Malignant diseases of the

colon and rectum

IV. Year

23.April 2013

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

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

• Macroscopic view:

• ulcerative

• polypoid, exophytic

• stenotisant, circular

• Diffuse, infiltrative

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.”

Screening

• Fecatest

• Colonoscopy

Rectoscopy recquired:

• Blood in the stool

• Before proctological operations

• Above 60

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

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

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

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

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

The distribution of adenomas and CRC according to

localization

Anatomy of the colorectal region

Arterial supply of the colorectal region

Lymphoid system of the colorectal system

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

• 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.

• 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.

Indication for surgery

• Emergency – acute indication :

1.Bleeding

2.Perforation

3.Obstruction

• Elective indication

• Planned, prepared intervention

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

Preparation of patient for elective

surgery

• Mechanical bowel cleansing

• Antibiotic prophylaxis

• Thrombosis prophylaxis

• Stress ulcus prophylaxis

• Urinary catheter

• Uretheral catheters

• Hydration

• Nasogastric tube

Types of operations

• Right hemicolectomy

• Transverse colon resection

• Left hemicolectomy

• Sigmoid resection

• Segmentel resections

• Extended resection

• Subtotal colectomy

Left hemicolectomy

Transverso-sigmoidostomy

Resection of the splenic flexure

Transverso-descendostomy

Tu coeci, Right hemicolectomy

With ileo-transversostomy

The same procedure is

performed both in acute and in

elective cases

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)

1.) Subtotal colectomy with ileo-colic anast. (A + E)

2.) Extended colon resection with

ascendo-sigmoidostomy (only E)

1.) Extended left hemicolectomy (only E)

(2.) Subtotal colectomy (A + E)

1.) Typical left hemicolectomy (E)

2.) Extended left hemicolectomy (E)

Sigmoid resection with descendo-

rectostomy (E)

Typical operation for

diverticulitis

and for sigmoid cancer

Extended right hemicolectomy with ileo-

descendostomy (A + E )

1.) Extended colon resection (E)

2.) Subtotal colectomy (A + E)

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

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

1.) Palliative resection of the sigmoid

2.) Palliative transversostomy

Types of palliative bypass procedures

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

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

Metastases:

lymphogenic: 1 pararectal

second central

haematogenous liver, bone, lung

peritoneum

Hartmann procedure

The two-step method

• Procedure for the treatment of obstructive

cancer of the sigmoid colon” (H.

Hartmann, Paris, 1921.)

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

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

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

Thank You

For Your attention