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

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.

10. Trattamento delle neoplasie
del colon:
Chirurgia open vs chirurgia
laparoscopica

11. Effetto del volume di LAC sui risultati:

13. Clips AMS lps

14. K colon
Quale intervento nei T4 ?

16. • 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%

18. 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

19. • 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%

21. ColoreCtal CanCer in
emergenCy

22. 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)

24. 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%)

25. B J Surg 1967

26. In-hospital mortality
42/762 pts
5.5%%
Non
influenzano la
prognosi a
breve termine

27. In-hospital
Diastatic perforation
60%
Tumour perforation
mortality 37%

28. Disease-free survival
(excluded mortality periop and stage IV)
Overall survival

31. 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%

32. Colorectal surgeon General surgeon
Morbidity
60.5%
CS 52.5%
p=0.01
GS
Mortality
28.3%
CS 17.9%
p<0.001
GS

33. Postoperative complications
Anastomotic dehiscence
Postoperative mortality

35. Chirurgo colorettale….
o chirurgo esperto???
Resezione colica,
resezione gastrica,
splenopancreasectomia

36. K colon destro
occluso

40. K FLESSURA EPATICA

43. Chirurgo colorettale….
o chirurgo esperto???

44. 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

47. 2010

48. 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.

49. Ann Surg
2004

51. 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).

54. Colon
irrigation
Manual
decompression
Leak
7%
1%
p=0.006
Wound
infection
14%
9%
p= ns
Mortality
7%
1%
p=0.006

55. 2012
Stent insertion before
subsequent surgery has no
effect on perioperative
mortality and long-term
survival.

58. 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