© Borgis - Postępy Nauk Medycznych 8/2013, s. 536-542
*Przemysław Ciesielski, Krzysztof Górnicki, Marcin Żuk, Maja Gorajska
Ocena wpływu czynników pośrednich (wieku, trybu operacji i czasu od rozpoznania do operacji) na zakres wykonywanych zabiegów operacyjnych u chorych na raka jelita grubego operowanych w Szpitalu Powiatowym w Wołominie
Evaluation of the impact of indirect factors (age, mode of operation and the time from diagnosis to surgery) on the scope of surgical procedures performed in patients with colorectal cancer who underwent surgery at the District Hospital in Wołomin
Department of General Surgery, District Hospital, Wołomin
Head of Department: Krzysztof Górnicki, MD, PhD
Streszczenie
Wstęp. Wyniki leczenia raka jelita grubego w Polsce należą do najgorszych w Europie. Wysoki odsetek nawrotów i niski 5-letnich przeżyć związany jest przede wszystkim z wykrywaniem raka w późnym stopniu zaawansowania.
Cel. Celem pracy była ocena wpływu czynników pośrednich (wieku, trybu przyjęcia oraz czasu od rozpoznania do operacji) na zakres zabiegu operacyjnego, tym samym jego radykalność u chorych leczonych w Szpitalu Powiatowym w Wołominie.
Materiał i metody. Materiał stanowiła grupa 105 chorych operowanych z powodu raka jelita grubego w Oddziale Chirurgii Ogólnej Szpitala Powiatowego w Wołominie w okresie od stycznia 2010 do grudnia 2012 roku.
Metoda: Chorych podzielono na cztery grupy odpowiadające czterem stadiom zaawansowania nowotworu jelita grubego. Oceniano wiek, tryb operacji oraz czas, jaki upłynął od rozpoznania do operacji w każdej z grup chorych. Obliczono ilość operacji paliatywnych i radykalnych dla każdego stopnia zaawansowania i porównano cztery grupy pod kątem wpływu, jaki miały opisane czynniki pośrednie na ilość operacji paliatywnych i radykalnych w każdej z grup.
Wyniki. W stopniu IV zaawansowania choroby, w grupie chorych poniżej 70 roku życia, liczba operacji radykalnych i paliatywnych była taka sama. W grupie chorych powyżej 70 roku życia liczba operacji paliatywnych wzrosła dwukrotnie.
Wśród operowanych w trybie planowym utrzymywał się wysoki odsetek operacji radykalnych, w odróżnieniu do operowanych w trybie ostrego dyżuru, gdzie w stopniu III zaawansowania choroby liczba operacji paliatywnych i radykalnych zrównała się, a w stopniu IV liczba operacji radykalnych znacznie zmalała.
Wnioski. 1. Czynnik pośredni – wiek powyżej 70 roku życia wpływa na zwiększenie liczby operacji paliatywnych w grupie chorych z IV stopniem zaawansowania nowotworu. 2. Czynnik pośredni – operacja w trybie dyżurowym wpływa na zwiększenie częstości operacji paliatywnych w III i IV stopniu zaawansowania choroby nowotworowej. 3. Czynnik pośredni – skrócenie czasu od rozpoznania do operacji poniżej 30 dni nie zwiększa szans na radykalizację zabiegu operacyjnego.
Summary
Introduction. The results of treatment of colorectal cancer in Poland are among the worst in Europe. The detection of cancer in the late stages of development results in high recurrence rate and a low 5-year survival.
Aim. The aim of this study was to assess the impact of indirect factors (age, mode of admission and time from diagnosis to surgery) to the extent of surgery, thus its radical, in patients treated in the District Hospital in Wołomin.
Material and methods. The material was a group of 105 patients operated on colorectal cancer in the Department of General Surgery at the District Hospital in Wołomin in the period from January 2010 to December 2012.
Method: Patients were divided into four groups corresponding to the four stages of cancer of the colon. The age, mode of operation, as well as the elapsed time from diagnosis to surgery for each group of patients were estimated. The number of palliative and radical operation for each stage and compared the four groups was calculated. Each group was compared in the terms of the impact described indirect factors on the number of palliative and radical surgery.
Results. The same number of palliative and radical operations for patients under 70 years old who were in stage IV of the disease was observed. In patients over 70 years old the number of palliative surgery was doubled.
High percentage of radical surgery remained among the elective patients, as opposed to surgery on the duty, where in stage III disease, the number of palliative radical surgery were equal, and stage IV the number of radical surgery significantly decreased.
Conclusions. 1. Indirect factor: age above 70 years old increases the number of palliative surgery in patients with stage IV cancer. 2. Indirect factor: the emergent operation increases the frequency of palliative operations in III and stage IV cancer. 3. Indirect factor: reducing the time from diagnosis to surgery less than 30 days does not increase the chances of radicalization of the surgery.
INTRODUCTION
The increase in morbidity and mortality from colorectal cancer is observed not only in Poland but throughout the world (1). The results of treatment of colorectal cancer in Poland belong to the worst in Europe (2). A large percentage of relapses and low 5-year survival rate is related to the detection of cancer in late stages of development. The main factor determining the resection is the stage of cancer. Indirect factors such as age, mode of adoption and the need for ad hoc surgery and the time elapsed from diagnosis to surgery are also of great importance. The common denominator for these interactors is the awareness of patients concerning the problem of colorectal cancer and their participation in prevention programs.
In the community living in the area of Wołomin District, which consists of mainly rural areas and small urban centers, the awareness of cancer prevention is very low, as evidenced by the high percentage of patients operated under emergency service and low social response to the proposed program of colorectal cancer prevention.
AIM
The aim of this study was to assess the impact of indirect factors: age, mode of admission and time from diagnosis to surgery on the scope of surgery, thus its radicality, in patients operated due to colorectal cancer in the District Hospital in Wołomin.
MATERIAL AND METHODS
Records were evaluated retrospectively in 105 patients (M – 60, F – 46) between the ages of 43 to 87 (mean age – 71 years) who underwent surgery for colon cancer in the Department of General Surgery at the District Hospital in Wołomin in the period from January 2010 to December 2012. Documentation of the prevention program concerning colorectal cancer in the District Hospital in Wołomin carried out in the years 2009-2012 was also examined for patients’ participation in the program.
Patients were divided into four groups according to the stages of colon tumor classification AJCC/American Joined Committee on Cancer (3). AJCC Rating scale based on TNM result estimated by histopathological examination of the surgery preparation with complementary M feature basing on intraoperative examination, chest X-ray and pelvis and abdomen CT.
Age for admission and operations was estimated, as well as the elapsed time from diagnosis to surgery for each group of patients. Number of palliative and radical surgery for each stage was calculated. Operations were considered radical when considered right and left-side colon cut, tumor resection (transverse or sigmoid notch cut), front of the rectum cut, abdominoperineal rectal subtraction, Hartmann’s operations (for patients with N0). Hartmann’s operations were considered palliative (for patients with N1 or N2 feature) as well as digestive bypass, selecting a loop stoma of the small or large intestine.
Four groups were compared in terms of the impact of the described interactors on the amount of palliative procedures or resections in each of the four groups.
Taking into account the criterion of age, patients were divided into groups below and above 60 years of age and below and above 70 years of age, basing on the National Cancer Registry data, showing a significant increase in incidence in the 7th and 8th decade of life.
Mode of admission and operations, and the date of diagnosis were assessed on the basis of the source documentation of patient hospital stay associated with surgery. The time from diagnosis to surgery was calculated taking into account the data of colonoscopy, considering the date of diagnosis being the date of the result of pathological examination of slices taken during colonoscopy. In the study group, the elapsed time between diagnosis and surgery was between 0 and 144 days (the mean 72 days). The limit of time differentiating groups with respect to the “time from diagnosis to surgery” was set at 30 days, considering that this is the time allowing, in diagnosed outpatients, for vaccination, completing examinations necessary to determine the stage (staging) and oncologist consultation and planning therapy. All patients with rectal cancers were treated systematically, had received radiation called “short path”, which did not affect the waiting time for surgery more than up to 30 days. For obvious reasons, patients operated under emergency department were excluded from the assessment for the parameter “time from diagnosis to surgery”, their diagnosis date is the date of operation.
RESULTS
The stage of cancer in the group of patients treated in the years 2010-2012 is shown in figure 1.
| The stage of cancer at the AJCC scale | Number of patients | % |
| I | 10 | 9.52 |
| II | 22 | 20.95 |
| III | 38 | 36.19 |
| IV | 35 | 33.33 |
Fig. 1. The incidence of various degrees of severity of cancer in the study group.
Patients with stage I and II (without N + feature in the pTNM assessment) were a group of 32 patients (30.5%), there were 73 patients in the third and fourth stages of development of cancer (69.5% of the study group). The scope of surgery in patients with colorectal cancer at the District Hospital in Wołomin included palliative and radical operations, and the main factor determining the disease severity was assessed by the surgeon during the procedure. Among patients who underwent elective operations the decision on the scope and radicality of surgery was based on an assessment of the general condition of the patient and evaluation of all the results of additional examinations, among patients operated under emergency department decisions were also taken on the basis of the state of the patient before and during treatment, local conditions in the case of obstruction or the degree of peritoneal cavity contamination with intestinal contents in complicated cases.
In the whole group 70% underwent radical operations. In patients with early progression of cancer (stage I and II) radical operations were performed in 16 cases (94% of patients < 60 years old). Number of radical surgery in patients with advanced stage III twice outnumbered palliative surgery. An exactly opposite dependency can be observed in patients with stage IV of the disease (fig. 2).
| Type of operation | | The advancement of cancer in the AJCC scale |
| I | II | III | IV |
| Total | 10 | 22 | 38 | 35 |
| Palliative | 32 | 0 | 2 | 10 | 21 |
| Radical | 73 | 10 | 20 | 28 | 14 |
Fig. 2. The number distribution of palliative and radical procedures performed in different stages of cancer in the study group.
The majority of the study group consisted of patients over 60 years of age (88 patients – 84%), there were 57 patients who were older than 70 (64%). In both groups tumors in the third and fourth stages of development predominated (> 60 – 59 patients, > 70 – 39 patients). In patients under 60 radical operations were performed in 94% of cases, in the group of patients over 60 radical operations were possible in 64% of cases (tab. 1).
Table 1. The frequency of resection and palliative operations performed in relation to the stage of cancer in the age groups below and above 60 years of age.
| Age | Stage | Number of patients | | Radical surgery | Palliative surgery |
| < 60 | I | 1 | 1 | 16 patients (94%) | 1 patient (6%) |
| 17 patients (16%) | II | 2 | 2 |
| III | 12 | 11 |
| IV | 2 | 2 |
| > 60 years of age | I | 9 | 9 | 57 patients (64%) | 31 patients (36%) |
| 88 patients (84%) | II | 20 | 19 |
| III | 26 | 25 |
| IV | 33 | 31 |
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