© Borgis - Postępy Nauk Medycznych 3/2016, s. 172-176
Zbigniew Lorenc, *Wiktor Krawczyk
Co nowego w koloproktologii?
What’s new in coloproctology?
Clinical Department of General and Trauma Surgery, Saint's Barbara Specialistic Hospital no 5 in Sosnowiec
Head of Deparment: Zbigniew Lorenc, MD, PhD, Associate Professor
Ze względu na obserwowany wzrost zapadalności na schorzenia jelita grubego problem ten stanowi bardzo ważny element codziennej pracy większości oddziałów oraz ambulatoriów chirurgicznych. Pojawiają się nowe sposoby postępowania chirurgicznego, w części przypadków wchodząc na stałe do panelu leczniczego, w innych zaś po pierwszych próbach nie uzyskując trwałej akceptacji. Rak jelita grubego (RJG) stanowi obecnie trzecią pozycję wśród wszystkich zachorowań na nowotwory i czwartą w grupie przyczyn zgonów. Znane są czynniki rozwoju RJG zarówno genetyczne, jak i środowiskowe. Wprowadzenie nowych metod diagnostycznych, takich jak TK, NMR, EUS, PET daje nadzieję na zwiększenie odsetka rozpoznania choroby w stadium pozwalającym na uzyskanie najlepszych wyników leczenia. Leczenie operacyjne jest podstawową metodą leczniczą w RJG. Ze względu na rosnącą częstość zachorowań zainteresowanie nieswoistymi chorobami zapalnymi jelit (NZJ) jest wciąż bardzo duże. Postęp, jaki się w tym zakresie dokonuje, dotyczy zarówno leczenia farmakologicznego (nowe preparaty lecznicze), jak i rozpoznania czynników mających wpływ na powstanie i rozwój choroby. W leczeniu szczeliny odbytu problemem może być zła tolerancja farmakoterapii stosowanej w tym schorzeniu, głównie preparatów opartych na nitroglicerynie. Podjęto próby stymulacji nerwu piszczelowego, wprowadzenia odpowiedniej diety w celu poprawy wyników leczenia. W leczeniu przetoki odbytu coraz częściej obserwuje się korzystny efekt po zastosowaniu techniki LIFT, polegającej na podwiązaniu kanału przetoki w przestrzeni międzyzwieraczowej. W leczeniu choroby hemoroidalnej w ostatnich latach rozwijają się techniki oparte na zamykaniu naczyń przy wykorzystaniu techniki dopplerowskiej.
Because of the growing incidence of large intestine diseases, the issue is a very important element of the daily work of most surgical wards and infirmaries. New surgical procedures are appearing, and some of them become standard procedure, while others fail to gain general acceptance after a few tries. Colorectal cancer (CRCA) is currently the third most popular cancer and the fourth most popular cause of death. Both genetic and environmental factors for CRCA development are known. The introduction of new diagnostic methods such as CT, NMR, PET allows for hope for an increase in the percentage of recognized cases of the disease in a stage, which would make it possible to achieve optimal therapeutic results. Surgery is the basic method of CRCA treatment. Because of the growing frequency of their occurrence, the interest in non-specific inflammatory bowel diseases (IBD) remains very high. Progress in the matter is related to pharmacological therapy (new medicinal products), as well as to recognition of factors, which influence the occurrence and development of the disease. In anal fissure treatment, low tolerance for the pharmacotherapy used against the disease, mainly nitroglycerin-based products, can be a problem. Attempts were made with stimulation the posterior tibial nerve and special diet. In anal fissure therapy, positive results are frequently observed when the LIFT technique is used, which means closure of the fissure channel through the intersphincteric approach. In haemorrhoid disease therapy, techniques based on vessel sealing with the Doppler technique – DGHL, have been developing during the most recent few years.
Because of the growing incidence of large intestine diseases, the issue is a very important element of the daily work of most surgical wards and infirmaries. New surgical procedures are appearing, and some of them become standard procedure, while others fail to gain general acceptance after a few tries.
Colorectal cancer (CRCA) is currently the third most popular cancer and the fourth most popular cause of death (1). Both genetic and environmental factors for CRCA development are known: age over 50 (90% of patients), occurrences of CRCA in the patient’s immediate family, colon polyps, inflammatory bowel diseases, wrong eating habits (obesity, alcohol, tobacco). At the same time, physical activity, the right diet (fruit, fiber, vegetables, fish, D and B6 vitamins, preparations of calcium and magnesium), the use of non-steroidal anti-inflammatory drugs, as well as substitute homeotherapy in postmenopausal women, decrease the risk of CRCA development. During the recent years, there have been some reports about the influence of alcohol consumed on CRCA development. The research results are not clear, yet a certain tendency related to the issue can be observed. In a thesis written with the purpose of researching the correlation between alcohol consumption and development of CRCA in the Mediterranean population, the protective influence of moderate amounts of red wine (up to 35 grams per day) were proven, in the male group of patients, but not in females. However, larger amounts (more than 48 grams per day), mainly in the male group, increased the risk of cancer development. Following the Mediterranean diet was related to a decrease in CRCA development in both sexes (2). Obesity, the rising frequency of which we are also observing in our own country, is not only a higher-risk factor for CRCA development, but also the cause of the increase in percentage of complications in treatment for the disease. This was the conclusion of the authors of a thesis, analyzing the results of therapy of 1048 patients in whose the increased BMI caused worse healing of postoperative wounds and the frequency of eventration occurrence (3). The most important prognostic factor is CRCA advancement at the moment of its recognition, and proper prophylaxis, as well as early diagnosis allow for the improvement of therapeutic results. The most important element of the therapy is surgery, and the implementation of complementary therapy (radio- and chemotherapy) has improved the therapeutic results in the scope of decreasing the percentage of local and distant recurrences, as well as increasing time of survival in advanced cases. In prophylaxis, the basic method is endoscopic screening. Colonoscopy, apart from its diagnostic value, allows for the removal of polyps, which are precancerous conditions for CRCA. However, there are cases of delayed CRCA recognition, after a colonoscopy was performed not very long before, during which no pathological changes were recognized. Literature has introduced the name “interval cancers” for the abovementioned situations. The reason for delayed recognition of “interval cancers” may be the fact that they are small, flat changes, which are not very well visible during endoscopy, especially if the large intestine was not properly prepared or if the endoscopic polypectomy conducted was not thorough enough (4). Some forms of CRCA, which develop in relation to disturbances in DNA repair processes as the reason of cancer development may take on the form of flat changes, quickly-developing polypoid lesions, which develop into cancers during a short period, under 3 years. It has been determined that such forms occur e.g. in the Lynch syndrome, and that they are more frequent in the right half of the colon (5). Similarly, CRCA occurs more frequently in the right half of the colon than in the left half in patients in whom gastroscopy has identified polyps in the duodenum (6). During the recent years it has been observed that CRCA occurrence in the age group of more than 50 years has not decreased, but that it has increased in younger patients, which probably means that the development of the disease is more aggressive in younger patients, however, no clear proof of this thesis has been produced. De Sousa et al. have examined 215 CRCA patients in age groups younger than 50 years (66 people) and older than 50 (149 people) and has not observed any difference in the overall survival rates or in recurrence-free survival in both groups. The independent factors, related to the advancement of the disease, were family history, tobacco smoking, and inflammatory bowel diseases (7). The introduction of new diagnostic methods allows for hope for an increase in the percentage of recognized cases of the disease in a stage, which would make it possible to achieve optimal therapeutic results. One of the important diagnostic factors here, as well as for therapy planning, is the recognition of metastasis in the lymph nodes. Unfortunately, the available diagnostic methods (CT, NMR, and EUS) are characterised by relatively low diagnostic sensitivity in the area of lymph node metastasis recognition. The introduction of PET, a very effective method, which improves the results of tumour diagnosis, local and distant recurrence recognition, allows for hope to improve the diagnostic results also in the area of lymph node metastasis. In a comparative research of PET and CT, Kwak et al. have assessed the usefulness of both methods in the area and has proven a similar effectiveness (87 and 88%, respectively) of both diagnostic methods (8).
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