàòèâåí ïåðèîä äîñòèãà äî 7-8 è ïîâå÷å, íî îáèêíîâåíî ñå ðåäóöèðà ñðåäíî äî 2-3 ñëåä 8-èÿ ñëåäîïåðàòèâåí äåí. Ïðåç ïîñëåäíèòå ãîäèíè ñå íàáëþäàâà çíà÷èòåëíî ðàçøèðÿâàíå íà ïîêàçàíèÿòà çà èçâúðøâàíå íà ÑÊ è òîâà óâëå÷åíèå çà ñúæàëåíèå âîäè è äî çàâèøàâàíå íà ìîðòàëèòåòà,òúé êàòî ïðèëàãàíåòî íà ìåòîäà ïðè ìíîãî óâðåäåíè âúçðàñòíè ïàöèåíòè ñúñ ñìóùåíèÿ â èíêîíòèíåíöèÿòà íåðÿäêî âîäè äî êðàéíî íåáëàãîïðèÿòíè ðåçóëòàòè. Òðÿáâà äà ñå îòáåëåæè ôàêòà, ÷å èíñóôèöèåöèÿòà íà èëåî-ñèãìî àíàñòîñòîìîçàòà å ïî-ðÿäêà îòêîëêîòî êîëî-êîëî àíîñòîìîçàòà è ïî-ðÿäêî å ïðè÷èíà çà ëåòàëåí èçõîä.

ÎÁÑÚÆÄÀÍÅ È ÈÇÂÎÄÈ Ïðåç ïîñëåäíèòå ãîäèíè â ñâåòîâåí ìàùàá ñå íàáëþäàâà òåíäåíöèÿ êúì èçâúðøâàíå íà åäíîåòàïíè îïåðàöèè ïðè îáñòðóêòèâåí èëåóñ íà ëåâèÿ êîëîí.Âúïðåêè ÷å òîçè òèï îïåðàöèè ñà ïðåäïî÷èòàíè âñå îùå íÿìà êàòåãîðè÷íè äîêàçàòåëñòâà çà

Ñóáòîòàëíàòà êîëåêòîìèÿ - ïðåäïî÷èòàí ìåòîä ...

ïðåèìóùåñòâîòî èì ïî îòíîøåíèå íà ñëåäîïåðàòèâíèÿ ìîðòàëèòåò. Ïðè îïðåäåëÿíå íà îïåðàòèâíàòà òàêòèêà å íåîáõîäèìî äà ñå âçåìàò ïðåäâèä - ëîêàëèçàöèÿòà íà ïðîöåñà, îáùîòî ñúñòîÿíèå íà ïàöèåíòà, òóìîðíèÿ ñòàäèé è ñúñòîÿíèåòî íà ïðîêñèìàëíîòî ÷åðâî. Ïðè ïàöèåíòè â ìíîãî òåæêî îáùî ñúñòîÿíèå ñ òåæúê êîìîðáèäèòåò ïúðâè÷íàòà êîëîñòîìà å ìíîãî äîáúð èçáîð. Ïðè áîëíè ñ òåæêè ïðîìåíè èëè ïåðôîðàöèÿ íà ïðîêñèìàëíîòî ÷åðâî, ñúìíèòåëíà âèòàëíîñò èëè íàöåïâàíå ïî ñåðîçàòà è êîìïåòåíòíà Áàóõèíîâà êëàïà ïðåïîðú÷èòåëíèÿ ìåòîä å ñóáòîòàëíàòà êîëåêòîìèÿ. Â ñëó÷àèòå,êîãàòî ïðîêñèìàëíîòî ÷åðâî å äèëàòèðàíî áåç íàöåïâàíå íà ñåðîçàòà, ïðè çàïàçåíà âèòàëíîñò è ïî-ìàëúê îïèò íà îïåðèðàùèÿ ïðåäïî÷èòàíèÿ ìåòîä å ïúðâè÷íàòà ðåçåêöèÿ ñ êîëîñòîìà ïî òèïà íà Hartmann èëè Mikulicz. Â ñëó÷àèòå, êîãàòî ïðîêñèìàëíîòî ÷åðâî å óìåðåíî äèëàòèðàíî ñúñ çàïàçåíà âèòàëíîñò ìîæå äà ñå îïèòà ïúðâè÷íà ðåçåêöèÿ ñ àíàñòîìîçà ñëåä èíòðàëóìåíåí ëàâàæ èëè ñëåä äåêîìïðåñèÿ ñïîðåä èçáîðà è îïèòà íà õèðóðãà. Òðÿáâà äà ñå èìà ïðåäâèä, ÷å ïðàâèëíî ïîäáðàíàòà îïåðàòèâíà òàêòèêà å îò îïðåäåëÿùî çíà÷åíèå çà ñíèæàâàíå íà ñëåäîïåðàòèâíèÿ ìîðòàëèòåò.

4. 5.

10.

11.

ÁÈËÈÎÃÐÀÔÈß 12. 1.

Bielecki K; Kaminski P; Klukowski M., Large bowel perforation: morbidity and mortality., Tech Coloproctol 2002 Dec;6(3):177-82 . Biondo S; Jaurrieta E; Marti Rague J., Role of resection and primary anastomosis of the left colon in the presence of peritonitis., Br J Surg 2000 Nov;87(11):1580-4.

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Gainant A., Prevention of anastomotic dehiscence in colorectal surgery., J Chir (Paris) 2000 Feb;137(1):45-50. Goligher,J.C.Surgery of the anus, rectum and colon. Baillier Tindall,London,4.Ed.,p447. Goyal A; Schein M. Current practices in left-sided colonic emergencies: a survey of US gastrointestinal surgeons., Dig Surg 2001;18(5):399-402 Holzer B; Schiessel R., Single and multiple interventions in ileus of the large intestine due to carcioma., Chirurg 2001 Aug;72(8):905-9. Hughes E,A.Guthnerson. Subtotal colectomy for obstructing carcinoma of the upper left colon. Dis.Col.&Rect.,1965,8,411-412. Kemal I Deen, MD, Rob ert D Madoff., Surgical Management of Left Colon Obstruction: The University of Minnesota Experience, Journal of the American College of Surgeons,December 1998, Volume 187 Number 6 Khan S, Pawlak SE, Eggenberger JC., Acute colonic perforation associated with colorectal cancer, Am Surg 2001 Mar;67(3):261-4. Lee YM; Law WL., Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions., J Am Coll Surg 2001 Jun;192(6):719-25. Pisanu A; Piu S; Altana ML., One-stage treatment of obstructing colorectal cancer., Chir Ital 2002 May-Jun;54(3):267-74. Runkel,N.S.,P.Schlag,V.Schwarz et al. Outcome after emergency surgery for cancer of the lar6. Pisanu A; Piu S; Altana ML., One-stage treatment of obstructing colorectal cancer., Chir Ital 2002 May-Jun;54(3):267-74. White,C.M.,J.Macfie.Immediate colectomy and primary anastomosis for acute obstruction due to carcinoma of the left colon and rectum. Dis.Col.&Rect.,1985,28,155-157.

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Scripta Scientifica Medica, 2009; vol. 41 (3), pp 267-268

ÈÍÒÐÀÎÏÅÐÀÒÈÂÍÎ ÌÀÐÊÈÐÀÍÅ ÍÀ ÑÅÍÒÈÍÅËÍÈ ÂÚÇËÈ Ñ ÐÀÄÈÎÍÓÊËÈÄÈ ÏÐÈ ÊÀÐÖÈÍÎÌ ÍÀ ÊÎËÎÍÀ - ÎÏÈÑÀÍÈÅ ÍÀ ÌÅÒÎÄÀ È ÏÚÐÂÎÍÀ×ÀËÍÈ ÐÅÇÓËÒÀÒÈ Ãåîðãèåâ Â., Â. Äèìèòðîâ Êëèíèêà ïî Îáùà è Êîðåìíà Õèðóðãèÿ - Ñïåöèàëèçèðàíà Áîëíèöà çà Àêòèâíî Ëå÷åíèå ïî Îíêîëîãèÿ ÅÀÄ-Ñîôèÿ ÐÅÇÞÌÅ Êàðöèíîìúò íà êîëîíà å âîäåùà ïðè÷èíà çà ñìúðòíîñò ñðåä îíêîëîãè÷íèòå çàáîëÿâàíèÿ. Ïðåöèçíîòî ñòàäèðàíå íà êàðöèíîìà íà êîëîíà ñ öåë îòêðèâàíå íà ìèêðîìåòàñòàçè å èçêëþ÷èòåëíî òðóäîåìêà çàäà÷à ïðè ïðèëàãàíå íà ðóòèííèòå ìåòîäè. Îòêðèâàíåòî íà ñåíòèíåëíèòå âúçëè è òÿõíîòî èçñëåäâàíå äàâà âúçìîæíîñò çà ïî-òî÷íî îïðåäåëÿíå íà ëèìôíèÿ ñòàòóñ íà ïàöèåíòà. Îñíîâíèòå ìåòîäè çà èíòðàîïåðàòèâíî ìàðêèðàíå íà ñåíòèíåëíèòå âúçëè ñà ÷ðåç èçïîëçâàíå íà áîè è íà ðàäèîíóêëèäè. Ïðèëîæåíèÿò îò íàñ ìåòîä çà èíòðàîïåðàòèâíî ìàðêèðàíå íà ñåíòèíåëíè âúçëè ñ ðàäèîíóêëèä ïðè êàðöèíîì íà êîëîíà ÷ðåç ñóáñåðîçíî èíæåêòèðàíå íà ìàðêèðàí ñ Tc-99m íàíîêëîèä è ïîñëåäâàùàòà èì äåòåêöèÿ ñ õèðóðãè÷íà ãàìà ñîíäà ïîçâîëÿâà áúðçî è ëåñíî îïðåäåëÿíå íà ñåíòèíåëíèòå âúçëè. Ïúðâîíà÷àëíèòå ðåçóëòàòè ïîêàçâàò âàëèäíîñò íà êîíöåïöèÿòà çà ñåíòèíåëíèòå ëèìôíè âúçëè è ïðèëîæèìîñò íà ìåòîäà ïðè êàðöèíîì íà êîëîíà.

Êëþ÷îâè äóìè: êàðöèíîì íà êîëîíà, ëèìôîãåííè ìåòàñòàçè, ñåíòèíåëíè âúçëè, ðàäèîíóêëèäè Ìåòàñòàçèòå â ðåãèîíàëíèòå ëèìôíè âúçëè ñà åäèí îò íàé-âàæíèòå ïðîãíîñòè÷íè ôàêòîðè ïðè çëîêà÷åñòâåíèòå òóìîðè, âêëþ÷èòåëíî è êàðöèíîìà íà êîëîíà. Åòî çàùî èíôîðìàöèÿòà çà àíãàæèðàíåòî íà ëèìôíèòå âúçëè å âàæíà ÷àñò îò âñÿêà ñèñòåìà çà ñòàäèðàíå. Ïàöèåíòèòå ñ àíãàæèðàíå íà ëèìôíèòå âúçëè èìàò ïî-ìàëêà ïðåæèâÿåìîñò è èìàò íóæäà îò àäþâàíòíà õèìèîòåðàïèÿ. Óñòàíîâåíî å, ÷å 20-40% îò ïàöèåíòèòå ñ òóìîðè èíôèëòðèðàùè ïðåç ìóñêóëíèÿ ñëîé íà ñòåíàòà, êîèòî íÿìàò èçÿâåíè ëèìôíè ìåòàñòàçè, â êðàéíà ñìåòêà óìèðàò îò çëîêà÷åñòâåíîòî çàáîëÿâàíå. Ñìÿòà ñå, ÷å åäíà îò ïðè÷èíèòå çà òîâà å íåðàçïîçíàâàíåòî íà ñúùåñòâóâàùè ìåòàñòàçè â ðåãèîíàëíèòå ëèìôíè âúçëè. Áèîïñèÿòà íà ñåíòèíåëíèòå ëèìôíè âúçëè ïîçâîëÿâà åäíî ïî-òî÷íî îïðåäåëÿíå íà ëèìôíèÿò ñòàòóñ íà ïàöèåíòà è ñúîòâåòíî ïî-ïðåöèçíî ñòàäèðàíå. Ïðåç 1999ã. Joosten è ñúòð. ñà ïúðâèòå, êîéòî èçïîëçâàò òåõíèêàòà çà ìàðêèðàíå ñ áàãðèëà íà ñåíòèíåëíèòå ëèìôíè âúçëè ïðè êàðöèíîì íà êîëîíà. Ñúùàòà ãîäèíà Saha è Wiese ñà ïúðâèòå, êîèòî îïèñâàò óñïåøíà òåõíèêà çà îòêðèâàíå íà ñåíòèíåëíè âúçëè, êàòî èçïîëçâàò ñèíüîòî áàãðèëî isosulfan blue (lymphazurin). Çà ïðúâ ïúò ëèìôíî êàðòèðàíå ïî âðåìå íà ëàïàðîñêîïñêà ðåçåêöèÿ å ñúîáùåíî îò Wood è ñúòð. ïðåç 2001ã. Ïúðâîòî ñúîáùåíèå çà èçïîëçâàíå íà ðàäèîíóêëèäè çà ìàðêèðàíå íà ñåíòèíåëíè ëèìôíè âúçëè ïðè êîëîðåêòàëåí êàðöèíîì å íà Kitagawa è ñúòð. îò

ßïîíèÿ îò 2001ã. Ïðåç 2003ã. Saha è ñúòð. ïðàâÿò ñðàâíèòåëåí àíàëèç íà äâàòà ìåòîäà çà ìàðêèðàíå íà ëèìôíèòå âúçëè - ñ îöâåòèòåëè è ñ ðàäèîíóêëèäè. Òå ñðàâíÿâàò ðåçóëòàòèòå îò åäíîâðåìåííîòî ïðèëîæåíèå íà isosulfan blue (lymphazurin) 1% è 99mTc-ìàðêèðàí ñåðåí êîëîèä (TSC). Íà áàçàòà íà ëèòåðàòóðíè äàííè çà ðàçðàáîòâàíåòî íà ìåòîäèêàòà çà ìàðêèðàíå íà ñåíòèíåëíè âúçëè ïðè êàðöèíîì íà êîëîíà îò äðóãè àâòîðè â íàøàòà êëèíèêà ñìå ðàçðàáîòèëè ñîáñòâåí ìåòîä è ïðîòîêîë çà èçâúðøâàíå íà èçñëåäâàíåòî.

Ñúùíîñò íà ìåòîäà: Èíòðàîïåðàòèâíî ñå èíæåêòèðà ïåðèòóìîðíî ìàðêèðàí ñ ðàäèîíóêëèä êîëîèä, êîéòî ïî ïúòÿ íà ëèìôíèÿ äðåíàæ ïîïàäà â ñòðàæåâèòå (ñåíòèíåëíè) ëèìôíè âúçëè - ëèìôíèòå âúçëè, êîèòî ïðèåìàò ëèìôà äèðåêòíî îò òóìîðà è ñëåäîâàòåëíî ñà ïúðâèòå, êîèòî ñå çàñÿãàò îò ìåòàñòàçè. Ïîñëåäâàùîòî îòêðèâàíå íà ñåíòèíåëíèòå âúçëè ñ ïîìîùòà íà õèðóðãè÷íà ãàìà-ñîíäà ïîçâîëÿâà ïî-òî÷íî ñòàäèðàíå è àäåêâàòíà ëèìôíà äèñåêöèÿ. Èçñëåäâàíåòî ñå èçâúðøâà îò õèðóðã ïîä ðúêîâîäñòâîòî è ñúäåéñòâèåòî íà ñïåöèàëèñò ïî íóêëåàðíà ìåäèöèíà.

Öåëè: Òî÷íîòî îïðåäåëÿíå íà ëèìôíèÿ äðåíàæ ïðè ïàöèåíòè ñ êàðöèíîì íà êîëîíà ñ öåë ïîäîáðÿâàíå íà

267

Ãåîðãèåâ Â., Â. Äèìèòðîâ

ñòàäèðàíåòî è èçâúðøâàíå íà àäåêâàòíà ëèìôíà äèñåêöèÿ.

Èíäèêàöèè: Ïðåäîïåðàòèâíè: 1. Äîêàçàí ïúðâè÷åí êàðöèíîì íà êîëîíà. 2. Íÿìà îáðàçíîäèàãíîñòè÷íè äàííè çà äàëå÷íè ìåòàñòàçè. 3. Íÿìà îáðàçíîäèàãíîñòè÷íè äàííè çà èíôèëòðàöèÿ íà ñúñåäíè îðãàíè. 4. Òóìîðúò å íåïàëïèðóåì ïðåç êîðåìíàòà ñòåíà. 5. Ïàöèíòúò íå å ïðåòúðïÿë äðóãè îïåðàòèâíè èíòåðâåíöèè çàñÿãàùè êîëîíà è/èëè ìåçîêîëîíà. 6. Íÿìàò äàííè çà îñòúð õèðóðãè÷åí êîðåì . Èíòðàîïåðàòèâíè: 1. Åäèíè÷åí òóìîð íà êîëîíà, êîéòî íå ïåðôîðèðà ñåðîçàòà è íå èíôèëòðèðà ñúñåäíè òúêàíè è îðãàíè. 2. Íÿìà ïàëïèðóåìè ïàêåòè óâåëè÷åíè ëèìôíè âúçëè â ìåçîêîëîíà. 3. Íå ñå îòêðèâàò âèçóàëíî è ïàëïàòîðíî ìåòàñòàçè â ÷åðíèÿ äðîá è äðóãèòå êîðåìíè îðãàíè. 4. Ëèïñà íà ïðåäõîæäàùè èíòåðâåíöèè â îáëàñòòà íà êîëîíà è ìåçîêîëîíà. 5. Îòñúñòâèå íà òåæêè âúçïàëèòåëíè çàáîëÿâàíèÿ íà êîëîíà (äèâåðòèêóëîçà, áîëåñò íà Êðîí, õðîíè÷åí óëöåðî-õåìîðàãè÷åí êîëèò è äðóãè). 6. Ëèïñà íà ìàñèâíè ñðàñòâàíèÿ îêîëî ñúîòâåòíèÿ ó÷àñòúê íà êîëîíà è/èëè ìåçîêîëîíà. 7. Íÿìà äàííè çà ïåðôîðàöèÿ è ïåðèòîíèò èëè èëåóñ ñ òåæêè çàñòîéíè è âúçïàëèòåëíè èçìåíåíèÿ. Ïðîòèâîïîêàçàíèÿ: Àáñîëþòíè: íÿìà Îòíîñèòåëíè: íÿìà Ñòðàíè÷íè åôåêòè: Íå ñà ñúîáùàâàíè. Ïîäãîòîâêà íà ïàöèåíòà: Íå å íåîáõîäèìà Èçïîëçâàíè ðàäèîôàðìàöåâòèöè: Ìàðêèðàíè ñ 99m Tc êîëîèäè (99mTc-nanocolloid). Àïàðàòóðà: Õèðóðãè÷íà ãàìà-ñîíäà Europrobe Ìåòîäèêà: 1. Èíòðàîïåðàòèâíî ìîáèëèçèðàíå íà ñúîòâåòíèÿ ó÷àñòúê îò êîëîíà. 2. 1cm3 99mTc-nanocolloid ñ àêòèâíîñò 1-2 mCi (37-74 MBq) ñå èíæåêòèðà ñóáñåðîçíî íà ÷åòèðè ìåñòà îêîëî òóìîðà ñ èíñóëèíîâà ñïðèíöîâêà. 3. Íà 30, 60, 90 è 120 ìèíóòà ñ õèðóðãè÷íà ãàìà-ñîíäà ñå äåòåêòèðà ðàçïðåäåëåíèåòî íà àêòèâíîñòòà â ðàç-

268

ëè÷íè ãðóïè ëèìôíè âúçëè ñ öåë îïðåäåëÿíå íà îïòèìàëíîòî âðåìå çà äåòåêöèÿ. 4. Ëèìôíèòå âúçëè íàòðóïàëè ðàäèîôàðìàöåâòèêà ñå ìàðêèðàò ñ õèðóðãè÷åí êîíåö è ñå âêëþ÷âàò â îáåìà íà ëèìôíàòà äèñåêöèÿ. 5. Ñëåä ðåçåöèðàíå íà ïðåïàðàòà êîðåìíàòà êóõèíà ñå ïðîâåðÿâà çà îñòàòú÷íà àêòèâíîñò ñ ãàìà-ñîíäàòà ñ öåë îòêðèâàíå íà åâåíòóàëíî íåîòñòðàíåíè ëèìôíè âúçëè äðåíèðàùè òóìîðà. Ïðè îòêðèâàíåòî íà òàêèâà ñúùèòå ñå îòñòðàíÿâàò. 6. Íåïîñðåäñòâåíî ñëåä îòñòðàíÿâàíå íà ðåçåêöèîííèÿ ïðåïàðàò âñè÷êè ëèìôíè âúçëè â íåãî ñå îòäèñåöèðàò. Èçìåðâà ñå àêòèâíîñòòà íà âñåêè îòäåëåí âúçåë ÷ðåç õèðóðãè÷íà ãàìà-ñîíäà. Ëèìôíèòå âúçëè íàòðóïàëè ðàäèîôàðìàöåâòèêà ñå èçïðàùàò ïîîòäåëíî è íîìåðèðàíè çà õèñòîëîãè÷íî èçñëåäâàíå.

Ïúðâîíà÷àëíè ðåçóëòàòè: Ìåòîäúò å ïðèëîæåí ïðè 10 áîëíè, êàòî ïðè âñè÷êèòå äåñåò óñïåøíî ñà îòêðèòè îò 1 äî 3 ñåíòèíåëíè ëèìôíè âúçåëà. Íå ñà óñòàíîâåíè ôàëøèâî-íåãàòèâíè ðåçóëòàòè.

Èçâîäè: Êàêòî ñå âèæäà îò ãîðåèçëîæåíîòî ìåòîäúò çà ìàðêèðàíå íà ñåíòèíåëíèòå âúçëè ïðè êàðöèíîì íà êîëîíà ñå ðàçðàáîòâà îò ïî-ìàëêî îò 10 ãîäèíè. Âñè÷êè àâòîðè ïóáëèêóâàëè ïðîó÷âàíèÿ ïî âúïðîñà îò÷èòàò ïîòåíöèàëíèòå ìó ïîëçè íàé-âå÷å çà ïðåöèçíîòî ñòàäèðàíå íà ïàöèåíòèòå ñ êàðöèíîì íà êîëîíà. Òúé êàòî ïðîó÷âàíèÿòà ñà â íà÷àëåí ñòàäèé âñå îùå èìà ìíîãî âúïðîñè, íà êîèòî òðÿáâà äà ñå îòãîâîðè. Êàêâî å çíà÷åíèåòî íà îòêðèòèòå ìèêðîìåòàñòàçè è êàêâà òðÿáâà äà å ëå÷åáíàòà òàêòèêà ïðè òåçè ïàöèåíòè? Òðÿáâà äà ñå ïîëîæàò è óñèëèÿ çà ïîäîáðÿâàíå íà òåõíèêàòà ñ öåë ïîñòèãàíå íà ïî-íèñêà ôàëøèâî íåãàòèâíà ÷åñòîòà. Òîâà áè ïîçâîëèëî äà ñå ìèñëè çà îãðàíè÷àâàíå îáåìà íà ðåçåêöèÿòà ïðè íÿêîè ïàöèåíòè. Áèîïñèÿòà íà ñåíòèíåëíèòå âúçëè ìîæå äà ñå êîìáèíèðà è ñ äðóãè ìîäåðíè ìîëåêóëÿðíè ìåòîäè è äà ñå ïðåöåíè çíà÷åíèåòî èì çà ïðîãíîçàòà íà ïàöèåíòà. Òúé êàòî ëèìôíèòå ìåòàñòàçè ïðîèçëèçàò îò íàé-àãðåñèâíèÿ ïóë îò òóìîðíè êëåòêè, òî èìåííî òåçè êëåòêè òðÿáâà äà áúäàò ùàòåëíî èçñëåäâàíè è äà îïðåäåëÿò ëå÷åáíàòà òàêòèêà.

Scripta Scientifica Medica, 2009; vol. 41 (3), pp 269-271

ÕÈÐÓÐÃÈ×ÍÎ ËÅ×ÅÍÈÅ ÏÐÈ ÄÈÂÅÐÒÈÊÓËÎÇÀ ÍÀ ÊÎËÎÍÀ ÏÅÒ ÃÎÄÈØÅÍ ÎÏÈÒ, ÏÎÊÀÇÀÍÈß, ÐÅÇÓËÒÀÒÈ, ÈÇÂÎÄÈ Áëèçíàøêè È., Ã. Êîòàøåâ, Ä. Àòàíàñîâ, Å. Äèìàíîâà ²² Õèðóðãè÷íî îòäåëåíèå â V-ÌÁÀË ãð.Ñîôèÿ ÐÅÇÞÌÅ Äèâåðòèêóëîçèñ, äèâåðòèêóëè, äèâåðòèêóëèòèñ ñà ðàçëè÷íè ôîðìè íà äèâåðòèêóëíèòå çàáîëÿâàíèÿ íà äåáåëîòî ÷åðâî. Òå ñà ðÿäêî ñðåùàíè â õèðóðãè÷íàòà ïðàêòèêà íîçîëîãè÷íè åäèíèöè - 1-3%. Íàé÷åñòàòà ëîêàëèçàöèÿ å â ñèãìàòà, êàòî ïðàâèëî, ïîðàäè ðàçëè÷íàòà àíàòîìè÷íà ñòðóêòóðà íà ìóñêóëàòóðàòà, ëèïñâàò â ðåêòóìà. Â 90% îò ñëó÷àèòå ñ äèâåðòèêóëè íà äåáåëîòî ÷åðâî, óñëîæíåíèÿ, êàòî âúçïàëèòåëåí ïðîöåñ, ïåðôîðàöèÿ èëè êúðâåíå ñå ðàçâèâàò â êîëîí ñèãìîèäåóì. Îïåðàòèâíàòà èíòåðâåíöèÿ å ðåçåêöèÿ íà çàñåãíàòèÿ ó÷àñòúê.

Êàòî îïðåäåëåíèå çà äèâåðòèêóëè íà êîëîíà, ñå ïðèåìà ïîÿâàòà íà õåðíèðàíå íà äåáåëî÷ðåâíà ìóêîçà, ïðèïëúçíàòà ïðåç öèðêóëÿðíàòà ìóñêóëàòóðà, â òî÷êèòå êúäåòî êðúâîíîñíèòå ñúäîâå ïåíåòðèðàò ïðåç ñòåíàòà íà äåáåëîòî ÷åðâî. Íàé ÷åñòî çàñåãíàòèÿ ó÷àñòúê å êîëîí ñèãìîèäåóì, íî ïðè àíàòîìè÷íî ïî ãîëÿì êîëîí, äèâåðòèêóëè ñå íàìèðàò è â öåêóìà. Â 90% îò ñëó÷àèòå ñèãìàòà å íàãúíàòà è ïî÷òè âèíàãè âúçïàëåíà, à êîãàòî å ñ äèâåðòèêóëè ñå ôîðìèðà çàáîëÿâàíåòî äèâåðòèêóëèòèñ. Ñìïòîìàòèêà

Äèâåðòèêóëîçèñ

Äèâåðòèêóëèòèñ

Ïðîòè÷àíå

Àñèìïòîìàòè÷íî

Êëèíè÷íà èçÿâà

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Colon irritabile

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Áîëêà

Ñåãìåíò

Ñèãìà, äåñöåíäåíñ, òðàíñâåðçóì, Ñèãìà, äåñöåíäåíñ. àñöåíäåíñ.

Ôåáðèëèòåò

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Êîíñòèïàöèÿ

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Ëåâêîöèòîçà

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Íåðàçïîëîæåíèå

Âàæíî å äà ñå íàïðàâè ðàçëèêà ìåæäó äèâåðòèêóëîçà, êîãàòî çàáîëÿâàíåòî ïðîòè÷à àñèìïòîìàòè÷íî è ñëó÷àèòå ñúñ ñèìïòîìàòèêà. Õèñòîëîãè÷íèòå èçñëåäâàíèÿ ïîêàçâàò, ÷å äèâåðòèêóëúò ñúäúðæà ïðîòðóçèÿ íà ìóêîçíàòà ìåìáðàíà íà äåáåëî÷ðåâíàòà ñòåíà ïîêðèòà ñ ïåðèòîíåóì. Íàé äåìîíñòðàòèâíà

äèàãíîñòè÷íà ñòîéíîñò çà äèâåðòèêóëîçà èìà èðèãîãðàôèÿòà. Äèâåðòèêóëèò å âúçïàëåíèå íà åäèí èëè ïîâå÷å äèâåðòèêàëà, îáèêíîâåííî ñú÷åòàíî ñ ïåðèêîëèò. Ïðîòè÷à äúëãè ãîäèíè áåçñèìïòîìíî, íî ïðè ïîÿâà íà ñèìïòîìàòèêà, òÿ ïðîãðåñèðà, óòåæíàâà ñå è âîäè äî ñåðèîçåí ðèñê îò óñëîæíåíèÿ. Äèâåðòèêóëèòúò íå å ïðåêàíöåðîçà, íî êàðöèíîìúò ìîæå äà ñúïúòñòâà çàáîëÿâàíåòî. Óñëîæíåíèÿòà ñà: · Ðåöèäèâèðàùè ïåðèîäè íà áîëêà îò âúçïàëèòåëåí õàðàêòåð · Ïåðôîðàöèÿ íà äèâåðòèêóë ñ ðàçâèòèå íà äèôóçåí ïåðèòîíèò èëè ëîêàëåí ïåðèêîëè÷åí àáñöåñ. · ×ðåâíà îáñòðóêöèÿ - îò ïðîãðåñèâíà âúçïàëèòåëíà ôèáðîçà íà çàñåãíàòèÿ ó÷àñòúê, èëè îò àäõåçèè íà òúíêîòî ÷åðâî êúì ïåðèêîëèòíè âúçïàëèòåëåíèÿ. · Õåìîðàãèÿ - äèâåðòèêóëèòúò ìîæå äà ñå ïðîÿâè ñ ïðîôóçíà äåáåëî÷ðåâíà õåìîðàãèÿ, íàëàãàùà êðúâîïðåëèâàíå â 17% îò ñëó÷àèòå. · Ôîðìèðàíå íà ÷ðåâíà ôèñòóëà - âåçèêîêîëè÷íà, âàãèíîêîëè÷íà, åíòåðîêîëè÷íà è ðÿäêî (äî 5%) âúíøíà êîëîêóòàíåóñíà ôèñòóëà. ×åñòîòàòà íà çàñåãíàòèòå ó÷àñòúöè îò äèâåðòèêóëîçà, ïðåäñòàâåíè â ïðîöåíòè å êàêòî ñëåäâà - coecum , colon ascendens, colon transversum, colon descendens - 10%, colon sigmoideum - 90%, â ðåêòóìà, êàòî ïðàâèëî íå ñå îòêðèâàò äèâåðòèêóëè. Êëèíè÷íîòî ïðîòè÷àíå å ñïîðåä èçÿâåíàòà ïàòîôèçèîëîãèÿ. Äèàãíîçàòà, ïðè êëèíè÷íà íàñî÷åíîñò å ëåñíà. Íàé ãîëÿìà äèàãíîñòè÷íà ñòîéíîñò èìà èðèãîãðàôèÿòà, âúçìîæíîñòèòå çà âèçóàëíî ïðåäñòàâÿíå ñ êîëîíîñêîïèÿ, ñà îãðàíè÷åíè, íî èìàò ñòîéíîñò ïðè óñëîæíåíèÿòà íà çàáîëÿâàíåòî. Ñïîðåä L.Buie (1943) äèâåðòèêóëîçàòà ñå óíàñëåäÿâà â 8-12%.

269

Áëèçíàøêè È., Ã. Êîòàøåâ, Ä. Àòàíàñîâ...

Äèâåðòèêóëîçàòà êàòî çàáîëÿâàíå íå å ïðåêàíöåðîçà, íî â 12% ìîæå äà ñå ñúïúòñòâà îò êàðöèíîì íà êîëîíà. Äèâåðòèêóëîçàòà ñå ëåêóâà êîíñåðâàòèâíî ñ äèåòà, ñëàáèòåëíè ñðåäñòâà, ïðè íåîáõîäèìîñò ñïàçìîëèòèöè. Îñòðèòå ôîðìè íà äèâåðòèêóëèòèñ ñå ëåêóâàò ñòàöèîíàðíî ñ âåíîçíè àïëèêàöèè íà àíòèáèîòèöè, ñïàçìîëèòèöè, âëèâàíå íà âîäíî-ñîëåâè ðàçòâîðè, îùå ñ ïîñòúïâàíåòî, ïðåäè äèàãíîñòè÷íîòî óòî÷íÿâàíå Îïåðàòèâíè ïðîöåäóðè ïðè äîâåðòèêóëîçà ñå íàëàãàò ñàìî ïðè 10-12% îò ïàöèåíòèòå. Òå, äî ñêîðî ñå îïåðèðàõà ïðè ðåöèäèâèðàùè àòàêè íà çàáîëÿâàíåòî, âîäåùè äî çíà÷èòåëíî âëîøàâàíå êà÷åñòâîòî íà æèâîò èëè äî ñåðèîçíè óñëîæíåíèÿ. Ñèìïòîìè

Äèâåðòèêóëèòèñ

Êàðöèíîì

Àíàìíåçà

Ïðîäúëæèòåëíà

Êðàòêà

×åñòà

25% ëèïñâà

Ïàëïàòîðíà íàõîäêà

25% íàëè÷íà

+/-

Êúðâåíå

Â 17% ÷åñòî ïðîôóçíî,íà ïåðèîäè

Â 65% îñêúäíî,ïåðñèñòèð àùî

Áîëêà

Îáðàçíà äèàãíîñòèêà

Äèôóçíè èëè Ëîêàëèçàöèÿ íà ñåãìåíòíè ïðîìåíè ïðîöåñà â êîëîíà íà êîëîíà

Ñèãìîèäîñêîïèÿ

Âúçïàëèòåëíè Íÿìà âúçïàëèòåëíè ïðîìåíè íàä ïðîìåíè íàä çàñåãíàòèÿ ñåãìåíò ïðîöåñà

Êîëîíîñêîïèÿ

Íå ñå îòêðèâà êàðöèíîì

Êàðöèíîì ñ áèîïñèÿ

1. Èäåàëíàòà îïåðàòèâíà èíòåðâåíöèÿ å åäíîåòàïíà ðåçåêöèÿ íà ñèãìàòà. Ïðîìåíåíèÿ ñåãìåíò ñå èçðÿçâà, ñëåä âíèìåòåëíî îòïðåïàðèðàíå è ÃÈÒ ñå âúçñòàíîâÿâà ñ end-to-end àíàñòîìîçà. Óñëîæíåíèÿ äåáåëî÷ðåâåí ó÷àñòúê, îáèêíîâåííî ñå íàìèðà ïðèðàñòíàë â äúãëàñîâîòî ïðîñòðàíñòâî. Âíèìàòåëíàòà ìîáèëèçàöèÿ è îòïðåïàðèðàíå íà ðåêòîñèãìîèäàëíàòà çîíà, çíà÷èòåëíî óëåñíÿâàò àíàñòîìîçèðàíåòî. 2. Ïðè íàëè÷èå íà îáñòðóêöèÿ, âúçïàëèòåëåí îòîê, àäõåçèè èëè èçïúëíåíî ñ ôåêàëèè ïðîêñèìàëíî ÷åðâî, îïåðàöèÿòà íà Õàðòìàí å ìåòîä íà èçáîð. Óñëîæíåíèÿ ñåãìåíò ñå ðåçåöèðà. Â òåæêè, êðèòè÷íè ñúñòîÿíèÿ, êàòî æèâîòîñïàñÿâàùà îïåðàöèÿ ñå ïðåïîðú÷âà òðàñâåðçîñòîìèÿòà, íî ñ ìîíîãî âèñîê îïåðàòèâåí ëåòàëèòåò. 3. Ïðè îñòðà ïåðôîðàöèÿ, òîòàëåí èëè äèôóçåí ïóðóëåíòåí ïåðèòîíèò, ñìúðòíîñòòà äîñòèãà äî 15%. Ïðè òåæúê ôåêóëåíòåí ïåðèòîíèò ñìúðòíîñòòà å íàä 50%. Ïî÷òè âèíàãè â òàêèâà ñëó÷àè ñå îòêðèâà ïíåâìîïåðèòîíåóì, äî 45% ïðåäîïåðàòèâíî è îêîëî 60% èíòðàîïåðàòèâíî. 270

4. Äåáåëî÷ðåâíè ôèñòóëè, ïúðâè÷íè èëè ñëåä ðåçåêöèÿ íà ïðîìåíåíèÿ îò äèâåðòèêóëîçà ó÷àñòúê ñà ðåäêè. Êîëî-âåçèêàëíà ôèñòóëà, êîëî-âàãèíàëíà ôèñòóëà, ñúùî ñà èçêëþ÷èòåëíî ðÿäêà ïàòîëîãèÿ. Ìîáèëèçàöèÿ, ñóòóðà è åâåíòóàëíà ïðîêñèìàëíà êîëîñòîìèÿ ñà ìåòîä íà èçáîð ïðè ëå÷åíèåòî. 5. Õåìîðàãèÿòà îò äèâåðòèêóëîçà, òðÿáâà äà ñå ðàçãðàíè÷è îò àíãèîäèñïëàçèÿòà. Îïåðàòèâíîòî ëå÷åíèå ñå ñúñòîè â ñåãìåíòàðíà ðåçåêöèÿ íà çàñåãíàòèÿ ó÷àñòúê ñ äåôèíèòèâíî èçëåêóâàíå. Çà ïåðèîä îò 5 ãîäèíè, âúâ ²² Õèðóðãè÷íî îòäåëåíèå íà V ÌÁÀË -Ñîôèÿ ñà ïðåìèíàëè 7363 áîëíè, îò òÿõ ñ äèâåðòèêóëîçà ñà áèëè 51 (0.71%). Ïðè âñè÷êè çàñåãíàòèÿ ñåãìåíò îò äåáåëîòî ÷åðâî å áèë colon sigmoideum. Â 13 ñëó÷àÿ îñâåí ñèãìàòà å áèë àíãàæèðàí è colon descendentes. Ïðîâåäåíî å áèëî êîíñåðâàòèâíî ëå÷åíèå ïðè 43 ïàöèåíòà, à 8 ñà áèëè îïåðèðàíè. Âñè÷êè îïåðèðàíè ñà áèëè ñ óñëîæíåíè ôîðìè íà çàáîëÿâàíåòî è òèïè÷íà ñèìïòîìàòèêà, êàêòî ñëåäâà: · Ïåðôîðàöèÿ íà ñèãìàòà ñ ïåðèòîíèò -3 · Âåçèêî-êîëè÷íà ôèñòóëà -3 · Âàãèíî-êîëè÷íà ôèñòóëà -1 · Ïðîôóçíà õåìîðàãèÿ - 1 Èçâúðøåíèòå îïåðàòèâíè èíòåðâåíöèè ñà: · Ñåãìåíòíà ðåçåêöèÿ íà ñèãìàòà ñ end-to-end àíàñòîìîçà - 3 · Ðåçåêöèÿ íà ñèãìàòà ïî Hartmann -5 Âèäúò íà îïåðàòèâíàòà èíòåðâåíöèÿ ñìå îïðåäåëÿëè ñïîðåä: · Ëîêàëèçàöèÿòà íà ïðîöåñà. · Âèäà íà óñëîæíåíèåòî íà çàáîëÿâàíåòî. · Ïðîòè÷àíåòî íà çàáîëÿâàíåòî -îñòðî èëè õðîíè÷íî. · Ñúïúòñòâàùà ïàòîëîãèÿ â ìàëêèÿ òàç. · Îáùîòî ñúñòîÿíèå íà áîëíèÿ è ïðåäõîäíè îïåðàòèâíè èíòåðâåíöèè. Íÿìàìå îïåðàòèâíà ñìúðòíîñò ïðè ëå÷åíèåòî íà áîëíèòå ñ òàçè íîçîëîãè÷íà åäèíèöà, íî áðîÿò íà îïåðèðàíèòå ïàöèåíòè å òâúðäå ìàëúê çà ñòàòèñòè÷åñêà äîñòîâåðíîñò. Îïåðàòèâíàòà èíòåðâåíöèÿ è ñëåäîïåðàòèâíîòî ïðîñëåäÿâàíå (äî 2 ã.) íè äàâàò îñíîâàíèå äà òâúðäèì, ÷å áîëíèòå ñà òðàéíî èçëåêóâàíè. Êàêâî ìîæåì äà çàêëþ÷èì îò òàêà ïðåäñòàâåíèÿ àíàëèç: · Êîíñåðâàòèâíî ñà ëåêóâàíå 43 áîëíè -84% · Îïåðàòèâíî ñà ëåêóâàíè 8 áîëíè -16% Ñðåäåí áîëíè÷åí ïðåñòîé ïðè êîíñåðâàòèâíî ëåêóâàíèòå ïàöèåíòè å 9 äíè. Ïðè îïåðèðàíèòå - 12 äíè. Ñúîòíîøåíèåòî, êîåòî ñå ïîëó÷àâà íè äàâà îñíîâàíèå äà ñè çàäàäåì ñëåäíèòå âúïðîñè. 1. Äî êîãà äà ñå ëåêóâà êîíñåðâàòèâíî? 2. Êàêâî äà ñå ëåêóâà êîíñåðâàòèâíî è êîÿ ñèìïòîìàòèêà? 3. Ðàäèêàëíî ëè å êîíñåðâàòèâíîòî ëå÷åíèå? 4. Êàêâî ïîâåäåíèå äà èçáåðåì è ñïîäåëèì ñ ïàöèåíòúò?

Õèðóðãè÷íî ëå÷åíèå ïðè äèâåðòèêóëîçà íà êîëîíà - ïåò ãîäèøåí îïèò...

5. Êîãà äà ñå îïåðèðà? Òðÿáâà ëè äà ñå ÷àêà óñëîæíåíèåòî? 6. Êàêúâ âèä îïåðàòèâíà èíòåðâåíöèÿ äà èçâúðøèì? 7. Êàêúâ îïåðàòèâåí ìåòîä å ïîäõîäÿù çà ïàöèåíòúò? Îò òàêà ïðåäñòàâåíèÿò ìàòåðèàë, ìîæåì äà íàïðàâè ñëåäíèòå èçâîäè: 1. Îïåðàòèâíîòî ëå÷åíèå íà äèâåðòèêóëíèòå çàáîëÿâàíèÿ íà äåáåëîòî ÷åðâî å ðàäèêàëåí ìåòîä íà ëå÷åíèå. 2. Âñè÷êè óñëîæíåíè ôîðìè íà çàáîëÿâàíåòî ñúùî ñå ðåøàâàò ðàäèêàëíî õèðóðãè÷íî, íî ìîðáèëèòåòà è ðèñêà îò îïåðàòèâíàòà èíòåðâåíöèÿ å çíà÷èòåëíî çàâèøåí. 3. Êàòî îïåðàòèâåí ìåòîä íà èçáîð å ðåçåêöèÿ íà çàñåãíàòèÿ ñåãìåíò. 4. Êîëêîòî ïî ðàíî ñå îòêðèå çàáîëÿâàíåòî, òîëêîç ïî ëåñíî è ìèíèèíâàçèâíî ñå ëåêóâà òî.

5. Îïåðàòèâíàòà ìåòîäèêà ïðè ðàííî îòêðèâàíå è ëå÷åíèå íà äèâåðòèêèëèòà å ëàïàðîñêîïñêà ìèíèèíâàçèâíà ðåçåêöèÿ íà çîíàòà íà èíòåðåñà. Â çàêëþ÷åíèå áèõ èçïîëçâàë âîåííà òåðìèíîëîãèÿ àêî õèðóðçèòå ñà ÷àñò îò àðìèÿòà íà ëå÷èòåëèòå, òî ãàñòðîåíòåðîëîçèòå ñà ðàçóçíàâàíåòî é. Êîëêîòî ïî òî÷íà å èíôîðìàöèÿòà, êîàòî íè ïîäàâàò, òîëêîâà ïî äîáðå ùå èçïîëçâàìå ìåòîäèêèòå ñè çà ëå÷åíèå.

ÊÍÈÃÎÏÈÑ 1.

Allan,R.N., Keigliley,M.R.B., Al ex an der,J. and Hawkins, E.(1990) Inflammatory Bowel Diseases, Churchill Livingstone, Edinburgh. Keighey, M.R.B. and Wil liams, N.S. (1999) Surgery of the Anus, Rectum and Colon, 2nd edn, W.B. Saunders, London. Buie, L.A., Practical proctology, Philadelphia, London.

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Scripta Scientifica Medica, 2009; vol. 41 (3), pp 273-275

ÏÎÂÅÄÅÍÈÅ ÏÐÈ ÎÁÒÓÐÀÖÈÎÍÅÍ ÈËÅÓÑ ÏÐÈ×ÈÍÅÍ ÎÒ ÊÎËÎÐÅÊÒÀËÅÍ ÐÀÊ ÇÀ 5 ÃÎÄÈØÅÍ ÏÅÐÈÎÄ /2003-2008/ Ñòåôàíîâ Ò., Ö. Ãóíåâ, Â. ×àêúðîâ, Ê. Ìóðäæåâ, Ç. Ìèëåñêè ÌÁÀË " Ïëîâäèâ" - II õèðóðãè÷íî îòäåëåíèå ÐÅÇÞÌÅ Îáòóðàöèÿòà êàòî íàé-÷åñòà ôîðìà íà óñëîæíåíèå ïðè äåáåëî÷ðåâíèÿ ðàê å ñïåøíî ñúñòîÿíèå èçèñêâàùî îïðåäåëåíî ïîâåäåíèå è îïåðàòèâíà òàêòèêà. Â ëÿâàòà ïîëîâèíà íà äåáåëîòî ÷åðâî ïî ÷åñòî ñå ðàçâèâà ÷ðåâíà íåïðîõîäèìîñò îò äÿñíàòà ïîðàäè 2 ïúòè ïî- ìàëêèÿ äèàìåòúð, åíäîôèòåí ðàñòåæ íà òóìîðèòå ñúñ ñòåíîòè÷åí õàðàêòåð è â äèñòàëíèÿ îòäåë íà ÷åðâîòî ñå ôîðìèðàò ôåêàëèè, êîèòî ñà ñ ïî- ïëúòíà êîíñèñòåíöèÿ (5). Öåëòà íà íàøåòî ñúîáùåíèå å äà ïðåäñòàâèì ïîâåäåíèå íè ïðè áîëíè ñ îáòóðàöèîííàòà ÷ðåâíà íåïðîõîäèìîñò, ïðè÷èíåíà îò êàðöèíîì è ñëåäîïåðàòèâíèòå íè ðåçóëòàòè â çàâèñèìîñò îò ïðåäïðèåòàòà òàêòèêà è ïîâåäåíèå. Îáåìúò è ìåòîäúò íà îïåðàòèâíîòî ëå÷åíèå äî ãîëÿìà ñòåïåí ñå îïðåäåëÿ îò ëîêàëèçàöèÿòà íà ìàëèãíåíèÿ ïðîöåñ. Èçâúðøâàò ñå ðàçëè÷íè ïî îáåì äåáåëî÷ðåâíè ðåçåêöèè è õåìèêîëåêòîìèè ñ ïîñëåäâàùà ïúðâè÷íà àíàñòîìîçà èëè èçâåæäàíå íà ÷ðåâíà ôèñòóëà. Îò 38 ïàöèåíòè îïåðèðàíè ïî ïîâîä íà îáòóðàöèîíåí èëåóñ â ëÿâ êîëîí ïðè 22 å èçâúðøåíà îïåðàöèÿòà íà Õàðòìàí, à ïðè 16 ëÿâà õåìèêîëåêòîìèÿ ñ ïîñëåäâàùà ïúðâè÷íà àíàñòîìîçà (1,2,3,4). Ìíîãîåòàïíèòå îïåðàòèâíè èíòåðâåíöèè ñúùî ñà ïîêàçàíè ïðè îïðåäåëåíè èíäèêàöèè, ïðè óñëîæíåíèÿ, êàòî ïåðôîðàöèÿ ñ ïåðèòîíèò èëè ïðè òåæêî îáùî ñúñòîÿíèå íà ïàöèåíòà ñ ìíîæåñòâî ïðèäðóæàâàùè çàáîëÿâàíèÿ. Ìíîãîåòàïíè îïåðàöèè ïðîâåäîõìå ïðè 6 áîëíè. Ïðåç ïîñëåäíèòå 5 ãîäèíè âúâ II õèðóðãè÷íî îòäåëåíèå ïðè ÌÁÀË "Ïëîâäèâ" áÿõà îïåðèðàíè 213 áîëíè çà çëîêà÷åñòâåíî çàáîëÿâàíå íà êîëîíà è ðåêòóìà. Ïîñòúïèëè ïî ñïåøíîñò è îïåðèðàíè ïî ïîâîä íà ïúëíà ÷ðåâíà íåïðîõîäèìîñò - 60 áîëíè /28,17%/. Ïàöèåíòèòå áÿõà íà âúçðàñò ìåæäó 33 è 85 ãîäèíè- 34 ìúæå è 26 æåíè. Âñè÷êè áîëíè ñà áèëè âúâ âòîðè è òðåòè êëèíè÷åí ñòàäèé, èçèñêâàù ñïåøíà îïåðàòèâíà èíòåðâåíöèÿ. Ëèïñàòà íà ïðîôèëàêòèêà è êúñíî ïîòúðñåíàòà ëåêàðñêà ïîìîù ñà â îñíîâàòà íà ñðàâíèòåëíî ãîëåìèÿ áðîé ïàöèåíòè ïîñòúïèëè è îïåðèðàíè ïî ñïåøíîñò è íàñòúïèëèòå ëîøè ñëåäîïåðàòèâíè ðåçóëòàòè. Õèðóðãè÷íîòî ïîâåäåíèå è òàêòèêà èìà îñíîâåí ïðèíîñ çà ïðåæèâÿåìîñòòà íà áîëíèòå. Íàé-÷åñòèòå ñëåäîïåðàòèâíè óñëîæíåíèÿ ñà èíñóôèöèåíöèÿ íà àíàñòîìîçàòà /30%/, ñëåäîïåðàòèâíà äèàðèÿ /25%/, ðàíåâà èíôåêöèÿ /10%/, ïðîëàïñ èëè åâàãèíàöèÿ íà ïðîòèâîåñòåñòâåíèÿ àíóñ /0,5%/ è äðóãè. Ñðåäåí áîëíè÷åí ïðåñòîé 13 äíè. Ñìúðòíîñòòà å îêîëî 5%.

Êëþ÷îâè äóìè: îáòóðàöèîíåí èëåóñ, êîëîðåêòàëåí ðàê, òàêòèêà ÓÂÎÄ Îáòóðàöèÿòà êàòî íàé-÷åñòà ôîðìà íà óñëîæíåíèå ïðè äåáåëî÷ðåâíèÿ ðàê å ñïåøíî ñúñòîÿíèå èçèñêâàùî îïðåäåëåíî ïîâåäåíèå è îïåðàòèâíà òàêòèêà. Îáèêíîâåíî îáòóðàöèÿòà íà äåáåëî÷ðåâíèÿ ëóìåí å ðåçóëòàò íå ñàìî íà ëîêàëíîòî ðàçðàñòâàíå íà òóìîðà, íî è íà âúçïàëèòåëíî-îòî÷íè èçìåíåíèÿ, êîèòî ìîãàò äà äîâåäàò äî ïúëíî çàïóøâàíå íà ÷ðåâíèÿ ëóìåí â îáëàñòòà íà ðàêà ñ ðàçâèòèå íà âòîðè÷íè ôóíêöèîíàëíè íàðóøåíèÿ ïîä ôîðìàòà íà äèíàìè÷íà íåïðîõîäèìîñò. Ïîñëåäíàòà ìîæå äà áúäå ïðåîäîëÿíà êîìïëåêñíî ñ êîíñåðâàòèâíè ìåðîïðèÿòèÿ (5). Êëàñèôèêàöèÿ íà èëåóñà (1): 1. Îñòúð 2. Ïîäîñòúð 3. Õðîíè÷åí

4. Õðîíè÷íî-ðåöèäèâèðàù Â ïàòîãåíåçàòà íà ñèíäðîìà íà ÷ðåâíàòà íåïðîõîäèìîñò ãîëÿìà ðîëÿ èãðàÿò íàðóøåíèÿòà íà âîäíî-åëåêòðîëèòíèÿ áàëàíñ è èíòîêñèêàöèÿòà íà îðãàíèçìà îò ðåçîðáöèÿòà íà òîêñè÷íèòå ïðîäóêòè íà ñòðàäàíèåòî. Â ëÿâàòà ïîëîâèíà íà äåáåëîòî ÷åðâî ïî ÷åñòî ñå ðàçâèâà ÷ðåâíà íåïðîõîäèìîñò îò äÿñíàòà ïîðàäè 2 ïúòè ïî- ìàëêèÿ äèàìåòúð, åíäîôèòåí ðàñòåæ íà òóìîðèòå ñúñ ñòåíîòè÷åí õàðàêòåð è â äèñòàëíèÿ îòäåë íà ÷åðâîòî ñå ôîðìèðàò ôåêàëèè, êîèòî ñà ñ ïî- ïëúòíà êîíñèñòåíöèÿ (5).

ÖÅË Öåëòà íà íàøåòî ñúîáùåíèå å äà ïðåäñòàâèì ïîâåäåíèå íè ïðè áîëíè ñ îáòóðàöèîííàòà ÷ðåâíà íåïðîõîäèìîñò, ïðè÷èíåíà îò êàðöèíîì è 273

Ñòåôàíîâ Ò., Ö. Ãóíåâ, Â. ×àêúðîâ...

ñëåäîïåðàòèâíèòå íè ðåçóëòàòè â çàâèñèìîñò îò ïðåäïðèåòàòà òàêòèêà è ïîâåäåíèå.

ÌÀÒÅÐÈÀË È ÌEÒÎÄÈ Ïðåç ïîñëåäíèòå 5 ãîäèíè âúâ II õèðóðãè÷íî îòäåëåíèå ïðè ÌÁÀË "Ïëîâäèâ" áÿõà îïåðèðàíè 213 áîëíè çà çëîêà÷åñòâåíî çàáîëÿâàíå íà êîëîíà è ðåêòóìà. Ïîñòúïèëè ïî ñïåøíîñò è îïåðèðàíè ïî ïîâîä íà ïúëíà ÷ðåâíà íåïðîõîäèìîñò- 60 áîëíè /28,17%/. Ïàöèåíòèòå áÿõà íà âúçðàñò ìåæäó 33 è 85 ãîäèíè - 34 ìúæå è 26 æåíè. Âñè÷êè áîëíè ñà áèëè âúâ âòîðè è òðåòè êëèíè÷åí ñòàäèé, èçèñêâàù ñïåøíà îïåðàòèâíà èíòåðâåíöèÿ. Ðàçïîëîæåíèå ïî äåáåëî÷ðåâíàòà ðàìêà

îáùî

èëåóñ

Ñà íà öåêóìà

Ñà íà âúçõîäÿùèÿ êîëîí

Ñà íà äÿñíà ôëåêñóðà

Ñà íà íàïðå÷íèÿ êîëîí

Ñà íà ëÿâà ôëåêñóðà

Ñà íà íèçõîäÿùèÿ êîëîí

Ñà íà ñèãìàòà

Ñà íà ðåêòóìà

â ïúðâèòå 24 ÷àñà

11 áîëíè

ñðî÷íè

2-7 äíè

ðàííè

îò 8- 15 äíè

Îïåðàòèâíè èíòåðâåíöèè ïðè èëåóñ åêñòðåìíè

Îáåìúò è ìåòîäúò íà îïåðàòèâíîòî ëå÷åíèå äî ãîëÿìà ñòåïåí ñå îïðåäåëÿ îò ëîêàëèçàöèÿòà íà ìàëèãíåíèÿ ïðîöåñ. Ïðè ëîêàëèçàöèÿ íà òóìîðà â äåñíèÿ êîëîí èçâúðøâàìå äÿñíà õåìèêîëåêòîìèÿ ñ ïîñëåäâàùà èëåîòðàíñâåðçîàíàñòîìîçà. Ïîâåäåíèåòî å îïðàâäàíî, ïîðàäè òîâà ÷å ñúóñòèåòî ñå èçâúðøâà íà íåóâðåäåí ó÷àñòúê. Ïðè ðàçøèðåí è âúçïàëåí òåðìèíàëåí èëåóì èçðàáîòâàõìå ïðîòåêòèâíà èëåîñòîìà ïðåä èëåî- òðàíñâåðçîàíàñòîìîçàòà. Ïðè ðàê ðàçïîëîæåí â ëåâèÿ êîëîí è ðåêòóìà ïðåä õèðóðãà ñòîè çàäà÷àòà, êàêúâ îáåì äà ðåçåöèðà è êàê äà çàâúðøè îïåðàöèÿòà ñ ïúðâè÷íà àíàñòîìîçà èëè äà ñå èçâåäå ïðîòèâîåñòåñòâåí àíóñ. Âàæíî çíà÷åíèå èìà 274

ñúñòîÿíèåòî íà ïðîêñèìàëíèÿ ó÷àñòúê íà êîëîíà íàä îáñòðóêöèÿòà, Áàóõèíîâàòà êëàïà è òúíêîòî ÷åðâî, íàëè÷èå íà ïåðôîðàöèÿ èëè íå. Îò 38 ïàöèåíòè îïåðèðàíè ïî ïîâîä íà îáòóðàöèîíåí èëåóñ â ëÿâ êîëîí ïðè 22 å èçâúðøåíà îïåðàöèÿòà íà Õàðòìàí, à ïðè 16 ëÿâà õåìèêîëåêòîìèÿ ñ ïîñëåäâàùà ïúðâè÷íà àíàñòîìîçà (1,2,3,4). Ìíîãîåòàïíèòå îïåðàòèâíè èíòåðâåíöèè ñúùî ñà ïîêàçàíè ïðè îïðåäåëåíè èíäèêàöèè- ïðè óñëîæíåíèÿ, êàòî ïåðôîðàöèÿ ñ ïåðèòîíèò èëè ïðè òåæêî îáùî ñúñòîÿíèå íà ïàöèåíòà ñ ìíîæåñòâî ïðèäðóæàâàùè çàáîëÿâàíèÿ. Ìíîãîåòàïíè îïåðàöèè ïðîâåäîõìå ïðè 6 áîëíè.

ÐÅÇÓËÒÀÒÈ Óñëîæíåíèÿ ïðè ïúëíàòà ÷ðåâíà íåïðîõîäèìîñò: 1. Ïåðôîðàöèÿ ñ ëîêàëåí èëè äèôóçåí ïåðèòîíèò- 5 áîëíè 2. Ïåðèòóìîðåí àáñöåñ- 2 3. Êúðâåíå-1 Îñíîâíèÿò ïðåîðèòåò å ðàöèîíàëíîñòòà è ñíèæàâàíå íà ïîñòîïåðàòèâíèÿ ìîðáèäèòåò è ìîðòàëèòåò. Âàæíî ìÿñòî â òàêòèêàòà è ïîâåäåíèåòî çàåìàò - îò êëèíè÷íà ãëåäíà òî÷êà - âðåìåòðàåíåòî, âèäà è èçÿâàòà íà ñèìïòîìèòå, âúçðàñòòà è ïðèäðóæàâàùèòå çàáîëÿâàíèÿ. È îò õèðóðãè÷íà ãëåäíà òî÷êà ëîêàëèçàöèÿòà è ðàçïðîñòðàíåíîñòòà íà òóìîðà, íàëè÷èåòî íà áëèçêè è äàëå÷íè ìåòàñòàçè, êàòî äâåòå ñòðàíè ñå äîïúëâàò. Çàïóøâàíåòî íà äåáåëî÷ðåâíàòà òðúáà å ñèíäðîì èçèñêâàù ñïåøíè ìåðîïðèÿòèÿ, êàòî â ïî-ãîëÿì áðîé îò ñëó÷àèòå ñå çàïî÷âàò ðåàíèìàöèîííè ìåðîïðèÿòèÿ, ñèìïòîìàòè÷íè è ãàçîãîííè ñðåäñòâà, ïîñòàâÿíå íà ÍÃÑ /íàçîãàñòðàëíà ñîíäà/ è ÏÓÊ /ïîñòîÿíåí óðåòðàëåí êàòåòúð/. Ïðè íÿêîè îò ïàöèåíòèòå áåøå îñúùåñòâåíà äîëíà åíäîñêîïèÿ- äàâàùà âèñîêà äèàãíîñòè÷íà èíôîðìàöèÿ, ïðè íÿêîè ñëó÷àè è ñ ëå÷åáíà öåë - åâàêóèðàíå íà ÷ðåâíîòî ñúäúðæèìî íàä ñòåñíåíèåòî ñ êàòåòúð çà îòáðåìåíÿâàíå (6). Ïðè âñè÷êè ïàöèåíòè áåøå èçâúðøåíà ïðåäîïåðàòèâíà êîíñóëòàöèÿ ñ èíòåðíèñò. Îò àïàðàòíèòå èçñëåäâàíèÿ ïðè âñè÷êè ïàöèåíòè áåøå èçâúðøåíà Ðå- ãðàôèÿ íà àáäîìåí /íàëè÷èå íà âîäíîâúçäóøíè íèâà/ è ÓÇÈ / óëòðàçâóêîâî èçñëåäâàíå/ íà êîðåìíè îðãàíè. Îò ëàáîðàòîðíèòå èçñëåäâàíèÿ â ðàçëè÷íà ñòåïåí ñå óñòàíîâèõà íàðóøàâàíå íà âîäíî- åëåêòðîëèòíèÿ áàëàíñ, ïðîòåèíèòå, àçîòíèòå òåëà, ïðîìÿíà â õåìîãðàìàòà, ÷åðíîäðîáíèòå ïðîáè, êð. çàõàð è àìèëàçàòà. Ïðè õèñòîëîãè÷íîòî èçñëåäâàíå ïðåîáëàäàâà àäåíîêàðöèíîìà ñ ðàçëè÷íà ñòåïåí íà äèôåðåíöèÿöèÿ.

Ïîâåäåíèå ïðè îáòóðàöèîíåí èëåóñ ïðè÷èíåí îò êîëîðåêòàëåí ðàê...

ÎÁÑÚÆÄÀÍÅ Ïðè ðàê ðàçïîëîæåí â ëåâèÿ êîëîí è ðåêòóìà ïðåä õèðóðãà ñòîè çàäà÷àòà, êàêúâ îáåì äà ðåçåöèðà è êàê äà çàâúðøè îïåðàöèÿòà ñ ïúðâè÷íà àíàñòîìîçà èëè äà ñå èçâåäå ïðîòèâîåñòåñòâåí àíóñ. Âàæíî çíà÷åíèå èìà ñúñòîÿíèåòî íà ïðîêñèìàëíèÿ ó÷àñòúê íà êîëîíà íàä îáñòðóêöèÿòà, Áàóõèíîâàòà êëàïà è òúíêîòî ÷åðâî, íàëè÷èå íà ïåðôîðàöèÿ èëè íå. Ïðåç 1921 ã. ôðåíñêèÿ õèðóðã Hartman ïðåäëàãà îïåðàöèÿ ïðè êîÿòî ñëåä îòñòðàíÿâàíå íà ÷ðåâíèÿ ñåãìåíò íîñåù áëàñòîìà íà îíêîëîãè÷íè îòñòîÿíèÿ, ïðîêñèìàëíèÿ ó÷àñòúê ñå èçâåæäà íà ïðåäíàòà êîðåìíà ñòåíà êàòî ïðîâèçîðåí ïðîòèâîåñòåñòâåí àíóñ, à äèñòàëíèÿ ñå çàäúíâà íà ãëóõî è ñå åêñòðàïåðèòîíèçèðà. Ñëåä 6 ìåñåöà ñå èçâúðøâà îïåðàöèÿ çà âúçñòàíîâÿâàíå íà ïàñàæà, àêî íÿìà äðóãè êîìïëèêàöèè. Ïðè îêîëî 30 % îò èçâúðøåíèòå ïúðâè÷íè àíàñòîìîçè íàñòúïâàò èíñóôèöèåíöèÿ, ïî ðàçëè÷íè èçòî÷íèöè. Ïðè ìíîãîåòàïíèòå îïåðàöèè ïðåìàõâàíåòî íà òóìîðà ñå îòëàãà âúâ âðåìåòî, ïðåç êîåòî ìàëèãíîìúò íàðàñòâà. Òåçè îïåðàöèè ñå èìàò â ïðåäâèä ñàìî ïðè óòåæíåíèòå ñëó÷àè. Äåêîìïðåñèÿòà íà ÷ðåâíèÿ òðàêò å íàïúëíî íåîáõîäèì çà äåçèíòîêñèêèðàíå íà îðãàíèçìà è ïî-áúðçîòî ìó âúçñòàíîâÿâàíå - ÷ðåâíè ñòîìè - êîëîñòîìà, öåêîñòîìà è èëåîñòîìà. Âúòðåøíèòå îáõîäíè àíàñòîìîçè èìàò ïàëèàòèâåí õàðàêòåð è íå îòãîâàðÿò íà îíêîëîãè÷íèòå ïðèíöèïè. Ïðè ëîêàëèçàöèÿ íà ðàêà â äåñíèÿ êîëîí è íåíàïðåäíàë èëåóñ íèå îñúùåñòâÿâàìå äÿñíà õåìèêîëåêòîìèÿ ñ ïúðâè÷íà àíàñòîìîçà. Ïðè òåæêî îáùî ñúñòîÿíèå íà áîëíèòå è íàëè÷èå íà ïåðèòîíèò å ïîêàçàíà äâóåòàïíà îïåðàöèÿ- äÿñíà õåìèêîëåêòîìèÿ ñ èëåîñòîìèÿ, íà âòîðèÿ åòàï ñå âúçñòàíîâÿâà ïàñàæà. Ïðè ìíîãî çàïóñíàòè ñëó÷àè ñå èçâåæäà èëåîñòîìèÿ. Ïðè ëåâîñòðàííà ëîêàëèçàöèÿ íà êàðöèíîìà, ïîâåäåíèåòî å ñïîðåä íàïðåäíàëà ëè å ÷ðåâíàòà íåïðîõîäèìîñò, äî êàêâà ñòåïåí è èìà ëè íàëè÷åí ïåðèòîíèò. Îïåðàòèâíèòå èíòåðâåíöèè ñà - ëÿâà õåìèêîëåêòîìèÿ ñ ïúðâè÷íà àíàñòîìîçà, îïåðàöèÿòà íà Õàðòìàí èëè èçâåæäàíå íà êîëîñòîìà, áåç ïðåìàõâàíå íà òóìîðà. Ïðè Ñà íà ðåêòóìà ñå èçâúðøâà àáäîìèíî- ïåðèíåàëíà åêñòèðïàöèÿ èëè ïðåäíà ðåçåêöèÿ ïðè ïî-ëåêèòå ñëó÷àè, ïðè òåæêè è çàïóñíàòè ñëó÷àè ñå îñúùåñòâÿâà äâóåòàïíà îïåðàöèÿ, êàòî íà ïúðâè åòàï ñå èçâåæäà äåáåëî÷ðåâíà ôèñòóëà-äâóöåôêà. Ïðè ðåçåêòàáèëíèòå ñëó÷àè ñìå ñå ñòàðàëè äà îòñòðàíèì ëèìôíèòå âúçëè îò òðèòå ëèìôíè êîëåêòîðà (1,2,3,4). Íàé-÷åñòèòå ñëåäîïåðàòèâíè óñëîæíåíèÿ ñà èíñóôèöèåíöèÿ íà àíàñòîìîçàòà /30%/, ñëåäîïåðàòèâíà

äèàðèÿ /25%/, ðàíåâà èíôåêöèÿ /10%/, ïðîëàïñ èëè åâàãèíàöèÿ íà ïðîòèâîåñòåñòâåíèÿ àíóñ /0,5%/ è äðóãè. Ñðåäåí áîëíè÷åí ïðåñòîé 13 äíè. Ñìúðòíîñòòà å îêîëî 5%. Áîëíèòå ñà èçïèñàíè àôåáðèëíè, ðàçäâèæåíè, çàõðàíåíè ñ âúçñòàíîâåí ïàñàæ è ïúðâè÷íî çàðàñòíàëà îïåðàòèâíà ðàíà. Ïðîêîíòðîëèðàíè ñà äî 24 ìåñ. ñëåä èçïèñâàíåòî.

ÈÇÂÎÄÈ · Ëèïñàòà íà ïðîôèëàêòèêà è êúñíî ïîòúðñåíàòà

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ëåêàðñêà ïîìîù ñà â îñíîâàòà íà ñðàâíèòåëíî ãîëåìèÿ áðîé ïàöèåíòè ïîñòúïèëè è îïåðèðàíè ïî ñïåøíîñò è íàñòúïèëèòå ëîøè ñëåäîïåðàòèâíè ðåçóëòàòè. Îáòóðàöèîííèÿò èëåóñ å íàé- ÷åñòîòî óñëîæíåíèå ïðè áîëíèòå ñ êîëîðåêòàëåí ðàê, ñðåùàùî ñå ïðè îêîëî 28,17% è èçèñêâàùî îïåðàòèâíî ëå÷åíèå â ñïåøåí ïîðÿäúê. Ëåâîñòðàííàòà ëîêàëèçàöèÿ å ïî- ÷åñòî ñðåùàíà ïî íàøè è äðóãè èçòî÷íèöè. Ïðåäîïåðàòèâíàòà ïîäãîòîâêà, ïðîâåäåíèòå êîíñóëòàöèè è ðåàíèìàöèîííèòå ìåðîïðèÿòèÿ èìàò âàæíî çíà÷åíèå çà èçõîäà îò çàáîëÿâàíåòî. Õèðóðãè÷íîòî ïîâåäåíèå è òàêòèêà èìà îñíîâåí ïðèíîñ çà ïðåæèâÿåìîñòòà íà áîëíèòå. Äåêîìïðåñèÿòà íà ÷ðåâíèÿ òðàêò òðÿáâà âèíàãè äà ñå èìà â ïðåäâèä ïðè íàïðåäíàëàòà ÷ðåâíà íåïðîõîäèìîñò. Ñòðåìåæúò å êúì åäíîåòàïíè ðàäèêàëíè îïåðàöèè, íî ïðè òåæêè, çàïóñíàòè óñëîæíåíè ñëó÷àè ñå ïðåìèíàâà êúì äâóåòàïíè îïåðàöèè.

ÊÍÈÃÎÏÈÑ 1.

2. 3. 4. 5. 6.

ßðúìîâ Í., Èâ. Âèà÷êè, Á. Êîðóêîâ. Òàêòèêà è îïåðàòèâíè ìåòîäè çà ëå÷åíèå íà óñëîæíåíèÿ êîëîðåêòàëåí ðàê. Õèðóðãèÿ 1999; 6: 29-34. ßðúìîâ Í., Å. Ïîïõðèñòîâà, Â. Öåêîâà. Óñëîæíåí êîëîðåêòàëåí ðàê. 2001; 140-148 Kourosh Khosraviani, Wil liam J. Camp bell, Thomas G. Parks. Eur J Surg 2000; 878-881 K. Smedh, L. Olsson, H., Johansson. British Journal of Surgery 2001, 88, 273- 277 M. Kruschewski, N. Punkel and H. J. Buhr. Int J of Colorectal Disease 1998, 247- 250 Torralba J. A., Robles R., Parrilla P. Subtotal colectomy versus intraoperative colonic irrigation in the management of obstructed left colon carcinoma, Dis. Colon Rectum 1998; 41: 18-22. Bur gess A., Large Bowel Obstruction. Surgeons. org website 2008

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XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

CYTOREDUCTIVE SURGERY OF COLORECTAL CANCER PATIENTS WITH MULTIPLE BILOBAR HEPATIC METASTASES Barsukov Y. A., V. A. Aliev, D. V. Kuzmichev, S. S. Gordeev, D. F. Kim Patients and methods: Data from 229 colorectal cancer patients with multiple bilobar colorectal cancer metastases were analysed (from 1998 to 2007). Surgical resection of primary tumor was performed in 182 of them (79.5%), and palliative surgery (divert ñolostomy or colonic bypass) was performed to 47 (20,5%) patients. 60% of patients received adjuvant mono- or polychemotherapy. Results: In symptomatic surgery patient group 2-year survival rate and median survival time were 4.7% and 5.4 months respectively. 2-year survival rate in group patients who had primary tumor removed with no adjuvant chemotherapy (105 patients) 2-year survival rate and median survival time were 18,2% and 9,9 months respectively. 2-year survival rate in

group of patients who received monochemotherapy after resection of primary tumor (37 patients) was 17% and the median survival time was 10.4 months. In group of 40 patients who received adjuvant polychemotherapy after removal of primary tumor, 2-year survival rate was 52.3% (3 times higher than in monochemotherapy patients group) and the median survival time was 23.4 months. 5-year survival was 17%. Conclusion: Cytoreductive surgeries improve results of treatment colorectal cancer patients with multiple hepatic metastases. Use of adjuvant polychemotherapy allows achieve 5-years survival in this group of patients, who earlier were considerable hopeless.

MULTIMODAL APPROACH TO TREATMENT OF RECTAL CANCER USING POLYRADIOMODIFICATION PROGRAMME Barsukov Y. A., S. I. Tkachev, A. V. Nikolaev, V. A. Aliev, Z. Z. Mammadli Polyradiomodification - it’s a use of multiple radiomodifyers, preferably differently active, with aim to reinforce efficacy of radiation therapy (RT). Preoperative RT in resectable rectal cancer reduces local recurrence rate, but it still remains high. Hyperthermia (HT) may add tumoricidal effects and improve the efficacy of RT. METRONIDAZOLE (MZ) and ÑÀÐÅCITABINE as a radiomodifiers together with HT may reinforce tumor radiosensitivity. Among 679 patients with rectal cancer T2 or T3 - 276 received RT alone, 224 received RT+HT. 179 patients received RT + HT + MZ or RT + HT + MZ + ÑÀÐÅCITABINE. Surgery followed 10-14 days after

RT. RT given as 5 Gy x 5 days (25 Gy). Intrarectal HT) was given on day 3, 4 and 5 of RT. MZ (10 gr/m2) in hydrogel form was administrated intrarectaly on days 3 and 5 of RT. Patients received ÑÀÐÅCITABINE orally 1,5 gr/m2 daily. Results: only one of 179 patients (0,6%) received RT+HT+METRONIDAZOLE±ÑÀÐÅCITABINE has local relapse of disease (48 month observation). Local recurrence in RT alone group was - 10,1 %, in RT+HT group - 4,5%. 4-years disease free survival was 72,0% and 75,0% in RT and RT+HT groups respectively, and 97,3% in polyradiomodification group.

SPHINCTER-SAVING TREATMENT OF MIDDLE AND LOW RECTAL CANCER IN PRESENCE OF POLYRADIOMODIFICATION PROGRAMME Barsukov Y. A., S. I. Tkachev, A. V. Nikolaev, D. V. Kuzmichev, Z. Z. Mammadli Increased ablastics of rectal surgery in presence of combined treatment allows raising the rate of sphincter-saving operation. Methods and patients: main point of polyradiomodification programme created in 2004 is - reinforcement of tumoricidal effect of radiation therapy (RT).

This achieves by use of intrarectal hyperthermia (HT) (superhigh frequency, SHF) using the “Yalik” and “Yahta-4” device, given on day 3, 4 and 5 of radiotherapy (frequency 460 MHz, exposure 60 min, temperature inside tumor 43,5-440C), just after irradiation. And METRONIDAZOLE (MZ) (10 gr/m2) in a form of 277

ABSTRACTS

hydrogel on basis of biopolymer Sodium alginate (KOLEGEL) administrate intrarectaly on days 3 and 5 of RT, exposure 5 hrs, prior to RT. And patients also received ÑÀÐÅCITABINE (XELODA) orally in daily dose of 1,5 gr/m2, twice a day, all 5 days of RT. We use combined approach in treatment of 577 patients with rectal cancer of middle and low third localization and sphincter-saving surgery was performed to 333 of them (59%). Among them in group received preoperative RT sphincter-saving surgery was performed to 101 of 191 (53%), in group received RT+HT to 124 of 218 (56%), and to 109 of 158 (68%) patients treated

by RT+HT+MZ±XELODA. Results: Local recurrence rate in group received RT (n=101) followed by surgery was 9.6%, in group received RT+HT (n=124) -was 4,9%. Among 109 patients included in polyradiomodification programme - only one (0,9%) has local recurrence - 4 years of observation. Conclusion: This optimistic results evidence competence of use of polyradiomodification programme in combined treatment of rectal cancer and broadening indication to sphincter-saving surgery for rectal cancer of middle and low third localization.

ADEQUATE MANAGEMENT OF RECTAL CANCER Jin C. Kim Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea The incidence of rectal cancer occupies as 30-60% of all colorectal cancer occurrences. Although the rectum is in continuity with the colon, molecular tumorigenesis differs greatly between them. Otherwise, it located in the pelvis adjacently with urologic and reproductive organs supported by levator and anal sphincter muscles. During recent 20 years, treatment modalities have been remarkably progressed in terms of sphincter-saving and reducing local recurrence with sound application of stapling devices and chemoradiotherapy. The concept of resection margin should be considered for both distal and radial margins. The latter aspect inevitably requires total or tumor-specific mesorectal excision (TME) including complete en bloc rectal resection with visceral pelvic peritoneum. Reported series present 2 -8 fold and 2 fold increases of local and systemic recurrences, respectively, in cases with positive radial margin. Preoperative or postoperative chemoradiotherapy had been proven to decrease local recurrence in most pro-

spective investigations. Some surgeons including Japanese ones prefer lateral pelvic lymph node dissection (LPLD) rather than radiotherapy. In our previous study, local recurrence between postoperative chemoradiotherapy (n=309) and LPLD (n=176) groups were 7.5% and 16.7%, respectively, in stage III rectal cancers underwent TME, exhibiting statistical significance (p = 0.044). Other controversial issues, i.e., laparoscopic rectal cancer operation, ultra-low anterior or intersphincteric resection, neoadjuvant therapy, and local excision will be discussed in this presentation. Conclusively, sphincter-saving operation maintaining bowel continuity, is mostly recommended, but oncologic safety must be observed. In addition, autonomic nerve preservation should be considered depending on biological properties of tumors, if not complete. Neoadjuvant treatment in advanced tumors appears to broaden resectability as well as functional preservation.

ANAL CANCER -DIAGNOSTIC AND TREAPEUTIC POSIBILITIES Nikolov St., Y. Yovtchev The anal cancer is comparatively rare malignant disease that affects the women more often than the men. The incidence ranges around 1% and is more commonly encountered after the 4-6th decade. The clinical expression is variable and frequently runs with an initial manifestation of a benign disease: pain, bleeding, visualized tumor with or without itching.

Key words: anal cancer, diagnostics, treatment. 278

We make it our aim to systematize the diagnostic and therapeutic methods used for that kind of nosology. The combination of opportune diagnosis and adequate treatment considerably enhances the five-year survival.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ANASTOMOTIC LEAKAGE AFTER ANTERIOR RESECTION FOR RECTAL CANCER Vekic B., R. Zivic, M. Cvetanovic, M. Jakovljevic, Z. Jovanovic, M. Kalezic KBC Dr.Dragisa Misovic Clinic of surgery, Belgrade, Serbia Background: The aim of this study is to present the incidence of anastomotic leakage after low anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication. Patients And Methods: During the four years (2004-2007), 107 patients underwent low anterior resection of the rectum for rectal cancer. Low anterior resection with total mesorectal excision (TME) was performed in all patients. The definition of the anastomotic leakage was based on clinical features, peripheral blood, CRP, investigations and abdominal CT scan.

Results: Clinically apparent anastomotic leakage developed in 9 patients (6,4%). Four patients were managed conservatively and five operatively. Postoperative mortality among the patients with anastomotic leakage was not recorded. Conclusions: The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low. It remains however the most serious complication following rectal resection for cancer

HAEMORRHOIDECTOMY USING ULTRACISION Vekic B., R. Zivic, M. Cvetanovic, M. Jakovljevic, Z. Jovanovic, Z. Zagorac, M. Kalezic KBC Dr. Dragisa Misovic, Clinic of surgery. Belgrade, Serbia. Aim: Haemorrhoidectomy with Ultracision is a variation of the classic Miligan- Morgan operation durig which the following is used electro-coagulation and cutting of the blood vessels. Results: Within the period of time from 2005 to 2007, 32 patients were operated on due to haemorrhoidal disease, 14 females and 18 males, mean age 46 years (31 to 75 year of age). 19 patients were operated in the III stadium of the disease, and 13 patients were operated in the IV stadium with secondary anaemia. Spinal anaesthesia was used in 24 patientes and general anaesthesia was used in 8 patients. In preoperative period a standard procedures were used: enaema, paraffin oil, metronidazol.

Intraoperative complications didnâ&#x20AC;&#x2122;t occur. 22 patients were hospitalized for 24 hours, and 10 patients were hospitalized for 48 hours. In postoperative period there was not bleeding and no need for reintervention. In postoperative period all patients were used analgetic Zodol or Diklofen. Conclusions: Ultracision haemorhoidectomy gives satisfactory results in treating haemorrhoidal disease. No bleeding occurs, postoperatively less pain compared with conventional scissors dissection and no need for special tehnical knoeledge is required. In shortns of the time length of the operation and can be performed as one day surgery.

TREATMENT A HOGE ANORECTAL MELANOMA Vekic B., R. Zivic, M. Cvetanovic, M. Jakovljevic, Z. Jovanovic, M. Kalezic KBC Dr.Dragisa Misovic Surgycal Clinic, Belgrade, Serbia Background: Primary anorectal melanoma is a very rare malignancy which represents 0.1%-4.6% of all anorectal

tumors1,2. This disease is sometimes mistaken for such benign conditions as either a haemorrhoid or rectal polyp. 279

ABSTRACTS

Methods: The authors report on a 52 years old man with rectal bleeding and bowel obstruction symptoms in which a huge anorectal melanoma in the region of the dentate line was detected during the inspection of an “anal polyp”. The tumor appeared as a polypoid intraluminal mass on the pelvis CT scan, 7cm in size, with no perirectal infiltration or lymphadenopathy. CT scans of the thorax and abdomen showed no signs of distant metastases. Results: After the diagnosis was established, abdominoperineal resection of the rectum was performed, since the tumor was large and obstructive. Only one of 14 removed perirectal lymph nodes was histologically positive on paraffine sections. Melanoma was classified as stage 3.

No adjuvant therapy has been admitted. Three months after initial treatment, the patient is alive and disease free. Conclusion: Anorectal malignant melanoma is often misdiagnosed, surgical procedure is the first choice for patients with AMM. Abdominal perineal resection versus wide local excision is still being debated. Different surgical modalities have been used in managing the disease with no clear evidence to favor one approach over another, but even when a radical surgery was undergone, the prognosis of patients with anal melanoma remains dismal3. Because the optimal treatment of these tumors is still unclear, a multidisciplinary approach including a surgeon, primary care physician, medical oncologist, radiation oncologist, and pathologist offers the patient the best outcome 4.

ANORECTAL MANOMETRY IN PATIENTS WITH ANAL FISSURES Iliev.S., I. Presolski, V. Grozev, P. Tonchev, T. Deliiski, A. Paul, C. Praveen, C, Piyush Surgical Clinic-UMBAL’’Georgi Stranski-Pleven”, Department of Septic Surgery, University Hospital “Georgi Stranski -Pleven” Aim: To record preoperative analcanal pressure at rest and at voluntary contraction. To record changes in tonus of anal sphincter after anal fissure treatment. Material and Methods: Prospective study for period of four years has been done (2006-2009).It included 72 patients with anal fissures-66 women and 6 men. History of disease was between 3-10 years. Fissures were treated by following methods- Sphincterotomy, Fissuroplasty with mucosal flap and lateral open sphincterotomy. For anorectal manometry we used 5-way ballon catheter for dyanamic recording of tonus of anal sphincter complex. Measurements were donr preoperatively and one month postoperatively. Control examinations were held after one week and after 1, 3 and 12 months. Results and Discussions: Successful closure of fissure was registered in 68 patients - 90%.In 4 patients reccurence was registered within one month of treatment. Registered anal canal pressure values in rest are:At the level of subcutaneous sphincter - 20-90 cm. Í2Î; Superficial sphincter - 40-105 cm. Í2Î; Deep sphincter - 60-110

cm. Í2Î; Puborectal Muscle -40-90 cm. Í2Î; Intrarectal Pressure -15-100 cm. Í2Î Registered anal canal pressure values at voluntary contraction are: At the level of subcutaneous sphincter - 80-210 cm. Í2Î; Superficial sphincter - 100-160 cm. Í2Î; Deep sphincter - 90-150 cm. Í2Î; Puborectal Muscle - 85-105 cm. Í2Î; Intrarectal Pressure - 45-100 cm. Í2Î. Postoperative anorectal manometry in patients without sphincterotomy showed that there is an average increase in analcanal pressure by 10 cm. Í2Î at voluntary contraction but pressure at rest remains the same. In contrast, patients with sphincterotomy showed that there is decrease in analcanal pressure by 20-30 cm. Í2Î at rest while values at voluntary contraction remains the same. After 3 months none of the patients complained of anal incontinence. Conclusions: Preoperative anal sphincteromanometry in patients with anal fissure is of great importance while considering surgical tactics. Interpretation of these results is very helpful in preventing postoperative anal incontinence.

Key words: Anorectal manometry, Chemical sphincterotomy, Lateral sphincterotomy, Anal fissure

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PLASTIC RECONSTRUCTIVE OPERATIONS ON THE ANAL SPHINCTER APPARATUS IN PATIENTS WITH ANAL INCONTINENCE. ROLE OF THE ANAL CANAL MANOMETERY Iliev S., I. Presolski, V. Grozev, P. Tonchev, T. Deliiski, A. Paul, C. Praveen, C. Piyush Department of Surgery, University Hospital “Georgi Stranski - Pleven, Department of Septic Surgery, University Hospital ”Georgi Stranski - Pleven Objective: To establish preoperative values of anal canal pressure at rest and during voluntary contraction of anal sphincter complex in patients with anal incontinence and to compare with the values recorded after surgical treatment. Materials and methods: Prospective study for a four-year period from 2006-2009 included 9 patients with IInd and IIIrd degree of anal incontinence. Eight women aged between 22 -79 years and a man aged 62 years were included. Duration of the disease was between 6 months and 22 years. For anorectal manometery we used five channeled balloon catheter for recording the dynamic tone of the anal sphincter complex. Measurements were taken preoperatively and during the first postoperative month. Operative methods undertaken were: Reconstruction of the anal sphincter with autograft; levatoroplasty and reconstruction of sphincter combined with intraabdominal fixation of rectum by Wells method and fixation of the uterus by Polloson -Pellanda method; levatoroplasty and unilateral Gracilis muscle plasty and bi-staged bilateral Gracilis plasty. Alloplastic reconstruction of the pelvic diaphragm with septokcen. Control examination were made in the first week and after 1, 6 and 12 months. Results and discussion: Improvement in the sphincter function was recorded in all the patients. In six patients full

recovery from inconticence was observed and two patients had an improvement from III-rdstage to II-nd and I-st stage of incontinence .The last patient after reoperation reported only partial incontinence of gas. Preoperative registered values of anal canal pressure at rest were: at the level of subcutaneous sphincter -3-10 cm Í2Î; superficial sphincter: 6-12 cm Í2Î; deep sphincter: 5-10cm Í2Î; puborectal muscle: 5-20 cm Í2Î; interectal pressure: 3-10 cm Í2Î. Registered values of anal canal pressure at voluntary contraction were: subcutaneous sphincter: 3-12 cm Í2Î; superficial sphincter:6 -15 cm Í2Î; deep sphincter: 5 - 20 cm Í2Î; puborectal muscle: 5-22 cm Í2Î; interrectal pressure - 5-15 cm Í2Î. Postoperative anorectal manometery showed a significant increase in baseline pressure within the anal canal at rest and under voluntary contraction, along with an improved sphincter function and decrease in the degree of incontinence. Conclusions: Treatment of anal incontinence is a complex process that starts before surgical treatment and continues thereafter. Results are reported based on questionnaires and scoring systems. Digital anorectal manometery is an objective method for recording the pressure in the anal canal and complements in evaluation of the effectiveness of treatment.

Key words: anorectal manometery, anal incontinence, gracilis plasty

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HAL-RAR PROCEDURES IN THE TREATMENT OF HEMORRHOIDAL DISEASE AND REDUCTION OF MUCOSAL RECTAL PROLAPSUS Zarkov K., Chr. Petkov First Surgical Department, Fifth General Hospital, Sofia, Bulgaria Background: The essential of the Doppler-guided hemorrhoid arterial ligation (HAL) operation is the high, exact and selective ligation of the arteries supplying blood to the hemorrhoids with the use of specially constructed by Prof. Morinaga anoscope with incorporated side-viewing Doppler head and a lateral window above it. Attacked is the cause not the consequence. After artery ligation, the arterial inflow to the piles suddenly drops, while venous outflow is not compromised. Hemorrhoids collapse and bleeding and pain cease. The decreased tension allows connective tissue regeneration that facilitates shrinkage of the pile and eventually leads to definitive prolapse decrease. This method is indicated and specific for hemorrhoids stages II and III and leads to excellent results. For hemorrhoids stages III and IV with expressed ano-rectal prolapse Recto Anal Repair technique (RAR) is performed using specially designed RAR-anoscope and RAR sleeve -this allows to make in one session hemorrhoid arterial ligation and reduction of mucosa prolapse. After the standard HAL procedure is completed, ano-rectal mucopexy is performed with running sutures of 2 to 4 stitches along each of the prolabing piles that are lifted and fixed in the anal canal, so leading to reduction of mucosa prolapse. In stage IV cases this may be combined with other methods for prolapse reduction -excision -simultaneously or after 6 months. If there is anal fissure or perianal this method should be combined with fissurectomy, fistulotomy or fistuloectomy and excision of hyperthrophic anal papillae. Aims: We review the existing knowledge published on various problems and aspects of HAL and RAR procedures for treating hemorrhoids with mucosa prolapse; also regarding and comparing the other methods for treating hemorrhoids and reduction of mucosa prolapse. We assess the designed concept for this operation, anesthesia, postoperative care, results, complications, need of second HAL-RAR procedure. Material and methods: We started HAL procedures in August 2005 and RAR procedures in January 2006. Until

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end of 2008 we performed 481 HAL and RAR operations. Our patients were mostly in III and IV stage - 90% ( 433 ). Some of the patients had history for hemorrhoid operation: Whitehead hemorrhoidectomy - 6; cryosurgery - 9; rubber band ligation -13; Longo operation - 5. Our concept: For hemorrhoids stages I, II and III without prolapse we performed HAL procedures -at least 12 sutures. For stages III and IV - HAL-RAR procedures -with 3 to 6 RAR sutures. For the prolabing fibrous mucosa-cutaneous doublicatures or hyperthrophic anal papillae now we prefer always to perform simultaneous excision. Until the end of 2006 we made simultaneous excision in 35% of cases but 1 to 6 months later we had to perform excision under local anesthesia in 30% of the rest. Results: Regress of the symptoms of hemorrhoids is achieved in 4-6 weeks after operation. In the first 7-14 postoperative days patients feel: tension, tenesmus; call for defecation, slight bleeding. Out of all 481 patients we had serious complications in: 1/ Significant bleeding with blood transfusions in 3 patients and operative hemostasis in 1 of them. No pelvic sepsis. 2/ Thrombosis of the hemorrhoids occurred in 3 patients. When we operate on thrombosed hemorrhoids and also to avoid thrombosis in the end of procedure we make slight incisions on some of the piles and extract the thrombus. Unsatisfying results after the procedure - 5% of all patients continue to have complains-pain, discomfort. To 5% of stage IV patients we offer a second HAL-RAR procedure to achieve maximal prolapse reduction. In 10 patients we made excision of the mucosa-cutaneous doublicatures 1-5 months after the HAL-RAR procedure. Conclusions. HAL-RAR procedure is adequate technique for treating hemorrhoids of all stages and mucosa prolapse reduction. It is versatile and may be combined with other methods. As a minimally invasive operation, it is less painful, less analgetics are used postoperatively and is cost-effective. Allows shorter postoperative hospital stay and early return to the everyday activities.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

RECONSTRUCTION OF THE PELVIC BOTTOM AFTER EXTENDED PELVIC SURGERY Zarkov K., N. Nickolov, Chr. Petkov, A. Assenov First Surgical Department, Fifth General Hospital, Sofia, Bulgaria Background: A huge pelvic cavity is formed after extended pelvic surgery (exenterations, especially in totals). It is not always possible to mobilize and use the remaining peritoneum to close the pelvic entry. Reconstruction of pelvic floor is necessary to preclude the small bowel from entering the pelvis and to prevent small bowel obstructions. Reconstructive techniques in use are: pedicle graft of greater omentum; mesh implants; pedicle muscle and myocutaneous flaps (PMF) - vertical rectus abdominis musculocutaneous flap (VRAM), transverse rectus abdominis musculocutaneous flap (TRAM) or transversus rectus abdominis musculoperitoneal flap (TRAMP), complex gluteal and rectus abdominus flaps, gracilis and sartorius flap; cecal pelvic transposition. The most common complications are: pelvic floor infection; fistulaformation; flap necrosis; bowel obstruction; postoperative perineal hernia. Aims: We review and discuss the existing techniques for reconstruction of the pelvic bottom after extended pelvic surgery. We assess the technique for pelvic reconstruction that we use -advantages, disadvantages, complications and to compare these with the other techniques. Material and methods: To reconstruct the pelvic floor we implant a mesh at the pelvic entry. The used mesh is Bulgarian Antibacterial Polycapronamid Mesh (BAPP) in the majority of cases and Prolene only in 11 patients. For the period 2001-2008 pelvic reconstruction was done in the course of 38 total, 37 anterior and 16 posterior pelvic exenterations (female with local relapse in pelvis of genital carcinoma or primary advanced genital, bowel or urinary cancer-aged from 28 to 75; five male with advanced urinary bladder and prostate carcinomas) and in 25

abdomino-perineal resections (females -9; males -16; aged from 56 to 78). Results: There is a discharge from the pelvic cavity that ends in 25 to 45 days. Pelvic cavity infection is the most common complication -in 61 of 116 (52%) assessed patients. Ileus/small bowel obstruction appeared in 3 patients. In 2 of them it was due to a leakage of the implanted mesh in pelvis and bowel incarceration and lead to reoperation. Discussion: Extended pelvic surgery leads to a huge pelvic cavity formation. The implanted mesh increases the stability of the pelvic floor and separates visceral organs from the formed pelvic cavity. It is a simple, reliable, and not time-consuming technique. Despite, the resultant perineal defect heals slowly by secondary intention. A major source of morbidity after pelvic exenterations are perineal wound complications, seen in up to 66% of cases - (52% in our series), but maintaining a cutaneous perineal hole allows easy access and treatment of possible pelvic abscesses as well as early recurrence diagnosis. Conservative treatment resolves pelvic cavity complications -reoperation was necessary only in 2 of the cases. BAPP mesh is originally designed for laparostomy formation and is not expensive. It is possible to be placed over the viscera and does not irritate the bowels like polypropylene meshes do. Conclusions: The mesh implant is a simple, reliable, and not time-consuming technique to form stable pelvic floor and separates visceral organs from the resultant pelvic cavity. Despite major morbidity associated with the formed pelvic cavity still remains very high, the complications are not numerous as types. Pelvic cavity complications are resolved mainly with conservative treatment.

COMPLICATIONS FOLLOWING PELVIC EXENTERATIONS Zarkov K., Chr. Petkov, A. Assenov, N. Nickolov First Surgical Department, Fifth General Hospital, Sofia, Bulgaria Background: The potential complications after pelvic exenteration are numerous. Almost every patient develops at least 1 complication, and approximately 40-50% experience a major complication requiring further diagnostic and therapeutic procedures. The complications following pelvic exenterations may be classified as: complications of uri-

nary system; complications of gastrointestinal system; complications of pelvic floor; rare complications. The major early postoperative complications include blood loss, massive bleeding from the sacral plexus, wound dehiscence, urinary tract infections, acute renal failure, urinary bladder dysfunction, ureter damage, sepsis, adult respiratory distress syndrome (ARDS), thrombophlebitis and 283

ABSTRACTS

pulmonary embolus, and anastomotic breakdown at the level of the bowel, urinary pouch, or ureteral sites; ileus/small bowel obstruction; re-operation. Early complications related to the construction of the reservoir include ureteral stricture/obstruction, anastomotic leak, reservoir-cutaneous fistula, difficulty in catheterization. Late complications are the ones that occur 6 weeks after operation. The rate of late complications is lower, but approximately one third of patients experience fistula, bowel obstruction, ureteral strictures, hydronephrosis, urinary incontinence renal failure, pyelonephritis; and chronic bowel obstructions; deep venous thrombosis and pulmonary emboli, flap necrosis, and stomal necrosis. Late complications related to reservoir construction are ureteral stricture/obstructions, incontinence, difficulty in catheterization, and urinary stones. Perineal small bowel fistula (PSF) after total or posterior pelvic exenteration is more frequently late (73%) than early (27%) complication. The most common complication related to pelvic floor is pelvic collection and pelvic floor infection, seen in up to 66% of cases. Conservative treatment resolves 80% - 84% of these complication cases. Aims: We review the existing knowledge on the problems of the complications after pelvic exenterations. We assess the postoperative complications, related to urinary system, gastrointestinal system and pelvic floor of our patients with pelvic exenterations, and also regarding the type of tumor -location, histopathology, primary or relapse. Survival also is reported. Materials and methods: We analyzed 131 patients operated through 1992-2008 in our hospital - performed were 38 total, 56 posterior and 37 anterior pelvic exenterations for advanced primary or relapse rectal, urological and genital carcinomas. Both internal iliac arteries are ligated. Fecal diversion - colostomy at left abdominal wall side; in some supralevator posterior exenteration cases -low rectal anastomosis. Urinary diversion - both ureters are brought out as

urostomies at right abdominal wall side. The formed pelvic cavity is separated from the rest abdominal cavity by implanting a mesh. Results: Patients are aged from 28 to 75. Operation duration -3 to 5 hours. Intraoperative mortality -0%. Postoperative mortality to 30th day -6 patients. Complications: Urinary tract bacterial growth or infections -present in all total and posterior pelvic exenteration patients. Hydronephrosis - in 4 patients - percutaneous nephrostomy was formed in one of them. Necrosis of the distal ureter formed like urostomy - resulting in reoperation - 5 patients. Ureteral stricture at the urostomy site -4 patients. Ileus/small bowel obstruction - 3 patients. Radiation colitis after radiotherapy in one led to bowel passage correction. Transversostomy was brought out in 5 patients with rectal anastomosis leakage. Pelvic cavity infection -58 patients. Pelvic cavity discharge ended in 25 to 65 days. Leakage of the implanted mesh in pelvis - 2 patients. Survival at the end of March 2009 - followed were 71 patients: Over 12 months -37; over 18 months -9; over 2 years -12; over 48 months - 8; over 5 years - 5 patients (16%) of 32 patients operated before 2004. Discussion: Although mortality has fallen to less than 5% in modern series (4.5% for our patients), treatment-related severe morbidity of pelvic exenteration still exceeds 50% (also for our patients), possibly because of compromised healing of irradiated tissue and use of complex reconstructive techniques. Reported 5-year survival rates after pelvic exenteration range from 23-61% (16% for our patients). Conclusions: Although postoperative mortality is low in modern series, the major morbidity of pelvic exenteration still remains very high. Despite the high level of invalidism, pelvic exenteration is the only more radical method for treatment of advanced primary and relapse tumors in the pelvis. Postoperative results are poor when the tumor is too widely spread.

ONCOLOGIC RESULTS AND QUALITY OF LIFE AFTER RADICAL TREATMENT OF RECTUM CARCINOMA Maslyankov S., M. Racheva, P. Atanasov, G. Kostov, G. Atanasov, Il. Popov, Iv. Popov, Dr. Metodiev, P. Nedeva* Surgery Department, MODOZS EOOD, Veliko Tarnovo, Bulgaria;*Pathology Department Introduction: Rectum carcinoma is an increasing problem during the last years with high percentage of advanced and complicated forms. A great variety of operative tactics is available and choosing the â&#x20AC;&#x153;rightâ&#x20AC;? one is a serious challenge. In some cases, with very low anastomoses, the patients often choose permanent stoma instead of low postoperative function. Psychosocial adaptation of this large enough contingent is very hard and adequate treatment policy is an important goal for the clinicians. 284

Aim: We present our experience with patients with rectum carcinomas in Specialized Oncology Hospital of Veliko Tarnovo for a 5-year period. It has been studied how different techniques affect the functional result and quality of life and how paraoperative treatment influences the derived oncologic result. Material and Methods: In the Specialized Oncology Hospital of Veliko Tarnovo 301 patients with rectum carcinoma have been potentially radically operated. The average

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

age was 64 (±0.5), with the youngest patient a woman of 42 and the oldest one - a man of 85. For the staging we used TNM/?TNM system. The goal was a maximal preoperative accuracy -aiming at an adequate planning of operative tactics and preparing the patient properly. For the studied period 23 persons (7.64%) were operated in stage I (T1-2). II stage was classified predominately - in 135(44.85%) cases. Lymph node involvement (N1-2) in 86 (28.57%) and 57 (18.94%) patients were classified as forth stage (M1). Analysis is performed on a basis of oncologic history cards, during patient’s routine examinations and performance of bowel function question paper. Quality of life investigation was performed by EORTC questionnaires QLQ C30 and QLQ C38 at regular visits in 3rd, 6th, etc. months. It covered 85 (28.24%) operated people. 26 patients were included in a group for examinations of genetic aberrations of MDR1 and CYP3A5 genes. Their presentation is related to poor differentiation of rectal tumors. Investigated factors like accompanying diseases (cardiovascular, diabetes, pulmonary obstruction), complicated forms of rectal tumors and the most frequent postoperative faults were considered also. The postoperative stay varied between 7 and 23 days (on average 12±0.8). Early relaparotomias were performed in 14 patients with 1% mortality (3 cases). Result and Discussion: The most common from the sphinctersparing operative procedures were anterior resection (98 -32.6%) at different height. Pull-through techniques (Babcock-Bacon, 4 -1.3%) were changed during the last years with everting methods: Maunsell-Weir 37(12.3%) and Parks type coloanal resection in 28(12.3%). Local excision is a treatment of choice for precancerous processes, but in 21 (7%) we found an early cancer. Extirpation of rectum (Miles procedure) we applied in 73 (24.25%) and in 37 (12.3%) of cases was performed

Hartman-type operation. Three (1%) pelvis exenterations compile the extract. With the goal of better postoperative function in 39 (20.4%) of sphincter-spared patients was applied transverse coloplasty pouch technique. In locally advanced distal rectum tumors we adopted preoperative telegamatherapy (20-50 Gy - 46 (15.3%)), but we prefer small-fractions scheme (20x2Gy). We have 12(4%) postoperative radiated cases, when the radicalism was suspicious. As a part of complex treatment in 163 patients with advanced disease adjuvant chemotherapy was applied. Excellent functional reserve and values of quality of life indexes are found in local excision group. From the conventional techniques the best point score is for upper anterior resection group. Extirpated patients and these with low anastomosis demonstrate worse quality of life values. But while the first group have improving overall score during the time, these with coloanal resection, even though with pouch application, have significantly lower (P£0.05) indexes for Role Functioning QLQ C30) and Body Image (QLQ C38). The same was found concerning certain symptom scales (Pain and Stoma-related problems), longitudinally to overall tendency of worse values for this group. It was reported the fact that the treatment is applied in different operative times and this increases the risk and the level of complications. As a result of poor quality of life four of sphincter-spared patients (2.1%) choose elective stomation. Conclusion: We have better onologic and functional result from early stages of rectum carcinoma disease. The increase of sphictersparing treatment in recent years should be done carefully, with a precise selection of patients and having feedback of the outcome. Using instruments for measuring quality of life is the possibility for an adequate clinical interpretation and dynamic control over individual operative tactics.

OBSTRUCTIVE SYNDROME CAUSED BY PRIMARY COLON-RECTAL CANCER Yaramov N., Sv. Toshev, M. Sokolov, K. Angelov Department of surgery, Medical University, University hospital “Aleksandrovska” Sofia This is a report on 311 patients presenting colorectal carcinoma with complication assuming the form of occlusive ileus, observed over the period 2005 through 2009. Obturation is the commonest complication of colonic carcinoma (48.9%) with the left colon being more often involved (58.3%). During the same period of time, occlusive ileus against the background of carcinoma of the rectum is diagnosed in 61 cases, representing 37 per cent of complicated forms of this malignant neoplasm.

The scope of operative management and the procedure used are largely determined by the location of primary malignancy. The timing of undertaking one or another operative intervention depends on the efficacy of preoperative preparation, degree of occlusive ileus progress, patientr’s age, concomi-tant diseases and the like. Failing to comply with or overlooking some of the aforementioned factors invariably exerts an unfavourable effect on the final outcome of treatment. In each patient presenting colorectal-carci-

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noma-induced occlusive ileus it is mandatory to precisely specify the scope of surgery, consistent with the patient’s

general condi-tion, and eliminate the underlying cause jeopardizing his life.

Key words: colorectal carcinoma, ileus, tactics and operative treatment

OUR EXPERIENCE IN THE TREATMENT OF RECTOVAGILAL FISTULA Yaramov N., M. Sokolov, Sv. Toshev, K. Angelov Department of surgery, Medical University, University hospital “Aleksandrovska” Sofia We presented our experience in treating 109 patients with acquired rectovaginal fistula operating in the Clinic of Surgery ýà 2001-2009. In 56 patients the modified method used by Gabriel, at 20 a modified method by Gabriel with sphincterolevatorplasty, in 3 abdomino-anal resection with the fall of the sigma in demucosal anal canal, in 13 defini-

tive anus preter and in 17 out temporary anus preter subsequent expression in Gabriel.To allow a conclusion that despite the small number of cases, our results of treatment of rectovaginal fistula are encouraging with good technical and operational performance is a reliable treatment.

Key words: recto-vaginal fistulas, diagnostic and operative problems

CURRENT TREATMENT OF IV STAGE COLO-RECTAL CARCINOMA -THE SURGEON’S VIEW Kolev N., A. Tonev, K. Ivanov, V. Ignatov, Sht. Shterv, E. Kiryazov University Hospital “St. Marina”, Medical University -Varna, Department of Colorectal Surgery, I-st Clinic of Surgery Introduction: In the past decades the improvement of surgical technologies and modern adjuvant therapy lead to revolutionary changes in multimodal approach in treatment of liver metastatic lesions from colorectal cancer. The achieved results are encouraging and the surgeons receive the opportunity for individual approach to every patient for maximizing the outcome. “Which approach is suitable for which patient?” is already not a disputable question. The classic surgical approach is consist of surgical treatment of the primary tumor at first place and after that treatment of liver metastases is commenced. Despite of that in many patients the metastatic process progresses and obstructs the sanitation of the primary lesion. Upon this some authors create strategy, which includes as first step powerful

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neoadjuvant chemotherapy, as second step is commenced resection of the metastases and as last level -resection of the primary tumor. According to some authors this inverted “approach” in the treatment of colorectal cancer leads to better results in respectability and survival rate. This approach is indicated in patients with non-obstructive tumors. In the basis of this “inverted approach” stays the opinion that the patient dies from the complications, connected with metastatic disease. Conclusion: The treatment of liver metastases from colorectal cancer is a dynamic and continuing process. The multimodal approach allows building individual strategy in the treatment every single patient.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

MOLECULAR MARKERS IN COLORECTAL CANCER Ivanov K., N. Kolev, A. Tonev *Department of Colorectal Surgery, I-st Clinic of Surgery, **Clinic of Hematology, ***Department of Clinical Morphology, University Hospital “St. Marina”, Medical University -Varna Background: Colorectal cancer (CRC) is the second leading cause of death by cancer in the developed countries, comprising nearly 25% of all malignancies Identifying CRC patients with higher risk early in the course of the disease would potentially increase survival. Methods: We performed immunohistochemical detection of a panel of molecular markers in 101 CRC biopsies. The markers are involved in disturbing of the signal chain on every level and proliferative activity (STAT3, Ki67), have anti-apoptotic impact -the suppressors (bcl2) and stimulators (bax,) are directly induced by tumor-suppressing protein (p53) due to direct transcript gene expression and areconnected with tumor progression and metastases (VEGF, MMP2 and

MMP9). Findings: We generate a patient-specific index named individual risk index (IRI), which would help in determining prognosis of CRC patients. A total of 67% of the patients with clinical stage prognosis exhibited discordance with the calculated IRI values. Similarly, half of the cases showed discordance between the grade of tumour differentiation and IRI. Interpretation: The frequent finding of early CRC (stage I or II) with an unfavourable IRI could provide a better prognostic data necessary to take appropriate treatment measures in order to improve the outcome of CRC. This fact is in the base of discussion of “hidden aggression” of the tumor which could lead to fast progression and metastasing. Such kinds of aggression could not be proven with routine morphological methods.

Key words: colorectal cancer, molecular prognosis, markers

PULS OXYMETRY IN THE BOWEL ANASTOMOTIC END IN COLO-RECTAL SURGERY Kolev N., A. Tonev, V. Ignatov, G. Ivanov, K. Ivanov Pulse oximetry has been one of the most significant technological advances in clinical monitoring in the last two decades. Pulse oximetry is a noninvasive photometric technique that provides information about the arterial blood oxygen saturation (SpO2) and heart rate, and has widespread clinical applications. When peripheral perfusion is poor, as in states of hypovolemia, hypothermia and vasoconstriction, or iatrogenic surgical trauma oxygenation readings become unreliable or cease. Sometimes the insufficiency of intestinal anastomosis may be due low perfusion of anastomotic end. The mechanism is the same as conventional pulse oximetry sensors which are attached to the most peripheral parts of the body, such as finger, ear or toe, where pulsate flow is most easily compromised. Since central blood flow may be

preferentially preserved, this topic explores a new alternative site, the anastomotic end of the bowels, for monitoring blood oxygen saturation by pulse oximetry. We present the basic physics, technology and applications of pulse oximetry including photoplethysmography. The limitations of this technique are also discussed leading to the proposed development of the anastomotic pulse oximeter. In conclusion, the use of our novel pulse oximeter has proven for the first time that the safety of anastomosis in colorectal surgery could be evaluate in one new manner which is reliable and accurate. Such kind of monitoring the blood oxygen saturation in patients with major colorectal surgery could decrease the rate of anastomotic complications.

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HIGH TECHNOLOGICAL MANAGEMENT OF COLORECTAL CANCER Kolev N., A. Tonev, V. Ignatov, K. Ivanov Introduction: A general improvement of colorectal cancer prognosis and treatment has been observed because of diffusion in screening, advancements in molecular biology, new developments in chemotherapy and surgical techniques. Through the data of our experience in colorectal cancer surgery, we evaluate changes in surgical procedures for colorectal neoplasms that influent most on improvements on the results. The use of molecular profiling, Dual Source CT, PET-CT, sentinel lymph node mapping,

endorectal and intraoperative ultrasonography are the most valuable diagnostic tools of future. The new laparoscopic instruments, staplers and devices for cutting and hemostasing make the difference between the past and present time. Patients and Methods: Patients with colorectal cancer were operated from 1994 to 2006. The main surgical procedures were recorded and classified.

LAPAROSCOPIC INTER-SPHINCTERIC RESECTION Ivanov K. I-st Clinic of Surgery, University Hospital "St. Marina" Intersphincteric resection (ISR) has been increasingly used as a surgical treatment for low rectal cancer. We hypothesized that high quality less invasive surgery could be achieved if ISR and laparoscopic surgery were combined. The patient was a 46-year-old male with rectal cancer on the lower rectum adjacent to the dentate line. The patient refused abdomino-perineal resection (APR), so we performed laparoscope ISR. This patient showed favorable recovery including postoperative anal function with no complications. This procedure is feasible and has favorable short-term results for the radical treatment of low rectal disease, while preserving anal function. This operative procedure may be appropriate for low rectal cancers to avoid a permanent colostomy. Results: Regression analysis showed an increase over time of right and left hemicolectomy. Both colectomy and endo-

scopic polypectomy showed significant rise over time. In contrast, abdominoperineal operations dropped during the study period. A similar decrease was observed for palliative surgery. Perioperative mortality declined from 16% to 3% of all operations; main factors associated with perioperative mortality were presence of comorbidities, increasing age and advanced stage. Conclusion: The better prognosis of patients with colorectal cancer was associated with changes of surgical techniques, with a tendency to prefer large operations over limited resections. Perioperative mortality showed a gradual decrease and is at present in the order of 3% to 6% of all operations. Improvements in survival rate and perioperative morbidity are observed.

ÍÀØÈßÒ ÎÏÈÒ Â ÎÏÅÐÀÒÈÂÍÎÒÎ ËÅ×ÅÍÈÅ ÍÀ ÄÈÑÒÀËÍÈÒÅ ÊÀÐÖÈÍÎÌÈ ÍÀ ÏÐÀÂÎÒÎ ×ÅÐÂÎ Äàìÿíîâ Í. ÂÌÀ, Ñåêòîð “Êîëîïðîêòîëîãèÿ”, ÊÅÕ Äèñòàëíèòå êàðöèíîìè íà ðåêòóìà (ÊÐ) àíãàæèðàò åêñòðàïåðèòî-íåàëíàòà ÷àñò íà ÷åðâîòî. Îñíîâíè ïðîáëåìè, êîèòî õèðóðãè÷åñêîòî ëå÷åíèå òðÿáâà äà

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ðàçðåøè, ñà ïðåæèâÿåìîñò áåç ðåöèäèâ íà çàáîëÿâàíåòî è èçáÿãâàíå íà äåôèíèòèâíîòî ñòîìèðàíå. Îïåðàòèâíàòà òåõíèêà îñâåí, ÷å âëèÿå íà

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ïðîãíîçàòà îïðåäåëÿ è ïîñòîïåðàòèâíîòî êà÷åñòâî íà æèâîò. 3D äèñåêöèÿòà å ñòàíäàðòíà îïåðàòèâíà òåõíèêà çà òðîåí êàðöèíîìåí êëèðúíñ - Ro ðåçåêöèÿ. Ðàäèêàëíî îïåðèðàíèòå ñà ñ 70% ïðåæèâÿåìîñò è ëîêàëíèòå ðåöèäèâè (ËÐ) ñà ïîä 10%. Äèñòàëíèòå ÑÇÎ, íåðâñúõðàíÿâàùàòà äèñåêöèÿ è ðåêîíñòðóêòèâíèòå àíàñòîìîçè, îïòèìèçèðàò ïîñòîïåðàòèâíàòà ôóíêöèÿ íà ìàëêîòàçîâèòå îðãàíè. Ìàòåðèàë è ìåòîäè: Ðàäèêàëíî îïåðèðàíè ñà 187 ïîñëåäîâàòåë-íè äèñòàëíè ÊÐ îò 1995 äî 2007ã., îò òÿõ 111 ñà ìúæå è 76 æåíè. Âúçðàñòòà å îò 21 äî 83 ã., à Ò3 òóìîðèòå ñà 52%, Ò4 - 7% èëè àâàíñèðàëèòå ÊÐ îáùî ñà 59%. Â ²²²-èÿ ñòàäèé íà çàáîëÿâàíåòî ñà 41 áîëíè (22%). Áëèçî 1/2 îò ÊÐ â ìàòåðèàëà äîñòèãàò íà 4 - 5 ñì îò àíîêóòàííèÿ ðúá (ÀÊÐ). ÐÅÇÓËÒÀÒÈ: ÑÇÎ ñà 141 (75%), îò êîèòî íèñêè ïðåäíè ðåçåêöèè íà ðåêòóìà (ÏÐÐ) è óëòàðíèñêè ÏÐÐ

ñà 56, 73 ðåñòîðàòèâíè ïðîêòåêòîìèè (ÐÏ) 3 Hartmann îïåðàöèè, 8 èíòðàñôèíêòåðíè ðåçåêöèè (ÈÑÐ) è 1 ðåñòîðàòèâíà ïðîêòîêîëåêòîìèÿ. Äèðåêòíèòå àíàñòîìîçè ñà 73, à ðåêîíñòðóêòèâíèòå - 66. Âèäîâåòå ÑÇÎ çàâèñÿò îò ðàçñòîÿíèåòî íà òóìîðà îò ÀÊÐ. Àáäîìèíîïåðèíåàëíè åêñòèðïàöèè (ÀÏÅ) ñà 48 ËÐ ñà 16, à ïåòãîäèøíàòà ïðåæèâÿåìîñò, ïðîñëåäåíà ïðè 59% îò ïàöèåíòèòå å 69%. Çàêëþ÷åíèå: Òðèèçìåðíàòà äèñåêöèÿ ïîñòèãà ïðè ¾ îò äèñòàëíèòå ÊÐ Ro ðåçåêòàò è çà òÿõ èíòåðâåíöèèòå òðÿáâà äà ñà ÑÇÎ. Ðåêîíñòðóêòèâíèòå àíàñòîìîçè è íåðâñúõðàíÿâàùàòà äèñåêöèÿ çà ãîëÿìà ÷àñò îò äèñòàëíèòå ÑÇÎ ïîñòèãàò êà÷åñòâî íà æèâîò áëèçêî äî ïðåäîïåðàòèâíîòî.

Êëþ÷îâè äóìè: äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ), ñôèíêòåðîçàïàçâàùè îïåðàöèè (ÑÇÎ)

ÕÈÐÓÐÃÈ×ÍÎ ËÅ×ÅÍÈÅ ÍÀ ÂÒÎÐÈ×ÍÀÒÀ ÂÇÐÈÂÍÀ ÒÐÀÂÌÀ ÍÀ ÒÀÇÀ, ÑÚ×ÅÒÀÍÀ Ñ ÏÐÎÍÈÊÂÀÙÎ ÍÀÐÀÍßÂÀÍÅ ÍÀ ÐÅÊÒÓÌÀ - ÊËÈÍÈ×ÅÍ ÑËÓ×ÀÉ Ìóòàô÷èéñêè Â., Í. Âëàäîâ, Âë. Ïåíîâ ÂÌÀ Ñîôèÿ, Êëèíèêà ïî Æëú÷íî-×åðíîäðîáíà è Ïàíêðåàòè÷íà Õèðóðãèÿ Èçîëèðàíèòå òðàâìàòè÷íè óâðåäè íà ðåêòóìà â ðåçóëòàò îò âçðèâíà òðàâìà ïîñòàâÿò çíà÷èòåëíè äèàãíîñòè÷íè è òåðàïåâòè÷íè ïðåäèçâèêàòåëñòâà. Ïðåäñòàâÿìå 36 ãîäèøåí âîåííîñëóæåù ñ âçðèâíî ïðîíèêâàùî íàðàíÿâàíå íà ðåêòóìà, óâðåæäàíèÿ íà ïèêî÷îïîëîâàòà ñèñòåìà è îïîðíîäâèãàòåëíèÿ àïàðàò ñú÷åòàíî ñ ìàñèâíà êðúâîçàãóáà è õåìîðàãè÷åí øîê.

Ëå÷åíèåòî íà ïàöèåíòà å èçâúðøâàíî ñúãëàñíî âîåííî-ìåäèöèíñêàòà äîêòðèíà íà NATO è íàé-ñúâðåìåííèòå õèðóðãè÷íè ïðèéîìè çà ëå÷åíèå íà áîéíèòå òðàâìè, ïîâå÷åòî îò òÿõ èçïîëçâàíè çà ïúðâè ïúò â Áúëãàðèÿ - Inter-Pulse Jet èðèãàöèÿ è V.A.C®. Therapy System.

Êëþ÷îâè äóìè: Âçðèâíà òðàâìà, Ïðîíèêâàùè íàðàíÿâàíèÿ íà ðåêòóìà, Êîëîñòîìà, Damage Control Surgery, Inter-Pulse Jet èðèãàöèÿ, V.A.C®. Therapy System

ÍÎÂÈ ÕÈÐÓÐÃÈ×ÍÈ ÏÎÄÕÎÄÈ ÏÐÈ ÌÓËÒÈÌÎÄÀËÍÎÒÎ ËÅ×ÅÍÈÅ ÍÀ ×ÅÐÍÎÄÐÎÁÍÈÒÅ ÊÎËÎÐÅÊÒÀËÍÈ ÌÅÒÀÑÒÀÇÈ Âëàäîâ Í., È. Âàñèëåâñêè, È. Òàêîðîâ Êëèíèêà ïî æëú÷íî-÷åðíîäðîáíà è ïàíêðåàòè÷íà õèðóðãèÿ, Âîåííî-ìåäèöèíñêà Àêàäåìèÿ - Ñîôèÿ Öåë: Öåëòà íà òîâà ïðîó÷âàíå å äà àíàëèçèðà âëèÿíèåòî íà àãðåñèâíîòî õèðóðãè÷íî ïîâåäåíèå ïðè ðåçåêöèè íà ÷åðíîäðîáíè êîëîðåêòàëíè ìåòàñòàçè

âúðõó çàáîëÿâîåìîñòòà, ñìúðòíîñòòà è ïðåæèâÿåìîñòòà, êàêòî è äà ñå èçòúêíå ïîëçàòà îò ìóëòèìîäàëíèÿ ïîäõîä â ïîñîêà íà óâåëè÷àâàíå 289

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ñòåïåíòà íà ðåçåêòàáèëíîñò ïðè ÷åðíîäðîáíèòå ìåòàñòàçè. Ïàöèåíòè è ìåòîäè: Îò ÿíóàðè 2004 ã. äî ìàé 2009 ã. â êëèíèêàòà ñà îïåðèðàíè 290 ïàöèåíòè îò êîëîðåêòàëåí êàðöèíîì. Ðàäèêàëíè ÷åðíîäðîáíè ðåçåêöèè ïðè 124 áîëíè ñ ÷åðíîäðîáíè ìåòàñòàçè ñ ïðèëàãàíåòî íà ðàçëè÷íè ìåòîäèêè çà óâåëè÷àâàíå íà ðåçåêòàáèëíîñòòà, êàòî 75 ñà ìúæå è 49 æåíè, íà ñðåäíà âúçðàñò 59 ãîäèíè. Ïðè 24 ïàöèåíòà /19.4%/ ñà èçâúðøåíè ñèíõðîííè åäíîåòàïíè ðåçåêöèè íà êîëîðåêòàëíèÿ êàðöèíîì ñ ÷åðíîäðîáíè ìåòàñòàçè; ïðè 2/24 å èçâúðøåíî åäíîåòàïíî õåìèêîëåêòîìèÿ, ìåòàñòàçåêòîìèÿ è ëèãèðàíå äåñíèÿ êëîí íà âåíà ïîðòå. Ïðè äðóãè 2/24 - åäíîåòàïíà ðåçåêöèÿ íà ïúðâè÷íèÿ òóìîð çàåäíî ñ ðåçåêöèÿ íà ÷åðíîäðîáíè

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ìåòàñòàçè è òåðìîàáëàöèÿ íà äðóãè. Ðåçåêöèÿ ñëåä àäþâàíòíà õèìèîòåðàïèÿ å èçâúðøåíî ïðè 35/124 ïàöèåíòà /28%/. Ðåçåêöèÿ ñëåä ëèãàòóðà íà äåñíèÿ êëîí íà âåíà ïîðòå ïðè 5 ïàöèåíòà. Â êîíòåêñòà íà àãðåñèâíîòî õèðóðãè÷íî ïîâåäåíèå ðåçåêöèè íà ìåòàñòàçè ïî-ãîëåìè îò 5 ñì. ñà èçâúðøåíè ïðè 20 ïàöèåíòà. Ïðè 5 ïàöèåíòà å èçâúðøåíà ïàðöèàëíà ðåçåêöèÿ íà âåíà ïîðòå. Ëàïàðîñêîïñêà ÷åðíîäðîáíà ðåçåêöèÿ ïðè ÷åðíîäâðîáíè ìåòàñòàçè â 9 ñëó÷àÿ. Çàêëþ÷åíèå: Íàëè÷èåòî íà ÷åðíîäðîáíè ìåòàñòàçè íå å ïðèçíàê íà èíêóðàáèëíîñò. Ëå÷åíèåòî íà ÷åðíîäðîáíèòå êîëîðåêòàëíè ìåòàñòàçè íà íàñòîÿùèÿ åòàï èçèñêâà ìóëòèìîäàëåí ïîäõîä, âêëþ÷âàù õåïàòîáèëèàðåí õèðóðã, îíêîëîã, ðàäèîëîã, àíåñòåçèîëîã è ãàñòðîåíòåðîëîã.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ÒÀÇÎÂÀÒÀ ÅÂÈÑÖÅÐÀÖÈß - ÌÅÒÎÄ ÍÀ ÈÇÁÎÐ Àíãåëîâà Å., Â. Äèìèòðîâ, Ï. Êóðòåâ, Ê. Ðàë÷åâ, Ë. Äæîíãîâ, Ë. Âàðòàíÿíîâ, Â. ßíêîâ, Â. Ãåîðãèåâ, Ê. Åíèêîâ, É. Ñèìåîíîâ ÑÁÀËÎ - Êëèíèêà ïî îáùà è êîðåìíà õèðóðãèÿ Òàçîâàòà åâèñöåðàöèÿ êàòî îïåðàòèâåí ìåòîä ñå õàðàêòåðèçèðà ñ íèñêà ïîïóëÿðíîñò, îáóñëîâåíà îò êðèòè÷íèòå åòàïè, ïðè êîèòî ñå íàðóøàâà êîíòèíåíòíîñòòà è ðåñïåêòèâíî êà÷åñòâîòî íà æèâîò íà ïàöèåíòà.Òîâà å ñâúðçàíî ñ íåãîâîòî èãíîðèðàíå è îáÿâÿâàíå íà ãîëÿì ïðîöåíò îò áîëíèòå êàòî íåîïåðàáèëíè. Öåë: Äà ñå ðàçêðèÿò äîïúëíèòåëíèòå âúçìîæíîñòè çà ðàçøèðÿâàíå îáåìà íà îïåðàòèâíèòå èíòåðâåíöèè ïðè ñïàçâàíå íà ìàêñèìàëíà îíêîëîãè÷íà ðàäèêàëíîñò çà óäúëæàâàíå ïðîäúëæèòåëíîñòòà è êà÷åñòâîòî íà æèâîò ïðè ïàöèåíòè ñ àâàíñèðàëè òóìîðè â ìàëêèÿ òàç. Ìàòåðèàë è Ìåòîäè: Èçñëåäâàíåòî âêëþ÷âà 107 áîëíè (77 æåíè (72 %), 30 ìúæå (28 %) íà âúçðàñò 31-76 ã.), îïåðèðàíè â êëèíèêàòà íà ÍÑÁÀËÎ ñ àâàíñèðàëè òóìîðíè ôîðìàöèè â ìàëêèÿ òàç çà ïåðèîäà îò 20012008 ãîä. Èçâúðøåíè ñà ñëåäíèòå îïåðàòèâíè èíòåðâåíöèè: · çàäíà òàçîâà åâèñöåðàöèÿ -60 áîëíè ( 56,07% ); · òîòàëíà òàçîâà åâèñöåðàöèÿ -12 áîëíè ( 11,21% ); · ïðåäíà òàçîâà åâèñöåðàöèÿ -25 áîëíè ( 23,36 %); · ÷àñòè÷íà òàçîâà åâèñöåðàöèÿ -10 áîëíè ( 9,35 %). Êàòî ðåêîíñòðóêòèâíèòå îïåðàòèâíè èíòåðâåíöèè ñà: · ðåçåêöèÿ íà ðåêòóìà - 16 ïàöèåíòà (14,95 %); · ðåçåêöèÿ íà ðåêòóìà ñ èçâåäåíà ïðîôèëàêòè÷íà èëåîñòîìà - 20 ïàöèåíòà (18,70%) îò êîèòî ïðè 13 å èçâåäíà èëåîñòîìà, à ïðè 7 òðàíçâåðçîñòîìà; · ðåçåêöèÿ íà ðåêòóìà ñ ïðîôèëàêòè÷íà èëåîñòîìà èçâúðøåíè ñúñ ñúøèâàòåë -14 ïàöèåíòà (13,08 %); · åêñòèðïàöèÿ íà ðåêòóìà -14 ïàöèåíòè (13,08 %); · îïåðàöèÿ ïî ìåòîäà íà Hartman -16 ïàöèåíòè (14,95 %); · ïðîêòîêîëåêòîìèè - 3 ïàöèåíòà (2,80 %);

· îïåðàöèÿ ïî ìåòîäà íà Briñker

-17 ïàöèåíòà (15,89 %); · óðåòåðîêóòàíåîñòîìà - 13 ïàöèåíòà (12,15 %); · îïåðàöèÿ ïî ìåòîäà íà Studer- 1 ïàöèåíòà (0,93 %); · òðàíñóðåòåðîàíàñòîìîçà t-t ñ íåôðîñòîìà

- 2 ïàöèåíòà (1,87 %). Ðåçóëòàòè: Ñðåäíàòà ïåò ãîäèøíà ïðåæèâÿåìîñò íà îïåðèðàíèòå ïàöèåíòè ñ òàçîâà åâèñöåðàöèÿ å 57 % ò.å. æèâè çà òîçè ïåðèîä îò âðåìå ñà 61 ïàöèåíòè, îò êîèòî 15 ìúæå è 46 æåíè. Ëèïñâà èíòðàîïåðàòèâíà ñìúðòíîñò. Ïî÷èíàë å åäèí ïàöèåíò ñ êëèíèêà íà ÁÒÅ 0,93 % ïîñòîïåðàòèâåí ìîðòàëèòåò. Ñëåäîïåðàòèâíèòå óñëîæíåíèÿ ñà íàñòúïèëè ïðè 23 (21,49%) ïàöèåíòà, ïðè êîåòî ñà èçâúðøåíè 12 ðåîïåðàöèè (11,21%): · êúðâåíå - 2 áîëíè (1,87%) - ðåîïåðèðàíè 2 (1,87 %); · ïåðèòîíèò -6 áîëíè (5,61 %) - ðåîïåðèðàíè 6 (5,61 %); · èëåóñ - 2 áîëíè (1,87 %); · äåõèñöåíöèÿ - 2 áîëíè (1,87 %) - ðåîïåðèðàíè 2 (1,87 %); · ñóïîðàöèÿ íà îïåðàòèâíà ðàíà - 2 áîëíè (1,87 %); · ìèêöèîííè - 5 áîëíè (4,67 %); · ëèìôîðåÿ - 1 áîëåí (0,93 %); · ëåçèÿ íà óðåòåð - 2 áîëíè (1,87 %) - ðåîïåðèðàíè 2 (1,87 %); · ÁÒÅ - 1 áîëåí (0,93 %). Çàêëþ÷åíèå: Òàçîâàòà åâèñöåðàöèÿ e ìóëòèäèñöèïëèíàðåí ìåòîä, êîéòî èìà ñâîåòî ïðèëîæåíèå ñëåä ùàòåëíà è àäåêâàòíà ïðåöåíêà â êîìïëåêñíîòî ëå÷åíèå íà àâàíñèðàëè òóìîðè â ìàëêèÿ òàç è å åòàï îò áîðáàòà ñâúðçàíà ñ ïîäîáðÿâàíå êà÷åñòâîòî íà æèâîò è íåãîâàòà ïðîäúëæèòåëíîñò.

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ËÀÏÀÐÎÑÊÎÏÑÊÎ ÈËÈ ÎÒÂÎÐÅÍÎ ÕÈÐÓÐÃÈ×ÍÎ ËÅ×ÅÍÈÅ ÍÀ ÇÀÁÎËßÂÀÍÈßÒÀ ÍÀ ÄÅÁÅËÎÒÎ È ÏÐÀÂÎÒÎ ×ÅÐÂÎ ÊÚÄÅ ÑÌÅ ÍÈÅ (12-ÃÎÄÈØÅÍ ÎÏÈÒ ÍÀ ÊËÈÍÈÊÀ ÏÎ ÅÍÄÎÑÊÎÏÑÊÀ ÕÈÐÓÐÃÈß - ÂÌÀ) Èâàíîâ Ï., K. Âàñèëåâ, Ã. Ãúðáåâ. Êëèíèêà ïî åíäîñêîïñêà õèðóðãèÿ, Âîåííî Ìåäèöèíñêà àêàäåìèÿ - Ñîôèÿ Ìíîãî ñêîðî ñëåä ïúðâàòà ëàïàðîñêîïñêà äåáåëî÷ðåâíà ðåçåêöèÿ (1991ã), ëàïàðîñêîïñêàòà êîëîðåêòàëíà õèðóðãèÿ íàâëåçå êàòî ìåòîä çà îïåðàòèâíî ëå÷åíèå íà ìàëèãíåíèòå è áåíèãíåíè çàáîëÿâàíèÿ íà äåáåëîòî è ïðàâîòî ÷åðâî. Ïðåç ãîäèíèòå ëàïàðîñêîïñêàòà êîëîðåêòàëíà õèðóðãèÿ ñå ðàçïðîñòðàíè ïîâñåìåñòíî â ãîëåìèòå áîëíè÷íè öåíòðîâå ïî ñâåòà, òúé êàòî å ñâúðçàíà ñ íàëè÷èåòî íà ñêúïîñòðóâàùà àïàðàòóðà, à îò õèðóðãè÷íèòå åêèïè ñå èçèñêâà ãîëÿì îïèò â ëàïàðîñêîïñêàòà õèðóðãèÿ. Â íàñòîÿùèÿ äîêëàä ñïîäåëÿìå íàøèÿò 12 ãîäèøåí îïèò îò ïðèëîæåíèåòî íà ëàïàðîñêîïñêà äåáåëî÷ðåâíà õèðóðãèÿ è àíàëèçèðàìå ïîñòèãíàòèòå ðåçóëòàòè. Ìàòåðèàë è ìåòîäè: Ïðåç ïåðèîäà 1998 -2009 ã. â êëèíèêàòà ñà èçâúðøåíè 166 ëàïàðîñêîïñêè êîëîðåêòàëíè ðåçåêöèè - 42 ïðè áåíèãíåíè è 124 ïðè ìàëèãíåíè çàáîëÿâàíèÿ íà äåáåëîòî è ïðàâîòî ÷åðâî. Èçâúðøåíè ñà âñè÷êè òèïîâå ðåçåêöèè -îò ñåãìåíòíà ðåçåêöèÿ íà ñèãìà äî ïðîêòîêîëåêòîìèÿ. Âúçðàñòòà íà ïàöèåíòèòå âàðèðà îò 29 äî 84 ãîäèíè. Àíàëèçèðàíèòå ðåçóëòàòè ñà áîëíè÷åí ïðåñòîé, îïåðàòèâíî âðåìå, âðåìå íà âúçñòàíîâÿâàíå íà ÷ðåâíèÿ ïàñàæ è ôèçè÷åñêàòà àêòèâíîñò, îïåðàòèâíàòà êðúâîçàãóáà, ñòåïåíòà íà ïîñòîïåðàòèâíà áîëêà, èíòðà è ïîñòîïåðàòèâíè óñëîæíåíèÿ, êà÷åñòâî íà æèâîò. Ïðè îïåðàöèèòå ïî ïîâîä íà ìàëèãíåíè ïðîöåñè îñâåí òîâà îò÷èòàìå áðîé îòñòðàíåíè ëèìôíè âúçëè, äúëæèíà íà ðåçåöèðàíèÿ ñåãìåíò, îòñòîÿíèå íà ðåçåêöèîííèòå ãðàíèöè è òÿõíàòà „÷èñòîòà”, òðàíñâåðçàëíà ãðàíèöà ïðè òîòàëíàòà ìåçîðåêòàëíà åêñöèçèÿ, ÷åñòîòà íà ðåöèäèâè è ðàííà è êúñíà ïðåæèâÿåìîñò. Ðåçóëòàòè: Îïåðàòèâíîòî âðåìå âàðèðàøå îò 80 ìèí. äî 325 ìèí., êàòî ñëåä ïúðâîíà÷àëíèòå 40 îïåðàöèè

292

÷óâñòâèòåëíî íàìàëÿâàøå. Ñðåäíèÿò áîëíè÷åí ïðåñòîé áåøå 4.7 äíè. Ïàöèåíòèòå ñå çàõðàíâàõà ñ òå÷íîñòè ïúðâèÿ ñëåäîïåðàòèâåí äåí, à ñ êàøàâè õðàíè îò âòîðèÿ. Ïàñàæúò ñå âúçñòàíîâÿâàøå ìåæäó 2 è 4 äåí îò îïåðàöèÿòà. Èìàøå äâà ñëó÷àÿ íà êîíâåðñèÿ. Íÿìàøå ïåðèîïåðàòèâíà ñìúðòíîñò. Ïîñòîïåðàòèâíèòå óñëîæíåíèÿ áÿõà 12.44%, êàòî òÿõíîòî ëå÷åíèå ïðîòè÷àøå ïî-ëåêî â ñðàâíåíèå ñ êîíâåíöèîíàëíèòå ðåçåêöèè è íå ñå íàëàãàõà ðåîïåðàöèè. Ñðåäíàòà îïåðàòèâíà êðúâîçàãóáà âàðèðàøå îò 100 äî 225 ìë. Èìàøå äâà ñëó÷àÿ íà ìåòàñòàçè íà òðîàêàðåí ïîðò. Áðîÿò îòñòðàíåíè ëèìôíè âúçëè áåøå â ãðàíèöèòå 9-26 â çàâèñèìîñò îò òèïà ðåçåêöèÿ, ðåçåêöèîííèòå ãðàíèöè, èçñëåäâàíè õèñòîëîãè÷íî áÿõà ÷èñòè ïðè âñè÷êèòå îïåðàöèè. Ïðåæèâÿåìîñòòà âàðèðàøå â çàâèñèìîñò îò âèäà íà òóìîðèòå è ñòàäèÿ, íî íå ñå ðàçëè÷àâàøå îò òàçè ïðè êîíâåíöèîíàëíèòå îïåðàòèâíè èíòåðâåíöèè. Èìàõìå 2 ñëó÷àÿ íà ðåöèäèâè. Èçâîäè: Èçõîæäàéêè îò ñâîÿ 12 ãîäèøåí îïèò, ìîæåì äà òâúðäèì, ÷å ëàïàðîñêîïñêàòà êîëîðåêòàëíà õèðóðãèÿ ïðèòåæàâà âñè÷êè ïðåäèìñòâà íà ìèíèèíâàçèâíà ìåòîäèêà, à èìåííî -ïî-êðàòúê áîëíè÷åí ïðåñòîé, ïî-áúðçî âúçñòàíîâÿâàíå íà ÷ðåâíèÿ ïàñàæ è ôèçè÷åñêàòà àêòèâíîñò, ïî-ìàëêà ñëåäîïåðàòèâíà áîëêà, ïî-äîáúð êîçìåòè÷åí åôåêò. Àíàëèçà íà äàííèòå è ïðîñëåäÿâàíåòî íà ðåçóëòàòèòå íè äàâà îñíîâàíèå äà ïðèåìåì, ÷å ëàïàðîñêîïñêàòà õèðóðãèÿ íà äåáåëîòî ÷åðâî è ðåêòóìà èìà ñâîåòî ìÿñòî ïðè îïåðàòèâíîòî ëå÷åíèå íà çàáîëÿâàíèÿòà íà êîëîíà è ðåêòóìà, òÿ å òåõíè÷åñêè òðóäíà, íî ùàäÿùà è íîñåùà ïîëçè íà ïàöèåíòà, à íå íà ïîñëåäíî ìÿñòî -å è èêîíîìè÷åñêè èçãîäíà.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ÎÖÅÍÚ×ÍÀ ÑÊÀËÀ ÇÀ ÎÏÐÅÄÅËßÍÅ ÊÀ×ÅÑÒÂÎÒÎ ÍÀ ÆÈÂÎÒ ÑËÅÄ ÒÐÀÍÑÀÍÀËÍÀ ÅÍÄÎÑÊÎÏÑÊÀ ÌÈÊÐÎÕÈÐÓÐÃÈß Ãúðáåâ Ã., Ê. Âàñèëåâ, Ï. Èâàíîâ Âîåííîìåäèöèíñêà Àêàäåìèÿ, Ñîôèÿ, Êëèíèêà ïî åíäîñêîïñêà õèðóðãèÿ Âúâåäåíèå: Êà÷åñòâîòî íà æèâîò íà ïàöèåíòèòå å îñíîâåí åëåìåíò îò òúðñåíèÿòà íà õèðóðçèòå íà íîâè è óñúâúðøåíñòâàíè õèðóðãè÷íè òåõíèêè. Êîãàòî ñðàâíÿâà ÒÅÌ ñ ëàïàðîñêîïñêàòà è ñ îòâîðåíàòà õèðóðãèÿ, G. Buess êàçâà: „Ïîñòîÿííà ñòîìà, èìïîòåíòíîñò, óðèíàðíà äèñôóíêöèÿ, çíà÷èòåëíî ïî-âèñîê ïðîöåíò ñëåäîïåðàòèâíè óñëîæíåíèÿ è ñìúðòíîñò - òîâà ëè å äîáðàòà ìåäèöèíà?” Ìàòåðèàë è ìåòîäè: Â äîñòúïíàòà íè ëèòåðàòóðà íå îòêðèõìå ñêàëà, ïî êîÿòî áúðçî è ëåñíî äà îïðåäåëÿìå êà÷åñòâîòî íà æèâîò íà ïàöèåíòèòå ñëåä ÒÅÌ è ñëåä ëàïàðîñêîïñêè (ËÐ) è îòâîðåíè (ÎÐ) êîëîðåêòàëíè ðåçåêöèè. Àíàëèçèðàìå êà÷åñòâîòî íà æèâîò (ÊÆ) ñëåä ÒÅÌ, ÎÐ è ËÐ êàòî èçïîëçâàìå ñúçäàäåíàòà îò íàñ òàáëèöà çà îöåíêà íà Êà÷åñòâî íà æèâîò è èçïîëçâàéêè êðèòåðèèòå íà EuroQol -EQ-5D, EQ-VAS. Ðåçóëòàòè è îáñúæäàíå: Èçïîëçâàíàòà îò íàñ îöåíú÷íà ñêàëà îáåäèíÿâà è âêëþ÷âà êðèòåðèè îò òåçè òðè ñêàëè è òî÷íà è ñðàâíèòåëíî ëåñíà çà åæåäíåâíî ïðèëîæåíèå. Ìàêñèìàëíèÿò áðîé òî÷êè å 18 è òîâà å êðèòåðèé çà íåïðîìåíåíî îò îïåðàöèÿòà ñúñòîÿíèå.

Ïðèåìàìå ÷å ïîíèæåíèåòî äî 3 òî÷êè å êðèòåðèé çà îòëè÷íî êà÷åñòâî íà æèâîò, çà äîáðî -ïîíèæåíèå 4-6 òî÷êè, çà çàäîâîëèòåëíî - ïîíèæåíèå 7-8 òî÷êè è çà ëîøî -ïîíèæåíèå íàä 8 òî÷êè. Êà÷åñòâîòî íà æèâîò íà ñåäìè ñëåäîïåðàòèâåí äåí ïðè ïàöèåíòèòå ñëåä ÒÅÌ å ñðåäíî 15 òî÷êè (12÷18 òî÷êè), ñëåä ËÐ - 12 òî÷êè, à ñëåä ÎÐ -3 òî÷êè Çàêëþ÷åíèå: Êîëîðåêòàëíèòå îòâîðåíè è ëàïàðîñêîïñêè îïåðàöèè ñà ñúïðîâîäåíè ñúñ ñåêñóàëíà è óðèíàðíà äèñôóíêöèÿ, çíà÷èòåëíî ïî-âèñîê ïðîöåíò ñëåäîïåðàòèâíè óñëîæíåíèÿ è ñìúðòíîñò. Ïîíèæåíèåòî íà êà÷åñòâîòî íà æèâîò ïðè ÒÅÌ å íàé-âå÷å çà ñìåòêà íà ñëó÷àèòå íà âðåìåíà äèñôóíêöèÿ íà àíîðåêòàëíèòå ñôèíêòåðè. Íèå íå íàáëþäàâàìå ñëó÷àè íà ïúëíà èíêîíòèíåíöèÿ, à ñàìî íà âðåìåííà äèñôóíêöèÿ, èçðàçÿâàùà ñå åäèíñòâåíî â íåêîíòðîëèðóåìî èçïóñêàíå íà ãàçîâå. Òåçè îïëàêâàíèÿ îòçâó÷àâàò çà 5-6 äî 12 äíè. Íà ïðîñëåäÿâàùèòå âèçèòè íà 30-ÿ ñëåäîïåðàòèâåí äåí ïàöèåíòèòå ñïîäåëÿò, ÷å òåçè îïëàêâàíèÿ ñà íàïúëíî îòçâó÷àëè.

ËÀÏÀÐÎÑÊÎÏÑÊÀ ÓËÒÐÀÍÈÑÊÀ ÏÐÅÄÍÀ ÐÅÇÅÊÖÈß Ñ ÊÎËÎÀÍÀËÍÀ ÀÍÀÑÒÎÌÎÇÀ - ÐÀÍÍÈ ÐÅÇÓËÒÀÒÈ Âàñèëåâ Ê., Ï. Èâàíîâ, Ã. Ãúðáåâ, Ã. Ãðèãîðîâ, Â. Õðèñòîâà Êëèíèêà ïî åíäîñêîïñêà õèðóðãèÿ, Âîåííî Ìåäèöèíñêà àêàäåìèÿ - Ñîôèÿ Âúâåäåíèå: Ïðåäñòàâÿìå íàøèÿ íà÷àëåí îïèò îò ëå÷åíèåòî íà ðåêòàëíèÿ êàðöèíîì ðàçïîëîæåí â äîëíàòà ÷àñò íà ðåêòóìà, êàòî èçïîëçâàíèòå ëàïàðîñêîïñêè òåõíèêè íå íàðóøàâàò îíêîëîãè÷íèòå ïðèíöèïè çà ëå÷åíèå. Ìàòåðèàë è ìåòîäè: Çà âðåìåòî îò 2006 äî 2008 ãîäèíà - òðè ãîäèøåí ïåðèîä ñìå èçâúðøèëè 26 ëàïàðîñêîïñêè îïåðàòèâíè èíòåðâåíöèè, ïðè êîòî ñìå èçïîëçâàëè òåõíèêè çà îñúùåñòâÿâàíå íà êîëîàíàëíè àíàñòîìîçè ðàçäåëåíè â äâå ãðóïè. Ïðè 20 ïàöèåíòè ñ íèñúê ðåêòàëåí êàðöèíîì, ñëåä ðåçåêöèÿòà ñìå ïðèëîæèëè ñòàïëåðíà òåõíèêà çà èçâúðøâàíå íà óëòðàíèñêàòà àíàñòîìîçà è 6 ïàöèåíòè ïðè êîèòî ñìå èçâúðøèëè èíòðàñôèíêòåðíà ðåçåêöèÿ ñ åêñòðàêîðïîðàëíà àíàñòîìîçà. Ëàïàðîñêîïñêà òîòàëíà

ìåçîðåêòàëíà åêñöèçèÿ (ËÒÌÅ) ñìå èçâúðøèëè ïðè âñè÷êè ïàöèåíòè â ïúëåí îáåì ñúñ ñúõðàíÿâàíå íà èíåðâàöèÿòà íà òàçîâîòî äúíî. Ïðè ñòàïëåðíàòà òåõíèêà ñìå èçâúðøâàëè àíàñòîìîçàòà êðàé â êðàé, êàòî ñìå ïîñòàâÿëè ïðåäèìíî êîðåìåí äðåíàæ è ñàìî ïðè íóæäà íà îãðàíè÷åí áðîé ïàöèåíòè òðàíñïåðèíåàëåí. Íå ñìå èçïîëçâàëè ïðîòåêòèâíà ñòîìà èëè êîëîïëàñòèêà. Íå èçâúðøâàìå ïåðèòîíèçàöèÿ íà òàçîâîòî äúíî. Ïðè 6-òå ñëó÷àÿ ñ èíòðàñôèíêòåðíà ðåçåêöèÿ èçâúðøâàìå êîëî-àíàëíàòà àíàñòîìîçà êàòî èçïîëçâàìå ïðîçðà÷åí àíîñêîï íà Longo. Ïðè òåçè ïàöèåíòè ñúùî áå íàïðàâåíà ËÒÌÅ â ïúëåí îáåì. Ïðè 1 ïàöèåíò ñìå ïðîâåëè íåîàäþâàíòíà ðàäèîõèìèîòåðàïèÿ, à ïðè îñòàíàëèòå - ñëåäîïåðàòèâíà ðàäèîõèìèîòåðàïèÿ. 293

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Ðåçóëòàòè: Ïàöèåíòèòå ñìå ïðîñëåäèëè 8 äî 36 ìåñåöà. Íÿìàìå ïî÷èíàë ïàöèåíò. Èìàìå åäèí ñëó÷àé íà àíîðåêòàëíà äèñôóíêöèÿ â ïðîäúëæåíèå íà 3 ìåñåöà. Ïðè ñòàïëåðíàòà òåõíèêà ïîëó÷èõìå ïðè äâàìà ïàöèåíòà èíñóôèöèåíöèè íà àíàñòîìîçàòà ëåêóâàíè êîíñåðâàòèâíî. Ïðè 80% îò îïåðèðàíèòå ÷ðåâíèÿ ïàñàæ ñå âúñòàíîâè äî 24-èÿ ÷àñ îò äåíÿ íà îïåðàöèÿòà, à âåðòèêàëèçèðàíåòî íà ïàöèåíòèòå çàïî÷âàøå â äåíÿ íà îïåðàöèÿòà 6 äî 8 ÷àñà ñëåä èçëèçàíå îò àíåñòåçèÿ.

Ñëåäîïåðàòèâíèÿ áîëíè÷åí ïðåñòîé å â ïîðÿäúêà íà 4 äî 6 äíè. Çàêëþ÷åíèå: Óëòðàíèñêàòà ðåçåêöèÿ íà ðåêòóìà å ìåòîä ñ îãðàíè÷åíî ïðèëîæåíèå ïðè ñòðîãî ñåëåêòèðàíè ïàöèåíòè. Âúçìîæíîñòèòå íà ëàïàðîñêîïñêàòà õèðóðãèÿ ðàçøèðè ïîêàçàíèÿòà çà ïðèëîæåíèåòî íà íèñêè êîëîàíàëíè àíàñòîìîçè. ËÒÌÅ ïîçâîëÿâà ïî-äîáðî ñúõðàíÿâàíå íà èíåðâàöèÿòà íà òàçîâîòî äúíî îñèãóðÿâàùî ïî-äîáðà óðèíàðíà è ñåêñóàëíà ôóíöèÿ íà ïàöèåíòà. Êà÷åñòâîòî íà æèâîò ïðè òåçè ïàöèåíòè å çíà÷èòåëíî ïî-äîáðî.

ËÈÌÔÎÎÒÈ×ÀÍÅ È ËÈÌÔÎÃÅÍÍÎ ÌÅÒÀÑÒÀÇÈÐÀÍÅ ÏÐÈ ÐÀÊ ÍÀ ÄÎËÍÀÒÀ È ÑÐÅÄÍÀ ÒÐÅÒÀ ÍÀ ÐÅÊÒÓÌÀ Äèìèòðîâ Ä. , Ò. Äåëèéñêè ÓÌÁÀË “Ã. Ñòðàíñêè”ÅÀÄ Êëèíèêà ïî Õèðóðãèÿ ”Ïðîô. Ñò. Áàåâ”, Îòäåëåíèå ïî Îíêîõèðóðãèÿ -ãð. Ïëåâåí Ïîçíàâàíåòî íà àíàòîìî-ôèçèîëîãè÷íèòå îñîáåíîñòè â ëèìôîîòè÷àíåòî îò ïðàâîòî ÷åðâî è ñúîòâåòíî íà÷èíèòå, ïîñîêàòà íà ëèìôîãåííî ìåòàñòàçèðàíå äàâà âúçìîæíîñòòà äà ñå èçãðàäè íàé -òî÷íà êîíöåïöèÿ è ñòðàòåãèÿ â ðàäèêàëíîòî õèðóðãè÷íî ëå÷åíèå ïðè ðàêà íà ðåêòóìà. Öåë: Íèå ñè ïîñòàâèõìå çà öåë äà ïðîó÷èì ëèìôíîòî îòòè÷àíå è íà÷èíèòå íà ëèìôíîòî ìåòàñòàçèðàíå ïðè ðàê íà äîëíàòà è ñðåäíà òðåòà íà ðåêòóìà (ÐÄÑÒÐ), ÷ðåç èçïîëçâàíåòî íà ìàðêèðàíåòî è áèîïñèÿ íà ñåíòèíåëíè ëèìôíè âúçëè (ÌÁÑËÂ). Ìàòåðèàëè è ìåòîäè: Èçñëåäâàíè è îïåðèðàíè áÿõà 86 ïîñëåäîâàòåëíè ïàöèåíòè îïåðèðàíè çà ÐÄÑÒÐ çà ïåðèîä îò 2 ãîäèíè ñúîáðàçíî ëîêàëèçàöèÿòà è ñòàäèÿ íà çàáîëÿâàíåòî. Ïðè 20 îò ïàöèåíòèòå ñå ïðèëîæè òðèêîìïîíåíòåí ìåòîä çà ÌÁÑËÂ ñ ïðåäîïåðàòèâíî èíæåêòèðàíå òðàíñààíàëíî, ñòðîãî ñóáìóêîçíî íà ðàäèîêîëîèä è ïîñëåäâàùî èíòðàîïåðàòèâíî èíæåêòèðàíå íà Patent Blue V. Â ëàòåðàëíèòå ëèãàìåíòè íà ðåêòóìà ñå èíæåêòèðà èíòðàîïåðàòèâíî Indocyanine green. Ïðè îñòàíàëèòå 66 ïàöèåíòè áåøå èçïîëçâàí ìåòîäà íà èíòðàîïåðàòèâíî èíæåêòèðàíå íà

äâåòå áàãðèëà. Ïîñëåäâà òúðñåíå çà ìàðêèðàíè â ñèíüî èëè çåëåíî è ñ ðú÷íà ãàìà ñîíäà çà ðàäèîàêòèâíè ëèìôíè âúçëè. Áåøå èçâúðøâàíà äèñåêöèÿ íà ïðåïàðàòà è èçãîòâÿíåòî íà ëèìôíà êàðòà ñ òî÷íî îïèñàíèå íà ðàçïîëîæåíèåòî è áðîÿ íà ñåíòèíåëíèòå è íåñåíòèíåëíèòå ëèìôíè âúçëè ñïðÿìî òóìîðà. Ñëåäâà õèñòîëîãè÷íî è èìóíîõèñòîõèìè÷íî èçñëåäâàíå íà ÑËÂ è õèñòîëîãè÷íî çà îñòàíàëèòå ëèìôíè âúçëè. Ðåçóëòàòè: Ñðåäíèÿ áðîé íà îòêðèòèòå ëèìôíè âúçëè â ðåçåêòàò áÿõ 11.5. N ïîëîæèòåëíè ñà 41% îò ñëó÷àéòå. Îáùî áÿõà îòêðèòè 155 ÑËÂ. Â ñåäåì îò ñëó÷àéòå ñå îòêðè èëèà÷åí ÑËÂ. Îáñúæäàíå: Íà áàçàòà íà ïðèëîæåíèåòî íà ìåòîäà ÌÁÑËÂ óñòàíîâèõìå, ÷å ïðè ëèïñàòà íà îòêëîíåíèå (Ò1,2 êàðöèíîìè, Nî) îò ôèçèîëîãè÷íîòî ëèìôîîòè÷àíå â ðåãèîíà òî å ïðåäèìíî â ìåçåíòåðèàëíèÿ ëèìôåí áàñåéí (96.5%). Ñòàòèñòè÷åñêèÿ àíàëèç äîêàçâà, ÷å òîïîãðàôèÿòà (èëèà÷íî èëè ìåçåíòåðèàëíî) íà ÑËÂ çàâèñè îò òóìîðíàòà èíôèëòðàöèÿ íà òóìîðà (p=0.07) è ëèìôíàòà èíâàçèÿ (p=0.05). Íàëè÷èåòî íà ò.í. SKIP ìåòàñòàçèðàíå â òàçè êîõîðòà îòêðèõìå â 5.9% îò ïàöèåíòèòå ñ ïîëîæèòåëåí N ñòàòóñ.

Êëþ÷îâè äóìè: Ðàê íà ðåêòóì, ëèìôîîòè÷àíå, ëèìôíî ìåòàñòàçèðàíå, ÑËÂ

294

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ÐÀÇØÈÐßÂÀÍÅ ÍÀ ÎÁÅÌÀ ÍÀ ËÈÌÔÍÀÒÀ ÄÈÑÅÊÖÈß ÏÐÈ ÕÈÐÓÐÃÈß ÍÀ ÐÅÊÒÀËÍÈß ÊÀÐÖÈÍÎÌ Å ÔÈÇÈÎËÎÃÈ×ÍÎ È ÊËÈÍÈ×ÍÎ ÍÅÖÅËÅÑÚÎÁÐÀÇÍÎ -ÄÈÑÊÓÑÈß Â ÏÎÄÊÐÅÏÀ ÍÀ ÍÀÖÈÎÍÀËÍÀÒÀ ÑÒÐÀÒÅÃÈß Äåëèéñêè Ò., Ä. Äèìèòðîâ ÓÌÁÀË “Ã. Ñòðàíñêè”ÅÀÄ Êëèíèêà ïî Õèðóðãèÿ ”ïðîô. Ñò. Áàåâ”, Îòäåëåíèå ïî Îíêîõèðóðãèÿ -ãð. Ïëåâåí Íàöèîíàëíèÿò ñòàíäàðò çà îáåìà íà ëèìôíàòà äèñåêöèÿ ïðè ðåêòàëåí êàðöèíîì ñõîäíî íà ïîâå÷åòî ñòðàíè âêëþ÷âà îòñòðàíÿâàíå â áëîê ñ ÷åðâîòî è ëèìôíè âúçëè ïî ñèñòåìàòà íà a.mes. inferior (ïîä èëè íàä èçëèçàíåòî íà à. colica sinistra). Â ñúùîòî âðåìå âåðíè íà ñõâàùàíèÿòà ñè îò ïðåäè 20 è ïîâå÷å ãîäèíè õèðóðçèòå îò ðåäèöà ñòðàíè ïðîïàãàíäèðàò è èçâúðøâàò ðóòèííà ìàëêîòàçîâà ëèìôíà äèñåêöèÿ ñõîäíà â íÿêîè ñëó÷àè íà òàçè èçâúðøâàíà ïðè ãèíåêîëîãè÷íèòå êàðöèíîìè. Òåçè ðàçëè÷èÿ íå ñà áèëè â îáåêòà íà íàó÷íè ïðîó÷âàíèÿ íà íàøè àâòîðè. Îòäåëíè ñúîáùåíèÿ çà äèñåêöèè èçâúí ðåãèîíà íà a.mes. inferior ñà áèëè ïîâå÷å êàòî äåìîíñòðèðàíå íà ïðèâúðçàíîñò êúì „ðàçëè÷íèÿ” áåç ñîáñòâåíè ïðîó÷âàíèÿ çà ìîòèâèòå çà òîçè ïîäõîä. Òîâà ñïîðåä íàñ ïðàâè ïîëåçíà äèñêóñèÿòà â òàçè íàñîêà. È äâåòå òàêòèêè ñå ïîçîâàâàò íà åäíè è ñúùè òåîðåòè÷íî àíàòîìî - ôèçèîëîãè÷íè è êëèíè÷íè êàòåãîðèè, íî ñ îáðàòåí çíàê íà ñòîéíîñòèòå íà òåçè êàòåãîðèè Âúâ ôóíäàìåíòàëíî òåîðåòè÷åí àñïåêò ôèçèîëîãè÷íîòî ëèìôîîòè÷àíå îò äèñòàëíèÿ ðåêòóì êúì òàçîâèòå ëèìôíè êîëåêòîðè ñïîðåä åâðîïåéñêèòå è äðóãè ó÷åíè å ïðåäñòàâåíî êàòî ïðåíåáðåæèìî ( äî 2%), à ÿïîíñêèòå è àçèàòñêèòå àâòîðè ãî ïðåäñòàâÿò êàòî çíà÷èìî (äî 21%). È äâåòå ãðóïè ñå áàçèðàò íà íàó÷íè ïðîó÷âàíèÿ íà ëèìôîîòòè÷àíåòî ÷ðåç áàãðèëíè è äðóãè ïî ñëîæíè àïàðàòíè ìåòîäè (ïîçèòðîíåìèñèîííà òîìîãðàôèÿ è íóêëåàðíè ìåòîäè). Â êëèíè÷åí àñïåêò è äâåòå ãðóïè ñå áàçèðàò íà ðîëÿòà íà ìàëêî òàçîâèÿ ëèìôåí ðåãèîí çà ðàçïðîñòðàíåíèåòî íà òóìîðà. Åâðîïåéñêèòå ó÷åíè ãî ïðèåìàò êàòî èçðàç íà ëîøî ïðîãíîñòè÷íà àâàíñèðàëîñò íà çàáîëÿâàíåòî, èçëèçàùî îò ðàìêèòå íà ôèçèîëîãè÷íîñòòà íà

ëèìôîîòè÷àíå è íà êîíòðîëà íà çàáîëÿâàíåòî, à ÿïîíñêèòå àâòîðè ãî ïðèåìàò çà àâàíñèðàë åòàï íà ëîêîðåãèîíàëíîòî ðàçïðîñòðàíåíèå, ïðè êîåòî å âúçìîæíî äà ñå ïîñòèãàíå ëîêàëåí êîíòðîë. Òåçè äâå ðàçëè÷íè ïîçèöèè îáÿñíÿâàò ðàçëè÷èÿòà â ñòàíäàðòèòå - çà ÿïîíöèòå ìàëêîòàçîâàòà äèñåêöèÿ å àêò íà ïðîôèëàêòè÷íà äîðè ëå÷åáíà ëèìôàäåíåêòîìèÿ, à çà åâðîïåéöèòå -å íåíóæíà íàìåñà ñ ìàëúê ïîòåíöèàëåí ïðèíîñ îò ïðîãíîñòè÷íî - ïðåäèêòèâåí õàðàêòåð è ñ îùå ïî ìàëúê òåðàïåâòè÷åí åôåêò. Çà íåîòñòúï÷èâîñòòà îò ñîáñòâåíèòå ïîçèöèè ãîâîðè è íà÷èíà, ïî êîéòî äâåòå ãðóïè îáÿñíÿâàò áåçñïîðíèÿ ôàêò íà ïîëîæèòåëíèÿ åôåêò íà íåîàäþâàíòíà ëú÷åõèìèîòåðàïèÿ - âúçäåéñòâà âúðõó ðåãèîíàëíèÿò êîíòðîë íà ìåçåíòåðèàëíîòî ñúîòâåòíî íà èëèà÷íîòî ðàçïðîñòðàíåíèå íà çàáîëÿâàíåòî è îò òàì èäâà ïîäîáðÿâàíåòî íà ïðîãíîçàòà. Âúçïðèåìàíåòî íà êîíöåïöèÿòà çà òîòàëíàòà ìåçîðåêòàëíà åêñöèçèÿ è îò äâåòå ãðóïè íå ïðèìèðÿâà ïðîòèâîðå÷èÿòà -çà åâðîïåéöèòå òîâà å ïîñòèæåíèå îò áàçàëåí õàðàêòåð, çà ÿïîíöèòå -÷àñòè÷åí óñïåõ â òåðèòîðèÿòà íà ìåçåíòåðèàëíîòî ìåòåñòàçèðàíå, íåðåøàâàù âúïðîñèòå íà ëàòåðàëíîòî ìåòàñòàçèðàíå. Áåç äà ñè ïîñòàâÿìå çà öåë äà ñå íàìåñâàìå â ñïîðà ÷ðåç îáøèðíè ïðîó÷âàíèÿ, íèå ñå âúçïîëçâàìå îò âúçìîæíîñòòà ïðè ìàðêèðàíåòî íà ñåíòèíåëíèòå ëèìôíè âúçëè äà ñå ïðàâÿò íàáëþäåíèÿ è èçâîäè âúðõó ôèçèîëîãèÿòà íà ëèìôîîòè÷àíåòî è íà÷èíèòå íà ëèìôíîòî ìåòàñòàçèðàíå. Óñòàíîâèõìå, ÷å ïðè óñëîâèÿ áåç ñìóùåíèÿ âúâ ôèçèîëîãè÷íîòî ëèìôîîòè÷àíå, òî å ñàìî â ìåçåíòåðèàëíèÿ áàñåéí. Ïðè ðàíåí êàðöèíîì (Ò 1,2 No) òî å 96.5%, äîêàòî ñ ëîêàëíî íàïðåäâàíå íà ïðîöåñà (Ò3,4 N1,2 òóìîðè) íàëè÷èåòî íà ëèìôíà èíâàçèÿ ñå íàáëþäàâà è ëàòåðàëíî - ìåòàñòàçè â 13.8%.

Êëþ÷îâè äóìè: Ðàê íà ðåêòóìà, ëèìôíà äèñåêöèÿ

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ABSTRACTS

ÕÈÐÓÐÃÈ×ÍÈ ÐÅÇÅÊÖÈÎÍÍÈ ÃÐÀÍÈÖÈ ÏÐÈ ÐÅÊÒÀËÅÍ ÊÀÐÖÈÍÎÌ -ÄÈÑÊÓÑÈß Â ÏÎÄÊÐÅÏÀ ÍÀ ÍÀÖÈÎÍÀËÍÀÒÀ ÑÒÐÀÒÅÃÈß Äåëèéñêè Ò.1, Ä. Äàðäàíîâ2 1

Êëèíèêà ïî Õèðóðãèÿ, ÓÌÁÀË „Ä-ð Ãåîðãè Ñòðàíñêè”, Ïëåâåí, Ìåäèöèíñêè Óíèâåðñèòåò -Ïëåâåí, 2Êëèíèêà ïî Õèðóðãèÿ, Ìåäèöèíñêè Èíñòèòóò -ÌÂÐ, Ñîôèÿ

Ñúñòîÿíèåòî íà ðåçåêöèîííèòå ãðàíèöè å åäèí îò íàé-âàæíèòå ïðîãíîñòè÷íè ôàêòîðè çà ëîêîðåãèîíàëíèÿ êîíòðîë íà çàáîëÿâàíåòî ïðè õèðóðãè÷íîòî òðåòèðàíå íà ðåêòàëíèÿ êàðöèíîì. Ïðàâèëíèÿò ïîäõîä êúì ïîñòèãàíåòî íà ÷èñòà ðåçåêöèîííà ãðàíèöà è àäåêâàòíàòà èíòåðïðåòàöèÿ íà òÿõíàòà çíà÷èìîñò å âàæåí îöåíú÷åí ôàêòîð çà ïðîôåñèîíàëíàòà çðÿëîñò íà õèðóðãà. Íàöèîíàëíèòå ñòàíäàðòè ïðèåìàò êàòî îáùà ïðåïîðúêà äà ñå ïðàâè îöåíêà íà ñúñòîÿíèåòî íà ðåçåêöèîííèòå ãðàíèöè è äà ñå ïîëàãàò óñèëèÿ êúì ïîñòèãàíå íà îíêîëîãè÷íà ðàäèêàëíîñò. Â ïî-äåòàéëèçèðàí âèä ïðåïîðúêèòå ìîãàò äà áúäàò ðàçãúíàòè êàòî âúçïðèåìàíå íà êîíêðåòíè êðèòåðèè çà îõàðàêòåðèçèðàíå íà ïîíÿòèåòî „÷èñòè ãðàíèöè” è íà êàòåãîðèçèðàíåòî íà êà÷åñòâîòî íà òåõíè÷åñêîòî èçïúëíåíèå íà îïåðàöèÿòà â åòàïà íà ïîñòèãàíåòî íà ñèãóðíîñò íà ãðàíè÷íèòå çîíè íà ðåçåêòàòà. Çà êëèíè÷íàòà ïðàêòèêà çíà÷èìè ñå íàëîæèõà äèñòàëíàòà è öèðêóìôåðåíòíàòà ãðàíèöà. Äèñòàëíàòà ãðàíèöà çàñÿãà äâå ñòðóêòóðè -÷ðåâíàòà ñòåíà è ò.í. „ìåçîðåêòóì” (ðåêòàëíàòà àäâåíòèöèÿ). Èçõîæäàéêè îò ïîñòàíîâêàòà è ìÿñòîòî íà ðåçåöèðàíåòî íà òåçè äâå ñòðóêòóðè ñå îïðåäåëÿ îêîí÷àòåëíî èíòðàîïåðàòèâíî ÷ðåç èçìåðâàíå íà îòñòîÿíèå îò ìàêðîñêîïñêèòå î÷åðòàíèÿ íà òóìîðà. Êàòî îáùî ïðèåìëèâè ñåãà ñå ïðèåìà ðàçñòîÿíèå ñúîòâåòíî 2 ñì è 5 ñì. Â ïî-êîíêðåòåí àñïåêò âçåìàéêè ïðåäâèä íÿêîè õàðàêòåðèñòèêè íà òóìîðà -èíâàçèÿ â ÷ðåâíàòà ñòåíà, ñòåïåí íà äèôåðåíöèàöèÿ, ïðèëîæåíà íåîàäþâàíòíà ëú÷åòåðàïèÿ è äð. äèñòàëíèòå ãðàíèöè ìîãàò äà áúäàò íàìàëåíè äî ðåñï. 1,5 ñì è 4 ñì (Ò 1-2, G1) áåç òîâà äà ñå îòðàçÿâà âúðõó ðàäèêàëíîñòòà íà îïåðàöèÿòà êàòî ñúùåâðåìåííî ïîçâîëÿâà èçâúðøâàíåòî íà ñôèíêòåðîñúõðàíÿâàùà ðåçåêöèÿ. Ïî äðóã íà÷èí ñòîè âúïðîñúò ñ öèðêóìôåðåíòíàòà ãðàíèöà, íàðå÷åíà îùå ëàòåðàëíà èëè ðàäèàëíà, êîÿòî ïî ñúùåñòâî ñå ðàçïîëàãà âúðõó äåôèíèðàíà àíàòîìè÷íà ñòðóêòóðà -ðåêòàëíàòà ôàñöèÿ. Ñëåäâàéêè ñòàíäàðòíèÿ ïëàí íà åêñòðàôàñöèàëíà ìîáèëèçàöèÿ íà ðåêòóìà, öèðêóìôåðåíòíàòà ãðàíèöà ñå ïðåäñòàâÿ íà ðåçåêòàòà êàòî íåæíà öèïà ïîêðèâàùà àäâåíòèöèÿòà (ìåçîòî) íà ðåêòóìà. Îáùîïðèåòî å òàçè ãðàíèöà äà ñå äåôèíèðà êàòî îòðèöàòåëíà, àêî íÿìà òóìîðíî àíãàæèðàíå íà ïîíå 1ìì îò íåÿ. Ïî òîçè íà÷èí ñòàâà ëåñíî äà ñå êàæå êîãà òÿ å ïîëîæèòåëíà è êîãà -íå, êàòî 296

å çàäúëæèòåëíî äà ñå îòáåëÿçâà òî÷íîòî ðàçñòîÿíèå îò ïåðèôåðíèÿ òóìîðåí ôðîíò äî ãðàíèöàòà. Íà ïðàêòèêà îáà÷å ñèòóàöèÿòà ñå óñëîæíÿâà îò ñëîæíîñòòà íà õèðóðãè÷íàòà òåõíèêà, ÷ðåç êîÿòo ñå ïîñòèãà åêñòðàôàñöèàëíà äèñåêöèÿ áåç íàâëèçàíå â „ìåçîòî”, êîåòî âñúùíîñò å ìÿñòîòî íà ëàòåðàëíîòî ðàçïðîñòðàíåíèå íà òóìîðà. Òàêà íåñúâúðøåíñòâà â îïåðàòèâíàòà òåõíèêà ñúçäàâàò íîâà, èçêóñòâåíà öèðêóìôåðåíòíà ðåçåêöèîííà ãðàíèöà, êîÿòî ñå ïðåìåñòâà êúì òóìîðà è ìîæå äî òàêàâà ñòåïåí äà ñå äîáëèæè äî íåãî, ÷å äà ñòàíå „ÿòðîãåííî” ïîëîæèòåëíà. Ïî òîçè íà÷èí îöåíêàòà íà êà÷åñòâîòî íà îïåðàòèâíèÿ ïðåïàðàò ïî îïðåäåëåíè êðèòåðèè å ñâúðçàíà ñúñ ñòàòóñà íà öèðêóìôåðåíòíàòà ãðàíèöà è äàâà èíäèðåêòíà îáåêòèâíà îöåíêà íà êà÷åñòâîòî è ðàäèêàëíîñòòà íà îïåðàöèÿòà. Èìàéêè èíôîðìàöèÿ çà äâàòà ôàêòîðà -ñòàòóñ íà öèðêóìôåðåíòíàòà ãðàíèöà è êà÷åñòâî íà îïåðàòèâíèÿ ïðåïàðàò, èíòåðïðåòèðàíè ñúîáðàçíî ïàòîëîãè÷íîòî ñòàäèðàíå, ìîæå äà ñå íàïðàâè çàêëþ÷åíèå äàëè ïîëîæèòåëíàòà ëàòåðàëíà ãðàíèöà ñå äúëæè íà àâàíñèðàë òóìîð èëè íà ñóáîïòèìàëíà ëàòåðàëíà ìîáèëèçàöèÿ. Ëîãè÷íî âúçíèêâà âúïðîñúò çà ìåõàíèçìèòå, ÷ðåç êîèòî õèðóðãúò ìîæå äà ïîâëèÿå âúðõó ïðîöåñà „ïîñòèãàíå íà ÷èñòè ðåçåêöèîííè ãðàíèöè”. Òå ñà íÿêîëêî: ïðåöèçíîñò íà òåõíè÷åñêîòî èçïúëíåíèå íà îïåðàöèÿòà ñúîáðàçíî ñòàíäàðòèòå çà àäåêâàòíèÿ îáåì íà îïåðàöèÿòà; ïðåîïåðàòèâíî âúçäåéñòâèå âúðõó ðàçïðîñòðàíåíîñòòà íà òóìîðà â äèñòàëíà è ëàòåðàëíà ïîñîêà. Ïîñòèãàíåòî íà ïðåöèçíîñò íà îïåðàòèâíàòà òåõíèêà å âúïðîñ íà çàäúëáî÷åíà òåîðåòè÷íà ïîäãîòîâêà è íàòðóïâàíå ïðàêòè÷åñêè îïèò, à âúçäåéñòâèåòî âúðõó ðàçïðîñòðàíåíîñòòà íà òóìîðà èçèñêâà ðåàëèçèðàíå íà ïðåîïåðàòèâíà ëú÷å èëè ëú÷åõèìèîëå÷åíèå â íåîàäþâàíòåí ïëàí. Çàäúëæèòåëíî óñëîâèå å äîáðîòî ïðåäîïåðàòèâíî ëîêîðåãèîíàëíî òóìîðíî ñòàäèðàíå. Ñëåäâàéêè ãîðåèçëîæåíèòå ïîñòàíîâêè, çàëåãíàëè â ðåäèöà åâðîïåéñêè, àìåðèêàíñêè è äð. ïðåïîðúêè, íèå â íàøàòà ïðàêòèêà ñå óâåðèõìå âúâ âåðíîñòòà íà ñòàíîâèùåòî çà ñòåïåíòà íà äèñòàëíîòî ðàçïðîñòðàíåíèå è íà áëàãîïðèÿòíîòî âëèÿíèå íà íåîàäþâàíòíîòî ëå÷åíèå âúðõó äèñòàëíîòî è ëàòåðàëíîòî ðàçïðîñòðàíåíèå íà òóìîðà. Îöåíèõìå, ÷å â ïðàêòè÷åñêè ïëàí ñìå ïîñòèãíàëè áëèçî 100% ÷èñòè

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

äèñòàëíè è íàä 85% ÷èñòè öèðêóìôåðåíòíè ãðàíèöè è â îêîëî 90% - ïðåöèçíîñò íà ñëåäâàíå íà åêñòðàôàñöèàëåí ïëàí íà äèñåêöèÿ, áåç íàðóøàâàíå öåëîñòòà íà ðåêòàëíàòà ôàñöèÿ. Ïðåäëå÷åáíàòà îáðàçíà äèàãíîñòèêà ñ ìàãíèòíîðåçîíàíñíà òîìîãðàôèÿ äîñòîâåðíî ìîæå äà ïðåäâèäè ïîòåíöèàëíî ïîëîæèòåëíà öèðêóìôåðåíòíà ãðàíèöà

ïðè èçâúðøâàíå íà ðåêòàëíà ìîáèëèçàöèÿ â ñòàíäàðòåí ïëàí. Â ïîñëåäíèòå ñëó÷àè íåîàäþâàíòàíà ëú÷åòåðàïèÿ è/èëè ïî-ðàçøèðåíà äèñåêöèÿ å îïðàâäàíà çà ïîñòèãàíå íà ÷èñòè ðåçåêöèîííè ãðàíèöè.

ÊËÈÍÈÊÎ-ÌÎÐÔÎËÎÃÈ×ÍÀ ÕÀÐÀÊÒÅÐÈÑÒÈÊÀ ÍÀ ÏÀÖÈÅÍÒÈÒÅ Ñ ÊÎËÎÐÅÊÒÀËÅÍ ÊÀÐÖÈÍÎÌ ÎÏÅÐÈÐÀÍÈ ÇÀ 5-ÃÎÄÈØÅÍ ÏÅÐÈÎÄ Â ÊËÈÍÈÊÀÒÀ ÏÎ ÕÈÐÓÐÃÈß ÍÀ ÌÈ-ÌÂÐ Êèðîâ Ã., Á. Ìîøåâ, Ä. Äàðäàíîâ, Ä. Òîäîðîâ, Ñ. Äèìîâ, È. Ëîçåâ, Ã. Êîíäàðåâ Êëèíèêà ïî Õèðóðãèÿ, Ìåäèöèíñêè Èíñòèòóò -ÌÂÐ Êîëîðåêòàëíèÿò êàðöèíîì å åäíî îò íàé-÷åñòèòå îíêîëîãè÷íè çàáîëÿâàíèÿ ñ òåíäåíöèÿ çà ïîñòîÿííî óâåëè÷àâàíå íà çàáîëåâàåìîñòòà ïðåç ïîñëåäíèòå ãîäèíè. Ïðåäñòàâÿìå è àíàëèçèðàìå êëèíèêî-ìîðôîëîãè÷íèòå õàðàêòåðèñòèêè íà 385 ïàöèåíòà ñ êîëîðåêòàëåí êàðöèíîì îïåðèðàíè â Êëèíèêàòà ïî Õèðóðãèÿ íà Ìåäèöèíñêèÿ Èíñòèòóò íà ÌÂÐ çà ïåðèîäà ÿíóàðè 2004 ã. - ÿíóàðè 2009 ã. Ïðîó÷åíè ñà ñëåäíèòå ïàðàìåòðè - âúçðàñò, ïîë, ëîêàëèçàöèÿ, ñèìïòîìè, êëèíè÷íî-ëàáîðàòîðíè è îáðàçíî-äèàãíîñòè÷íè íàõîäêè, ôàìèëíà

îáðåìåíåíîñò, êëèíè÷íî è ïàòîëîãè÷íî ñòàäèðàíå, èçâúðøåíà îïåðàöèÿ, õèñòîëîãè÷åí òèï, ñòåïåí íà äèôåðåíöèàöèÿ è äð. Èçâúðøåíà å ñòàòèñòè÷åñêà îáðàáîòêà íà äàííèòå. Íåìàëêà ÷àñò îò áîëíèòå ñå ïðåäñòàâÿò ñ ëîêàëíî àâàíñèðàëî èëè ìåòàñòàçèðàëî çàáîëÿâàíå, êàêòî è ñ ïðîÿâè íà ÷ðåâíà íåïðîõîäèìîñò. Òîâà ïîñòàâÿ íà äíåâåí ðåä íåîáõîäèìîñòòà îò ðàííà äèàãíîñòèêà ÷ðåç âúâåæäàíå íà ïðîãðàìè çà ñêðèíèíã, êîåòî ùå äîâåäå äî ïîäîáðÿâàíå íà ñëåäîïåðàòèâíèòå ðåçóëòàòè îò ëå÷åíèåòî íà äåáåëî÷ðåâíèÿ êàðöèíîì.

ÑÈÍÄÐÎÌ ÍÀ ÑÎËÈÒÀÐÍÀÒÀ ÐÅÊÒÀËÍÀ ßÇÂÀ Äàðäàíîâ Ä., Ã. Êèðîâ, Á. Ìîøåâ, È. Ëîçåâ Êëèíèêà ïî Õèðóðãèÿ, Ìåäèöèíñêè Èíñòèòóò -ÌÂÐ Ñèíäðîìúò íà ñîëèòàðíàòà ðåêòàëíà ÿçâà å ðÿäêî çàáîëÿâàíå ñ âñå îùå íåèçâåñòíà ïðè÷èíà. Â ïàòîãåíåçàòà ñå îòäàâà çíà÷åíèå íà ëîêàëíàòà òúêàííà èñõåìèÿ è ìèêðîòðàâìà. Ïðîòè÷à ñ íåõàðàêòåðíè ñèìòîìè -õåìîðàãèÿ, òåíåçìè, äèàðèÿ èëè çàïåê, ñòåíîçà è äð. Âëèçà â äèôåðåíöèàëíàòà äèàãíîçà íà âúçïàëèòåëíèòå è çëîêà÷åñòâåíèòå çàáîëÿâàíèÿ, çàñÿãàùè ðåêòóìà. Õèðóðãè÷íîòî ëå÷åíèå å ïîêàçàíî çà ñèìòîìàòè÷íèòå ñëó÷àè. Ñïåöèàëåí èíòåðåñ ïðåäñòàâëÿâàò ñëó÷àèòå ïðè êîèòî íå ìîæå äà ñå èçêëþ÷è ìàëèãíåí ïðîöåñ, êîãàòî òðÿáâà äà ñå èçâúðøè ðàäèêàëíà ðåçåêöèÿ. Ïðåäñòàâÿìå ñëó÷àé íà 69 ãîäèøíà ïàöèåíòêà ñ òåæêîñòåïåííà ðåêòàëíà ñòåíîçà â ïðîêñèìàëíàòà

òðåòà íà ðåêòóìà, êëèíè÷íî, ðåêòîñêîïñêè è èðèãîãðàôñêè ïðèåòà çà êàðöèíîì. Äâóêðàòíî èçâúðøåíèòå áèîïñèè íå äîêàçâàò, íî è íå îòõâúðëÿò äèàãíîçàòà êàðöèíîì. Èçâúðøåíà å íèñêà ïðåäíà ðåçåêöèÿ íà ðåêòóìà ñ èíòðàîïåðàòèâíà äèàãíîçà -ñòåíîçèðàù ÿçâåíîèíôèëòðàòèâåí êàðöèíîì ñ ïðîðàñòâàíå êúì ìåçåíòåðèóìà íà èëåàëíà áðèìêà. Õèñòîëîãè÷íîòî èçñëåäâàíå íà îïåðàòèâíèÿ ïðåïàðàò ïîêàçà ðåêòàëíà ÿçâà ñ ïîêðèòà ïåðôîðàöèÿ. Ñèíäðîìúò íà ñîëèòàðíàòà ðåêòàëíà ÿçâà òðÿáâà äà ñå èìà ïðåäâèä ïðè ïàöèåíòè ñúñ ñóñïåêöèÿ çà ìàëèãíåíà, íî íåäîêàçàíà õèñòîëîãè÷íî ðåêòàëíà ëåçèÿ. Ðåçåêöèÿòà íà ðåêòóìà å ñðåäñòâî íà èçáîð ïðè ëå÷åíèåòî íà çàáîëÿâàíåòî. 297

ABSTRACTS

TERMINOLOGIA ANATOMICA ANORECTALIS ÊËÈÍÈ×ÍÈ ÀÑÏÅÊÒÈ Äàðäàíîâ Ä. Êëèíèêà ïî Õèðóðãèÿ, Ìåäèöèíñêè Èíñòèòóò -ÌÂÐ, Êàòåäðà ïî Àíàòîìèÿ è Õèñòîëîãèÿ, Ìåäèöèíñêè Ôàêóëòåò, Ñîôèéñêè Óíèâåðñèòåò „Ñâ. Êëèìåíò Îõðèäñêè” Öåëòà íà âñÿêà ìåæäóíàðîäíà íîìåíêëàòóðà èëè òåðìèíîëîãèÿ å äà ñå óëåñíè ðàçáèðàíåòî è êîìóíèêàöèÿòà ìåæäó ðàçëè÷íèòå èçñëåäîâàòåëè â äàäåíà îáëàñò. Íàìèðà ñå, ÷å â îáëàñòòà íà àíîðåêòàëíàòà òåðìèíîëîãèÿ ñúùåñòâóâà äîñòà ðàçëè÷íè ñòàíîâèùà íà àâòîðè îò ðàçëè÷íè ñòðàíè è ðàçëè÷íè ìîðôîëîãè÷íè è êëèíè÷íè ñïåöèàëíîñòè. Öåë íà íàñòîÿùîòî èçñëåäâàíå å äà ñå ïðåäñòàâè èñòîðè÷åñêîòî ðàçâèòèå íà àíîðåêòàëíàòà àíàòîìè÷íà íîìåíêëàòóðà è íàñòîÿùèòå ìåæäóíàðîäíè ëàòèíñêè Terminologia anatomica è Terminologia histologica ñ òÿõíîòî ïðèëîæåíèå â êëèíè÷íàòà ìåäèöèíà. Ïðåäëàãàò ñå è áúëãàðñêè íàèìåíîâàíèÿ íà îòäåëíèòå ñòðóêòóðè â àíîðåêòàëíàòà îáëàñò. Äèñêóòèðàò ñå è èçïîëçâàíèòå â ìîðôîëîãè÷íàòà è êëèíè÷íà ëèòåðàòóðà ðàçëè÷íè äåôèíèöèè íà àíàëíèÿ êàíàë:

àíàòîìè÷åí, õèðóðãè÷åí, åìáðèîëîãè÷åí, õèñòîëîãè÷åí, îíêîëîãè÷åí, ðåíòãåíîëîãè÷åí è äð. Ñïåöèàëíî âíèìàíèå çàñëóæàâà òåðìèíúò àíîðåêòóì, êîéòî âêëþ÷âà â ñåáå ñè àíàëíèÿò êàíàë è ñúñåäíàòà íàé-äèñòàëíà ÷àñò íà ðåêòóìà. Àíàëèçèðàò ñå ìåæäóíàðîäíàòà êëàñèôèêàöèÿ íà áîëåñòèòå â íåéíàòà ÷àñò çà çëîêà÷åñòâåíèòå òóìîðè íà ðåêòóìà, àíàëíèÿ êàíàë è àíóñà. Ïðåäñòàâÿ ñå è àíàòîìè÷íîòî ïîäðàçäåëåíèå íà àíàëíèÿ êàíàë ñïîðåä ÔÍÌ êëàñèôèêàöèÿòà íà îíêîëîãè÷íèòå áîëåñòè. Êàòî îáîáùåíèå ñå ïðåäëàãà àíàòîìè÷íà ñõåìà íà îòäåëíèòå îáëàñòè è çîíè íà àíîðåêòàëíàòà îáëàñò, âêëþ÷âàùà äèñòàëíàòà ÷àñò îò ðåêòóìà, àíàëíèÿ êàíàë è àíóñà. Òàçè ñõåìà å ñúîáðàçåíà êàêòî ñ ìîðôîëîãè÷íàòà òî÷íîñò, òàêà è ñ êëèíè÷íàòà öåëåñúîáðàçíîñò è èçïîëçâàåìîñò.

ÕÈÐÓÐÃÈ×ÍÎ ËÅ×ÅÍÈÅ ÍÀ ÏÎÑÐÀÄÈÀÖÈÎÍÍÈÒÅ ÓÑËÎÆÍÅÍÈß Â ÌÀËÊÈß ÒÀÇ Âàðòàíÿíîâ Ë., Â. ßíêîâ, Â. Äèìèòðîâ, Ï. Êóðòåâ, Ë. Äæîíãîâ, Ê. Ðàë÷åâ, Å. Àíãåëîâà, É. Ñèìåîíîâ, Ê. Åíèêîâ, Â. Ãåîðãèåâ Öåë: ×åñòîòàòà íà ëú÷åâèòå óâðåäè â ìàëêèÿ òàç îñòàâà âèñîêà,âúïðåêè ïîäîáðåíàòà òåõíèêà íà ëú÷åëå÷åíèå Öåëòà à íàøåòî ðåòðîñïåêòèâíî ïðî÷âàíå å àíàëèç íà ëúåâèòå óâðåæäàíèÿ â ìàëêèÿ òàç è õèðóðãèíèòå ìåòîäè íà ëå÷åíèå Îáõâàíàò å ïåðèîäà 1980-2008 Ìàòåðèàëè è ìåòîäè: Çà ïåðèîäà 1980-2008ã â êëèíèêàòà ñà ëåêóâàíè 39 ïàöèåíòà, âñè÷êè ñ ïðîâåäåíà ñëåäîïåðàòèâíà ëú÷åòåðàïèÿ: ìúæå - 4 îáëú÷åíè çà êàðöèíîì íà ïðîñòàòàòà, æåíè - 35 ðàçïðåäåëåíè êàêòòî ñëåäâà 32 - ñ ñëåäîïåðàòèâíà ëú÷åòåðàïèÿ çà êàðöèíîì íà ìàòî÷íàòà øèèêà, 2 - ñ êàðöèíîì íà ðåêòóìà è 1 - ñ êàðöèíîì íà âëàãàëèùåòî. Îò òÿõ îïåðèðàíè ñà 37, êàòî ïðè 17 å èçâúðøåíî ðàäèêàëíî îòñòðàíÿâàíå íà ëú÷åâîïðîìåíåíèòå ñòðóêòóðè, à ïðè 20 - ïàëèàòèâíè äåðèâàöèîííè îïåðàöèè. Çàêëþ÷åíèå: Îáñúæäà ñå ïðîôèëàêòèêàòà íà ëú÷åâèòå óñëîæíåíèÿ çà îïòèìèçèðàíå íà ÷åñòîòàòà íà

298

õðîíè÷íèòå ðàäèàöèîííè åíòåðèòè è ïðîêòîñèãìîèäèòè, êîÿòî îñòàâà âèñîêà îò 5%-23% ñïîðåä ðàçëè÷íè àâòîðè, êàòî ïðè 75% îáëúâåíåòî å Çà êàðöèíîì íà ìàòîíàòà øèèêà è ðàê íà åíäîìåòðèìà Âúïðåêè âèñîêîòî òåõíîëîãè÷íî íèâî â ñúâðåìåííàòà ëú÷åòåðàïèÿ ðåøàâàù ôàêòîð â ïðîôèëàêòèêàòà íà ëú÷åâèòå óñëîæíåíèÿ å ñëåäâàíåòî íà îïòèìàëåí àëãîðèòúì â êîìáèíèðàíîòî ëå÷åíèå íà ìàëêîòàçîâèòå òóìîðè. Ïðè íåîáõîäèìîñò îò ñëåäîïåðàòèâíà ëú÷åòåðàïèÿ å çàäúëæèòåëíî èçîëèðàíåòî íà ìàëêèÿ òàç. Ïðè ñúìíåíèå â ÷èñòîòàòà íà ðåçåêöèîííèòå ëèíèè, îñâåí èçîëèðàíå íà ìàëêèÿ òàç å íåîáõîäèìî ìàðêèðàíå íà ñóñïåêòíèòå çîíè ñ ðåíòãåí-ïîçèòèâíè êëèïñè. Ïðè òåõíè÷åñêà âúçìîæíîñò å çàäúëæèòåëíî èçâúðøâàíåòî íà ùàòåëíà ëèìôíà äèñåêöèÿ â îáòóðàòîðíèÿ è èëèà÷íèòå ëèìôíè áàñåéíè, ïîðàäè âèñîêèÿ ðèñê îò ðàäèàöèîííè óñëîæíåíèÿ ïðè åâåíòóàëíà ëú÷åòåðàïèÿ íà ñúùèòå.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ÕÅÌÎÐÎÈÄÀËÍÀ ÄÅÀÐÒÅÐÈÀËÈÇÀÖÈß ÏÎ ÄÎÏËÅÐÎÂ ÊÎÍÒÐÎË -ÕÈÐÓÐÃÈ×Íß ÀËÒÅÐÍÀÒÈÂÀ ÇÀ ËÅ×ÅÍÈÅ ÍÀ ÕÅÌÎÐÎÈÄÀËÍÀÒÀ ÁÎËÅÑÒ Äàñêàëîâ Âë., Å. Áåëîêîíñêè, Ì. Òàáàêîâ Êàòåäðà Ñïåøíà Ìåäèöèíà, Êëèíèêàïî Êîðåìíà õèðóðãèÿ, ÂÌÀ-Ñîôèÿ, Áúëãàðèÿ Ïðåç 1995 ãîäèíà ïðîô. Ìîðèíàãà âúâåæäà ëèãèðàíåòî íà õåìîðîèäàëíèòå àðòåðèè ïîä Äîïëåðîâ êîíòðîë êàòî ìåòîä çà ëå÷åíèå íà âúòðåøíè õåìîðîèäè âúâ âñè÷êè êëèíè÷íè ñòàäèè. Ïðåäñòàâÿìå íàøèòå ðåçóëòàòè îò ëå÷åíèåòî íà òîçè ìåòîä íà 117 ïàöèåíòà âúâ ÂÌÀ-Ñîôèÿ. Èçïîëçâà ñå ñïåöèàëíî êîíñòðóèðàí ïðîêòîñêîï (HAL-DOPPLER, A.M.I., Feldkirch, Austria) ñ âãðàäåí äîïëåðîâ óëòðàçâóêîâ äàò÷èê, ÷ðåç êîéòî ñå îòêðèâàò è ïðîøèâíî ëèãèðàò

òåðìèíàëíèòå ðàçêëîíåíèÿ íà ãîðíèòå õåìîðîèäàëíè àðòåðèè. Òîâà âîäè äî ìîìåíòàëíî ïðåóñòàíîâÿâàíå íà êúðâåíåòî è ïîñòåïåíî èç÷åçâàíà íà õåìîðîèäàëíèòå âúçëè. Ìåòîäúò å óñïåøåí, ìàëêîòðàâìàòè÷åí, ëåñåí çà îâëàäÿâàíå è å ñâúðçàí ñ íèñúê ïðîöåíò ïåðèîïåðàòèâíè è êúñíè ïîñòîïåðàòèâíè óñëîæíåíèÿ. Äîïëåð-íàñî÷åíîòî ëèãèðàíå íà õåìîðîèäàëíèòå àðòåðèè å ñèãóðíà è åôåêòèâíà àëòåðíàòèâà íà âñè÷êè äðóãè ìåòîäè çà ëå÷åíèå íà õåìîðîèäàëíàòà áîëåñò.

ÏÎÄÃÎÒÎÂÊÀ ÍÀ ÄÅÁÅËÎÒÎ ×ÅÐÂÎ ÇÀ ÅÍÄÎÑÊÎÏÑÊÎ ÈÇÑËÅÄÂÀÍÅ -ÎÒÊÐÈÒÎ ÐÀÍÄÎÌÈÇÈÐÀÍÎ ÑÐÀÂÍÈÒÅËÍÎ ÏÐÎÓ×ÂÀÍÅ ÍÀ ÐÀÇËÈ×ÍÈ ÄÎÇÈ ÎÒ ÄÂÀ ÏÐÅÏÀÐÀÒÀ ÇÀ ÑÀËÈÍÅÍ ËÀÂÀÆ Ïåí÷åâ Ï., Á. Âëàäèìèðîâ, Â. Íàêîâ, Í. Êîëåâ, Ä. Àëàìàíîâ Êëèíèêà ïî ãàñòðîåíòåðîëîãèÿ, ÓÌÁÀË „Öàðèöà Éîàííà-ÈÑÓË” Ñîôèÿ Ïîäãîòîâêàòà íà êîëîíà çà åíäîñêîïñêî èçñëåäâàíå å âàæåí åòàï îò ñàìîòî èçñëåäâàíå. Äîáðå ïî÷èñòåíîòî ÷åðâî äàâà âúçìîæíîñò çà òî÷íà äèàãíîçà, êàòî ñúùåâðåìåííî çíà÷èòåëíî îáëåê÷àâà ìàíüîâðèòå ïðè ñàìàòà åíäîñêîïèÿ -ïðàâè ÿ ïî-áúðçà áåçáîëåçíåíà è áåçîïàñíà. Ïîâå÷å îò 15 ãîäèíè êàòî ñòàíäàðò â äîëíàòà åíäîñêîïèÿ ñå íàëàãà ïîëèåòèëåíãëèêîë (ÏÅÃ) -ñàëèííèÿò ëàâàæ íà ÷åðâàòà ïðèëàãàí per os èëè ïðåç äóîäåíàëíà ñîíäà. Êúì íàñòîÿùèÿ ìîìåíò íà áúëãàðñêèÿ ïàçàð ñà ðåãèñòðèðàíè äâà îðèãèíàëíè ïðåïàðàòà çà ÏÅ-ñàëèíåí ëàâàæ-Fortrans - îò îêîëî 10 ã è Endofalk® îò 1 ãîäèíà. Öåë: Äà íàìåðèì îïòèìàëíîòî êîëè÷åñòâî ðàçòâîð êîåòî äàâà êà÷åñòâåíî ïî÷èñòâàíå íà êîëîíà ïðè äîáðà ïîíîñèìîñò êàòî ñðàâíèì äâà äîçîâè ðåæèìà îò äâàòà íàëè÷íè ïðåïàðàòà. Ìàòåðèàë è ìåòîäè: Ìåæäó ñåïòåìâðè 2008 è ôåâðóàðè 2009 56 ïàöèåíòà (32 æåíè è 24 ìúæå) íà ñðåäíà âúçðàñò 48,3 ±16,2 ãîäèíè, íàñî÷åíè çà êîëîíîñêîïèÿ êúì Êëèíèêàòà ïî ãàñòðîåíòåðîëîãèÿ íà ÓÌÁÀË „Öàðèöà Éîàííà - ÈÑÓË” ñà ðàíäîìèçèðàíè â ñúîòíîøåíèå 1:1:1:1 äà ñå ïîäãîòâÿò çà êîëîíîñêîïèÿ ñúîòâåòíî ñ 3 ëèòðà Endofalk® , èëè 3 ëèòðà Fortrans èëè 2 ëèòðà Endofalk® èëè 2 ëèòðà Fortrans. Äîçîâèÿò

ðåæèì -„íàâåäíúæ” -ëèòúð íà ÷àñ ñëåä 6 ÷àñîâî ïðåäâàðèòåëíî ãëàäóâàíå áåç äèåòè÷íè îãðàíè÷åíèÿ. Èçêëþ÷âàùè êðèòåðèè - ïðåäøåñòâàùà õèðóðãè÷íà ðåçåêöèÿ íà ÃÈÒ, äèàðè÷íî ñúñòîÿíèå ñ íàä 10 ñïîíòàííè äåôåêàöèè çà 24 ÷. Ïàöèåíòèòå ñà ðàíäîìèçèðàíè ïî ïîë, âúçðàñò, íàñî÷âàùà äèàãíîçà è äåôåêàöèîíåí ðèòúì. Ðåçóëòàòèòå ñà îò÷åòåíè ïî 5 ñòåïåííà àíàëîãîâà ñêàëà íà æèâî è íà çàïèñ îò âòîðè èçñëåäîâàòåë. Ïàöèåíòèòå ñà ðåãèñòðèðàëè òÿõíàòà îöåíêà çà ïîäãîâêàòà ïî òðèñòåïåííà ñêàëà. Ðåçóëòàòè: Òîòàëíà ÔÊÑ å ïîñòèãíàòà ïðè âñè÷êè ïàöèåíòè, ïðèåìàëè 3 ëèòðà Endofalk®, ïðè 13 (92,8%) ïðèåìàëè 3ë Fortrans, 13 (92,8%) - ïðèåìàëè 2 ëèòðà Fortrans, è 11 (78,6%) ïðèåìàëè 2ë Endofalk®. Êà÷åñòâîòî íà ïî÷èñòâàíåòî å áèëî êàêòî ñëåäâà: íàéäîáðî ïðè 3ë Endofalk®, ñëåäâàíî îò 3ë Fortrans, 2ë Fortrans è 2ë Endofalk®, êàòî ðàçëèêèòå ñà ñòàòèñòè÷åñêè äîñòîâåðíè ñàìî ìåæäó 3ë è 2ë Endofalk®. Ïàöèåíòèòå ñà ïîíåñëè íàé-äîáðå 2ë Endofalk®, ñëåäâàí îò 3ë Endofalk®, 2ë Fortrans è 3ë Fortrans. Íå å íàáëþäàâàíà çàâèñèìîñò ìåæäó ïîëà, âúçðàñòòà, íàñî÷âàùàòà äèàãíîçà è êà÷åñòâîòî íà ïîäãîòîâêàòà â ÷åòèðèòå ãðóïè. Ïàöèåíòèòå ñ 2ë Endofalk® è êîíñòèïàöèÿ ñà áèëè ïî-ëîøî ïî÷èñòåíè. 299

ABSTRACTS

Æåíèòå ñà ïîíàñÿëè ïî-äîáðå Endofalk®. Íå ñà íàáëþäàâàíè ñåðèîçíè ñòðàíè÷íè ÿâëåíèÿ â ÷åòèðèòå ãðóïè. Èçâîäè: È äâàòà èçïîëçâàíè ïðåïàðàòà äàâàò äîáðî ïî÷èñòâàíå â äîçà 3 ëèòðà. Íàé-êà÷åñòâåíî ïî÷èñòâàíå íà äåáåëîòî ÷åðâî çà êîëîíîñêîïèÿ ñå ïîñòèãà ñ 3ë

Endofalk® ïðèåòè „íàâåäíúæ” â äåíÿ ïðåäè èçñëåäâàíåòî. Endofalk® å ïî-äîáðå ïîíàñÿíèÿò îò äâàòà ïðåïàðàòà è ïðè äâåòå äîçèðîâêè è æåíñêèÿ ïîë. Ïðè êîíñòèïàöèÿ 2 ëèòðà Endofalk® íå ñà äîñòàòú÷íè çà êà÷åñòâåíî ïî÷èñòâàíå.

ÁÎËÅÑÒÒÀ ÍÀ ÊÐÎÍ ÊÀÒÎ ÑËÓ×ÀÉÍÀ ÅÍÄÎÑÊÎÏÑÊÀ ÍÀÕÎÄÊÀ? Ïåí÷åâ Ï. Êëèíèêà ïî ãàñòðîåíòåðîëîãèÿ ÓÌÁÀË „Öàðèöà Éîàííà-ÈÑÓË” Âúâåäåíèå: Íà÷àëîòî íà Áîëåñòòà íà Êðîí (ÁÊ) ÷åñòî å íåÿñíî. Íå å èçâåñòåí ïåðèîäúò, â êîéòî òÿ ñå ðàçâèâà ëàòåíòíî è àíòåäàòèðà êëèíè÷íèòå ñèïòîìè è åíäîñêîïñêèòå èçìåíåíèÿ. ×åñòî äèàãíîçàòà ñå ïîñòàâÿ îïåðàòèâíî, ñ óñòàíîâÿâàíå íà îñòúð èëåèò ïðè àïåíäåêòîìèÿ, ôèáðîñòåíîòè÷íè èçìåíåíèÿ ïðè èëåóñ, ñâîáîäíà ïåðôîðàöèÿ èëè àáäîìèíàëíà (âúçïàëèòåëíà) ìàñà. Ñëåä âúâåæäàíåòî íà ò.íàð „áèîëîãè÷íî ëå÷åíèå” ñå ñìÿòà, ÷å îçäðàâÿâàíåòî íà åíäîñêîïñêè äîëîâèìèòå ëåçèè (mucosal healing) ïðîìåíÿ õîäà íà ÁÊ, íàìàëÿâà áðîÿ íà õîñïèòàëèçàöèèòå è íåîáõîäèìîñòòà îò õèðóðãè÷íî ëå÷åíèå. Íî êàêâà å „âúçðàñòòà” íà åíäîñêîïñêèòå ëåçèè -àôòè, ãîëåìè è ìàëêè ÿçâè, ôèñòóëè êîèòî îçäðàâÿâàò îò áèîëîãè÷íîòî ëå÷åíèå? Êîãà âñúùíîñò îò èñòèíñêîòî íà÷àëî íà ÁÊ çàïî÷âà ëå÷åíèåòî? Äàëè àêî çàïî÷íå êàêâîòî è äà å ëå÷åíèå â ñàìîòî íà÷àëî ïðîãíîçàòà íÿìà äà ñå ïðîìåíè - çàñåãà ñà îòâîðåíè âúïðîñè. Ìàòåðèàë è ìåòîäè: Ñïîäåëÿìå îïèò îò 14 ïàöèåíòà, åíäîñêîïèðàíè îò íàñ â ïåðèîäà 2004-2008 ã. Èíäèêàöèèòå çà êîëîèëåîñêîïèÿòà ñà áèëè ñêðèíèíã çàðàäè ôàìèëíà îáðåìåíåíîñò ñ êîëîðåêòàëåí ðàê èëè ìèíèìàëíè îïëàêâàíèÿ ïî òèïà íà äðàçíèìî ÷åðâî -êîðåìåí äèñêîìôîðò, ïîäóâàíå, ñëàáè áîëêè âúâ âðúçêà ñ äåôåêàöèîííèÿ ðèòúì â ïðàäúëæåíèå íà 2-6 ìåñåöà. Ïðè âñè÷êè å èçêëþ÷åí ðåäîâåí èëè ñëó÷àåí ïðèåì íà ÍÏÂÑ è èíôåêöèîçíî çàáîëÿâàíå. Ðåçóëòàòè: Åíäîñêîïñêàòà íàõîäêà å áèëà îãíèùíà õèïåðåìèÿ è àôòîèäíè ëåçèè â òåðìèíàëíèÿ èëåóì ïðè âñè÷êè, èëåóì+ êîëîí àñöåíäåíñ ïðè 3-ìà,

300

èëåóì+öåêóì+ êîëîí äåñöåíäåíñ ïðè 1. Ñòåíîçè, ôèñòóëè è áåëåçè íà õðîíè÷íî ðåöèäèâèðàùî âúçïàëåíèå (ïñåâäîïîëèïè, öèêàòðèêñè) íå ñà îòêðèòè. Õèñòîëîãè÷íî -îò ìèíèìàëíè íåñïåöèôè÷íè âúçïàëèòåëíè ïðîìåíè, äî ëèìôîöèòíà èíôèëòðàöèÿ ñóáìóêîçíî è åäèíè÷íè ôèñóðàëíè ÿçâè, ãðàíóëîìè íå ñà íàìåðåíè. Ïðîâåäåíî å ëå÷åíèå ñ 5-ASA 4 ã/24 ÷ ïðè 7 îò ïàöèåíòèòå, 3 ã/24 ÷ ïðè 6 (ñ äî 3 àôòè â òåðì èëåóì), ïðè 1 ñ áóäåçîíèä 9 ìã, çàìåíåí îò 5-ASA ñëåä 3 ìåñåöà. 6 ìåñåöà îò íà÷àëîòî íà ëå÷åíèåòî 13/14 ïàöèåíòà ñà áåç îïëàêâàíèÿ (åäèí ïðîäúëæàâà äà èìà õëàáàâè èçõîæäàíèÿ, êàêòî â ïðåäè ëå÷åíèåòî). Ïàöèåíòèòå ñà ïðîñëåäåíè åíäîñêîïñêè îò 6 äî 60 ìåñåöà. Èçìåíåíèÿòà èç÷åçâàò íàïúëíî èëè íàìàëÿâàò ïî ðàçïðîñòðàíåíèå ïðåç ïúðâèòå 6 ìåñåöà ïðè âñè÷êè ñ èçêëþ÷åíèå íà ëåêóâàíèÿ ïúðâîíà÷àëíî ñ áóäåçîíèä ïðè êîéòî ñå óâåëè÷àâàò àôòèòå â êîëîíà. 4 îò ïðîñëåäÿâàíèòå ñàìè ïðåóñòàíîâÿâàò ëå÷åíèåòî ñëåä ïúðâàòà ãîäèíà. Ïðè îñòàíàëèòå äîçàòà íà 5-ASA ñå íàìàëÿâà ïîñòåïåííî ñ ¼ ïðåç 6 ìåñåöå ñúãëàñíî âúçïðèåòèÿ êîíñåñíñóñ. 3-ìà îò ãðóïàòà ñà íàáëþäàâàíè â ïðîäúëæåíèå íà 60 ìåñåöà è ñà áåç êëèíè÷íè îïëàêâàíèÿ è åíäîñêîïñêè ïðîìåíè. Èçâîäè: Ïðîñïåêòèâíî íàáëþäàâàõìå è ëåêóâàõìå ãðóïà áîëíè ñ ìèíèìàëíè åíäîñêîïñêè ïðîìåíè ïî òèïà íà áîëåñò íà Êðîí. Ðåçóëòàòèòå îò íàøèòå íàáëþäåíèÿ âîäÿò êúì èçâîäà, ÷å âåðîÿòíî 5-ASA âîäè äî „mucosal healing” è ïðåäîòâðàòÿâà ïðîãðåñèðàíåòî íà áîëåñòòà â òåçè ñëó÷àè. Íåîáõîäèìè ñà äâîéíî ñëåïè ïëàöåáî êîíòðîëèðàíè ïðîó÷âàíèÿ çà ïîòâúðæäàâàíåòî íà ïîäîáíà õèïîòåçà.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ÎÏÈÒ ÇÀ ÈÍÄÈÂÈÄÓÀËÅÍ ÏÎÄÕÎÄ ÍÀ ËÅ×ÅÍÈÅ ÏÐÈ ÁÎËÍÈ Ñ ÊÀÐÖÈÍÎÌ ÍÀ ÐÅÊÒÓÌÀ È ÍÅÎÏÅÐÀÁÈËÍÈ ×ÅÐÍÎÄÐÎÁÍÈ ÌÅÒÀÑÒÀÇÈ Êóðòåâ Ï., Â. Äèìèòðîâ, Êð. Ðàë÷åâ, Ë. Äæîíãîâ, Ë. Âàðòàíÿíîâ, Å. Àíãåëîâà, Âë. ßíêîâ, Â. Ãåîðãèåâ, É. Ñèìåîíîâ, Ã. Êóðòåâà, Ê. Åíèêîâ ÑÁÀËÎ-ÅÀÄ Ñîôèÿ Öåë: Öåëòà íà ïðîó÷âàíåòî å äà ñå àíàëèçèðà ïðåæèâÿåìîñòòà íà áîëíè ñ ðàê íà ðåêòóìà è àâàíñèðàëè ÷åðíîäðîáíè ìåòàñòàçè ïðè êîèòî å èçâúðøåíà ðåçåêöèÿ íà ïúðâè÷íîòî îãíèùå è å ïðîâåäåíà ñëåäîïåðàòèâíà õèìèîòåðàïèÿ. Ìàòåðèàë è ìåòîäè: Îïåðèðàíè ñà 74 áîëíè ñ êàðöèíîì íà ðåêòóìà è ÷åðíîäðîáíè ìåòàñòàçè çà ïåðèîä îò 13 ãîäèíè. Áîëíèòå ñà ðàçïðåäåëåíè êàêòî ñëåäâà:

Ðàçïðåäåëåíèå íà áîëíèòå ïî èíâàçèÿ íà òóìîðà â ìåçîðåêòóìà Èíâàçèÿ â ìåçîðåêòóìà

Áðîé

Ïðîöåíò

Ñ èíâàçèÿ

70.27

Áåç èíâàçèÿ

29.72

Îáùî

100

Ðàçïðåäåëåíèå íà áîëíèòå ïî ïîë Ïîë

Áðîé

Ïðîöåíò

Ìúæå

63.51

Æåíè

36.48

Îáùî

100

Ðàçïðåäåëåíèå íà áîëíèòå ïî õèñòîëîãè÷åí âàðèàíò íà òóìîðà Õèñòîëîãè÷åí âàðèàíò

Áðîé

Ïðîöåíò

Âèñîêî äèô.

21.62

Óìåðåíî äèô.

60.81

Íèñêî äèô.

Îáùî

Áðîé íà ìåòàñòàçè

ñïîðåä

áðîÿ

Ïðîöåíò

1-4

54.05

Íàä 4 ìåòàñòàçè

45.94

Îáùî

100

Ðàçïðåäåëåíèå íà áîëíèòå ïî âèä íà îïåðàòèâíàòà èíòåðâåíöèÿ Âèä

Ïðîöåíò

Åêñòèðïàöèÿ

20.27

17.56

Ñôèíêòåðîñúõð.

62.16

100

Ïðåäíà ðåçåêöèÿ

17.56

Îáùî

100

Áðîé

Ïðîöåíò

Ãîðíà òðåòà

32.43

Ñðåäíà òðåòà

Äîëíà òðåòà Îáùî

íà

Áðîé íà áîëíè

Áðîé

Ðàçïðåäåëåíèå íà áîëíèòå ïî ëîêàëèçàöèÿ íà òóìîðà Ëîêàëèçàöèÿ íà òóìîðà

Ðàçïðåäåëåíèå íà áîëíèòå ìåòàñòàçèòå â ÷åðíèÿ äðîá.

Ðàçïðåäåëåíèå íà áîëíèòå ñïîðåä âúçðàñòòà Âúçðàñò

Áðîé íà áîëíè

Ïðîöåíò

20-30

1.35

47.29

31-40

1.35

20.27

41-50

20.27

100

51-60

24.32

61-70

40.54

71-80

12.16

Îáùî

100

301

ABSTRACTS

Âñè÷êè áîëíè ñà ïðîâåëè ñëåäîïåðàòèâíà õèìèîòåðàïèÿ ïî ñòàíäàðòíà ñõåìà Ðåçóëòàòè: Óñòàíîâÿâàò ñå äâå ãðóïè áîëíè ñ ïðåæèâÿåìîñò äî 8 ìåñåöà ñëåä îïåðàöèÿòà è äðóãà ãðóïà ñ ïðåæèâÿåìîñò íàä 20 ìåñåöà. Ïðàâè ñå

ñòàòèñòè÷åñêè àíàëèç íà ôàêòîðèòå äîâåëè äî ïî-âèñîêàòà ïðåæèâÿåìîñò. Çàêëþ÷åíèå: Àâòîðèòå ïðåäëàãàò ìîäåë çà èíäèâèäàëíî îïðåäåëÿíå íà òàêòèêàòà çà ëå÷åíèå ïðè òåçè áîëíè.

ÌÅÒÎÄÈ ÇÀ ÂÚÇÒÀÍÎÂßÂÀÍÅ ÍÀ ÏÀÑÀÆÀ ÏÐÈ ÓËÒÐÀÍÈÑÊÈ ÐÅÇÅÊÖÈÈ ÍÀ ÐÅÊÒÓÌÀ ßíêîâ Â., Â. Äèìèòðîâ, Ï. Êóðòåâ, Ë. Äæîíãîâ, Å. Àíãåëîâà, Ë. Âàðòàíÿíîâ, Ê. Ðàë÷åâ, Â. Ãåîðãèåâ, Ê. Åíèêîâ, É. Ñèìåîíîâ ÍÑÁÀËÎ, Êëèíèêà ïî îáùà è êîðåìíà õèðóðãèÿ Âúâåäåíàòà îò Heald òîòàëíà ìåçîðåêòàëíà åêñöèçèÿ, íåîàäþâàíòíàòà ëú÷åòàðàïèÿ è ñúâðåìâåííèòå ðàçáèðàíèÿ çà ëîêàëíèÿ ðàñòåæ è ìåòàñòàçèðàíå íà ðåêòàëíèòå òóìîðè äîâåäîõà äî ðàçøèðÿâàíå ïîêàçàíèÿòà çà ñôèíêòåð-ñúõðàíÿâàùè îïåðàöèè. Âúçòàíîâÿâàíåòî íà ïàñàæà ñëåä íèñêà ðåçåêöèÿ íà ðåêòóìà å ïðåäèçâèêàòåëñòâî çà õèðóðãà, êðèå âèñîê ðèñê çà ïàöèåíòà è èçèñêâà îïèòåí è äîáðå ñðàáîòåí åêèï. Öåëòà íà òîâà ïðîó÷âàíå å äà ñå îöåíÿò èçïîëçâàíèòå îïåðàòèâíè òåõíèêè çà âúçòàíîâÿâàíå íà ïàñàæà ïðè óëòðàíèñêè ðåçåêöèè íà ðåêòóìà. Àâòîðèòå îïèñâàò ìåòîä ñ 2 ìîäèôèêàöèè çà îñúùåñòâÿâàíå íà óëòðàíèñêà òðàíñàáäîìèíàëíà àíàñòîìîçà. Ìàòåðèàë è ìåòîäè: Çà ïåðèîäà 2001 -2008 ã. â êëèíèêàòà ñà íàïðàâåíè 452 íèñêè è óëòðàíèñêè ðåçåêöèè íà ðåêòóìà ñ ïúðâè÷íî âúçòàíîâÿâàíå íà ïàñàæà. Ñ êàðöèíîì â äèñòàëíà ïîëîâèíà íà ðåêòóìà áÿõà 404 ïàöèåíòè, 9 îò òÿõ -ñ ðåöèäèâíè òóìîðè. 1 ïàöèåíòêà áåøå ñ ïúðâè÷åí ëèïîñàðêîì íà ðåêòóìà, 22 - ñ èíôèëòðàöèÿ íà ðåêòóìà îò òóìîðè ñ äðóãà ïúðâè÷íà ëîêàëèçàöèÿ, 24 -ñ äîáðîêà÷åñòâåíè çàáîëÿâàíèÿ. Â I ñòàäèé áÿõà 7,65% îò áîëíèòå, II ñòàäèé - 62,46%, III ñòàäèé -19,5%. Èçâúðøèõà ñå 42 (10,37%) ïàëèàòèâíè ðåçåêöèè ïðè ïàöèåíòè â IV ñòàäèé. 92% îò îïåðèðàíèòå áÿõà ñ ëîêàëíî àâàíñèðàëè òóìîðè (T3, T4). 134 (33%) áÿõà ïðîâåëè íåîàäþâàíòíà ëú÷åòåðàïèÿ, à 59% îò òÿõ -äðåáíî-ôðàêöèîíèðàíà. Àíàñòîìîçàòà å îñúùåñòâåíà òðàíñàáäîìèíàëíî ïðè 223 áîëíè (49%), ïðè 124 (55,6%) îò òÿõ -ñ àâòîìàòè÷åí ñúøèâàòåë. 2008 ãîäèíà 89% îò íèñêèòå ðåêòàëíè àíàñòîìîçè ñà íàïðàâåíè

òðàíñàáäîìèíàëíî. Ïðè 2 å èçâúðøåíà òðàíññàêðàëíà ðåçåêöèÿ íà ðåêòóìà. Ìîáèëèçèðàíå íà ëèåíàëíàòà ôëåêñóðà ñå å íàëîæèëî ïðè 79% îò àáäîìèíî-àíàëíèòå ðåçåêöèè è ïðè 30% îò íèñêèòå ïðåäíè ðåçåêöèè. Ïðîôèëàêòè÷íà ñòîìà å áèëà íàïðàâåíà â 89% îò ñëó÷àèòå, êàòî ïîíàñòîÿùåì ïðîôèëàêòè÷íàòà òðàíñâåðçîñòîìèÿ å ïî÷òè íàïúëíî èçìåñòåíà îò èëåîñòîìèÿòà. Ðåçóëòàòè: Ñðåäíèÿò ñëåäîïåðàòèâåí ïðåñòîé çà öåëèÿ ïåðèîä å 12,1 äíè, êàòî çà 2008 ã. òîé å ñíèæåí íà 10,3 äíè. Ïî÷èíàõà 2 áîëíè (0,44%) ñ êàðòèíàòà íà ìàñèâíà áåëîäðîáíà òðîìáîåìáîëèÿ. Óñëîæíåíèÿ â ñëåäîïåðàòèâíèÿ ïåðèîä íàñòúïèõà ïðè 75 áîëíè (16,59%): ìèêöèîííè ñìóùåíèÿ ñ ðåòåíöèÿ íà óðèíàòà -18 áîëíè (3,98%), êëèíè÷íî èçÿâåíà èíñóôèöèåíöèÿ íà àíàñòîìîçàòà - 17 (3,76%), îò êîèòî ðåîïåðàöèÿ ñå íàëîæè ïðè 9, ìåõàíè÷åí èëåóñ - 7 (1,54%), ïàðàëèòè÷åí èëåóñ - 4 (0,88%), ñóïóðàöèÿ íà îïåðàòèâíàòà ðàíà - 3 (0,66%), äåõèñöåíöèÿ íà îïåðàòèâíàòà ðàíà - 2 (0,44%), áåëîäðîáíà òðîìáîåìáîëèÿ - 3 (0,66%), äðóãè - 15 (3,31%). Íå ñå óñòàíîâÿâà ñúùåñòâåíà ðàçëèêà â ÷åñòîòàòà íà àíàñòîìîòè÷íàòà èíñóôèöèåíöèÿ ïðè òðàíñàáäîìèíàëíèÿ è òðàíññôèíêòåðíèÿ ìåòîä, êàêòî è ìåæäó àïàðàòíèÿ è ìàíóàëíèÿ. Çàêëþ÷åíèå: Ñ÷èòàìå, ÷å ïðè âúçìîæíîñò çà îñúùåñòâÿâàíå íà îíêîëîãè÷íî ðîäèêàëíà ðåçåêöèÿ, àíàòîìè÷íè ïðåäïîñòàâêè è äîáðå îâëàäÿíà òåõíèêà òðàíñàáäîìèíàëíàòà àíàñòîìîçà å ìåòîä íà èçáîð, ïîðàäè ïî-ìàëêàòà òðàâìà íà àíàëíî-ñôèíêòåðíèÿ êîìïëåêñ è ïî-êðàòêèÿ ïåðèîä äî çàòâàðÿíå íà ïðîòåêòèâíàòà ñòîìà.

Êëþ÷îâè äóìè: íèñúê ðåêòàëåí êàðöèíîì, óëòðàíèñêà ðåçåêöèÿ, àáäîìèíî-àíàëíà ðåçåêöèÿ, òðàíññôèíêòåðíà ðåçåêöèÿ

302

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ÕÈÐÓÐÃÈ×ÍÎ ËÅ×ÅÍÈÅ ÍÀ ÐÀÊÀ ÇÀ ÄÅÁÅËÎÒÎ È ÏÐÀÂÎÒÎ ×ÅÐÂÎ ÇÀ ÑÐÎÊ ÎÒ 10 ÃÎÄÈÍÈ -ÐÅÇÓËÒÀÒÈ Äàìÿíîâ Ä., Å. Êîñòàäèíîâ, Á. Êîðóêîâ, Í. Ïåíêîâ, Ï. Ïúðâàíîâ, Ð. Ëîçàíîâ, Ã. Ãåí÷åâ Êëèíèêà ïî õèðóðãèÿ, ÓÌÁÀË „Öàðèöà Èîàííà -ÈÑÓË”, Ñîôèÿ Êîëîðåêòàëíèÿò êàðöèíîì (ÊÐÊ) å âîäåùà íåîïëàçèÿ íà ãàñòðîèíòåñòèíàëíèÿ òðàêò. Áðîÿò íà íîâîçàáîëåëèòå ó íàñ íàäõâúðëÿ 4000 ãîäèøíî, à ïîëîâèíàòà îò òÿõ ñà â ²²² è ²V êëèíè÷åí ñòàäèé. Íåçàâèñèìî îò ñòàäèÿ õèðóðãè÷íîòî ëå÷åíèå å êëþ÷îâ åëåìåíò â êîìïëåêñíèÿ òåðàïåâòè÷åí ïîäõîä êúì ïàöèåíòèòå. Çà ñðîê îò 10 ãîäèíè â Êëèíèêàòà ñà îïåðèðàíè 1368 ïàöèåíòè ñ ïúðâè÷åí ÊÐÊ ïðè ñðåäíà âúçðàñò 68,4 ãîäèíè è íåçíà÷èòåëíî ïðåîáëàäàâàíå íà ìúæêèÿ ïîë. Íàä 75-ãîäèøíà âúçðàñò ñà 20,8% îò ïàöèåíòèòå. Äèñòàëíî ðàçïîëîæåíèå íà òóìîðèòå èìà ïðè 43,7% îò ïàöèåíòèòå. Ëåâîñòðàííà ëîêàëèçàöèÿ ïðè 30,6%, à äÿñíîñòðàííà - ïðè 25,7%. Â ñòàäèè ²²² è ²V ñà 41% îò áîëíèòå ñ êàðöèíîì íà ðåêòóìà è 45,6% îò òåçè ñ ðàê íà êîëîíà. Ñ äàííè çà îáòóðàöèîíåí èëåóñ è îïåðàðèðàíè ïî ñïåøíîñò ñà 209 ïàöèåíòè (15,4%). Ðåçóëòàòè: Ïðîöåíòúò íà íàìåñèòå ñ ðåçåêöèÿ íà ïúðâè÷íèÿ òóìîð äîñòèãà 85,3%. Íî ïðè êîíòèíãåíòà ñúñ ñïåøíè îïåðàöèè å 71,3%. Îáùàòà 30-äíåâíà

ñìúðòíîñò å 3,8% ñðåä ïëàíîâî è 10% - ñðåä ñïåøíî îïåðèðàíèòå. Îáùàòà ÷åñòîòà íà óñëîæíåíèÿòà å 14,7%, êàòî íà èíñóôèöèåíöèèòå íà àíàñòîìîçàòà ñå ïàäàò 4,4%. Íàëèöå å ðàçëèêà â ïðîöåíòà íà èíñóôèöèåíöèèòå ïðè ëîêàëèçàöèÿ íà àíàñòîìîçàòà â îáëàñòòà íà êîëîíà -1,7% è ïðè àíàñòîìîçè ñ ðåêòóìà -7,2%. Â îáùàòà ãðóïà äÿëúò íà ïàëèàòèâíèòå íàìåñè å 21,7%. Ïðè ëîêàëèçàöèÿ â ðåêòóìà 63,7% îò îïåðàöèèòå ñà ñôèíêòåðîñúõðàíÿâàùè. Èçâîäè: Íåçàâèñèìî îò ïåðñèñòèðàùàòà âèñîêà ÷åñòîòà íà ëîêàëíî àâàíñèðàëèòå è ìåòàñòàòè÷íè êàðöèíîìè å íàëèöå òåíäåíöèÿ çà óâåëè÷àâàíå ÷åñòîòàíà ðàäèêàëíèòå è íà ñôèíêòåðîçàïàçâàùèòå íàìåñè ïðè íèñêè è ñðàâíèìè ñ ïóáëèêóâàíèòå â ëèòåðàòóðàòà ÷åñòîòà íà ìîðòàëèòåòà è ìîðáèäèòåòà. Íåîáõîäèìà å ïîâèøåíà äèàãíîñòè÷íà àêòèâíîñò è êîëàáîðàöèÿ ñ õèìèî- è ëú÷åòåðàïåâòè çà äîïúëíèòåëíî ïîäîáðÿâàíå íà ðåçóëòàòèòå îò êîìïëåêñíîòî ëå÷åíèå íà áîëíèòå ñ ÊÐÊ.

ÍÅÎÏËÀÑÒÈ×ÅÍ ÎÁÒÓÐÀÖÈÎÍÅÍ ÄÅÁÅËÎ×ÐÅÂÅÍ ÈËÅÓÑ -ÔÀÊÒÎÐÈ, ÏÐÈ ÈÇÁÎÐÀ ÍÀ ÅÄÍÎ- ÈËÈ ÄÂÓÅÒÀÏÍÀ ÎÏÅÐÀÖÈß Äàìÿíîâ Ä., Å. Êîñòàäèíîâ, Í. Ïåòêîâ, Á. Êîðóêîâ, Ä. Âàñèëåâ, Ï. Ãåðçèëîâ, Ð. Äèìèòðîâ, Ï. Ïúðâàíîâ, Ð. Ëîçàíîâ, Ã. Ãåí÷åâ, Ã. Æåëåâ, Ì. Êåðìåä÷èåâ Êëèíèêà ïî õèðóðãèÿ, ÓÌÁÀË „Öàðèöà Èîàííà -ÈÑÓË”, Ñîôèÿ Îáòóðàöèÿòà íà äåáåëîòî ÷åðâî îò êàðöèíîì å ÷åñòà ïðè÷èíà çà ñïåøíà äåáåëî÷ðåâíà îïåðàöèÿ. Â òàçè ñèòóàöèÿ òÿ å ñâúðçàíà ñ ïî-âèñîêà ñìúðòíîñò, ìîðáèäèòåò è âëîøåíà îíêîëîãè÷íà ïðîãíîçà. Íàïðåäíàëàòà âúçðàñò, íàëè÷èåòî íà ïðèäðóæàâàùè çàáîëÿâàíèÿ è âëîøåíèÿò ñòàòóñ, ðàçâèòèåòî íà èëåóñ/èëåóñ-ïåðèòîíèò, ïîâèøåíàòà ÷åñòîòà íà àâàíñèðàëè òóìîðè è ïîíèæåíàòà ÷åñòîòà íà ðåçåêöèîííèòå íàìåñè ñà îñíîâíèòå îáñúæäàíè ïðè÷èíè çà íåáëàãîïðèÿòåí èçõîä. Ïðåç ïîñëåäíèòå 10 ãîäèíè ñðåä îïåðèðàíèòå â êëèíèêàòà ïî õèðóðãèÿ 1368 áîëíè ñ ïúðâè÷åí êîëîðåêòàëåí êàðöèíîì, ïðè 209 (15,4%) ñå óñòàíîâÿâà îáòóðàöèîíåí èëåóñ. Ñðåäíàòà âúçðàñò íà áîëíèòå ñ ÷ðåâíà íåïðîõîäèìîñò

å 67,3 ã. (22 -96 ã.). Ïðèäðóæàâàùè çàáîëÿâàíèÿ ñà ðåãèñòðèðàíè ïðè 44,9% îò òÿõ, à ñòåïåíòà íà ðèñêà å îò÷åòåíà ñ ÀSA ²²² è ²V, ñúîòâåòíî ïðè 40,2% è 27,8%. Òóìîðèòå ñà áèëè ñ äèñòàëíî ðàçïîëîæåíèå â 69% îò ñëó÷àèòå, à ïðè 5 áîëíè (2,4%) ñà íàìåðåíè ñèíõðîííè êàðöèíîìè. Â ²V êëèíè÷åí ñòàäèé ïî TNM ñà 25,8% îò áîëíèòå, à âúâ ôàçà íà ðàçâèòèå íà ïåðèòîíèò ñà 32 ïàöèåíòè. Ðåçóëòàòè: Ðåçåêöèÿ íà òóìîðà å âúçìîæíà ïðè 149 áîëíè (71,3%), êàòî ïðîöåíòúò å ñèãíèôèêàíòíî ïî-íèñúê ïðè ëåâîñòðàííèòå ëîêàëèçàöèè -70,7% vs. 77,5% (ð<0,05). 30-äíåâíàòà ñìúðòíîñò å 10% (21/209 áîëíè), ñèãíèôèêàíòíî ïî-âèñîêà îò òàçè ñðåä îáùàòà ãðóïà îïåðèðàíè -4,2% ïðè ð<0,05. Óñëîæíåíèÿ ñå 303

ABSTRACTS

ðàçâèâàò ïðè 20,2% îò îïåðèðàíèòå, êàòî ðàçëèêàòà ñ îáùàòà ãðóïà íå å ñòàòèñòè÷åñêè çíà÷èìà. Ñðåäíèÿò ñëåäîïåðàòèâåí ïðåñòîé å ñðåäíî 11 äíè, íî ïðè ðàçâèòèå íà óñëîæíåíèÿ äîñòèãà 14,1 äíè. Ñðåä ïàöèåíòèòå ñ ëÿâîñòðàííà ëîêàëèçàöèÿ å èçâúðøåíà ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà ïðè 36 áîëíè (25,2%), à äèñêîíòèíþèòåòíà ðåçåêöèÿ (òèï Hartmann) -ïðè 65 (45,5%). Èçïîëçâàéêè ñòàíäàðòíè ñòàòèñòè÷åñêè ìåòîäè (t-òåñò è ð-òåñò). Äâåòå ãðóïè ñà ñðàâíåíè ïî ñëåäíèòå ïîêàçàòåëè: ñðåäíà âúçðàñò, äÿë íà ïàöèåíòèòå íà/íàä 80 ãîäèíè, ASA ² + ²², ASA ²²² + ²V,

êëèíè÷åí ñòàäèé íà çàáîëÿâàíåòî, íàëè÷èå íà ïåðèòîíèò, óñëîæíåíèÿ è ñìúðòíîñò. Ðàçëèêèòå íå äîñòèãàò ñèãíèôèêàíòíîñò çà íèòî åäèí îò èçñëåäâàíèòå ôàêòîðè. Èçâîäè: Ñïåøíèòå îïåðàöèè ïðè èëåóñ, îáóñëîâåí îò äåáåëî÷ðåâåí êàðöèíîì, ñà ñâúðçàíè ñ ïîâèøåí ëåòàëèòåò è ïî-íèñêà ÷åñòîòà íà ðåçåêöèîííèòå íàìåñè ïðè ëÿâîñòðàííà ëîêàëèçàöèÿ. Èçâúðøâàíåòî íà ðåçåêöèÿ ñ ïúðâè÷íà àíàñòîìîçà ïðè äèñòàëíèòå êàðöèíîìè íå âîäè äî ïîâèøåí äÿë íà óñëîæíåíèÿòà è ñìúðòíîñòòà.

ÓÑËÎÆÍÅÍÀÒÀ ÄÈÂÅÐÒÈÊÓËÎÇÀ ÍÀ ÄÅÁÅËÎÒÎ ×ÅÐÂÎ ÂÑÅ ÏÎ-×ÅÑÒ ÏÐÎÁËÅÌ Â ÑÚÂÐÅÌÅÍÍÀÒÀ ÕÈÐÓÐÃÈ×ÅÑÊÀ ÏÐÀÊÒÈÊÀ Äàìÿíîâ Ä., Á. Ñèìåîíîâ, Æ. Àíãåëîâ, Ä. Âàñèëåâ, Ï. Ãåðçèëîâ, Ã. Åôòèìîâ, À. Ëàòèôÿí Êëèíèêà ïî õèðóðãèÿ, ÓÌÁÀË „Öàðèöà Èîàííà -ÈÑÓË”, Ñîôèÿ Çà äèâåðòèêóëîçà íà äåáåëîòî ÷åðâî ñå ãîâîðè ïðè íàëè÷èå íà ìíîæåñòâåíè äèâåðòèêóëè ñ äèàìåòúð ñðåäíî 5-10 ìì. è ñïåöèôè÷íà ñòåíà, ñúäúðæàùà ìóêîçà è ñóáìóêîçà, ïîêðèòè îò ñåðîçà. Ñàìî 2 -5% îò áîëíèòå ñà äî 40 ãîäèíè. Îêîëî 25% îò ïàöèåíòèòå ñ äèâåðòèêóëîçà ðàçâèâàò óñëîæíåíèÿ. ×åñòîòàòà å ðàçëè÷íà âçàâèñèìîñò îò âúçðàñòòà: äî 40 ãîäèíè ñà ñàìî 5% îò âñè÷êè ïàöèåíòè ñ òîâà çàáîëÿâàíå; äî 60 ãîäèíè ÷åñòîòàòà íàðàñòâà íà 30%, à íà ïàöèåíòèòå íàä 80 ãîäèíè ñå ïàäàò 65%. Óñòàíîâåíî å, ÷å äî 50-ãîäèøíà âúçðàñò ïðåâàëèðàò ìúæåòå, à ñëåä òîâà ñúîòíîøåíèåòî ñå ïðîìåíÿ â ïîëçà íà æåíèòå. Çà õèðóðçèòå âàæíî çíà÷åíèå èìà è ôàêòúò, ÷å ìíîçèíñòâîòî äèâåðòèêóëè ñà ëîêàëèçèðàíè â ñèãìàòà, ÷åñòîòàòà íà äèâåðòèêóëèòå íàìàëÿâà ïî ïîñîêà íà colon ascendens. Çàáîëÿâàíåòî ñå ðàçâèâà ïî-àãðåñèâíî è âîäè ïî-çàêîíîìåðíî êúì îïåðàöèÿ ó ïî-ìëàäè õîðà.

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Õèðóðãè÷åñêîòî ëå÷åíèå ñå ñëó÷âà âúâ âúçðàñòòà äî 50 ãîäèíè ïðè ïî÷òè 50% îò ïàöèåíòèòå ñ äèâåðòèêóëîçà, à çà äðóãèòå âúçðàñòîâè ãðóïè äîñòèãà äî 30%. Îáåêò íà õèðóðãè÷åñêè èíòåðåñ ñà óñëîæíåíèÿòà: êúðâåíå (5-15%) è âúçïàëèòåëåí ïðîöåñ/äèâåðòèêóëèò (15-25%). Àâòîðèòå îòáåëÿçâàò íàðàñòâàùàòà ÷åñòîòà íà ïàöèåíòè, õîñïèòàëèçèðàíè ïðåç ïîñëåäíèòå 3 ãîäèíè (2006 -2009 ã.) â Êëèíèêàòà ïî õèðóðãèÿ ïî ïîâîä êîëî- èëè ðåêòîðàãèÿ. Òåõíèÿò áðîé äîñòèãà 27. Ðàçãëåæäàò ñå âúçìîæíèòå âúçïàëèòåëíè óñëîæíåíèÿ, ñâúðçàíè ñ ïîÿâà íà âúçïàëèòåëåí ïñåâäîòóìîð (àáñöåñ), ôîðìèðàíå íà ôèñòóëà (âúòðåøíà èëè âúíøíà) è ðàçâèòèå íà ïåðèòîíèò (ïåðôîðàöèÿ êúì êîðåìíàòà êóõèíà). Ñ ïîäîáíè óñëîæíåíèÿ ñà îïåðèðàíè 10 áîëíè. Àíàëèçèðà ñå õèðóðãè÷åñêàòà òàêòèêà è ìÿñòîòî íà îòêðèòèòå è ëàïàðîñêîïñêèòå íàìåñè.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ÁÎËÅÑÒÒÀ ÍÀ CROHN -ÐßÄÚÊ È ÒÐÓÄÅÍ ÕÈÐÓÐÃÈ×ÅÍ ÏÐÎÁËÅÌ Äàìÿíîâ Ä., Ï. Ïåí÷åâ, Á. Êîðóêîâ, Ñ. Ñòîéíîâ, Í. Ïåíêîâ, Å. Êîñòàäèíîâ, Ì. Êåðìåä÷èåâ, Ñ. Èâàíîâ, Ä. Àë Çàéÿò Êëèíèêà ïî õèðóðãèÿ, Êëèíèêà ïî ãàñòðîåíòåðîëîãèÿ, ÓÌÁÀË „Öàðèöà Èîàííà -ÈÑÓË”, Ñîôèÿ Áîëåñòòà íà íà Crohn îñòàâà òðóäåí çà ðåøàâàíå õèðóðãè÷åí ïðîáëåì ïîðàäè õðîíè÷íî ðåöèäèâèðàùèÿ õàðàêòåð è ðàçâèòèå íà çàáîëÿâàíåòî, íàëè÷èåòî íà ñåðèîçíè ïðåäîïåðàòèâíè óñëîæíåíèÿ, ñëåäîïåðàòèâíè ðåöèäèâè è òðóäíîñòè â îïåðàòèâíîòî ëå÷åíèå. Ïðåç ïîñëåäíèòå 20 ãîäèíè (1990 -2009 ã.) â Êëèíè÷íèÿ öåíòúð ïî ãàñòðîåíòåðîëîãèÿ ñà ëåêóâàíè 138 áîëíè ñ òîâà çàáîëÿâàíå. 53 îò òÿõ (38,4%) ïîñòúïâàò ïúðâîíà÷àëíî äèðåêòíî â õèðóðãè÷íî çâåíî. Îò òÿõ 51 ñà îïåðèðàíè ñêîðî ñëåä òîâà, à äâå æåíè ñà ëåêóâàíè êîíñåðâàòèâíî. Ñàìî ïðè 13 îò ïàöèåíòèòå ïðåäîïåðàòèâíàòà äèàãíîçà å ñâúðçàíà ñ îñòúð àïåíäèöèò, äîêàòî ïðè îñòàíàëèòå 40 ïàöèåíòè ïîäîçðåíèÿòà âàðèðàò ìåæäó 15 äðóãè çàáîëÿâàíèÿ.

Õèðóðãè÷íèÿò åêèï ïîñòàâÿ òî÷íà äèàãíîçà ïðè 29 îò îïåðèðàíèòå ïî âðåìå íà ïúðâè÷íàòà íàìåñà, íî ïðè îñòàíàëèòå 22 äåéñòâèòåëíèÿò õàðàêòåð íà áîëåñòòà ñå óòî÷íÿâà îò 6 äî 60 ìåñåöà, ïîðàäè êîåòî ëå÷åíèåòî íà òåçè ïàöèåíòè îñòàâà íåïðîâåäåíî èëè íåïðàâèëíî äî ðàçâèòèå íà íîâà óñëîæíåíà ñèòóàöèÿ. Àâòîðèòå ñïîäåëÿò ñâîÿ îïèò ïðè èçáîðà íà õèðóðãè÷åí ïðèéîì âçàâèñèìîñò îò ëîêàëèçàöèÿòà íà ïðîìåíèòå ïî ãàñòðîèíòåñòèíàëíèÿ òðàêò. Ïîä÷åðòàâà ñå íåîáõîäèìîñòòà îò ñú÷åòàíèå íà õèðóðãè÷íàòà íàìåñà ñ êîíñåðâàòèâíî ëå÷åíèå â èíòåðâàëèòå ñ öåë óäúëæàâàíå íà ïåðèîäèòå íà ðåìèñèÿ è ïîíèæàâàíå ïðîöåíòà íà ðåöèäèâèòå

ÏÎÊÀÇÀÍÈß È ÕÈÐÓÐÃÈ×ÅÑÊÀ ÒÀÊÒÈÊÀ ÏÐÈ ËÅ×ÅÍÈÅÒÎ ÍÀ ÓËÖÅÐÎÇÍÈß ÊÎËÈÒ Äàìÿíîâ Ä., Ï. Ïåí÷åâ, Ñ. Ñòîéíîâ, Í. Ïåíêîâ, Ï. Ïúðâàíîâ, Ð. Ëîçàíîâ, Á. Êîðóêîâ, Ã. Æåëåâ, Å. Êîñòàäèíîâ, Ñ. Èâàíîâ, Ä. Àë Çàéÿò Êëèíèêà ïî õèðóðãèÿ, Êëèíèêà ïî ãàñòðîåíòåðîëîãèÿ, ÓÌÁÀË „Öàðèöà Èîàííà -ÈÑÓË”, Ñîôèÿ Óëöåðîçíèÿò êîëèò å ðÿäêî çàáîëÿâàíå íà äåáåëîòî ÷åðâî. Êëèíè÷íàòà êàðòèíà ñå ðàçâèâà õðîíè÷íî èëè îñòðî, ïðåäèìíî â ïî-ìëàäà âúçðàñò. Ìíîçèíñòâîòî áîëíè ñà îáåêò íà äúëãîãîäèøíî ìåäèêàìåíòîçíî è äèåòè÷íî ëå÷åíèå ñ ðàçëè÷íè ïî äúëãîòðàéíîñò ïåðèîäè íà ðåìèñèÿ. Ïîêàçàíè ñà õèðóðãè÷åñêî ëå÷åíèå ñà: 1. Ïàöèåíòè ñ îñòðè óñëîæíåíèÿ -ïåðôîðàöèÿ, õåìîðàãèÿ, ñóáèëåóñ/èëåóñ. 2. Ïàöèåíòè ñ õðîíè÷íè óñëîæíåíèÿ - ñòåíîçà íà äåáåëîòî ÷åðâî, õðîíè÷åí ïàðàïðîêòèò, ìàëèãíåíà äåãåíåðàöèÿ. 3. Ïàöèåíòè ñ ÷åñòè îáîñòðÿíèÿ, êðàòêîòðàéíè ðåìèñèè è îáùè íàðóøåíèÿ - ðåäóêöèÿ íà òåãëî, àíåìèÿ, òåæêè åêñòðàêîëè÷íè óñëîæíåíèÿ è äð. Çà 25-ãîäèøåí ïåðèîä â Êëèíèêàòà ïî õèðóðãèÿ íà „ÓÌÁÀË „Öàðèöà Èîàííà” ñà ïðèåòè 21 áîëíè ñ òåæêè óñëîæíåíè ôîðìè íà óëöåðîçåí êîëèò. Òå

ïðåäñòàâëÿâàò îêîëî 12% îò ïàöèåíòèòå, ïðèåòè è ëåêóâàíè â Êëèíè÷íèÿ öåíòúð ïî ãàñòðîåíòåðîëîãèÿ, îñíîâíî â Êëèíèêàòà ïî ãàñòðîåíòåðîëîãèÿ. Ïî-ðÿäêî áîëíèòå ïîñòúïâàò çà êîíñåðâàòèâíî ëå÷åíèå äèðåêòíî â Êëèíèêàòà ïî õèðóðãèÿ. Ïàöèåíòèòå ñà 15 ìúæå è 6 æåíè íà âúçðàñò îò 17 äî 69 ãîäèíè. Îò ïîñòúïèëèòå â Êëèíèêàòà ïî õèðóðãèÿ 8 äóøè ñà ëåêóâàíè êîíñåðâàòèâíî, à 13 ñà ïîäëîæåíè íà îïåðàöèÿ/îïåðàöèè. Àâòîðèòå ïðàâÿò àíàëèç íà îñíîâíèòå êëèíè÷íè ïîêàçàòåëè, îáñúæäàò ïîêàçàíèÿòà çà îïåðàòèâíî ëå÷åíèå è ïîñî÷âàò âàðèàíòèòå çà èçáîð íà õèðóðãè÷åí ìåòîä ñïîðåä õàðàêòåðà íà óñëîæíåíàòà ôîðìà íà áîëåñòòà. Â ãðóïàòà èìà ñàìî 1 ëåòàëåí èçõîä (20-ãîäèøåí ìúæ, ïî÷èíàë íà 58-ÿ ñëåäîïåðàòèâåí äåí ñëåä íåêîëêîêðàòíè ñïîíòàííè òúíêî÷ðåâíè ïåðôîðàöèè è äèôóçåí ïåðèòîíèò).

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ABSTRACTS

ÎÑÎÁÅÍÎÑÒÈ ÍÀ ÍÅÂÐÎÅÍÄÎÊÐÈÍÍÈÒÅ ÒÓÌÎÐÈ (NET) È ÂÚÇÌÎÆÍÎÑÒÈ ÇÀ ÒßÕÍÎÒÎ ËÅ×ÅÍÈÅ Äàìÿíîâ Ä., È. Òåðçèåâ, Àðê. Èâàíîâ ÓÌÁÀË „Öàðèöà Èîàííà - ÈÑÓË”, Êëèíèêà ïî õèðóðãèÿ, Îòäåëåíèå ïî ïàòîàíàòîìèÿ; ÕÎ - ²V ãðàäñêà áîëíèöà -Ñîôèÿ Íåâðîåíäîêðèííèòå òóìîðè èçõîæäàò îò ïàíêðåàñíèÿ èíñóëàðåí àïàðàò, êàêòî è îò ãàñòðîèòíòåñòèíàëíèÿ òðàêò (êàðöèíîèäè). Êàðöèíîèäèòå ïðåäñòàâëÿâàò îêîëî 2% îò âñè÷êè ñòîìàøíî÷ðåâíè íîâîîáðàçóâàíèÿ. Ïî ñòàòèñòèêà íà ÑÀÙ ÷åñòîòàòà èì íàðàñòâà 3-4 ïúòè çà ïîñëåäíèòå 30 ãîäèíè. Àâòîðèòå ïðåäñòàâÿò øèðîêîâúçïðèåòèòå êëàñèôèêàöèè íà ÑÇÎ è ïî TNM íà ãàñòðîåíòåðîïàíêðåàòè÷íèòå NET. Ñïîäåëåíè ñà íàáëþäåíèÿòà â ÊÖÃÅ íà ÓÌÁÀË

„Öàðèöà Èîàííà-ÈÑÓË” íà 8 ïàöèåíòè ïðåç ïîñëåäíèòå 3 ãîäèíè. Îïèñàíè ñà íÿêîè êîíêðåòíè õàðàêòåðèñòèêè â õèñòîïàòîëîãèòà, êëèíèêàòà, äèàãíîñòèêàòà è îïåðàòèâíîòî ëå÷åíèå íà NET, ëîêàëèçèðàíè â ñòîìàõà, äóîäåíóìà, èëåóìà, àïåíäèêñà, êîëîíà è ðåêòóìà. Ñúîáùåíè ñà äàííè çà 5-ãîäèøíàòà ïðåæèâÿåìîñò, êàêòî è îñíîâíèòå ïðèíöèïè çà õèðóðãè÷íî è êîìïëåêñíî ëå÷åíèå íà òåçè ñïåöèôè÷íè òóìîðè.

ÊÎÌÏËÅÊÑÍÎ ÏÎÂÅÄÅÍÈÅ ÏÐÈ ÃÀÑÒÐÎÈÍÒÅÑÒÈÍÀËÍÈ ÑÒÐÎÌÀËÍÈ ÒÓÌÎÐÈ (GIST) Äàìÿíîâ Ä., È. Òåðçèåâ, Ï. Êóðòåâ ÓÌÁÀË „Öàðèöà Èîàííà - ÈÑÓË”, Êëèíèêà ïî õèðóðãèÿ, Îòäåëåíèå ïî ïàòîàíàòîìèÿ; ÑÁÀËÎ -Ñîôèÿ, Êëèíèêà ïî õèðóðãèÿ Àâòîðèòå îïèñâàò õàðàêòåðíî êëèíè÷íî íàáëþäåíèå, êàêòî è îáùî 12 äèàãíîñòèöèðàíè ïðåç ïîñëåäíèòå 2,5 ãîäèíè áîëíè ñ ãàñòðîèíòåñòèíàëíè ñòðîìàëíè òóìîðè. Çà÷åñòÿâàíåòî íà òàçè äèàãíîçà å ïîâîä äà ñå ïðåäñòàâÿò íîâîñòèòå çà òåçè âñå îùå òðóäíî ïàòîìîðôîëîãè÷íî äèôåðåíöèðàíè òóìîðè. Ñúîáùåíè ñà íîâîñòèòå â èçÿñíÿâàíåòî íà èìóíîõèñòîõèìè÷íèòå è ìîëåêóëÿðíîáèîëîãè÷íè îñîáåíîñòè íà GIST. Òå ïðåäñòàâëÿâàò 1-3% îò âñè÷êè çëîêà÷åñòâåíè òóìîðè ïî ñòîìàøíî-÷ðåâíèÿ òðàêò. Íàé-÷åñòî ñà ëîêàëèçèðàíè â ñòîìàõà (65%), â òúíêîòî ÷åðâî (25%), â êîëîí/ðåêòóì (10%), äîêàòî â õðàíîïðîâîäà ñà ðÿäêîñò. Ñúîáùåíè ñà õàðàêòåðíè

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îñîáåíîñòè îòíîñíî òÿõíàòà ÷åñòîòà â ïîñî÷åíèòå îðãàíè, ìàêðîñêîïñêè è ìèêðîñêîïñêè õàðàêòåðèñòèêè, ôàêòîðè, ñâúðçàíè ñ ïðåæèâÿåìîñòòà. Îòáåëÿçàíî å, ÷å âñè÷êè GIST ìîãàò äà ìåòàñòàçèðàò èëè äà èíôèëòðèðàò ñúñåäíè îðãàíè, êîåòî å îñíîâàíèå äà ñå î÷àêâà ðåöèäèâ íà çàáîëÿâàíåòî. Âúâ âðúçêà ñ òîâà ñå ïîä÷åðòàâà âàæíîñòòà íà õèðóðãè÷åñêàòà íàìåñà, êîÿòî òðÿáâà äà áúäå âúâ âèäèìî çäðàâè òúêàíè, à â ñëåäîïåðàòèâíèÿ ïåðèîä äà ñå èçïîëçâà õèìèîòåðàïèÿ ñ Imatinib. Ïîñëåäíèÿò ïîçâîëÿâà ïî-êîíñåðâàòèâíà õèðóðãèÿ, íàìàëåíà êðúâîçàãóáà è îïåðàòèâåí ðèñê, à ñå ïîñòèãà íÿêîëîêîãîäèøíà ïî-äîáðà ïðåæèâÿåìîñò.

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ÁÈËÎÁÀÐÍÈ ×ÅÐÍÎÄÐÎÁÍÈ ÐÅÇÅÊÖÈÈ ÏÐÈ ÌÅÒÀÑÒÀÇÈ ÎÒ ÊÎËÎÐÅÊÒÀËÅÍ ÐÀÊ Êîñòîâ Ä., Í. Äðàãíåâ,*Ã. Êîáàêîâ, Â. Èâàíîâ, Ð. Ïàòàíîâ, È. Ïëà÷êîâ Êëèíèêà ïî õèðóðãèÿ, ÁÁÀË Âàðíà êúì ÂÌÀ Ñîôèÿ, *ÌÄÎÇÑ “Ä-ð Ìàðêî Ìàðêîâ” ÅÎÎÄ-Âàðíà Öåë: Ðåçåêöèÿòà íà ÷åðíèÿ äðîá å îñíîâåí ìåòîä â ëå÷åáíàòà ñòðàòåãèÿ íà ìåòàñòàçèòå îò êîëîðåêòàëåí ðàê. Â ïðàêòèêà å âñå îùå íåäîñòàòú÷íî äîáðå äåôèíèðàíî õèðóðãè÷íîòî ëå÷åíèå íà áèëîáàðíèòå ÷åðíîäðîáíè ìåòàñòàçè. Ïðåäñòàâÿìå íàøèÿò îïèò ñ ðåçåêöèÿòà íà ÷åðíèÿ äðîá ïðè áèëîáàðíè ìåòàñòàçè. Ìàòåðèàë è ìåòîäè: Çà ïåðèîä îò äåñåò ãîäèíè â Êëèíèêàòà ïî õèðóðãèÿ íà ÁÁÀË, Âàðíà ñà èçâúðøåíè 31 ñåãìåíòíè ÷åðíîäðîáíè ðåçåêöèè ïðè áèëîáàðíè ñèíõðîííè è ìåòàõðîííè ìåòàñòàçè îò êîëîðåêòàëåí ðàê. Ðåçèöèðàíè ñà îò äâà äî ÷åòèðè ÷åðíîäðîáíè ñåãìåíòà îò äåñíèÿ è ëåâèÿ õåìèäðîá. Ïðîó÷åíè ñà ñëåäîïåðàòèâíèòå óñëîæíåíèÿ è ñìúðòíîñò, êàêòî è äúëãîñðî÷íàòà ïðåæèâÿåìîñò. Ðåçóëòàòè: ×åñòîòàòà íà ñëåäîïåðàòèâíèòå óñëîæíåíèÿ âàðèðà â çàâèñèìîñò îò áðîÿ íà

îòñòðàíåíèòà ÷åðíîäðîáíè ñåãìåíòà. Ïðè ðåçåêöèÿ íà äâà ñåãìåíòà òÿ å 12%, à ïðè îòñòðàíÿâàíå íà ÷åòèðè ñåãìåíòà òÿ äîñòèãà 48%. ×åñòîòàòà íà ñëåäîïåðàòèâíàòà ñìúðòíîñò å 0.6%. Òðè ãîäèíè ïðåæèâÿâàò ñðåäíî 33% îò ïàöèåíòèòå. Èçâîäè: Áèëîáàðíàòà ÷åðíîäðîáíà ðåçåêöèÿ å óäà÷åí ìåòîä çà õèðóðãè÷íî ëå÷åíèå íà ìåòàñòàçè, ëîêàëèçèðàíè â ëåâèÿ è äåñíèÿ õåìèäðîá. Ìåòîäúò óäúëæàâà çíà÷èòåëíî ïðåæèâÿåìîñòòà, â ñðàâíåíèå ñ ñàìîñòîÿòåëíîòî ïðèëîæåíèå íà õèìèîòåðàïèÿ. Îïåðàöèÿòà å àëòåðíàòèâà íà ãîëåìèòå ïî îáåì ÷åðíîäðîáíè ðåçåêöèè, âêëþ÷âàùè ëÿâàòà è äÿñíàòà òðèñåêöèîíåêòîìèÿ. Çà èçâúðøâàíåòî íà áèëîáàðíè ðåçåêöèè å íóæíî äåòàéëíî ïîçíàâàíå íà èíòðàïàðåíõèìíàòà ÷åðíîäðîáíà àíàòîìèÿ è îïèò â ÷åðíîäðîáíàòà õèðóðãèÿ.

ÌÅÇÎÕÅÏÀÒÅÊÒÎÌÈß ÏÐÈ ÌÅÒÀÑÒÀÇÈ ÎÒ ÊÎËÎÐÅÊÒÀËÅÍ ÐÀÊ Êîñòîâ Ä., Í. Äðàãíåâ,*Ã. Êîáàêîâ, Â. Èâàíîâ, Ð. Ïàòàíîâ, È. Ïëà÷êîâ Êëèíèêà ïî õèðóðãèÿ, ÁÁÀË Âàðíà êúì ÂÌÀ Ñîôèÿ, *ÌÄÎÇÑ “ä-ð Ìàðêî Ìàðêîâ” ÅÎÎÄ-Âàðíà Öåë: Äà ñå ïðåäñòàâÿò îïåðàòèâíî-òåõíè÷åñêèòå îñîáåíîñòè íà ìåçîõåïàòåêòîìèÿòà è äà ñå ïðîó÷àò ñëåäîïåðàòèâíèòå ðåçóëòàòè ñëåä ïðèëàãàíå íà ìåòîäèêàòà ïðè ÷åðíîäðîáíè ìåòàñòàçè îò êîëîðåêòàëåí ðàê. Ìàòåðèàë è ìåòîäè: Çà ïåðèîä îò äåñåò ãîäèíè â Êëèíèêàòà ïî õèðóðãèÿ íà ÁÁÀË, Âàðíà ñà èçâúðøåíè 17 ìåçîõåïàòåêòîìèè ïðè ñèíõðîííè è ìåòàõðîííè ìåòàñòàçè îò êîëîðåêòàëåí ðàê. Îïåðàòèâíèÿò îáåì âêëþ÷âà îòñòðàíÿâàíå íà IV,V,VIII+I ñåãìåíòè (n=4) èëè ðåçåêöèÿ íà IV,V,VIII (n=13) ñåãìåíòè. Ïðîó÷åíè ñà ñëåäîïåðàòèâíèòå ñìúðòíîñò è äúëãîñðî÷íàòà ïðåæèâÿåìîñò íà áàçàòà íà ãðóïà îò 21 ïðîãíîñòè÷íè êðèòåðèÿ. Ðåçóëòàòè: Ñëåäîïåðàòèâíèòå óñëîæíåíèÿ çàñÿãàò 48% îò áîëíèòå. ×åñòîòàòà íà ñëåäîïåðàòèâíàòà ñìúðòíîñò å 0.6%. Òðè ãîäèíè ïðåæèâÿâàò ñðåäíî 55%

îò ïàöèåíòèòå. Ôàêòîðèòå, âëèÿåùè âúðõó ïðåæèâÿåìîñòòà ñà òóìîðíàòà äèôåðåíöèàöèÿ (p<0.605, p<0.729), íèâîòî íà CEA (p<0.903, p<0.765), äèàìåòúðúò íà ìåòàñòàçèòå (p<0.699, p<0.713), ñúñòîÿíèåòî íà ðåçåêöèîííèòå ïîâúðõíîñòè (p<0.928), íàëè÷èåòî íà ïîëîæèòåëíè ëèìôíè âúçëè â õåïàòîäóîäåíàëíèÿ ëèãàìåíò (p<0.626), ðàçïðîñòðàíåíèåòî íà ìåòàñòàçèòå (p<0.898) è áðîÿò íà ïðîãíîñòè÷íèòå êðèòåðèè, âúâåäåíè îò Memorial Sloan-Kettering Cancer Center Risk Score (p<0.707, p<0.762). Èçâîäè: Ìåçîõåïàòåêòîìèÿòà å àëòåðíàòèâà íà ëÿâàòà èëè äÿñíàòà òðèñåêöèîíåêòîìèÿ. Òÿ å ïðîôèëàêòè÷íà ìÿðêà ñðåùó ðàçâèòèåòî íà ñëåäîïåðàòèâíà ÷åðíîäðîáíà íåäñòàòú÷íîñò, êîÿòî e âúçìîæíî ñëåäîïåðàòèâíî óñëîæíåíèå ñëåä îòñòðàíÿâàíå íà ïîâå÷å îò ÷åòèðè ÷åðíîäðîáíè ñåãìåíòà.

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ABSTRACTS

ÀÍÀÒÎÌÈ×ÍÀ ÌÎÍÎÑÅÃÌÅÍÒÅÊÒÎÌÈß ÏÐÈ ÌÅÒÀÑÒÀÇÈ ÎÒ ÊÎËÎÐÅÊÒÀËÅÍ ÐÀÊ Êîñòîâ Ä., Í. Äðàãíåâ, *Ã. Êîáàêîâ, Â. Èâàíîâ, Ð. Ïàòàíîâ, È. Ïëà÷êîâ Êëèíèêà ïî õèðóðãèÿ, ÁÁÀË Âàðíà êúì ÂÌÀ Ñîôèÿ, *ÌÄÎÇÑ “ä-ð Ìàðêî Ìàðêîâ” ÅÎÎÄ-Âàðíà Öåë: Äà ñå ïðåäñòàâÿò îïåðàòèâíî-òåõíè÷åñêèòå îñîáåíîñòè è ïðåèìóùåñòâàòà íà ìîíîñåãìåíòíèòå ÷åðíîäðîáíè ðåçåêöèè ïðè ìåòàñòàçè îò êîëîðåêòàëåí ðàê. Ìàòåðèàë è ìåòîäè: Çà ïåðèîä îò äåñåò ãîäèíè â Êëèíèêàòà ïî õèðóðãèÿ íà ÁÁÀË, Âàðíà ñà èçâúðøåíè 27 ìîíîñåãìåíòíè ðåçåêöèè íà ÷åðíèÿ äðîá ïðè ñèíõðîííè è ìåòàõðîííè ìåòàñòàçè îò êîëîðåêòàëåí ðàê. Îïåðàòèâíèÿò îáåì âêëþ÷âà ñàìîñòîÿòåëíî îòñòðàíÿâàíå îò ² äî VIII ñåãìåíò: ² (n=3), II (n=2), III (n=3), IV (n=9), V (n=2), VI (n=4), VII (n=2), VIII (n=2). Ïðîó÷åíè ñà ñëåäîïåðàòèâíèòå ñìúðòíîñò è óñëîæíåíèÿ. Áîëíèòå ñà ïðîñëåäåíè â ðàìêèòå íà òðè ãîäèíè, êàòî å ïðîñëåäåíà äúëãîñðî÷íàòà ïðåæèâÿåìîñò íà áàçàòà íà ãðóïà îò 21 ïðîãíîñòè÷íè êðèòåðèÿ. Ðåçóëòàòè: Ñëåäîïåðàòèâíèòå óñëîæíåíèÿ ñàñÿãàò 21% îò îïåðèðàíèòå áîëíè. Ñìúðòåí èçõîä íå å ðåãèñòðèðàí â ðàìêèòå íà 90 äíè ñëåäîïåðàòèâíî. Òðè

ãîäèíè ïðåæèâÿâàò ñðåäíî 55% îò ïàöèåíòèòå. Ôàêòîðèòå, âëèÿåùè âúðõó ïðåæèâÿåìîñòòà ñà òóìîðíàòà äèôåðåíöèàöèÿ (p<0.605, p<0.729), íèâîòî íà CEA (p<0.903, p<0.765), äèàìåòúðúò íà ìåòàñòàçèòå (p<0.699, p<0.713), ñúñòîÿíèåòî íà ðåçåêöèîííèòå ïîâúðõíîñòè (p<0.928), íàëè÷èåòî íà ïîëîæèòåëíè ëèìôíè âúçëè â õåïàòîäóîäåíàëíèÿ ëèãàìåíò (p<0.626), ðàçïðîñòðàíåíèåòî íà ìåòàñòàçèòå (p<0.898) è áðîÿò íà ïðîãíîñòè÷íèòå êðèòåðèè, âúâåäåíè îò Memorial Sloan-Kettering Cancer Center Risk Score (p<0.707, p<0.762). Èçâîäè: Ìîíîñåãìåíòíàòà ÷åðíîäðîáíà ðåçåêöèÿ å ïðåâàíòèâíà ìÿðêà ñðåùó ðàçâèòèåòî íà ñëåäîïåðàòèâíà ÷åðíîäðîáíà íåäîñòàòú÷íîñò. Îïåðàöèÿòà èçèñêâà äåòàéëíî ïîçíàâàíå íà èíòðàïàðåíõèìíàòà ïîðòàëíà òðèàäà. Ñëåäîïåðàòèâíàòà ïðåæèâÿåìîñò å àíàëîãè÷íà ïî ïðîäúëæèòåëíîñò íà òàçè, ïîñòèãíàòà ñëåä õåìèõåïàòåêòîìèÿ.

ÈÍÒÐÀÑÔÈÍÊÒÅÐÍÈÒÅ ÐÅÇÅÊÖÈÈ - ÀËÒÅÐÍÀÒÈÂÀ ÍÀ ÀÏÅ ÇÀ ÄÈÑÒÀËÍÈÒÅ ÊÐ Äàìÿíîâ Í., Á. Ãàéäåâà, Â Õðèñòîâà ÂÌÀ, Ñåêòîð êîëîïðîêòîëîãèÿ, ÊÅÕ Êîíöåïöèÿòà íà E.Miles îïðåäåëÿ ÀÏÅ êàòî "çëàòåí" ñòàíäàðò â ðåêòàëíàòà îíêîõèðóðãèÿ çà äåñåòèëåòèÿ. Ñåãà ïîçíàíèÿòà çà èíòðàìóðàëíî ðàçïðîñòðàíåíèå íà äèñòàëíèòå ÊÐ ñà îñíîâàíèå çà çàìÿíà íà ïðàâèëîòî çà 5 ñì äèñòàíöèÿ íà äèñòàëíàòà ðåçåêöèîííà ëèíèÿ (ÄÐË) îò òóìîðà ñ êîíöåïöèÿòà çà äîñòàòú÷íîñòòà íà 2 ñì îòñòîÿíèå çà èíòðàìóðàëåí êëèðúíñ. Íàëè÷èåòî íà ÷àñò îò àíàëíèÿ êàíàë, ñâîáîäåí îò òóìîðíà èíôèëòðàöèÿ, å ïðåäïîñòàâêà çà ÑÇÎ, êîåòî ñå ïîñòèãà ñ ÈÑÐ. Àíàëíàòà ôóíêöèÿ ñëåä ÈÑÐ ñ ðåêîíñòðóêòèâíè àíàñòîìîçè, íåçàâèñèìî îò ÷àñòè÷íàòà è âðåìåííà èíêîíòèíåíöèÿ, íîùíàòà çàãóáà íà êîíòðîë è ñòðåñäåôåêàöèÿòà, å ïðèåìëèâà çà áîëíèòå. Îïëàêâàíèÿòà îòñëàáâàò ñ âðåìåòî, à ôèçèîòåðàïåâòè÷íè ïðîöåäóðè, ìåäèêàìåíòè è

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õðàíèòåëåí ðåæèì ïîäïîìàãàò îïòèìèçèðàíåòî íà àíàëíàòà ôóíêöèÿ. Öåë: Ïðåöåíêà íà êà÷åñòâîòî íà æèâîò ñëåä ÈÑÐ, ñðàâíåíî ñ òîâà íà ÐÏ è ñå îïðåäåëè ìÿñòîòî íà ÈÑÐ â îïåðàòèâíîòî ëå÷åíèå íà ÊÐ, ðàçïîëîæåíè â áëèçîñò ñ àíîðåêòàëíîòî ñúåäèíåíèå. Ìàòåðèàë è ìåòîäè: Îñúùåñòâåíè ñà 8 ÈÑÐ íà ÊÐ íà 1-2 ñì íàä linea dentata. Åêñöèçèðà ñå ðåêòóìà è äèñòàëíàòà ÷àñò íà àíàëíèÿ êàíàë, ñëåä åêñòðàôàñöèàëíà ìîáèëèçàöèÿ äî õèàòóñà. Ñ ïîìîùòà íà Cleveland Clinic Incontinence Score (CCIS) è Wexner score áå îöåíåíà àíàëíàòà ôóíêöèÿ, êàòî ñå ñðàâíè ñ òàçè ïðè ðåñòîðàòèâíà ïðîòåêòîìèÿ (ÐÏ) ñ äèðåêòíè àíàñòîìîçè. Áðîÿò íà òî÷êèòå îïðåäåëÿ ñòåïåíèòå íà íàðóøåíèå íà êîíòðîëà. CCIS å çà îöåíêà íà ÷àñòè÷íàòà èíêîíòèíåíöèÿ, à Wexner score âêëþ÷âà è

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

âëèÿíèåòî é âúðõó íà÷èíà íà æèâîò. Ñðåäíèÿò áðîé íà äåôåêàöèè ñëåä ÈÑÐ çà 24 ÷àñà å 2.29 (1-4). Ñòðåñäåôåêàöèè èìàò 4-ìà îò ïàöèåíòèòå ñ ÈÑÐ. Îñòàíàëèòå ïàðàìåòðè è ôóíêöèîíàëíè ðåçóëòàòè íå äàâàò ñòàòèñòè÷åñêè äîñòîâåðíà ðàçëèêà, êîãàòî ñå ñðàâíÿò ñ äàííèòå îò äèðåêòíèòå ÐÏ. Ôóíêöèîíàëíèÿò åôåêò ïðè ÈÑÐ ñ ðåêîíñòðóêòèâíè ñúóñòèÿ íàïîäîáÿâà òîçè íà ÐÏ ñ äèðåêòíè ÊÀÀ. Ïúðâàòà ÈÑÐ áå ñ äèðåêòíà ÊÀÀ, à ñëåäâàùèòå ñ ðåêîíñòðóêòèâíè - 2

êîëè÷íè j-pouch'à, 3 ìîäèôèöèðàíè êîëîïëàñòèêè è 2 ëàòåðîòåðìèíàëíè àíàñòîìîçè. Ðåçóëòàòè: Ñëåä ÈÑÐ è ÐÏ ñå ðåäóêöèðà îñòàòú÷íîòî íàëÿãàíå â ÀÊ. Ìàêñèìàëíîòî âîëåâî íàëÿãàíå áúðçî äîñòèãà èçõîäíèòå ñòîé-íîñòè è ïðè ñòðåñäåôåêàöèÿ ìîæå êîìïåíñàòîðíî äà ñå ïîâèøè. Íÿìà ðàçëèêà â ôóíêöèîíàëíèòå ðåçóëòàòè íà ÈÑÐ è ÐÏ. Çàêëþ÷åíèå: ÈÑÐ å îíêîëîãè÷íî è ôóíêöèîíàëíî èçäúðæàíà ïðî-öåäóðà çà òóìîðè, ðàçïîëîæåíè â áëèçîñò äî àíîðåêòàëíîòî ñúåäèíåíèå.

Êëþ÷îâè äóìè: äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ), ñôèíêòåðî-çàïàçâàùè îïåðàöèè (ÑÇÎ), èíòðàñôèíêòåðíè ðåçåêöèè (ÈÑÐ)

ÌÀÍÓÀËÍÈ ÈËÈ ÌÅÕÀÍÈ×ÍÈ ÀÍÀÑÒÎÌÎÇÈ Â ÎÏÅÐÀÒÈÂÍÎÒÎ ËÅ×ÅÍÈÅ ÍÀ ÊÀÐÖÈÍÎÌÀ ÍÀ ÄÈÑÒÀËÍÈß ÐÅÊÒÓÌ Äàìÿíîâ Í., Ï. Òîäîðîâ ÂÌÀ Ñåêòîð êîëîïðîêòîëîãèÿ ÊÅÕ Ñúâðåìåííèòå ñõâàùàíèÿ çà äèñòàëíî ðàçïðîñòðàíåíèå íà ñóá-ïåðèòîíåàëíèòå ÊÐ è ðàçâèòèåòî íà õèðóðãèÿòà íà ïðàâîòî ÷åðâî ñ íàâëèçàíåòî íà òðàíñàíàëíèòå òåõíèêè ñà ïðåäïîñòàâêè çà óâåëè÷àâàíå íà ÑÇÎ. Âèäúò íà ÑÇÎ ñå îïðåäåëÿ îò íèâîòî íà äèñòàëíàòà ðåçåêöèÿ è àêî òÿ å äî 5-ÿ ñì îò àíîêóòàííèÿ ðúá, äîñòúïúò å àáäîìèíàëåí - óëòðà íèñêà ïðåäíà ðåçåêöèÿ íà ðåêòóìà (ÓÍÏÐÐ). Ðåñòîðàòèâíèòå ïðîòåêòîìèè (ÐÏ) ïðåìàõâàò öåëèÿ ðåêòóì ñ êîìáèíèðàí àáäîìåíî-òðàíñàíàëåí äîñòúï è àíàñòîìîçà íà linea dentata. Îáåìúò íà äèñòàëíà ðåçåêöèÿ çà èíòåðñôèíêòåðíèòå ðåçåêöèè (ÈÑÐ) âêëþ÷âà è ïðîêñèìàëíàòà ÷àñò íà àíàëíèÿ êàíàë ñ âúòðåñôèíñòåðíà àíàñòîìîçà. Ïðè ÍÏÐÐ àíàñòîìîçèðàíåòî ìîæå äà å ìàíóàëíî èëè ìåõàíè÷íî, ÐÏ è ÈÑÐ ñà ñ òðàíñàíàëíè ðåçåêöèè íà íèâî íà linea dentata è ïî-äèñòàëíî, êîåòî ãè ïðàâè ïðèîðèòåòíî ìàíóàëíè. ÓÍÏÐÐ ñà ñ ìåõàíè÷íèòå óøèâàòåëè, êîèòî ñïåñòÿâàò òðàâìàòè÷íèÿ òðàíñàíàëåí äîñòúï. Îãðàíè÷åíî å èçïîëçâàíå íà ñòàïëåðè ïðè äèñòàëíàòà ðåçåêöèîííà ëèíèÿ (ÄÐË) â àíàëíèÿ êàíàë ïîðàäè ôàêòà, ÷å äèñòàëíèÿò êðàé íà àíàñòîìîçàòà ñå ñúñòîè ñàìî îò ëèãàâè÷íèÿ ñëîé è ðèñêúò îò èíñóôèöèåíöèÿ å âèñîê. Öåë: îïðåäåëÿíå èíäèêàöèèòå çà ìåõàíè÷íè è ìàíóàëíè àíàñòîìîçè ïðè äèñòàëíèòå ÑÇÎ.

Ìàòåðèàë è ìåòîäè: ÑÇÎ ñà 141, îò òÿõ 138 ñà ðåñòîðàòèâíè, ìåõàíè÷íèòå àíàñòîìîçè ñà 18. ÓÍÏÐÐ ñà 16 è ñà ñ öèðêóëÿðíè ñòàïëåðè, êàòî çà 14 ïàöèåíòà ñå ñïåñòÿâà òðàíñàíàëíèÿ äîñòúï. Îñòàíàëèòå 2 ÓÍÏÐÐ è 2 ÐÏ ñà ñ åâåðòèðàíå íà îñòàòúêà îò ðåêòóìà, ñëåä êîåòî ñ êåñèåí øåâ ñå çàòâàðÿ ëóìåíà íà ÷åðâîòî. Ñòàïëåðúò ñå ïîñòàâÿ â ÷óêàíà, êîéòî ñå èçáóòâà íàä ëåâàòîðèòå è ñå îñúùåñòâÿâà ìåõàíè÷íà àíàñòîìîçà ñ äèñòàëíèÿ êîëîí. Ìàíóàëíèòå àíàñòîìîçè îáùî ñà 120. Ðåçóëòàòè: Èíñóôèöèåíöèèòå íà ìåõàíè÷íèòå àíàñòîìîçè ñà 2 îò 16 ÓÍÏÐÐ (12.5%), à äåõåðìåòèçàöèèòå íà ìàíóàëíèòå ñà 4 îò 40 ÍÏÐÐ (10%). 20 ñà äåõåðìåòèçàöèèòå ïðè 77 ÐÏ (26%). Èíñóôèöèåíöèÿ èìà ñëåä 1 êîëè÷åí j pouch (8%), 1 ñëåä ìåõàíè÷íà ÊÀÀ è 7 îò 58 äèðåêòíè ìàíóàëíè ÊÀÀ (12%). Åäíà áå äåõåðìåòèçàöèÿòà ñëåä ìåõàíè÷íà ÊÀÀ, êîÿòî áå êúñíà, íî ïðîòå÷å êàòî êëèíè÷íî çíà÷èìà. Çàêëþ÷åíèå: Óñëîæíåíèÿòà íà ìåõàíè÷íèòå è ìàíóàëíèòå àíàñòîìîçè ïðè äèñòàëíèòå ÑÇÎ ñà ñõîäíè. Çà ïî÷òè âñè÷êè ÓÍÏÐÐ ñòàïëåðèòå ñïåñòÿâàò òðàíñàíàëíèÿ äîñòúï, êîåòî îïðåäåëÿ ïðèîðèòåòà èì çà ÓÍÏÐÐ. ÍÏÐÐ, ÐÏ è ÈÑÐ ñà ïîäõîäÿùè çà ìàíóàëåí øåâ, êàòî çà ïúðâèòå òîé å ïðåïîðú÷èòåëåí è çàâèñè îò óìåíèÿòà íà îïåðàòîðà, äîêàòî çà ÐÏ è ÈÑÐ å ìåòîä íà èçáîð.

Êëþ÷îâè äóìè: äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ), ñôèíêòåðîçàïàçâàùè îïåðàöèè (ÑÇÎ), ìàíóàëíè è ìåõàíè÷íè àíàñòîìîçè

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ABSTRACTS

ÊÚÑÍÈ ÐÅÇÓËÒÀÒÈ ÎÒ ÎÏÅÐÀÒÈÂÍÎÒÎ ËÅ×ÅÍÈÅ ÍÀ ÎÁÑÒÐÓÊÒÈÂÍÈß ÊÎËÎÐÅÊÒÀËÅÍ ÊÀÐÖÈÍÎÌ Ñâèëåíîâ Ë., Â. Ìàðèíîâ, Ñò. Ïåòðîâ, Þ. Âàíåâ, Ê. Êîñòîâ, Ê. Ïåòðîâ ÓÌÁÀËÑÌ "Ïèðîãîâ", ²²²-òà Õèðóðãè÷íà êëèíèêà Óâîä: Èëåóñúò ïðè îáñòðóêòèâåí êîëîðåêòàëåí êàðöèíîì å ñåðèîçíî ñïåøíî ñúñòîÿíèå íà íåîïëàñòè÷íîòî çàáîëÿâàíå ñúñ çíà÷èòåëíà ÷åñòîòà íà ïåðèîïåðàòèâíèòå óñëîæíåíèÿ è ëåòàëèòåò (5 - 18%). Ïðàêòèêàòà íà ìíîãîåòàïíè îïåðàöèè ïðåç 70 - 80-òå ãîäèíè íà ìèíàëèÿ âåê è ïî-êúñíî âúçïðèåòàòà òàêòèêà çà èíòðàîïåðàòèâåí ëàâàæ è åäíîåòàïíè îïåðàöèè ñ àíàñòîìîçà ïðè óìåðåíî íàïðåäíàë èëåóñåí ñòàäèè è ñóáòîòàëíè êîëåêòîìèè ñ àíàñòîìîçà ïðè íàïðåäíàë èëåóñ ñà äîâåëè äî äîáðè íåïîñðåäñòâåíèòå ðåçóëòàòè îò îïåðàöèÿòà. Â ïîñëåäíèòå äâå äåñåòèëåòèÿ íà ïðåäåí ïëàí èçïúêâà íåîáõîäèìîñòòà è ïðåöåíêàòà çà èçâúðøâàíå íà ðàäèêàëíà ïúðâè÷íà îïåðàöèÿ ñ êîíòðîë íà îíêîëîãè÷íèÿ ðåçóëòàò (ñðåäíà ïðîäúëæèòåëíîñò íà ëèïñà íà ðåöèäèâ ñëåäîïåðàòèâíî, ïåòãîäèøíà ïðåæèâÿåìîñò, èëè áåçñèìïòîìíà ïðåæèâÿåìîñò ïðè íåðàäèêàëíî ëå÷åíèå). Ìàòåðèàë è ðåçóëòàòè: Çà 1 ãîäèíè (2007 ã.) â Ñåêöèÿòà ïî ñïåøíà õèðóðãèÿ íà ÓÌÁÀËÑÌ "Ïèðîãîâ" ñà îïåðèðàíè 67 ïàöèåíòè ñ èëåóñ ïðè îáñòðóêòèâåí êîëîðåêòàëåí êàðöèíîì. Æåíèòå ñà 31, à ìúæåòå - 36, ñðåäíàòà âúçðàñò å 68,9 ã. Ëîêàëèçàöèÿòà íà îáñòðóêòèðàùèÿò òóìîð å ëÿâ õåìèêîëîí - 9, äåñåí

õåìèêîëîí 11, ñèãìîâèäíî äåáåëî ÷åðâî - 38, ðåêòóì 9. Ðàííè óñëîæíåíèÿ ñà íàñòúïèëè ïðè 11 ïàöèåíòè ñ îáù ëåòàëèòåò 8.9% (6 ïî÷èíàëè). Ïðîñëåäåíè ñà 52 îò ïàöèåíòèòå çà ñðîê 19-23 ìåñåöà. Âðåìåâîòî èçðàâíÿâàíå íà äàííèòå ïîêàçâà ïðåæèâÿåìîñò îò 83% íà 6-òèÿò ìåñåö; 69% íà 12 ìåñåö; 66% íà 18%; 52% íà 24 ìåñåö. Ñðåäíàòà ïðèæèâÿåìîñò çà 24 ìåñåöà ïðè ²V òóìîðåí ñòàäèé å 14%; ïðè ²²² - 39%; ²² - 66%. Íÿìà çíà÷èìè îòëè÷èÿ â ñðåäíàòà ïðåæèâÿåìîñò ñïîðåä èëåóñíèÿò ñòàäèè ïðè ïàöèåíòèòå ïðåîäîëÿëè ðàííèÿ ñëåäîïåðàòèâåí ïåðèîä. Îáñúæäàíå. Â óñëîâèÿòà íà èëåóñ ïðè êîëîðåêòàëåí êàðöèíîì íà ïðåäåí ïëàí èçïúêâà íåîáõîäèìîñòòà îò æèâîòîñïàñÿâàùà ïðîöåäóðà. Çàòîâà ÷åñòîòàòà íà íåðàäèêàëíè îïåðàöèè å âñå îùå çíà÷èòåëíî. Ïðè èçâúðøâàíå íà ðàäèêàëíà îïåðàöèÿ îòëîæåíèòå îíêîëîãè÷íè ðåçóëòàòè çà òóìîðíè ñòàäèè (²-âè è ²²-ðè) äîáëèæàâàò òåçè ïðè ïëàíîâî îïåðèðàíèòå ïàöèåíòè. Ðàçóìíà àëòåðíàòèâà ñ îãëåä ðàäèêàëíîñòòà å èçâúðøâàíå íà èëåóñíî-ðàçðåøàâàùà îïåðàöèÿ ñ ðàííà (4-6 ñåäìèöè) ïîñëåäâàùà ðàäèêàëíà îïåðàöèÿ. Îò ðåøàâàùî çíà÷åíèå å îïèòà íà õèðóðãè÷íèÿ åêèï, îöåíêàòà íà ñúñòîÿíèåòî íà ïàöèåíòà è ðàçâèòèåòî íà òóìîðíèÿ ñòàäèé.

ÏÀÐÀÑÒÎÌÈÀËÍÈ ÕÅÐÍÈÈ ÑËÅÄ ÊÎËÎÐÅÊÒÀËÍÀ ÕÈÐÓÐÃÈß Âàíåâ Þ. , Ê. Êîñòîâ, Ë. Ñâèëåíîâ, Ñò. Ïåòðîâ ÓÌÁÀËÑÌ "Ïèðîãîâ", ²²²-òà Õèðóðãè÷íà êëèíèêà Åòèîëîãèÿ, åïèäåìèîëîãèÿ, òèïîâå:. Ïàðàñòîìèàëíèòå õåðíèè ñå ïðîÿâÿâàò ïðè 18%-35% îò ïàöèåíòèòå ïðåêàðàëè êîëîðåêòàëíà õèðóðãèÿ ñ ôîðìèðàíå íà âðåìåííà èëè äåôèíèòèâíà êîëîñòîìà, íî â ñðàâíåíèå ñ îñòàíàëèòå âèäîâå õåðíèè ñà ðÿäêîñò è ïðîáëåìèòå íà ïàòîëîãèÿòà è ëå÷åíèåòî èì ñà äèñêóòèðàíè ñïîðàäè÷íî. Ïðåäñòàâëÿâàò äåôåêò íà ôàñöèàëíèÿ ïðúñòåí íà êîëîñòîìàòà èëè â íåïîñðåäñòâåíî ñúñåäñòâî. Íàé-÷åñòî ñå ïðè÷èíÿâàò îò èíñóôèöèåíöèÿ íà øåâîâåòå íà ôàñöèÿòà è ÷ðåâíàòà ñòåíà, ïîñòîïåðàòèâíà èíôåêöèÿ, õèïîíóòðèöèÿ è äðóãè ïî-ðåäêè ôàêòîðè. Ñúùåñòâóâàò äîêàçàòåëñòâà, 310

÷å ðåàëíàòà èì ÷åñòîòà çíà÷èòåëíî íàäâèøàâà òàçè íà êëèíè÷íî óñòàíîâåíèòå. Îñâåí îáè÷àéíèòå ñèìïòîìè (õåðíèðàíå, áîëêè è òåæåñò), ïàðàñòîìèàëíèòå õåðíèè íàðóøàâàò ôóíêöèîíèðàíåòî íà êîëîñòîìèòå (30-40%), ïðåäðàçïîëàãàò êúì óñëîæíåíèÿ (15-20% èíêàðöåðàöèè) è íàðóøàâàò êà÷åñòâîòî íà æèâîò. Íÿìà îáùîïðèåòà êëàñèôèêàöèÿ, íî ïî àíàëîãèÿ ñ äèàôðàãìàëíèòå õåðíèè ìîãàò äà ñå ðàçãðàíè÷àò: åêñòðàîðèôèöèàëíè (õåðíèàëíîòî îòâúðñòèå ãðàíè÷è ñúñ ñóôèöèåíòåí ôàñöèàëåí ïðúñòåí íà êîëîñòîìàòà; ïàðöèàëíè ïàðàñòîìèàëíè (÷àñòè÷íà ðàçêúñâàíå íà

XIth NATIONAL CONFERENCE OF COLOPROCTOLOGY

ôàñöèàëíèÿ ïðúñòåí); òîòàëíè ïàðàñòîìèàëíè (öÿëîñòíî ðàçêúñâàíå íà ïðúñòåíà). Ìåòîäè íà ëå÷åíèå è ðåçóëòàòè: Êîíñåðâàòèâíîòî ëå÷åíèå ñå ñúñòîè îò ðåïîçèöèÿ, ïîñòàâÿíå íà óêðåïâàùè êîëîñòîìíèÿ îòâîð êîëàíè è ãðèæè çà ðåäîâíî ïî÷èñòâàíå íà ïðèâîäÿùèÿ äåáåëî÷ðåâåí ñåãìåíò. Ïðåïîðú÷âà ñå ïðè ïàöèåíòè ñ âèñîê îïåðàòèâåí ðèñê (íàïðåäíàëà âúçðàñò, íàïðåäíàë ñòàäèè íà íåîïëàñòè÷íî çàáîëÿâàíå, ñúïúòñòâàùè çàáîëÿâàíèÿ). Ïðè 40-45% ðåäóöèðàíåòî òåæåñòòà íà ñèìïòîìèòå å çíà÷èòåëíî. Õèðóðãè÷íîòî ëå÷åíèå ñå ñúñòîè â ïëàñòè÷íî ðåïàðèðàíå è óêðåïâàíå íà õåðíèàëíîòî îòâúðñòèå. Ïðè ìàëêè åêñòðàîðèôèöèàëíè èëè ÷àñòè÷íè ïàðàñòîìèàëíè õåðíèè òúêàííèòå ïëàñòèêè ñ ÷àñòè÷åí äîñòúï ìîãàò äà ïîñòèãíàò óñïåøåí ðåçóëòàò ïðè 60-65% îò îïåðèðàíèòå. Ðåöèäèâèòå (30-35%) ñå ïîÿâÿâàò íàé-÷åñòî ïðåç ïúðâàòà è ñëåä òðåòàòà ãîäèíà ñëåä ðåïàðàöèÿòà. Òåõíèêèòå ñ èìïëàíòèðàíå íà ñèíòåòè÷íè ìðåæè ñà çíà÷èòåëíî ïî åôèêàñíè (10-15% ðåöèäèâè), íî èçèñêâàò çíà÷èòåëåí îïèò è ïðåöèçíà õèðóðãè÷íà òåõíèêà. Íàé ñåðèîçíè ïðîáëåìè ñà êúäå äà ñå ïîñòàâè ïëàòíîòî è êàê äà ñå ïðåäïàçè ÷ðåâíèÿ ñåãìåíò îò ëàöåðàöèÿ, ôèñòóëèçèðàíå èëè ñòðèêòóðà. Ñåïòè÷íèòå óñëîæíåíèÿ ñå ðåäóöèðàò (ïîä 8%) ÷ðåç ïðåöèçíà ÷ðåâíà ïîäãîòîâêà è ïåðèîïåðàòèâíà àíòèáàêòåðèàëíà ïðîôèëàêòèêà. Íàø îïèò: Çà 3 ãîäèíè (2006-2008 ã.) â ²²²-òà Õèðóðãè÷íà êëèíèêà íà ÓÌÁÀËÑÌ "Ïèðîãîâ" ñà îïåðèðàíè 12 ïàöèåíòè ñ ïàðàñòîìèàëíè õåðíèè.

Æåíèòå ñà 7, à ìúæåòå - 5, ñðåäíàòà âúçðàñò å 63,4 ã. Ñðåäíî âðåìå îò ïðåäøåñòâàùàòà îïåðàöèÿ å 14 ìåñåöà. Åêñòðàîðèôèöèàëíè õåðíèè ñà óñòàíîâåíè ïðè 2 îò ñëó÷àèòå, ïàðöèàëíè ïàðàñòîìèàëíè - 7, òîòàëíè ïàðàñòîìèàëíè - 3. Èçâúðøåíè ñà ñëåäíèòå îïåðàöèè: 1. Åêñöèçèÿ ñ ôàñöèàëíà ðåïàðàöèÿ è ÷àñòè÷íî ïðåôèêñèðàíå íà ÷ðåâíàòà ñòåíà ñ ëîêàëåí äîñòúï - 3 (1 åêñòðàîðèôèöèàëíè, 2 ÷àñòè÷íè ïàðàñòîìèàëíè); 2. Ðåïàðàöèÿ ñ ïëàòíî ñ ëîêàëåí äîñòúï - 6 (1 åêñòðàîðèôèöèàëíà, 4 ÷àñòè÷íè ïàðàñòîìèàëíè, 1 òîòàëíà ïàðàñòîìèàëíà); 3. Ðåïàðàöèÿ ñ ïëàòíî ñ ëàïàðîòîìèÿ è ëîêàëåí äîñòúï - 3 (1 ÷àñòè÷íè ïàðàñòîìèàëíè è 2 òîòàëíè ïàðàñòîìèàëíè). Ñëåäîïåðàòèâíèòå óñëîæíåíèÿ ñà áèëè 4 ñóïóðàöèè íà îïåðàòèâíàòà ðàíà, âñè÷êèòå ëåêóâàíè êîíñåðâàòèâíî. Ïðè ïðîñëåäÿâàíå íà 8 ïàöèåíòè çà ïåðèîä ñðåäíî îò 18,5 ìåñåöà ñà óñòàíîâåíè 2 ðåöèäèâà (25%) - è äâàòà ñëó÷àÿ ñëåä òúêàííà õåðíèîðåïàðàöèÿ. Îáñúæäàíå: Àêòèâíîòî õèðóðãè÷íî ïîâåäåíèå ïðè ïàðàñòîìèàëíè õåðíèè ñëåä êîðåêòíà îöåíêà íà ïîêàçàíèÿòà è íà ñúñòîÿíèåòî íà ïàöèåíòèòå å ñúâðåìåíåí ïîäõîä çà ëå÷åíèåòî èì. Àëîïëàñòè÷íèòå òåõíèêè (ïëàòíà) ïðåäñòàâëÿâàò ìåòîä íà èçáîð, íî èçèñêâàò çíà÷èòåëåí îïèò è ïîçíàâàíå íà êà÷åñòâàòà íà ñèíòåòè÷íèòå ìðåæè. Ïîëåçíî å ïðåäîïåðàòèâíîòî òèïèçèðàíå íà ïàðàñòîìèàëíèòå õåðíèè. Îöåíêàòà íà ðàçëè÷íèòå òåõíèêè ìîãàò äà ïðåäïîëîæàò ïðàêòèêàòà çà "ïúðâè÷íî ñòàáèëèçèðàíà" êîëîñòîìà.

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AUTHOR'S INDEX Aliev V. A. ................................277 Angelov K. ................................285, 286 Arnaudov P................................241 Assenov A. ................................283 Atanasov B. ...............................219, 235 Atanasov G................................284 Atanasov P. ...............................284 Barsukov Y. A...........................277 Boev B.......................................219, 235 Bozhkov V. ...............................241 Chernopolsky P. ........................241 Cvetanovic M. ...........................279, 280 Deliiski T...................................280, 281 Georgiev K. ...............................241 Gordeev S. S..............................277 Grozev V. ..................................280, 281 Hadzhiev B................................219, 231, 235, 278 Ignatov V...................................286, 287, 288 Iliev S. .......................................280, 281 Ivanov G....................................287 Ivanov K....................................286, 287, 288 Ivanov T. ...................................241 Jakovljevic M. ...........................279 Jovanovic Z. ..............................279 Kalezic M. .................................279 Kim D. F....................................277 Kim Jin C. .................................278 Kiryazov E. ...............................286 Kolev N. ....................................286, 287, 288 Kostov G. ..................................284 Kuzmichev D. V........................277 Madjov R...................................241 Mammadli Z. Z. ........................277 Maslyankov S............................284 Metodiev Dr. .............................284 Nedeva P. ..................................284 Nickolov N. ...............................283 Nikolaev A. V. ..........................277 Nikolov St. ................................279 Paul A........................................280, 281 Petkov Chr.................................281, 282 Petkov V....................................219, 235

Piyush C. ...................................280, 281 Popov Il. ....................................284 Popov Iv. ...................................284 Praveen C. .................................280, 281 Presolski I..................................280, 281 Racheva M.................................284 Sakakushev B. ...........................219, 235 Shterv Sht. .................................286 Sokolov M.................................285, 286 Tkachev S. I. .............................277 Tonchev P..................................280, 281 Tonev A.....................................286, 287, 288 Toshev Sv..................................285, 286 Vekic B......................................279 Veltchev L. ................................225 Yaramov N. ...............................285, 286 Yovtchev Y. ..............................278 Zagorac Z. .................................279 Zarkov K. ..................................282, 283 Zivic R.......................................279 Àë Çàéÿò Ä................................305 Àëàìàíîâ Ä. .............................299 Àíãåëîâ Æ. ...............................304 Àíãåëîâà Å. ..............................291, 298, 301, 302 Àòàíàñîâ Ä. ..............................269 Áåëîêîíñêè Å. ..........................299 Áëàãîâ É. ..................................245, 257 Áëèçíàøêè È............................269 Âàíåâ Þ. ..................................310 Âàðòàíÿíîâ Ë. ..........................291, 298, 301, 302 Âàñèëåâ K. ................................292 Âàñèëåâ Ä. ................................303, 304 Âàñèëåâ Ê. ................................293 Âàñèëåâñêè È. ..........................289 Âëàäèìèðîâ Á. .........................299 Âëàäîâ Í...................................289 Ãàéäåâà Á..................................308 Ãåí÷åâ Ã....................................303 Ãåîðãèåâ Â. 267, 291, 298, 301, 302 Ãåðçèëîâ Ï. ..............................303, 304 Ãðèãîðîâ Ã................................293

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Ãðèãîðîâ È. ..............................245 Ãóíåâ Ö.....................................273 Ãúðáåâ Ã. ..................................293, 292 Äàìÿíîâ Ä. ...............................303, 304, 305, 306 Äàìÿíîâ Í. ...............................288, 308, 309 Äàðäàíîâ Ä...............................296, 297, 298 Äàñêàëîâ Âë. ............................299 Äåêîâà È...................................249, 253 Äåëèéñêè Ò...............................294, 295, 296 Äæîíãîâ Ë. ...............................291, 298, 301, 302 Äèìàíîâà Å. .............................269 Äèìèòðîâ Â. .............................267, 291, 298, 301, 302 Äèìèòðîâ Ä. .............................294, 295 Äèìèòðîâ Ð. .............................303 Äèìîâ Ñ....................................297 Äðàãíåâ Í. ................................307, 308 Åíèêîâ Ê...................................291, 298, 301, 302 Åôòèìîâ Ã. ...............................304 Æåëåâ Ã.....................................303 Æåëåâ Ã.....................................305 Çèÿ Ä. ........................................257 Èâàíîâ Àðê. .............................306 Èâàíîâ Â...................................307, 308 Èâàíîâ Ï. .................................292, 293 Èâàíîâ Ñ...................................305 Êåðìåä÷èåâ Ì..........................303, 305 Êèðîâ Ã.....................................297 Êîáàêîâ Ã. ................................307, 308 Êîâà÷åâ Í. ................................261 Êîëåâ Í.....................................299 Êîíäàðåâ Ã. ..............................297 Êîðóêîâ Á. ................................303, 305 Êîñòàäèíîâ Å. ..........................303, 305 Êîñòîâ Ä. ..................................307, 308 Êîñòîâ Ê. ..................................310 Êîòàøåâ Ã.................................269 Êóðòåâ Ï...................................291, 298, 301, 302, 306 Êóðòåâà Ã..................................301 Ëàòèôÿí À. ...............................304 Ëîçàíîâ Ð..................................303, 305 Ëîçåâ È. ....................................297

Ìàðèíîâ Â................................310 Ìèëåñêè Ç.................................273 Ìîøåâ Á. ..................................297 Ìóðäæåâ Ê. ..............................273 Ìóòàô÷èéñêè Â. ......................289 Íàêîâ Â.....................................299 Ïàòàíîâ Ð. ................................307, 308 Ïåíêîâ Í. .................................303, 305 Ïåíîâ Âë. .................................289 Ïåí÷åâ Ï. .................................299, 300, 305 Ïåòêîâ Í...................................303 Ïåòêîâ Þ. ................................249, 253 Ïåòðîâ Ê...................................310 Ïåòðîâ Ñò. ................................310 Ïëà÷êîâ È. ...............................307, 308 Ïîæàðëèåâ Ò. ...........................245, 257 Ïîïîâ Â. ...................................261 Ïúðâàíîâ Ï. .............................303, 305 Ïúðâîâ À. .................................261 Ðàäåíîâñêè Ä. ..........................261 Ðàäèîíîâ Ì. .............................257 Ðàë÷åâ Ê....................................291, 298, 302 Ðàë÷åâ Êð..................................301 Ñâèëåíîâ Ë...............................310 Ñå÷àíîâ È.................................257 Ñèìåîíîâ Á. .............................304 Ñèìåîíîâ É..............................291, 298, 301, 302 Ñòåôàíîâ Ò...............................273 Ñòîéêîâ Ä.................................249, 253 Ñòîéíîâ Ñ.................................305 Ñòîÿíîâ Â.................................261 Ñòðàøèëîâ Ñ............................249 Òàáàêîâ Ì. ...............................299 Òàêîðîâ È.................................289 Òåðçèåâ È. ................................306 Òîäîðîâ Ä.................................297 Òîäîðîâ Ï.................................309 Òîìîâ Î. ...................................245 Õðèñòîâà Â. ..............................293, 308 ×àêúðîâ Â. ................................273 ßíêîâ Â.....................................291, 298, 302 ßíêîâ Âë...................................301

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PERMUTERM SUBJECT INDEX abdominal tuberculosis, bowel obstruction, lymph nodes _____________________________241 anal cancer, diagnostics, treatment ___________279 Anal fistula, Fistula-in-ano, Fibrin glue, Fibri sealant, Fistula anal plug _______________231 anal incontinence, anorectal manometery, gracilis plasty ____________________________281 Anastomosis leakage /AL/, Colorectal Cancer Surgery /CRCS/ ____________________219 anorectal manometery, anal incontinence, gracilis plasty _________________281 Anorectal manometry, Chemical sphincterotomy, Lateral sphincterotomy, Anal fissure ____________________________281 bowel obstruction, abdominal tuberculosis, lymph nodes___________________241 Chemical sphincterotomy, Anorectal manometry, Lateral sphincterotomy, Anal fissure ______________________________281 Colorectal Cancer Surgery /CRCS/, Anastomosis leakage /AL/ __________________219 colorectal cancer, molecular prognosis, markers _________________________________287 colorectal carcinoma, ileus, tactics and operative treatment ________________________286 diagnostic and operative problems, recto-vaginal fistulas_______________________286 diagnostics, anal cancer, treatment ___________279 enhanced recovery after surgery /ERAS/, fast track surgery /FT/, colorectal cancer/CRC ______________________________235 fast track surgery /FT/, enhanced recovery after surgery /ERAS/, colorectal cancer /CRC/ ____________________235 Fistula-in-ano, Anal fistula, Fibrin glue, Fibri sealant, Fistula anal plug _______________231 ileus, colorectal carcinoma, tactics and operative treatment ________________________________286 molecular prognosis, colorectal cancer, markers _________________________________287 recto-vaginal fistulas, diagnostic and operative problems ________________________286 Âçðèâíà òðàâìà, Ïðîíèêâàùè íàðàíÿâàíèÿ íà ðåêòóìà, Êîëîñòîìà, Damage Control Surgery, Inter-Pulse Jet èðèãàöèÿ, V.A.C®. Therapy System _______289 äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ), ñôèíêòåðî-çàïàçâàùè îïåðàöèè (ÑÇÎ), èíòðàñôèíêòåðíè ðåçåêöèè (ÈÑÐ) __________309

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äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ), ñôèíêòåðîçàïàçâàùè îïåðàöèè (ÑÇÎ) _______289 äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ), ñôèíêòåðîçàïàçâàùè îïåðàöèè (ÑÇÎ), ìàíóàëíè è ìåõàíè÷íè àíàñòîìîçè__________309 êàðöèíîì íà êîëîíà, ëèìôîãåííè ìåòàñòàçè, ñåíòèíåëíè âúçëè, ðàäèîíóêëèäè ___________________________267 êîëîíîñêîïèÿ, ÿòðîãåííè ëåçèè, ïåðôîðàöèÿ íà êîëîíà ____________________245 êîëîðåêòàëåí ðàê, îáòóðàöèîíåí èëåóñ, òàêòèêà ___________________________273 ëèìôíà äèñåêöèÿ, Ðàê íà ðåêòóìà__________295 ëèìôîãåííè ìåòàñòàçè, êàðöèíîì íà êîëîíà, ñåíòèíåëíè âúçëè, ðàäèîíóêëèäè ___________________________267 ëèìôîîòè÷àíå, Ðàê íà ðåêòóì, ëèìôíî ìåòàñòàçèðàíå, ÑËÂ _______________294 ëîêàëíî àâàíñèðàë êîëîðåêòàëåí êàðöèíîì, óñëîæíåíèÿ, êîëîðåêòàëåí êàðöèíîì _______________________________257 íèñúê ðåêòàëåí êàðöèíîì, óëòðàíèñêà ðåçåêöèÿ, àáäîìèíî-àíàëíà ðåçåêöèÿ, òðàíññôèíêòåðíà ðåçåêöèÿ ________302 îáòóðàöèîíåí èëåóñ, êîëîðåêòàëåí ðàê, òàêòèêà _____________________________273 Ïðîíèêâàùè íàðàíÿâàíèÿ íà ðåêòóìà, Âçðèâíà òðàâìà, Êîëîñòîìà, Damage Control Surgery, Inter-Pulse Jet èðèãàöèÿ, V.A.C®. Therapy System ___________________289 Ðàê íà ðåêòóì, ëèìôîîòè÷àíå, ëèìôíî ìåòàñòàçèðàíå, ÑËÂ _______________294 Ðàê íà ðåêòóìà, ëèìôíà äèñåêöèÿ__________295 ñôèíêòåðî-çàïàçâàùè îïåðàöèè (ÑÇÎ), äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ), èíòðàñôèíêòåðíè ðåçåêöèè (ÈÑÐ) __________309 ñôèíêòåðîçàïàçâàùè îïåðàöèè (ÑÇÎ), äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ) _________289 ñôèíêòåðîçàïàçâàùè îïåðàöèè (ÑÇÎ), äèñòàëåí êàðöèíîì íà ðåêòóìà (ÊÐ), ìàíóàëíè è ìåõàíè÷íè àíàñòîìîçè__________309 óëòðàíèñêà ðåçåêöèÿ, íèñúê ðåêòàëåí êàðöèíîì, àáäîìèíî-àíàëíà ðåçåêöèÿ, òðàíññôèíêòåðíà ðåçåêöèÿ ________302 óñëîæíåíèÿ, ëîêàëíî àâàíñèðàë êîëîðåêòàëåí êàðöèíîì, êîëîðåêòàëåí êàðöèíîì _______________________________257 ÿòðîãåííè ëåçèè, êîëîíîñêîïèÿ, ïåðôîðàöèÿ íà êîëîíà ____________________245

INSTRUCTIONS TO AUTHORS Scripta Scientifica Medica is the official publication of Medical University Prof. Dr. Paraskev Stoyanov, Varna, Bulgaria. It is currently disseminated among medical university libraries from all over the world on exchange basis. This peer-reviewed annual accepts for publication original articles, unpublished papers recently presented at national and international congress proceedings, and book reviews from Bulgarian and foreign authors. The contributions should be devoted to actual topics in contemporary biomedicine, clinical medicine and interdisciplinary fields as well. They should not have been submitted or accepted for publication elsewhere. The journal publication is offered to the national and international readership in English only. The manuscript signed by all the authors has to be submitted in duplicate to the Editor-in-Chief of Scripta Scientifica Medica. Prof. Anelia Klisarova, MD, PhD, DSc Medical University Prof. Dr. Paraskev Stoyanov, Varna 55 Marin Drinov Street BG-9002 Varna Bulgaria Phone: +359-52- 611 899 Fax: +359-52- 650 019 E-mail: cio_varna@yahoo.com The contributors are encouraged to submit the files of the text and figures of their revised manuscripts on a 3,5”-diskette in any recent MS Word format. The authors must strictly follow some main instructions listed below. The manuscript of an original paper should not exceed 7 double-spaced pages with wide margins. The total volume of the text, tables, and references should not exceed 15000 characters. The structure of the article should include the following sections: Introduction, Material and Methods, Results and Discussion, and Conclusion(s). Additionally, there should be: a structured abstract of 200-250 words; key-words (5 to 6 words or non-verbal phrases); a reference list (up to 20 references); a complete address of the author for correspondence (postal and e-mail address, if available), and, eventually, an appropriate number of tables and figures. The tables and legends to the figures should be provided on separate sheets. Data sheets of diagrams should be obligatorily provided. Location of tables and figures should be indicated in the text and on the left margin of the corresponding page. No data reiteration in the text, tables, and figures is permitted. Photographs and microphotographs have to be sufficiently contrasted and up to 12x18 cm in size. Black-and-white pictures, drawings and diagrams are accepted only. Cited authors are ordered alphabetically in the reference list starting with those in the Cyrillic alphabet. Most commonly, these authors should be identified in the text of the article by Arabic numerals in parentheses. Please, do not make use of CapsLock option at all. Preparation of references Numbering of all the publications cited in the text should correspond to that in the list of references. Bibliographic citations of articles in journals should contain initials and names of all the authors (or at least the first six ones), article title, abbreviated title of the journal according to the style used in Index Medicus (National Library of Medicine, Bethesda, MD, USA), volume, year of publication, issue number (absolutely obligatory for Bulgarian and Russian journals), and page numbers (from-till). The citations of books should contain initials and names of the authors (up to three), book title, number of edition (if any), editor(s) (if any), location of publishing, publishing house and year of publication. Book chapters should contain initials and names of the authors of the chapter, title of the whole book, editor(s) (if any), location of publishing, publishing house, year of publication and page numbers (from-till). Congress proceedings should contain along with data as for book chapters, location and date of the corresponding meeting, kind of materials (abstracts or full papers), and page numbers. Author’s name of the dissertation, title, location, institution, and year of defence should be indicated. With patents and licences, author’s names (if any), registration number, and year of publication should be shown. Personal communications containing the name of the author cited and the date should be accompanied by his (her) permission in written for the corresponding statement.

Let us give some examples. 1. 2. 3.

Biderman, I., S. Somien, Z. Shimshoni. In: Tissue Nutrition and Viability. A. R. Hargens, ed. New York, etc., Springer-Verlag, 1986, 121-134. Goute, A. M., A. R. Haynes, M. J. Owen. New aspects of psychotic drug usage.- J. Clin. Psychopharmacol., 8, 1988, No 4, 315-317. Youmans, G. P., A. N. Lewin. Tuberculosis. 3rd ed. Philadelphia, etc., W. W. Saunders, 1979.

The authors will receive 25 reprints of their articles along with a sample copy of the issue free of charge.

SCRIPTA SCIENTIFICA MEDICA, VOL. XXXXI, (3), pp. 213 - 316 Editor-in-Chief: Prof. Anelia Klissarova, MD, PhD, DSc Co-Editor-in-Chief: Assoc. Prof. Rossen Madjov, MD, PhD, DSc

Technical editor: A. Antonov, E. Jordanova Cover art editor: E. Spasov

Publ. Lit. group: III-3 Sent to printers: August, 2009 Print sheets: 28 Format: 8/60x84 Approved for printing: September, 2009 Total print: 300

ISSN 0582-3250

Med i cal Uni ver sity 55 Marin Drinov Street, Varna, BG-9002