Značaj obuke i obrazovanja u izvođenju totalne mezorektalne ekscizije u hirurgiji karcinoma rektuma
Sažetak
Uvod/Cilj. U poslednje dve decenije postignut je značajan napredak u hirurgiji karcinoma rektuma. Preoperativna radioterapija, uvođenje staplera kopči i ponajviše unapređena hirurška tehnika umnogome su doprineli boljim rezultatima lečenja, pre svega smanjivanjem učestalosti ranih hirurških komplikacija i stope lokalnih recidiva. Cilj ovog istraživanja bio je da se uporede operativni i postoperativni rezultati u lečenju karcinoma rektuma između dve grupe hirurga – onih koji se usko bave kolorektalnom hirurgijom i onih koji se ovom problematikom bave sporadično. Metode. Ova retrospektivna studija obuhvatila je 146 bolesnika koji su operisani na Institutu za onkologiju Vojvodine u periodu od 1. 1. 2008. do 31. 12. 2010. godine. Bolesnici su bili podeljeni u dve grupe. U prvoj grupi N1 bio je 101 bolesnik koje su operisali visoko edukovani hirurzi za totalnu mezorektalnu eksciziju (TME), a u drugoj N2 bilo je 45 bolesnika koje su operisali hirurzi bez edukacije iz TME. Rezultati. Preoperativnu hemioiradijaciju primilo je 49 (33,56%) bolesnika. Utvrđena je statistički značajna razlika između dve grupe u trajanju operacije i potrebi za krvnim derivatima tokom operacije. Dehiscenciju anastomoze indentifikovali smo kod 3 bolesnika iz N1 grupe i kod 10 bolesnika iz N2 grupe. Sedam (4,79%) bolesnika razvilo je lokalni recidiv nakon operativnog lečenja. Statistički značajna razlika ustanovljena je u broju lokalnih recidiva i dehiscencije anastomoze između dve upoređivane grupe. Zaključak. Neophodno je kontinuirano obrazovanje i obuka u hirurgiji karcinoma rektuma kako bi se savladale nove tehnologije i hirurške tehnike, te unapredili rezultati hirurškog lečenja.
Reference
Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345(9): 638−46.
Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004; 351(17): 1731−740.
Fazio VW, Zutshi M, Remzi FH, Parc Y, Ruppert R, Fürst A, et al. A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers. Ann Surg 2007; 246(3): 481−8.
Pietra N, Sarli L, Costi R, Ouchemi C, Grattarola M, Peracchia A. Role of follow-up in management of local recurrences of colorectal cancer: A prospective, randomized study. Dis Colon Rectum 1998; 41(9): 1127−33.
Taylor FG, Quirke P, Heald RJ, Moran B, Blomqvist L, Swift I, et al. Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann Surg 2011; 253(4): 711−9.
Richardson DP, Porter GA, Johnson PM. Surgeon knowledge contributes to the relationship between surgeon volume and patient outcomes in rectal cancer. Ann. Surg 2013; 257(2): 295−301.
Pelletier JS, Degara C, Porter G, Ghosh S, Schiller D. Retrospective review of rectal cancer surgery in northern Alberta. Can J Surg 2013; 56(4): 51−8.
Martling A, Cedermark B, Johansson H, Rutqvist LE, Holm T. The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer. Br J Surg 2002; 89(8): 1008−13.
Ricciardi R, Roberts PL, Read TE, Baxter NN, Marcello PW, Schoetz DJ. Presence of specialty surgeons reduces the likelihood of colostomy after proctectomy for rectal cancer. Dis Colon Rec-tum 2011; 54(2): 207−13.
Cong Z, Fu C, Wang H, Liu L, Zhang W, Wang H. Influencing factors of symptomatic anastomotic leakage after anterior resection of the rectum for cancer. World J Surg 2009; 33(6): 1292−7.
Meyerhardt JA, Tepper JE, Niedzwiecki D, Hollis DR, Schrag D, Ayanian JZ, et al. Impact of hospital procedure volume on surgical operation and long-term outcomes in high-risk curatively resected rectal cancer: Findings from the Intergroup 0114 Study. J Clin Oncol 2004; 22(1): 166−74.
Phang TP. Evolving rectal cancer management in British Columbia. Can J Surg 2010; 53(4): 222−4.
Simunovic M, Coates A, Goldsmith CH, Thabane L, Reeson D, Smith A, et al. The cluster-randomized Quality Initiative in Rectal Cancer trial: Evaluating a quality-improvement strategy in surgery. CMAJ 2010; 182(12): 301−6.
Taflampas P, Christodoulakis M, Tsiftsis DD. Anastomotic leakage after low anterior resection for rectal cancer: Facts, obscurity, and fiction. Surg Today 2009; 39(3): 183−8.
Vignali A, Fazio VW, Lavery IC, Milsom JW, Church JM, Hull TL, et al. Factors associated with the occurrence of leaks in stapled rectal anastomoses: A review of 1,014 patients. J Am Coll Surg 1997; 185(2): 105−13.
Radovanovic Z, Petrovic T, Radovanovic D, Breberina M, Golubovic A, Lukic D. Single versus double stapling anastomotic technique in rectal cancer surgery. Surg Today 2014; 44(6): 1026−31.
Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: A randomized multicenter trial. Ann Surg 2007; 246(2): 207−14.
Martling A, Holm T, Rutqvist LE, Johansson H, Moran BJ, Heald RJ, et al. Impact of a surgical training programme on rectal cancer outcomes in Stockholm. Br J Surg 2005; 92(2): 225−9.
Swedish rectal cancer trial. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 1997; 336(14): 980−7.
Harnsberger JR, Vernava VM, Longo WE. Radical abdominopelvic lymphadenectomy: Historic perspective and current role in the surgical management of rectal cancer. Dis Colon Rectum 1994; 37(1): 73−87.