Download - Evolution of surgery in colorectal cancer
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BYDr. G .MADHU KUMAR
UNDER THE GUIDANCE OF DR. P. NANCHARAIAH
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The large intestine is formed by the following anatomic entities:
Ileocecal valve Appendix Cecum Ascending colon Hepatic flexure Transverse colon Splenic flexure Descending colon Sigmoid colon Anorectum
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Right and left colon are considered
retroperitoneal
Transverse and sigmoid colon are
intraperitoneal structures
First surgical step is mobilization of the
colon and its mesentery
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arterial blood supply to the colon superior mesenteric artery inferior mesenteric arterycommunicate in a watershed area in the
splenic flexure (artery of Drummond)
Arterial blood supply to the rectum Extensive intramural anastomoses between
the superior, middle, and inferior rectal arteries
superior rectal artery originates from the inferior mesenteric artery
middle, and inferior rectal arteries arise from internal iilac artery
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Lymphatics of colon
superior mesenteric, and the inferior
mesenteric groups of lymph nodes
Lymphatics of Rectum
inferior mesenteric nodes
iliac nodes
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Specific cause of colorectal cancer is not
known many
Genetic and environmental risk factors
have been identified.
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GENETIC RISK FACTORSENVIRONMENTAL RISK
FACTORS
Sporadic colon cancer -
Chromosomal deletions, K-
ras, DCC, p53, APC
Familial polyposis
syndromes - Polyps start
after age 10–20, cancer in
100% at age 40
Hereditary nonpolyposis
colon cancer
Inflammatory bowel disease
Geographic variation
Age
Diet
Physical inactivity
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Colorectal cancer refers to cancer
originating in the colon or rectum and can
develop in any of the four sections
Colorectal cancer develops slowly over a
period of years (~10-15 yrs)
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Colorectal cancer begins usually as a polyp
A polyp is a growth of tissue that starts in the lining and grows into the center of the colon or rectum
Over 95% of colon and rectal cancers are adenocarcinomas
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Adenocarcinoma
Mucinous adenocarcinoma
Signet ring cell carcinoma
Small cell carcinoma (oat cell)
Small cell adenosquamous carcinoma
Squamous cell carcinoma
Undifferentiated carcinoma (medullary)
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Cancer occurs when cells grow and divide without regulation and order (Stage 0, I, and IIA)
Metastasis occurs when cancer cells break away from a tumor and spread to other parts of the body via the blood or lymph system (Stage IIB, III, and IV)
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Staging is a standardized way that describes the spread of cancer in
relation to the layers of the wall of the colon or rectum, nearby lymph
nodes, and other organs
The stage is dependent on the extent of spread through the different
tissue layers affected
The stage is an important factor in determining treatment options and
prognosis
• One of the major staging systems in use is the AJCC (American
Joint Committee on Cancer) staging scheme, which is defined in
terms of primary tumor (T), regional lymph nodes(N), and distant
metastasis (M)
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T Categories: Describes the extent of spread of the primary tumor (T) through the layers of tissue that form the wall of the colon and rectum
• Tis: Cancer is in its earliest stage, has not grown beyond mucosa. Also known as carcinoma in situ or intramucosal carcinoma
• T1: Cancer has grown through mucosa and extends into submucosa
• T2: Cancer extends into thick muscle layer
• T3: Cancer has spread to subserosa but not to any nearby organs or tissues
• T4: Cancer has spread completely through wall of the colon or rectum into nearby tissues or organs
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N categories: describes the absence or
presence of metastasis to nearby lymph
nodes (N)
• N0: No lymph node involvement
• N1: Cancer cells found in 1-3 regional
lymph nodes
• N2: Cancer cells found in 4 or more
regional lymph nodes
M Categories: describes the absence or
presence of distant metastasis (M)
M0: No distant spread
M1: Distant spread is present
Lymph nodes are
small, bean shaped
structures that form
and store white blood
cells to fight infection.
An iceball in a
patient with a
metastases from
a colon cancer
receiving
cryosurgery
treatment
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Stage TNM Category Survival
Rate
Stage 0: Tis, N0, M0 The earliest stage. Has not grown beyond inner layer (mucosa) of colon or
rectum.
Stage I: T1, N0, M0
T2, N0, M0
93% Has grown into submucosa (T1) or muscularis propria (T2)
Stage IIA:
Stage IIB:
T3, N0, M0
T4, N0, M0
85%
72%
IIA: Has spread into subserosa (T3).
IIB: Has grown into other nearby tissues or organs (T4).
Stage IIIA:
Stage IIIB:
Stage IIIC:
T1-T2, N1, M0
T3-T4, N1, M0
Any T, N2, M0
83%
64%
44%
IIIA: Has grown into submucosa (T1) or into muscularis propria (T2) and
has spread to 1-3 nearby lymph nodes (N1)
IIIB: Has spread into subserosa (T3) or into nearby tissues or organs (T4),
and has spread to 1-3 nearby lymph nodes (N1)
IIIC: Any stage of T, but has spread to 4 or more nearby lymph nodes (N2).
Stage IV: Any T, Any N, M1 8% Any T or N, and has spread to distant sites such as liver, lung, peritoneum
(membrane lining abdominal cavity), or ovaries (M1).
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Open procedures
Laparoscopic procedures
Robotic surgical procedures
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They were started as perineal resection and later were modified to abdominoperineal resection
First perineal resection was done by :: FAGET [ 1739 ]
Later LISFRANC have done 9 perinealresections in series of which 3 died due to sepsis
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PAUL KRASKE (1885)
First procedure with resection and
anastomosis
Posterior incision including removal of the
coccyx
Healing was often disturbed and frequently
resulted in rectal fistulas
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Maunsell (1892)
Abdominal procedure in which the colon
was pulled through the anus and a
coloanal anastomosis constructed.
Poor anorectal function
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KOCHER (1874)
Resection of os coccyx in combination with
perianal phase
Better exposure
Less blood loss
Better lymph node dissection
Less wound infections
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MILES (1908) Described abdominoperineal excision
Postoperative mortality of 10% and a local recurrence rate of 30%
It has been treated as gold standard for several decades
But over past 30 years the incidence of APE has decreased due to high recurrence rates
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HENRY A HARTMANN (1860-1952)
Rectosigmoid resection and closure of
the rectal stump and colostomy
Still popular
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CUTHBERT DUKES - (1890-1977)
Classification of the rectal cancer
Dixon and Best (1940)
Popularised the sphincter saving operation
Anterior resection of the rectum
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Lazorthes and Parc (1986)
The J-pouch anastomosis
to improve functional outcome
Z´graggen
Coloplasty
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Mechanical staplers
Circular staplers it has become possible to
perform an anastomosis all the way down
to the pelvic floor
Single stapling technique has evolved into
the double stapling and the triple stapling
techniques
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Heald (1982)
Total mesorectal excision (TME)
sharp dissection under direct vision in
embryological avascular planes, excising
the rectum together with an intact
mesorectum covered posteriorly and
laterally by the mesorectal fascia
sphincter saving excision
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Complication anastomotic leakage
A diverting loop ileostomy was done to
prevent anastomotic leakage
wider lateral excision, aimed at resecting
the so-called lateral lymphnodes was
proposed
Increased urogenital morbidity
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Buess (1985)
Transanal Endoscopic Microsurgery
Medically frail patients
Palliative
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Primary treatment objective to prevent
local tumor complications, i.e., obstruction,
perforation, bleeding, and pain
Even in the presence of distant
metastases in the liver or lung, resection is
done.
Restoring the intestinal continuity is the
best palliation
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Standard Resections of the Colon
Tumor Location Resection Description of Extent Major Blood Vessel Safety Margin
Cecum Right hemicolectomy Terminal ileum to mid transverse colon, right flexure included
Ileocolic artery, Right colic artery, Right branch of mid colic artery
5 cm
Ascending colon Right hemicolectomy Terminal ileum to mid transverse colon, right flexure included
Ileocolic artery, Right colic artery, Right branch of mid colic artery
5 cm
Hepatic flexure Extended right hemicolectomy
Terminal ileum to descending colon (distal to left flexure)
Ileocolic artery, Right colic artery, Mid colic artery
5 cm
Transverse colon Extended right hemicolectomy
Terminal ileum to descending colon (distal to left flexure)
Ileocolic artery, Right colic artery, Mid colic artery
5 cm
(Transverse colon resection)
Transverse colon (including both flexures)
Mid colic artery
Splenic flexure Extended left hemicolectomy
Right flexure to rectosigmoid colon (sigmoid, beginning of rectum)
Mid colic artery, Left colic artery, Inferior mesenteric artery
5 cm
Descending colon Left hemicolectomy Left flexure to sigmoid colon (beginning of rectum)
Inferior mesenteric artery, Left branch of mid colic artery
5 cm
Sigmoid colon Rectosigmoid resection
Descending colon to rectum Superior hemorrhoidal artery, Inferior mesenteric artery
5 cm
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open procedures were combined with
radiotherapy
Local recurrence with
Surgery alone : 29%
Surgery combined with radiotherapy : 11%
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In late 80’s the success of laparoscopic
gall bladder procedures has laid
foundation for its use in laparoscopic colo
rectal surgeries
Now it has become the main stay of
colorectal surgeries
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ADVANTAGES
Less blood loss
Early return of the intestinal motility
Lesser duration of hospital stay
Early ambulation of the patient
In the early post operative period the
patients have shown better reserve of
cellular immune response
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DISADVANTAGES
Prolonged duration of surgery
Need for technically expertised people
More costly
Most common – increased chances of
recurrence at the port site
Chances of recurrance if the tumor is handled
many times during the surgery
Risk of vascular injuries as all the
abdominal quadrants are made involved
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The laparoscopic approach to colectomy is slowly gaining acceptance for the management of colorectal pathology
Considered reasonable in a palliative setting
Recent studies suggests very less port site recurrences
Moderate quality-of-life benefit but otherwise no difference in outcome and survival between
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3 – 4 trocars are inserted
Colon should be mobilized to the same
extent as during open surgery
Vascular pedicle is identified and
transected
Large bowel exteriorized through a small
but sleeve-protected abdominal incision
Extra-abdominal resection and
anastomosis are performed
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Preservation of the autonomic nerves is also possible during laparoscopic TME
Technical feasibility of performing laparoscopic TME was demonstrated in several prospective studies
Complete resection of the mesorectumwith intact visceral fascia
For rectal cancer, laparoscopic technique can be more complex depending on the tumor location
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In contrast to open and laparoscopic procedures , the robotic surgical procedure gives a high definition 3-D imaging with articulating instruments that mimic human hand
It is more helpful in operating in narrow areas as that for rectum
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Hence robotic TME ( TOTAL MESORECTAL EXCISION ) is more safer than open and laparoscopic TME
The acceptance of these MINIMALLY INVASIVE TECHNIQUES by the surgeons and patients has been widely increasing now a days
But due to onchologic concerns application of this techniques to rectum is more slower
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