1. Common small and large intestinal surgical diseases Part II
Khayal AlKhayal, MD, FRCSC
Assistant Professor of Surgery
Consultant Colorectal Surgeon
2010
Done by : 428 surgery team
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2. Colorectal cancer
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3. Outline Definitions Polyps Basics of colorectal cancer Surgery Staging
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4. Perspective
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5. Definitions Colon = large bowel = large intestine
Rectum - terminal portion of the colon
Polyp - benign growth; not invasive
There 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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6. 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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7. Colon and Rectum
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8. 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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9. What is a polyp?
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10. Polyp - Cancer Sequence
The process from benign polyp to cancer takes from 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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13. The Effect of Age on the Incidence of
Colorectal Cancer and Colorectal Polyps
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14. Removing polyps prevents cancer
Colonoscopy
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15. Squamous cell carcinoma
Colorectal Carcinoma
Classification
Adenocarcinoma 95%
Carcinoid
Lymphoma
Sarcoma
Squamous cell carcinoma
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16. 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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17. Etiology of Colorectal Cancer
Incidence in left is more than right….why ?
Because sigmoid colon is narrow
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18. Risk Factors Genetics, Family history Polyps
Personal history
One first degree family member doubles risk
Hereditary colorectal cancer syndomes
Polyps
Inflammatory bowel disease (Chron’s Disease and Ulcerative Collitis).
Other
Diet, nutrients, smoking, ETOH
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19. Colorectal Cancer Risk Based on Family History
General population “ sporadic “ %
One 1st degree CRC X* (12-18%)
Two 1st degree CRC X*
One 1st degree CRC < 50 y *
One 2nd or 3rd CRC X
Two 2nd degree CRC X*
One first degree with polyp 2X*
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20. Clinical presentation
Bleeding - gross, occult, anemia (37%)
Change in bowel habit – pain, diarrhea, constipation, alternating pattern
Obstruction – more common with left sided lesions most common cause of bowel obstruction in the elderly
Vague abdominal pains
Change in caliber of the stools
Weight loss
Abdominal mass
Asymptomatic
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21. 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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23. 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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25. 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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26. 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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27. Abdominoperineal resection
Right hemi Colectomy
Left hemicolectomy
Abdominoperineal resection
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28. Low Anterior resection
Subtotal Colectomy
Low Anterior resection
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29. 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.
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30. 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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35. 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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36. 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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37. Some notes mentioned about CEA IMP
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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38. Pathology of Colorectal Cancer
Macroscopic:
Microscopic (differentiation):
Well
Moderately
Poorly
Lymph node involvement
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39. Staging ( Where is it Growing?)
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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40. 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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41. TNM Staging Stage 0 – Tis tumors Stage 1 – T1 and T2 tumors
Invasion of mucosa
Stage 1 – T1 and T2 tumors
Invasion of sub mucosa & muscularis propria
Stage 2 – T3 and T4 tumors
Invasion of full thickness & adjecent organ
Stage 3 – Any lymph node involvement
Stage 4 – Distant metastases
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42. 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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43. 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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44. Summary
Common Cancer
Can be prevented through screening and resection of polyps
Surgery is the primary treatment
Slow but steady improvement in survival
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