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Approach to colorectal cancer

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Approach to colorectal cancer

  1. 1. Approach to Colorectal Cancer & a bit about stomas Dr Elizabeth Brown Elizabeth.brown25@nhs.net
  2. 2. Clinical Presentation • Change in bowel habit – – – – Loose stool Frequent stool Rectal bleeding Tenesmus • Rectal/abdominal mass • Iron deficiency anaemia • Screening • Complications – Bowel Obstruction – Perforation • Secondaries – Liver metastases – jaundice, ascites, hepatomegal y • General effects of cancer (likely metastases) – Anaemia – Anorexia – Weight loss
  3. 3. Tumours disobey the rules, but generally… Left Colon Rectal Bleeding Change in bowel habit More present with obstruction Right Colon Anaemia Mass Pain Usually no change in bowel habit Less present with obstruction Rectal Tumours Tenesmus ‘Wet wind’ Rectal Bleeding
  4. 4. Risk factors for Colorectal Cancer • • • • Increasing age Colorectal polyps Inflammatory bowel disease – UC FHx – FAP – HNPCC – Any first degree relative • • • • Obesity Diet Smoking Acromegaly
  5. 5. Factors that may lower risk of Colorectal Cancer • Diet rich in vegetables, garlic, milk, calcium • Exercise • Low dose aspirin & NSAIDS
  6. 6. Examination • General signs – Anaemia – Evidence of weight loss • Abdomen – Evidence of obstruction – Palpable mass • Digital rectal examination – Rectal bleeding – Palpable mass in rectum/pouch of Douglas • Evidence of spread – – – – Hepatomegaly Jaundice Ascites Supraclavicular lymphadenopathy
  7. 7. GP referrals for suspected LGI Cancer: • When are you going to make an urgent referral? – Symptoms suggestive of LGI cancer – Age ≥40yrs with rectal bleeding + change in bowel habit for ≥ 6 weeks – Age ≥60yrs with rectal bleeding without change in bowel habit or anal symptoms for ≥ 6 weeks – Age ≥60yrs with change in bowel habit for ≥ 6 weeks – Any patient with RIF mass – Any patient with rectal mass – Iron deficiency anaemia <11 Males & <10 Females
  8. 8. • In borderline patients what important points in the history might sway you to refer urgently? – Particularly if Hx of Ulcerative Colitis or if FHx • What test can the GP do that will be useful to the Colorectal specialist? – Full Blood Count
  9. 9. Investigations • Gold standard = • Visualise tumour • Take biopsies • Alternatives: – Flexible sigmoidoscopy - & biopsies – Double contrast barium enema – CT colonography
  10. 10. Staging Investigations • CT with contrast – Chest, Abdomen & Pelvis – Probably the only staging investigation required • If another suspicious lesion found on CT, perhaps follow up with PET scan • Liver mets best investigated by MRI • If early rectal tumour (T1/T2) – endorectal USS (EUS)
  11. 11. Screening • General population – Faecal occult blood test (FOB) – Age 60-73yrs – 6 test cards every 2 years for FOB – If FOB +ve… • →Colonoscopy • High risk groups (strong FHx or UC) – Colonoscopy used for screening, not FOB
  12. 12. What is the role of serum CEA? • Not for diagnosis of colorectal Ca • Not for screening • Useful for follow up – if CEA ↑ suggests recurrence How do we follow up patients postcolorectal cancer? • Surveillance Colonoscopies
  13. 13. Dukes’ Classification - A – Tumour confined to mucosa & submucosa - >90% 5 year survival - B – Invasion of muscle wall - ~65% 5 year survival - C – Regional Lymph Nodes involved - ~30% 5 year survival - D – Distant spread e.g. liver, bladder
  14. 14. Spread of colorectal cancer • Local – Bladder & ureters • – Small bowel & stomach – Uterus/vagina or • prostate – Abdominal/Pelvic wall • Lymphatics – Mesenteric LNs – Groin LNs (rectal CA) – Supraclavicular LNs Blood – Portal vein → Liver – Lungs Transcoelomic – Peritoneal seedings
  15. 15. Surgery for bowel cancer • Principles: – Ideally empty bowel • Enemas & laxatives – Remove the tumour • Wide resection of growth – Lymphadenectomy • Regional LNs – Neo-adjuvant chemotherapy • Rectal Ca T1 or T2 only • Not colonic tumours • Aim to downsize tumour before surgery
  16. 16. Surgery for Colorectal Cancer Ascending colon tumour → Right Hemicolectomy
  17. 17. Surgery for Colorectal Cancer Transverse Colon Tumour → Transverse colectomy
  18. 18. Surgery for Colorectal Cancer Descending colon tumour → Left Hemicolectomy
  19. 19. Surgery for Colorectal Cancer Sigmoid Tumour → Sigmoid colectomy
  20. 20. Surgery for Colorectal Cancer Rectal Tumour → Abdominoperoneal (AP) resection
  21. 21. Synchronous Colon Cancers • 2 separate resections • Or subtotal colectomy:
  22. 22. Primary anastomosis • Primary anastomosis – If minimal contamination – Healthy tissue quality – Clinically stable
  23. 23. Anastomotic breakdown/Anastomotic leak: • High morbidity & mortality – – – – – – – – Can be subtle or obvious Fever Oliguria Ileus Raised WCC & CRP Peritonitis Drain/wound – enteric contents Usually non-specific examination unless peritonitic • NEEDS URGENT CT ABDOMEN & PELVIS • Small abscess/localised collection – CT guided drainage with broad spectrum antibiotics • IF GENERALISED PERITONITIS: NEEDS LAPAROTOMY
  24. 24. Stomas • Temporary stoma – Primary resection with proximal diversion – To decompress dilated colon before resection of obstructing lesion – Free perforation with peritonitis – Faecal contamination (unprepared bowel) – Poor nutrition – low albumin – For reversal procedure in future with anastomosis • Permanent stoma – AP resections – Ileostomy after subtotal colectomy (although ileorectal anastomosis is an option)
  25. 25. • A stoma is… – …surgically created communication between a hollow viscus and the skin or external environment – Ileostomies, Colostomies, Urostomies, technically a tracheostomy…
  26. 26. Colostomy • Usually left-sided • Bag contains more solid stool • Flush to skin
  27. 27. Ileostomy • Usually right-sided • Bag contains liquid stool • Spouted from skin – To protect against pancreatic enzyme secretions
  28. 28. Loop Ileostomy • 2 openings when examine stoma • Ileum brought to surface & antimesenteric boder opened • Rod is used to stop the opened bowel loop falling back inside • Simple to reverse so used for temporary diversion • Loop ileostomies preferable to loop colostomies as better blood supply
  29. 29. Early complications of stomas • Bleeding – unlikely to have large bleed – some blood in stoma bag acceptable • Ischaemia & necrosis – Dusky stoma colour – Needs resiting • Retraction – Risk of faecal peritonitis – Back to theatre • Obstruction – Due to oedema or hard stool – Examine stoma with gloves • High output ileostomy – Severe dehydration – Electrolyte disturbances • Parastomal dermatitis – Leaking ileostomy
  30. 30. Late complications of stomas • Parastomal hernia – Stoma/bowel obstruction – Strangulation – Stoma may need resiting • • • • • Prolapse Stenosis of stomal orifice Stomal diarrhoea Psychological problems Underlying disease e.g. Crohn’s peristomal fistulae

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