The study is based on the analysis of the results of treatment of 289 elderly and senile patients with complicated CC in the general surgery department of St. Petersburg Hospital for War Veterans in the period from 2008 to 2016. All patients were divided into two groups: the control (n = 156) and the main group (n = 133). For patients of the control group, the diagnostics and treatment of CC complications was carried out according to the traditional approach. The management of patients of the main group was implemented according to the principles of a multidisciplinary approach using modern methods of diagnostics and treatment. To implement all points of the interdisciplinary approach, patients who required emergency surgical intervention according to absolute indications (colon perforation, decompensated degree of acute colonic obstruction (ACO)) were excluded from the study.

The age of patients varied from 62 to 95 years, with an average of 80.4 years in the control group and 81 years in the main group. All patients in both groups had comorbidities, most often from the cardiovascular and nervous systems (Fig. 1).

Distribution of patients by comorbidities. ACS is atherosclerotic cardiosclerosis; PICS is postinfarction cardiosclerosis; CVD is cerebrovascular disease; PUS and D are peptic ulcer of the stomach and duodenum; OALEV is obliterating atherosclerosis of lower extremity vessels.

The effect of comorbidity on the course of the perioperative period was estimated using an age-dependent Charlson coefficient. The median of the Charlson index was 7.6 [4; 12] in both groups. According to the CR-POSSUM scale, the probability of the development of a lethal outcome in the postoperative period varied within 2.5–81.4%, being at an average of 20.7% for the control group and 20.6% for the main group. The 3rd degree of operational and anesthetic risk according to ASA was registered for most patients of both groups (176, 60.9%). For patients of both groups, the tumors were more often localized in the left half of the colon, and especially in the sigmoid colon (Fig. 2).

Distribution of patients by localization of the tumor in the colon.

In the control group, stage II of the oncological process was diagnosed in 68 patients; stage III, in 57; and stage IV, in 31. In the main group, stage II was diagnosed in 61 patients; stage III, in 44; and stage IV, in 28. Thus, patients of the control and main groups were comparable in gender, age, presence and severity of comorbidities, degree of operational and anesthetic risk, and stage of oncological process.

To optimize the multidisciplinary approach, the treatment and diagnostic process was divided into separate stages (preoperative, operative and postoperative).

With the development of CC complication in a patient that did not require emergency surgical intervention, their hospitalization was carried out in the surgical department. In this case, it was possible to implement the principles of a multidisciplinary approach more broadly and completely. It is obvious that surgery for a patient with CC complication is inevitable in the short term. In this context, the main task of the multidisciplinary team at the preoperative stage was to prepare the patient for the upcoming operation as quickly and efficiently as possible. The time factor is a key aspect of the multidisciplinary approach, which allows implementation of its full potential. To “lengthen” the pause that appeared, it is important to interpret correctly the complication of CC and its severity.

The diagnostics of CC complications is based on standard methods of examination. At the same time, the question of the timing and extent of surgical intervention is often decided on subjective data. Thus, in the case of acute intestinal obstruction, it is necessary to establish not only that there is an obstruction, but also its degree, since its plays a significant role when choosing a treatment strategy. It is known that a compensated degree of intestinal obstruction generally responds well to conservative treatment, while with a subcompensated degree, conservative measures taken within 14–20 h do not worsen the state of the patient. In this regard, correctly establishing the degree of ACO plays a significant role. However, interpretation of the degree of the latter only on the basis of clinical and radiological data is not always accurate. Along with traditional methods of diagnostics, we used measurement of the intra-abdominal pressure, i.e., the study of hemodynamic parameters in unpaired arteries of the abdominal aorta for patients of the main group. Measurement of the intra-abdominal pressure allows more reliable judgment on the degree of ACO. Studies of the intra-abdominal pressure were carried out 2–4 times/day depending on the severity of the state of patients by measuring the pressure in the bladder. With a compensated degree of ACO, the intra-abdominal pressure varied from 8 to 15 mm Hg; on average it was 12.8 ± 1.7 mm Hg. With a subcompensated degree of ACO, the indices of the intra-abdominal pressure varied from 15 to 20 mm Hg; on average it was 17.8 ± 2.1 mm Hg. An increase in the degree of ACO is accompanied by an increase in the intra-abdominal pressure, which has a direct or indirect effect on almost all organs and systems, including on splanchnic blood flow. To estimate the regional blood flow in unpaired arteries of the abdominal aorta, doppler examination was used. The intestinal obstruction was accompanied by a reduction in blood flow; there was a decrease in the vessel diameter, a decrease in the volumetric blood-flow rate with an increase in the vascular-wall resistance index; moreover, the higher the degree of ACO, the more pronounced these changes were.

There was a significant link between the degree of intestinal obstruction, level of intra-abdominal hypertension, and hemodynamic indices. Thus, studying the intra-abdominal pressure (along with hemodynamic indices of vessels of the abdominal aorta) allowed a more reliable representation of the degree of ACO to be obtained. In addition, estimation of these indices in the process of conservative treatment gave an idea of the dynamics of the course of intestinal obstruction, thus allowing to define more clearly the timing of surgical intervention.

With ACO complicated by perifocal inflammation, the urgency of surgical intervention is determined by the degree of severity of paracancerous inflammatory changes that can vary from the formation of perifocal infiltrate to peritonitis. Obviously, it is difficult to judge the severity of inflammatory changes only on the basis of clinical and laboratory data and an ultrasound of the abdominal-cavity organs. In this context, it is important to use helical CT more frequently. Besides the latter, we performed a variant of CT (perfusion CT) for patients of the main group. This study allowed more accurate determination of the tumor staging according to the TNM system, to estimate the nature of paratumorous changes, as well as to carry out differential diagnostics between inflammatory and oncological lesions of the colon (Fig. 3).

(a) Color parametric map of the blood flow (BF) velocity; (b) multiplanar reconstruction in the axial projection into the arterial phase; (c) time versus density graph in the abdominal aorta (ROI 1), tumor of the rectosigmoid colon (ROI 2), and intact intestinal wall (ROI 3).

Application of the described additional methods of diagnostics allowed most patients of the main group to undergo operation on a delayed basis.

Along with diagnostics of the type of developed complication and staging of the oncological process, estimation of the functional state of organs and systems is important. Electrocardiogram (ECG) is usually used for this; less often, echo CG, estimation of the respiratory function and examination by medical specialists. However, the use of only these methods does not allow for a complete understanding of the functional operability of a patient. Along with these methods, study of the myocardial index (Tei) and estimation of the trophological status were carried out for patients of the main group. It is known that the state of the cardiovascular system is one of the decisive factors in the choice of the extent and method of surgical intervention and determines the risks of the development of vascular postoperative complications. Determination of the myocardial index allows judgment to be made regarding the effectiveness of left ventricular (LV) contractility. With a value of the myocardial index of more than 0.79, clinical and instrumental predictors of the development of acute left ventricular failure were diagnosed in patients. We classified patients with such values of the Tei index in the risk group. Further cardiotropic pharmacological correction allowed the prevention of possible cardiovascular complications. The trophological status was also estimated for patients of both groups. At the same time, not only the initial state, but also the dynamics of body weight for the previous 2 months before hospitalization were determined for those patients of the main group. Thus, despite the fact that most patients had a BMI that was normal or above normal, more than half of them had a protein-energy deficiency requiring correction, which was carried out according to the developed protocol.

Along with elimination of the complication itself, the minimization of surgical aggression while maintaining an adequate oncological volume and functional result are the main tasks facing the surgeon when performing surgery for CC complications. Significant progress in the treatment of colon cancer is associated with the active introduction of endovideosurgical technologies. Conducted randomized trials have proved the advantage of laparoscopic operations on the colon with its oncopathology as compared with traditional ones, including in elderly and senile patients. The question of performing laparoscopic operations in cases of the development of complications of colon cancer remains controversial. Undoubtedly, operations performed under conditions of tension carboxyperitoneum in an aging patient with the presence of a number of comorbidities are fraught with negative aspects. On the other hand, the desire of a surgeon to reduce surgical aggression gives grounds for the inclusion of these operations in the arsenal of care for patients with complications of colon cancer. In our opinion, the introduction and use of endovideosurgical technologies in the treatment of complicated forms of CC is the foundation of a multidisciplinary approach in making a decision on the extent of surgical intervention in a particular patient.

The continuation of collegiate management of patients under the supervision of the attending physician was a basis for the multidisciplinary approach in the postoperative period. In addition, the principles of protocols for accelerated recovery and rehabilitation after surgical operations were used in the postoperative period (ERAS, FAST TRACK): a reduction of time spent in the resuscitation-and-intensive-care unit, early activation, early enteral therapy, early removal of catheters, tubes, and drains, rational antibacterial therapy, and physiotherapy treatment.

Statistical processing of the results was carried out using the programs Statistica 8.0 for Windows and Microsoft Excel. Analysis of the significance of differences in the mean values was carried out according to Student’s t criterion, the assessment of the contingency of qualitative traits was carried out using the Pearson χ2 criterion. The results were considered statistically significant at р < 0.05.