Differentiated surgical tactics in patients with colic polyps and polyposis

Modern approaches to surgical treatment of patients with colic polyps and polyposis (CPP)
Although the discussion on possibilities of conservative treatment of colic polyps, in particular -by taking non-steroid anti-inflammatory drugs, aspirin, therapeutic enemas with celandine juice, is still going on [12,14,21,25], majority of specialists [2,3,4,8,12,14,19,21,24] adhere to the opinion, that the only adequate method of treatment of the disease is surgery, and the main reason for that is cancerous transformation of the polyps. 
There are numerous publications on the issues of surgical treatment of diffuse colic polyposis. As far back as in 1923 году G. Pennington expressed the opinion, that the only radical treatment of diffuse colic polyposis is colectomy with permanent ileostoma. Until recent times the single-stage operations like colproctectomy, subtotal colectomy were treated as unsafe for patients due to significant shifts in homeostasis caused. For this reason number of authors preferred multi-step operations [18, 19, 21,]. However the recent studies demonstrated, that in this case 63,4% patients develop complications, lethality rate reaches 19,4% [21, 24], and risk of neoplastic transformation in the remaining parts of colon remains high. This makes impossible to perform the next step of surgical intervention due to increased extent of cancerous process or presence of remote metastases [1,2,3,18]. V.D.Feodorov and А.М. Nikitin [19,24] studied the results of multi-step (93 patients) and one-step (174 patients) operations.
Postoperative complications have been observed correspondingly in 63,4 и 39,1% of patients, lethality rate comprised 19,4 и 9,7%. Over recent years colorectal surgeons in such cases tend to perform sphincter-preserving operations. There are two trends: one – colproctectomy and forming the enteric reservoirs [2.3,12,19,21]; the second – using the method of endoscopic polypectomy for sanation of the remaining parts of colon before surgery and in consequent periods of observation [4.5,9,11,13,15]. 
After the report of Doniec J.M. in 2003 about usage of high frequency current during fibrocolonoscopy in treatment of colic polyps, regardless to their localization, the coagulation method became widespread. The experience to date allows holding it safe and highly efficient in CPP cases. [4, 6, 9, 26]. 
Number of authors [4, 11, 15, 16] think, that active case finding and timely removal of polyps significantly reduces the risk of development of colon cancer in 99.5% of examined patients.  
In 1983 Bergmann U. et al. for the first time implemented the method of transanal removal of benign rectal tumors using transanal endoscopic microsurgery (ТЕМ).
It is possible to remove neoplasms of lower and medium parts of rectal ampulla together with sub-mucosal layer, using specially designed operating rectoscope with three-D optics using up to four microsurgical instruments. This method provides adequate lateral resection line in case of benign tumors, and in case of malignant ones allows to expand the extent of intervention up to segmental or even to circular resection of the lesion site of the organ across to whole mass of enteric wall with formation of end-to-end anastomosis. The main application point of the method is treatment of “large” (more than 3 cm in diameter), trailing and malignant villous tumors, because electric coagulation in such cases leads to unsatisfactory results. [22,23].
Spreading of polyps through the entire gastro-intestinal tract, grave condition of patients complicates both diagnostics and choice of surgical tactics. Some authors [17.19, 21, 24] propose combination of both endoscopic and open surgery, depending on the character of the lesion and clinical course of the disease. Its important to note, that regardless to the progress in surgical treatment of CPP, the complications and fatality rates remain high enough and amount to 4-40% [17,21,24]. Multi-step operations lead to highest number of complications and lethality. Complications often occur at colectomy with abdominoanal proctectomy with pulling-through the ileum to anal canal, as well as at subtotal colectomy with ileorectal anastomosis. So, there occur: strictures of the pulled-down bowel (2.8%) и ileostomic fistulas (1.2%) [19,21,24]. Ileus, which occurs in about 3,3% patients, is the main cause of lethality at such operations. The main cause of lethality of patients in the long term is progression of cancer (24,1%). 
Thus, the choice of tactics and method of surgical treatment in CPP remains the issue of the day. Surgical tactics has to be differentiated and individual, depending on the character of the disease and the level of involvement of colon. Timely diagnostic and prognosis of course of CPP is a prerequisite for development and choosing the most effective differentiated surgical tactics. 

Objective
Development of differentiated surgical tactics in patients with CPP based on utilization of advanced complex of diagnostics and prognosis of the risk of malignization of colic polyps. 

Materials and methods
There are analyzed results of diagnostics and treatment of 183 patients with CPP, who were treated at Republican Coloproctology Research Center (RCPRC) and Republican Oncology Research Center (ROCR) of the Ministry of Health of Uzbekistan in 1998-2008. The patients were divided into 2 groups. The 1st (comparison) group consisted of 81 patients, in which the traditional examination and surgical treatment methods were used. The 2nd (main) group consisted of 102 patients in which there were applied the newly developed methods of complex diagnostic and differentiated surgical tactics. The main group consisted of 60 males (58.8%) and 42 females (41.2%), and the comparison one of 52 (64,2%) males и 29 (35,8%) females (Table 1). 

Table 1
Distribution of patients by sex and age
Age of patients (years) Main group Comparison group
Males Females Total Males Females Total
Abs. % Abs. % Abs. % Abs. % Abs. % Abs. %
Under 20 3 2,9 4 3,9 7 6,8 2 2,5 0 0 2 2,5
20-29 10 9,8 15 14,7 25 24,5 16 19,7 5 6,2 21 25,9
30-39 12 11,8 2 2,0 14 13,7 3 3,7 2 2,5 5 6,2
40-49 9 8,8 14 13,7 23 22,5 12 14,8 7 8,6 19 23,4
50-59 13 12,7 7 6,9 20 19,6 11 13,6 13 16,0 24 29,6
60 and older 13 12,7 0 0,0 13 12,7 7 8,6 3 3,7 10 12,3
Total 60 58,8 42 41,2 102 100,0 51 63,0 30 37,0 81 100,0
Average age 45,6±1,92 37,1±1,85 42,0±1,41 42,3±2,17 44,0±2,63 42,9±1,68

Average age of patients in the main group made 42.0±1.41 years, in the comparison group – 42,9±1,68 years, i.e. patients of the two groups were comparable by age and sex. 

The clinical forms of CPP in patients are presented in the Table 2.  
Table 2 
Distribution of patients by clinical features, n=183
Clinical forms Main group Comparison group
Solitary polyps 33 19
Multiple polyps 18 27
Diffuse leasons 43 28
Out of them Peuts-Jegher’s syndrome 9 2
Malignant polyposis 8 7
Distal part of intestine 70 65
Left side 12 6

Subtotal 3 4
Total 17 6
Villous polyps 14 9
Ademonatous 35 22
Adenopapillomatous 27 18
Hyperplastic 10 11
Proliferative 5 9
Cancer in citu 11 13
Complications
Posthemorragic anemia 22 31
Cachexy 7 2
Strictures 6 3
Chronic colonic ileus 7 11
Malignization 10 5
Toxic dilatation of colon 2 1
Acute colonic ileus (intussusception) 3 5
Bleeding from rectum 35 32
Colonic perforation 1 1

The main group had more severe clinical features than the comparison one (Table 2). 

Substantiation of the algorithm of the differentiated surgical tactics
We developed the complex of diagnostic and prognostic criteria for evaluation of disease severity and risk of malignization of CPP. There were identified 4 malignization risk groups – minimal, moderate, significant and high risk. On the basis of published data and on our own experience we developed the algorithm of differentiated surgical tactics in patients with CPP depending on the malignization risk group. (Picture 1). 
1 group – minimal malignization risk, includes patients with preclinical phase and initial disease symptoms, with solitary adenomatous and villous polyps no bigger than 5-8 mm, less than 10 items in total, in most cases with involvement of rectum only, that is why there were used transanal and endoscopic methods of surgical treatment.
2 group – moderate malignization risk, includes patients with multiple proliferating and hyperplastic polyps with size not exceeding 15mm, up to 50-100 pieces in total, mainly with involvement of rectum and distal parts of sigma. We, as the majority of modern authors, adhere to tactics of dynamic [7, 20] endoscopic bipolar electrocoagulation of these polyps. 
While performing the endoscopic polypectomy we were guided by the following criteria:
1) Excision has to be started from the most proximally located adenomas, to avoid traumatizing the eschar formed after coagulation during sometimes unavoidable multiple insertions of endoscope.;
2) One should not try to remove all the polyps in one step, depending of their quantity and size the polyps, the aim of the endoscopic intervention can be fulfilled in several steps with removal of 20-30 polyps in one session.;
3) First of all one should remove the biggest and suspicious in terms of malignization polyps, in which the electrocoagulation is performed on the level of basement of the pedicle with subsequent histological examination of not less than 3-4 of them, capturing into microscopic section all parts of the polyp (basement, peduncle and head);
4) All patients have to be kept under observation by the specialized facility; intervals between check-ups should not exceed 6 months. 
3rd group – significant malignization risk. There are included patients with diffuse polyposis, initial presentations of Peuts-Jeghers, Trucot, Gardner syndroms, with polyps sized between 15-30 mm, 100-500 pieces in total, of adenopapillomatous, proliferative, and dysplastic nature. In this group there is implemented two-step radical surgery tactics. During the 2nd step, if necessary, there were performed reconstructive operations. In these patients, depending on the character, level and extent of lesion there are performed either one-step resections of the involved parts of colon, or combination of resection with unloading ileostomy. The second variant is usually used as urgent operation in weak patients with significant weight loss. In several months – after stabilization of their condition – reconstructive operation with closure of the ileostomy is performed. 
In number of cases, when other organs of gastro-intestinal tract are involved – intestine, stomach or gallbladder – the simultaneous operations are performed in those cases where general condition of the patient allows. 
In the group 4 – high malignization risk, which includes patients with total diffuse polyposis of colon, intestinal polyposis of gastrointestinal tract (Peuts-Jeghers, Trucot, Gardner syndromes), malignant polyps or transformation from cancer in situ into adenocarcinoma – there are used 3 variants of surgical tactics. 
If there are gastric polyps –endoscopic bipolar electrocoagulation of gastric and colonic polyps has been performed as the 1st step. On the second step there were performed radical extended operations on colon with lymphodissection, and on the 3rd stage – reconstructive operations.
In case of polyps of intestine the first radical extended operations are performed on intestine and colon, and roughly in 1 year after that – reconstructive ones.
In case if there is no polyps in stomach and intestine the two-step tactics is used – radical extended operations on colon as the first step and reconstructive operations after 1 year as the second step. We propose the algorithm of differentiated surgical tactics in patients with CPP (picture 1). 
Picture 1.  
ALGORITHM OF DIFFERENTIANTED SURGICAL TACTICS IN PATIENTS WITH COLIC POLYPS AND POLYPOSIS

Results of treatment
The Table 3 shows the types of operations performed in the main and comparison groups. One can see that the groups are comparable by the character and volume of operations.  
Table 3
Types of operations in patients with CPP
Type of operation Main group, 
n=85 Comparison group, n=73
Transanal polypectomy 29 (34,1) 19 (26,0)
Total colectomy, ileostomy 9 (10,6) 4 (5,5)
Abdomino-anal proctectomy with pull-down of proximal parts of colon to anal canal 22 (25,9) 15 (23,3)
Sub-total colectomy with colorectal anastomosis 1 (1,2) 1 (1,4)
Abdomino-anal proctectomy, colostomy 4 (4,7) 13 (17,9)
Hartmann’s operation 3 (3,5) 2 (2,7)
Left hemicolectomy with transverso-rectal anastomosis 1 (1,2) 2 (2,7)
Duhamel’s operation with colorectal anastomosis – 1 (1,4)
Abdomino-perineal extirpation of rectum, colostomy – 2 (2,7)
Laparotomy, enterotomy, proctotomy, polypectomy, resection of intestine, side-to-side anastomosis 1 (1,2) 2 (2,7)
Sigmoid colectomy with colorectal anastomosis (CDH-29 or CDH-31 apparatus) 1 (1,2) 4 (5,5)
Total coloproctectomy, disinvagination of intestine, ileostomy 0 (0%) 1 (1,4%)
Preventive double-barrel ileostomy 1 (1,2) –
Operation of DeLorme 1 (1,2) –
Operation of Miculicz 1 (1,2) –
Reconstructive operations 11 (12,9) 5 (6,8)

In 25 patients there are performed simultaneous operations. Abdominoanal proctectomy with pulling down of proximal parts of colon to anal canal was combined in 5 patients with removal of ovarian cysts, hysterectomy, echinococcectomy and Bilroth 1 partial gastrectomy. Left hemicolectomy with transverse-rectal anastomosis in 2 patients was combined with cholecystectomy and ureterolythotomy. Right hemicolectomy with ileotrasversoanastomosis in 4 patients was combined with ovarian cyctectomy and echinococcectomy. Sigmoid colectomy with colorectal anastomosis in 3 patients combined with Kummel’s posterior rectopexy and amputation of uterus. Sub-total colectomy with colorectal anastomosis in 2 patients combined with appendectomy and ovarian cystectomy. Total colectomy with ileorectal anastomosis in 5 patients combined with cholecystectomy, gastric resection and herniotomy. Sigmoid colectomy with colorectal anastomosis in 4 patients combined with appendectomy, ovarian cystectomy and metrofiromectomy. Reconstructive operations in 4 patients combined with cholecystectomy, gastric resection and herniotomy. In 4 patients gastric resection and in 1 patient cholecystectomy have been performed due to Peuts-Jegher’s syndrome (diffuse polyposis of stomach and gallbladder). 
The data we brought confirm the correctness of the chosen surgical tactics and indicate the need to improve the methods of early diagnostics of CPP. In Table 4 there are shown the results of treatment of main and comparison groups. As it is seen, recovery rate in the main group was significantly higher than in the comparison one – 83,5±3,7% and 65,7±5,2%, and the rate of relapses was significantly lower – 1,2±2,2% и 12,3±3,5% accordingly. 
Таблица 4. 
Results of surgical treatment of patients with CPP in the comparison groups

Treatment outcome Main group, n=85 Comparison group, n=73
абс. % абс. %
Recovery 71 83,5±3,7* 48 65,7±5,2
Improvement 8 9,4±2,8* 12 16,4±4,2
No change 1 1,2±1,2 4 5,5±2,4
Worsening 1 1,2±1,2 – 0±0
Relapse 1 1,2±2,2* 9 12,3±3,5
Fatal outcome 3 3,5±2,0* – –
Footnote * – Differences between the indicators of main and comparative group are statistically valid (Р<0.05).

At the same time, one should note, that there were no fatal outcomes in the patients of comparison group, whereas in the main group 3 patients (3,5±2,0%) died due to cardiac failure (2) и ileus (1). Cardiac failure was a cause of death of 1 patient with multiple polyps, who undergone reconstructive operation and 1 patient with diffuse polyposis after simultaneous operation. Ileus was a cause of death of 1 patient with diffuse polyposis, who undergone radical (abdominoanal proctectomy, subtotal colproctectomy, single-barrelled ascendostomy) operation. As seen, fatal outcomes in the main group were attributed to severe baseline condition, and in 2 out of 3 cases they occurred after expanded reconstructive operations. 
Conclusions
1. In patients with colonic polyps and polyposis the differentiated surgical tactics should be applied, using both endoscopic and radical operations, taking into account the extent and character of involvement, as well as the risk of malignization. 
2. In order to choose differentiated surgical tactics in these patients 4 groups of severity of lesion and malignization risk have to be distinguished on the basis of criteria we developed earlier. 
3. Application of the developed algorithm of differentiated surgical tactics allows improving the treatment outcomes significantly, particularly to increase recovery rate and reduce the rate of relapses several times. 
4. As necessary the operations on colon have to be complemented by operations on other gastrointestinal tract organs (stomach, intestine, gallbladder etc.).
5. There is a need in further development of surgical tactics, preoperative preparation, anaesthetic and resuscitation management in patients with colonic polyps and polyposis, especially in the 3rd and 4th risk groups, in debilitated patients and in cases of urgent operations. 

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