1 Colon and Rectal CancerProf Walid El shazly MD of Surgery A prof of coloretal surgery
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4 Cancer colon and rectum (Incidence)General 2nd common after brochogenic carcinoma in men 4th common in females Age Abroad old Egypt 40y
5 Etiology Of Colon CancerHereditary nonpolyposis colon cancer 5-6% Sporadic Colon Cancer 92% Chronic IBD 1% Familial Adenomatous polyposis and rare syndromes 1%
6 Cancer colon and rectum (Etiology)Diet Diet lacking vegetables Low residue diet---increase constipation High fiber diet----increase bile---carcinogens Cooked meat -----carcinogens Precancerous lesions Polyps--- tubuls, villous, FAP IBD Uretrocolic anastomsis
7 Familial Adenomatous Polyposis (FAP)Autosomal dominant inheritance of mutated APC gene in chromosome 5 Hundreds to thousands of colorectal adenomas, average age of onset 16 Colon cancer by age 45 (mean age 39, &% by age 21)
8 Familial Adenomatous Polyposis (FAP)Genetic tests, counseling age 10 to 12 Flexible sigmoidoscopy annually or biannually for positive genetic test Colectomy when adenomas develop
9 Hereditary Nonpolyposis Colorectal Cancer Syndrome (HNPCC)Autosomal dominant inheritance of altered mismatch repair gene Cancers preceded by a few rapidly growing adenomas Cancers multiple, proximal, younger age of onset
10 Cancer colon and rectum (pathology)5 % 3% 3% 5 % 5 % 12 % 21% 7 % 38% 2%
11 Pathology ( NEA)
12 Pathology (MP) Adenocarcinoma 95% Mucoid or colloid signet ringWell differentiated Moderately differentiated Poorly differentiated Mucoid or colloid signet ring Squamous cell carcinoma Rare types
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14 Stage 0 Colorectal CancerKnown as “cancer in situ,” meaning the cancer is located in the mucosa Removal of the polyp (polypectomy) is the usual treatment
15 Stage I Colorectal Cancercancer has grown through mucosa and invaded the muscularis (muscular coat) Treatment is surgery to remove the tumor and some surrounding lymph nodes
16 Stage I Colorectal Cancer
17 Stage II Colorectal CancerThe cancer has grown beyond the muscularis of the colon or rectum but has not spread to the lymph nodes
18 Stage II Colorectal Cancer
19 Stage III Colorectal CancerThe cancer has spread to the regional lymph nodes (lymph nodes near the colon and rectum)
20 Stage III Colorectal Cancer
21 Stage IV Colorectal CancerThe cancer has spread outside of the colon or rectum to other areas of the body
22 Stage IV Colorectal Cancer
23 Stage IV Colorectal Cancer
24 Stage IV Colorectal Cancer
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26 Methods of spread Intramural spread Lymphatic spreadSpread is three-dimensional; the distal margin is of great concern in low rectal cancers (2-3 cm are considered enough) Extension to adjacent structures Lymphatic spread N 1 Epicolic N 2 paracolic N 3 intermediate (SMA, IMA) N 4 central groups of LN (para Aortic).
28 Methods of spread Hematogenous spread Transperitoneal spreadPredominantly to the liver The lung is the second affected organ Transperitoneal spread Seedlings malignant ascites omental deposits Specially occurring in mucinous cancer and is beyond surgical cure.
29 Clinical picture of cancer Colon & Rectum
30 Alteration in bowel habit inthe form of mild diarrhea Alteration in bowel habit Sever form mainly constipation Vague upper abdominal pain Anemia, which is quite severe Intestinal obstruction is late Intestinal obstruction early A mass felt in early cases A mass felt in advanced cases Complication of Perforation hge Complication of Acute appendicitis Intussussption Perforation hge
31 1- Rectal bleeding most frequent presentation.2-Sense of incomplete evacuation 3-Tenesmus is prominent in rectal cancer 4- Recent alteration in bowel habit (increasing constipation alternating with diarrhea or spurious morning diarrhea
32 Signs Cancer Rectum General Anaemia & loss of weight Lung metastasesCancer colon General Anaemia & loss of weight Virchow’s LN Oedema of LL Abdominal Abdominal Mass Liver mass Ascites PR & PV Krukenberg Plummer’s shelf Cancer Rectum General Anaemia & loss of weight Lung metastases Abdominal Liver mass Ascites PR Mass in the rectum 90 % of cases
33 Investigations Liver function CBC anaemia Stool for occult bloodLaboratory Liver function CBC anaemia Stool for occult blood Tumor markers (CEA &Ca19)
34 Investigations Radiological Proctosigmoidoscopy ColonoscopyChest x ray or CT Double contrast barium enema Ultrasonography for the liver and LN CT or MRI which will more accurately delineate the LN and perirectal fat Proctosigmoidoscopy Diagnose almost 50% of the cases Colonoscopy It is the gold standard
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49 General Rules (1) Preoperative preparation Traditional methodPre by 5 days low residue diet Pre by 4 days low residue diet Pre by 3 days fluid only Pre by 2 days NPO Pre by 1 days NPO Mechanical & Chemical
50 General Rules (1) Chemical Preoperative preparation MechanicalLaxative at night 60 cm parrafin Cleaning enema up to 4 time per day Chemical Neomycin Erythromycin Metronidazole
51 General Rules (1) Preoperative preparation Rapid methodPolyethylene glycol can be drunk or given through NG Tube 2-3 liters over 24 hours Alternatively (in urgent cases) on table lavage using appendix stump as a portal of entry can be very effective
52 General Rules (2) Radical resectionAny surgical resection requires 5 cm proximal and 2 cm distal clearance for colonic lesions Radial margin should be histopathologically free of tumor if possible Lymph node resection should be performed to the origin of the feeding vessel
53 General Rules (3) During resectionSurgical resection requires 5 cm proximal and 2 cm distal clearance for colonic lesions Early vein ligation High artery ligation Non touch technique En block resection
54 General Rules (3) Asses operabilityTumor mobile or fixed LN involvement Peritoneal; seedlings Malignant ascites Liver metastases
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56 Depending on site of lesion surgical optionsCaecum, ascending colon,– Right hemicolectomy hepatic flexure --Extended right hemicolectomy Transverse colon – transverse colectomy or Extended right hemicolectomy Splenic flexure, descending colon – Left hemicolectomy Sigmoid colon – sigmoidectomy or Anterior resection
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60 Caecum
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92 Rectal cancer
93 Cancer rectum Upper 1/3 --- Anterior resection Lower 1/3Abdomino-perineal resection with proximal permanent stoma
94 Anterior Resection
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97 Anterior resection
98 Abdominperinal resection
99 Cancer rectum Middle 1/3 ---Abdomino-perineal resection with proximal permanent stoma Low Anterior resection with stapler Sphincter saving options Abdoinosacral approach Pull-through with trans-anal colo-anal anastmosis
101 Rectal Dissection Anterior
102 Rectal Dissection Posterior
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108 Low Anterior resection with stappler
109 Low Anterior resection with stappler
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