“We Operate On People Even 84-86 Years Old”

“We operate on people even 84-86 years old”

Why cancer should be treated only in specialized departments, are there any "advantages" of regional medicine in comparison with federal, how to form a "team" and why it is necessary to feed the patient the next day after the operation, the head of the oncology and proctology department of the Nizhny Novgorod region told Mednovosti Clinical Oncology Center, Ph. D. Vitaly Terekhov.

Photo from the personal archive of Vitaly Terekhov /

Why cancer should be treated only in specialized departments, are there any "advantages" of regional medicine in comparison with federal, how to form a "team" and why it is necessary to feed the patient the next day after the operation, the head of the oncology and proctology department of the Nizhny Novgorod region told Mednovosti Clinical Oncology Center, Ph. D. Vitaly Terekhov.

About federal and regional medicine

Vitaly Mikhailovich, surgeons in the regions, unlike their colleagues from central clinics, have to be "generalists" and provide almost any assistance within their specialty. Is this good or bad?

- Indeed, the specificity of regional medicine is such that doctors are forced to provide multidisciplinary care. If we talk about our specialty, in many regions such patients are operated either on the basis of the abdominal department in oncologic dispensaries, or in the general medical network. At the same time, a patient operated on in an ordinary coloproctology department often “disappears” - he does not register with the dispensary, is not observed anywhere. And we sometimes have to deal with relapses or progression of the disease.

When 20 years ago I underwent an internship at an oncological dispensary, where I still work, there was no specialization in colorectal cancer either. The patients operated on in the coloproctological departments of the city simply did not get to us and remained without combined treatment. Today, the dispensary has the only department of oncological coloproctology with 45 beds in the region. We deal only with tumors of the colon and rectum in a full cycle: the patient is operated on, if necessary, receives complex treatment and remains on the dispensary. And if the disease progresses, we cope with it ourselves.

Does regional medicine have any advantages over federal medicine?

When there is a flow of patients, your task is to help them quickly and reliably, and in this whirlwind the complexity of the work is forgotten, the most important thing is that you have enough strength. In federal medicine, more complex cases are concentrated, but dispensary control is lame here. Patients return home, and often doctors from the federal center do not even know what is happening to them, if there is no personal contact with local doctors. And in the system of an oncological dispensary, the patient is under constant supervision, and you see your work, and the patient understands that he is being dealt with.

About patients

What is the most difficult part of working with cancer patients? There are times when you just don't want to see the sick?

- If a doctor does not want to see patients, then he must leave the profession. When this feeling arises, you always need to extrapolate the situation to your relatives, how you, as a doctor, would talk to loved ones. The patient is in trouble, he is seriously ill, and he must give himself completely to work, then the result is completely different.

Unfortunately, many people, especially the elderly, have very low adherence to treatment. Firstly, many believe that everything, we have survived. Secondly, the dispensary, or as it is called, the cancer hospital, is the place where "you can't get there, they'll ruin us." And therefore, a lot depends on how the first meeting with the doctor goes. It is necessary to build a conversation with the patient so that he trusts you, to give him hope. Even the phrase that you will be given a stoma may sound different. Often a person is more frightened not even by the admixture of blood in the feces and the forthcoming treatment, but by the fact that after an operation on the intestines he will be taken out with a “tube to the side”. And we must make it clear to him that this is just not the biggest problem.

And the most difficult thing in working with patients is to tell him or his family that we could not cope with the tumor. And heavy night thoughts haunting the doctor that something could have been done differently. Unfortunately, such things happen.

And what is needed to reduce such situations?

- Of course, earlier diagnosis and initiation of treatment. Unfortunately, organizational problems remain in the general medical network, where the diagnostic search takes a lot of time. Although everything seems to be done according to the standards. Let's say a patient waits for two weeks for a turn for an MRI of the pelvis, comes back to the clinic, he is sent for the next examination, and he waits again for two weeks. If such patients with a preliminary diagnosis come directly to us, we try to speed up this process. Therefore, the phone number and e-mail of our department hang in a prominent place in all polyclinics, and we consult many patients, recommending in absentia a set of necessary examinations for treatment.

Can you do something in the most general medical network to make it more agile?

- This is a difficult process, but it is going on. We work with polyclinics, analyze the stories of patients sent to us, and in what time frame they reach us. It is very difficult to break the mentality of local doctors, who often believe that a patient over 60 years old who has a tumor of the colon or rectum is an old person whose life has passed and we need to calm down. We have a completely different position - age is not a contraindication to surgery. We operate on people even 84-86 years old. A functionally performed operation (for example, laparoscopic anterior resection) makes it possible even to dispense with a stoma, and not to invalidate a patient even over 85 years old. In another clinic, these patients would simply be refused. But in order for polyclinics to understand that there is an active structure that will not refuse, but will really help, we need to show the results of our work.

About screening and clinical examination

Early detection of diseases is also the task of the polyclinic. Many oncologists were disappointed by the clinical examination, although it was initially said that it also had an oncological component, the same fecal occult blood test

- Clinical examination did not meet expectations in terms of cancer detection. It did not focus on the search for cancer. In fact, it is necessary to develop a new program aimed specifically at the early detection of cancer. You can create and popularize such things as check-ups (a full range of examinations), even if paid, many patients are ready to undergo such an examination in order to protect themselves. The main thing is that a high-quality diagnosis is carried out, excluding cancer of the main five localizations. For this, it is necessary to perform such studies as gastroscopy, colonoscopy, chest CT, mammography.

The occult blood test does little to diagnose colorectal cancer. The main thing should be a regular, every five years, endoscopic examination. Among people over 40, those who must pass it must be selected. There are not so many of them. Small polyps detected during colonoscopy are immediately removed, and this saves them from degenerating into a cancerous tumor. Sometimes there are findings that point to a family history. We had a case when mother and daughter went to the operation in turn - one after another.

Many people are afraid of colonoscopy. Do oncologists themselves undergo this study?

- Personally, I had my first colonoscopy when I was 35. Some of my colleagues who have a burdened hereditary history have done this already at the age of 30. And we talk about this to patients, convincing them to protect themselves and their relatives for the next five years. Moreover, sometimes it is enough to even do not colonoscopy, but sigmoidoscopy. Because 40% of tumors are located in the rectum and sigmoid colon.

If the clinical examination begins to effectively detect cancer, the incidence will also increase. Will the domestic oncology service be able to receive so many patients?

- Active work on detecting tumors has already led to the fact that the number of patients has increased. Most hospitals now have enough diagnostic equipment aimed at diagnosing oncology. We have a lot of patients who, during ultrasound, find liver metastases, and then we figure out where these metastases come from. And often with colonoscopy we find already a primary intestinal tumor. And when our endoscopists examine patients with large intestine polyps, they are often sent to us for surgical treatment with suspected tumor.

Improving the efficiency of clinical examination should go in parallel with changing the structure of the service, so that it is ready for this volume. In addition, although the diagnosis of cancer has reached a different level, we still detect stages 3-4. To address the issue of early diagnosis, serious programmatic infusions are needed.

About n Izhegorodskiy oncologic dispensary

What are the capabilities of the Nizhny Novgorod Oncology Dispensary?

- The main problem of the dispensary is that we do not have a centralized surgical building, and the existing three buildings are very scattered and, moreover, they are all built in 1969. With its current activity, the dispensary needs a modern surgical building.

But in terms of the level of assistance and areas of specialization, we are not inferior to Kazan, St. Petersburg or Moscow. We are actively using new equipment received under the modernization program in 2012. We have a very developed endoscopic service, now it is one of the leaders in the country in submucosal dissections of villous tumors and colon polyps. Our capacities allow us to perform 3-4 abdominal, including laparoscopic, operations per day. We send more severe cases to federal centers according to quotas. Rare recurrences of tumors that require resection of the sacrum, evisceration of the pelvis should be treated in a multidisciplinary clinic. Unfortunately, we do not have this.

About the team

What is the most difficult part of your job as a department manager?

- The most difficult thing is probably to be alone. And so, if there is a desire to organize the work well, support from the administration and, most importantly, the team, then everything can be solved, and there is nothing particularly complicated in this position. I now have five resident surgeons on my staff. Three of them already practically own most of those manipulations that are standardized not only in our country, but also abroad, and can independently perform complex operations.

At the moment when we formed our department and recruited employees, the stage of active development of laparoscopic coloproctology, transanal surgery, large multicomponent operations on the small pelvis began. And many young doctors wanted to visit us. Unfortunately, in many surgical clinics, residents are only entrusted with writing case histories. The position “we won't show you anything, it's all secret, only I can do it” scares people away. You can't create a team like that. You must be open and not hide your experience, motivate young residents, give them the opportunity to develop, and then they have an interest in the profession.

Who did the older generation of colorectal oncologists study with?

- The development of oncological coloproctology in our country is largely due to the active position of the Russian Society of Colorectal Surgeons and its leader, professor of the First Moscow State Medical University. Sechenov Petr Vladimirovich Tsarkov. When ten years ago he conducted the first Russian School of Colorectal Surgery, there was a colossal hunger for information in the country, no one communicated or discussed their problems and achievements.

Now the situation is completely different. And the popularity of these "schools" is very high - not every big congress gathers more than a thousand people. And most of all, at these conferences, specialists are interested in surgical activity and new approaches to treatment. The operations are going live, and you can't hide or embellish anything here. Today, there are regional branches of the Society throughout the country, and we also hold regional "schools" where specialists from central institutions come with master classes, and where we show our level.

About a paradigm shift

How has the oncological operational tactics changed during your work?

- Has changed a lot. Moreover, I began to break stereotypes with myself in order to set an example for my employees. This is the use of not manual, but mechanical anastomosis, the use of laparoscopy where everyone is used to operating in an open way. But making changes and breaking stereotypes is not easy. It took me one and a half to two years to convince leading surgeons that patients can be fed the next day after the operation. Not to mention not putting drains in some situations - it just shocked both my youth and experienced surgeons.

Are you talking about Fast Track surgery now?

- Yes. Although we have not yet implemented it in full. In order to be admitted to the hospital on the day of surgery, the patient must be examined and fully sanitized on an outpatient basis. Unfortunately, we do not have this. But the management of the postoperative period and the first day are practically on the Fast Track. When we in the intensive care unit raise the patient to his feet in the evening after the operation and give him a drink of water, we see a sparkle in his eyes - the person understands that he will live. “The operation is over, I can stand, drink, move on the very first day” - this is the best motivation that helps the patient to recover more than any medication.