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Malignant diseases of the
colon and rectum
IV. Year
23.April 2013
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Epidemiology
• Most frequent cancer after skin malignancies
• 2000: 95.000 int the USA
• USA 50.000 death/year
• Hungary: 6000/year
• Increased incidency
• Increasing among women
• Male/female ratio about similar
• High risk above 40
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Predisposing factors
• low fiber, rich in protein
• Genetical factors
• Lack of physical activity
• Colitis Ulcerosa
• Crohn's disease
• Colitis due to radiotherapy
• Adenomas (precancerosis)
• Status after cholecystectomy?
• Hereditery Nonpolyposis Colorectal Cancer (HNPCC): Familial cancer syndrome
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• Macroscopic view:
• ulcerative
• polypoid, exophytic
• stenotisant, circular
• Diffuse, infiltrative
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Signs
• Moderate abdominal distension
• Constipation/diarrhea alteration
• Bloody stool
• Right side napkin ring sign – few symptoms
• Left side cauliflower like tumor more complaints
• Bleeding: pink, red, mahagony, black or inapparent (occult)
• Altered (dark) blood suggest a proximal lesion
• Pain: anal, anorectal, abdominal
• Palpable tumor: anal, perianal, abdominal
• Incontinency
Screening is the way of future to treat early
cases and to improve survival results.”
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Screening
• Fecatest
• Colonoscopy
Rectoscopy recquired:
• Blood in the stool
• Before proctological operations
• Above 60
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Diagnosis
RDI: 60% of cancers shows
Touch – advanced cancers
Tumor markers: CEA, CA 19-9
Rectoscopy, anoscopy
Colonoscopy (biopsy, mucosectomy)
(Irrigoscopy)
Gynecological investigation (sigmoid)
Cystoscopy (rectosigmoid)
Urographia (cecal)
Ultrasound
Endosonographia – (rectal)
MRI
Virtual colonoscopy
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Abdominal US
1.Detection of abdominal masses
2.Detection of abdominal fluid
3.Distinction of solid and cystic structures
4.Detection of lesions (solid or cystic) in the parenchymatous organs
5.Detection of stones (biliary, urinary)
6.Intraluminal detection of the rectum
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CT scan
• CT scan (the method of staging in
oncology) show :
1.Tumorous infiltration of the bowel wall
2.Tumorous infiltration and involvement of
neighbouring organs,
3.Lymphnode metastasis
4.Liver metastasis
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Ademoma, Polyp - Carcinoma
ADENOMA Therapy
with moderated polypectomy
or mild atypic cells
Adenoma Therapy
with seriously polypectomy
atypic cells
Adenoma Therapy
Invasive cancer Surgical
resection
Adenoma Therapy
Polypoid cancer surgical
resection
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Classification of polypoid lesions
Neoplastic Non-neoplastic Submucosal
Premalignant (adenomas)
Malignant
(malignant adenomas,
carcinomas)
Epithelial Lymphoid collection
Pneumatosis cystoides
intestinalis
Colitis cystica profunda
Lipoma
Carcinoid
Metastatic lesions
Leiomyoma
Hemangioma
Fibroma
Endometriosis
Other
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The distribution of adenomas and CRC according to
localization
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Anatomy of the colorectal region
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Arterial supply of the colorectal region
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Lymphoid system of the colorectal system
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Surgery of CRC
Update Preparation for surgery
• Admission 1 – 2 days before surgery
• Large bowel operations needs preoperative preparation
of the CR tract
to prevent septic complications caused by the endogenic
factor – the pathogenic bacterial flora of the large
intestines
• Bowel preparation for elective CR surgery
1. Mechanical preparation
2. Antibiotic prophylaxis
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• Mechanical cleansing of the bowels
1.Laxatives, enemas
2.Wash out or wash through with saline
solution
3.or with high osmolarity solutions like
Mannit, or polyglykoll (this is the update
method of choice, effective and quick),
Sufficient effect in 12 hours.
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• Antibiotic prophylaxis
• Should controll every bacteria during the
whole procedure at the operative site
• In CR surgery it means control of both
aerob and anaerob bacteria
• In our practice a third generation
cephalosporine and metronidazol
combination proved to be very sufficient.
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Indication for surgery
• Emergency – acute indication :
1.Bleeding
2.Perforation
3.Obstruction
• Elective indication
• Planned, prepared intervention
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Urgent indications
• Primary colo-colic anastomosis is not
recommended without bowel preparation
• In acute surgery preoperative preparation
is not possible
• Ileocolic anastomosis is possible even in
acute large bowel surgery
1.Ileal content is fluid
2.Bacterial flora is less pathogenic
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Preparation of patient for elective
surgery
• Mechanical bowel cleansing
• Antibiotic prophylaxis
• Thrombosis prophylaxis
• Stress ulcus prophylaxis
• Urinary catheter
• Uretheral catheters
• Hydration
• Nasogastric tube
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Types of operations
• Right hemicolectomy
• Transverse colon resection
• Left hemicolectomy
• Sigmoid resection
• Segmentel resections
• Extended resection
• Subtotal colectomy
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Left hemicolectomy
Transverso-sigmoidostomy
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Resection of the splenic flexure
Transverso-descendostomy
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Tu coeci, Right hemicolectomy
With ileo-transversostomy
The same procedure is
performed both in acute and in
elective cases
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1.) Extended right hemicolectomy for Ca of the hepatic flexure
with ileodescendostomy (for acute surgery as well)
2.) Extended transverse resection with colo-colic anastomosis
(only for electice surgery)
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1.) Subtotal colectomy with ileo-colic anast. (A + E)
2.) Extended colon resection with
ascendo-sigmoidostomy (only E)
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1.) Extended left hemicolectomy (only E)
(2.) Subtotal colectomy (A + E)
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1.) Typical left hemicolectomy (E)
2.) Extended left hemicolectomy (E)
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Sigmoid resection with descendo-
rectostomy (E)
Typical operation for
diverticulitis
and for sigmoid cancer
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Extended right hemicolectomy with ileo-
descendostomy (A + E )
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1.) Extended colon resection (E)
2.) Subtotal colectomy (A + E)
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Palliative surgery
• To treat life endangering consequencies of
the tumor (ileus, bleeding, septic
complication)
• To improve quality of life
• To save functions of high importance
(respiration, digestion, passage, feeding)
• To prolong survival
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Palliative interventions for inoperable
CRC
• Palliative resection: resecable primary
tumor with distant metastasis –
oncological inoperability
• Palliative colostomy to treat the
obstruction
• Palliative bypass to reconstruct the
continuity of the digestive tract
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1.) Palliative resection of the sigmoid
2.) Palliative transversostomy
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Types of palliative bypass procedures
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Changes of the radicality in surgery
of colorectal cancers
Other new aspects
The regional lymph node surgery
Appearance of minimally invasive
techniques (laparoscopic colectomy, TEM)
Surgery of distant metastases
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Staging:
Dukes A: localised just to the intestinal wall
B: the tumor invade the surrounding fatty tissue, but it's intact lymph nodes
C. lymph nodes metastasesC1: Reg. lymph nodes infiltration
C2: paraaortic lymphnodes infiltration
TNM:T - primary tumor.T1 - invades the submucosaT2 - ~ the muscularis propriaT3 - ~ a subserosal layer, perirectal tissue breaksT4 - the tumor perforates to the visceral peritoneum or other organs directly infiltrated
N - reg. Lymphnodes
N1 - metastasis pericolic 1-3, respectively. perirectal lymph nodes intacts
N2 - ~ 4 or more referrals
M - distant metastasisT1 = T2 = The Dukes I.st.T3, T4 = B = II.st. DukesT1-T4, N1-N3 = C = III.st. Dukes
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Metastases:
lymphogenic: 1 pararectal
second central
haematogenous liver, bone, lung
peritoneum
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Hartmann procedure
The two-step method
• Procedure for the treatment of obstructive
cancer of the sigmoid colon” (H.
Hartmann, Paris, 1921.)
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Colonic ileus
the three-stage surgery
I. Exploration, stoma preparation
(ileostoma, coecostoma,
transversostoma)
II. Resection, anastomosis
III. After 4-6 weeks irrigoscopy,
anastomosis controll and colostomy
closure
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New approaches to rectal cancer surgery
Sphincter preservation in the middle and lower thirds cancers
TME of the middle and lower third of cancers
High ligation of AMI
Multi-organ resection in advanced cancer
Minimally invasive methods
TEM
Laparoscopic resection
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APRE rectal amputation
Sigmoid and rectum, abdominal mobilization
Perineal incision around the anus and rectum,
perineal removal of the lower third of the
rectum, the anus, and the anal verge with
sphincter
Single-barreled end colostomy preparation with
the oral part of descending colon
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Thank You
For Your attention