tratamiento del cáncer de colon localmente avanzado
TRANSCRIPT
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Tratamiento del cancer de colon localmente avanzado
Pete SagarSt James’s University Hospital,
Leeds, England
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Surgery for advanced colonic cancer
Pete SagarSt James’s University Hospital,
Leeds, England
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Recent history
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Prone APER
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MR in rectal cancer
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Assessment of circumferential margins
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Pre-operative radiotherapy
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Colon cancer
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Distant history
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King John signs Magna Carta1215
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Battle of Agincourt 1415
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Battle of Waterloo1815
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Battle with advanced colon cancer
• Invasion into adjacent organs
• Invasion into abdominal wall
• Tackling nodal challenges
• Troublesome recurrences
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Napoleon’s master plan:Strategy
• Appreciation of terrain
• Superb timing
• Steady nerve
• Espirit de corps
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A Surgeon’s master plan:Strategy
• Appreciation of terrain
• Superb timing
• Steady nerve
• Espirit de corps
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Behind the colon
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Around the hepatic flexure
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Blood supply
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Blood supply to the left colon
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Napoleon’s master plan:Strategy
• Appreciation of terrain
• Superb timing
• Steady nerve
• Espirit de corps
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Locally advanced colon cancer
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R colon Ca
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R colon Ca about to fistulate
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Direct involvement of abdominal wall
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Biological mesh with vacuum assisted closure
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Napoleon’s tactical art
Engage…..
Then wait and see
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R colon Ca : SMV & branches
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Napoleon’s master plan:Strategy
• Appreciation of terrain
• Superb timing
• Steady nerve
• Espirit de corps
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Hepatic flexure invading duodenum
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Hepatic flexure cancer invading pylorus, D1 and D2
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Right colon Ca invading duodenum
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Close to, but not invading, segment V of the liver
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Splenic flexure Ca invading pancreas
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Napoleon’s master plan:Strategy
• Appreciation of terrain
• Superb timing
• Steady nerve
• Espirit de corps
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A surgeon’s masterful plan
• Appreciation of hazards
• Timing & boldness
• Team work
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Bataillion carré
• Right & left flanks attack
• Central strike force
• Flexibility
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Manoeuvre sur les derriers
• Dashes for Vienna in 1805 and 1809
• Get behind the enemy
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Corps system
•“Converge all forces on the point I want to attack”
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Locally advanced transverse colon cancer
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Locally advanced transverse colon cancer
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Locally advanced transverse colon cancer
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The Sun of Austerlitz
• Iconic image of genius and luck
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Splenic flexure cancer invading spleen, kidney tail of pancreas
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Invasion into pancreas and kidney
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Invasion into kidney and spleen
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Spenic flexure cancer invading spleen , kidney tail of pancreas
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Spenic flexure cancer invading spleen , kidney tail of pancreas
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CT scan – caecal cancer
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Caecal cancer with sacral involvement
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Scalloping of the sacrum
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Involved pelvic side wall
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Tackling the pelvic side wallThink of the five layers
• Peritoneum & ureter• Vessels
• Nerves• Muscles
• Bones
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1st layer – peritoneum & ureter
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2nd layer - Iliac vessels
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3rd layer - sacral nerves
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4th layer – pelvic muscles
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5th layer – pelvic bones
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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
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Multivisceral resection
• Perioperative mortality = 4.2%• Postoperative morbidity = 42%• 5 year survival = 50.3%
• R0 resection strongest association with 5 year survival
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• Main involved organs:– Abdominal wall– Small bowel– Ureter– Pancreas– Bladder
Multimodality treatment for locally advanced colon cancer
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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
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Preoperative chemotherapy for locally advanced colon cancer
• Neoadjuvant chemo used in oesophageal, gastric and rectal Ca
• ? Eradicates micrometastases
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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
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Classification of recurrent colon cancer
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Nodal deposit on renal fascia
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Recurrence of colonic cancer
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Recurrence invading iliacus/iliac bone
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Colon ca recurrence invading symphysis pubis
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MRI - mucinous drop metastasis
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Colonic drop metastasis
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Colonic drop metastasis
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If discovered at operation….
• Describe findings in detail ….
• AND REFER !
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Mistakes
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Biggest mistake
• Rule 1
• Page 1
• Book of war
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Biggest mistake
• Never march on Moscow
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Colonic vessels
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Splenic injury
• Good exposure & visualisation• Avoid unnecessary traction• Place retractors carefully• Take care dividing adhesions
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Bleeding from the inferior mesenteric vessels
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Activité, activité, vitesse !
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Watch the top end
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Pack & go for coffee
• Pack firmly, not roughly, to avoid shearing
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Overstretch
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Conclusion
• Know the terrain – high quality imaging
• Be bold when necessary
• Don’t over reach
• Have a get out plan
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Never march on Moscow in winter
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