clinical features ,investigations and management of colorectal cancers

1. COLORECTAL CANCER

2. COLORECTAL CANCER:
• M/c cancer in GIT
• M/c cause of cancer death in GIT
• Male>female
• >55 years
• RECTUM(35%) >sigmoid[30%]>caecum[15%]

3. RISK FACTORS:
1)DIET: Obesity and high fat diet
• Selenium deficiency
• Vitamin C deficiency and smoking –low
association
• High fibre diet – protective
• Animal fat(red meat) – causative
2) ULCERATIVE COLITIS-> 10 years –1% / year risk of
cancer
3) RADIATION
4) CHOLECYSTECTOMY—RIGHT SIDED COLON
CANCER

4. FAMILIAL CANCER:
• 1) ADENOMATOUS POLYP:
• *FAP- Familial adenomatous polyposis
• AD, chromosome 5q
• Gene APC– ADENOCARCINOMA THEORY( FEARSON AND VOGELSTEIN THEORY)
• Normal mucosa APC MUTATION ---beta catenin increase
• | |
• -- WNT PATHWAY CYCD1/MYC
• Aberrant dysplastic crypt
• |(COX)
• Early adenoma
• |(RAS)
• Intermediate adenoma
• |(DCC)
• Late adenoma
• |(p53)
• CARCINOMA

5. • After puberty, polyp appears about >100 in number
in next 10 years
• |
• Cancer risk 100% --4th decade
• |
• TOTAL PROCTOCOLECTOMY DONE
2) ATTENUATED FAP:
• Polyp <100
• 40-60 years

6. 3) GARDNER SYNDROME:
Fibroma, sebaceous cyst, osteoma, lipoma, desmoid
tumour
• Desmoid tumour in gardner syndrome
• It’s intraabdominal, aggressive
• Retroperitonium/ mesentry– fixed to vessel
• 4) TURCOT SYNDROME:
• Cancer seen in young 20-30 years
• Polyp- cancer
• CNS tumour-in adults– glioblastoma multiforme
• In children- medulloblastoma

7. HAMARTOMATOUS POLYP:
• 1) PEUTZ- JEGHER SYNDROME:
• AD, CHR19, STK11/ LKB
• Not premalignant
• Polyp– JEJUNUM> DUODENUM> COLON
• Mucocutaneous melanosis
• Increased cancer in Git –colon, breast, testis( sertoli
cell tumour/ ovary / uterus

8. • 2) COWDENS SYNDROME:
• AD, CHR10, PTEN MUTATION
• All three germ cell tumour seen
• Polyp/ cancer in colon
• Other breast, thyroid, uterine, facial trichilemma, renal
tumour, macrocephaly, glycogenacaonthosis
• 3) MUIR TORRE SYNDROME:
• Breast, colon cancer
• Skin tumour- sebaceous adenoma, keratoaconthoma
• MSH, MLH-1 GENE

9. NON- FAMILIAL CANCER:
• 1) CRONCKITE CANADA SYNDROME:
• Polyp/ cancer risk low
• Thick mucosa
• Deep crypts
• Foveolar hypertropy
• Incresed mucus loss-- loss of proteins
• Ectodermal dysplasia- nail dystropy, alopecia, skin
pigmentation

10. HNPCC:M/C FAMILIAL
CONDITION
• Lynch l- colon cancer
• Lynch ll- colon cancer with stomach, pancreas, uterus, ovary,
skin, uro( transitional cell cancer of upper tract- pelvis, ureter),
neuro( same as turcot)
• GENE- MSI( MMR- Mismatch repair gene)
• MSH-2—75%, MLH –15%
• |
• TGF, BAX decreased– decreased cell death
• |
• Increased cell proliferation
• Right sided cancer
• Better prognosis
• MSI – H has better prognosis

13. Clinical features:
1) Bleeding per rectum:
• Earliest symptoms
• Painless and bright red color
2) Tenesmus:
3) Altered bowel habits
4) Pain – late symptom
Colicky type
Seen inadvanced cancers invading
mesorectum, prostate, bladder anteriorly, sacral
plexus posteriorly
5) Weight loss – metastatic disease

14. INVESTIGATION:
• Per abdomen examination:
• Normal in early stage
• In stenosing tumours at rectosigmoid junction present
as subacute large bowel obstruction- abd distension
• In liver mets, palpable liver seen
• PER RECTAL EXAMINATION:
• Neoplasm situated within 7-8 cmnof anal verge felt on
DRE
• In female- PV examination to be done to rule out
involvement of Posterior vaginal wall
• To evaluate anal sphincter complex

15. • COLONOSCOPY – To exclude synchronous tumour
• If a adenoma found- conveniently snared and
removed via coloscopy
• If there is stenosing cancer- CT colonoscopy Or
barium enema performed

16. To stage:
• Imaging of chest, abdomen and pelvis by CT
• Local Pelvic imaging by MRI

17. CECT:

18. MRI:

19. Types of carcinoma spread:
• LOCAL SPREAD:
• Occurs Circumferentially than longitudinal spread
• Anterior- prostate, seminal vesicle, bladder in male
• Vagina and uterus in females
• Posterior- sacrum and sacral plexus
• Laterally –ureter
• Downward spread is rare

20. • LYMPHATIC SPREAD:
• Above peritoneal reflection- upward
• When neoplasm confined to middle rectal artery-
lateral spread
• VENOUS SPREAD:
• LIVER, LUNGS, ADRENALS
• PERITONEAL DISSEMINATION

21. DUKE’S STAGING

22. • Stage A- prognosis excellent >90 survival
• Stage B- 70% survival
• Stage C- poor prognosis 40% survival

25. HISTOPATHOLOGICAL GRADING:
1) Adenocarcinoma (m/c) – derived from malignant
transformation of columnar rectal epithelium
• Well differentiated
• Moderately differentiated
• Poorly differentiated
2) Primary mucoid carcinoma –signet ring cells seen
• Signet ring carcinoma grow rapidly, metastasise
early and have a poor prognosis

27. Treatment

33. Rectum
• Length - 12 -15 cm
• Sacculation,appendix
epiploicae,tenia coli are
absent
• Ends 2-3 cm front and below
the coccyx

34. Houston valves
• Horizontal folds/ plica transversalis:
1st- left wall 12-14 cm above anal canal
2nd- anterior and right wall, 7.5cm above
anal canal
3rd- left wall at upper end of rectal
ampulla, above anus

36. Peritoneal reflection
1.Resection done above peritoneal reflection - AR
2.Resection done below peritoneal reflection - LAR

37. Levator ani muscles
• Puborectalis
• Pubococcygeus
• Iliococcygeus
Divides pelvis into pelvic proper
and perineum
Arises from white line of pelvic
fascia

38. Fascia coverings in rectum
• Fascia propria
• Presacral fascia
• Waldeyers fascia (rectosacral
fascia)
• Denonwilliers Fascia
Holy plane of safety- stay within these fascial planes
• If u stay above the waldeyers fascia- AR
• Cut and enter waldeyers fascia- LAR

39. 1.Superior rectal artery- End
branch of IMA
2.Middle rectal artery- Internal
iliac artery branch
3.Inferior Rectal artery-
Internal pudental artery
Arterial supply

40. Venous supply
• Superior rectal veins
Drains upper 2/3rd
rectum and enters IMV
• Lower rectum and anus
Drains into MRV and IRV
to internal iliac veins

41. Lymph node drainage
• Upper 2/3rd Drains to inferior mesentric and para
aortic nodes.
• Lower 1/3rd Drains
Cephalad into IM nodes
Inferior and laterally into Internal Iliac nodes
• Below dentate Drains into inguinal nodes

42. Nerve plexus
• Superior hypogastric plexus
Contains sympathetic nerves
High ligation of IMA can cause damage and cause
retrograde ejaculation and bladder dysfunction
• Inferior hypogastric plexus
Contains both sympathetic and parasympathetic nerves
Injury can cause Impotence and atonic bladder

43. Margins
• AR- Proximal rectal cancer, safety margin 5cm.
• LAR- Middle and Lower rectal cancer, safety margin
2cm above dentate line.
• ULAR- safety margin 0.5-1cm above dentate line.

44. APR

45. Indications
• Very low rectal malignancies that involve the
sphincter complex or cannot be removed with a 2-
cm distal margin.
• Anal cancer
Preoperative preparation
• The patient is placed on a liquid diet for a day.
• Bowel preparation the afternoon or evening prior
to surgery.
• Complete evacuation of the colon with laxatives or
purgative.
• Appropriate nonabsorbable antibiotics may be
given.
• Parenteral antibiotic coverage is given just prior to
surgery

46. Position
• Lloyd Davies lithotomy with padded Allen stirupps

47. INCISION

48. Procedure - Abdominal dissection
• With the left hand, the surgeon thoroughly explores
the abdomen from above downward, palpating first
the liver to ascertain the presence or absence of
metastases
• Then the region of the aorta and common iliac and
hemorrhoidal vessels for evidence of lymph nodes
• Palpation and inspection of the growth, to determine
the extent and resectability

49. Mobilization of sigmoid
• The sigmoid is grasped and retracted medially in
order that the surgeon may obtain a clear view of
the fibrous bands that anchor the sigmoid to the
left pelvic wall.
• The adjacent adhesive bands are divided with long
curved scissors or electrocautery.

50. • The next important step in the
operation is the visualization of
the left ureter throughout its
course over the pelvic brim and
down to the bladder.
• It may be included in the division
of the structures unless it is
carefully retracted to the left side
of the pelvis

51. • The fingers of the surgeon’s left hand can
be passed completely behind the bowel
toward the right side.
• With the fingers used as blunt dissectors, the
right peritoneal reflection can be tented
upward, separating it from the underlying
structures, including the right ureter.
• This enables the surgeon to divide the
peritoneum readily and safely with scissors or
electrocautery.

52. TME
• The TME requires meticulous sharp or
electrocautery dissection under direct vision.
• The TME technique is widely used both with
sphincter preservation in very low rectal
anastomoses and with abdominoperineal
resection.
• The peritoneum along the right side of the
rectosigmoid junction is incised lateral to the
in inferior mesenteric and superior
hemorrhoidal vessels.
• Known complications from this blunt
dissection include hemorrhage from torn
presacral veins, perforation into the rectum,
and injury to the pelvic autonomic nerves.

53. • The right ureter is identified beneath the
residual peritoneum, and its course over the
iliac vessels is exposed with blunt gauze
dissection. The proximal bowel is retracted
anteriorly and laterally.
• The superior hypogastric nerves are visualized
just below the iliac vessels and the ureters.
The dissection proceeds behind the superior
hemorrhoidal vessels toward the entrance of
the presacral space behind the sacral
promontory.
• Division of the retrosacral fascia or ligament
just below the sacral curvature at about S2 is
done sharply in the midline with scissors or
electrocautery, using a long, insulated
tip.Posterior dissection continues down to the
level of the coccyx.

54. • The peritoneal reflection in the
pouch of Douglas is incised about 1
cm up its anterior reflection over the
bladder in men or behind the uterus
in women.
• The sharp dissection proceeds
anterior to Denonvilliers’ fascia until
the prostate and seminal vesicles or
the rectovaginal septum is seen.
• The paths of the anterior and
posterior dissections show the close
adherence to the presacral fascia
posteriorly and to the actual prostate
and seminal vesicles anteriorly.

55. • After the rectum is mobilized,
the specimen should have a
wide zone of relatively smooth
fat about the middle and
upper rectum.
• The course of the ureters and
the autonomic plexus is noted
as the dissection is carried
down to the levators.
• Afer it has been determined
that the rectal tumor can be
completely freed from the
adjacent structures, the blood
supply to the rectosigmoid is
divided.

56. • The venous drainage should be
ligated as early as possible to keep
the vascular spread of tumor cells to
a minimum.
• It is desirable to ligate the inferior
mesenteric artery just distal to the
origin of the left colic artery.
• The sigmoid is divided where it
appears to be viable and will extend
beyond the surface of the skin for 5
to 8 cm without being under undue
tension.
• The surgeon is now ready to begin
the perineal portion of the
resection.

57. Perineal dissection
• To prevent contamination, the anus is sealed
securely, either by several interrupted sutures
of heavy silk or by a purse-string suture.
• Incision is made through the skin and
subcutaneous tissue at least 2 cm away from
the closed anal orifice. All blood vessels are
clamped and tied to prevent further blood
as the operation progresses.
• The posterior portion of the incision is
extended backward over the coccyx, and the
anus is tipped upward to enable its
attachments to the coccyx to be severed
more readily.
• After the anococcygeal raphe is severed and
the presacral space is entered, the
accumulated blood from above is suctioned
out.

58. • Identify the levator muscles on either
side. The levator muscle is exposed on
one side and, with the finger held
beneath it, is divided between paired
clamps as far away from the rectum
as possible.
• Care must be taken to avoid bringing
the dissection too close the rectum at
this point, as this risks compromising
the circumferential margin.
• Following the ligation of all bleeding
points on one side, a similar division of
the levator ani muscles is carried out
on the opposite side.

59. • The skin and subcutaneous tissue of
the perineum are retracted upward,
while the anus is pulled downward
and backward to assist in the
exposure.
• The rectum is pulled down, the
remaining attachments of the levator
ani muscles and transversus perinea
are divided, and all bleeding points
are ligated.
• The upper end of the bowel segment
is grasped and delivered posteriorly
over the coccyx. A retractor is
introduced anteriorly to assist in
exposure, while any remaining
anterior attachments of the rectum
are divided.

60. • Approximate the divided levator ani muscles in the midline.
• Closed suction Silastic catheter drains are placed in the presacral
space and brought out through the skin lateral in the incision and
secured to the skin.
CLOSURE

61. • When the patient’s anatomy permits, a pedicled omental flap
based on the left or right gastroepiploic artery can be created
and laid into the pelvic defect.
• When enough omentum is available, this both fills the volume
of the pelvis and covers the raw surfaces of the dissection.

62. • The exteriorized portion of the bowel is then inspected to make
certain that active pulsation is present in its blood supply.
• Sufficient intestine should have been provided to ensure atleast 5 to
6 cm of viable bowel protruding above the skin level.

63. Post OP
• The patient is traditionally maintained on constant
bladder drainage for 5 to 7 days. In males the loss of
bladder tone may result in one of the most distressing
postoperative complications. Frequent and thorough
evaluation of the patient’s ability to empty the bladder is
essential untill good function has returned.