duc m. vo, md - peacehealth · pdf filecolorectal cancer pathway pre-op teaching intra-op...

Duc M. Vo, MD

None

Scenario 1 – colon cancer Preop eval, Treatment

Scenario 2 – rectal cancer Preop eval, Treatment

Colorectal cancer pathway Pre-op teaching Intra-op management Post-op care

35 year old man with a 1 week history of severe abdominal pain. CT scan showed mass in the ascending colon, no liver masses. Colonoscopy confirmed near obstructing adenocarcinoma

H&P Colonoscopy Imaging of chest, abdomen, pelvis Basic labs CEA

If no evidence metastatic disease Surgery

56 year with rectal bleeding. Colonoscopy shows a rectal cancer at 7 cm.

Preop eval H&P Colonoscopy Imaging of chest, abdomen, pelvis Basic labs CEA No evidence metastatic disease

T1, select T2, no evidence of nodal or metastatic disease local excision +/- adjuvant treatment Radical resection

If T3/T4 or evidence of nodal disease neoadjuvant treatment (because high risk of locoregional recurrence)

5 ½ weeks of radiation and chemotherapy 6-8 weeks recovery Low anterior resection vs APR with diverting

ileostomy (3 months after diagnosis) 6 month of adjuvant chemotherapy Ileostomy reversal (9 months after starting

treatment)

Better local control Better vascularized and oxygenated tissue is more

sensitive to radiation Decreased toxicity Downstaging tumor More likely to preserve sphincters

Decrease radiation injury to small intestine Remove irradiated tissue Sterilizing tumor, decrease risk of tumor spillage

Decreased length of stay No difference in mortality or morbidity Increased satisfaction in patients, supportive

staff, and physicians

Components Preop, Intraop, Postop

Managing expectations (preop classes) Early feeding Early ambulation Expected discharge in 2-3 days Multimodality analgesia- not pain free

Preop tylenol and gabapentin

Prepare for marathon Nutritional optimization Carbo loading +/- bowel prep

Meeting with enterostomal therapist

Control surgical stress Minimizing incision Laparoscopic when indicated

Maintain euvolemia Goal directed fluid administration Preventing bowel edema- obstruction/ileus

No postop nasogastric tubes Avoid drains

Ambulating 6 hours postop Clears and crackers 4 hours postop Tylenol, NSAIDS and Neurontin if appropriate Epidural

Narcotics prn Foley removal within 24 hours

good pain control with oral analgesia taking solid food, no intravenous fluids independently mobile or same level as prior to willing to go home

Scenario 1: pT2 N0 (20 lymph nodes negative), home on POD 2

Scenario 2: ypT0 N1 (2 of 10 lymph nodes positive), home on POD 2

Decreased length of stay on average 2 days Mortality: zero Morbidity: same as prior to implementation Satisfaction Patients, nurses, dieticians, ostomal therapists,

surgeons