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III. SURGERY
mph™ 76.29.29 CLINICAL EVALUATION OF LONG-TERM SURGICAL TREATMENT RESULTS IN PATIENTS WITH ULCERATIVE COLITIS
AraeB P.M. -
orcid.org/0000-0001-9688-4880
Agaev R.M., Mamedov M.M., Musaev Kh.N., Aliev Yu.G., Alieva K.A., Mamedov N.I., Alieva A.M., Dzhafarali Z.Ye.
Scientific Center of Surgery named after M.A. Topchibashev, Baku, Azerbaijan
Abstract
The study was carried out on the basis of the Scientific Center of Surgery named after M.A. Topchiba-shev in the Department of Surgical Coloproctology and Surgical Clinic of the Azerbaijan Medical University KeyWordS (AMU), 37 patients were inpatient. All hospitalized patients underwent general clinical (collection of com-ulcerative colitis, plaints, study of anamnesis, physical examination data), laboratory, as well as endoscopic, morphological anamnesis and radiological examinations.
Ойык жаралы колит бар наукастарда хирургиялык емдеудщ алшак нэтижелерш клиникалык багалау
Агаев Р.М., Мамедов М.М., Мусаев Х.Н., Алиев Ю.Г., Алиева К.А., Мамедов Н.И., Алиева А.М., Джафарали З.Е.
М.А. Топчибашев атында?ы ?ылыми хирургия орталь™, Баку, Эзiрбайжан
Ацдатпа
_ Зерттеу М.А.Топчибашев атындары гылыми хирургия орталь^ы непз1нде Эзербайжан медициналык
университету (АМУ) хирургиялык колопроктология жэне хирургиялык клиника бел1м1нде журпзщ1, 37 наукас Туйш сездер стационарлыкжагдайда болды. Ауруханага жаткызыл€ан барлык наукастар жалпы клиникалык (ша€ымдарды жинау, спеЦификалыК ойык жаралы анамнезд1 зерттеу, физикалык тексеру деректер1), зертханалык, сонымен катар эндоскопиялык, морфологиялык колит, анамнез жэне рентгенологиялык тексерулерден eni.
Клиническая оценка отдаленных результатов при хирургическом лечение у больных с неспецифическим язвенным колитом
Агаев Р.М.,Мамедов М.М., Мусаев Х.Н., Алиев Ю.Г., Алиева K.A., Мамедов Н.И., Алиева A.M.
Научный центр хирургии им. М.А. Топчибашева, Баку, Азербайджан
Аннотация
Исследование проводилось на базе Научного центра хирургии имени М.А. Топчибашева при кафедре хирургической колопроктологии и хирургической клиники Азербайджанского медицинского университета (АМУ), на Ключевые Слова стационарном лечении находились 37 пациентов. Всем госпитализированным больным проводились общеклини-неспеЦифтеский ценный ческие (сбор жалоб, изучение анамнеза, данные физикального обследования), лабораторные, а также эндоско-колит, анамез пические, морфологические и рентгенологические исследования.
Relevance
Ulcerative colitis (UC) is a nonspecific autoimmune lesion of the large bowel of unexplained etiology, known since the middle of the 19th century. Since the middle of the 20th century, there has been a fairly rapid increase in the incidence, mainly of residents of the most developed countries [1,8,19]. With relatively mild forms of UC (usually with distal and left-sided lesions of the colon), under the influence of modern conservative treatment, it is possible to obtain satisfactory results [3, 5, 8, 9, 11, 12, 22]. At the same time, severe forms of the disease are very resistant to conservative therapy and in most cases lead either to severe complications requiring urgent surgical intervention, or to a forced elective surgery due to the development of "colitic carcinoma". The risk of malignancy in UC increases sharply with a disease duration of more than 10 years, especially if the disease began at the age of less than 18 years [2,3,7,21,23]. Frequent and prolonged exacerbations of severe UC, accompanied by severe intoxication and blood loss, lead to patient exhaustion, profound metabolic disorders, anemia, hormonal dependence due to the inevitable transition to steroid therapy with all its negative consequences.
A radical operation for severe ulcerative colitis is panproctocolectomy, in which a cure is achieved at the cost of a permanent ileostomy. Given the crippling nature of this surgical intervention, the indications for it in the past were made rather carefully. However, the improvement of the surgical technique by forming an ileoanal anastomosis with a reservoir from the ileum (pocket) has led to a significant expansion of indications for surgical treatment of ulcerative colitis [6, 14, 17, 20]. However, such operations are often accompanied by complications and undesirable consequences (anastomosis failure - 10-20% of cases, inflammation in the pocket area - up to 30%, fecal incontinence, disorders of sexual function and function of the pelvic organs - up to 30% of cases) [1, 18, 19].
Domestic surgeons, like most foreign authors, both in emergency and in elective surgery, most often perform subtotal colectomy with temporary imposition of ileo- and sigmoidostomy. The high risk of developing ileorectoanastomosis failure, associated with a pronounced destructive inflammatory process in the rectum, forces surgeons to perform the operation in 2 stages (followed by restorative operation). Although during reconstructive surgery, it is still necessary to anastomose the ileum with the stump of the sigmoid or rectum affected by colitis [5, 6, 7, 9, 19].
A number of surgeons consider total colectomy with one-stage ileorectostomy to be the operation
of choice in the surgical treatment of ulcerative colitis. With a favorable outcome, this operation eliminates the need to perform a second intervention, accelerates the onset of recovery without a period when the patient is forced to have a functioning ileostomy. The long-term results of single-stage surgical treatment of ulcerative colitis remain unexplored, there is no data on the morphofunctional state of ileorectoanastomosis, the mucous membrane of the ileum and rectum after total colectomy. All of the above determined the relevance of this topic and served as the basis for determining the goal and main objectives of the study.
Materials and methods
On the basis of the Scientific Center of Surgery named after M.A. Topchibashev at the Department of Surgical Coloproctology and in Surgical Clinic of the Azerbaijan Medical University (AMU) 37 patients were on inpatient treatment (23 males (62.2%), 14 females (37.8%). The age of patients ranged from 5 to 49 years, the average age was 14.7±2.7 years), who were treated with a diagnosis of moderate and severe ulcerative colitis in the period from 2011 to 2019. During these years, the department performed 27 subtotal and total colec-tomies with one-stage ileorectostomy in patients (aged 18 to 49 years). Depending on the method of forming the anastomosis, the patients were divided into two groups.
The control group included 10 patients who were operated on from 1998 to 2006 by traditional methods, with the formation of an ileostomy.
27 patients made up the main group of those operated from 2011 to 2019. Fixation in the ileal stump of a wide silicone tube (ileostomy drainage) and its removal transrectally outward after subtotal and total colectomies with simultaneous ileorectos-tomy for UC provides in the immediate postoperative period emptying of the small intestine without contact of the intestinal chyme with the sutures of the ileorectoanastomosis, providing favorable conditions for the healing of the intestinal suture.
All hospitalized patients underwent general clinical (collection of complaints, study of anamnesis, physical examination data), laboratory, as well as endoscopic, morphological and radiological examinations. Laboratory blood tests, including biochemical analysis, urinalysis, microbiological studies of feces, were carried out according to generally accepted methods. Examination of the rectum and colon was performed sequentially. During general and rectal examinations, the state of the tissues of the perianal region and the anal canal, the rectal sphincter closure function, preparation of the rectum for endoscopic examination, as well
Figure 1, 2.
Histological changes in the colon with a pronounced degree of activity of nonspecific ulcerative colitis: a - deep folds of the mucous membrane (MM); b - crypt abscesses in MM; c - slit erosion; d - polypoid swelling in MM; fig. a-d staining with hematoxylin and eosin, enlargement 250.
as the preliminary determination of the pathological process and the assessment of the nature of rectal discharge were assessed.
All patients underwent sigmoidoscopy with biopsy, in which the condition of the mucous membrane, its color, vascular pattern, the nature of inflammatory and destructive changes, and bleeding were assessed. To prepare for sigmoidoscopy in patients with ulcerative colitis, a cleansing enema with isotonic sodium chloride solution was performed in the evening before the study and in the morning 1.5-2 hours before sigmoidoscopy.
During sigmoidoscopy, all patients showed damage to the mucous membrane of the rectum and sigmoid colon, which was manifested by their sharp hyperemia, edema, looseness and contact bleeding. In all patients, against the background of a pronounced inflammatory process, erosive and ulcerative changes were also observed. In patients with the most severe colitis, erosions and ulcers were numerous. In 17 (45.9%) cases, significant narrowing of the rectum was revealed, and in 8 patients the rectum was narrower than the tube of the pediatric rectoscope. In 20 (54.1%) patients, pseu-dopolyps were found in the sigmoid colon, which are areas of growth of granulation tissue or islets of preserved inflamed mucosa against the background of cicatricial retractions.
The severity of pathological changes detected by sigmoidoscopy has always been adequate to the severity of clinical manifestations. In more than half of patients with severe and long-lasting disease, inflammatory and destructive changes were combined with the processes of regeneration and scarring.
Histological examination of biopsy specimens of the rectal mucosa was performed in all patients. In this case, slit-like erosion and ulcerative defects were found, the bottom of which was represented by purulent-necrotic detritus or granulation tissue. The lamina propria of the mucous membrane was
abundantly infiltrated with lymphocytes, plasma cells, and eosinophils. The lumen of the crypts was made with inflammatory detritus with the formation of crypt abscesses. A pronounced plethora of capillaries with leukodiapedesis was observed throughout the mucous membrane (Fig. 1).
Comparison of the data obtained during the histological study of the biotic material and the resected intestine showed that changes in the rectal mucosa fully reflect the essence of changes in other parts of the intestine, and therefore a biopsy of the rectal mucosa can be used to establish the nature and severity of the process (Fig. 2).
Fibrocolonoscopy with biopsy is one of the important methods of examination of patients with UC. Fibrocolonoscopy was performed during the observation in 22 (59.5%) patients before admission to the surgical hospital. At the same time, total colonoscopy was carried out only in 10 (45.5%) patients, up to the transverse colon - in 7 (31.8%), in 5 (22.7%) patients the study was carried out up to the sigmoid colon. As a rule, the obstacle to the high carrying out of the colonoscope was poor bowel cleansing, as well as kinks of the colon and doli-chosigma. In 100% of cases, pathological changes were characterized by severe hyperemia, multiple erosions in 100% of cases, ulcers in 20 (54.1%) patients, pseudopolyposis in 9 (24.3%) patients, contact bleeding, spontaneous bleeding in 8 (21.6 %) patients.
Evaluation of long-term results of simultaneous subtotal and total colectomy with ileorectostomy for severe nonspecific ulcerative colitis (Fig. 3) in patients showed that in almost 95% of patients in the first 1-2 years after surgery, regression of systemic complications of UC occurred, and ulcerative proctitis tends to subside and persistent long-term remission. Only in 3.1% of patients, colectomy with ileorectostomy did not lead to relief of the inflammatory and ulcerative process in the rectum (Fig. 4).
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Conclusion
Evaluation of long-term results of one-stage total colectomy with ileorectostomy for severe nonspecific ulcerative colitis in patients showed that in almost 91% of patients in the first 1-2 years after surgery there was a regression of systemic complications of UC, and ulcerative proctitis tends to subside and persistent long-term remission. Comparison of the data of endo-
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