1. Colon and Rectal Cancer
Prof Walid El shazly
MD of Surgery
A prof of coloretal surgery

4. Cancer colon and rectum (Incidence)
General
2nd common after brochogenic carcinoma in men
4th common in females
Age
Abroad old
Egypt 40y

5. Etiology Of Colon Cancer
Hereditary nonpolyposis colon cancer
5-6%
Sporadic Colon Cancer
92%
Chronic IBD 1%
Familial Adenomatous polyposis
and rare syndromes 1%

6. Cancer colon and rectum (Etiology)
Diet
Diet lacking vegetables
Low residue diet---increase constipation
High fiber diet----increase bile---carcinogens
Cooked meat -----carcinogens
Precancerous lesions
Polyps--- tubuls, villous, FAP
IBD
Uretrocolic anastomsis

7. Familial Adenomatous Polyposis (FAP)
Autosomal dominant inheritance of mutated APC gene in chromosome 5
Hundreds to thousands of colorectal adenomas, average age of onset 16
Colon cancer by age 45 (mean age 39, &% by age 21)

8. Familial Adenomatous Polyposis (FAP)
Genetic tests, counseling age 10 to 12
Flexible sigmoidoscopy
annually or biannually for positive genetic test
Colectomy when adenomas develop

9. Hereditary Nonpolyposis Colorectal Cancer Syndrome (HNPCC)
Autosomal dominant inheritance of altered mismatch repair gene
Cancers preceded by a few rapidly growing adenomas
Cancers multiple, proximal, younger age of onset

10. Cancer colon and rectum (pathology)
5 % 3% 3%
5 %
5 %
12 %
21%
7 %
38% 2%

11. Pathology ( NEA)

12. Pathology (MP) Adenocarcinoma 95% Mucoid or colloid signet ring
Well differentiated
Moderately differentiated
Poorly differentiated
Mucoid or colloid signet ring
Squamous cell carcinoma
Rare types

14. Stage 0 Colorectal Cancer
Known as “cancer in situ,” meaning the cancer is located in the mucosa
Removal of the polyp (polypectomy) is the usual treatment

15. Stage I Colorectal Cancer
cancer has grown through mucosa and invaded the muscularis (muscular coat)
Treatment is surgery to remove the tumor and some surrounding lymph nodes

16. Stage I Colorectal Cancer

17. Stage II Colorectal Cancer
The cancer has grown beyond the muscularis of the colon or rectum but has not spread to the lymph nodes

18. Stage II Colorectal Cancer

19. Stage III Colorectal Cancer
The cancer has spread to the regional lymph nodes (lymph nodes near the colon and rectum)

20. Stage III Colorectal Cancer

21. Stage IV Colorectal Cancer
The cancer has spread outside of the colon or rectum to other areas of the body

22. Stage IV Colorectal Cancer

23. Stage IV Colorectal Cancer

24. Stage IV Colorectal Cancer

26. Methods of spread Intramural spread Lymphatic spread
Spread is three-dimensional;
the distal margin is of great concern in low rectal cancers (2-3 cm are considered enough)
Extension to adjacent structures
Lymphatic spread
N 1 Epicolic
N 2 paracolic
N 3 intermediate (SMA, IMA)
N 4 central groups of LN (para Aortic).

27. IMA
Superior rectal
Internal iliac
Middle rectal
Inferior rectal
Inguinal LN

28. Methods of spread Hematogenous spread Transperitoneal spread
Predominantly to the liver
The lung is the second affected organ
Transperitoneal spread
Seedlings
malignant ascites
omental deposits
Specially occurring in mucinous cancer and is beyond surgical cure.

29. Clinical picture of cancer Colon & Rectum

30. Alteration in bowel habit in
the form of mild diarrhea
Alteration in bowel habit
Sever form mainly
constipation
Vague upper
abdominal pain
Anemia, which is quite severe
Intestinal obstruction is late
Intestinal obstruction
early
A mass
felt in early cases
A mass
felt in advanced cases
Complication of
Perforation
hge
Complication of
Acute appendicitis
Intussussption
Perforation
hge

31. 1- Rectal bleeding most frequent presentation.
2-Sense of incomplete evacuation
3-Tenesmus is prominent in rectal cancer
4- Recent alteration in bowel habit (increasing constipation
alternating with diarrhea or spurious morning diarrhea

32. Signs Cancer Rectum General Anaemia & loss of weight Lung metastases
Cancer colon
General
Anaemia & loss of weight
Virchow’s LN
Oedema of LL
Abdominal
Abdominal Mass
Liver mass
Ascites
PR & PV
Krukenberg
Plummer’s shelf
Cancer Rectum
General
Anaemia & loss of weight
Lung metastases
Abdominal
Liver mass
Ascites PR
Mass in the rectum 90 % of cases

33. Investigations Liver function CBC anaemia Stool for occult blood
Laboratory
Liver function
CBC anaemia
Stool for occult blood
Tumor markers (CEA &Ca19)

34. Investigations Radiological Proctosigmoidoscopy Colonoscopy
Chest x ray or CT
Double contrast barium enema
Ultrasonography for the liver and LN
CT or MRI which will more accurately delineate the LN and perirectal fat
Proctosigmoidoscopy
Diagnose almost 50% of the cases
Colonoscopy
It is the gold standard

39. Rectal cancer

41. Cancer colon

42. Cancer caecum

47. Cancer sigmoid

49. General Rules (1) Preoperative preparation Traditional method
Pre by 5 days low residue diet
Pre by 4 days low residue diet
Pre by 3 days fluid only
Pre by 2 days NPO
Pre by 1 days NPO
Mechanical &
Chemical

50. General Rules (1) Chemical Preoperative preparation Mechanical
Laxative at night 60 cm parrafin
Cleaning enema up to 4 time per day
Chemical
Neomycin
Erythromycin
Metronidazole

51. General Rules (1) Preoperative preparation Rapid method
Polyethylene glycol can be drunk or given through NG Tube 2-3 liters over 24 hours
Alternatively (in urgent cases) on table lavage using appendix stump as a portal of entry can be very effective

52. General Rules (2) Radical resection
Any surgical resection requires 5 cm proximal and 2 cm distal clearance for colonic lesions
Radial margin should be histopathologically free of tumor if possible
Lymph node resection should be performed to the origin of the feeding vessel

53. General Rules (3) During resection
Surgical resection requires 5 cm proximal and 2 cm distal clearance for colonic lesions
Early vein ligation
High artery ligation
Non touch technique
En block resection

54. General Rules (3) Asses operability
Tumor mobile or fixed
LN involvement
Peritoneal; seedlings
Malignant ascites
Liver metastases

56. Depending on site of lesion surgical options
Caecum, ascending colon,– Right hemicolectomy
hepatic flexure --Extended right hemicolectomy
Transverse colon – transverse colectomy or Extended right hemicolectomy
Splenic flexure, descending colon – Left hemicolectomy
Sigmoid colon – sigmoidectomy or Anterior resection

60. Caecum

92. Rectal cancer

93. Cancer rectum Upper 1/3 --- Anterior resection Lower 1/3
Abdomino-perineal resection with proximal permanent stoma

94. Anterior Resection

97. Anterior resection

98. Abdominperinal resection

99. Cancer rectum Middle 1/3 ---
Abdomino-perineal resection with proximal permanent stoma
Low Anterior resection with stapler
Sphincter saving options
Abdoinosacral approach
Pull-through with trans-anal colo-anal anastmosis

100. Low Anterior Resection

101. Rectal Dissection
Anterior

102. Rectal Dissection
Posterior

108. Low Anterior resection with stappler

109. Low Anterior resection with stappler