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3DIAGNOSIS AND TREATMENT OF MULTIPLE PRIMARY TUMORS OF THE COLON
AND OTHER ORGANS OF THE ABDOMINAL CAVITY
NavruzovS.N., AbdujapparovS.B., Ten Ya.V.
(National Research Center of Oncology, Uzbekistan)
РЕЗЮМЕ
Диагностика и лечение первично-множественных опухолей толстой кишки и других органов брюшной полости С. Б.Абдужаппаров, Я. В. Тен
(Республиканский Научный Центр Онкологии, Узбекистан)
В статье проведен анализ возможных причин возникновения первично множественных опухолей толстой кишки и других органов брюшной полости. Проведен краткий обзор литературы, а также начальный этап собственных исследований о больных с ПМЗО, прошедших лечение в РОНЦ МЗ РУз. Данные исследования показали, что у большинства больных с ПМЗО отмечалось поражение одновременно или отсрочено двух или более органов и систем, имеются определенные различия в проведении предоперационной подготовки, оперативного вмешательства и ведения послеоперационного периода. В ходе проведения предоперационной подготовки больных необходимо учитывать объем операции и кровопотери, что оказывает решающее влияние на исход оперативного лечения и прогноз заболевания.
РЕЗЮМЕ
Диагностика и лечение первично-множественных опухолей толстой кишки и других органов брюшной полости Абдужаппаров С. Б., Тен Я. В.
УзР ССВ, Республика Онкология Илмий Маркази, Тошкент
Маколада йугон ичак ва корин бушлигининг бошка бирламчи куплаб усмаларининг пайдо булиши эхтимолий сабаблари тахлили урганиб чикилган. Адабиётни кискача обзори, х,амда УзР ССВ РОИМда бирламчи куплаб х,авфли усмалар (БКХ,У) билан даволанган беморларда утказган изланувчиларнинг шахсий тадкокотларини бошлангич боскичлари х,ам ёритиб берилган. Тадкикотларда БКХУ купчилик беморлара бир ёки хар х,ил вактларда, икки ёки ундан ортик орган ва тизимларда пайдо булиши, жаррохлик амалиётларидан олдинги тайёрлов ишларинини олиб боришда, жаррохлик вактида ва жаррохлик амалиётларидан кейинги даврда аник фарклар борлигини курсатади. Жаррохлик амалиётларидан олдинги тайёрлов ишларини олиб боришда, амалиёт ва кон йукотиш хажмини назарда тутиш зарур, чунки бу амалиётнинг кечишига ва касалликни кейинги прогнозини х,ал килишда уз таъсирини курса-тади.
RESUME.
Diagnosis and treatment of multiple primary tumors of the colon and other organs of the abdominal cavity
S.B.Abdujapparov, Ya.V.Ten
(National Research Center of Oncology, Uzbekistan)
The article analyzes the potential causes of multiple primary tumors of the colon and other organs of the abdominal cavity. The brief review of the literature, as well as the initial stage of the own research on patients with MPMN treated in RORC MoH. These studies have shown that most patients with MPMN noted simultaneously defeat or delay of two or more organs and systems, there are some differences in the preoperative preparation, surgery and postoperative period. During the preoperative preparation of patients it is necessary to take into account the amount of blood loss and operation that has a decisive influence on the outcome of surgical treatment and prognosis of the disease.
ACTUALITY
Primary malignant neoplasms (MN) - one of the most urgent problems of modern oncology, causing permanent interest of clinicians, in view of the fact that the problems of their early diagnosis, prognosis and tactics are still not solved. At present, together with an increase in total cancer incidence and an increase in the incidence of multiple primary MN of colon and rectum, which make up 17% of all observations of multiple primary malignancies (MPM) they are considered as one of the most common sites. The existence of one or more two human tumors in different organs, independent from each other has long been known. The first documented observation of multiple primary tumors is a description of Abu Ali Ibn Sina (Avicenna) at the turn of the XXI centuries. The first scientific studies (MPM) belong to London surgeon, John Pearson, conducted in 1793. However, the founders of the primary multiplicity deservedly considered to be T.Billroth. After works of T.Billroth (1898), devoted to the justification of the possibility of the existence of this disease, the interest in it began to grow, there is a need for working classifications and a clear definition of "primary multiple tumors."
Key words: colon cancer, multiple primary tumors, the incidence, synchronous, metachronous.
By definition, multiple primary tumors (MPT) - two or more tumors that develop in the body which: have a different or the same tissue origin (histogenesis); different or the same biological potential (malignant, benign, or various combinations thereof); different or the same histological structure; localized in one organ (or paired organs) of one system in dif-
ferent organs of the same system or in different organs of different systems; detected simultaneously (synchronously), sequentially (metachronous) or in combination (synchronous metachronous, metachronous synchronous or synchronous metachronous synchronous); match rules excluding the possibility of recurrence, germination and / or metastasis of one (or more) of the same tumor.
For an explanation of multiple lesions several hypotheses are assumed. As the risk of secondary tumor development view such therapeutic effects carried out on the primary tumor, as radiotherapy, chemotherapy, immunosuppression, which leads to contributing to the launch mechanism of carcinogenesis [3]. Another theory suggests that different cancers may have the same etiologic factors, and exposure time of the agent plays a decisive role in the emergence of several malignant tumors [4]. Finally, there is evidence of MPMN pol-yetiology. Immunodeficiency, hereditary predisposition may contribute to recurrence of the disease in the same patient [5].
According to the Institute of Oncology and Medical Radiology named after N.N. Alexandrov, from 1400 patients with cancer of the corpus uteri multiple primary cancer of the colon was observed in 46 (3.3%) which developed metachronous or synchronous. Short intervals between the detection are typical for blind gut and colon. In contrast, radiation induced neoplasm of rectosigmoid department occur in 12-18 years after combined radiotherapy of patients with cervical or uterine body.
As for the etiopathogenesis of colon MPMN, then there is reason to consider them in terms of multicentric theory, as a manifestation of the mucous membrane of carcinogenic factors causing the development of tumor simultaneously or successively from several centers. Mersheimer, Ringel and Eisenberg (1964), noting a variety of localization of tumors of the MPMN colon emphasize the greater frequency of their position only in this body: the defeat of the colon in 30% of the rectum - in 26% of cases. These are the options colon and rectum MPMN must be considered as multicentric.
Material and methods of study:
The Department of Coloproctology RORC MoH of the RU 172 patients with colon MPMN and other organs of the abdominal cavity were supervised. Men were - 90, women -82. The age of patients was 57, 7 ± 2,5 years old. Synchronous multiple primary tumors were detected in 62 (%), while 15 patients - intraoperatively, including primary metachronous multiple - 101 (%), primary multiple synchronous metachro-nous - 9.
Surgery for primary m
The primary colon carcinoma tumors was observed in 69 patients, with cecal lesions was noted in 10, ascending colon - in 7, the transverse colon - in 11, the descending colon
- in 11, the sigmoid colon - in 30 patients. Secondary tumors found in the sigmoid colon - in 7, in the rectum - in 8, the ascending colon - in 4, cecum - at 9, the transverse colon - in 5, the anal canal - at 11, the stomach - in 3, in the kidneys - in 6, bladder - in 8, ovary - in 8 patients. In one case, bladder tumor was detected as the tertiary tumor, and in one patient - basal cell carcinoma of the skin.
In this stage T3N0M0 detected in 26, T4N1M0 - in 31, T4N1M1 - in 12 patients.
The primary tumor of colon cancer ascertained in 42 patients. Wherein the secondary tumor was located in the sig-moid colon in 14, in anal canal - in 8, in the transverse colon -in 4, the stomach - in 3, bladder - in 6, the kidneys - in 3 and 4 patients in the ovary. According to TNM system: T2N0M0 -in 6; T3N0M0 - in 7; T3N1M0 - in 5; T4N1M0 - in 18 u T3N1M1- in 6 patients.
Stomach cancer as the primary tumor was detected in 7 patients. Secondary tumor of the transverse colon was detected in 3 of the sigmoid colon in 4 patients, stage of disease: T4N0M0 - in 5, T3N1M0 - in 2 patients. MPMN of ovary (9) and cervix (5) as primary tumors are detected in 14 patients. In this case, the secondary tumor was located in the descending colon - in 4, in the sigmoid colon - in 4, rectum and anal canal - in 4 patients.
MPMN of urinary system (kidney and bladder) as the primary tumor are determined in 19 patients. In this case, the secondary tumor was located in the sigmoid colon - in 2, the ascending colon - in 2, the transverse colon - in 5, in the anal canal and rectum - in 10 patients, in stages T2N0M0 detected
- in 4, T3N0M0 - in 10 and T4N1M0 in patients.
All patients were examined by a comprehensive program to include radial, endoscopic methods of investigation and determination of the levels of tumor markers. The following types of surgeries have been conducted in patients with tumors of the synchronous operations shown in Table №1:
Table №1
synchronous tumors n = 62_
№ Type of surgery Number %
1 Dextral hemicolectomy + gastrectomy 3 4,8%
2 Resection of the transverse colon +nephrectomy 3 4,8%%
3 Resection of the transverse colon + tuboovariectomy 3 4,8%
4 Resection of sigmoid colon + hysterectomy with appendages 5 8%
5 Sigmoid colectomy + abdominoperineal extirpation of rectum 5 8%
6 Total colectomy 5 8%
7 Anterior resection of the rectum + sigmoid colectomy 17 27,4%
8 Abdomino-anal resection of rectum + gastrectomy 5 8%
9 Anterior resection of the rectum + hysterectomy with appendages 3 4,8%
10 Abdominoperineal extirpation of rectum + sigmoid colectomy 5 8%
11 Abdominoperineal extirpation of rectum + hysterectomy 4 6,4%
12 Hartmann's Operation + resection of the bladder 4 6,4%
Total: 62 100
As seen from Table №1, all operations were combined, and had expanded character. The most frequently performed was anterior resection of the rectum (27.4%).
Operations with metachronous multiple primary tumors n = 101
Table №2
№ Surgery Number %
1 Dextral hemicolectomy 10 9.9%
2 Resection of the transverse colon 6 5.9%%
3 Sinistral hemicolectomy 12 11.8%
4 Resection of the transverse colon 16 15.8%%
5 Abdominoperineal extirpation of rectum 11 10.8%%
6 Abdomino-anal resection of rectum 17 16.8%%
7 Anterior resection of the rectum 22 21.7%%
8 Hartmann's operation 7 6.9%%
The nature of the operations in metachronous tumors determined by the localization process in the colon. From the data presented in Table №2 it is clear that the greatest number of transactions amounted to the frontal (21.7%) and abdominal-anal (16.8%) resection of the rectum.
Results and discussion:
Taking into account the factor that simultaneously defeat or delay of two or more organ systems were noted in patients, there were some differences in the preoperative prep-
aration, surgery and postoperative care, compared with patients who were observed solitary tumor of the colon. During the preoperative preparation is necessary to consider the amount of blood loss and operation, which will have a decisive influence on the outcome of surgical treatment. When analyzing the nature of postoperative surgical complications number of which is represented in Table 3, 18 patients had various complications. Of these the most formidable was anastomotic leak(2.3%) of the colon, which was accompanied by the development of peritonitis.
Table №3
Postoperative complications n = 172
№ Nature of surgical complications Number %
1 Anastomotic leak with peritonitis development 4 2.3%%
2 Necrosis of the relegated intestine and its retraction 2 1.1%%
3 Intestinal obstruction 2 1.1%%
4 Suppuration of postoperative wound 4 2.3%%
5 Bleeding from Presacral area 2 1.1%
6 Eventration of postoperative wound 4 2.3%
Total: 18 10.4%
Mortality: 2 1.1%
Intestinal obstruction, bleeding and postoperative №4) PATE, acute heart attack, stroke occurred in 2 cases. wound eventration were observed in 8 patients who need to Postoperative mortality - in 4 cases (2.2%). perform relaparatomy. Of therapeutic complications (Table Postoperative complications of therapeutic profile
Table №4
№ Therapeutic complications Number %
1 PATE 2 1.1%
2 Acute myocardial infarction 2 1.1%
3 Acute cerebrovascular disease 2 1.1%
4 Pneumonia 6 3.4%
5 Cystitis 8 2.3%
6 Acute urinary retention 4 2.3%
Total: 24 13.9%
Mortality 2 1.1%
At morphologic study of remote agents as the primary tumor172 drugs were investigated. Adenocarcinoma was verified in 68% of cases, while with the same frequency high-, medium- and low-differentiated forms were met.(Table №5).
Studies have shown that the detection of synchronous multiple primary tumors after surgery, it is possible to recom-
mend chemotherapy schemes which depends on the histo-logic type of the tumor and the distribution process. Carrying out the same radiotherapy in MPMN is possible in the absence of intestinal obstruction, and is preferably a holding non-adjuvant large fractional or adjuvant therapy in resected tumor bed in classic mode of fractionation.
Table №5
№ Types of tumors Number %
1. Adenocarcinoma 116 68%
a)high -diffrentiated 40 34,4%
6) moderate -differentiated 37 31,9%
b) low-differentiated 39 33,7%
2. Squamous cell carcinoma 21 12,2%
№ Types of tumors Number %%
3. Unclassified cancer 18 10,4%
4. Renal cell carcinoma 14 8,1%%
5. Transitional cell carcinoma 3 1,8%%
Conclusions
1. MPMN of colon, rectum, and other abdominal organs make up 17% of all malignant neoplasms of colon, which requires a particular approach to diagnosis and treatment.
2. The most likely theory of the emergence of MPMN is the multicentric growth of tumor with a simultaneous invasion of the abdominal cavity.
3. When a synchronous multiple primary tumors of the colon and other organs of the abdominal cavity it is necessary to adhere to the tactics of simultaneous removal of detected tumors.
4. In case of impossibility of simultaneous removal of the tumor on the first stage it is necessary to remove the tumor, which is the most common and can cause any complications.
МЕДИКО-СОЦИАЛЬНАЯ ХАРАКТЕРИСТИКА И ОЦЕНКА КАЧЕСТВА ЖИЗНИ ПАЦИЕНТОВ, НУЖДАЮЩИХСЯ В ЛЕЧЕБНО-РЕАНИМАЦИОННЫХ МЕРОПРИЯТИЯХ
Тягунов Д. С., Кадырова Т.А., Ступина К. И.
Северо-Западный государственный медицинский университет имени И.И. Мечникова,
Санкт-Петербург, Россия
MEDICAL AND SOCIAL CHARACTERISTICS AND EVALUATION OF QUALITY OF LIFE OF PATIENTS IN NEED OF MEDICAL RESUSCITATION
D. Tiagunov, T. Kadirova. K. Stupina, North-Western State Medical University named after I.I. Mechnikov, Saint-Petersburg, Russia
АННОТАЦИЯ
В структуре нежелательных осложнений стационаров особое место занимают осложнения, вызванные пребыванием пациентов в отделениях реанимации и интенсивной терапии. Данные осложнения возникают как в следствии несовершенного и парой устаревшего реанимационного оборудования, дефицита лекарственных препаратов, недостатка расходного материала так из-за медицинских ошибок связанных с несоблюдением санитарно-гигиенических нормативов, недостаточным инфекционным контролем, спровоцированным низкой мотивацией или недостаточной квалификацией медицинского персонала, что серьёзно повышает риск нежелательных осложнений в условиях отделения реанимации и интенсивной терапии. Возникшие осложнения негативно сказываются на качестве жизни пациентов. В современной медицине принято считать, что качество жизни пациентов до и после пребывания в отделении реанимации и интенсивной терапии не претерпевает существенных изменений и остается достаточно высоким (Недашковский Э.В., Заволожин С.А., 2011г.). Данное утверждение неверное, так как во многих случаях после пребывания в отделении реанимации и интенсивной терапии качества жизни пациентов изменяется и порой в положительную сторону. Исследование качества жизни позволяет принципиально изменить традиционный взгляд на проблему болезни и больного.
Ключевые слова: качества жизни, отделение реанимации, медико-социальная характеристика.
ABSTRACT
The structure of the unwanted complications hospitals occupy a special place complications caused by a stay of patients in intensive care. These complications arise as a consequence of an imperfect and a pair of old resuscitation equipment, shortage of medicines, lack of consumables so because of medical errors related to non-compliance with sanitary and hygienic standards, inadequate infection control, provoked by low motivation or insufficient training of medical staff, which seriously increases the risk of adverse complications in an intensive care unit and intensive care. Of complications negatively affect the quality of life of patients. In modern medicine, it is assumed that the quality of life of patients before and after a stay in the intensive care unit does not undergo significant changes, and remains quite high (Nedashkovsky EV, Zavolozhin SA, 2011.). This statement is incorrect, because in many cases, after a stay in the intensive care unit and an intensive care patient quality of life changes, and sometimes in a positive way. Quality of life allows you to fundamentally change the traditional approach to the problem of the disease and the patient.
Key words: quality of life, intensive care unit, medical and social characteristics.
Введение. Отделение реанимации и интенсивной терапии является узкоспециализированным подразделением любого стационара. В большинстве случаев лечение в отделении реанимации и интенсивной терапии проходят пациенты, находящиеся в критических состояниях, в
связи с тяжелыми заболеваниями или травмами, а также пациенты после тяжелых и сложных оперативных вмешательств. Незнание, а порой и непонимание пациентами особенностей лечебного режима в отделении не так уж редко становится причиной возникновения серьезных
