Dr. Pete Sagar St James's University Hospital Leeds, England

1. Tratamiento del cancer de colon
localmente avanzado
Pete Sagar
St James’s University Hospital,
Leeds, England

2. Surgery for advanced colonic
cancer
Pete Sagar
St James’s University Hospital,
Leeds, England

3. Recent history

6. Prone APER

7. MR in rectal cancer

8. Assessment of circumferential margins

9. Pre-operative radiotherapy

10. Colon cancer

11. Distant history

12. King John signs Magna Carta
1215

13. Battle of Agincourt
1415

14. Battle of Waterloo
1815

15. Battle with advanced colon cancer
• Invasion into adjacent organs
• Invasion into abdominal wall
• Tackling nodal challenges
• Troublesome recurrences

16. Napoleon’s master plan:
Strategy
• Appreciation of
terrain
• Superb timing
• Steady nerve
• Espirit de corps

17. A Surgeon’s master plan:
Strategy
• Appreciation of
terrain
• Superb timing
• Steady nerve
• Espirit de corps

18. Behind the colon

19. Around the hepatic flexure

20. Blood supply

21. Blood supply to the left colon

22. Napoleon’s master plan:
Strategy
• Appreciation of
terrain
• Superb timing
• Steady nerve
• Espirit de corps

23. Locally advanced colon cancer

24. R colon Ca

25. R colon Ca about to fistulate

26. Direct involvement of abdominal wall

27. Biological mesh with vacuum
assisted closure

28. Napoleon’s tactical art
Engage
…..
Then wait and see

29. R colon Ca : SMV & branches

30. Napoleon’s master plan:
Strategy
• Appreciation of
terrain
• Superb timing
• Steady nerve
• Espirit de corps

31. Hepatic flexure invading duodenum

32. Hepatic flexure cancer invading
pylorus, D1 and D2

33. Right colon Ca invading duodenum

34. Close to, but not invading, segment V
of the liver

35. Splenic flexure Ca invading pancreas

36. Napoleon’s master plan:
Strategy
• Appreciation of
terrain
• Superb timing
• Steady nerve
• Espirit de corps

37. A surgeon’s masterful plan
• Appreciation of
hazards
• Timing & boldness
• Team work

38. Bataillion carré
• Right & left flanks
attack
• Central strike force
• Flexibility

39. Manoeuvre sur les derriers
• Dashes for Vienna
in 1805 and 1809
• Get behind the
enemy

40. Corps system
•“Converge all forces
on the point I want to
attack”

41. Locally advanced transverse colon
cancer

42. Locally advanced transverse colon
cancer

43. Locally advanced transverse colon
cancer

44. The Sun of Austerlitz
• Iconic image of
genius and luck

45. Splenic flexure cancer invading spleen, kidney
tail of pancreas

46. Invasion into pancreas and kidney

47. Invasion into kidney and spleen

48. Spenic flexure cancer invading spleen ,
kidney tail of pancreas

49. Spenic flexure cancer invading spleen ,
kidney tail of pancreas

50. CT scan – caecal cancer

51. Caecal cancer with sacral involvement

52. Scalloping of the sacrum

53. Involved pelvic side wall

54. Tackling the pelvic side wall
Think of the five layers
• Peritoneum & ureter
• Vessels
• Nerves
• Muscles
• Bones

55. 1st
layer – peritoneum & ureter

56. 2nd
layer - Iliac vessels

57. 3rd
layer - sacral nerves

58. 4th
layer – pelvic muscles

59. 5th
layer – pelvic bones

60. Multivisceral resection of colorectal
cancer: Systematic review
• 22 studies
• 1575 patients
• 87% primary, 13% recurrent
• 64% rectal, 36% colon
• Bladder and reproductive organs most
common resection
Mohan et al Ann Surg Oncol 2013, 2929-36

61. Multivisceral resection
• Perioperative mortality = 4.2%
• Postoperative morbidity = 42%
• 5 year survival = 50.3%
• R0 resection strongest association with
5 year survival

62. • Main involved organs:
– Abdominal wall
– Small bowel
– Ureter
– Pancreas
– Bladder
Multimodality treatment for locally
advanced colon cancer

63. Problems with multivisceral resection
• Not always possible to identify need for
MVR
• Distinguish inflammatory from invasion
• Significant morbidity
• USA – most patients with locally
advanced colon ca not offered MVR

64. Preoperative chemotherapy for locally
advanced colon cancer
• Neoadjuvant chemo
used in
oesophageal,
gastric and rectal Ca
• ? Eradicates
micrometastases

65. Multimodality treatment for locally
advanced colon cancer
• Mayo clinic
• N=25
• External & intraop radiotherapy,
surgery, & chemotherapy
• Median survival = 38.2 months
• 5 year survival = 49%
Taylor et al Annals Surg Oncol 2002; 177-
82

66. Classification of recurrent colon
cancer

67. Nodal deposit on renal fascia

68. Recurrence of colonic cancer

69. Recurrence invading iliacus/iliac bone

70. Colon ca recurrence invading
symphysis pubis

71. MRI - mucinous drop metastasis

72. Colonic drop metastasis

73. Colonic drop metastasis

74. If discovered at operation….
• Describe findings in
detail ….
• AND REFER !

75. Mistakes

76. Biggest mistake
• Rule 1
• Page 1
• Book of war

77. Biggest mistake
• Never march on
Moscow

78. Colonic vessels

79. Splenic injury
• Good exposure & visualisation
• Avoid unnecessary traction
• Place retractors carefully
• Take care dividing adhesions

80. Bleeding from the inferior mesenteric
vessels

81. Activité, activité, vitesse !

82. Watch the top end

83. Pack & go for coffee
• Pack firmly, not roughly, to avoid shearing

84. Overstretch

85. Conclusion
• Know the terrain – high quality imaging
• Be bold when necessary
• Don’t over reach
• Have a get out plan

86. Never march on Moscow in winter