This document discusses colorectal cancer (CRC), including its epidemiology, etiology, screening, clinical presentation, staging, prognostic factors, preoperative preparation, surgical techniques, and palliative care approaches. CRC is the third most common cause of cancer death worldwide, with higher rates in men. Risk factors include diet, obesity, smoking, and inflammatory bowel disease. Screening can detect early-stage cancers and remove pre-cancerous polyps to reduce mortality. Surgery aims to remove the primary tumor and adequate lymph nodes while preserving organ function through techniques like colectomies and anastomoses.

1. Dr Bachar RAAD MD, FACS.
RCMC Yanbu
Surgical Club
DEC.2014.

2. Epidemiology:
In the world, CRC is the third most common cause of cancer
death, responsible for 639000 death annually.(1)
In USA 1 in every 17 people will develop CRC at some point in
life.(2)
Incidence in men is 61 per 100,000 as compared to 45 per
100,000 females.
Distribution of colon cancer is 18% in right colon , 9 %
transverse colon , 5% descending colon, 25% sigmoid colon,
and 43% in the rectum
1- World health organization mortality database. World health organization. (Accessed 9 Dec 2009.)
2- Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA cancer J Clin. 2009;59:225-49.

3. Etiology
Dietary constituents and supplements: Dietary fat, Red
meat, Alcohol, Fruits and Vegetable, Fiber, Calcium and
Vit. D, Folate, Aspirin and NSAI drugs.
Obesity with an up to twofold increased risk of CRC.
Physical activity: greater PA is associated with reduced
risk of CRC.
Smoking with two to threefold elevation of adenoma risk.
Cholecystectomy: the association with CRC in
inconsistent, but seems to be strongest for cancer of the
proximal colon.
Inflammatory bowel disease and family history: ulcerative
colitis, crohn, polyposis.

4. Screening
There is clear evidence that CRC can be
prevented by detecting and removing
adenomatous polyps and that detecting
early stage cancers reduce mortality from
the disease.*
* Newcomb P, Norfleet R, Storer B, Surawicz T, Marcus P. Screening sigmoidoscopy and colorectal cancer mortality. J
Natl Cancer inst. 1992;84:1572-5.

5. Screening
2008, US Preventive
Task Force recommendation.
2008, US Preventive Task Force recommendation.

6. Clinical presentation
In symptomatic patients the most common presenting symptoms are:
1- Abdominal pain (most common).
2- Change in bowel habits.
3- Rectal bleeding and occult blood in stool.*
*-Breat RW, Steel GD, Merck HR, et al. Manengement and survival of patients
with adenocarcinoma of colon and rectum. J Am Coll Surg.1995;181:225-36

7. Staging and Prognostic factors
The original staging system for colorectal cancer was reported by
Cuthbert Dukes’ in 1930 and it has three stages A,B and C.
Modified Dukes’.
Subdividing Dukes’.
Astler-coller modification.

8. Staging and Prognostic factors
TNM staging is the system developed by the American joint
committee of cancer.
T
Tis : carcinoma in situ.
T1 : Invasion into submucosa.
T2 : Invasion into muscularis propria.
T3 : invasion into subserosa.
T4 : Invasion to other organs.
N
N0 : No Lymph nodes / N1 : 1-3 Lymph nodes/ N2: >4 Lymph nodes
M
M0 : No metastasis / M1 : Distant metastasis

9. Staging and Prognostic factors
Typically, the combination of T, N, and M will lead to
one of the four stages based on the combination of
findings.
Stage 0 Tis, N0, M0.
Stage 1 T1 or T2, N0, M0.
Stage 2 T3 or T4, N0, M0.
Stage 3 any T, N1 or N2, M0.
Stage 4 any T, any N, M1.

10. Staging and Prognostic factors
In addition to TNM staging, the histologic grade of the tumor as
well as the completeness of the resection should be assessed.
The absence or presence of residual tumor following resection is
designated by the letter R, as indicated below, and should be
indicated in the operative report:
• R0—complete tumor resection with all margins histologically
negative
• R1—incomplete tumor resection with microscopic
surgical resection margin involvement (margins grossly
uninvolved)
• R2—incomplete tumor resection with gross residual
tumor that was not resected (primary tumor, regional
nodes, macroscopic margin involvement).*
*-Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst.
2001;93:583–596.

11. Clinical Prognostic Factors
 Age, as many cancers, colon cancer incidence
increases with increasing age.
 Symptoms, obstruction and perforation are
poor prognostic signs, overall 5-years survival
is 33%.*
 Blood transfusion, can cause immuno
suppression.
 Adjacent organ involvement.
*-Chen HS, Sheen-Chen SM, obstruction and perforation in colo rectal
adenocarcinoma, analysis of prognosis. Surgery, 2000;127:370-6.

12. Histologic Factors
 Histologic grade, poorly differentiated tumors have a
worse prognosis stage for stage compared to better
differentiated tumors.*
 Tumor budding, undifferentiated portion of tumors at
the leading invasive edge, associated with a high risk
of recurrence.*
 Mucin production; Signet-cell histology.
 Venous, perineural, lymph nodes invasion.
 Positive margins.
*-Cooper HS, Slemmer JR, Surgical pathology af carcinoma of colon and rectum. Semin oncol. 1991;18:367-80.
*- Nakamura T, Mitomi H, Kickuchi S, et al. evaluation of use fullness of tumor budding on the prediction of
metastases to the lungs and liver after curative excision of colorectal cancer, Hepatogastroenterology, 2005;52:1432-
5.

13. Carcinoembryonic Antigen, CEA.*
 A glycoprotein absent in normal mucosa, but present in
97% of patients with colo-rectal cancer.
 Patients with disease confined to mucosa and sub
mucosa will have elevated CEA level in 40-60% of cases.
 If CEA level does not fall postoperatively then occult
metastases may be present, (adj therapy).
 A CEA level greater than 15 mg/ml predicts an
increasing risk of metastases.
 A normal CEA level preoperative may become elevated
with metastases or recurrences.
*- The standard practice task force, The American Society of Colon and Rectal Surgeons. Practice
parameters for the surveillance and follow up of patients with colo rectal cancer. Dis Colon Rectum,
2004;47:807-17.

14. Preoperative Preparation
The tow most important prognostic indicators remain the
degree of bowel wall invasion and status of the lymph nodes.
Effective preparation requires knowledge of patient’s
physiologic status, tumor location, and clinical stage.

15. Preoperative Preparation
.

16. Preoperative Preparation
Localization of the tumor and its histopathology are
important in selecting an operative plan and the
optimal resection margins.
 Colonoscopy is widely used today and represents
the optimal means of detecting a cancer.
 CT allows the localization of lesions, identification
of local organ invasion and distant metastasis.
 Endoluminal US and MRI has become extremely
useful in staging of rectal cancer.
 Combined PET/CT appears to provide the most
accurate detection of liver metastases (97%).*
*-Orlacchio A, Scillaci O, Fusco N, et al. Role of PET/CT in detection of liver metastases from
colorectal cancer. Radiol Med. 2009;114:571-85.

17. Preoperative Preparation
Mechanical cleansing combined with oral
antibiotics reduces the concentration of
anaerobic and aerobic bacteria within the
colon and decreases the incidence of wound
infection from 35 to 9%.*
*- Matheson DM, Arabi Y, Baxter-Smith D, et al. Randomized multicentric trial of oral bowel preparation and
antimicrobials for elective colorectal operations. Br J Surg 1978;65:597-600.

18. Preoperative Preparation
 Bucher and al. reviewed 565 patients with mechanical bowel
preparation versus 579 without a preparation, demontrated a
higher anastomotic leak rate in the mechanical prep group.*
 Slim and al. reported an updated review and meta-analysis of
randomized controlled trials of patients. They found no
difference between the groups for anastomotic leak rate or the
incidence of pelvic or abdominal abscess.*
*- Guenaga KF, Matos D, Castro AA,et al. mechanical bowel preparation for elective colorectal surgery. Cohrane database Syst
Rev. 2003:CD001544.
*- Slim K, Vicaut E, Launay savary MV, et al.abdated systematic review and meta analysis of randomized clinical trials on the role
of bowel preparation before colo rectal surgery. Ann Surgery 2009;249:203-9.

19. Preoperative Preparation
While there is no enough data to make
recomendations for the use of bowel preperation in
colorectal surgery, we conclude that the routine use
of mechanical bowel preparation should be
abondoned, and replaced by liquid diet for three
days before elective surgery with appopriate
antimicrobials medications.

20. Surgical Technique
The principles of oncologic resection are a wide
mesenteric resection achieved by ligating the
feeding artery at its origin with adequate distal and
proximal margins.
With the recommendation of a minimum of 12
lymph nodes should be examined.*
*-Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl cancer inst.
2001;93:583-96.

21. Surgical Technique
Right hemi colectomy: the terminal
ileum should be divided 10-15 cm
proximal to the ileocecal valve to
allow for good vascular supply,
the transverse colon is divided
to the right of the main trunk of
the middle colic artery or to the
left for Extended RT hemi colectomy.

22. Surgical Technique
Left hemi colectomy: lateral to medial
or medial to lateral approach.
Inferior mesenteric artery should be
ligated at its origin, and the inferior
mesenteric vein ligated near the
ligament of Treitz.
Identification of the left ureter.
Bowel transected with at least 5 cm
proximal margin and distal site
on the top of the rectum.

23. Surgical Technique
Total colectomy with ileorectal anastomosis:
Applied to circumstances, where the patient has
been diagnosed with HNPCC, attenuated Familial
Adenomatous Polyposis, metachronous cancers in
separate colon segments, and in acute malignant
distal colon obstructions with unknown status of the
proximal bowel.

24. Surgical procedures and principles in rectal
surgery.
The result is that primary resection and
anastomosis without a colostomy or ileostomy
are the rule rather than exception.

25. Palliation should be the goal in a patient for
whom curative resection is not possible:
 If patient is a reasonable operative risk.
 If the primary lesion is not resectable.
 Significant metastatic disease and the
primary tumor is small.

26. A colonic stent can be used if the patient
needs to be relieved of an partial obstruction.
Stent is just temporary maneuver, patient for
reevaluation after chemo or chemo-radio
therapy for diversion or resection.

27. Variability in outcome in rectal surgery is
based on:
 Surgeon and hospital volume.
 Total mesorectal excision.
 Distal margins and radial margins.
 Lateral lymph nodes dissection.
 Selection of appropriate therapy for rectal
cancer.

28.  Surgeon and hospital volume.
When hospital with highest quartile of volume
(more than 20 procedures annually) were
compared with those with lowest quartile
(fewer than seven procedures annually),
there were statistically significant differences
in colostomy rates (29.5 versus 36.6%), 30
day post operative mortality (1.6 versus
4.8%), and overall 2 years survival (83.7
versus 76.6%).*
* Hodgson DC, Zhang W, Zaslavsky AM, et al. Relation of hospital volume to colostomy rates and survival for patients with rectal
cancer. J Natl cancer inst. 2003;95:(01):708-16.

29.  Total mesorectal excision.

30.  Total mesorectal excision.
Post operative impotence and retrograde
ejaculation or both have been observed in 25-
75% of cases when blunt dissection done causing
damage of pelvic autonomic sympathic and para
s. nerves.
By contrast after TME with careful nerve sparing
dissection, impotence has been reported in
only 10-29% of cases.*
*Masui H, Ike H, Yamaguchi S, et al. Male sexual function after autonomic nerve-preserving
operation for rectal cancer. Dis Colon Rectum, 1996;39(10):1140-5.

31.  Distal and radial margins
The first line of rectal cancer spread is upward
along the lymphatic course.
A 2-cm distal margin is generally justifiable over 5-
cm proximal margin.
A frozen section analysis of the distal margin must
be performed to comfirm a cancer free margin.

32.  Lateral lymph nodes dissection
A complete clearance of lateral lymph nodes
or extended lateral lymph nodes dissection
for lying rectal cancer is a controversial
topic.
Associated with a much higher rate of urinary
and sexual dysfunctions as compared to
standard TME.
Become a routine practice in Japan.

33.  Selection of appropriate therapy for Rectal
Cancer.
Presently the surgeon has three major curative
options:
- Local excision,
- Sphincter-saving abdominal surgery,
- Abdominoperineal Resection, APR.
Each patient with rectal cancer should be
individually evaluated, and a technical plan is
customized to their stage, gender, age, and body
habitus.

34. T1 invasion into the submucosa.
T2 invasion into the muscularis
propria.
T3 invasion the mesorectal fat.
T4 invasion of other organs.

35. Special circumstances
 Laparoscopic colon resection for Cancer*
Laparoscopic technique has been used for more
than 15 years.
Faster return of bowel function, shorter length of
stay, less narcotic use.
Conversion did not have any negative impact on the
oncologic outcome.
With adequate experience, laparoscopic colectomy
for colon cancer is safe and provides similar
outcomes to open colectomy.
*- Buunen M, Veldkamp R, Hop W, et al. survival after laparoscopic surgery versus open for colorectal cancer. Lancet oncol,
2009;10:44-52.

36. Special circumstances
 Acute obstruction
The associated bacterial overgrowth coupled with possible
impairment of blood flow in the proximal bowel has been
the primary factors that have classically dictated resection
and proximal diversion.
Colonic stent can serve as bridge to elective surgery in
patient with operable cancer.
Emergency surgery is associated with operative mortalities
as high as 23% and reduce quality of life.*
*- Morino M, Bertello A, Garbarini A, et al. malignant colonic obstruction managed by endoscopic stent decompression followed by laparoscopic
coloctomy. Surg Endosc 2002;16:1483-7.

37. Special circumstances
 Prophylactic Oophorectomy,
The debate continue regarding the relative risk and
benefits of a prophylactic oophorectomy in female
patient with colorectal cancer.
The risk of micro metastatic implants in the ovary
increases with tumor stage and approaches the
10%.*
*-Mackeigan JM, Ferguson JA. Prophylactic oophorectomy and colorectal cancer in premenopausal
patients. Dis Colon Rectum 1979;22:401-5.

38. Special circumstances
 Colon Cancer and AAA.
Vascular surgeons preferred to repair the AAA first,
whereas the nonvascular surgeons preferred colectomy.
Any aneurysm >6 cm should be repaired first or
synchronously with the colon resection, to avoid rupture.
Endo vascular repair followed by colectomy within the
next couple of days, or under a single anesthetic time,
and this is being increasingly supported by the
literature.*
*-Veraldi GF, Minicozzi A, Genco B, et al. endovascular treatment in patient with AAA and synchronous neoplasm. Chr
Italy, 2008;60:23-31.

39. Special circumstances
 Colon cancer and liver metastases,
The risk of simultaneous colectomy and hepatectomy do not
appear to be excessive in selected patients operated by expert
surgeons, and long term survival rates seem to be similar.*
16% of previously unresectable patients can be down staged and
eventually undergo curative resection with as high as 40% 5-
years survival.*
When metastatic disease is not resectable, upfront chemotherapy
without resection of primary lesion may be reasonable approach.
*- Adam R, Delvart V, Pascal G, et al. Rescue surgery for unresectable colorectal liver metastases down staged by chemotherapy: a
model long time survival. Ann Surg. 2004;240:644-57.

40. Outcome of surgery for colorectal cancer
 Overall 5-years survival rates after major
surgery for colorectal cancer are as follow:
stage I, 85-100%; stage II, 60-80%; stage
III, 30-50%.
 The risk of locoregional recurrence following
colectomy should be below 5%.

41. Summary
 Surgery of colonic cancer has been increasingly
better defined and the data clearly support the
benefits of wide mesenteric resection, clear
radial margins, and resection of adherent
adjacent organs.
 To allow accurate staging, 12 nodes or more
should be examined.
 Attention to surgical detail coupled with
improved perioperative care strategies, are
essential to minimize operative morbidity and
mortality.

42. THANK YOU…