Common small and large intestinal surgical diseases Part II Khayal AlKhayal, MD, FRCSC Assistant Professor of Surgery Consultant Colorectal Surgeon 2010 Done by : 428 surgery team 428 surgery team

Colorectal cancer 428 surgery team

Outline Definitions Polyps Basics of colorectal cancer Surgery Staging 428 surgery team

Perspective 428 surgery team

Definitions Colon = large bowel = large intestine Rectum - terminal portion of the colon Polyp - benign growth; not invasive There 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 428 surgery team

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 428 surgery team

Colon and Rectum 428 surgery team

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 428 surgery team

What is a polyp? 428 surgery team

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%. 428 surgery team

428 surgery team

428 surgery team

The Effect of Age on the Incidence of Colorectal Cancer and Colorectal Polyps 428 surgery team

Removing polyps prevents cancer Colonoscopy 428 surgery team

Squamous cell carcinoma Colorectal Carcinoma Classification Adenocarcinoma 95% Carcinoid Lymphoma Sarcoma Squamous cell carcinoma 428 surgery team

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 428 surgery team

Etiology of Colorectal Cancer Incidence in left is more than right….why ? Because sigmoid colon is narrow 428 surgery team

Risk Factors Genetics, Family history Polyps Personal history One first degree family member doubles risk Hereditary colorectal cancer syndomes Polyps Inflammatory bowel disease (Chron’s Disease and Ulcerative Collitis). Other Diet, nutrients, smoking, ETOH 428 surgery team

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* 428 surgery team

Clinical presentation Bleeding - gross, occult, anemia (37%) Change in bowel habit – pain, diarrhea, constipation, alternating pattern Obstruction – more common with left sided lesions most common cause of bowel obstruction in the elderly Vague abdominal pains Change in caliber of the stools Weight loss Abdominal mass Asymptomatic 428 surgery team

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 “ 428 surgery team

428 surgery team

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 428 surgery team

428 surgery team

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 “ 428 surgery team

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 428 surgery team

Abdominoperineal resection Right hemi Colectomy Left hemicolectomy Abdominoperineal resection 428 surgery team

Low Anterior resection Subtotal Colectomy Low Anterior resection 428 surgery team

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. 428 surgery team

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 428 surgery team

428 surgery team

428 surgery team

428 surgery team

428 surgery team

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 428 surgery team

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 428 surgery team

Some notes mentioned about CEA IMP 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 . 428 surgery team

Pathology of Colorectal Cancer Macroscopic: Microscopic (differentiation): Well Moderately Poorly Lymph node involvement 428 surgery team

Staging ( Where is it Growing?) 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 428 surgery team

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) 428 surgery team

TNM Staging Stage 0 – Tis tumors Stage 1 – T1 and T2 tumors Invasion of mucosa Stage 1 – T1 and T2 tumors Invasion of sub mucosa & muscularis propria Stage 2 – T3 and T4 tumors Invasion of full thickness & adjecent organ Stage 3 – Any lymph node involvement Stage 4 – Distant metastases 428 surgery team

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 428 surgery team

Survival and TNM Stage STAGE 5-Year Survival 1 90% 2 80%^ 3 27-69%* 1 90% 2 80%^ 3 27-69%* 4 8% ^for T3N0 tumors *depends on # of nodes involved 428 surgery team

Summary Common Cancer Can be prevented through screening and resection of polyps Surgery is the primary treatment Slow but steady improvement in survival 428 surgery team

428 surgery team