V Kyosev, V Mutafchiyski, K Vasilev, P Ivanov, G Grigorov, G Kotashev, V Hristova, H Petrov, M Sokolov¹, Sv Maslyankov¹, Sv Toshev¹, K Angelov¹ (+6 others)
2015 Scripta Scientifica Medica   unpublished
AIMS: Ulcerative colitis (UC) is a chronic bowel disease defined by rectosigmoid mucosal inflammation and is associated with an immune system dysregulation. For intractable or complicated ulcerative colitis (UC), restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice. However, when nutritional status and haemoglobin levels are poor or if the patient is receiving treatment with steroids, pouch fashioning should be delayed and an urgent/emergency subtotal
more » ... emergency subtotal colectomy(SC) with terminal ileostomy and closure of a long rectal stump is to be preferred. MATERIAL AND METHODS: A 44 year-old female from Burgas was admitted urgently to the country hospital three years ago followed by multiple diarrheic stools with blood and severe abdominal cramping. The patient had experience with recurrent episodes of ulcerative colitis for 12 years. Her condition got worse despite the intensive medical treatment and underwent colectomy with terminal ileostomy and closure of a long rectal stump. The postoperative hospital course was unremarkable, with findings for seven wound formed intestinal fistulas. Patient perceived intestinal fistulas as significant nuisance, associated with bad cosmetic results and a poor quality of life. In 2014, the patient referred herself to our institution for restorative bowel surgery and fistulas elimination. RESULTS: In April, 2014, the patient underwent partial rectal-TEM-mucosectomy, approximately 30 days later, she underwent definitive rectal-TEM-mucosectomy. Her immediate postoperative course was oral 5-aminosalicylic acid therapy for 3 months. However, after therapy, biopsy samples, taken at the time of proctoscopy from rectal wall, were negative for presence of rectal mucosa and inflammation. The patient was hospitalized again in our institution, laparotomy with ileorectal J-pouch anastomosis and fistulas elimination were performed. The postoperative course was benign and she was discharged from the hospital on 14 POD. Postoperative follow included proctoscopy with biopsy every 3 months in the first and the second year, after that, every 6 months for a 5-year period. CONCLUSIONS: Rectal-TEM-mucosectomy is currently the technique of choice for patients with UP, it has shown to be superior to conventional surgical techniques. TEM-technique allows better visualization of the surgical field and guarantees complete eradication of the UP and incidence of mucosal dysplasia and cancer development. Patients undergoing rectal-TEM-mucosectomy show earlier return to normal activity and hospital discharge. The TEM-technique has demonstrated significantly lower recurrence rates. 56 ABSTRACT Introduction. Preoperative determination of the patient as such with advanced disease (locally advanced tumor, engaged regional and non-regional lymph nodes, distant metastases) is often difficult, especially for the first two sets of characteristics, but it is a key point in planning the type and volume of the operation. A lack of presentation of patients with suspected advanced disease to specialized oncology board (multidisciplinary team meeting) prior to surgery leads to inadequate preoperative planning of the type and volume (potentially curative, i.e. radical surgery or palliative surgery) of the intervention in many cases. In a clinical sense, the term "advanced colorectal cancer," especially locally advanced colorectal carcinoma (LACRC) concentrates in itself efforts to determine the dividing line between the possibility of radical and non-radical treatment-in particular, surgical resection. The final decision about the type (potentially radical or palliative surgery) and the volume of resection is taken by the surgeon intraoperatively through an assessment of the specific tumor situs, co-morbidity and technical ability as the main objective is to achieve complete R0-resection.