Colon Cancer Surgical Management, update.
Dr. Tadesse Habteyohannes
AAU, CHS
Colon cancer is among the largest cancers in the world and current treatment options, especially cure intent are a must. This slide will update on the current surgical recommendation for colon cancer based on location and stage. It also includes prognostic discriminants on the outcome of the disease.
If you have any questions you can reach me at
tadesurgery@gmail.com or by phone +251911567541
2. Colorectal cancer statistics, 2023
CA A Cancer J Clinicians, Volume: 73, Issue: 3, Pages: 233-254, First published: 01 March 2023, DOI: (10.3322/caac.21772)
Risk factors
Screening
Evaluation
Treatment
46%
57%
long-term trends in colorectal cancer incidence and mortality
3. Preoperative evaluation
Candidates for Resection
General Principles
Colon Resection
Special Considerations
Introduction
Outline of presentation
Complicated Colon ca
Prognostic Discriminants
and Results
6. Preoperative Evaluation
Independent risk factors:
Age (1.5 per 10-
year increase)
American
Society of
Anesthesiologists
(ASA) grade
Tumor/Node/
Metastasis (TNM)
staging (or for stage
IV vs. I–III = 2.6)
Mode of surgery
(or for urgent vs.
Nonurgent =
2.1),
No-carcinoma
resection versus
carcinoma resection
(OR = 4.5)
Hematocrit
level.
The primary endpoint is to minimize operative mortality
and morbidity
7. Preoperative Tumor Localization
Determine the precise location of the tumor
Colonoscopy (Diagnosis and ? localization)
Repeat flexible sigmoidoscopy
CT) may demonstrate the exact location of the tumor
Endoscopic tattoo placement
8. Preoperative preparation
IV
Antimicrobial
prophylaxis
Bowel
Preparation
Prophylactic
Ureteric
Stenting
Thrombo-
prophylaxis
Bowel Preparation and antibiotic use
• The subject of considerable controversy.
• Mechanical and antibiotic preparation has recently been questioned.
• Most surgeons currently use some form of mechanical cleansing and systemic
prophylactic antibiotics.
• Many are returning to the use of oral antibiotics as well.
Prophylactic ureteral
stenting
• Intraoperative identification.
• Can help identify the ureters but
will not prevent injury.
• High risk for ureteral injury
• Bulky tumors
• Obesity
• Undergoing reoperations
• Prior pelvic surgery, and/or prior
radiation
Thromboprophylaxis
Moderate-to-high risk
Chemical thromboprophylaxis in
addition to mechanical
prophylaxis.
Starting either immediately
before surgery or shortly
thereafter.
9. Neoadjuvant therapy
No consensus as
to which patients
are suitable for
neoadjuvant
therapy rather
than upfront
surgery.
(NCCN)-> Bulky
nodal disease or
clinical T4b
colon cancer
For patients with locally advanced colon cancer, neoadjuvant
systemic therapy is associated with several potential
advantages:
Early
administration of
systemic therapy
may reduce the
risk of
micrometastases
Reduction of the
primary tumor
can facilitate
surgical resection
Better
compliance with
systemic therapy
when it is
delivered
preoperatively
10. Is there a contraindication?
CANDIDATES FOR
RESECTION
11. CANDIDATES FOR RESECTION
Surgical resection is the
only curative treatment
modality for localized
colon cancer,
Selected patients with
limited, potentially
resectable metastatic
disease
• Unresectable metastatic diseases unless complicated
• Increasing age may be accompanied by higher rates
of medical comorbidity
13. Approach
Exploration of
the abdomen
Techniques
General Principles…
Approach
• Open
• Minimally
invasive
techniques
• Laparoscopic
• Robotics
Exploration of the abdomen
• Incisions should provide maximum exposure
for the planned resection.
• Attention should be directed to ruling out the
presence of metastatic disease
• Special attention is given to the liver and the
pelvis.
• The use of paramedian incisions appears
quite antiquated.
• For emergency operations, a midline incision
seems the access of choice
All
operations
can
be
performed
through
a
midline
incision.
Right hemicolectomy
Oblique right-sided
abdominal incision.
Transverse colon lesions
Supraumbilical transverse
incision.
Splenic flexure lesions
Left subcostal transverse
incision combined with
the right lateral position.
For left-sided colonic
lesions
Sub umbilical transverse
incision.
For descending colon
lesions
Oblique incision may
prove very convenient. .
No-Touch Technique
• Developed due to concern about
dislodging tumor cells
• A recent randomized controlled trial of
conventional colectomy vs no-touch for
colon cancer resection found no
difference
• Disease-free survival
• Overall survival
• Recurrence-free survival in stages II
and III colon cancer patients
• At least a 5-cm margin
• Feeding vessel should be taken
at its origin(Maximize
lymphadenectomy)
• Non- peritonalized margins
marked with ink to assess for
completeness of resection
Extent of Resection
Extent of resection
14. General Principles…
Extent of resection
Extent of resection Adjacent Tissue/Organ
Invasion
• Adhesions are malignant in
about 40% of cases.
• En bloc resection is favored
• Uncertainty
• Direct invasion
• Merely abutment
15. General Principles…
Extent of resection
Extent of resection
• Aims to remove the tumor, its
associated lymphovascular
supply (including central
vascular ligation), and
mesocolon in an intact envelope
of visceral peritoneum.
• The most feared complication
during CME is damage to the
SMV(1.6%)
Mesocolic Excision
16. General Principles…
Extent of resection
Margins
• In colon cancer, the radial margin (or circumferential resection margin, CRM) represents
the adventitial soft tissue closest to the deepest penetration of the tumor.
• It is created surgically by blunt or sharp dissection of the retroperitoneal aspect.
• The serosal (peritoneal) surface does not constitute a surgical margin.
• The radial margins should be assessed in all colonic segments with nonperitonealized
surfaces.
• Mark the area of non-peritonealized surface with a clip or suture.
• Local recurrence rate
• 38.2%(CRM-positive)
• 10.0% (CRM-negative)
17. General Principles…
Extent of resection
Extent of resection Tumor Deposits
• Had different terms used interchangeably
• They are not counted as lymph nodes
replaced by tumors.
• Arise from lymphovascular invasion or,
occasionally, PNI.
• The number of tumor deposits should be
recorded in the pathology report.
• 5-year survival rate showed (P < .0001).
• 91.5% (pN0 tumors without satellite
nodules)
• 37.0% (pN0 tumors and the presence of
satellite nodules)
18. General Principles…
Extent of resection
Extent of resection
Perineural Invasion
PNI is associated with a
significantly worse
prognosis.
PNI is included as a high-
risk factor for systemic
recurrence.
19. General Principles…
Lymphadenectomy
• At least 12 lymph nodes
• Examination of lymph nodes allows
for accurate cancer staging
• Selection of patients for adjuvant
therapy
• The extent of lymph node resection is
debated
Extent of resection
Extent of
resection
21. 1. Cecum and Ascending Colon Cancer
Cecum and Ascending Colon Cancer
• Right hemicolectomy with ileocolic anastomosis
is recommended.
• The anatomic boundaries of the resection
include approximately 10 cm proximal to the
ileocecal valve and the proximal transverse
colon.
22. 1. Cecum and Ascending Colon Cancer …
For a medial to lateral
technique(Open/ MIS)
• The abdomen should be thoroughly
inspected
• The tumor is assessed for
resectability
• Limits of resection
• Anastomosis(per surgeon
preference)
Technical Aspects In a lateral to medial approach
• Transects the white line of Toldt
• Colon and mesocolon are mobilized
off the retroperitoneum and
duodenum.
• The hepatic flexure is freed(liver
superiorly and duodenum
posteriorly)
• The ileocolic, right colic and right
branch of the middle colic vessels
are then ligated at their origins.
23. 2. Hepatic Flexure Colon Cancer
Depending
on location
Right
hemicolectomy
An extended
right
hemicolectomy
Technical Aspects
• Extended right hemicolectomy(vascular
division include the main middle colic
arterial trunk)
• The lesser sac is opened along its entire
length
• The splenic flexure may need to be
mobilized to create a tension-free
anastomosis.
• The colon and the mesentery are then
resected according to the divided blood
supply distribution.
• An ileocolic anastomosis is then
created.
24. 3. Transverse Colon Cancer
Options include
Extended right
colectomy
Extended left
colectomy
Subtotal colectomy
Segmental transverse
colectomy
The best procedure is the one that removes the regional lymphatic
drainage
Challenging to decide which surgical procedure(Location)
25. 3. Transverse Colon Cancer…
Technical Aspects
• Proximal transverse colon cancers are typically managed with an extended
right colectomy
• Lesions in the mid to distal aspect of the transverse colon
• Extended right colectomy
• Extended left colectomy(ligation of the middle colic artery main branch in
addition to the left colic artery )
• Segment transverse colectomy
• Segmental transverse colectomy is most appropriate for patients with a tumor
in the mid-transverse colon with a redundant colon where mobility is not an
issue.
• An end-to-end Colo-colonic
26. 4. Splenic Flexure and Descending Colon Cancer
Usually treated by a left colectomy.
Involves high ligation of the left colic artery and left branch of
the middle colic artery.
Mesenteric resection includes the areas drained by the distal
half of the transverse colon and the descending colon.
Anastomosis is typically transverse colon to sigmoid colon.
If colorectal anastomosis is performed, then the root of the IMA
can be divided.(Formal left hemicolectomy)
Fig. Formal left hemicolectomy for
descending colon tumor
Fig-Segmental left hemicolectomy for
splenic flexure tumor
27. 4. Splenic Flexure and Descending Colon Cancer…
Technical Aspects
• Position (split leg or low lithotomy)
• The small bowel should be positioned on the patient’s right side
• The inferior mesenteric vein is divided adjacent to the ligament of Treitz.
• For tumors located in the distal descending colon, a more formal left
colectomy includes resection of the sigmoid colon and a colorectal
anastomosis.
• The mesentery is lifted off of the retroperitoneum, and the entire left
colon from the distal transverse colon to the top of the rectum is removed.
• It is important to note that attempts at anastomosis can be difficult due to
reach and tension.
• IMV should be ligated proximally.
• Transverse colon should be mobilized and omentum released from the
stomach.
• A retroileal anastomosis.
28. 5. Sigmoid Colon Cancer
Sigmoid colon cancer is treated with either a
• Sigmoid colectomy
• Left colectomy(proximal lesions)
• Anterior resection
More are best served with left colectomy (as outlined above) to ensure
adequate lymph node harvest.
Tumors in the mid to distal sigmoid colon are adequately treated with anterior
resection of the rectosigmoid/sigmoid colectomy.
No proven oncologic benefit for formal left colectomy for distal sigmoid colon
tumors.
Fig. 25.8 Sigmoid colectomy
29. 5. Sigmoid Colon Cancer…
Technical Aspects
• An anterior resection is performed for tumors of
the mid and distal sigmoid colon.
• The patient is placed in low lithotomy(Davis)
position.
• For a medial-to-lateral approach
• Lebel of resection
• Anastomosis without tension
• Air leak test
31. Surgical Resection for Colon Cancer in the Setting of
Lynch Syndrome
Most commonly identified genetically inherited CRC- 2-
4%
NCCN Colon/Rectal Cancer panel endorses universal
MMR or MSI testing
• Helpful in selecting adjuvant therapy in stage II & IV patients
Increased risk of developing metachronous colon cancers.
Total abdominal or subtotal colectomy as opposed to a
segmental colectomy.
Fig. Subtotal colectomy
32. Invasion of Adjacent Viscera
The surgeon should not hesitate to resect attached structures
To perform an adequate curative operation, it sometimes becomes
necessary to excise en bloc all or part of the attached viscus
“To extreme diseases, extreme remedies”
It is estimated that such attachment occurs in approximately 10%
Occasionally a carcinoma becomes attached to the abdominal
wall or the adjacent viscera
33. Invasion of Adjacent Viscera…
Urinary Tract Involvement by Colorectal Carcinoma
• Three distinct clinical scenarios the urinary tract may be affected
by colorectal carcinoma:
• Involvement by primary colorectal carcinoma
• Involvement of recurrent carcinoma
• Unexpected intraoperative findings
34. Invasion of Adjacent Viscera…
Primary involvement of the urinary tract
• Occurs in 5% of patients with primary colorectal carcinoma
• Dome of the bladder(most common presentation
• Lower ureter
• Base of the bladder
• Locally advanced disease with direct invasion of adjacent organs may result in
fistula formation (50% no symptoms) or hydronephrosis.
• Diagnosis
• CT
• MRI
• Cystoscopy
35. Invasion of Adjacent Viscera…
Bladder involvement
• En bloc resection of the carcinoma and all adherent
bladder
• Total pelvic exenteration is appropriate for direct
invasion(in the absence of distant metastases )
• Trigone
• Vesicoureteral junction
• Intramural ureter
36. Invasion of Adjacent Viscera…
Ureteric involvement
• Bilateral involvement -> total pelvic exenteration
• Unilateral ureteric invasion -> en bloc resection of the affected segment
• Ipsilateral ureteroureterostomy over a double-j stent for short resections of
the distal ureter
• Boari flap _> longer segment proximal ureter
• Cystourethrectomy and ureteric crossover of the ureterovesical junction
• Ileal interposition long ureteric segment
• Nephrectomy(rarely)
37. Invasion of Adjacent Viscera…
Unexpected Intraoperative Involvement
• In some circumstances, the correct decision is to defer
resectional operation in favor of radiotherapy or a subsequent
more aggressive one-stage procedure.
• Fortunately, with current preoperative staging, this occurrence is
less common.
38. Synchronous Carcinomas
The incidence is reported to be 1.5 to 7.6%.
• Synchronous carcinomas are located in the same anatomic region,
a conventional resection
• When the carcinomas are widely separated, a subtotal colectomy
No significant difference in “highest stage” survival
rates
Recommendations for the treatment of patients with colon carcinoma and
associated polyps involve the same considerations.
40. Emergency presentation ->
poor outcomes.
More advanced carcinomas
Longer hospital stay and
higher costs compared with
elective surgery.
The duration of hospital stay
was the strongest
determinant of cost.
About 15% of patients with
colon cancer will present
with acute obstruction or
perforation.
Management varies based on
the location of the tumor and
the clinical presentation.
Complicated Carcinomas
41. Obstruction
When
complete
obstruction of
the colon
arises as a
result of a
carcinoma
• Level of the colon that is obstructed
• Experience of the treating surgeon.
If the patient’s condition can be stabilized and there is evidence of
resolution of the occlusion, bowel preparation, and elective
resection is the ideal solution.
42. Obstruction…
For right-sided colonic
obstructions,
• Right hemicolectomy (resection and
primary anastomosis)
Distal transverse
colon(controversial)
• Proximal diversion ->Definitive resection.
• Extended right hemicolectomy(Primary ileo-
descending colon anastomosis)
43. Obstruction…
Three-stage procedure
Obstruction of the left
colon(greater controversy)
Traditionally, these patients have
undergone a three-stage
operation
• Transverse colostomy/cecostomy
• Resection and anastomosis
• Closure of the colostomy
44. Obstruction…
Hartmann’s Procedure
Some
surgeons have
advocated an
immediate
resection
without
anastomosis
Left-sided
colostomy is
much less of
a burden than
a transverse
colostomy
Rates of
colostomy
closure of
60% or more
are common
Significant
morbidity can
be associated
with
colostomy
closure
Appropriate
for a patient
with
perforation of
the left colon
and for the
elderly unfit
patient
45. Obstruction…
Subtotal colectomy
Primary
ileosigmoid
anastomosis or
even ileorectal
anastomosis.
Advantages offered by this operation include the following:
No stoma
problems
A one-stage
procedure with a
single
hospitalization
A shorter
hospital stay
with financial
savings
Removal of
synchronous
proximal
neoplasms and
reduced risk of
metachronous
lesions
46. Obstruction…
Primary Resection
Rather boldly, some
surgeons have
performed a
resection with
primary anastomosis
in the absence of
bowel preparation.
An intracolonic
bypass has been
suggested as a
treatment.
Still others have
suggested a primary
resection with
anastomosis and
proximal diversion.
47. Obstruction…
Stenting
It was first introduced as a
definitive palliative treatment
• Resection for cure was not
appropriate due to very
advanced local disease
• Metastatic disease
• Unacceptably high operative
risk
“Bridge-to-surgery”
Suitable lesions for endoluminal
colorectal stenting include
• Obstructing both primary left-
sided colorectal carcinomas
• Extracolonic malignancies such as
prostate, bladder, ovarian, or
pancreatic.
49. Perforation
3 to 9% of patients with colorectal
carcinomas
Present with signs and symptoms of
generalized peritonitis
The carcinoma itself may be perforated,
or there may be a left-sided carcinoma
associated with a right-sided perforation.
Each situation is handled differently.
• Inappropriate to perform a
primary anastomosis
• The proximal bowel is
brought out as a stoma
• The distal bowel is drawn out
as a mucous fistula or closed
as a Hartmann pouch
If the patient already
has generalized
peritonitis
50. Perforation…
• Resection and Diversion
(Double barrel)
• Another option is to resect the
perforated diseased bowel
and perform a primary
anastomosis
• Proximal diversionary
stoma
For a right-sided
perforation
51. Perforation…
When there is an
obstructing lesion of the
left colon and a
perforation of the right
colon
Subtotal colectomy
encompassing removal of
the perforated colon and
the malignancy in one
operation
52. Perforation…
Localized Peritonitis on the right side
• Right hemicolectomy and primary anastomosis
If the localized peritonitis occurs on the left side
• Resection of the diseased segment
• Management of the ends involves the same
considerations as with the obstructed unprepared
bowel.
53. Bleeding
Massive
bleeding from
a carcinoma is
an unusual
complication
When it arises,
it offers the
built-in
advantage of
being a colonic
cathartic
If bleeding is so profuse that urgent
operation is required
Mechanical
cleansing is
automatically
present
Affected portion
of bowel can be
resected with a
primary
anastomosis
54. Obstructive colitis
Obstructive colitis is an ulceroinflammatory condition that occurs in a dilated
segment of the colon proximal to an obstructing or partially obstructing lesion
The entity is rarely reported ( 0.3 to 3.1% )
Affects both men and women over 50 years of age
The left side of the colon, especially the sigmoid colon, is usually involved in
obstructive colitis
55. Indications for subtotal colectomy
Patients with synchronous carcinomas in different portions of the colon
Associated polyps (not removed by colonoscopy)
Acute or subacute obstruction
Associated sigmoid diverticulosis (symptomatic)
Prior transverse colostomy for obstruction
Young patient age (< 50 years) with a positive family history
Adherence of the sigmoid colon to a cecal carcinoma
56. POSTOPERATIVE CARE AND FOLLOW-UP
Postoperative management of
colectomy patients emphasizes
• Reduced perioperative fluid volume
• Early postoperative feeding
• Early ambulation
• Multimodal pain control
• Prevention of nausea and vomiting
• Early Adjuvant Chemotherapy (Those
Deserved)
"Enhanced
recovery after
colorectal surgery”
58. Prognostic Discriminants
Prognostic discriminants
Clinical features
Pathological features
Biochemical
• Age
• Sex
• History
• Obstruction
• Perforation
• Adjacent organ involvement
• Presence of metastatic disease
• Systemic manifestation
• Techniques of resection
• Colorectal Specialization and Surgical
Volume
• Perioperative Blood Transfusion
• Previous Appendectomy
Clinical features
• Location
• Size
• Configuration
• Microscopy
• Residual disease
• Staging
• Lymph node status
• Venous invasion
• Perineural invasion
Pathologic features
• Preoperative Carcinoembryonic Antigen
Levels
• Tumor markers
Biochemical and Special Investigations
59. CRCs are usually staged after surgical exploration
of the abdomen and pathologic examination of the
surgical specimen.
• Grade of the cancer
• Depth of penetration and extension to adjacent structures (T)
• Number of regional lymph nodes evaluated
• Number of positive regional lymph nodes (N)
• An assessment of the presence of distant metastases to other
organs, to the peritoneum or an abdominal structure, or in non-
regional lymph nodes (M)
• The status of proximal, distal, radial, and mesenteric margins
• Lymphovascular invasion
• Perineural invasion (PNI)
• Tumor deposits
60. Prognostic Discriminants…
High-risk factors for recurrence
• Poorly differentiated histology (exclusive of those that are
MSI-H)
• Lymphatic/vascular invasion
• Perineural invasion
• Close, indeterminate, or positive margins
• Bowel obstruction
• Localized perforation
• Less than 12 lymph nodes examined
61. Results
A more useful measure of surgical
treatment is the overall or absolute
survival rate
5-year survival rates for patients
with large bowel carcinoma operated
on for cure vary from 5.7 to 74 %.
Trends in colorectal cancer incidence (1975–2019) and mortality (1930–2020) rates by sex, United States. Because of changes in the International Classification of Diseases coding for mortality, numerator information has changed over time. Incidence rates exclude appendiceal cancer, are age‐adjusted to the 2000 US standard population, and adjusted for reporting delays. Source: Incidence: Surveillance, Epidemiology, and End Results Program, 2022; Mortality: National Center for Health Statistics, 2022.
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Key Concepts
Surgical resection- the cornerstone of treatment for stage I–III colon cancer
The extent of colectomy is based on the anatomic location of the tumor.
The goals of resection are to achieve negative circumferential margins
Examination of lymph nodes allows for accurate cancer staging
The most accurate predictor of outcomes, TNM system (Clinical & pathologic stage.)
An adjunct in the process of informed consent and for monitoring surgical performance through time.
The T component of colon cancer staging is very important in prognostication
T4,N0 tumors have a lower survival than those with T1–2,N1–2 tumors.
AJCC Cancer Staging Manual includes the M1c category for peritoneal carcinomatosis with or without blood-borne metastasis to visceral organs.
Patients with peritoneal metastases have a shorter DFS and OS than those without peritoneal involvement.
When planning a colectomy, it is essential to determine the precise location of the tumor. Typically, the diagnosis of neoplasia is made after identification and biopsy of the tumor on colonoscopy, with note of the location of the tumor made on the report. However, mislocalization of the tumor, based on preoperative colonoscopy alone, occurs in 11–21% of cases and can result in a different surgical procedure than originally planned in 11% of cases (2–5). This number may be even higher when cecal and rectal tumors are excluded, due to the lack of definitive landmarks in the distal ascending, transverse and left colon, and variations in patient anatomy. It should also be noted that localization based on “centimeters from the anal verge” should never be relied upon, as this is often a highly inaccurate measurement when performed during the course of flexible colonoscopy. This is especially important for tumors in the rectosigmoid, where misclassification of tumor location can lead to inappropriate treatment. Many experienced colorectal surgeons will repeat flexible sigmoidoscopy on any patient referred to them with a neoplasm anywhere in the left colon, to avoid the mistake of taking a patient with a rectal cancer directly to the operating room for resection.
It is preferable to inject the tattoo only distal to the tumor, rather than both proximal and distal, as occasionally only one tattoo site can be identified intraoperatively. In addition, usually, it is the distal extent of the lesion that is most critical for the surgeon when performing resection.
Prophylactic ureteral stenting
The key to prevent intraoperative identification.
Placement of ureteral stents can help identify the ureters but will not prevent injury. Some surgeons routinely consult a urologist to have ureteral stents placed.
However, a more selective approach may be prudent, only placing ureteral stents for those patients at high risk for ureteral injury, such as those with bulky tumors, obesity, undergoing reoperations (benign or recurrent disease), prior pelvic surgery, and/or prior radiation.
Thromboprophylaxis — Patients undergoing colon resection frequently are at moderate-to-high risk for developing a deep venous thrombosis (DVT) given their age, presence of malignancy, and nature and duration of surgery
Anticipated splenectomy — When the surgeon anticipates that left hemicolectomy will require splenectomy (eg, large splenic flexure cancers, local invasion of the spleen), vaccination to prevent sepsis should ideally be administered two weeks prior to colon surgery [32].
CANDIDATES FOR RESECTION
Surgical resection is the only curative treatment modality for localized colon cancer,
Selected patients with limited, potentially resectable metastatic disease
Contraindications
Unresectable metastatic disease are generally not candidates for resection of the primary colon tumor in the absence of symptoms or complications (eg, perforation, obstruction) attributable to the primary tumor.
Increasing age may be accompanied by higher rates of medical comorbidity. Some patients may not be appropriate candidates for resection due to medical comorbidities.
No-Touch Technique
Developed due to concern about dislodging tumor cells into the circulation during tumor manipulation.
Concern - need to deal with the ureter, gonadal vessels, and duodenum without the benefit of adequate exposure.
This technique showed initial promise in terms of prognosis.
A recent randomized controlled trial of conventional colectomy versus no-touch for colon cancer resection found no difference
Disease-free survival,
Overall survival
Recurrence-free survival in stages II and III colon cancer patients
Lateral to medial approach or Medial to lateral approach
Role of extended lymphadenectomy for synchronous extra-regional lymph node metastasis, such as para-aortic lymph node metastasis in colorectal cancer.= No added survival benefit!!
Role of extended lymphadenectomy for synchronous extra-regional lymph node metastasis, such as para-aortic lymph node metastasis in colorectal cancer.= No added survival benefit!!
Role of extended lymphadenectomy for synchronous extra-regional lymph node metastasis, such as para-aortic lymph node metastasis in colorectal cancer.= No added survival benefit!!
Role of extended lymphadenectomy for synchronous extra-regional lymph node metastasis, such as para-aortic lymph node metastasis in colorectal cancer.= No added survival benefit!!
Role of extended lymphadenectomy for synchronous extra-regional lymph node metastasis, such as para-aortic lymph node metastasis in colorectal cancer.= No added survival benefit!!
The number of harvested lymph nodes and the ratio of involved versus harvested nodes can be used as markers
Adequacy of surgical resection
Associated with patient outcomes.
Regardless of approach, most patients are positioned supine on the operating table, unless intraoperative colonoscopy is anticipated.
operating surgeon stands on the left side of the table.
Tilting the table right side up.
The surgeon then identifies the ileocolic artery and performs a high ligation adjacent to the duodenum,
The lesser sac is often opened to mobilize the transverse colon and complete the mobilization of the hepatic flexure
Closure of the mesenteric defect is controversial, as the defect is large and unlikely to cause obstruction.
The omentum of the hepatic flexure and transverse colon that is being resected is typically taken with the specimen.
Reliable data indicate that mobilization along anatomic planes is important and improves prognosis (36).
trunk
Challenging to decide which surgical procedure to utilize for cancer of the transverse colon
Blood supply comes from the middle colic, along with the right and left colic vessels.
In the case of mid-transverse colon cancer, a transverse colectomy may be considered. The principles of high ligation of the middle colic artery and drainage of regional lymphatics remain the cornerstone of care. In this case, the anastomosis is ascending to descending colon anastomosis which requires mobilization of both segments and can be challenging or awkward technically.
An end-to-end Colo-colonic anastomosis is usually performed due to the risk of tension on a side-to-side anastomosis caused by the two sides of the colon mesentery retracting back toward their original position. There is also concern regarding the adequacy of the lymphadenectomy that occurs with segmental resection of the transverse colon. For these reasons, many surgeons treat mid-transverse colon lesions with an extended right colectomy which is easier for mobilization of the small bowel for an ileocolic anastomosis. A limited segmental transverse colectomy can be offered for palliative reasons or in frail patients who may not tolerate an extended resection.
Splenic Flexure and Descending Colon Cancer
The root of the IMA and superior hemorrhoidal artery is preserved to maintain arterial flow to the remaining sigmoid colon.
If colorectal anastomosis is performed, then the root of the IMA can be divided.
If splenectomy anticipated prophylaxis Antibiotics 2 weeks earlier
Sigmoid colon cancer is treated with either a sigmoid colectomy or a left colectomy, depending on the location of the tumor in the sigmoid colon.
More proximal lesions are best served with left colectomy (as outlined above) to ensure adequate lymph node harvest.
Tumors in the mid to distal sigmoid colon are adequately treated with anterior resection of the rectosigmoid/sigmoid colectomy.
There has not been a proven oncologic benefit for formal left colectomy for distal sigmoid colon tumors.
As discussed previously, several studies have demonstrated that there is no survival advantage of “high” ligation of the IMA although lack of precise anatomic definitions makes it difficult to draw definitive conclusions (8, 40, 41). During mobilization of the sigmoid colon and the ligation of the vessels, the left ureter should be identified and preserved. Most injuries of the ureter occur at the level of the iliac artery.
For a medial to lateral approach, the peritoneum is incised along the root of the sigmoid mesocolon, from IMA origin to just distal to the sacral promontory. Dissection just deep to the arc of the superior hemorrhoidal vessels allows for identification and preservation of the hypogastric nerves, left ureter, and gonadal vessels. At this point, a decision is made as to whether to divide the IMA at the aorta or preserve the left colic artery and instead divide the superior hemorrhoidal artery at its origin (Fig. 25.8). One then completes the dissection of the sigmoid and descending colon and its mesentery off of the retroperitoneum. The distal aspect of resection is the upper rectum, and the proximal aspect of resection is typically the junction of the descending and sigmoid colon, assuring appropriate margins and pulsatile arterial flow to the proximal colon conduit. One then determines if the descending colon will reach without tension to the rectal stump.
If there is any tension, additional maneuvers to create length for the colon conduit include high ligation of the inferior mesenteric vein at the inferior border of the pancreas and complete splenic flexure mobilization. Some surgeons will routinely mobilize the splenic flexure, while some do so selectively. The anastomosis is then created, typically in an end-to-end fashion with an endoscopic stapler. As per routine, endoscopic inspection and pneumatic anastomotic leak testing, preferably with carbon dioxide as the instilled gas, should be performed.
Lateral to medial/Medial to lateral
The procedure is initiated by incising the peritoneum along the white line of toldt.
The inter-sigmoid fossa, a small depression in the peritoneum that acts as a guide to the underlying ureter.
As the sigmoid mesentery is further mobilized, care is taken to displace the mesosigmoid from the left ureter, which is seen coursing over the iliac vessels.
The gonadal vessels should be protected similarly because injury will result in troublesome bleeding.
After lateral mobilization and determination of the proximal line of resection, the peritoneum over the medial aspect of the mesosigmoid is incised toward the root of the inferior mesenteric artery to the level of the proposed ligation and then downward toward the pelvis.
The inferior mesenteric artery, with its left colic and sigmoidal branches, will be identified.
Simple technique for high ligation of the inferior mesenteric artery and vein.
When a curable colon cancer is diagnosed in the setting of Lynch syndrome, the American Society of Colon and Rectal Surgeons recommends total abdominal or subtotal colectomy as opposed to a segmental colectomy due to the reduced risk of metachronous cancer afforded by extended resection (43).
The philosophy of treatment to be followed in these circumstances might best be expressed by the quote attributed to Hippocrates: “To extreme diseases, extreme remedies.”
Often, these adhesions are inflammatory in nature and not caused by malignant infiltration, so the prognosis frequently is better than might have been anticipated originally (▶Table 22.5).
An exception to these recommendations might be when the duodenum or bladder base is extensively involved, in which case the primary lesion is removed and the structures at risk are marked with metal clips. Under these circumstances, the morbidity and mortality rates of the radical operation involving an anterior exenteration or Whipple’s procedure would probably exceed any possible benefit derived from a very radical operation. However, Curley et al156 reported on 12 patients in whom the carcinoma involved the duodenum or pancreatic head and who underwent an en bloc extended right hemicolectomy and pancreaticoduodenectomy. There were no operative deaths, and malignant invasion was confirmed in all patients. At the time of reporting, 8 of the 12 patients were alive at a median of 42 months.
The authors concluded that colorectal carcinoma adherent to adjacent organs must be treated by en bloc resection because separation of organs results in unacceptably high local recurrence and poor 5-year survival rates. On the other hand, the results of en bloc resection were comparable to those of standard colectomy for nonadherent carcinomas.
Adherence to or invasion of the dome of the bladder is the most common presentation and most frequently occurs in rectosigmoid malignancies. Locally advanced disease with direct invasion of adjacent organs may result in fistula formation, but half of such patients have no symptoms at presentation. Involvement of the trigone may compromise the intramural ureter. Lower third lesions of the rectum may involve the prostate gland and prostatic urethra. A CT is usually performed as part of the standard investigation of patients with sigmoid or rectal carcinoma but is mandatory in patients with urinary symptoms. In addition to staging, computed tomography (CT) allows localization of the ureters and confirms bilateral renal function, although it tends to overestimate the need for urinary organ resection. CT is more likely to produce a falsepositive diagnosis of pelvic floor or piriform muscle invasion than magnetic resonance imaging (MRI) and is less likely to identify sacral bone invasion when it is present. Modern highresolution MRI (sensitivity 97% and specificity 98%) is superior to CT (sensitivity 70% and specificity 85%) in staging locally advanced primary or recurrent rectal carcinomas, with better detection of penetration of the fascia propria and involvement of the potential circumferential resection margin. Cystoscopy diagnoses the cause of genitourinary symptoms in 79 to 87% of patients with rectal carcinoma. Only 57% of patients with a mucosal abnormality at cystoscopy have bladder invasion at final pathology, yet locating the vesical opening of a malignant rectovesical fistula improves identification of patients who require pelvic exenteration for adequate resection.
A particular difficulty arises when unexpected local extensive disease is identified at operation. Discovery of a rectosigmoid carcinoma adherent to the bladder for which one can envisage a relatively straightforward en bloc resection with primary closure of the bladder clearly differs from a carcinoma likely to require complex reconstruction. Important are issues relating to the quality of the preoperative informed consent, particularly if the proposed resection requires a procedure with the potential for considerably greater morbidity and mortality than anticipated or an unexpected impact on postoperative quality of life such as necessity to create a stoma.
172 In a series of 2,586 patients, an incidence of 1.8% was reported.172 Bussey et al173 reported on 3,381 patients who survived conventional resections for carcinoma of the colon and rectum at St. Mark’s Hospital in London and found an overall incidence of metachronous carcinoma of 1.5%. The incidence rose to 3% in those cases followed up for at least 20 years. For those patients in whom an associated adenomatous polyp was found in the original operative specimen, the level rose to 5%. In a more recent study, synchronous carcinomas were found in 4.4% of patients.174 Passman et al175 reported on an 18-year multi-institutional database of 4,878 patients with colon carcinoma. There were 160 patients (3.3%) with 339 synchronous carcinomas. Eight percent of these patients had more than two lesions at the time of diagnosis. Based on highest stage lesion, 1% of patients were at stage 0, 28% at stage I, 33% at stage II, 25% at stage III, and 11% at stage IV. The disease-specific 5-year survival rate by highest stage was 87% for stage 0 or I, 69% for stage II, 50% for stage III, and 14% for stage IV.
No significant difference in “highest stage” survival rates for patients with synchronous carcinomas with same-stage solitary carcinomas.
Synchronous carcinomas are located in the same anatomic region, a conventional resection
When the carcinomas are widely separated, a subtotal colectomy
In their review of 115 obstructing carcinomas, Sjödahl et al106 found that 37% were right sided (proximal to splenic flexure) and 63% were left sided. Only 4% were Dukes’ A, while 15% already had distant metastases. Interestingly, a study by Nozoe et al107 found the mean size of the obstructing carcinoma was 3.7 cm, which was significantly smaller than that of nonobstructing carcinomas (5.4 cm). The proportion of lymph node metastases in obstructing carcinomas was 66.9%, which was significantly higher than that in nonobstructing carcinomas (42.4%). The proportion of carcinomas classified into Dukes’ C or D in obstructing carcinomas was 84.6% and was significantly higher than that in nonobstructing carcinomas (52.5%).
Lee et al109 compared the operative results of 243 patients who had emergency operations for right- and left-sided obstructions from primary colorectal carcinomas. One hundred and seven patients had obstruction at or proximal to the splenic flexure (right-sided lesions) and 136 had lesions distal to the splenic flexure (left-sided lesions). The primary resection rate was 91.8%. Of the 223 patients with primary resection, primary anastomosis was possible in 88% of patients. Among the 101 primary anastomosis patients with left-sided obstruction, segmental resection with on-table lavage was performed in 75 patients and subtotal colectomy was performed in 26 patients. The overall operative mortality rate was 9.4%, although that of the patients with primary resection and anastomosis was 8.1%. The anastomotic leakage rate for those with primary resection and anastomosis was 6.1%. There were no differences in the mortality or leakage rates between patients with right- and left-sided lesions (mortality 7.3 vs. 8.9% and leakage 5.3 vs. 6.9%). Colocolonic anastomosis did not show a significant difference in leakage rate when compared with ileocolonic anastomosis (6.1 vs. 6%).
In a review of the subject, Deans et al110 reported that between 70 and 80% of patients having a transverse colostomy undergo resection of their carcinoma during the first hospitalization, with a hospital stay of 30 to 55 days. Overall, 25% of patients do not undergo closure of their colostomy because they are unfit or unwilling to undergo an additional operation. Overall mortality rates range from 2 to 15%, mostly in the 10% range, with morbidity rates ranging from 20 to 37%, often related to stoma complications, ranging from 6 to 14%. Although many reports show that the combined mortality rate of the three-stage procedure is similar to that of primary resection with delayed anastomosis, there is the suggestion that long-term survival is decreased in the three-stage operation.110 Sjödahl et al106 found a modest increase in 5-year survival rate of 38% for immediate resection compared with a rate of 29% for a staged resection. Although proximal decompression is still promoted as a simple, safe initial option, the cumulative morbidity and mortality rates, survival disadvantage, prolonged hospital stay, and necessity of repeated operations make the three-stage procedure most unfavored.
Some surgeons have advocated an immediate resection without anastomosis (i.e., a proximal colostomy and mucous fistula or closed rectal stump, Hartmann’s procedure). The perceived advantages include immediate removal of the carcinoma, avoidance of an anastomosis in less-than-ideal circumstances, and more rapid convalescence and shorter hospital stay. In the event it proves to be permanent, a left-sided colostomy is much less of a burden than a transverse colostomy. The overall operative mortality rate has ranged from 6 to 12%, mostly in the 10% range,111 with hospital stay ranging from 17 to 30 days. Rates of colostomy closure of 60% or more are common. It must be remembered that significant morbidity can be associated with colostomy closure. In their report on 130 stomas and their subsequent closure, Porter et al111 experienced a complication rate of 44%. Nevertheless, Hartmann’s procedure combines primary resection and relief of the obstruction with acceptable morbidity and mortality rates. It is particularly appropriate for a patient with perforation of the left colon and for the elderly unfit patient.
Wong et al112 reported on 35 patients who presented with left-sided obstructing carcinoma. Unsuspected synchronous proximal lesions occurred in 12 patients (32%)—3 carcinomas, 8 adenomas, and 1 with another synchronous carcinoma and polyp. Initial reports stressed the technical demands of this operation, but, with care, good results can be obtained. Operative mortality rates of 3 to 11% have been reported and morbidity rates are low, with a leakage rate of 4% and a hospital stay of 15 to 20 days.111 Subtotal colectomy carries a risk of diarrhea and/or fecal incontinence, particularly in elderly patients. However, most reported experiences has not rated this a significant problem. The overall morbidity rate (6 vs. 44%) and length of hospital stay (17 vs. 34 days) are significantly less than after combined procedures.113 Perez et al114 evaluated the results of emergency subtotal colectomy in 35 patients with obstructing carcinoma of the left colon. The postoperative mortality rate was 6%, and complications were significant: wound infection, 28%; ileus,17%; evisceration, 8%; intestinal obstruction, 8%; and anastomotic leak, 11%. In a series of 35 patients, Lau et al115 reported a complication rate of 31%, which included an anastomotic leak rate of 3%. Their review of the literature revealed leak rates that ranged from 0 to 4.5% for subtotal colectomy and 0 to 14% for colonic lavage methods.
To shed light on the issue, Kronborg126 conducted a randomized trial in which he compared the results of traditional staged procedures with an initial transverse colostomy, followed by curative resection, and subsequent colostomy closure with immediate resection and end colostomy and mucous fistula with subsequent re-anastomosis. He found no difference in mortality or carcinoma-specific survival rates between the two treatments.
From this constellation of choices, it becomes difficult to select the best one. Ultimately, the selection depends on the surgeon’s experience and preference. An informed decision rests on the recognition of the comparable morbidity and mortality rates for the single procedure compared with the combined morbidity and mortality rates of the multiple operations of the staged procedures. Fielding et al127 recorded an operative mortality rate of 25% for primary resection and 34% for staged resection. This prospective study compared the outcome of primary staged resection in colonic obstruction and failed to show any difference in mortality rates between these options.
The authors’ preference is to extend the primary resection for lesions as far as the sigmoid colon. It appears worthwhile to cleanse the bowel distal to the obstruction, and a primary anastomosis then can be constructed between the terminal ileum and the sigmoid colon. The morbidity and mortality rates are lower than those found with the staged approach, and the length of hospitalization is shorter. By eliminating a second or third hospitalization and a temporary colostomy, palliation is better for those patients who ultimately die from recurrent disease. Furthermore, those patients who undergo resection for cure may have increased rates of long-term survival. If the lesion is so distal that there would be little remaining reservoir by resecting all the obstructed colon proximal to the carcinoma, a reasonable alternative would be to cleanse the bowel distal to the carcinoma, perform a primary resection, and use on-table lavage, with a primary anastomosis. In the very debilitated patient, consideration should be given to a right transverse colostomy
Intestinal stenting is a procedure that is becoming more widespread.
It is also not appropriate for lesions less than 5 cm from the anal verge. The actual length of the lesion is not a theoretical limitation.
Although it is not mandatory, it is probably best that stents be placed under endoscopic guidance with the aid of fluoroscopy. The administration of prophylactic antibiotics is probably wise. The procedure is conducted under conscious sedation. A catheter over a guide wire is advanced through the lesion. Contrast is injected into the proximal lumen. Once deployed, the stents expand and become incorporated into the surrounding tissue by pressure necrosis, thus anchoring the stent.
Dauphine et al131 reviewed their experience with 26 selfexpanding metal stents as the initial interventional approach in the management of acute malignant large bowel obstruction. In 14 patients, the stents were placed for palliation, whereas in 12, they were placed as a bridge to surgery. In 85%, stent placement was successful on the first occasion. In the remaining four individuals, one was successfully stented at the second occasion, and three required emergency operation. Nine of the 12 patients (75%) in the bridge-to-surgery group underwent elective colon resection. In the palliative group, 29% had reobstruction of the stents and in 9% the stent migrated. In the remaining 62%, the stent was patent until the patient died or until the time of last follow-up. Colonic stents achieved immediate nonoperative decompression and proved to be both safe and effective.
They concluded that patients treated with stents are discharged earlier than after open operation. Stents do not affect survival. Although stents are expensive, the procedure appears to be cost-effective since emergency operation can be avoided with acute bowel obstruction, and in those with advanced disease no resection of the colon is necessary.
Saegesser and Sandblom143 stressed the fact that simple suture repair of an ischemic colon will not hold and that a temporary colostomy placed in an ischemic or inflamed bowel will pull through. The authors believe that the practice of closure of the perforation and relief of obstruction by colostomy or by exteriorization of the perforated cecum is illogical and inadequate. The surgeon should proceed with resection of the carcinoma and the entire distended part of the ischemic and perforated colon. A subtotal colectomy might even be considered if only a left-sided perforation is present, since this operation would fulfill the criteria of removing the diseased and unprepared bowel. Another option for management of the patient with a perforation remote from the diseased segment is to bring out the perforated segment as a stoma, either by colostomy or cecostomy.
Patients with obstructive colitis usually complain of bleeding per rectum and abdominal pain as well as nausea and vomiting, all of which are indistinguishable from the symptoms of colorectal carcinoma. Regardless of severity and distribution pattern, a diagnostic feature of obstructive colitis is the presence of an intact mucosal segment of about 2 to 6cm long between the carcinoma and the colitis. The area of colitis is usually a single confluent area, often with regular geographic margins, which is well demarcated from the surrounding normal mucosa.
The absolute survival rate automatically takes into account the resectability and operative mortality rates as well as the success of the operation in eradicating the carcinoma.
