Assessment & ManagementOrla Dunlea

Surgical Resident

It is common 80 Australians die each week from colon

cancer 1/12 of us will be diagnosed with it in our

lifetime

It is preventable 90% is treatable if detected early enough Currently <40% is detected in the early

stages

M=F

Peak incidence at 65 years

Family history

Ulcerative colitis x 8-10 years

History of polyps

Fibre intake? (Proposed by Burkitt – Irish)

Aspirin reduces risk

Morphological term – protrudes from the bowel wall into the lumen

Pedunculated Sessile

Tubulovillous Most common type Pedunculated

Tubular Least malignant potential Polyps found in FAP

Villous Most malignant potential Frond-like Mucus-secreting which

may be presenting complaint or low K+

Right sided Anaemia

RIF mass

Don’t tend to cause obstruction (unless the ileocaecal valve is involved) as diameter is greater than left & stool is more liquid

Presentation with mets Obstructive jaundice – nodes compressing porta hepaticus Ureteric or duodenal obstruction – retroperitoneal lymph nodes Weight loss, anorexia, hepatomegaly due to liver mets

Left sided Change in bowel habit

PR bleeding

Tenesmus (lower rectal lesion)

Pericolic abscess – erodes through the bowel wall, LIF pain, tender & swinging pyrexia

Large bowel obstruction – acute presentation

Signs of anaemia Weight loss Abdo exam

Normal Palpable mass Hepatomegaly due to mets Ascites

PR exam Mass Local extension into pouch of douglas Amount of fixation to local structures FOB

Bloods CEA HB LFTs

Barium enema

Colonoscopy Visualise tumour Biopsy tumour Look for other

tumours/polyps +/- stenting if palliative

If histology confirmed Imaging

U/S for liver Mets CT thorax/abdo/pelvis with contrast for staging MRI /endoanal U/S for rectal CA (if MRI incompatible)

Apple core lesion

Stage of cancer – is it operable?

QOL & life expectancy prior to surgery

Does the patient want surgery?

Suitable for anaesthetic- anaesthetic review

Co-morbidities – IHD, DM, COPD etc

Are risks of complications too high?

Nutrition and ability to heal

Routine bloods – FBC, U&Es, LFTs, Coag

Group & cross match CEA for baseline CXR Consent +/-bowel prep NPO Catheter IVABs TEDS

(Radiotherapy) (Chemotherapy) (Stoma education) (Stoma

positioning) (PFTs) (Echo/cardiac

mibi/ coronary angio)

Caecal & R colon tumours

Proximal or mid-transverse colon tumours

Splenic flexure and left colon tumours

Sigmoid tumours

Low rectal tumours, FAP

Permanent stoma

Hartman’s procedure with formation of a stoma

If present acutely

If anastomotic healing doubtful

~50% will be reversed

HNPCC

FAP

Multiple tumours

Early Bleeding Infection Perforation Local structure damage – ureters, bladder, spleen,

duodenum Anastomotic leak or breakdown Wound infection Wound dehiscence Sepsis & multiorgan failure Stoma problems TPN

Late Diarrhoea due to short bowel syndrome Impotence – pelvic parasympathetic nerve damage Small bowel obstruction

Adhesions 2nd radiotherapy

Duke’s A Bowel wall only No nodes No mets 75% 5 year survival

Duke’s B Through muscularis

propria No nodes No mets 55% 5 year survival

Duke’s C C1

Node positive but only around tumour & not distal

40% 5 year survival C2

Node positive up to proximal resection margin

20% 5 year survival

Duke’s D Distant metastasis

T = Tumour T1 – Invasion into submucosa (connective tissue & glands) T2 – Invasion into muscularis propria (muscles layers) T3 – Invasion into subserosa T4 – Invasion to local organ or structures +/- visceral

peritoneum

N = Nodes N0 - No lymph node invasion N1 – spread to 1-3 regional lymph nodes N2 - >4 regional lymph nodes

M = Metastasis M0 – No mets M1 – Distant mets

Lymphatic spread to mesenteric & then para-aortic nodes

In the blood to the liver

Unusually to bone, lung or brain

Absence or presence of liver mets most important factor in

determining prognosis!!!

5-Fluorouracil +/- Leucovorin

Following resection of stage 3, +/- stage 2

Metastatic disease

Radiation may be used in rectal cancer to reduce the size of the lesion & allow preservation of sphincter

CEA levels

Colonoscopy

CT thorax/abdo/pelvis

Hereditary non-polyposis colorectal cancer (HNPCC)

Lynch syndrome 1 – hereditary colon cancer Lynch syndrome 2 – hereditary colon cancer +

increased risk of other GIT or reproductive tumours

Familial adenomatous polyposis (FAP)

Unknown mutations

DNA mismatch repair gene mutation (several different chromosome locations)

Autosomal dominant – 50% chance of offspring having mutation

Polyps become malignant over 2-3 years (compared to 8-10 years for non hereditary colon cancer)

70-80% lifetime chance of getting colon cancer

Lynch syndrome 2 increased risk of endometrial, ovarian, upper urinary tract & stomach

Treatment Colectomy with ileo-rectal anastomosis Colectomy & permanent ileostomy

Used to identify people at risk of HNPCC >3 more relatives with HNPCC-related cancer 2 successive generations At least 1 of the cancers diagnosed <50 years FAP has been excluded

Rare 100% penetrance Autosomal dominant Deletion on chromosome 5 (adenomatous

polyposis coli gene) Extra-intestinal features – BORED

Brain tumours Osteomas Retinal pigment hypertrophy Epidermal cysts Dentition abnormality

Treatment Panproctocolectomy & ileostomy

Good for screening as present in ~95% people with gene

National screening programme if >50 years

Home FOB test – send off – GP contacted if positive

Polyps with the most potential to become malignant are tubulovillous polyps – T or F

Mr Murphy is a 69 year old man who has noticed passage of blood with stools over the last week – please take a history. What investigations would you like to perform?

Post-operative patient with a stoma Ostomy = Surgically created opening connecting

an internal organ to the surface of the body Stoma = The opening of the ostomy

Stoma important for exams Ileostomy Colostomy Ileal-conduit

EXTREMELY COMMON FOR LONG

CASES!!!!!!

Ileostomy To protect a distal at

risk anastomosis Distal bowel rest for

Crohn’s Permanent after

panproctocolectomy

Colostomy To protect a distal at

risk anastomosis Perforation, infection

or ischaemia means an anastomosis would not heal & may be performed at later date

Permanent after abdomino-perineal resection

1. Stoma itself2. Stoma surroundings3. Stoma bag

1. Stoma itself Where is it? How many lumens? Type of spout Does it look healthy?

2. Stoma surroundings Skin Scars Patient general health

3. Stoma bag What kind of bag? What’s in the bag?

1. Stoma itself Where is it?

How many lumens?

Type of spout

Does it look healthy?

RIF = ileostomy, left = colostomy – but beware

2 = may be loop ileostomy (temporary)

Flush with skin = colostomy, spouted= ileostomy (or prolapsing colostomy!)

Ischaemic? Prolapsing? Retracted? Stenosed?

2. Stoma surroundings Skin

Scars

Patient general health

Rash, necrosis, parastomal hernia

Previous surgeries, previous stoma sites

Young =UC or Crohn’s, dehydrated looking = high stoma output, cachexic = palliative stoma

3. Stoma bag What kind of bag?

What’s in the bag?

Tap & transparent = post-op for output measurements. Non-transparent no tap = long-term

Greenish fluid = ileostomy

Brownish = colostomy

Yellow = ileal-conduit

Any mucus or blood?

Choosing a site Stoma nurse Important for success of the stoma post-op Assess site when sitting, standing Avoid

Previous scars/wound site Belt line Bony prominence Umbilicus Skin crease Obesity poses problems

1. Stoma itself

2. Area surrounding stoma

3. Living with a stoma

1. Stoma itself Ischaemia Retraction Prolapse Obstruction Stenosis

2. Area surrounding stoma Leakage Hernia Skin irritation (ileostomy) Fistula (Crohn’s)

3. Living with a stoma Increased output/short gut syndrome (electrolytes,

dehydration) Psychological/psychosexual – especially if odour

(charcoal filter helps) Kidney & gall stones (if terminal ileum

diseased/sacrificed)

“From little things, big things grow”

N Engl J Med. 2010 Jan 7;362(1):85; author reply 85.Screening for colorectal cancer. Mohammed F.

Lancet. 2009 Mar 7;373(9666):790-2.Rectal cancer: optimum treatment leads to optimum results. Madoff RD.