A Lecture based on Bailey and Love for History for surgical infection for fourth year

1. Prof. Khalid Masud Gondal
FCPS(Pak),FICS(USA),FCPS(BD),DCPS(HPE)
Professor of surgery KEMU
Councilor & Regional Director CPSP Lahore
Carcinoma Rectum & Colon
Lecture II

2. THIS LECTURE IS
ABOUT
• Classification of Colorectal Carcinomas
• How to Prepare a patient for surgery with CRC?
• Oncologic Principles Of Surgery
• Siting of Stomas
• Surgical options for CRC
• Stage specific treatment

3. Various Classification
Systems for CRC
• The carcinoma colon is classified
according to
o Duke’s Classification
o Modified Asler Coller
o UICC Classification
o AJCC Classification

4. • Staging
• ps
Polyp–Apremalignant
condition
Pedunculated Sessile

5. AJCC Classification of Colorectal Carcinoma
Tis:
Carcinoma
in Situ
Or
Invasion of
lamina
propria
N=0
M=0
N=0
M=0
Tany
Nany
M1
Metasta
sis

6. Management Plan
o Preoperative staging
o Assess operability
o Synchronous tumors exclusion
o Stoma issues
o Aim: removal of primary tumor and its draining loco
regional lymph nodes
o Histological grading for adjuvant therapy

7. Pre-operative bowel preparation
48
hours before
surgery
Dietary
restriction to
Solid foods

8. Pre-operative bowel preparation
48
hours before
surgery
Only Liquids
are allowed

9. Pre-operative bowel preparation
24hours before
surgery
Clear Liquids
only are
allowed

10. Pre-operative bowel preparation
pre-op
day
• Purgatives as Sodium Picosulphate
• Per Rectal Enemas &
• I/V Antibiotics

11. Mechanical bowel preparation:
• Prograde washout using nasogastric tube with saline
• If patient presents with obstruction, then consider on
table lavage

12. Management Principles
• Any surgical resection requires 5 cm proximal
and 2 cm distal clearance for colonic lesions
• 1 cm distal clearance of rectal lesions adequate if
mesorectum resected
• Lymph node resection performed to the origin of
the feeding vessel
• En Bloc resection of adherent tumours should be
performed

13. Operability:
• Liver palpated for secondary deposits
• Peritoneum especially pelvic peritoneum and
omentum inspected for tumour seedlings
• Various draining lymph node groups palpated for
enlargement
• Tumour examined for mobility/fixity and operability

14. Counseling and siting of stoma:
• Counseling and siting of stoma:
• Take consent regarding permanent colostomy
• Counseling with stoma nurse
• Explain the care of stoma

15. Counseling and siting of stoma:
• Correct Siting of stoma
o In a triangle between
ASIS, umbilicus and
lateral border of rectus
sheath
o Should be through the
rectus muscle

16. Procedures
for
CRC
OPEN / LAPAROSCOPY

17. Right hemi colectomy
• Carcinoma of cecum or
right colon
• Ileocolic vessels, right colic
vessels and right branches of
middle colic vessels ligated and
divided
• Ileal- transverse colic
anastomosis

18. Extended right Hemicolectomy:
o For lesions of hepatic flexure
or proximal transverse colon
o Right colon and proximal 2/3rd
transverse colon resected
o Ileocolic, right colic and right and
left branches of middle colic ligated
and divided
o Distal ileal-distal transverse colon
anastomosis

19. Transverse colectomy:
• Lesions in mid-
transverse colon
• Middle colic vessels ligated
and divided
• A transverse colocolic
anastomosis

20. Left hemicolectomy
• Tumours confined to splenic
flexure or descending
colon
• Left branches of middle colic,
left colic vessels, first brances
of sigmoid vessels ligated and
divided
• Colocolic anastomosis

21. Extended Left hemicolectomy
• Tumours in distal
transverse colon
• Left colectomy is extended
proximally to include right
branch of middle colic
artery
• Colocolic anastomosis

22. Sigmoid colectomy
o Tumours of sigmoid colon
o Ligation and division of sigmoid
brances of inferior mesenteric
artery
o Anastomosis between descending
colon and rectum

23. Synchronous tumors
Management
oTotal colectomy:
• Ileocolic, right colic, middle colic, left colic and
sigmoid vessles ligated and divided.
• Superior rectal vessels preserved
• Anastomosis between ileum and upper rectum
o Subtotal colectomy:
• Sigmoid vessels preserved
• Anastomosis between ileum
and sigmoid colon

24. I II III IV
• No risk of lymph node metastasis
• Complete excision of polyp with tumour free margins.
• If complete excision not possible; consider segmental
resection

25. • Segmental colectomy is advised especially if
• Lympho-vascular invasion
• Poorly differentiated
• Tumor within 1 mm resection margin
I II III IV

26. I II III IV
• Surgical resection
• Adjuvant Chemotherapy– controversial role

27. I II III IV
• Lymph node metastasis T any, N1, M0
• Surgical resection
• Adjuvant chemotherapy must be given
o5-Flourouracil based regimens

28. • Selected patients with isolated resectable metastasis---- consider
metastatectomy
• Two stage procedure or combined with resection of primary tumour
• Consider use of palliative treatment:
• Colonic stenting
• Diversion colostomy
• Definitive chemotherapy treatment in all advanced cases
I II III IV

30. Management of
Rectal
carcinoma

31. Principles of management
• Rectal Carcinoma:
o Radical excision of the rectum, with mesorectum and
associated lymph nodes should be the aim
o Restore gastrointestinal continuity whenever possible
o Preserve continence by saving sphincter whenever
possible

32. • Holy plane of Heald: Between mesorectum and sacrum
• The fascial envelope
o Posteriorly Waldeyer s Fascia: Between rectum and sacrum
o Anteriorly: Denonvilliers Fascia
o Lateral Ligaments with middle rectal vessels
Management -Rectal Carcinoma:

33. Rectal Carcinoma
• AIM
o Resection of the tumour
• Low/ Anterior resection
• Abdominoperineal resection
• Pelvic Sweep
o Total mesorectal excision

34. Anterior Resection:
o Carcinoma of upper
two thirds of rectum
o Radical excision of
tumour with atleast 2
cm margin + TME

35. Rectal Carcinoma:
Anterior Resection
o High proximal ligation of inferior
mesenteric vessels
o Rectum mobilized and
removed
o End to end anastomosis
• Manual or stapling
o Protecting stoma may be required

36. Low Anterior Resection
Using a EndoStapling Gun

37. Abdomino-perineal
resction:
o Abdominal procedure:
• Pelvic colon mobilized
• Pelvic peritoneum divided
• Inferior mesenteric artery divided and ligated
• Rectosigmoid mesentry divided
• Hypogastric plexus saved by dissecting in the Holy plane
• Lateral ligaments with middle rectal vessels divided after
ligation

38. Abdomino-perineal
resction
o Preineal approach:
• Elliptical incision around anus
• Levator ani divided laterally
• Waldeyer s Fascia incised n divided
• Rectum mobilized from all sides
• Rectum and anus removed per rectally
• End colostomy made
• Perineal wound closedaround drain

39. Rectal Carcinoma:
o Laparoscopic treatment
options:
• Laparoscopic colon
mobilization
• Laparoscopic anterior
resection:
• Laparoscopic
abdominoprenial
resection

40. Rectal Carcinoma
o Pelvic exentration:
o Removal of all pelvic
organs
o Alongwith internal iliac and
obturator group of lymph
nodes
o Both internal iliac vessels
ligated and divided
o Urinary diversion with ileal
conduit is required

42. Adjuvant Chemotherapy
for CRC
• All patients with Stage III
• Patients with Stage II (High risk)
o Number of lymph nodes involved
o T4 lesions
o Perforation
o Peritumour Lymph vascular involvement
o Poorly differentiated histology
o Assessment of anticipated life expectancy

43. Adjuvant Chemotherapy
for CRC
• Chemotherapy
o 5-FU/ leucovorin
• Intraoperative radiotherapy

44. Follow up and Surveillance:
o Colonic cancer:
• Colonoscpy 12 months after the diagnosis
• Repeated every 3 to 5 years
o Rectal carcinoma:
• Most recurrences occur within 2 years
• Patient followed for at least 2 years
• CEA every 2-3 months for 2 years
• Endorectal ultrasounds

45. Further advances
• Role of
o Radio-immunoguided surgery
o Targeted chemotherapy
In management of colorectal malignancy

46. Tis:
Carcinoma
in Situ
Or
Invasion of
lamina
propria
N=0
M=0
N=0
M=0
Tany
Nany
M1
Metasta
sis
5yearsurvivalaftertreatment
forCRC
I II III IV
5-1030
7090