Common small and large intestinal surgical diseases

Part II

Khayal AlKhayal, MD, FRCSCAssistant Professor of SurgeryConsultant Colorectal Surgeon

2010

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Done by : 428 surgery team

Colorectal cancer

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Outline

• Definitions• Polyps• Basics of colorectal cancer• Surgery• Staging

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Perspective

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Definitions• Colon = large bowel = large intestine• Rectum - terminal portion of the colon• Polyp - benign growth; not invasiveThere are many types of polyp , such as inflammatory ,

hyperplastic , and adenoma , and the last one ONLY can develop to cancer .

• Adenoma - type of polyp and has chance to develop cancer but not all.

• Cancer - malignant growth; invasive (through basement membrane)

• Stage - where the cancer is growing ( IMP for management )• Primary - the original tumour, where it started• Metastases - where the tumour has spread to

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Cancer

A cancer cell :• is immortal ( lives forever)

• multiplies uncontrollably• can live on its own without neighbors• can live in other parts of the body

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Colon and Rectum

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Colorectal Cancer

• Most cancers are acquired some are inherited• Almost all cancers begin as a benign polyp or

adenoma• Only a tiny percentage of adenomas become

cancers

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What is a polyp?

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Polyp - Cancer Sequence

• The process from benign polyp to cancer takes from 7 - 10 years • The transformation into cancer is based on

– the type of polyp

– Size of polyp

• Multiple polyps = greater risk of cancer• Tubular , Villus and Tubuloviilus are types of polyps .• Note:Villus histological feature have a high chance to develop

carcinoma 40%.

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The Effect of Age on the Incidence of Colorectal Cancer and Colorectal Polyps

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Removing polyps prevents cancer

Removing polyps prevents cancer

ColonoscopyColonoscopy

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Colorectal CarcinomaColorectal Carcinoma

ClassificationAdenocarcinoma 95%

CarcinoidLymphoma

SarcomaSquamous cell carcinoma

ClassificationAdenocarcinoma 95%

CarcinoidLymphoma

SarcomaSquamous cell carcinoma

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Epidemiology• 3th most common malignancy worldwide.

• 1st most common in Saudi males.

• second to lung cancer as a cause of cancer death

• 21,500 new cases, 8900 will die (2008) “ more than one third “

• risk of CRC – women 1/16 , men 1/14

• peek incidence in 7th decade but it can occur at any age

CRC : colorectal ca .7th decade means : 61 – 70 years old

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Etiology of Colorectal Cancer

Incidence in left is more than right….why ?Because sigmoid colon is narrow

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Risk Factors

1. Genetics, Family history• Personal history• One first degree family member doubles risk• Hereditary colorectal cancer syndomes

2. Polyps3. Inflammatory bowel disease (Chron’s Disease and

Ulcerative Collitis).4. Other

• Diet, nutrients, smoking, ETOH

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Colorectal Cancer Risk Based on Family History

• General population “ sporadic “ 6%• One 1st degree CRC 2-3X* (12-18%)• Two 1st degree CRC 3-4X*• One 1st degree CRC < 50 y 3-4*

• One 2nd or 3rd CRC 1.5X• Two 2nd degree CRC 2-3X*

• One first degree with polyp 2X*

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Clinical presentation1. Bleeding - gross, occult, anemia (37%)2. Change in bowel habit – pain, diarrhea, constipation,

alternating pattern 3. Obstruction – more common with left sided lesions most

common cause of bowel obstruction in the elderly4. Vague abdominal pains5. Change in caliber of the stools6. Weight loss7. Abdominal mass8. Asymptomatic

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Investigations• General:

– Complete history and physical (DRE)• Endoscopic (identify primary, synchronous lesions)

– Flexible sigmoidoscopy– Colonoscopy “ to roll out other lesions “

• Staging– Endorectal ultrasound (rectal cancer)– Chest x-ray (metastases)– Liver ultrasound (metastases)– Abdominal CT scan (metastases)

• Bloodwork– CBC electrolytes, CEA (tumour marker)• Tumour marker used for prognosis of the disease and to follow up

the patient .* CEA : CarcinoEmbryonic Antigen “ not specefic marker “

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Surgical therapy

• Surgery is the most important variable in the treatment of colorectal cancer

• Radiation and chemotherapy alone cannot cure any stage of colorectal cancer

• The site of tumour dictates the basic procedure

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Preoperative preparation• Evaluation of medical problems• Mechanical bowel preparation (cleanes the bowel by causing

diarrhea) – Colyte , Oral fleet

• IV antibiotics (because it is contaminated gross contamination wound)

• DVT prevention ( blood clots in the legs)– Heparin shots– Compression stockings

• Foley catheter “ for the urinary bladder “

• Epidural catheter “ for reduce the pain “

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Principles of Surgery “how to do surgery”

• Examine the entire abdomen• Remove the appropriate segment of the colon

with adequate margins• Remove the corresponding lymph nodes• Open vs laparoscopic approach

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Right hemi Colectomy

Left hemicolectomyAbdominoperineal resection

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Subtotal Colectomy

Anterior resection

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• When the tumor in the right side we do right hemi colectomy

• When the tumor in the left side we do left hemi colectomty

• When the tumor in the sigmoid colon we do anterior resection

• When the tumor in the rectum or below we do lower anterior restriction or abdomino-perineal resection. 29428 surgery team

Ostomy• The intestine is brought out through a hole in the

abdominal wall

Colostomy ( colon on the skin)• Permanent when the rectum is removed• Temporary when it is unsafe to make a join

Ileostomy ( ileum on the skin)• Temporary when the join needs time to heal

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Recovery

• Surgery 2 to 4 hours• Hospital stay 4 to 10 days

– IV, urine catheter, compression stockings, intravenous pain killers, blood thinner

– Discharge when ambulating, eating, bowel function, good pain control

• Recovery 4 weeks

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Follow up

• Office visit every 3 months for two years then every 6 months for 3 years

• Regular blood work (CEA)• Colonoscopy at year 1 and 4 and every 5 years• CT scan yearly

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Some notes mentioned about CEAIMP

• CEA used to detect the prognosis : higher CEA worse prognosis.

• Also used to detect recurrence: for example: (normal CEA is <5).If CEA was 50 then after surgery it becomes 5 then after some time

it raised to 50 again . Here we suspect recurrence.

*also if CEA was 100 and after a surgery it is still 100 that indicate there is another mass has not been removed .

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Pathology of Colorectal Cancer

• Macroscopic:

• Microscopic (differentiation):– Well– Moderately– Poorly

• Lymph node involvement

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Staging ( Where is it Growing?)

1. How far into the wall has it grown? T stage• Tis – invasion of mucosa only• T1 – Invasion of submucosa• T2 – Invasion of muscularis propria• T3 – Full thickness/perirectal fat• T4 – Invasion into adjacent organs

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Staging ( Where is it Growing?)2. Is it growing in other places?

N stage, M stage• N1 – 1-3 lymph nodes• N2 - >4 lymph nodes• N3 – distant lymph nodes• M1 – Distant organ ( liver, lung)

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TNM Staging

• Stage 0 – Tis tumorsInvasion of mucosa

• Stage 1 – T1 and T2 tumorsInvasion of sub mucosa & muscularis propria

• Stage 2 – T3 and T4 tumorsInvasion of full thickness & adjecent organ

• Stage 3 – Any lymph node involvement

• Stage 4 – Distant metastases

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Who Gets Additional Treatment?

• COLON– All stage 3 patients (positive nodes) -

chemotherapy– High risk stage 2 patients

• RECTUM– All stage 2 and stage 3 patients should get

radiation and chemo

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Survival and TNM Stage

• STAGE 5-Year Survival 1 90%

2 80%^3 27-69%*4 8%

^for T3N0 tumors*depends on # of nodes involved

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Summary

1. Common Cancer2. Can be prevented through screening and

resection of polyps3. Surgery is the primary treatment4. Slow but steady improvement in survival

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