1. Treatment of colon carcinoma involves surgical resection of the primary tumor with adequate margins along with lymph node dissection and reconnection of the gastrointestinal tract. The extent of resection depends on the location and spread of the cancer. 2. Thorough knowledge of the blood supply and lymphatic drainage of the colon is important for surgery planning. Nutritional status, bowel preparation with antibiotics, and thromboembolic prophylaxis are important preoperatively. 3. Post-operatively, adjuvant chemotherapy may be administered depending on cancer stage and other risk factors. Patients are monitored closely with follow-up imaging and tumor marker screening.

1. TREATMENT OF COLON CARCINOMA
SHASWATA SAHA
10.03.2017 MALDA MEDICAL COLLEGE
Objectives
•Removal of the primary cancer with adequate margins
•Regional lymphadenectomy
•Restoration of the continuity of the GI tract by anastomosis
•En block removal of adjacent organ if involved

2. THE EXTENT OF RESECTION IS
DETERMINED BY
•location of the cancer
•its blood supply and draining lymphatic system
•presence or absence of direct extension into adjacent
organs
So a detailed knowledge of blood supply and lymphatic
drainage is important for the surgery.

3. BLOOD SUPPLY OF THE COLON
The colic branches of the
superior mesentric artery
i.e. iliocolic right colic and
middle colic artery and The
inferior mesentric artery
i.e left colic and sigmoidal
branches supply the colon .
They anastomoses
circumferentially from
iliocoecal junction to
rectosigmoidal junction
and located close to
inner margin of colon
(within 3cm ) and called
the marginal arcade or
artery of Drummond.

4. LYMPHATIC DRAINAGE FOLLOWS THE ARTERIAL
SUPPLY
The Colic lymph node are
distributed in following four
groups
1.Epicolic nodes : lie on the wall of
the colon.
2.Paracolic nodes : lie very close to
the marginal artery (of Drummond)
3.Intermediate colic nodes :lie
along the ileocolic, right colic, middle
colic and left colic, arteries, and drain
into terminal nodes.
4.Preterminal nodes : lie along
trunks of superior and inferior
mesenteric arteries.

5. PREOPERATIVE WORKUP AND PLANNING
For elective Surgery preoperative workup is to be done
depending upon the patients comorbidities.
The additional workup in preoperative period to be done
are
 Nutritional status evaluation
 Preoperative bowel preparation
 Thromboembolic prophylaxis
 Catheterization
 Optional nasogastric tube
 Preoperative epidural anaesthesia

6. NUTRITIONAL STATUS EVALUATION
Two parameters to be checked for are
 Serum albumin indicates long term nutrition(21 days)
 Serum prealbumin indicates short term nutrition(3-5 days)
They are important as –
A low prealbumin (<3.5g/dl ) is a risk factor for anastomoses leak.
They assessment determines the patients who would be benefitted by
the parenteral nutrition postoperatively.

7. Preoperative Bowel Preparation
Purging the foecal
matter
Administration of
antibiotics
• Previously it was thought to
reduce chances of post operative
infection
and anastomoses leakage.
• But as the colonocytes get the
nutrition from free fatty acids
produced by fermentation of
lipids by commensal bacteria
(109 /ml)
• Nowadays the purging though
done in practice the advantages
are debatable.
•To prevent surgical site infection the
role of antibiotics has been proven
through randomized controlled trials.
•It is given as prophylactic doses 30
minutes before surgery and if
surgery is proloned it should be
given in 4 hourly doses.
•Postoperative antibiotics are not
advisable as they increase chances
of Clostridium difficile colitis ,
candida infection, bacterial
resistance.

8. Perio
d
Agents used Adverse
effects
Before
1980
Bisacodyl , castor oil, senna
with whole bowel nasogastric irrigation
+mannitol irrigation +repeated enemas
Dehydration
Electrolyte imbalance
Severe abdominal
cramps
Low tolerance
1980 Polythene glycol
+ large volume of fluid
infusion
(used in case of renal insufficiency ,
liver diseases , CHF)
Abdominal cramps
Nausea
vomiting
1990 Oral Sodium Phosphate Impaired renal function
Hypernatrimia
Hyperphosphatemia
Mechanical Preparation agents

9. ANTIBIOTICS
Regimens used preoperatively are
1. Single antibiotics (IV Etrapenem / Piperacillin /tazobactam)
2. Combination of 2nd /3rd generation cephalosporin + Metronidazole
3. Combination of Fluoroquinolone +Metronidazole + Clindamycin
4. Triple combinations of Amoxicillin- clavulinic acid + Metronidzole +
Aminoglycosides

10. Thromboembolic prophylaxis
 is given by Subcuteneous or IV Low Molecular
weight heparin and/or with intermittent
pneumatic calf stockings to prevent chances of
a. Deep vein thrombosis
b. Pulmonary embolism
LMWH is given from 2 hours before surgery until patient
achieve full ambulation post operatively.

11. GENERAL TECHNICAL PRINCIPALS
The length of bowel and mesentery resected is dictated by tumor
location and distribution of the primary artery but a radical resection
of a colonic tumor should achieve at least a 5-cm clearance at the
proximal and distal margin also.

12. Right hemicolectomy is
done
For lesions in Cecum ,
Ascending colon , or
proximal 1/3 of Transverse
colon
This involves removal of the
from 4 to 6 cm proximal to
the ileocecal valve to the
portion of the transverse
colon supplied by the right
branch of the middle colic
artery .
An anastomosis is
fashioned between the

13. An extended right
hemicolectomy
is the procedure of choice
for most transverse
colon lesions
This involves division of the
right and middle colic
arteries at their origin, with
removal of the right and
transverse colon supplied by
these vessels. The
anastomosis is fashioned
between the terminal ileum

14. Post-Operative Management
Adjuvant
Chemotherapy
Monitoring

15. ADJUVANT CHEMOTHERAPY
In post operative period can be administered by
following regimens
•5-Fluorouracil (5-FU) and Leucovorin(LV) in Mayo-clinic , Rosewell park,
De gramont regimens with toxicity causing myelosuppression and GI side
effects
• Oral Fluoropyrimidine therapy can be given using 2 prodrug Capecitabine
and Uracil/Tegafur with less side effects than 5-FU/LV regimen with more or
less same efficacy
•Though most widely Used Regimen is modified FOLFOX 6 using
5-FU/LV with Oxaliplatin

16. FOR STAGE I
DISEASE
After operation proper
1. Colonoscopic examination
should be done annually
and if any polyp is found it
is removed. Then
Examination can be done 5
yearly. If familial
association is present
colonoscopy should be
more frequently done.
2. CEA level is assesed 3
monthly in first 2 years. If
value is high MRI or PET
scan is done for detection
of metastasis.
For Stage II disease
After operation proper
Adjuvant chemotherapy with 5-
Fluorouracil & Leucovorin regimen is
advised in stage 2 diseaseif
associated with any of the poor
prognostic factors like
a. T4 lesions
b. Insufficient lymph node sampling
c. Poorly differentiated lesions
d. Bowel perforation
These should be associated with CEA
level assesment 3 monthly for 2
year and 6 monthly for 5 years
And annual CT scan.

17. FOR STAGE III OR IV DISEASE
•Adjuvent chemotherapy is advised with both 5-FU +Leucovorin
regimen and Oxaliplatin .
•If associated with metastasis asymptomatic cases should be
treated with Adjuvant chemotherapy without delay in post
operative period
•And if associated with symptomatic involvement of lung or
hepatic segment the segment is amenable to resection
•Monoclonal antibodies like Bevacizumab , Cetuximab,
Panitimumab can be added with 5-FU Oxaipaltin regimen.