terapia del cancro colorettale: gestione chirurgica - gastrolearning®

Università Cattolica Del Sacro CuoreUniversità Cattolica Del Sacro CuoreChirurgia DigestivaChirurgia Digestiva

CANCRO DEL CANCRO DEL COLON-RETTOCOLON-RETTO

Prof. Giovanni Battista DogliettoProf. Giovanni Battista Doglietto

CARCINOMA COLO-RETTALECARCINOMA COLO-RETTALE• 50000 nuovi casi/anno in Italia50000 nuovi casi/anno in Italia

• Quale linfoadenectomia ?Quale linfoadenectomia ?

• infiltr. organi circostanti → 6-10% dei casi: infiltr. organi circostanti → 6-10% dei casi: quale interventoquale intervento

• 40% dei pazienti ha un’età maggiore di 70 anni40% dei pazienti ha un’età maggiore di 70 anni

• Intervento laparotomico o laparoscopico ?Intervento laparotomico o laparoscopico ?

• Urgenza vs ElezioneUrgenza vs Elezione

Ruolo della linfadenectomia nel cancro del colon

1990 Working Party Report to the World Congress of Gastroenterology

+National Cancer Institute

• Fielding LP ,et al . Clinicopathological staging for colorectal cancer: an International Documentation System (IDS) and an International Comprehensive Anatomical Terminology (ICAT) . J Gastroenterol Hepatol 1991 ;6 : 325 – 44 .

• Nelson H , et al . Guidelines 2000 for colon and rectal cancer surgery . J Natl Cancer Inst 2001 ; 93 : 583 – 96 .

• Otchy D , et al . Practice parameters for colon cancer . Dis Colon Rectum2004 ; 47 : 1269 – 84 .

Radicalità oncologica = linfadenectomia a 12 lfn

Affiliations of authors: Department of Surgical Oncology, The University ofTexas M. D. Anderson Cancer Center, Houston, TX (GJC, MARB, JMS);

Department of Pediatrics, Baylor College of Medicine, Houston, TX (VAM) .

Evidenza: Ia

Risultati:• Studi “nested coort”:A) Intergroup 0089 trial (USA – 3411pz):

Linfadenectomia efficace = fattore incidente sulla sopravvivenza, sia per

N0 che per N+!!

+ 15% + 12%

+23% + 19 %

+ 11%

+ 28 %

T3-4/N0

T1-T4/N1

T1-T4/N2 + 20% + 16% + 19%

B) INTACC study (Italia – 3491pz):

Linfadenectomia efficace = fattore incidente sulla sopravvivenza, per N0

ma non per N+!!

T3-T4/N0 + 8%

+ 7%

+ 17%

+ 11%

T1-4/N1-2

NB: L’ N richiede una linfadenectomia di almeno 12 linfonodi (TNM VI for colo-rectal cancer).

Il nuovo TNM VII (in elaborazione) ne prevederà 15.

Trattamento delle neoplasie del colon:

Chirurgia open vs chirurgia laparoscopica

Effetto del volume di LAC sui risultati:

Clips AMS lps

K colonQuale intervento nei T4 ?

• 1981-1996 → 618 pz sottoposti a resezione chirurgica per carcinoma del colon

• 88 resezioni allargate (14.2%): 70 curative (14.3%) e 18 palliative (14.1%)

in letteratura dal 16% al 67%

6

1313

1212

pseudomixomaperitoneigastric cancer

colo-rectalcancerperitonealsarcomaovary cancer

mesothelioma

appendixcancer

HYPERTHERMIC INTRAPERITONEAL INTRAOPERATIVE CHEMOTERAPY HYPERTHERMIC INTRAPERITONEAL INTRAOPERATIVE CHEMOTERAPY N°43 PROCEDURE (38 PATIENTS) N°43 PROCEDURE (38 PATIENTS) Personal Experience April 1999-November 2008

• 1981-1996 → 346 pz sottoposti a resezione chirurgica per carcinoma del retto

• 26 resezioni allargate (7.5%): 23 curative (7.3%) e 3 palliative (9.4%)

• 7/23 (30.4%) recidive di malattia nel gruppo di resezioni curative “allargate”

• 48/291 (16.5%) recidive di malattia nel gruppo di resezioni curative “non allargate”

in letteratura dal 16% al 67%

Colorectal cancer in emergency

15-30 % k colon as emergency

obstruction 78% perforation 10% bleeding 4%

Bad prognosisshort and long-term

Higher frequency non-curative resection (OR 2.452, p<0.0001)

Emergency ptsObstruction 547 (55.5%)Perforation 84 (8.5%)Bleeding 355 (36%)

5-yr cancer-specific survivalElective 56.3%Emergency 38.5%

P<0.001

B J Surg 1967

In-hospital mortality42/762 pts

5.5%%

Non influenzano la prognosi a breve termine

In-hospital mortality

Diastatic perforation 60%

Tumour perforation 37%

Disease-free survival (excluded mortality periop and stage IV)

Overall survival

Primary versus staged resection for acute obstructing colorectal carcinoma.Sjödahl R, Franzén T, Nyström PO.

Department of Surgery, University Hospital, Linköping, Sweden.Br J Surg 1992

115 pts obstruction colon cancer

Primary resection 40 pts

Staged resection 40 pts

Primary StagedMortality 10% 15%

Hospital stay 18 days 45 days

5-yr survival 38% 29%

22 righ-side

18 left-side

Morbidity CS 52.5% GS 60.5%

p=0.01

Colorectal surgeon General surgeon

Mortality CS 17.9% GS 28.3%

p<0.001

Postoperative complications

Anastomotic dehiscence

Postoperative mortality

Chirurgo colorettale….

o chirurgo esperto???

Resezione colica, resezione gastrica,splenopancreasectomia

K colon destro occluso

K FLESSURA EPATICA

Chirurgo colorettale….

o chirurgo esperto???

2010

Single-stage Two-stage Three stage

1. Stoma2. Resection3. Closing the

stoma

1. Hartmann2. Reversing

end colostomy

Resection +

primary anastomosis +/- stoma

Mortality 20%Stoma complication 10-34%Definitve stoma 30%Stoma reversal

Mortality 4% Leak 16%

?

2010

Hartmann should be preferred to colostomy forOLCC, since colostomy appears to be associated with longeroverall hospital stay and need for multiple operations but not with a reduction in peri-operative morbidity(Grade of recommendation 2B )

!!! Unresectable diasease, neoadjuvant therapy, “dramati scenario””!!!

Theoretical benefits loop colostomy:colonic decompression;minimal surgical trauma;Reduction of the risk of contamination from unprepared bowel; staging and multidisciplinary evaluation prior to definitive treatment.

Ann Surg 2004

Total colectomy for OLCC (without cecal perforation or evidence of synchronous right colonic cancers) should not longer be preferred to segmental colectomy with i.o. colon irrigation, since the two procedures are associated with same mortality/ morbidity, while total colectomy is associated with higher rates impaired bowel function (Grade of recommendation 1A).

The two techniques are associated with same mortality/morbidity rate. MD is a shorter and simpler procedure. Either procedure could be performed, depending of the experience/preference of the surgeon(Grade of recommendation 1A).

Colon irrigation

Manual decompression

Leak 7% 1% p=0.006Wound infection

14% 9% p= ns

Mortality 7% 1% p=0.006

2012

Stent insertion before subsequent surgery has no effect on perioperative mortality and long-term survival.

EnterocutaneostomiaEnterocutaneostomia

Esteriorizzazione sulla cute di un segmento intestinale (lleo Esteriorizzazione sulla cute di un segmento intestinale (lleo o colon) attraverso la parete addominale.o colon) attraverso la parete addominale.

Terminale - Escludente (a canna di fucile)Terminale - Escludente (a canna di fucile)

Temporanea - DefinitivaTemporanea - Definitiva

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