This document discusses recent developments in the treatment of colorectal cancer, including screening, surgical advances, chemotherapy, chemoprevention, radiation therapy, endoscopic robotic systems, liquid biopsies, and aspirin use. It also covers total mesorectal excision for rectal cancer, local excision techniques, non-operative management, and laparoscopic versus open surgery. Immunotherapy is noted as a potential treatment for patients with Lynch syndrome.
Surgery is the cornerstone treatment for rectal cancer. Total mesorectal excision (TME) surgery has improved outcomes by removing the rectum and surrounding tissues in one piece. Local excision may be adequate for early stage T1N0 tumors with low-risk features, otherwise radical TME surgery is recommended. Neoadjuvant chemoradiation improves outcomes for more advanced T3/T4 or node-positive cancers by downstaging tumors. Laparoscopic surgery outcomes are similar to open surgery.
The document discusses recent surgical updates for pancreatic resections. It introduces novel techniques for pancreatic resections like the Cattell Braasch maneuver, triangle operation, and modified Appleby procedure. It summarizes outcomes from using these techniques on 45 patients, finding no mortality and comparable morbidity. The document also discusses techniques like vein resection without reconstruction that can increase resectability in select cases.
This document discusses chemotherapy trials and regimens for colon cancer. It summarizes several landmark trials that established the benefit of 5-FU-based adjuvant chemotherapy for stage III colon cancer. The MOSAIC, NSABP C-07 and NO16968 trials showed that adding oxaliplatin to 5-FU improves disease-free survival for stage III disease. For stage II, the benefit of oxaliplatin is unclear. The document also discusses staging, risk factors, treatment guidelines, neoadjuvant therapy and radiation therapy options for colon cancer.
This study analyzed data from patients in the Netherlands who underwent preoperative endoscopic biliary drainage (EBD) followed by pancreatoduodenectomy for pancreatic or periampullary cancers between 2017-2018. The study found that over 50% of patients received plastic stents for EBD despite guidelines recommending self-expanding metal stents (SEMS). Patients who received SEMS had fewer episodes of cholangitis but similar overall complication rates. Additionally, SEMS were associated with shorter time to surgery, less postoperative pancreatic fistula, and shorter hospital stay. The results suggest greater implementation of SEMS is needed in accordance with guidelines.
The document discusses several trials evaluating preoperative chemoradiotherapy versus postoperative chemoradiotherapy or radiotherapy alone for rectal cancer. Some key trials found that preoperative therapy improved local recurrence rates and survival compared to postoperative or no adjuvant therapy. Longer intervals between preoperative radiotherapy and surgery were associated with higher rates of tumor downstaging. Adding oxaliplatin or chemotherapy without radiation improved survival outcomes in some trials. Ongoing studies are exploring chemotherapy alone and targeted agents in rectal cancer.
The document discusses the role of radiation therapy in treating soft tissue sarcoma. It notes that radiation reduces local recurrence rates after surgery and allows for limb salvage procedures. Both preoperative and postoperative radiation are discussed, with advantages and disadvantages listed for each approach. Intensity modulated radiation therapy and brachytherapy are presented as techniques that may improve local control while reducing toxicity. The timing, dose, and volume of radiation treatment are important considerations. Overall, the document evaluates the evidence for integrating radiation therapy with surgery and chemotherapy to effectively treat soft tissue sarcomas.
The document discusses the role of various prophylactic surgeries in cancer prevention. It covers surgeries to reduce risk of breast cancer, ovarian cancer, colon cancer, gastric cancer, and medullary thyroid cancer for patients with genetic mutations or family histories that increase cancer risk. For each cancer type, it describes genetic factors, screening guidelines, timing of risk-reducing surgeries, and surgical options. The goal of these surgeries is to prevent cancer or detect it at an early stage through procedures such as mastectomy, salpingo-oophorectomy, colectomy, and thyroidectomy.
The document discusses urological morbidity following pelvic surgeries. It describes the retroperitoneal spaces at risk of injury during surgeries like radical hysterectomy and rectal surgery. Key nerves like the hypogastric and pelvic splanchnic nerves that innervate the bladder are discussed. Injury to these nerves can result in failure to store or empty the bladder. Nerve-sparing techniques during surgery aim to preserve bladder function by avoiding damage to these nerves. Post-operative urodynamics can identify bladder dysfunction not apparent from symptoms alone.
Surgery is the cornerstone treatment for rectal cancer. Total mesorectal excision (TME) surgery has improved outcomes by removing the rectum and surrounding tissues in one piece. Local excision may be adequate for early stage T1N0 tumors with low-risk features, otherwise radical TME surgery is recommended. Neoadjuvant chemoradiation improves outcomes for more advanced T3/T4 or node-positive cancers by downstaging tumors. Laparoscopic surgery outcomes are similar to open surgery.
The document discusses recent surgical updates for pancreatic resections. It introduces novel techniques for pancreatic resections like the Cattell Braasch maneuver, triangle operation, and modified Appleby procedure. It summarizes outcomes from using these techniques on 45 patients, finding no mortality and comparable morbidity. The document also discusses techniques like vein resection without reconstruction that can increase resectability in select cases.
This document discusses chemotherapy trials and regimens for colon cancer. It summarizes several landmark trials that established the benefit of 5-FU-based adjuvant chemotherapy for stage III colon cancer. The MOSAIC, NSABP C-07 and NO16968 trials showed that adding oxaliplatin to 5-FU improves disease-free survival for stage III disease. For stage II, the benefit of oxaliplatin is unclear. The document also discusses staging, risk factors, treatment guidelines, neoadjuvant therapy and radiation therapy options for colon cancer.
This study analyzed data from patients in the Netherlands who underwent preoperative endoscopic biliary drainage (EBD) followed by pancreatoduodenectomy for pancreatic or periampullary cancers between 2017-2018. The study found that over 50% of patients received plastic stents for EBD despite guidelines recommending self-expanding metal stents (SEMS). Patients who received SEMS had fewer episodes of cholangitis but similar overall complication rates. Additionally, SEMS were associated with shorter time to surgery, less postoperative pancreatic fistula, and shorter hospital stay. The results suggest greater implementation of SEMS is needed in accordance with guidelines.
The document discusses several trials evaluating preoperative chemoradiotherapy versus postoperative chemoradiotherapy or radiotherapy alone for rectal cancer. Some key trials found that preoperative therapy improved local recurrence rates and survival compared to postoperative or no adjuvant therapy. Longer intervals between preoperative radiotherapy and surgery were associated with higher rates of tumor downstaging. Adding oxaliplatin or chemotherapy without radiation improved survival outcomes in some trials. Ongoing studies are exploring chemotherapy alone and targeted agents in rectal cancer.
The document discusses the role of radiation therapy in treating soft tissue sarcoma. It notes that radiation reduces local recurrence rates after surgery and allows for limb salvage procedures. Both preoperative and postoperative radiation are discussed, with advantages and disadvantages listed for each approach. Intensity modulated radiation therapy and brachytherapy are presented as techniques that may improve local control while reducing toxicity. The timing, dose, and volume of radiation treatment are important considerations. Overall, the document evaluates the evidence for integrating radiation therapy with surgery and chemotherapy to effectively treat soft tissue sarcomas.
The document discusses the role of various prophylactic surgeries in cancer prevention. It covers surgeries to reduce risk of breast cancer, ovarian cancer, colon cancer, gastric cancer, and medullary thyroid cancer for patients with genetic mutations or family histories that increase cancer risk. For each cancer type, it describes genetic factors, screening guidelines, timing of risk-reducing surgeries, and surgical options. The goal of these surgeries is to prevent cancer or detect it at an early stage through procedures such as mastectomy, salpingo-oophorectomy, colectomy, and thyroidectomy.
The document discusses urological morbidity following pelvic surgeries. It describes the retroperitoneal spaces at risk of injury during surgeries like radical hysterectomy and rectal surgery. Key nerves like the hypogastric and pelvic splanchnic nerves that innervate the bladder are discussed. Injury to these nerves can result in failure to store or empty the bladder. Nerve-sparing techniques during surgery aim to preserve bladder function by avoiding damage to these nerves. Post-operative urodynamics can identify bladder dysfunction not apparent from symptoms alone.
The document discusses the history and evolution of surgical trials for colon cancer. It summarizes several key randomized controlled trials comparing laparoscopic versus open colectomy. The trials demonstrated that laparoscopic colectomy is associated with shorter hospital stays and faster recovery, without increased morbidity or affecting long-term oncologic outcomes. More recent studies also support the complete mesocolic excision technique with central vascular ligation over traditional Japanese D3 surgery for improved lymph node yield and potentially better survival. New technologies like robotic assistance and magnetic endoscopic probes aim to advance minimally invasive colon surgery and cancer screening.
Bone tumor biopsies require careful planning and execution to avoid complications and ensure an accurate diagnosis. A poorly performed biopsy can lead to misdiagnosis, unnecessary procedures like amputation, and negatively impact survival. The biopsy should be done at a specialized oncology center and follow principles like using the shortest tract away from neurovascular structures, obtaining enough tissue for analysis, and ensuring hemostasis. Following these guidelines helps optimize patient outcomes and treatment.
1) Total neoadjuvant therapy (TNT) involves chemotherapy before and after chemoradiotherapy for locally advanced rectal cancer, aiming to increase downstaging and improve outcomes.
2) A review found TNT achieved a 22% pathological complete response rate compared to 13% for chemoradiotherapy alone, with possibly improved survival.
3) However, most evidence comes from observational studies. Two randomized controlled trials found TNT reduced distant metastases and improved disease-free survival compared to chemoradiotherapy alone.
This document discusses the surgical management of upper urinary tract urothelial cell carcinomas. It covers radical nephroureterectomy as the gold standard treatment and explores laparoscopic versus open approaches. For localized low-grade tumors, conservative kidney-sparing options are discussed, including endoscopic tumor ablation using ureteroscopy or percutaneous access. Follow-up includes potential adjuvant instillation of bacillus Calmette-Guérin or mitomycin C into the renal collecting system.
The document summarizes key landmark breast cancer trials that helped establish modern standards of care. The NSABP B-04 trial showed that modified radical mastectomy was as effective as radical mastectomy. The NSABP B-06 and Milan trials established breast-conserving surgery plus radiation as an equivalent alternative to mastectomy. The NSABP B-32 trial demonstrated sentinel node biopsy alone had similar outcomes as axillary dissection for node-negative cancer. Subsequent trials like ALMANAC and Z011 found sentinel node biopsy reduced arm morbidity without compromising survival. These trials provided critical evidence supporting less invasive surgical approaches for breast cancer.
Role of laparoscopic surgery in colorectal cancerDr Amit Dangi
Laparoscopic surgery for colorectal cancer has been studied extensively. Early studies showed potential short-term benefits of laparoscopy over open surgery but also raised concerns about port site tumor recurrence. Later randomized controlled trials demonstrated laparoscopy is oncologically equivalent to open surgery for colon cancer with some short-term recovery benefits. Studies of laparoscopy for rectal cancer found short-term benefits but higher rates of positive margins, though long-term oncologic outcomes were similar. New techniques like robotic surgery are being explored but have not proven more cost-effective than laparoscopy.
This document discusses skin sparing mastectomy (SSM) and nipple sparing mastectomy (NSM). It provides details on the anatomy of the breast and history of breast cancer treatment. SSM aims to remove all breast tissue while preserving the skin and NAC. NSM further preserves the nipple. Selection criteria for NSM include small tumor size and distance from NAC. Outcomes of SSM and NSM are similar to MRM with acceptable morbidity. Complication rates of NSM include nipple necrosis around 7% and occult nipple involvement around 10%. Frozen section of subareolar tissue during NSM helps guide decision for NAC removal. Overall, SSM and NSM provide improved cosmetic
COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAPDr Amit Dangi
THIS PRESENTATION DESCRIBES THE NOVEL SURGICAL TECHNIQUE OF TOTAL ANORECTAL RECONSTRUCTION WITH ANTROPYLORUS TRANSPOSITION AND GLUTEOPLASTY AND ITS RESULTS.
This document discusses the history and technique of the extended abdominoperineal excision (ELAPE) surgery for rectal cancer. It begins with Miles' description of the standard abdominoperineal resection (APR) in 1908. The ELAPE technique was developed to address high circumferential resection margin positivity and local recurrence rates with APR for low rectal cancers. The ELAPE surgery extends the abdominal phase of resection using total mesorectal excision principles and removes the levator muscles en bloc during the perineal phase. Initial studies show ELAPE reduces bowel perforation and positive margin rates compared to APR, with potentially lower local recurrence. However, large randomized controlled trials are still needed to establish EL
Robotic colorectal surgery technique, advantages, disadvantages and its impac...Apollo Hospitals
The use of robotics in colorectal surgery is gaining momentum of late. Technical advances, such as three-dimensional imaging, a stable camera platform, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling and instruments with multiple degrees of freedom, have helped many surgeons adapt to it easily. There is a shorter learning curve compared to the standard laparoscopic surgery. This article helps to give an outline as to how robotic colorectal surgery can go a long way in the future of colorectal surgery.
This document discusses changes in the management of rectal cancer over time. It proposes separating treatment into early, TME, and beyond TME tumors. Total mesorectal excision (TME) surgery, which removes the rectum and surrounding tissue, reduced local recurrence rates from 30% to under 10%. Neoadjuvant therapies combined with TME further improved outcomes. Advancements like improved imaging and minimally invasive techniques have led to a paradigm shift. Rectal cancer is now conceptualized and treated according to tumor location and stage.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
1) The authors reviewed outcomes of 104 consecutive minimally invasive esophagectomies (MIEs) performed between 1998-2007.
2) Surgical approaches included thoracoscopic/laparoscopic esophagectomy with cervical anastomosis (n=47), minimally invasive Ivor Lewis esophagectomy (n=51), and others.
3) Complications included anastomotic leak in 9.6% of patients and stricture in 26%. Mortality was 1.9% at 30 days and 2.9% in-hospital. Mean lymph nodes retrieved was 13.8.
Long Term Outcomes following Laparoscopic Colorectal Surgeryensteve
The document discusses long term outcomes of laparoscopic versus open colorectal surgery based on various studies. Single institution studies and randomized controlled trials found similar long term survival rates between the two procedures. Larger multicenter randomized trials found no difference in 3-year overall or disease-free survival for colon cancer patients undergoing laparoscopic versus open surgery. Current evidence suggests laparoscopic colorectal surgery is not inferior to open surgery for cancer treatment.
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
Selection of surgical procedure for esophageal cancer ver 3.0Vivek Verma
Esophageal cancer is typically treated through surgical resection, which involves removing part of the esophagus. The type of surgery depends on the location and stage of the cancer. Common procedures include McKeown esophagectomy, transhiatal esophagectomy, and Ivor Lewis esophagectomy. While esophagectomy is a major surgery with risks of complications, minimally invasive techniques and extensive lymph node dissection may improve short and long-term outcomes for patients.
Laparoscopic colorectal cancer surgery trialsOliver Anderson
Laparoscopic colorectal cancer surgery was developed in the 1990s. Key trials showed it has better short-term outcomes like lower morbidity compared to open surgery, while providing equivalent long-term cancer outcomes. However, some controversies remain regarding complete resection margins and total mesorectal excision for rectal cancers with this approach.
Laparoscopic Colon Resection - Anterior ApproachGeorge S. Ferzli
1) The document discusses laparoscopic colon resection techniques, including an anterior approach where trocars are placed in the inguinal crease and the sigmoid colon is cut.
2) Studies comparing laparoscopic and open colon resection for cancer show that laparoscopic surgery results in less blood loss, shorter hospital stays, and fewer wound complications with similar long-term survival and recurrence rates.
3) A retrospective study of over 100 patients undergoing laparoscopic colon resection for cancer found 5-year survival rates similar to open surgery and rates reported in the National Cancer Database, suggesting laparoscopic surgery is a safe and effective treatment for colon cancer.
This document describes a technique for performing a single layer continuous hand-sewn esophagogastric anastomosis during a thoracolaparoscopic Ivor Lewis esophagectomy. The technique was performed on 5 patients with lower esophageal adenocarcinoma. No intraoperative complications or postoperative anastomotic leaks occurred. The mean operative time was 338 minutes and mean hospital stay was 8 days. This preliminary study suggests the technique of a thoracoscopic single layer continuous hand-sewn anastomosis is a feasible and safe method for esophagogastric anastomosis during minimally invasive Ivor Lewis esophagectomy. However, larger comparative studies are still needed to fully validate this technique.
This document provides an overview of colorectal carcinoma, including its anatomy, genetics, risk factors, screening, diagnosis, staging, and treatment strategies. Some key points:
- Colorectal cancer is one of the most common cancers worldwide. Proximal colon cancer is usually related to microsatellite instability, while distal colon cancer is associated with chromosomal instability.
- Risk factors include diet, smoking, inflammation. Screening includes fecal occult blood tests and endoscopy starting at age 50.
- Staging involves examining tumor depth, lymph node involvement, and metastasis. Treatment depends on stage but generally involves surgical resection with or without chemotherapy or radiation. The goal is sphincter preservation for rectal cancers
This document discusses the management of vulvar cancer and summarizes key changes over time. It notes that vulvar cancer is predominantly a disease of postmenopausal women and can be preceded by vulvar intraepithelial neoplasia. For early stage disease, radical local excision is usually sufficient. For advanced disease, radical vulvectomy or pelvic exenteration may be needed. Lymph node status is the most important prognostic factor, and inguinofemoral lymphadenectomy or sentinel lymph node biopsy is recommended. The role of preoperative chemoradiation to downstage tumors and allow less radical surgery is also discussed.
The document discusses the history and evolution of surgical trials for colon cancer. It summarizes several key randomized controlled trials comparing laparoscopic versus open colectomy. The trials demonstrated that laparoscopic colectomy is associated with shorter hospital stays and faster recovery, without increased morbidity or affecting long-term oncologic outcomes. More recent studies also support the complete mesocolic excision technique with central vascular ligation over traditional Japanese D3 surgery for improved lymph node yield and potentially better survival. New technologies like robotic assistance and magnetic endoscopic probes aim to advance minimally invasive colon surgery and cancer screening.
Bone tumor biopsies require careful planning and execution to avoid complications and ensure an accurate diagnosis. A poorly performed biopsy can lead to misdiagnosis, unnecessary procedures like amputation, and negatively impact survival. The biopsy should be done at a specialized oncology center and follow principles like using the shortest tract away from neurovascular structures, obtaining enough tissue for analysis, and ensuring hemostasis. Following these guidelines helps optimize patient outcomes and treatment.
1) Total neoadjuvant therapy (TNT) involves chemotherapy before and after chemoradiotherapy for locally advanced rectal cancer, aiming to increase downstaging and improve outcomes.
2) A review found TNT achieved a 22% pathological complete response rate compared to 13% for chemoradiotherapy alone, with possibly improved survival.
3) However, most evidence comes from observational studies. Two randomized controlled trials found TNT reduced distant metastases and improved disease-free survival compared to chemoradiotherapy alone.
This document discusses the surgical management of upper urinary tract urothelial cell carcinomas. It covers radical nephroureterectomy as the gold standard treatment and explores laparoscopic versus open approaches. For localized low-grade tumors, conservative kidney-sparing options are discussed, including endoscopic tumor ablation using ureteroscopy or percutaneous access. Follow-up includes potential adjuvant instillation of bacillus Calmette-Guérin or mitomycin C into the renal collecting system.
The document summarizes key landmark breast cancer trials that helped establish modern standards of care. The NSABP B-04 trial showed that modified radical mastectomy was as effective as radical mastectomy. The NSABP B-06 and Milan trials established breast-conserving surgery plus radiation as an equivalent alternative to mastectomy. The NSABP B-32 trial demonstrated sentinel node biopsy alone had similar outcomes as axillary dissection for node-negative cancer. Subsequent trials like ALMANAC and Z011 found sentinel node biopsy reduced arm morbidity without compromising survival. These trials provided critical evidence supporting less invasive surgical approaches for breast cancer.
Role of laparoscopic surgery in colorectal cancerDr Amit Dangi
Laparoscopic surgery for colorectal cancer has been studied extensively. Early studies showed potential short-term benefits of laparoscopy over open surgery but also raised concerns about port site tumor recurrence. Later randomized controlled trials demonstrated laparoscopy is oncologically equivalent to open surgery for colon cancer with some short-term recovery benefits. Studies of laparoscopy for rectal cancer found short-term benefits but higher rates of positive margins, though long-term oncologic outcomes were similar. New techniques like robotic surgery are being explored but have not proven more cost-effective than laparoscopy.
This document discusses skin sparing mastectomy (SSM) and nipple sparing mastectomy (NSM). It provides details on the anatomy of the breast and history of breast cancer treatment. SSM aims to remove all breast tissue while preserving the skin and NAC. NSM further preserves the nipple. Selection criteria for NSM include small tumor size and distance from NAC. Outcomes of SSM and NSM are similar to MRM with acceptable morbidity. Complication rates of NSM include nipple necrosis around 7% and occult nipple involvement around 10%. Frozen section of subareolar tissue during NSM helps guide decision for NAC removal. Overall, SSM and NSM provide improved cosmetic
COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAPDr Amit Dangi
THIS PRESENTATION DESCRIBES THE NOVEL SURGICAL TECHNIQUE OF TOTAL ANORECTAL RECONSTRUCTION WITH ANTROPYLORUS TRANSPOSITION AND GLUTEOPLASTY AND ITS RESULTS.
This document discusses the history and technique of the extended abdominoperineal excision (ELAPE) surgery for rectal cancer. It begins with Miles' description of the standard abdominoperineal resection (APR) in 1908. The ELAPE technique was developed to address high circumferential resection margin positivity and local recurrence rates with APR for low rectal cancers. The ELAPE surgery extends the abdominal phase of resection using total mesorectal excision principles and removes the levator muscles en bloc during the perineal phase. Initial studies show ELAPE reduces bowel perforation and positive margin rates compared to APR, with potentially lower local recurrence. However, large randomized controlled trials are still needed to establish EL
Robotic colorectal surgery technique, advantages, disadvantages and its impac...Apollo Hospitals
The use of robotics in colorectal surgery is gaining momentum of late. Technical advances, such as three-dimensional imaging, a stable camera platform, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling and instruments with multiple degrees of freedom, have helped many surgeons adapt to it easily. There is a shorter learning curve compared to the standard laparoscopic surgery. This article helps to give an outline as to how robotic colorectal surgery can go a long way in the future of colorectal surgery.
This document discusses changes in the management of rectal cancer over time. It proposes separating treatment into early, TME, and beyond TME tumors. Total mesorectal excision (TME) surgery, which removes the rectum and surrounding tissue, reduced local recurrence rates from 30% to under 10%. Neoadjuvant therapies combined with TME further improved outcomes. Advancements like improved imaging and minimally invasive techniques have led to a paradigm shift. Rectal cancer is now conceptualized and treated according to tumor location and stage.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
1) The authors reviewed outcomes of 104 consecutive minimally invasive esophagectomies (MIEs) performed between 1998-2007.
2) Surgical approaches included thoracoscopic/laparoscopic esophagectomy with cervical anastomosis (n=47), minimally invasive Ivor Lewis esophagectomy (n=51), and others.
3) Complications included anastomotic leak in 9.6% of patients and stricture in 26%. Mortality was 1.9% at 30 days and 2.9% in-hospital. Mean lymph nodes retrieved was 13.8.
Long Term Outcomes following Laparoscopic Colorectal Surgeryensteve
The document discusses long term outcomes of laparoscopic versus open colorectal surgery based on various studies. Single institution studies and randomized controlled trials found similar long term survival rates between the two procedures. Larger multicenter randomized trials found no difference in 3-year overall or disease-free survival for colon cancer patients undergoing laparoscopic versus open surgery. Current evidence suggests laparoscopic colorectal surgery is not inferior to open surgery for cancer treatment.
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
Selection of surgical procedure for esophageal cancer ver 3.0Vivek Verma
Esophageal cancer is typically treated through surgical resection, which involves removing part of the esophagus. The type of surgery depends on the location and stage of the cancer. Common procedures include McKeown esophagectomy, transhiatal esophagectomy, and Ivor Lewis esophagectomy. While esophagectomy is a major surgery with risks of complications, minimally invasive techniques and extensive lymph node dissection may improve short and long-term outcomes for patients.
Laparoscopic colorectal cancer surgery trialsOliver Anderson
Laparoscopic colorectal cancer surgery was developed in the 1990s. Key trials showed it has better short-term outcomes like lower morbidity compared to open surgery, while providing equivalent long-term cancer outcomes. However, some controversies remain regarding complete resection margins and total mesorectal excision for rectal cancers with this approach.
Laparoscopic Colon Resection - Anterior ApproachGeorge S. Ferzli
1) The document discusses laparoscopic colon resection techniques, including an anterior approach where trocars are placed in the inguinal crease and the sigmoid colon is cut.
2) Studies comparing laparoscopic and open colon resection for cancer show that laparoscopic surgery results in less blood loss, shorter hospital stays, and fewer wound complications with similar long-term survival and recurrence rates.
3) A retrospective study of over 100 patients undergoing laparoscopic colon resection for cancer found 5-year survival rates similar to open surgery and rates reported in the National Cancer Database, suggesting laparoscopic surgery is a safe and effective treatment for colon cancer.
This document describes a technique for performing a single layer continuous hand-sewn esophagogastric anastomosis during a thoracolaparoscopic Ivor Lewis esophagectomy. The technique was performed on 5 patients with lower esophageal adenocarcinoma. No intraoperative complications or postoperative anastomotic leaks occurred. The mean operative time was 338 minutes and mean hospital stay was 8 days. This preliminary study suggests the technique of a thoracoscopic single layer continuous hand-sewn anastomosis is a feasible and safe method for esophagogastric anastomosis during minimally invasive Ivor Lewis esophagectomy. However, larger comparative studies are still needed to fully validate this technique.
This document provides an overview of colorectal carcinoma, including its anatomy, genetics, risk factors, screening, diagnosis, staging, and treatment strategies. Some key points:
- Colorectal cancer is one of the most common cancers worldwide. Proximal colon cancer is usually related to microsatellite instability, while distal colon cancer is associated with chromosomal instability.
- Risk factors include diet, smoking, inflammation. Screening includes fecal occult blood tests and endoscopy starting at age 50.
- Staging involves examining tumor depth, lymph node involvement, and metastasis. Treatment depends on stage but generally involves surgical resection with or without chemotherapy or radiation. The goal is sphincter preservation for rectal cancers
This document discusses the management of vulvar cancer and summarizes key changes over time. It notes that vulvar cancer is predominantly a disease of postmenopausal women and can be preceded by vulvar intraepithelial neoplasia. For early stage disease, radical local excision is usually sufficient. For advanced disease, radical vulvectomy or pelvic exenteration may be needed. Lymph node status is the most important prognostic factor, and inguinofemoral lymphadenectomy or sentinel lymph node biopsy is recommended. The role of preoperative chemoradiation to downstage tumors and allow less radical surgery is also discussed.
This document provides guidance on grossing colorectal specimens, including colon and rectal resection specimens. It discusses:
- Key steps for gross examination including measuring specimens, identifying structures, and evaluating resection margins and lymph nodes
- Anatomy of the colon and relationships to peritoneum
- Identification and sampling of lesions such as polyps, tumors, and areas of inflammation
- Unique handling considerations for rectal specimens including evaluation of the mesorectum
The document emphasizes the importance of thorough gross examination and appropriate sampling to accurately assess resection margins, lymph node status, and other prognostic factors.
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Η Λαπαροσκοπική Χειρουργική στον Καρκίνο του Παχέος Εντέρου και του ΟρθούDimitris P. Korkolis
One of the most common cancers in the world
US: 4th most common cancer
(after lung, prostate, and breast cancers)
2nd most common cause of cancer death
(after lung cancer)
2007: 130,000 new cases of CRC
56,500 deaths caused by CRC
This document summarizes information about gastric carcinoma (stomach cancer). It covers the epidemiology, anatomy, pathology, risk factors, clinical presentation, staging, and treatment of gastric cancer. Key points include:
- Gastric cancer was previously a leading cause of cancer death but now ranks fourth most common. Incidence is highest in China and Japan.
- The stomach has extensive lymphatic drainage involving 16 lymph node stations.
- 95% of gastric cancers are adenocarcinomas. Other rare types include squamous cell carcinoma and carcinoid tumors.
- Risk factors include smoking, obesity, and H. pylori infection. Symptoms are often vague but may include weight loss, abdominal pain,
Esophagus has rich submucosal network of lymphatics which makes longitudinal spread of tumor prevalent.There is propensity for early spread and widespread nodal metastasis.
Adequate proximal (10 cm) and distal resection margin must be achieved.
Dr Ashutosh Mal presented information on colorectal cancer (CRC) management and recent updates. The presentation covered screening, staging, diagnosis, and treatment options for CRC including surgery, chemotherapy, targeted therapy, immunotherapy, and radiotherapy. Recent advances discussed were total mesorectal excision, sphincter-saving surgery techniques like the colonic J-pouch, laparoscopic colorectal surgery, colonic stenting for obstructing cancers, and transanal endoscopic microsurgery.
This document provides an overview of rectal carcinoma. It discusses the epidemiology, risk factors, clinical presentation, investigations, staging, and treatment options. Rectal carcinoma is the third most common cause of cancer deaths in the USA, with over 150,000 new cases diagnosed annually. Treatment may involve local excision, low anterior resection, abdominoperineal resection, or multivisceral resection depending on the stage, size, and location of the tumor. Total mesorectal excision and adjuvant chemoradiation are important to reduce local recurrence rates.
The document discusses the surgical management of primary tumors, regional lymph nodes, and distant metastases. It covers topics like radical vs conservative surgery, lymphadenectomy, sentinel lymph node biopsy, and criteria for resection of distant metastases. It also discusses the use of chemotherapy, including neoadjuvant chemotherapy and response evaluation criteria.
This document provides information on carcinoma of the rectum, including its anatomy, epidemiology, risk factors, clinical presentation, diagnostic workup, staging, treatment options of surgery, chemotherapy and radiotherapy, and prognosis. Key points include:
- The rectum is located in the pelvis and is about 12-15 cm long, divided into upper, middle, and lower thirds.
- Colorectal cancer is the third most common cancer globally and rectal cancer makes up about 28% of cases.
- Risk factors include age over 50, family history, smoking, obesity, and inflammatory bowel disease.
- Treatment involves total mesorectal excision surgery with or without neoadjuvant chemor
ROLE OF DIAGNOSTIC LAPROSCOPY IN ABDOMINAL MALIGNANCIES.pptxparikshithm1
Laparoscopy provides accurate diagnosis and staging of abdominal malignancies through direct visualization of the peritoneal cavity and organs. It can detect occult metastases that may be missed on imaging, avoiding unnecessary laparotomies in nonresectable cases. Laparoscopic ultrasound further enhances staging by allowing visualization of deeply located liver lesions and lymph nodes. For several cancer types including pancreatic and hepatobiliary malignancies, laparoscopy with ultrasound routinely changes management by identifying inoperable cases.
Dr. Ashutosh Mukherji's document discusses contouring for rectal cancers. It provides guidelines for clinical target volume (CTV) delineation based on international consensus. The CTV should encompass the tumor, mesorectum, presacrum, and lymph node regions depending on tumor stage and location. Proper contouring is important for administering precise radiotherapy doses to treat rectal cancer while avoiding unnecessary radiation to healthy tissues.
Three field lymphnode dissection in treating the esophageal cancer reviews the role of lymph node dissection in esophageal cancer treatment. It discusses that while 3-field lymphadenectomy provides better survival and reduces recurrence by removing more lymph nodes, it also has higher morbidity. Recent improvements in imaging and minimally invasive surgery have increased the feasibility of 3-field lymphadenectomy. The conclusion is that 3-field lymphadenectomy is becoming standard for esophageal cancer with cervical or upper mediastinal node metastasis, as it provides no difference in survival or postoperative outcomes compared to 2-field lymphadenectomy.
1. Rectal cancer is a common malignancy that arises in the rectum, usually within 15 cm of the anal verge.
2. Diagnostic workup includes physical exam, proctoscopy, biopsy of the primary tumor, and imaging. Blood tests like CEA are also done.
3. Treatment involves a multidisciplinary approach with surgery, often total mesorectal excision, along with pre- or post-operative chemoradiation to reduce the risk of recurrence. The type of surgery depends on how far the cancer has spread.
Surgical management of colorectal cancer.pptxHamSayshi1
Surgical treatment of Colorectal Cancer Current Treatment Guidelines 2024...A reveiw of literature
palliative management of CRC and Mechanical bowel preparation in case of CRC alongwith Treatment guidleines of grade 4 CRC in presence of metastasis
The document describes the anatomy, blood supply, innervation, and common cancers of the urinary bladder. It discusses the following key points:
- The bladder wall has four layers - serous, muscular, submucosal, and mucosal coats. The detrusor muscle in the muscular layer allows the bladder to expand and contract.
- The main arteries supplying the bladder are branches from the internal iliac arteries. Lymph drainage is to the external and internal iliac and sacral nodes.
- Over 90% of bladder cancers are transitional cell carcinomas. Risk factors include smoking, occupational exposures, schistosomiasis infection, and certain drugs.
-
This document discusses the management of early laryngeal cancer. It covers diagnosis using laryngoscopy, radiological imaging like CT scans and MRI, and staging of laryngeal malignancies. Recommended treatments for early and late stage cancers are transoral laser microsurgery, radiotherapy, open partial laryngectomy, and total laryngectomy. Transoral laser microsurgery is described as the standard treatment for mid-cord glottic cancers and offers advantages like better voice quality and minimal swallowing difficulty compared to radiotherapy. Radiotherapy is an alternative organ-preserving option for early laryngeal cancers. Open partial laryngectomies include vertical and horizontal procedures tailored to the location and size of the tumor.
This document provides information about carcinoma of the esophagus, including its epidemiology, risk factors, pathological classification, clinical features, investigations, diagnosis and staging, and treatment. Carcinoma of the esophagus is most common in China, South Africa and parts of India. Risk factors include alcohol, tobacco, Barrett's esophagus, and gastroesophageal reflux disease. Investigation may include endoscopy, biopsy, imaging studies. Treatment depends on the stage - early stage cancers may be treated with surgery while advanced or metastatic cancers receive palliative approaches like chemotherapy or radiation.
This document provides information about carcinoma of the esophagus, including its epidemiology, risk factors, pathological classification, clinical features, investigations, diagnosis and staging, and treatment. Carcinoma of the esophagus is most common in China, South Africa, and parts of India. It typically presents with dysphagia. Investigations include endoscopy with biopsy, imaging like CT and PET scans, and endoscopic ultrasound. Treatment depends on the stage, with surgery or chemoradiation used for early-stage or locally advanced carcinoma, and palliative approaches for metastatic disease.
1. Paranasal sinuses tumors can occur in the ethmoid sinuses, frontal sinuses, sphenoid sinus, and maxillary antrum.
2. The most common histology is squamous cell carcinoma, followed by minor salivary gland tumors and lymphomas.
3. Tumors commonly spread to nearby structures like the orbits, nasal cavity, maxillary antrum, and cranial fossa. Distant spread is usually to the lungs.
4. Treatment involves surgery if possible followed by radiation therapy. Advanced cases are treated with chemoradiation. Endoscopic approaches are increasingly used for ethmoid sinus tumors.
This document provides information on osteoradionecrosis (ORN), including its definition, history, risk factors, clinical presentation, diagnosis, treatment and more. Some key points:
- ORN is defined as exposed irradiated bone that fails to heal for 3 months without evidence of tumor recurrence. It is most commonly caused by radiation therapy combined with trauma.
- Risk factors include high radiation dose, brachytherapy, trauma from dental procedures, tobacco/alcohol use. The mandible is more commonly affected than the maxilla.
- Clinical presentation may include pain, swelling, tooth mobility or exposure of necrotic bone. Advanced cases can involve pathological fracture or draining fistulae
Carcinoma of the maxillary sinus is rare, constituting 3-5% of head and neck cancers. The maxillary sinus is the most common site. Anatomy of the maxilla includes processes, surfaces, and articulations with other bones. Maxillary sinus boundaries include the roof, medial wall, floor, and buttresses. Ohngren's line divides lesions into suprastructure and infrastructure types. Spread can occur via routes like the pterygomaxillary space. Risk factors include wood dust and HPV. Pathology is usually squamous cell carcinoma. Symptoms include oral, nasal, auditory, and facial issues. Diagnosis involves imaging like CT and MRI. Management involves surgery with or without radiation depending on
This document discusses the etiopathogenesis of head and neck cancer. It covers various chemical, viral, dietary, and occupational carcinogens. Tobacco use, alcohol consumption, and HPV/EBV infection are highlighted as major risk factors. The mechanisms of carcinogenesis for these exposures involve induction of DNA damage and mutations in tumor suppressor genes like p53 and oncogenes like ras. Field cancerization is described as explaining multiple primary tumors in the head and neck region that share a clonal origin.
Non-melanoma skin cancers like basal cell carcinoma and squamous cell carcinoma primarily affect elderly individuals. They are usually treated with surgical excision, with Mohs micrographic surgery used for difficult locations. Early-stage cancers may also be treated with topical therapies or cryotherapy. Advanced cancers require wider excision and sometimes adjuvant radiation. Immunotherapy drugs have shown promise for locally advanced or recurrent cases. Screening and sun protection can help prevent non-melanoma skin cancers.
This document summarizes salivary gland tumors. It discusses the location and types of major and minor salivary glands. The most common tumors are pleomorphic adenoma, Warthin's tumor, and mucoepidermoid carcinoma. Risk factors for salivary gland cancers include radiation exposure and certain occupations. Treatment involves surgical resection of the gland with preservation of nearby structures like the facial nerve when possible. Post-operative complications can include facial nerve palsy.
This document discusses managing the mandible in oral cavity cancers. It covers the anatomy of the mandible, routes of tumor entry, assessing bony erosion, types of mandibular resection including marginal and segmental resection, classification of mandibular defects, and reconstruction techniques. Imaging plays an important role in evaluating mandibular invasion and determining the appropriate resection. Reconstruction may involve bone grafts, distraction osteogenesis, dental implants, or vascularized flaps to restore form and function following resection.
The document discusses various techniques for reconstructing defects of the lips after tumor resection, including:
1. The Abbe-Estlander flap rotates tissue from the opposite lip to repair defects of over 30% of the upper or lower lip.
2. The Karapandzic flap mobilizes tissue from the lower nasolabial region to reconstruct large lower lip defects.
3. The Johanson step ladder advancement flap excises small rectangles from the sides of the lower lip defect to close gaps.
It also describes techniques for reconstructing the vermilion border and commissures, as well as complications of lip reconstruction.
This document discusses the management of luminal breast cancers. It covers several topics:
1) The different breast cancer subtypes, including luminal A and B cancers, which make up 50-60% and 15-20% of cases respectively. Luminal A has a better prognosis while luminal B is more aggressive.
2) The need for molecular signatures to better classify cancers and predict outcomes. Trials have shown certain gene expression profiles can determine if chemotherapy is needed.
3) Guidelines for adjuvant systemic therapies for luminal cancers, including chemotherapy, endocrine therapy, radiation, and duration of treatment. Trials support extended endocrine therapy to lower recurrence risk.
4) Neoadjuvant endocrine therapy
The document discusses triple negative breast cancer (TNBC) and early stage disease. It covers molecular subtypes of breast cancer, challenges in treating TNBC due to lack of targeted therapies, and evidence that neoadjuvant chemotherapy can improve outcomes for TNBC patients who achieve a pathological complete response. Ongoing research aims to better predict which patients will respond to neoadjuvant treatment and identify new targeted therapies for TNBC subtypes.
This document discusses the management of early HER2+ breast cancer. It defines early breast cancer and describes the HER2+ subtype, which accounts for around 25% of cases. For early HER2+ breast cancer, neoadjuvant chemotherapy plus trastuzumab improves pathological complete response rates and long-term outcomes compared to chemotherapy alone. Multiple trials demonstrate the benefit of adding pertuzumab or T-DM1 to neoadjuvant regimens. Post-neoadjuvant surgery may require close evaluation of margins due to heterogeneous response.
A concise presentation on etiopathogenesis of head and neck cancer, oral potentially malignant disorders and role of epigenetics in head and neck cancer.
Transoral robotic surgery (TORS) was developed to overcome limitations of traditional open surgery for head and neck cancers. The da Vinci system allows 3 robotic arms to be inserted transorally for tumor resection with 10x magnification. TORS has expanded treatment options for cancers of the tonsils, base of tongue, larynx and thyroid. Outcomes data suggests TORS results in fewer complications and better swallowing compared to open surgery or chemoradiation. While long-term data is still needed, TORS has emerged as a viable alternative to traditional treatment paradigms for select head and neck cancers.
This document summarizes several landmark trials investigating chemotherapy and radiation therapy approaches for gastric cancer. Key points include:
- Perioperative chemotherapy is now standard for resectable stage II-IV gastric cancer based on trials like MAGIC and FLOT4 showing improved survival.
- FLOT4 established docetaxel-based chemotherapy as the preferred perioperative regimen.
- Adjuvant chemotherapy is recommended after curative surgery without neoadjuvant therapy based on the CLASSIC trial.
- Trials like ARTIST1/2 and CALGB80101 found no benefit to adding adjuvant radiation after D2 lymph node dissection.
- Targeted agents like trastuzumab and ramuc
This document discusses treatment strategies for gastric cancer, including surgery, endoscopic resection, and guidelines. It addresses topics such as the appropriate extent of lymph node dissection, whether to perform total or subtotal gastrectomy, when multi-organ resection may be necessary, and comparisons of open versus laparoscopic surgery. Palliative interventions like gastrojejunostomy or stenting are also evaluated. The document emphasizes individualizing treatment based on cancer stage and location, with the goal of an R0 resection while minimizing treatment-related morbidity.
This document discusses lymphoma, including Hodgkin and non-Hodgkin lymphoma. It provides information on the classification, staging, diagnostic testing, prognostic factors, and treatment approaches for both diseases. Key points include that lymphoma originates from lymphoid cells, the Reed-Sternberg cell is characteristic of Hodgkin lymphoma, staging involves the Ann Arbor system, and treatment often involves chemotherapy such as ABVD or R-CHOP depending on the specific lymphoma subtype and stage.
This document discusses anastomotic leakage following bowel surgery. It provides details on types of anastomoses, classification of leaks, risk factors, presentation, diagnosis, and management. Key points include: leaks are classified as early (<3 days), intermediate (4-7 days), or late (>8 days); grade A leaks are detected on imaging with no clinical features while grades B and C require intervention; and management depends on the severity and location of the leak, ranging from observation to drainage, antibiotics, diversion, or reoperation.
This document discusses ovarian germ cell tumors (OGCTs), including their subtypes, malignant potential, tumor markers expressed, routes of spread, grading systems, and treatment approaches. The main subtypes of OGCTs are dysgerminoma, endodermal sinus tumor, embryonal carcinoma, polyembryoma, choriocarcinoma, teratoma, and mixed germ cell tumors. Staging, grading, and the presence of certain subtypes and tumor markers determine the need for chemotherapy or surveillance following surgery. Long-term surveillance involves physical exams, serum tumor marker checks, and radiographic imaging for 5 years or more to monitor for recurrence.
Landmark chemotherapy trials in advanced ovarian cancer established platinum-based combinations as the standard of care. GOG 47 (1986) showed cisplatin improves response rates and progression-free survival compared to cyclophosphamide alone. GOG 111 (1996) found the combination of paclitaxel and cisplatin improved progression-free and overall survival over cyclophosphamide and cisplatin. Subsequent trials determined carboplatin as an effective alternative to cisplatin, with fewer side effects.
This document discusses intraperitoneal chemotherapy for epithelial ovarian carcinoma. It provides a brief history of intraperitoneal chemotherapy and outlines the rationale for delivering chemotherapy directly into the peritoneal cavity. The document summarizes several key trials that demonstrated improved progression-free and overall survival with intraperitoneal chemotherapy compared to intravenous chemotherapy alone for optimally debulked stage III ovarian cancer. It also discusses patient selection, technical considerations, administration of intraperitoneal chemotherapy, and potential complications. Emerging techniques like hyperthermic intraperitoneal chemotherapy and pressurized intraperitoneal aerosol chemotherapy are also summarized.
More from Cancer surgery By Royapettah Oncology Group (20)
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
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Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
6. PROF.S.SUBBIAH
Introduction
• Treatment options for colorectal cancer are
evolutionally changing, even in the last few
years
• Screening
• Surgical advances
• Chemotherapy - targetted therapy
• Chemoprevention?
• Radiation updates
11. PROF.S.SUBBIAH
What is new in colonoscopy?
• The third most common form of cancer worldwide —
relies heavily on colonoscopies.
• Traditional colonoscopies are expensive, painful and
require high levels of skills.
• New approaches
– magnetic probes precisely controlled by a robotic
arm, which allows for complex movement inside the
body.
– Still complicated and requires high level training.
12. PROF.S.SUBBIAH
Semi-automated robotic system
• James Martin, Bruno Scaglioni
• Simple movement commands from the user.
• The probe moves using machine intelligence and image
analysis to automatically guide itself along the colon.
16. PROF.S.SUBBIAH
History
• First reports of LAP for colon CA in 1990 - JACOBS
• Short-term benefits (pain, ileus, hospitalization) have not been then
pronounced compared to open surgery
• PSR has led to resistance among surgeons to learn the technique
17. PROF.S.SUBBIAH
Port site Recurrence
• Definition: Recurrence of tumor in a trocar wound without advanced
abdominal disease
• First report in 1993
• Initially reported rates: 0 - 21%*
• NOT necessarily with advanced cancer
• Cast a dark shadow over laparoscopic surgery for malignancy
Berends, Lancet 1994
19. PROF.S.SUBBIAH
Results
• LC took significantly longer Operating time (median 145 vs. 115
min; p-0.0001)
• Significantly less blood loss (median 100 vs. 175 mL; P-0.0001).
• Conversion rate was 17%, mainly due to bulky tumors and extensive
adhesions.
• Postoperative length of stay was 1.1 days shorter after LC (mean 8.2
vs. 9.3 days; p0.0001).
20. PROF.S.SUBBIAH
• Pathological outcomes- no difference between the two groups.
• Long-term oncologic evaluation revealed no significant differences
in DFS, OS, and recurrence.
• Low volume centers and High volume centers
• Similar to Barcelona and COST trials
21. PROF.S.SUBBIAH
Robotic vs lap colectomy.?
● Only observational cohort studies.
● In general, the robotic approach
● longer operating times and is more expensive
● Less blood loss, shorter time to recovery of bowel function,
shorter hospital stays, and lower rates of complications and
infections.
22. PROF.S.SUBBIAH
CME - Concept of improved resections?
● Hohenberger- Complete Mesocolic Excision- Germany
● Dissection within embryological planes of dorsal mesentery yields a
scatheless specimen.
● Analogous toTME concept by Heald et al.
● Mesocolon = dorsal mestentery.
● Visceral and parietal peritoneum covers the colon like a sheath
● Submesothelial connective tissue and interlobular septations.
23. PROF.S.SUBBIAH
Surgical Colonic Interfaces
● Extra fascial plane between the mesocolon and
retroperitoneum = “Toldt’s Fascia”.
● (I) “Colo-fascial interface” - confluence of colonic surface and
“Toldt’s Fascia”
● (II) “Meso-fascial interface” confluence of mesocolon and
“Toldt’s Fascia”
● (III) “Retro-fascial interface” confluence of retroperitoneum and
“Toldt’s Fascia”
25. PROF.S.SUBBIAH
CME vs Non CME colectomy?
● Japan (D3 lymphadnectomy) and Germany (CME + CVL).
● Complete mesocolic excision (CME) with central vascular
ligation resulted in greater mesentery and lymph node yields
than the Japanese D3 high tie surgery.
● Disadvantages - Differences in outcomes were not reported.
26. PROF.S.SUBBIAH
Other supportive evidences for CME
with CVL
● A retrospective, population based study in Denmark also supports
the benefit of a CME approach in patients with stage I–III colon
cancer, with a significant difference in 4-year DFS (P = .001) between
those undergoing CME resection (85.8%; 95% CI, 81.4–90.1) and
those undergoing conventional resection (75.9%, 95% CI, 72.2–79.7).
● A systematic review found that 4 of 9 prospective studies reported
improved lymph node harvest and survival with CME compared with
non-CME colectomy; the other studies reported improved specimen
quality.
33. PROF.S.SUBBIAH
Rectal cancer- where do we stand?
• Revolutionary last thirty years.
• Previously, local relapses in the pelvis in 30% LARC.
• 1st step to improve local control = Total mesorectal excision
(Reducing local relapses to less than 5%).
• 2nd step = Preoperative radiation (short course Vs long
course with CCRT).
34. PROF.S.SUBBIAH
Rectal cancer- what is known now?
• Magnetic resonance imaging = useful tool for locoregional staging
and for properly selecting patients for preoperative treatment
(Mercury trial).
• Nowadays, we know that preoperative Total neoadjuvant (TNT)
with chemotherapy also provides better control of systemic
relapses(RAPIDO and Rect 03 trial).
• Moreover, surgery can be avoided in 25% of patients and the
“watch and wait strategy” is considered safe and curative (Habr
Gama).
37. PROF.S.SUBBIAH
(1) Recognition of mobility between tissues of different embryological origins
(2) Sharp dissection under direct vision in a good light
(3) Gentle opening of the plane by continuous traction with no actual tearing.
DEFINE AN OPTIMAL DISSECTION PLANE around the cancer which must clear all
forms of extension and circumscribe predictably uninvolved tissues. ‘
“the whole rectum and mesorectum are one distinct lymphovascular entity”
38. PROF.S.SUBBIAH
• Circumferential resection margin (CRM) is the closest distance between the
radial resection margin and the tumor tissue by either direct tumor spread,
areas of neural or vascular invasion, or the nearest involved lymph node.
40. PROF.S.SUBBIAH
Total Mesorectal Excision
• The intramural spread of cancer downward is very rare, but extramural
spread appears both in distal and anterior directions.
• Anatomically three spaces can be distinguished around the rectum.
• The inner space is surrounded by a visceral fascia on the posterior side,
and Denonvillier’s fascia on the front of the rectum.
– Laterally they unite and are related to nerve plexus
• Intermediate space is limited by the parietal pelvis fascia on the posterior
side and the internal iliac arteries and their branches on both lateral sides,
and on the front.
43. PROF.S.SUBBIAH
• The outer space is localized outside the
internal iliac arteries and their branches
• TME = Removal of the internal space with the
visceral fasciation and Denon-Villiers fascia
whilst preserving the pelvis nerve plexus on
both lateral sides.
46. PROF.S.SUBBIAH
• TME should be performed to a level of 5 cm below the distal
margin of the primary tumour in the upper rectum or to the
pelvic floor (complete TME) for tumours in the lower or
middle rectum.
• A minimum negative proximal margin of 5 cm is required
• The minimum acceptable negative distal margin is 2 cm for
cancers located above the distal meso-rectal margin. For
cancers located at or below the distal meso-rectal margin, a 1
cm negative distal margin is acceptable.
What remains the gold standard in
surgery?
48. PROF.S.SUBBIAH
42 and 147 patients were ligated at the origin of the IMA (high tie) and just
below the origin of the LCA combined with LND around the origin of the
IMA (low tie with LND), respectively.
No significant differences were observed in the complication rate and OS
and RFS rates between high tie and low tie groups.
50. PROF.S.SUBBIAH
Transanal excision/ Transanal endoscopic surgery
(TES)
• Radical surgery for stage I and II rectal cancer can expect excellent long-
term results which approach 5-year local recurrence rates of 4.5 % and
90% 5-year disease free survival (DFS) rates
• Morbidity is high (30-68%) with a mortality that approaches 7% in
certain pooled studies
Journal of Gastro intestinal Oncology 2015
51. PROF.S.SUBBIAH
Criteria for Local rectal excision ?
Physical examination:
tumor <3cm
tumor <30% of bowel circumference
tumor within 15cm of dentate line
tumor freely mobile
Imaging (ERUS/MRI)
Tumor limited to submucosa(T1)
Lymphnode involvement(N0)
Histology:
Well to moderately differentiated
Absence of LVI or PNI
No mucinous or signet ring cell
component
Journal of Gastro intestinal Oncology 2015
53. PROF.S.SUBBIAH
• Local recurrence rates tend to be higher for both T1 (8.2-23%) and
T2 adenocarcinomas (13-30%) undergoing LE when compared to
radical surgery for T1-T2 disease (3-7.2%).
• No significant difference in DFS when compared to radical surgery.
54. PROF.S.SUBBIAH
Postoperative complications of TAE are
• Rectal bleeding which is the most common (6%),
• Rectal stenosis (5.5%),
• urinary retention (1.5%),
• fecal incontinence (0.5%), and
• rectovaginal fistula (<1%)
The most common complications TEM reported are
• hemorrhage (27%),
• urinary tract infection (21%), and
• suture line dehiscence (14%) and
• 4.3% conversion to radical procedures
Complications following the TAMIS procedure are infrequent with
an overall rate of 7.4% with conversion rate of 4%
55. PROF.S.SUBBIAH
NON OPERATIVE MANAGEMENT IN DISTAL RECTAL
CANCER
• Brazil
• Five-year overall and disease-free survival rates were 88% and 83%,
respectively, in Resection Group and 100% and 92% in Observation
Group
• NCCN 2021:
• “ In select patients achieving complete clinical response as
demonstrated by clinical examination, imaging and endoscopy
following neoadjuvant chemo radiotherapy may be advised
observation with strict serial monitoring after multidisciplinary team
discussion in select high volume centres”
57. PROF.S.SUBBIAH
Laparoscopic Vs Open rectal surgeries
• Two previous large RCT and several meta-
analyses showed similar pathological and
oncological outcomes between laparoscopic
and open approaches for rectal cancer
• The laparoscopic approach was regarded as a
standardized alternative to the open approach
59. PROF.S.SUBBIAH
• Robotic assistance has the potential to overcome limitations of
laparoscopic surgery
• Meta analysis - failed to show superiority of robotic assisted over
conventional laparoscopic surgery
• Safety, efficacy , short and long term outcomes were analysed ( 2017)
60. PROF.S.SUBBIAH
• The primary outcome - conversion to open laparotomy.
• Rate of urinary retention was significantly lower in the
robotic group than in the laparoscopic group (2.5% vs 7.5%, P
= .018).
• 28 of 230 patients (12.2%) in the conventional laparoscopic
and 19 of 236 patients (8.1%) in the robotic assisted
laparoscopic group
61. PROF.S.SUBBIAH
• 701 patients were randomized to the ME with LLND (n = 351) and ME
alone (n = 350) groups. ( 2017 Fujita et al )
• The 5-year relapse-free survival in the ME with LLND and ME alone
groups were 73.4% and 73.3%, respectively
• The 5-year overall survival, and 5-year local-recurrence-free survival
in the ME with LLND and ME alone groups were 92.6% and 90.2%,
and 87.7% and 82.4%, respectively.
• The numbers of patients with local recurrence were 26 (7.4%) and 44
(12.6%) in the ME with LLND and ME alone groups, respectively
62. PROF.S.SUBBIAH
• Ishihara et al reported that the incidence of LLN metastasis was estimated
to be 8.1% (18/222) even after preoperative CRT.
• Kusters et al reported that the lateral local recurrence rate was
significantly higher in patients with LLN larger than 10 mm in pre
treatment imaging.
• The safety and feasibility of laparoscopic versus open LLND showed similar
oncological outcomes between the groups.
• Establishment of criteria to accurately predict LLN status as well as
standardization of the technique of LLND is necessary in the future
63. PROF.S.SUBBIAH
228 patients with low rectal cancer <5cm from anal verge between 1996 to 2004
were enrolled
86% successful
24% morbidity and 0.4% mortality
Five year overall survival 91.9% and 83.4% DFS
Curability with intersphincteric resection was verified histologically, and
acceptable oncologic and functional outcomes were obtained by using these
procedures in patients with very low rectal cancer.
65. PROF.S.SUBBIAH
Liquid biopsy - biopsing your DNA
content.
• Liquid biopsies are a promising new approach
• To detect, analyze, and track DNA, cells, and other substances shed
from tumors into bodily fluids, such as blood and urine.
• COBRA trial which studies how well circulating tumor DNA (ctDNA)
testing in the blood works
• To identify patients with stage IIA colon cancer who might benefit
from additional treatment with chemotherapy after surgery.
66. PROF.S.SUBBIAH
Aspirin
• Recent studies have shown that daily low-dose aspirin may
prevent colorectal cancer.
• However, there are potential harms, particularly the risk of
gastrointestinal bleeding.
• Aspirin is currently recommended by the US Preventive
Services Task Force (USPSTF)Exit Disclaimer to prevent
colorectal cancer and cardiovascular disease in some
individuals age 50 to 69.
67. PROF.S.SUBBIAH
Immunotherapy for patients with
Lynch syndrome
• >5% of CRC
• Immune checkpoint inhibitors nivolumab (Opdivo), ipilimumab
(Yervoy), and pembrolizumab (Keytruda) have been approved for the
treatment of metastatic CRC in patients with Lynch syndrome.
• They also have been approved for metastatic CRC in patients with
microsatellite instability-high cancer (MSI-H).
68. PROF.S.SUBBIAH
Take home points
● Routine use of minimally invasive colon resection is generally not
recommended for tumors that are acutely obstructed or perforated
or tumors that are clearly locally invasive into surrounding structures
(ie, T4)
● Laparoscopic vs Open colectomy has advantages of laparoscopic
interventions with preserved oncologic outcomes.
● CME +CVL is better than High tie surgery
● Lap CME is better than Open CME.
● ERAS protocol for colonic resections- intrinsic advantages to return to
near normal life.
69. PROF.S.SUBBIAH
• T1N0 – select patients with low risk features – Local Excision
• Other T1,T2 – Radical Abdominal surgery with TME
• T3, T4 N+ - Neoadjuvant chemo RT Surgery
• Operable Early rectal cancer – NACRT- not useful due to
significant toxicity
• LAP > OPEN Radical Rectal Surgery
• Evolving – Robotic Surgery , Lateral Node dissections
which includes all vascular and lymphatic pathways and lymph nodes.
HC shows that lymphatic channels within the mesocolon are densely present in both
MRI from patients showing locally advanced rectal cancer with high-risk features. (A) Upper
third rectal cancer with peritoneal reflection invasion (cT4a). (B) Same patient showing extra-mural
vascular invasion. (C) Lower third rectal cancer in a male with invasion of the anterior part of the
mesorectal fascia (cT3d) and multiple large size peritumoral lymph nodes (N2) (D).