1 Tongji Hospital in HUSTColorectal Disease Jichao Qin Department of Surgery Tongji Hospital in HUST 1、 Hello, everyone. Let me introduce myself first. I am a surgeon from Tongji Hospital. In the next 2 hours, we would share something together. Today’s topic is colorectal diseases.
3 Blood supply of the Large intestineSMA(superior mesenteric artery) Middle colic artery Right colic artery Ileocolic artery IMA(inferior mesenteric artery) Left colic artery Sigmoid artery Superior rectal 3 Blood supply to the colon comes from branches of the superior mesenteric[səˈpiriə ˌmesənˈterik] artery (SMA) and inferior [ɪnˈfɪriɚ] mesenteric artery (IMA). SMA branches include Middle colic[ˈkɑlɪk] artery Right colic artery Ileocolic [ˌiliəukalik] artery IMA branches include Left colic artery Sigmoid artery the blood supply for low rectum and anal tube The branches from Middle and inferior rectal artery
4 Lymphatics of large intestine4 Lymphatic drainage[ˈdrenɪdʒ] from the colon is to the paracolic nodes, then to the Superior mesenteric nodes or inferior mesenteric nodes. Drain to the paraaortic/para-eotik/ lymph nodes. It is a dazzled network. But it is very important for surgical resection.
9 Morbidity and risk factors for CRC
10 Epidemiology Colorectal Cancer (CRC),which include colon cancer and rectal cancer, is one of the most popular malignant carcinoma. the third most common in the whole World the second most in USA the third most common in China Epidemiology[ˌɛpɪˌdimiˈɑlədʒi, -ˌdɛmi-]
11 High-risk groups for CRCgastrointestinal symptoms after the age of 50 a history of Colorectal Adenomas, Ulcerative Colitis, Schistosomiasis Colitis family history of Cancer and FAP (Familial Adenomatous Polyposis) a history of pelvic Radiation Therapy a history of Cholecystectomy or Appendectomy Colorectal adenomas has a close connection with colorectal cancer. Many experts consider adenomas may turn malignant in 10 years in average. schistosomiasis [ˌʃistəsəu'maiəsis] Colitis [kəu'laitis] Familial [fə'miljəl] Adenomatous [æde'nɔmətəs] Polyposis [pɔli'pəusis] adenocarcinoma Cholecystectomy [ˌkɔlisis'tektəmi] Appendectomy [ˌæpən'dektəmi]
12 Colorectal cancer incidence by age in the US11 This Figure show colorectal cancer incidence by age in the USA. The majority [məˈdʒɔriti] of colon cancer in the general population occurs after the age of 50
13 Percent of adenomas containing invasive cancer by size and histology12 The percent of adenomas containing invasive [in'veisiv] cancer by size and Histology [hisˈtɔlədʒi]. precancerous lesion
14 Probability of developing colorectal carcinoma in patients with ulcerative colitis an 0.5% cumulative incidence per year 13 precancerous lesion with ulcerative colitis, an 0.5% cumulative incidence per year
16 Pathology of CRCs
17 Gross appearance of tumor1． Endophytic (ulcerative) ——common type in Colorectal Cancer 2． Exophytic ——in right-sided tumors 3． Infiltrative ——in left-sided tumors 15 Gross appearance of tumor
21 Histological ClassificationAdenocarcinoma 95% Lymphoma Squamous cell carcinoma 19 The most common colon cancer cell type is adenocarcinoma [ˌædnəuˌkɑ:sə'nəumə] which accounts for 95% of cases. Other, rarer types include lymphoma and squamous ['skweiməs] cell carcinoma.
22 Development of Colorectal CarcinomaGrowth Malignant Transform Invade through the bowl wall Spread to regional lymph nodes Metastasize to distant sites 20 Development of Colorectal Carcinoma First, it is just growth; then Malignant Transform; and Invade through the bowl wall; Spread to regional lymph nodes Metastasize to distant sites
23 Dukes Classfication SystemCancer Staging System TNM Staging System Dukes Classfication System 21 Cancer Staging System There are two system TNM staging system and Dukes classification There are a complex system for professional. I wish you could learn by yourselves
24 How to diagnose CRCs
25 Signs & Symptoms General abdominal discomfort Change in bowel habitsWeight loss with no explained reason Constant tiredness Vomiting Change in bowel habits Blood in Stool Diarrhea Constipation 22 There are many Signs & Symptoms Blood in Stool is the most common. It account for 80% cases.
26 Diagnosis More useful for Diagnosis Biopsy EndoscopyDigital rectal exam Imaging examination Tumor markers Fecal Occult Blood Testing More useful for Diagnosis 23 We have many tools for diagnosis Fecal Occult [ˈfikəl] [əˈkʌlt, ˈɑkˌʌlt]
29 Double-contrast barium enema (DCBE)apple core 26 Barium ['bɛəriəm] enema ['enimə] demonstrating “apple core” lesion, caused by a coloncarcinoma.
30 CT image for hepatic metastasis
31 Tumor Markers (CEA) Relative with the extent of tumor.Combined with CA199 for monitoring of postoperative recurrence and evaluating prognosis Tumor Markers CEA is a useful marker for colorectal cancer. Combined with CA199 for monitoring of postoperative recurrence and evaluating prognosis
32 Fecal Occult Blood Testing (FOBT)Detects blood from cancers or large polyps Bleeding increases with polyp size and stage of cancer Limited sensitivity: 30% - 50% 29 FOBT Detects blood from cancers or large polyps Bleeding increases with polyp size and stage of cancer Limited sensitivity: 30% - 50%
33 Screening After the age of 50, persons should be screened withFOBT (Fecal occult blood testing ) annually DRE (Digital rectal exam) every 1 to 2 years Endoscopy every 5 years 30 After the age of 50, persons should be Screened with FOBT (Fecal occult blood testing ) annually DRE (Digital rectal exam) every 1 to 2 years Endoscopy every 5 years DCBE (Double-contrast barium enema) every 5 to 10 years.
34 How to treat CRCs Surgery Chemotherapy Radiotherapy ……
35 Surgical treatment of colon cancerA：Right hemicolectomy B：Transverse colectomy C：Left hemicolectomy D：Sigmoidectomy 31 Surgical treatment of colon cancer A：Right hemicolectomy B：Transverse colectomy C：Left hemicolectomy D：Sigmoidectomy
36 Right hemicolectomy 32 Right hemicolectomy[ˌhemikəˈlektəmi] Resection should include the greater omentum [əu'mentəm], 15cm terminal ileum ['iliəm], cecum, ascending colon, hepatic [hiˈpætik] flexure ['flekʃə] and right transverse colon and its mesentery ['mesəntəri] greater omentum , 15cm terminal ileum, cecum, ascending colon, hepatic flexure and right transverse colon and its mesentery
37 Transverse colectomy 33 Transverse colectomy Resection should include the greater omentum [əu'mentəm], transverse colon, hepatic [hiˈpætik] flexure ['flekʃə], splenic ['splenik] flexure ['flekʃə] and its mesentery ['mesəntəri]. the greater omentum , transverse colon, hepatic flexure splenic flexure and its mesentery
38 Left hemicolectomy 34 Left hemicolectomy Resection should include the greater omentum [əu'mentəm], left transverse colon, splenic ['splenik] flexure ['flekʃə], descending colon, its mesentery ['mesəntəri]. the greater omentum, left transverse colon, splenic flexure , descending colon, its mesentery
39 Sigmoidectomy Sigmoid colon and its mesentery 35Sigmoidectomy Resection should include Sigmoid colon and its mesentery ['mesəntəri] Sigmoid colon and its mesentery
40 Surgical treatment of rectal cancerSurgery remains the primary treatment. A more advanced tumor typically requires surgical removal of the section of bowl containing the tumor with sufficient margins, and radical en-bloc resection of mesentery and lymph nodes to reduce local recurrence Include: Local excision Abdominoperineal resection (APR, Miles) Lower anterior resection (LAR，Dixon) Hartmann operation 36 Surgical treatment of rectal cancer excision[ɪkˈsɪʒən] Abdominoperineal [æbˈdɔminəu] [ˌpɛrəˈniəm] anterior[ænˈtɪriɚ]
41 Surgical treatment of rectal cancer37 Lower anterior resection (LAR) indicates that the operation through an abdominal approach. The anastomosis is performed by a Stappler. Lower anterior resection (LAR)
42 Surgical treatment of rectal cancer38 Abdominoperineal resection (APR) The complete excision of the rectum and anus, through the abdomen and perineum, with creation of a colostomy [kə'lɔstəmi] Abdominoperineal resection (APR) (shown with colostomy)
43 Surgical treatment of rectal cancer39 Hartmann operation indicates that the operation through an abdominal approach,with creation of a colostomy [kə'lɔstəmi] Hartmann operation
45 Total Mesorectal Excision (TME)TME has become the "gold standard" treatment for rectal cancer Devised at 1982 by Professor Bill Heald 41 TME has become the "gold standard" treatment for rectal cancer Devised at 1982 by Professor Bill Heald
46 Adjuvant treatment of colorectal cancerNecessity :10% -25% of patients had liver metastases at surgery, 40-70% of recurrence or metastasis for patients with high risk Goal：reduce the likelihood of metastasis developing, slow tumor growth, improve survival Group: chemotherapy after surgery is usually only given if the cancer has spread to the lymph nodes (Stage III). 42 Adjuvant ['ædʒəvənt] treatment of colorectal cancer is necessary. Its goal is to reduce the likelihood of metastasis, improve survival
47 chemotherapy drugs 5-fluorouracil (5-FU) capecitabine (Xeloda)UFT or Tegafur-uracil Leucovorin (LV, folinic Acid) Irinotecan (Camptosar) Oxaliplatin (Eloxatin) Gemcitabine (Gemzar) Bevacizumab (Avastin) Cetuximab (Erbitux) Panitumumab (Vectibix) 43 Chemotherapy drugs include …
48 Radiotherapy (often combined with Chemotherapy for rectal cancer)Preoperative : shrink tumor size, improve the rate of sphincter sparing rectal surgery Intraoperative: for noncurative resection of the primary tumor Postoperative: decrease the risk of recurrence , increase 5-years survival rate。 sometimes chemotherapy agents are used to increase the effectiveness of radiation sensitizing tumor cells 44 Radiotherapy can be perform Preoperative, Intraoperative, Postoperative
49 Combined therapy for stages II and III rectal cancer45 This figure show combined postoperative radiation and chemotherapy significantly improves survival
50 Summary Adenocarcinoma of the colon and rectum is the third most common of new cancer cases and deaths . Colorectal cancer occurs in hereditary, sporadic, or familial forms. Surgical resection is the most effective treatment for colorectal cancer. Adjuvant treatment would improve survival rate. 46 Summary Adenocarcinoma of the colon and rectum is the third most common of new cancer cases and deaths . Colorectal cancer occurs in Hereditary [həˈreditəri] ,sporadic [spəˈrædik] , or familial forms. Surgical resection is the most effective treatment for colorectal cancer. Adjuvant ['ædʒəvənt] treatment would improve survival rate.
51 Other Colorectal Disease47 Now we would learn some Colorectal Disease
52 Sigmoid Volvulus ['vɔlvjuləs]48 Sigmoid Volvulus ['vɔlvjuləs]
54 Polyps & Polyposis 50 Polyps & Polyposis
56 Surgery treatments for Familial adenomatous polyposis52 Surgical resection is the only treatment. The best age at surgery is years anastomosis[‘ænəstə’məusis] Different anastomosis Surgery before the age of 20 (Rarely malignant transformation before 20) The best age at surgery：14-15 years
57 Anal Fissure [fɪʃɚ] 53 Anal Fissure
59 Excision of anal fissure54 A picture of anal fissure [ˈfiʃə]
60 Perianorectal Abscess57 Perianorectal Abscess
62 Incision and drainage 59 Incision[ɪnˈsɪʒən] and drainage is the treatment for Perianorectal Abscess levator ani[ləˈvetɚ ɑˈni]
63 Anal Fistula 60 Anal Fistula ['fistjulə]
66 Hemorrhoids 63 Hemorrhoids
67 Signs and symptoms rectal pain (external hemorrhoids)rectal bleeding (internal hemorrhoids) prolapse 64 Signs and symptoms of Hemorrhoids
69 Conservative treatmentIncreasing dietary fiber Exercise non-steroidal anti-inflammatory drugs (NSAID) Sitz bath 66 Conservative treatment
70 Procedures Rubber band ligation SclerotherapyDoppler guided transanal hemorrhoidal dearterialization Procedure for Prolapse and Hemorrhoids (PPH) 67 Procedures