Cardiovascular diseases and cancer are among the leading causes of death, thus occupying the first and the second places, respectively. Of all malignant tumors, colorectal cancer is the third among the causes of death. The similarity of the factors causing the development of cardiovascular comorbidity and colorectal cancer often allows to detect these diseases together. However, to date, there is no general tactics in cardiac surgery and oncology for treating this category of patients [8,9].
Elderly patients with colorectal cancer, aggravated by decompensated concomitant diseases, are often excluded from studies due to the lack of a unique treatment strategy for this category of patients [10,11,12]. The presence of concomitant diseases adds to the complexity of cancer treatment, as this can affect the prognosis and treatment. At the time of colorectal cancer detection, elderly patients already have a high risk of death from existing concomitant diseases .
The presence of colorectal cancer is associated with the risk of developing cardiovascular diseases and chronic heart failure in the elderly group . According to Kenzik K. M. et al., the detection of cardiovascular diseases was reported in 57% of cases in the group with a history of colorectal cancer, while in half of the cases, coronary insufficiency of varying degrees was diagnosed. In the age-matched control group of patients without CRC, these indicators were 22% and 18%, respectively .
The global increase in colorectal cancer incidence, aggravated by cardiac diseases, often in the stage of decompensation, is steadily leading to a growing number of patients admitted to both oncological and cardiac hospitals. Surgical treatment of colorectal cancer aggravated by cardiac comorbidity is accompanied by a high risk of early postoperative cardiovascular complications. Analyzing postoperative mortality in the treatment of colorectal cancer, Moghadamyeghaneh Z. et al. reported a high incidence of postoperative acute myocardial infarction which developed in 2% of operated patients and caused 6 times higher death rates than other non-surgical complications . The high rate of mortality after surgical interventions due to acute myocardial infarction, acute coronary insufficiency is also indicated by other researchers [17-20]. Treatment of ischemic heart disease can reduce the risk of acute myocardial infarction, and therefore reduce the risk of early death. Currently, along with drug therapy for ischemic heart disease, surgical interventions aimed at restoring adequate myocardial blood flow are being actively performed, both on an open heart and via low invasive methods .
People with congenital and acquired heart defects make up one of the most severe groups of cardiac surgery patients. Achievements in cardiology and cardiac surgery have significantly increased the life expectancy of patients with heart disease. At the same time, the risk of developing malignant diseases in this cohort of patients has naturally increased [22,23].
The problem of treating cardiac surgery patients with colorectal cancer has existed for a long time. In the earlier periods of study, stage-by-stage treatment was the only option. At the same time, surgeries were performed in different priority - cardiac surgery followed by surgery for colorectal cancer and vice versa. With the advancement of surgical technologies, reports on simultaneous operations for cardiac disease and colon malignancy began to appear. These reports are single, include a small number of patients. However, the result of these operations looks encouraging and indicates a fairly low postoperative mortality rate of 6% [24,25].
The problem of the surgical treatment tactics of both cardiac and oncological diseases remains unresolved. The main dilemma is the choice between staged surgery or one-stage surgical procedure. Most surgeons prefer the staged tactics, reasonably believing that significantly prolonged operative duration and greater surgical aggression in simultaneous operations increase the risks of postoperative complications and postoperative mortality .
On the other hand, the choice of the staged treatment may cause a number of problems. For example, when the cardiac surgery is performed before the oncological intervention, the risk of major tumor bleeding increases due to the need of heparin administration during the extracorporeal circulation . Besides, during the interval until the second operation, which normally takes from about 3 to 6 weeks, with the regular course of the postoperative period, progression of CRC may occur. Also, during the oncological stage there is a risk of intra- and postoperative cardiac complications which can lead to death .
In the world literature, there are isolated reports summarizing the experience of treating patients with concomitant cardiac and oncological diseases [25,28,29].
For example, Eagle KA et. al. and Komokata T. et. al. report in their works that simultaneous interventions do not increase and sometimes even significantly reduce the risk of cardiac complications in colorectal cancer. At the same time, longterm oncological results do not differ from those in patients without cardiovascular diseases .
At the same time, other authors are inclined to two-stage surgery, due to the large intraoperative trauma resulting from the surgical procedure in two major anatomical areas, the chest and abdominal cavities, which in their opinion increases the risk of complications, both during the operation and in the long-term period [30,31].
Based on our own, more than ten-year experience of onestage and two-stage treatment of this patient category, the simultaneous approach looks more preferable in comparison with two-stage surgery: the patient undergoes general anesthesia and intensive care only once; there is no need to wait for recovery after cardiac surgery in order to go on to the second stage, thereby reducing the risk of intestinal tumor progression . We would like to point out that, if possible, it is preferable to perform the cardiac surgical stage avoiding extracorporeal circulation in order to level the risk of developing complications it might cause.
Today, almost the entire range of colorectal operations, in most clinics, is performed by laparoscopic and/or robotassisted techniques . Minimally invasive technologies in heart and cardiovascular surgery are also gradually becoming commonplace in a number of hospitals . Conducting simultaneous interventions via hybrid methods within our research made it possible to reduce surgical trauma, shorten the length of hospital stay, reduce pain and minimize the risk of infectious complications.
In conclusion, we would like to say that simultaneous procedures in patients with heart disease and colorectal cancer via both traditional and laparoscopic methods are safe and prove to be satisfactory. Such interventions should be performed in large multidisciplinary medical centers by skilled surgeons with sufficient experience in performing cardiac and oncological interventions. Of course, this category of patients need further study of the immediate and long-term results of treatment as well development of choice criteria and optimal tactics for pre and postoperative management.