Download final copy ofCommon small and large intestinal surgical diseases_

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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Colorectal cancer
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Outline
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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 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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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
Colonoscopy
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Colorectal Carcinoma
Classification
Adenocarcinoma 95%
Carcinoid
Lymphoma
Sarcoma
Squamous 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
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Personal history
One first degree family member doubles risk
Hereditary colorectal cancer syndomes
2. Polyps
3. Inflammatory bowel disease (Chron’s Disease and
Ulcerative Collitis).
4. Other
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Diet, nutrients, smoking, ETOH
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Colorectal Cancer Risk Based on Family History
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General population “ sporadic “
One 1st degree CRC
Two 1st degree CRC
One 1st degree CRC < 50 y
6%
2-3X* (12-18%)
3-4X*
3-4*
• One 2nd or 3rd CRC
• Two 2nd degree CRC
1.5X
2-3X*
• One first degree with polyp
2X*
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Clinical presentation
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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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Investigations
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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
Abdominoperineal resection
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Left hemicolectomy
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Anterior resection
Subtotal Colectomy
Low 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.
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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 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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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 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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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
1
2
3
4
5-Year Survival
90%
80%^
27-69%*
8%
^for T3N0 tumors
*depends on # of nodes involved
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Summary
1. Common Cancer
2. Can be prevented through screening and
resection of polyps
3. Surgery is the primary treatment
4. Slow but steady improvement in survival
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