![Page 1: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/1.jpg)
Common small and large intestinal surgical diseases
Part II
Khayal AlKhayal, MD, FRCSCAssistant Professor of SurgeryConsultant Colorectal Surgeon
2010
1428 surgery team
Done by : 428 surgery team
![Page 2: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/2.jpg)
Colorectal cancer
2428 surgery team
![Page 3: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/3.jpg)
Outline
• Definitions• Polyps• Basics of colorectal cancer• Surgery• Staging
3428 surgery team
![Page 4: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/4.jpg)
Perspective
4428 surgery team
![Page 5: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/5.jpg)
Definitions• Colon = large bowel = large intestine• Rectum - terminal portion of the colon• Polyp - benign growth; not invasiveThere are many types of polyp , such as inflammatory ,
hyperplastic , and adenoma , and the last one ONLY can develop to cancer .
• Adenoma - type of polyp and has chance to develop cancer but not all.
• Cancer - malignant growth; invasive (through basement membrane)
• Stage - where the cancer is growing ( IMP for management )• Primary - the original tumour, where it started• Metastases - where the tumour has spread to
5428 surgery team
![Page 6: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/6.jpg)
Cancer
A cancer cell :• is immortal ( lives forever)
• multiplies uncontrollably• can live on its own without neighbors• can live in other parts of the body
6428 surgery team
![Page 7: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/7.jpg)
Colon and Rectum
7428 surgery team
![Page 8: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/8.jpg)
Colorectal Cancer
• Most cancers are acquired some are inherited• Almost all cancers begin as a benign polyp or
adenoma• Only a tiny percentage of adenomas become
cancers
8428 surgery team
![Page 9: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/9.jpg)
What is a polyp?
9428 surgery team
![Page 10: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/10.jpg)
Polyp - Cancer Sequence
• The process from benign polyp to cancer takes from 7 - 10 years • The transformation into cancer is based on
– the type of polyp
– Size of polyp
• Multiple polyps = greater risk of cancer• Tubular , Villus and Tubuloviilus are types of polyps .• Note:Villus histological feature have a high chance to develop
carcinoma 40%.
10428 surgery team
![Page 11: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/11.jpg)
11428 surgery team
![Page 12: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/12.jpg)
12428 surgery team
![Page 13: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/13.jpg)
The Effect of Age on the Incidence of Colorectal Cancer and Colorectal Polyps
13428 surgery team
![Page 14: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/14.jpg)
Removing polyps prevents cancer
Removing polyps prevents cancer
ColonoscopyColonoscopy
14428 surgery team
![Page 15: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/15.jpg)
Colorectal CarcinomaColorectal Carcinoma
ClassificationAdenocarcinoma 95%
CarcinoidLymphoma
SarcomaSquamous cell carcinoma
ClassificationAdenocarcinoma 95%
CarcinoidLymphoma
SarcomaSquamous cell carcinoma
15428 surgery team
![Page 16: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/16.jpg)
Epidemiology• 3th most common malignancy worldwide.
• 1st most common in Saudi males.
• second to lung cancer as a cause of cancer death
• 21,500 new cases, 8900 will die (2008) “ more than one third “
• risk of CRC – women 1/16 , men 1/14
• peek incidence in 7th decade but it can occur at any age
CRC : colorectal ca .7th decade means : 61 – 70 years old
16428 surgery team
![Page 17: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/17.jpg)
Etiology of Colorectal Cancer
Incidence in left is more than right….why ?Because sigmoid colon is narrow
17428 surgery team
![Page 18: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/18.jpg)
Risk Factors
1. Genetics, Family history• Personal history• One first degree family member doubles risk• Hereditary colorectal cancer syndomes
2. Polyps3. Inflammatory bowel disease (Chron’s Disease and
Ulcerative Collitis).4. Other
• Diet, nutrients, smoking, ETOH
18428 surgery team
![Page 19: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/19.jpg)
Colorectal Cancer Risk Based on Family History
• General population “ sporadic “ 6%• One 1st degree CRC 2-3X* (12-18%)• Two 1st degree CRC 3-4X*• One 1st degree CRC < 50 y 3-4*
• One 2nd or 3rd CRC 1.5X• Two 2nd degree CRC 2-3X*
• One first degree with polyp 2X*
19428 surgery team
![Page 20: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/20.jpg)
Clinical presentation1. Bleeding - gross, occult, anemia (37%)2. Change in bowel habit – pain, diarrhea, constipation,
alternating pattern 3. Obstruction – more common with left sided lesions most
common cause of bowel obstruction in the elderly4. Vague abdominal pains5. Change in caliber of the stools6. Weight loss7. Abdominal mass8. Asymptomatic
20428 surgery team
![Page 21: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/21.jpg)
Investigations• General:
– Complete history and physical (DRE)• Endoscopic (identify primary, synchronous lesions)
– Flexible sigmoidoscopy– Colonoscopy “ to roll out other lesions “
• Staging– Endorectal ultrasound (rectal cancer)– Chest x-ray (metastases)– Liver ultrasound (metastases)– Abdominal CT scan (metastases)
• Bloodwork– CBC electrolytes, CEA (tumour marker)• Tumour marker used for prognosis of the disease and to follow up
the patient .* CEA : CarcinoEmbryonic Antigen “ not specefic marker “
21428 surgery team
![Page 22: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/22.jpg)
22428 surgery team
![Page 23: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/23.jpg)
Surgical therapy
• Surgery is the most important variable in the treatment of colorectal cancer
• Radiation and chemotherapy alone cannot cure any stage of colorectal cancer
• The site of tumour dictates the basic procedure
23428 surgery team
![Page 24: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/24.jpg)
24428 surgery team
![Page 25: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/25.jpg)
Preoperative preparation• Evaluation of medical problems• Mechanical bowel preparation (cleanes the bowel by causing
diarrhea) – Colyte , Oral fleet
• IV antibiotics (because it is contaminated gross contamination wound)
• DVT prevention ( blood clots in the legs)– Heparin shots– Compression stockings
• Foley catheter “ for the urinary bladder “
• Epidural catheter “ for reduce the pain “
25428 surgery team
![Page 26: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/26.jpg)
Principles of Surgery “how to do surgery”
• Examine the entire abdomen• Remove the appropriate segment of the colon
with adequate margins• Remove the corresponding lymph nodes• Open vs laparoscopic approach
26428 surgery team
![Page 27: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/27.jpg)
Right hemi Colectomy
Left hemicolectomyAbdominoperineal resection
27428 surgery team
![Page 28: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/28.jpg)
Subtotal Colectomy
Anterior resection
Low Anterior resection28428 surgery team
![Page 29: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/29.jpg)
• When the tumor in the right side we do right hemi colectomy
• When the tumor in the left side we do left hemi colectomty
• When the tumor in the sigmoid colon we do anterior resection
• When the tumor in the rectum or below we do lower anterior restriction or abdomino-perineal resection. 29428 surgery team
![Page 30: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/30.jpg)
Ostomy• The intestine is brought out through a hole in the
abdominal wall
Colostomy ( colon on the skin)• Permanent when the rectum is removed• Temporary when it is unsafe to make a join
Ileostomy ( ileum on the skin)• Temporary when the join needs time to heal
30428 surgery team
![Page 31: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/31.jpg)
31428 surgery team
![Page 32: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/32.jpg)
32428 surgery team
![Page 33: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/33.jpg)
33428 surgery team
![Page 34: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/34.jpg)
34428 surgery team
![Page 35: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/35.jpg)
Recovery
• Surgery 2 to 4 hours• Hospital stay 4 to 10 days
– IV, urine catheter, compression stockings, intravenous pain killers, blood thinner
– Discharge when ambulating, eating, bowel function, good pain control
• Recovery 4 weeks
35428 surgery team
![Page 36: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/36.jpg)
Follow up
• Office visit every 3 months for two years then every 6 months for 3 years
• Regular blood work (CEA)• Colonoscopy at year 1 and 4 and every 5 years• CT scan yearly
36428 surgery team
![Page 37: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/37.jpg)
Some notes mentioned about CEAIMP
• CEA used to detect the prognosis : higher CEA worse prognosis.
• Also used to detect recurrence: for example: (normal CEA is <5).If CEA was 50 then after surgery it becomes 5 then after some time
it raised to 50 again . Here we suspect recurrence.
*also if CEA was 100 and after a surgery it is still 100 that indicate there is another mass has not been removed .
37428 surgery team
![Page 38: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/38.jpg)
Pathology of Colorectal Cancer
• Macroscopic:
• Microscopic (differentiation):– Well– Moderately– Poorly
• Lymph node involvement
38428 surgery team
![Page 39: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/39.jpg)
Staging ( Where is it Growing?)
1. How far into the wall has it grown? T stage• Tis – invasion of mucosa only• T1 – Invasion of submucosa• T2 – Invasion of muscularis propria• T3 – Full thickness/perirectal fat• T4 – Invasion into adjacent organs
39428 surgery team
![Page 40: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/40.jpg)
Staging ( Where is it Growing?)2. Is it growing in other places?
N stage, M stage• N1 – 1-3 lymph nodes• N2 - >4 lymph nodes• N3 – distant lymph nodes• M1 – Distant organ ( liver, lung)
40428 surgery team
![Page 41: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/41.jpg)
TNM Staging
• Stage 0 – Tis tumorsInvasion of mucosa
• Stage 1 – T1 and T2 tumorsInvasion of sub mucosa & muscularis propria
• Stage 2 – T3 and T4 tumorsInvasion of full thickness & adjecent organ
• Stage 3 – Any lymph node involvement
• Stage 4 – Distant metastases
41428 surgery team
![Page 42: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/42.jpg)
Who Gets Additional Treatment?
• COLON– All stage 3 patients (positive nodes) -
chemotherapy– High risk stage 2 patients
• RECTUM– All stage 2 and stage 3 patients should get
radiation and chemo
42428 surgery team
![Page 43: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/43.jpg)
Survival and TNM Stage
• STAGE 5-Year Survival 1 90%
2 80%^3 27-69%*4 8%
^for T3N0 tumors*depends on # of nodes involved
43428 surgery team
![Page 44: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/44.jpg)
Summary
1. Common Cancer2. Can be prevented through screening and
resection of polyps3. Surgery is the primary treatment4. Slow but steady improvement in survival
44428 surgery team
![Page 45: Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010](https://reader035.vdocuments.mx/reader035/viewer/2022070408/56649e595503460f94b534e9/html5/thumbnails/45.jpg)
45428 surgery team