MODERN MANAGEMENT IN SURGICAL TREATMENT OF COLON CANCER

UNIVERSITY OF MEDICINE AND PHARMACY OF CRAIOVA MODERN MANAGEMENT IN SURGICAL TREATMENT OF COLON CANCER PHD THESIS ABSTRACT SCIENTIFIC ADVISOR: PROF.UNIV. DR. ION GEORGESCU PHD FELLOW: BICĂ MARIUS CRAIOVA 2011 1

INTRODUCTION Colon cancer is an important public health issue it s incidence ranking 4 th in the world among all cancers. The incidence is higher in developed countries like USA, Western and Northern Europe, Australia, New Zeeland. Lately, there is an increase in the incidence of colon cancer both in developed countries and in Eastern Europe, Romania included. This is due to the change in population s diet and lifestyle that have become similar to the western population. The higher incidence of colon cancer can be explained by the rapid development of diagnosis tools, by increased accessibility to diagnosis centers and by a better health education of the population. Technical progress applied in surgery included vascular sealing tools and mechanical sutures. The use of these tools became a routine leading to shorter operative time and lower morbidity and mortality rates. Also, it contributed to widening the surgical approach to advanced colon cancer, with multivisceral resections for locally advanced cancer and resection of metastasis for metastatic cancer. For emergency surgery in colon cancer the surgical approach is more aggressive with extended colon resection in bowel obstruction and/or peritonitis, or two staged interventions with initial decompression of the colon followed by colic resection in second stage. Although the progress in surgery and anesthesia are the result of clinical and scientific research, they have been influenced by management policies of reducing costs and hospital stay. A new concept emerged fast track surgery or ERAS (Early Rehabilitation After Surgery). The aim of this concept is to optimize the perioperative management of the patient in order to reduce morbidity, to accelerate patient s recovery after surgery and, not less important, to reduce hospital stay and costs. Fast track surgery implies the combination of preoperative education of the patient, new techniques in anesthesia, analgesia and surgery that aim to reduce organism s response to surgical stress, attenuation of pain and discomfort and an aggressive postoperative rehabilitation including early oral nutrition and rapid mobilization. This way fast track surgery can shorten the time needed for postoperative recovery, can reduce hospital stay and can lower morbidity and mortality. Key words: colon, cancer, multivisceral resection, emergency surgery, fast track surgery. 2

STUDY S AIM AND OBJECTIVES The aim of this research is to reevaluate the surgical treatment of colon cancer taking into consideration the progress of the past 9 years in concept and technological advances. The objectives of the study were: The analysis of the concepts and results of emergency surgical treatment of colon cancer The analysis of the results of elective treatment of colon cancer A comparative study of modern and traditional methods of perioperative management MATERIAL AND METHOD 1. Study of conceptual evolution of surgical treatment in colon cancer We did a retrospective and prospective study of the colon cancer patients admitted in The 1 st Surgical Clinic of The County Clinical Emergency Hospital of Craiova between 2001 and 2009. A study group was formed by applying just one selection criteria: the diagnosis of colon cancer or recto-sigmoid junction cancer. The study group was divided in two subgroups: The group of patients with colon cancer that underwent emergency surgery group A The group of patients with colon cancer that underwent elective surgery group B We created a study protocol for observing and analyzing each patient following patient history, clinical and imaging data, treatment and postoperative outcome. The following parameters were analyzed: Demographic data Annual number of cases Tumor topography Surgical history and co morbidities Clinical, biological and imaging diagnosis 3

Distribution of complicated/uncomplicated forms of disease Surgical treatment: emergency or elective, radical or palliative, resections or internal/external diversions Postoperative morbidity and mortality 2. Study of fast track surgery in colon cancer We did a comparative case-matched study between two groups of patients: Fast track group patients with colon cancer that underwent perioperative fast track protocol (at least 8 measures) Traditional group matched cases control group For the two groups we compared: duration until bowel movement, duration of hospital stay, hospital costs, postoperative morbidity and mortality. RESULTS The study group had 319 colon cancer patients. We selected the two subgroups: Group A 105 patients that underwent emergency surgery Group B 210 patients that underwent elective surgery. The annual distribution of cases showed an increase in the number of cases from 22-25 cases/year in 2001-2003 to 55 cases in 2009. There were 128 cases with complicated colon cancer (40.1%) and 191 cases with uncomplicated colon cancer (59.9%). The annual distribution of complicated and uncomplicated forms showed a higher percentage of uncomplicated cases in the last years of the study. (Fig. 23) forme complicate forme necomplicate 40 35 39 35 40 30 27 25 20 15 10 16 9 15 8 13 9 13 12 13 12 13 16 14 15 5 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 Fig. 23 Distribuţia anuală a formelor evolutive 4

The emergency treatment of complicated colon cancer included one stage or two staged interventions. There were 105 patients that underwent emergency surgery, 84 cases with left colon cancer and 21 cases with right colon cancer. For the left colon there were 10 one stage interventions (11.9%) and 74 two staged interventions (88.1%). Postoperative morbidity was higher for one stage interventions compared to two staged ones. We had 70% wound infections for one stage and 36.5% for two staged operations. The rate of fistula was 50% for one stage and 2.2% for two staged interventions. Mortality was 30% for one stage surgery and 5.4% for two staged surgery. For left colon there were 11 one stage interventions (52.4%) and 10 two staged interventions (47.6%). There were 63.6% wound infections for one stage surgery and 40% for two staged interventions. The rate of fistula was 18.1% for one stage surgery and 0 for two staged operations. Mortality was 9.1% for one stage and 0 for two staged surgery. The elective treatment was applied to 210 patients. There were: Right colectomy 65 cases (31%) Left colectomy 64 cases (30.4%) Rectosigmoidectomy 27 cases (12.8%) Segmental colectomy 40 cases (19%) Hartmann operation 1 case (0.4%) Subtotal colectomy 4 cases (1.9%) Total colectomy 4 cases (1.9%) Internal diversions 2 cases (0.9%) External diversions 3 cases (1.4%) We analyzed the surgical approach in locally advanced colon cancer. There were 79 patients with locally advanced colon cancer (T4) (25% of cases). 49 patients (57%) underwent major surgical interventions with multivisceral resections of the colon tumor and the organ or part of invaded organ. Postoperative morbidity for these cases was higher than the uncomplicated cases morbidity. There were 35.5% wound infections, 17.7% fistulas, 6.6% peritonitis, 31.1% general complications and 8.8% mortality. Over the 9 years of study we found an increase in the annual number of multivisceral resections with percentages varying from 37.5% at the beginning of the study (2001) to over 5

80% of locally advanced cases in the last two years. Despite the higher morbidity the tendency is to perform multivisceral resections rather than diversions or dissection of tumor adhesions. The fast track study We analyzed a group of 36 patients that underwent perioperative fast track protocol. The measures applied were: Discussion with patient all of the patients received explanations and were asked to cooperate in order to obtain a fast postoperative recovery Mechanical bowel preparation was performed for 15 patients (41.7%) Normal diet the day before surgery 61.1% Ingestion of rich carbohydrate liquids 2-3 hours before surgery 55.5% Short acting and rapid installing anesthetics 100% Epidural anesthesia 50% Restrictive volume of fluids during surgery 58.3% Maintaining normotermia 94.4% O2 therapy 75% Non-opioid analgesia 80.5% Peritoneal drainage we used it for all 36 patients Removing NG tube immediately after surgery 94.4%. Only 3 patients needed reinstalling of the NG tube, representing 8.8% Early oral feeding 88.8% of patients Early active mobilization 86.1% All patients in the study received a minimum of 8 measures of the fast track protocol. We compared the duration until the first bowel movement, duration of hospital stay, costs and postoperative morbidity between the fast track group and a traditional group of patient selected from all cancer colon patients creating a case matched control group. We found that for the fast track group, the medium duration until the first bowel movement was 48 hours compared to 67.33 hours for the traditional group. There was a significant difference between the two groups. The medium duration of the postoperative hospital stay was 6.5 days for the fast track group and 12.9 for the traditional group, also a significant difference between the two groups. The costs were 33.3% lower for the fast track group compared to the traditional group. 6

Also, postoperative morbidity was lower in the fast track group when compared to the traditional group. CONCLUSIONS 1. Colon cancer incidence in our country has a tendency to rise in the past years; this fact has been demonstrated by our study that has recorded an increase in the annual number of colon cancer cases. 2. Although diagnosis tools are more advanced, colon cancer still has a late diagnosis, 72% of cases being stage III and IV and only 28% of cases being stage I and II 3. Multivisceral resections are a therapeutic option for locally advanced colon cancer, but biological, general and lesion status have to be considered. Our study showed a tendency of rise for the annual rate of multivisceral resections for locally advanced cancer. 4. In complicated left colon cancer we prefer two staged interventions because they are associated with lower morbidity and mortality in comparison with one stage procedures. For complicated right colon cancer, although possible for a higher number of cases, one stage procedures are followed by higher morbidity compared to two staged procedures. 5. Fast track protocol is a modern approach of colon cancer surgery that implies the optimization of perioperative management of patient in order to decrease morbidity, to accelerate patient s recovery after surgery and to reduce hospital stay and costs. 6. In our study the rate of appliance for the fast track protocol was 41.8%. The othe 58.2% did not meet the selection criteria. 7. The measures that had the highest rate of appliance were: Discussion with patient 100% No premedication 100% Short acting and rapid installing anesthetics 100% Maintaining normotermia 94.4% O2 therapy 75% Non-opioid analgesia 80.5% Removing NG tube immediately after surgery 94.4% Early removing of urinary catheter 91.6% 7

Early oral feeding 88.8% of patients Early active mobilization 86.1% 8. The measures that were least applied were: Absence of mechanical bowel preparation 58.3% Probiotics 0% Normal diet the day before surgery 61.1% Ingestion of rich carbohydrate liquids 2-3 hours before surgery 55.5% Epidural anesthesia 50% Restrictive volume of fluids during surgery 58.3% Minimally invasive approach (laparoscopy) 0% Absence of peritoneal drainage 0% 9. The results of our study justify the use of fast track protocol in colon cancer surgery: The decrease in the duration until the first bowel movement by 28.7% in the fast track group compared to the traditional group The decrease in the duration of postoperative hospital stay by 49.6% in the fast track group compared to the traditional group 33.3% lower costs for the fast track group compared to the traditional group Lower morbidity in the fast track group compared to the traditional group 10. Fast track approach in colon cancer surgery is superior to traditional approach, not only by lowering costs and hospital stay but by a faster patient s recovery and lower morbidity rates. 8

SELECTIVE REFERENCES Kehlet H., Wilmore D. W. Fast-track surgery: Introduction. ACS Surgery online; posted 06.07.2006 Grigoraş Ioana Fast-track surgery a new concept the perioperative anaesthetic management. Jurnalul de Chirurgie, Iaşi, 2007; Vol. 3; Nr. 2: 89-92 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaest 1997; 78: 606-617 Rodt S. A., Christensen H., Thaysen H.V., Carlsson P. S. Fast-track in abdominal sugery. A challenge to the surgeon and the anaesthesiologist. University Hospital of Arhus, Denmark, www.kuleuven.be/anesthesie/congressen/2007/saturday/rodt.pdf Zonca P., Stigler J., Malz T., Neoral C., Hajek M., Stiglerova S. Do we really apply fast-track surgery? Bratisl Lek Listy 2008; 109(2): 61-65 Ruiz-Rabelo J. F., Monjero Ares Inmaculada, Torregrosa-Gallud A., Delgado Plasencia L., Cuesta M. A. Programas de rehabilitación multimodal (fast-track) en cirurgía laparoscópica colorrectal. Cir Esp. 2006; 80(6): 361-8 Dachman A.H., Yoshida H. - Virtual colonography: past, present, and future. Radiol Clin North Am 2003; 41:377 Turnbull R.B., Kyle K., Watson F.R., Spratt J. - Cancer of colon: the influence of no touch isolation technique on survival rates;.ann Surg 1967;166:420 5 Veldkamp R., Gholghesaei M., Buunen M., Meijer D.W., Jaap Bonjer H., et al. - Laparoscopic Resection of Colonic Carcinoma; EAES consensus conference Lisbon, June 2, 2002 Janson M., Lindholm Elisabet, Anderberg B., Haglind Eva Randomized trial of health-related quality of life after open and laparoscopic surgery for colon cancer; Surg Endosc 2007; 21: 747-753 Nygren J. The metabolic effects of fasting and surgery Best Practice & Research Clinical Anaesthesiology 2006, Vol. 20, No. 3: 429-438 Fa-Si-Oen P., Roumen R., Buitenweg J., Van de Velde C., Van Geldere D. Et al Mechanical bowel preparation or not? Outcome of a multicenter, randomised trial in elective open colon surgery. Dis Colon Rectum, August 2005; Vol. 48; No. 8: 1509-1516 Kehlet H., Büchler M. W., Beart Jr R. W., Billingham R. P., Williamson R. Care after colonic operation is it evidence-based? Results from a multinational survey in Europe and the United States. J Am Coll Surg, January 2006; Vol. 202; No. 1: 45-54 Zmora O., Mahajna A., Bar-Zakai B., Hershko D., Shabtai M., Krausz M., Ayalon A. Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Results of a prospective randomised trial. Tech Coloproctol, 01 July 2006; 10(2): 131-5 Wille-Jorgensen P., Guenaga Katia F., Castro A. A., Matos D. Clinical value of preoperative bowel cleansing in elective colorectal surgery: a systematic review. Dis Colon Rectum, August 2003; Vol. 46; No. 8: 1013-1020 9

CURRICULLUM VITAE NUME: DATA SI LOCUL NAŞTERII: ADRESA: Bică Marius 13. 03. 1980, Craiova Str. Castanilor Nr. 18, Bl. 8E, Sc. 1, Ap. 19, Craiova, Dolj STUDII: 1986 1992: Şcoala Generală Nr. 32 Craiova 1992 1994: Şcoala Normală Ştefan Velovan Craiova 1994 1998: Colegiul Naţional Nicolae Bălcescu Craiova 1998 2004: Facultatea De Medicină Generală din Cadrul UMF Craiova 2005-20011: Rezidenţiat, Prin Concurs, Specialitatea Chirurgie Generală în Clinica I Chirurgie a Spitalului Clinic Judeţean De Urgenţă Craiova 2005 2010: Doctorand în Domeniul Fundamental Sănătate, Domeniul Medicina La UMF Craiova, Conducător de Doctorat, Prof. Dr. Ion Georgescu, tema: Managementul modern în tratamentul chirurgical al cancerului de colon Aprilie 2010 Depunerea Tezei de Doctorat Octombrie 2010 Susţinere şi promovare Examen de Specialitate Din Februarie 2011: Medic Specialist Chirurg LUCRĂRI PUBLICATE ÎN EXTENSO ÎN REVISTE INTERNAŢIONALE INDEXATE ISI/MEDLINE 1. Ghelase F., Mogos D.S., Mărgăritescu D., Iordache S., Ghelase M.S., Râmboiu S., Mogos G., Bică M., Săftoiu A., Georgescu I.. Correlation of adenomatous polyps and early colorectal cancer. Diagnostic and therapeutic implications. Chirurgia. 2009; 104(2):159-65 10

LUCRĂRI PUBLICATE ÎN EXTENSO ÎN REVISTE NAŢIONALE RECUNOSCUTE DE CNCSIS: 1. M. Bică, I. Georgescu. Emergency treatment of complicated colon cancer. Acta Medica Marisiensis (Târgu Mureş), 2010, vol 56, nr. 4: 396-398 2. M. Bică, I. Georgescu. Atitudinea chirurgicală modern în cancerul de colon avansat. Medicina Modernă (Bucureşti), 2010, vol 17, nr 10: 528-532. REZUMATE PUBLICATE ÎN VOLUM DE REZUMATE LA MANIFESTĂRI ŞTIINŢIFICE INTERNAŢIONALE: 1. M. Bică, E. Georgescu, R. Bazăverde, S. Râmboiu, B. Cotoi, I. Georgescu. Gastric outlet obstruction due to large gastric lipoma. Fostering research on rare diseases in Eastern European countries, sept 2006, Plovdiv, Bulgaria 2. S. Râmboiu, T. Bratiloveanu, Milena Georgescu, D. Cârţu, V. Şurlin, M. Bică, Chiuţu Luminiţa, I. Georgescu, R. Nemeş. What should we do if the right liver color suddenly turns dark during laparoscopic cholecystectomy? 4th Serbian Romanian Surgical Conference, Zrenjanin, Serbia, nov 2009 3. Georgescu I., Bica M, Chiutu L., Georgescu M. Mechanical Bowel preparation - yes or no? International Symposium of Coloproctology, october 7-9, 2010, Sava center, Belgrad, Serbia 4. Georgescu E., Bica M., Cartu D., Georgescu I., Nemes R. Diagnosis and Therapeutical Management in Colon Cancer International Symposium of Coloproctology, october 7-9, 2010, Sava center, Belgrad, Serbia 5. Surlin V., Bica M., Margaritescu D., Nemes R., Georgescu I. Fast Trak Surgery In Colon Cancer International Symposium of Coloproctology, october 7-9, 2010, Sava center, Belgrad, Serbia 6. M. Bică, V. Şurlin, D. Cârţu, S. Râmboiu, E. Georgescu, I. Georgescu Surgical treatment of colon cancer 5 th Romanian-Serbian Surgical Conference, Timişoara, 25-26 november, 2010 11

REZUMATE PUBLICATE ÎN VOLUM CU ISSN/ISBN LA MANIFESTĂRI ŞTIINŢIFICE NAŢIONALE: 1. M. Bică, T. Bălşeanu, Cristina Bobaru Dificultăţi Terapeutice În Fractura Deschisă De Femur Sesiunea De Comunicări Ştiinţifice Pentru Studenţi Şi Tineri Medici Craiova 24 26 Mai 2002 2. M. Bică, Cătălina Bulucea Splenectomia În Boala Cooley Sesiunea De Comunicări Ştiinţifice Pentru Studenţi Şi Tineri Medici Craiova 15 17 Aprilie 2005 3. Cătălina Bulucea, M. Bică Hemosideroza Pulmonară Esenţială: Concepte Etiopatogenice Vechi Şi Noi - Sesiunea De Comunicări Ştiinţifice Pentru Studenţi Şi Tineri Medici Craiova 15 17 Aprilie 2005 4. V. Şurlin, I. Georgescu, A. Săftoiu, F. Ghelase, M. Ciurea, A. Roşu, M. Bică, E. Georgescu, F. Cioară, A. Stoenescu - Pancreatita Acută Biliară Atitudine Terapeutică Conferinţa Naţională De Chirurgie Chirurgia Pancreasului 25-29 Mai 2005, Iaşi 5. M. Bică, Cătălina Bulucea, D. Bulucea Indicaţiile splenectomiei în Boala Cooley la copil Zilele UMF Craiova Iunie 2005 6. V. Şurlin, D. Cârţu, D. Mărgăritescu, M. Ciurea, E. Georgescu, F. Cioară, A. Roşu, M. Bică, I. Georgescu Cura Eventraţiilor Postoperatorii Prin Plastie Cu Plasă Sintetică Supraaponevrotică Conferinţa Interjudeţeană De Chirurgie, Zilele UMF Craiova, 3 Iunie 2005 7. V. Şurlin, D. Cârţu, D. Mărgăritescu, M. Ciurea, F. Cioară, A. Roşu, M. Bică, E. Georgescu, I. Georgescu Cura Eventraţiilor Postoperatorii Prin Plastie Cu Plasă Sintetică Supraaponevrotică Conferinţa Interjudeţeană De Chirurgie, Zilele UMF Craiova, 3 Iunie 2005 8. O. Ştiru, L. Dorobanţu, Daniela Marinescu, M. Bică Studiul Patenţei Fistulei Arteriovenoase Brahio- Brahiale Al IV-Lea Congres Naţional De Nefrologie, Craiova 21 24 Septembrie 2005 9. F. Cioară, V. Băleanu, M. Bică, S.M. Ghelase, C. Siloşi, H. Traila, T. Bratiloveanu, A. Roşu, S. Săndulescu, F. Ghelase Studiul complicaţiilor septice perioperatorii în apendicita acută Al XXIII-lea Congres Naţional de Chirurgie, Băile Felix, 24-27 mai 2006 10. E. Georgescu, G. Mogoş, M. Bică, I. Georgescu Invaginaţie gastro-duodenală prin lipom gastric voluminos Al XXIII-lea Congres Naţional de Chirurgie, Băile Felix, 24-27 mai 2006 12

11. I. Georgescu, V. Şurlin, A. Stoiculescu, F. Cioară, M. Bică, T. Bratiloveanu, E. Georgescu, I. Busuioc, F. Ghelase, R. Nemeş Tratamentul chirurgical laparoscopic al colecistitei acute Conferinţa Naţională de Chirurgie, Bucureşti, 18-21 aprile 2007, Revista Chirurgia, număr special, vol. 102, supliment 1, 18-21 aprilie 2007, pag 63 12. E. Georgescu, M. Bică, V. Şurlin, Luminiţa Chiuţu, F. Cioară, S. Râmboiu, I. Georgescu, R. Nemeş Tendinţe moderne în tratamentul pancreatitelor acute severe Congresul Naţional de Chirurgie, Eforie Nord, 4-7 iunie 2008, Revista Chirurgia, vol 103, Supliment 1, 2008 13. E. Georgescu, M. Bică, V. Şurlin, Luminiţa Chiuţu, F. Cioară, A. Ciocanea, S. Râmboiu, I. Georgescu, R. Nemeş Tendinţe moderne în tratamentul pancreatitelor acute severe Zilele UMF Craiova, 6-7 iunie 2008, Volum de rezumate, Ed. Medicală Universitară, Craiova 14. V. Şurlin, S. Săndulescu, D. Cârţu, D. Mărgăritescu, S. Râmboiu, M. Bică, F. Cioară, D. Mănescu, I. Georgescu, R. Nemeş Simpatectomia lombară retroperitoneoscopică reîncărcată Al IV-lea Congres Naţional ARCE, Iaşi, 29-31 octombrie, 2008 15. I. Georgescu, V. Şurlin, D. Mărgăritescu, M. Bică, S. Săndulescu, A. Rotaru, Milena Georgescu, L. Martin, R. Nemeş Tratamentul chirurgical al cancerului de colon. Analiza rezultatelor din ultimii 8 ani Conferinţa Naţională de Chirurgie, Tg Mureş, 27-29 mai 2009 16. M. Bică, A. Olaru, Milena Georgescu, S. Săndulescu, V. Şurlin, D. Mărgăritescu,, A. Rotaru, L. Martin, V Vilcea, I. Georgescu Tratamentul chirurgical al cancerului de colon. Analiza rezultatelor din ultimii 8 ani Zilele UMF Craiova 5-6 iunie 2009, volum de rezumate, Ed Medicală Universitară Craiova 17. Marinescu Daniela, Pârvănescu H., Bică M., Ciurea M., Cârţu D., Didu S., Pătraşcu Ş., Georgescu I., Nemeş R. Traumatism grav de membru superior. Prezentare de caz Zilele UMF Craiova 5-6 iunie 2009, volum de rezumate, Ed Medicală Universitară Craiova 18. S. Râmboiu, T. Bratiloveanu, M. Georgescu, D. Cârţu, V. Şurlin, M. Bică, L. Chiuţu, I. Georgescu, R. Nemeş Ce facem dacă în cursul unei colecistectomii laparoscopice ficatul drept devine cianotic? Al V-lea Congres Naţional al Asociaţiei Române de Chirurgie Endoscopică Bucureşti, 11-14 noiembrie 2009 19. I. Georgescu, M. Bică, F. Cioară, D. Cârţu, Luminiţa Chiuţu, E. Georgescu, R. Nemeş Tratamentul chirurgical al cancerului de colon Congresul Naţional de Chirurgie, ediţia a XXV-a, Cluj-Napoca, 3-6 mai 2010 13

20. V. Şurlin, E. Georgescu, R. Nemeş, I. Georgescu, M. Bică Reabilitarea rapidă în chirurgia cancerului de colon Congresul Naţional de Chirurgie, ediţia a XXV-a, Cluj-Napoca, 3-6 mai 2010 21. R. Nemeş, Daniela Marinescu, S. Săndulescu, E. Georgescu, F. Ghiţă, M. Bică, B. Cîrju Ischemia acută traumatică a membrelor Congresul Naţional de Chirurgie, ediţia a XXV-a, Cluj-Napoca, 3-6 mai 2010 22. M. Bică, I. Georgescu, F. Cioară, D. Cârţu, Luminiţa Chiuţu, E. Georgescu, S. Săndulescu, R. Nemeş Modalităţi de diagnostic şi tratament în cancerul de colon Zilele UMF Craiova, 4-5 iunie 2010 23. M. Bică, Georgescu I, Georgescu E Pregătirea mecanică a colonului. Da sau nu? Zilele UMF Craiova, 4-5 iunie 2010 24. M Bică, D. Cârţu, A. Rotaru, L. Chiuţu, S. Scurtu, V. Vilcea, A. Săpunaru, L. Dan, I. Georgescu Tratamentul cancerului de colon local avansat Conferinţa Naţională de Chirurgie, Sibiu, 19-21 mai 2011 25. M. Bică, D. Mărgăritescu, T. Bratiloveanu, S. Săndulescu, S. Pătraşcu, F. Cioară, F. Ghiţă, M. Gruia, I. Georgescu Tratamentul de urgenţă al cancerului de colon Conferinţa Naţională de Chirurgie, Sibiu, 19-21 mai 2011 26. M Bică, D. Cârţu, A. Rotaru, L. Chiuţu, S. Scurtu, V. Vilcea, A. Săpunaru, L. Dan, I. Georgescu Rezecţiile multiviscerale în cancerul de colon local avansat Zilele UMF Craiova, 3-4 iunie 2011 14