Presentatie van huidige waarde van CT Colonoscopie, toelichting van de techniek, bespreking van toekomstmogelijkheden en mogelijke rol bij screening naar colorectaal carcinoom
In deze presentatie wordt toegelicht wat de huidige stand van zaken is betreffende CT colografie voor diagnostiek en screening van colorectaal carcinoom
Presentatie van huidige waarde van CT Colonoscopie, toelichting van de techniek, bespreking van toekomstmogelijkheden en mogelijke rol bij screening naar colorectaal carcinoom
In deze presentatie wordt toegelicht wat de huidige stand van zaken is betreffende CT colografie voor diagnostiek en screening van colorectaal carcinoom
1) This case involves a 22-year-old man who presented with abdominal pain and was found to have early acute appendicitis on ultrasound.
2) Despite having minimal clinical symptoms and a normal blood test, ultrasound was repeated and again found evidence of early acute appendicitis.
3) The patient was admitted for a laparoscopic appendectomy.
This document describes the extralevator abdominoperineal excision (APE) technique for rectal cancer. APE involves removing the levator muscles and anal canal en bloc through an extended posterior perineal approach. This results in a more cylindrical specimen compared to conventional abdominoperineal resection (APR), reducing risks of a positive circumferential resection margin or bowel perforation. In a study of 28 patients who underwent APE, the technique had a low rate of complications and local recurrence compared to conventional APR. Reconstruction using a gluteus maximus flap also reduced perineal wound issues.
Complete Mesocolic Excision (CME) is a surgical technique for colon cancer based on Total Mesorectal Excision principles for rectal cancer. CME involves sharp dissection along embryonic planes between the visceral and parietal fascia to remove the colon and intact mesocolon lymphovascular package. Central ligation of supplying vessels also aims to maximize lymph node harvest. A study of over 1,300 colon cancer patients who underwent CME found improved 5-year cancer survival rates and reduced local recurrence compared to previous techniques, correlated with higher lymph node counts. CME principles include producing an intact specimen and maximizing lymph node dissection for improved oncologic outcomes.
Standardized Surgery for Colonic Cancer - Complete Mesocolic Excision (CMF)SociedadColoprocto
The document discusses the technique of complete mesocolic excision (CME) for colon cancer surgery. It describes CME as the standardized removal of the entire mesocolon and central ligation of supplying arteries based on embryological planes. Studies from Erlangen, Germany show that using CME results in improved lymph node harvest, lower complication rates, reduced local recurrence, and increased 5-year cancer-related survival for colon cancer patients compared to conventional surgery. The expertise of the surgeon also impacts postoperative outcomes.
This document discusses strategies for treating locally advanced colon cancer. It begins with comparisons to Napoleon's military strategies, emphasizing appreciation of terrain, timing, steady nerve, and teamwork. It then discusses specific challenges of locally advanced colon cancer like invasion of adjacent organs or abdominal wall. Multivisciplinary treatment including neoadjuvant chemotherapy and multivisceral resection is discussed. Recurrent colon cancer and complications of treatment are also mentioned. Throughout, surgical strategies are compared to Napoleon's tactical approaches to warfare.
The document discusses total mesorectal excision (TME) as the standard surgery for rectal cancer. It summarizes several trials showing that TME combined with preoperative radiotherapy reduces local recurrence rates compared to radiotherapy and older surgery techniques. The document also discusses techniques to improve quality of TME surgery and reduce sexual dysfunction, as well as standardizing multimodal therapy for rectal cancer.
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
1. Surgery for rectal cancer aims to remove the tumor and surrounding tissue while preserving nerve function to maintain bowel and bladder control.
2. The gold standard surgery is total mesorectal excision (TME), which provides a low local recurrence rate below 10% due to complete removal of surrounding tissue.
3. TME requires meticulous technique by an experienced colorectal surgeon to dissect the rectum from the surrounding tissue while preserving nerves.
1) This case involves a 22-year-old man who presented with abdominal pain and was found to have early acute appendicitis on ultrasound.
2) Despite having minimal clinical symptoms and a normal blood test, ultrasound was repeated and again found evidence of early acute appendicitis.
3) The patient was admitted for a laparoscopic appendectomy.
This document describes the extralevator abdominoperineal excision (APE) technique for rectal cancer. APE involves removing the levator muscles and anal canal en bloc through an extended posterior perineal approach. This results in a more cylindrical specimen compared to conventional abdominoperineal resection (APR), reducing risks of a positive circumferential resection margin or bowel perforation. In a study of 28 patients who underwent APE, the technique had a low rate of complications and local recurrence compared to conventional APR. Reconstruction using a gluteus maximus flap also reduced perineal wound issues.
Complete Mesocolic Excision (CME) is a surgical technique for colon cancer based on Total Mesorectal Excision principles for rectal cancer. CME involves sharp dissection along embryonic planes between the visceral and parietal fascia to remove the colon and intact mesocolon lymphovascular package. Central ligation of supplying vessels also aims to maximize lymph node harvest. A study of over 1,300 colon cancer patients who underwent CME found improved 5-year cancer survival rates and reduced local recurrence compared to previous techniques, correlated with higher lymph node counts. CME principles include producing an intact specimen and maximizing lymph node dissection for improved oncologic outcomes.
Standardized Surgery for Colonic Cancer - Complete Mesocolic Excision (CMF)SociedadColoprocto
The document discusses the technique of complete mesocolic excision (CME) for colon cancer surgery. It describes CME as the standardized removal of the entire mesocolon and central ligation of supplying arteries based on embryological planes. Studies from Erlangen, Germany show that using CME results in improved lymph node harvest, lower complication rates, reduced local recurrence, and increased 5-year cancer-related survival for colon cancer patients compared to conventional surgery. The expertise of the surgeon also impacts postoperative outcomes.
This document discusses strategies for treating locally advanced colon cancer. It begins with comparisons to Napoleon's military strategies, emphasizing appreciation of terrain, timing, steady nerve, and teamwork. It then discusses specific challenges of locally advanced colon cancer like invasion of adjacent organs or abdominal wall. Multivisciplinary treatment including neoadjuvant chemotherapy and multivisceral resection is discussed. Recurrent colon cancer and complications of treatment are also mentioned. Throughout, surgical strategies are compared to Napoleon's tactical approaches to warfare.
The document discusses total mesorectal excision (TME) as the standard surgery for rectal cancer. It summarizes several trials showing that TME combined with preoperative radiotherapy reduces local recurrence rates compared to radiotherapy and older surgery techniques. The document also discusses techniques to improve quality of TME surgery and reduce sexual dysfunction, as well as standardizing multimodal therapy for rectal cancer.
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
1. Surgery for rectal cancer aims to remove the tumor and surrounding tissue while preserving nerve function to maintain bowel and bladder control.
2. The gold standard surgery is total mesorectal excision (TME), which provides a low local recurrence rate below 10% due to complete removal of surrounding tissue.
3. TME requires meticulous technique by an experienced colorectal surgeon to dissect the rectum from the surrounding tissue while preserving nerves.
3. Galblaastumoren
• Incidentie 1,2 / 100.000
• 6de decade
• 1:3, Man:Vrouw
• Frequent voorkomen Israël, Mexico, Chili, Japan,
Oost-Europa en “Native Americans”
• Meest voorkomende galwegtumor
• 5de meest voorkomende gastro-intestinale tumor
• 1% APO bij CCE
4. Galblaastumoren
• Risico-factoren
• Galstenen (grote en cholesterol, 75-90 %) en
poliepen
• Porcelijnen galblaas (20-60%)
• Chronisch inflammatoire condities zoals
cholecysto-enterische fistel of tyfoïd
• Afwijkende pancreatico-biliaire junctie met een
lang gemeenschappelijk kanaal tussen de
ductus choledocus en ductus pancreaticus,
choledochuscysten
• IBS en polyposis coli
5. Galblaastumoren
• Risico-factoren
• 70-90 % aanwezigheid van galstenen bij
galblaastumoren. Algemeen risico op
galblaastumor in patiënten met galblaasstenen
beperkt.
• Incidentie van galblaastumor bij patiënten met
galstenen varieert van 0.3 tot 3%
• Niet-aangetoonde risico-factoren
• Medicatie zoals Aldomet, orale contraceptiva en
INH
• Rubber-blootstelling
6. Galblaastumoren
• Pathologie
• Premaligne letsels
• Progressie mucosale dysplasie naar
carcinoma-in-situ en invasief carcinoma.
• Gemiddelde duur 15 jaar
• Galblaaspoliepen
• 3-6 % patiënten met galstenen
• Overgrote meerderheid cholesterolpoliepen,
niet maligne
• 1% adenomateuze poliepen
10. Galblaastumoren
Work-up
• Labo
• Vergevorderde ziekte met anemie,
hypoalbuminemie, leukocytose, gestegen AF en
bilirubine
• Tumormerkers
• CEA – hoge specificiteit (90%) lage
sensitiviteit (50%)
• Ca 19-9 - 75% specificiteit en sensitiviteit bij
concentraties >20 U/ml
11. Galblaastumoren
Work-up
Beeldvorming
Echografie
Discontinue mucosa, echogene mucosa en
submucosale echolucencie. Doppler-
flowmeting differentiatie maligne en benigne
Contrast enhanced ultrasound ?
CT abdomen
Grootte en uitgebreidheid ziekte. Informatie
lokale uitgebreidheid en metastasen
Massa die lumen opvult (42%), polypoïde
massa (26%) diffuse wandverdikking (6%).
16. Galblaastumoren
Work-up• Beeldvorming
• CT abdomen
• Aanwezigheid lokale en regionale
adenopathieën - Grootte > 1 cm en
ringvormig identificatie pathologische klieren
preoperatief in 80%.
• MRI
• Mate van lever- en LK-aantasting
• Evaluatie galweg thv de leverhilus en van
de hepatische vaten
• Icterus – Maligne strictuur galweg oorzaak
is van icterus
18. Galblaastumoren
Behandeling
• Galblaaspoliepen
• Resectie wanneer leeftijd > 50 jaar, solitaire
poliep, grootte > 1 cm
• Poliep < 1 cm - observatie met seriële 6-
maandelijkse echografie, LCCE te overwegen
• Poliep 1-2 cm en asymptomatisch – LCCE met
beperkt risico tumor seeding, vriescoupe voor
eventuele definitieve behandeling
• Poliep > 2 cm met geen maligniteit aantoonbaar
beeldvorming – Open CCE risico seeding te
beperken en groot risico per-operatieve maligniteit
19. Galblaastumoren
Behandeling
• Stage -1- T1a Tumoren - Invasie lamina propria-
Curatieve CCE.
• Stage 1- T1b Tumoren - Invasie muscularis.
Goede lange-termijn overleving CCE, verdere
resectie omwille hogere kans recidief in situ
• Stage 2- en-bloc resection galblaas met
segmenten IV-b and V lever met
lymfeklierdissectie hepato-duodenaal ligament
• Stage 3&4 niet-resecabel
20. Galblaastumoren
Behandeling
• Diagnostische laparoscopie
• 48% occulte metastatische aantasting ondanks
negatieve beeldvorming – vriescoupe
• En bloc resectie galblaas met 2 cm marge.
Vroeger niet-anatomische wedge resectie van
aanliggend leverweefsel => kleine marges
• Heden anatomische resectie lever segmenten IVb
en V. Indien niet mogelijk zonder voldoende
marge extended rechter hepatectomie
21. Galblaastumoren
Behandeling
• Regionale lymfadenectomie en negatieve ductus
cysticus marge. Indien negatieve marge niet
mogelijk ductus choledochusresectie met
hepatico-jejunostomie
• Resectie LK van het hepatoduodenaal ligament is
aangeraden hoewel geen bewijs voor verbetering
overleving
• Vroeger resectie retropancreatische en coeliacale
klieren maar heden worden ze door sommigen
beschouwd als metastasen op afstand en dus
irresecabel
22. Galblaastumoren
Technische aspecten
• CCE met en-bloc resectie segment IVb en V en
radicale lymfadenectomie hepatoduodenaal
ligament
• Subcostale incisie
• Resectie eventuele vroegere port sites incisies
en umbilicale port
• Peroperatieve echografie relatie tumor met
vasculaire structuren en levermeta's
• Geen pre-operatieve benefit drainage icterus
23. Galblaastumoren
Technische pitfalls
• N1 LK blauw
• Hepatoduodenaal
ligament, arteria
hepatica
communis en
truncus coeliacus
• N2 LK rood
• Retropancreatisch
retrogastrisch en
aortacavaal niet-
resecabel
• Kocher-maneuver
24. Galblaastumoren
Technische pitfalls• Excisie hoogste
peri-pancreatische
LK
• Vriescoupe
• Klier + en patiënt
slechte status =>
geen resectie
• Resectie =>
retropancreatisch en
aortacavaal LK
evidement +/-
pancreatico-
duodenectomie
25. Galblaastumoren
Technische pitfalls
• Brug leverweefsel 4b en 3
sectie basis ligamentum
falciforme en linker porta
pedikel
• Transsectie ductus
choledochus
– Dissectie LK thv porta
– Inspectie vaten
– En bloc dissectie
hepatoduodenale,
coeliacale en
portocavale LK
26. Galblaastumoren
Technische pitfalls
• Inspectie vena portae en arteria
hepatica
– Vena porta reconstructie
(VPC)
– Rechter hemi-hepatectomie
(AHD of VPD)
• Transsectie ductus hepaticus
dexter en sinister
– Thv umbilicale fissuur
– Retractie naar boven DHS
– Transsectie DHD
29. Galblaastumoren
Resultaten
• 5-jaars overleving < 5%. 67% patiënten
presenteren vergevorderde ziekte met mediane
overleving 5-8 maanden.
• Patiënten met curatieve resectie 5 jaars-overleving
17% - 90%.
• T-1- Overleving 85 -100% met enkel CCE.
• Cave T1b letsels grotere kans recidief in situ.
Extended en bloc resectie met lymfadenectomie
aangeraden.
30. Galblaastumoren
Resultaten
• T-2- En bloc resectie en lymfadenectomie met 60-100%
5-jaars overleving.
• T-3- Niet-resecabel. Japan extensieve radicale resectie
en lymfadenectomie met pancreaticoduodenectomie in
aantal kleine series en selecte patienten 5-
jaarsoverleving 46-83%
• Geen benefit adjuvante radio- of chemotherapie
• Palliatieve setting
• Single-agent chemotherapie (gemcitabine,
capecitabine, 5-fluorouracil)
• Combinatie chemotherapie (gemcitabine, capecitabine
en 5-fluorouracil met cisplatinum of oxaliplatinum)
31. Galblaastumoren
Resultaten
• Dr. Alfred Blalock 1924-” In malignancy of the
Gallbladder, when the diagnosis of Malignancy can be
made without exploration, no operation should be
performed, in as much as it only shortens the patient’s
life.”
• Beperkte resultaten