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Terapia del cancro colorettale: gestione chirurgica - Gastrolearning®
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Terapia del cancro colorettale: gestione chirurgica - Gastrolearning®

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Gastrolearning II modulo/1a lezione
Terapia del cancro colorettale - Gestione chirurgica
Prof. G.B. Doglietto - Università Cattolica Sacro Cuore (Roma).

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  • 1. CANCRO DEL COLON-RETTO Università Cattolica Del Sacro Cuore Chirurgia Digestiva Prof. Giovanni Battista Doglietto
  • 2. CARCINOMA COLO-RETTALE • 50000 nuovi casi/anno in Italia • Quale linfoadenectomia ? • infiltr. organi circostanti → 6-10% dei casi: quale intervento • 40% dei pazienti ha un’età maggiore di 70 anni • Intervento laparotomico o laparoscopico ? • Urgenza vs Elezione
  • 3. Ruolo della linfadenectomia nel cancro del colon
  • 4. 1990 Working Party Report to the World Congress of Gastroenterology + National Cancer Institute • • • Fielding LP ,et al . Clinicopathological staging for colorectal cancer: an International Documentation System (IDS) and an International Comprehensive Anatomical Terminology (ICAT) . J Gastroenterol Hepatol 1991 ;6 : 325 – 44 . Nelson H , et al . Guidelines 2000 for colon and rectal cancer surgery . J Natl Cancer Inst 2001 ; 93 : 583 – 96 . Otchy D , et al . Practice parameters for colon cancer . Dis Colon Rectum 2004 ; 47 : 1269 – 84 . Radicalità oncologica = linfadenectomia a 12 lfn
  • 5. Evidenza: Ia Affiliations of authors: Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX (GJC, MARB, JMS); Department of Pediatrics, Baylor College of Medicine, Houston, TX (VAM) .
  • 6. Risultati: • Studi “nested coort”: A) Intergroup 0089 trial (USA – 3411pz): T3-4/N0 T1-T4/N1 T1-T4/N2 + 15% +23% + 20% + 11% + 12% + 28 % + 19 % + 16% + 19% Linfadenectomia efficace = fattore incidente sulla sopravvivenza, sia per N0 che per N+!!
  • 7. B) INTACC study (Italia – 3491pz): + 7% T3-T4/N0 + 8% + 11% + 17% T1-4/N1-2 Linfadenectomia efficace = fattore incidente sulla sopravvivenza, per N0 ma non per N+!!
  • 8. NB: L’ N richiede una linfadenectomia di almeno 12 linfonodi (TNM VI for colo-rectal cancer). Il nuovo TNM VII (in elaborazione) ne prevederà 15.
  • 9. Trattamento delle neoplasie del colon: Chirurgia open vs chirurgia laparoscopica
  • 10. Effetto del volume di LAC sui risultati:
  • 11. Clips AMS lps
  • 12. K colon Quale intervento nei T4 ?
  • 13. • 1981-1996 → 618 pz sottoposti a resezione chirurgica per carcinoma del colon • 88 resezioni allargate (14.2%): 70 curative (14.3%) e 18 palliative (14.1%) in letteratura dal 16% al 67%
  • 14. HYPERTHERMIC INTRAPERITONEAL INTRAOPERATIVE CHEMOTERAPY N°43 PROCEDURE (38 PATIENTS) pseudomixoma Personal Experience April 1999-November 2008 peritonei gastric cancer 13 13 6 2 1 2 1 colo-rectal cancer peritoneal sarcoma ovary cancer mesothelioma appendix cancer
  • 15. • 1981-1996 → 346 pz sottoposti a resezione chirurgica per carcinoma del retto • 26 resezioni allargate (7.5%): 23 curative (7.3%) e 3 palliative (9.4%) • 7/23 (30.4%) recidive di malattia nel gruppo di resezioni curative “allargate” • 48/291 (16.5%) recidive di malattia nel gruppo di resezioni curative “non allargate” in letteratura dal 16% al 67%
  • 16. ColoreCtal CanCer in emergenCy
  • 17. 15-30 % k colon as emergency obstruction 78% perforation 10% bleeding 4% Bad prognosis short and long-term Higher frequency non-curative resection (OR 2.452, p<0.0001)
  • 18. Emergency pts Obstruction Perforation Bleeding 5-yr cancer-specific survival Elective 56.3% Emergency 38.5% P<0.001 547 (55.5%) 84 (8.5%) 355 (36%)
  • 19. B J Surg 1967
  • 20. In-hospital mortality 42/762 pts 5.5%% Non influenzano la prognosi a breve termine
  • 21. In-hospital Diastatic perforation 60% Tumour perforation mortality 37%
  • 22. Disease-free survival (excluded mortality periop and stage IV) Overall survival
  • 23. Primary versus staged resection for acute obstructing colorectal carcinoma. Br J Surg 1992 Sjödahl R, Franzén T, Nyström PO. Department of Surgery, University Hospital, Linköping, Sweden. 115 pts obstruction colon cancer Primary resection 40 pts 22 righ-side 18 left-side Staged resection 40 pts Primary Staged Mortality 10% 15% Hospital stay 18 days 45 days 5-yr survival 38% 29%
  • 24. Colorectal surgeon General surgeon Morbidity 60.5% CS 52.5% p=0.01 GS Mortality 28.3% CS 17.9% p<0.001 GS
  • 25. Postoperative complications Anastomotic dehiscence Postoperative mortality
  • 26. Chirurgo colorettale…. o chirurgo esperto??? Resezione colica, resezione gastrica, splenopancreasectomia
  • 27. K colon destro occluso
  • 28. K FLESSURA EPATICA
  • 29. Chirurgo colorettale…. o chirurgo esperto???
  • 30. 2010 Single-stage Two-stage Resection + 1. Hartmann primary anastomosis 2. Reversing end +/- stoma colostomy Mortality 20% Stoma complication 10-34% Definitve stoma 30% Stoma reversal Mortality 4% Leak 16% Three stage ? 1. Stoma 2. Resection 3. Closing the stoma
  • 31. 2010
  • 32. Hartmann should be preferred to colostomy for OLCC, since colostomy appears to be associated with longer overall hospital stay and need for multiple operations but not with a reduction in peri-operative morbidity (Grade of recommendation 2B ) !!! Unresectable diasease, neoadjuvant therapy, “dramati scenario””!!! Theoretical benefits loop colostomy: colonic decompression; minimal surgical trauma; Reduction of the risk of contamination from unprepared bowel; staging and multidisciplinary evaluation prior to definitive treatment.
  • 33. Ann Surg 2004
  • 34. Total colectomy for OLCC (without cecal perforation or evidence of synchronous right colonic cancers) should not longer be preferred to segmental colectomy with i.o. colon irrigation, since the two procedures are associated with same mortality/ morbidity, while total colectomy is associated with higher rates impaired bowel function (Grade of recommendation 1A). The two techniques are associated with same mortality/morbidity rate. MD is a shorter and simpler procedure. Either procedure could be performed, depending of the experience/preference of the surgeon (Grade of recommendation 1A).
  • 35. Colon irrigation Manual decompression Leak 7% 1% p=0.006 Wound infection 14% 9% p= ns Mortality 7% 1% p=0.006
  • 36. 2012 Stent insertion before subsequent surgery has no effect on perioperative mortality and long-term survival.
  • 37. Enterocutaneostomia Esteriorizzazione sulla cute di un segmento intestinale (lleo o colon) attraverso la parete addominale. Terminale - Escludente (a canna di fucile) Temporanea - Definitiva 1 2