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Главная Статьи Основные положения рекомендаций Европейского общества гастроинтестинальной эндоскопии по подготовке толстой кишки к скрининговой колоноскопии 2017

Статьи: Основные положения рекомендаций Европейского общества гастроинтестинальной эндоскопии по подготовке толстой кишки к скрининговой колоноскопии 2017

45 мин
Авторы: С.В. Кашин Н.В. Нехайкова 2017г.

Аннотация:

Рак толстой кишки (колоректальный рак, КРР) является основным, глобальным бременем мирового здравоохранения. Ежегодно в мире насчитывается более 1,3 млн новых случаев заболеваемости КРР и 700 тыс. случаев смерти от этого заболевания. В нашей стране КРР занимает третье место в структуре онкологической заболеваемости (30,0 на 100 тыс. населения) и смертности от онкологических заболеваний (19,9 на 100 тыс. населения) у мужчин и второе место в структуре онкологической заболеваемости (21,8 на 100 тыс. населения) и смертности от онкологических заболеваний (11,5 на 100 тыс. населения) у женщин. 


Не менее 95% случаев КРР развивается из существующих полиповидных или плоских аденом в толстой кишке. Поэтому прерывание последовательности аденома—аденокарцинома является профилактической мерой в отношении КРР. 

Скрининг КРР осуществляет профилактику КРР по двум направлениям: 
  1. обнаружение и удаление предраковых изменений, которые позднее могут подвергнуться малигнизации; 
  2. обнаружение КРР на ранней стадии, который может быть эффективно пролечен, что является хорошим прогностическим критерием для полного выздоровления пациента. 
Результаты ряда исследований показывают, что от 3 до 6% КРР диагностируются в промежутке между скрининговой колоноскопией и постскрининговой колоноскопией, проводимой в рамках эндоскопического наблюдения. Большинство этих случаев рака (интервальный рак) развилось из образований, пропущенных во время проведения скрининговой колоноскопии. В соответствии с проведенными исследованиями и представленными доказательствами эффективность колоноскопии зависит от качества осмотра слизистой оболочки толстой кишки. Высокое качество очистки толстой кишки является важной предпосылкой для улучшения качества колоноскопии, потому что даже небольшое количество остаточного кишечного содержимого может скрывать значительные по размеру новообразования толстой кишки. Показатель очистки толстой кишки перед колоноскопией является одним из семи ключевых показателей эффективности выполнения колоноскопии. 

Для оценки уровня очистки толстой кишки используют различные валидированные шкалы. Наиболее часто применяют шкалы Оттава (Ottawa Bowel Preparation Scale) и Бостон (Boston Bowel Preparation Scale). 

ESGE (European Society of Gastrointestinal Endoscopy) в 2013 г. представило рекомендации по подготовке толстой кишки к колоноскопии. 
  1. ESGE рекомендует диету с низким содержанием клетчатки в день накануне колоноскопии. 
  2. ESGE не дает никаких рекомендаций относительно использования диеты с низким содержанием клетчатки в течение более чем 24 ч до момента исследования. 
  3. ESGE не рекомендует рутинное использование прокинетиков в качестве дополнения к подготовке кишечника к колоноскопии. 
  4. ESGE предлагает добавлять симетикон к стандартной подготовке кишечника к колоноскопии. 
  5. ESGE рекомендует двухэтапный режим приема (сплитрежим) 4 л раствора полиэтиленгликоля (ПЭГ) (или режим приема всей дозы слабительного препарата в день исследования в случае выполнения колоноскопии во второй половине дня) для рутинной подготовки толстой кишки.
  6. Двухэтапный режим приема (сплит-режим) 2 л ПЭГ в комбинации с аскорбатом или пикосульфатом натрия и цитратом магния (или режим приема всей дозы слабительного препарата в день исследования в случае выполнения колоноскопии во второй половине дня) может быть приемлемой альтернативой, особенно в случае амбулаторной колоноскопии. 
  7. У пациентов с почечной недостаточностью ПЭГ является единственным рекомендованным препаратом для подготовки кишечника. 
  8. Временной интервал между приемом последней дозы препарата для подготовки кишечника и колоноскопией должен быть минимизирован и составлять не более 4 ч. 
  9. ESGE не рекомендует рутинное использование фосфата натрия для подготовки кишечника к колоноскопии из-за риска развития побочных эффектов. 
  10. ESGE рекомендует, чтобы проведение письменного и устного информирования пациентов по подготовке кишечника к колоноскопии осуществлялось медицинскими работниками. 
Стандарт: минимальный стандарт — не менее 90%; целевой стандарт — не менее 95% . Если минимальный стандарт (не менее 90%) не был достигнут, то необходимо провести анализ факторов, влияющих на подготовку толстой кишки на уровне эндоскопического отделения.

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