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Perspectives of diagnostics and treatment of colonic polyps and polyposis

Introduction. The problem of colonic polyps and polyposis (CPP) remains significant many years and becomes more and more acute as the incidence of the disease grows. Nobody of clinicians is currently hesitant, that the problem remains significant practically in all its' aspects – diagnostics (especially at early stages); treatment (choice of the surgery technique, single-step or multistep approach in surgery tactics); the issues of further treatment policy, depending on long-term outcomes [1,3,4,5,6].

Urgency of the problem is conditioned by the prevalence of the disease, its social importance, long and recurrent course, and the risk of severe complications, including malignant transformation  [1, 3, 5, 6, 7,9].

Many researchers point out that part of CPP patients develop colorectal cancer, that is why surgeons tend to pay more and more attention to possibilities of early detection of CPP [5, 6,11,12,14,15]. The currently used diagnostic methods (X-ray, endoscopy) have a number of shortcomings and often do not allow making a definite diagnosis [2, 5, 8, 9].  Traditionally on the first stage they perform irrigoscopy (radiologic investigation), then the colonofibroscopy with biopsy. In case of false-negative results of X-ray examination, some clinicians refrain from carrying out endoscopic investigation. The significant radiation exposure, long terms which are

required for getting the examination results, technical difficulties for preparation of the colon for examination, high costs related to technological processes around X-ray films – all these factors push for searching new, more appropriate diagnostic methods  [9]. Performing colonofibroscopy and interpretation of its results at CPP cases remains a challenge. [5,8,15,18,19,20]. The difficulties are due to presence of mucus, blood in colonic lumen, regardless to thorough preparation, as well as rigidness, deformation of colonic walls, long duration (according to Uzbek MoH – 60-150 min.) of the procedure, and in addition - negative perception of it by patients. All these factors complicate the process of examination.

Numerous research works are being conducted to evaluate specificity and sensitivity of different examination methods at CPP, however the quality of diagnostics and respective treatment results are still unfavorable [2,5,8,10,13].

Introduction of multispiral computed tomography – virtual colonoscopy (MSCT-VC) is a significant step forward in diagnostics of CPP. The issue of choice of examination method which would help surgeons in identification of treatment approach and establishing optimal terms of surgical intervention is still unresolved [2, 3, 10, 12,23].

Objective: To evaluate the perspectives of early diagnostics and treatment options in patients with CPP.

Material and methods: There are analyzed the results of in-patient treatment of 56 patients at Republican Coloproctology Research Center in 2006-2009.  The patients were from 15 to 72 years old. The mean age of patients was 36+0,4 years. The patients have undergone traditional examination tests and MSCT-VC. The suitable treatment policy has been chosen based on findings. MSCT-VC has been performed on Phillips Medical Systems CT Scan. (Netherlands). The advantages of MSCT are safety, more precise localization of the lesion, opportunity to explore whole colon, verification of the lesion in terms of malignization. [2,10,16,17]. The process of examination has been recorded to DVD. The method allows to reveal small plane and stumpy polyps, which are hidden in haustra and can be missed during the ordinary colonofibroscopy [21,22.24.25]. This method is significantly less time consuming, and the risk of complications is minimal. After preliminary preparation the patient is laid down on the gentry table and the standard MSCT scanning of abdomen and pelvis is performed. The total duration of the examination is limited by 10-15 minutes, and the MSCT itself consumes about 3-5 minutes.

Results: MSCT-VC allowed clear identification of localization and severity of lesion of specific areas of colon, which was helpful in making choice on treatment method. The character of distribution of co-morbidity revealed in examined patients is reflected in the Table 1.

Table 1. Co-morbidity in patients with CPP

Co-morbidity

Number of patients

abs.(%)

Chronic hepatocholecystitis

8 (14,0%)

Ischemic heart disease

12 (21,0%)

Essential hypertension

11 (19,0 %)

Cholelithiasis

3 (5,0%)

Chronic bronchitis

3 (5,0%)

Chronic pancreatitis

2 (3,0%)

Neurocirculatory dystonia

1 (1,2%)

Ovarian cyst

3 (5,0%)

Out of the total co-morbidity cardiovascular diseases (ischemic heart disease and essential hypertension) were the most frequent ones and were found in 23 patients (41,0%).  Chronic hepatocholecystitis has been found in 8 patients (14%). The share of other concomitant diseases (cholelythiasis, chronic bronchitis, chronic pancreatitis, neurcirculatory dystonia, ovarial cyst) did not exceed 5%. Cholelythiasis, chronic bronchitis and ovarial cysts were most frequent ones amongst them – by 3 cases (5%).

The retrospective analysis of examination data of patients with diffuse polyposis operated on in our clinic revealed the following frequency of different localizations of colonic lesions: lesions of left part of colon - in 38 patients (66,7%), right part of colon in 8 patients (13,9%), transverse colon - in 18 patients (32,1%), descending colon - in 24 patient (41,7%), sigmoid colon in 42 (75%)  и rectum in 45 patients (80,6%). The data presented shows that frequency of polyposis increases towards the distal parts of colon. The following complications have been revealed: bleeding in 39 patients (69,4%), posthemorragic hypochromic anemia in 24 (41,7%), malignization of polyps - in 8 cases (13,9%). The disease recurrence has been noted in 3 cases (5,6%). All patients were operated on. Spreading of polyps to the entire gastro-intestinal tract complicated the process of choosing the surgical intervention type.

Table 2. Types of surgical operations performed to patients with CPP.

№

Type of surgery

Abs. %

1

Total colectomy, ileostomy

6 (10,0%)

2

Reconstructive-restoring surgery

11 (19 %)

3

Abdominoanal resection of rectum with pulling through the  proximal parts of colon to anal channel with putting colonic-anal anastomosis.

15 (27,3%)

4

Subtotal colectomy with colorectal anastomosis

4 (26%)

5

Abdomino-anal resection of rectum, colostomy.

6 (10,0%)

6

Hartmann's operation

2 (3%)

7

Right side haemicolectomy, ileotransverse anastomosis

4 (6%)

8

Duamel's operation

1 (1,3%)

9

Leftside haemicolectomy, transverse-rectal anastomosis.

2 ( 3%)

10

Total colectomy with ileorectal anastomosis

4 (6%)

11

Laparotomy, enterostomy, proctotomy, polipectomy

1 (1,3%)

In 14 (25%) patients the repeated endoscopic sanitization of gastrointestinal tract has been done before radical surgery. In the cases with initially grave condition of patients with anemia and cachexia the surgery was divided into 2 stages. Depending on the level of lesions, the affected part of colon has been removed and the intact healthy parts brought down to anal channel with creation of coloanal anastomosis. During the second stage the multiple endoscopic sanitization of the residual discrete polyps has been performed. There were 2 (3%) lethal outcomes: in the first case – due to cardiovascular collapse, in the second – due to progressive peritonitis.

Conclusions:

1. In future the virtual colonoscopy has to become the integral part of diagnostic examination of patients with CPP. It facilitates the early detection of colonic lesions.
2. While choosing the surgical approaches it is important to take into account the general somatic health of patients with CPP, which is one of the crucial factors determining the disease outcome and significantly influencing the mortality rate.
3. The most effective treatment option is two-stage surgical intervention, with removal of the affected part of the colon and pulling-through the intact parts of colon to anal canal and forming colo-anal anastomosis, and if necessary – with multiple postoperative endoscopic sanitization.

References:

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19. Ming-Yao Su, Chen-Ming Hsu, Yu-Pin Ho et al. Endoscopic mucosal resection for colonie non-polypoid neoplasma// Ann. J. Gastroenterol.-2005. –Vol. 100. –P.2174-2179.  Endoscopic mucosal resection for colonic non-polypoid neoplasms /Ning-Yao Su, Chen-Ming Hsu, Yu-Pin Ho et al. //Amer J. Gastroenterol. – 2005. – Vol.100. – P.2174-2179.

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About the Author

Prof. S.N.Navrouzov, D.A.Sapaev, Sh.A.Sapaeva

Republican Coloproctology Research Center

Tashkent Medical Academy

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