GENERAL SURGERY Case Presentation III-B Dr. Erasmo Members: de Leon, Gemma de Mesa, Angelica de Vera, Jestha dela Cruz, Ciara

Case: Colon Mass Female 45 y/o Moderate severe colicky abdominal pain Abdominal distention Nausea – 2 days

Last month Weight loss (15 lbs.) 3 weeks Frequent episodes of watery stools alternating with hard, small caliber stools 24 hrs Not passed any stool or gas PTA Vomited twice HPI

Family History Father died at 50 y/o – colon cancer Aunt (father side) died at 52 – colon cancer Cousins diagnosed with some form of abdominal cancer Eldest of 4 (40, 36, and 33 y/o) – all well

Physical Examination Normosthenic female vital signs - normal. Chest and lungs -normal. Abdomen globularly distended normal to hyperactive bowel sounds soft, nontender. DRE - normal.

Clinical working impression Obstruction due to possible colon CA

Basis: Hx and PE Chief complaint: Moderate severe colicky abdominal pain Abdominal distention Nausea – 2 days HPI PTA, - vomited previously‐taken food twice. not passed any stool or gas in the last 24 hours. frequent episodes of watery stools alternating with hard, small caliber stools for the last 3 weeks. lost 15 pounds in the last month. FH Father died at 50 y/o – colon cancer Aunt (father side) died at 52 – colon cancer Cousins diagnosed with some form of abdominal cancer Eldest of 4 (40, 36, and 33 y/o) – all well

Basis: Usual manifestation of Colon Cancer obstruction has not passed any stool or gas in the last 24 hours Change in bowel habits frequent episodes of watery stools alternating with hard, small caliber stools for the last 3 weeks blood streaked stools Palpable abdominal mass

Basis: Other manifestation of Colon Cancer Weight loss Family history of colorectal cancer Other GI symptoms Rectal examination

Ancillary Tests Double contrast Barium enema Colonoscopy CT Scan MRI Virtual colonoscopy

Double contrast barium enema colon is first filled with barium the barium is drained out, leaving only a thin layer of barium on the wall of the colon colon is then filled with air This provides a detailed view of the inner surface of the colon, making it easier to see narrowed areas (strictures), diverticula, or inflammation. This technique can miss the (less common) flat polyp.

Colonoscopy A lighted probe called a colonoscope is inserted into the rectum and the entire colon to look for polyps and other abnormalities that may be caused by cancer. A colonoscopy has the advantage that if polyps are found during the procedure they can be immediately removed. Tissue can also be taken for biopsy.

CT SCAN an x-ray test that produces detailed cross-sectional images of your body Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. Unlike a regular x-ray, a CT scan creates detailed images of the soft tissues in the body. This test can help tell if colon cancer has spread into your liver or other organs.

MRI provide detailed images of soft tissues in the body uses radio waves and strong magnets instead of x-rays useful in looking at abnormal areas in the liver that might be due to cancer spread They can also help determine the extent of rectal cancers. little more uncomfortable than CT scans First, they take longer -- often up to an hour. Second, you have to lie inside a narrow tube, which is confining and can upset people with claustrophobia

VIRTUAL COLONOSCOPY replaces X-ray films in the double contrast barium enema with a special computed tomography scan requires special workstation software in order for the radiologist to interpret This technique is approaching colonoscopy in sensitivity for polyps. However, any polyps found must still be removed by standard colonoscopy.

Therapeutic plans Surgery is the ONLY hope Adjuvant chemotherapy for Colon CA – Stage III disease – High risk Stage II disease Obstruction High grade histology

What is your interpretation of Abdominal films?

Differentiating SBO from Paralytic Ileus SBOIleus PainColickyNot a prominent feature Abdominal distensionFrequently prominentSometimes not apparent Bowel soundsUsually increasedUsually absent Small bowel dilatationPresent Large bowel dilatationAbsentPresent

Mechanical Obstruction of the lumen Obturation of the lumen Lesions extrinsic to bowel Lesions of the bowel Congenital Traumatic Neoplastic

Obstruction secondary to small bowel neoplasm typically asymptomatic in its early stages, but more than 90% of patients eventually develop symptoms as the disease progresses Manifestations in the patient nausea vomiting intestinal obstruction abdominal pain weight loss distended abdomen

Characteristic features on abdominal flat and upright radiographs: dilated bowel loops air fluid levels proximal to the point with little or no gas distally air fluid levels are more pronounced and a step ladder pattern is seen

Work-up Laboratory evaluation (cbc, serum electrolytes, blood chemistry, cardiopulmonary assessment) Contrast radiography Enterocyclis Abdominal CT scan Upper GI series with small bowel follow through Abdominal Ultrasound

Enterocyclis Barium small bowel enema Involves filling the small intestine with barium liquid while xray images are being taken 90 % sensitivity in detection of small bowel tumors Test of choice Abdominal CT scan Has low sensivity in detecting mucosal and intramural lesions Can demonstrate large tumors Useful in staging intestinal malignancies

Contrast Enema and UGIS with small bowel follow through Useful if diagnosis is uncertain or demonstrating partially obstructing lesion Ba enema is usually done first to rule out colonic obstruction Abdominal Ultrasound May demonstrate larger tumors (>4cm) Can differentuate between intramural, intraluminal and extraluminal growth patterns

Initial Treatment Aggressive fluid resuscitation (rehydrate, correct elec abn, put foley catheter to monitor urine output) Nasogastric suction (to prevent aspiration and for decompression Administration of analgesia and antiemetic as indicated clinically Antibiotics Early surgical consultation.

Surgical excision of small bowel neoplasm Primary treatment for cancer of the small intestine For benign neoplasms: Exploratory laparotomy with excision of the lesion provides the safest and most direct method for lesion identification and treatment. For malignant neoplasms: Surgical Resection provides the only hope of cure for patients with small-bowel adenocarcinomas. others have have unresectable disease as a result of extensive local disease or metastases to regional lymph nodes, the liver, or the peritoneum. Chemotherapy and Radiotherapy Useful if the cancer is widespread

A proctosigmoidoscopy is done 4 hours after admission and reveals the following at the 18 cm level

Staging AJCC stageTNM stageTNM stage criteria for colorectal cancer Stage 0Tis N0 M0Tis: Tumor confined to mucosa; cancer-in-situmucosa Stage 1T1 N0 M0T1: Tumor invades submucosasubmucosa Stage 1T2 N0 M0T2: Tumor invades muscularis propriamuscularis propria Stage II - AT3 N0 M0T3: Tumor invades subserosa or beyond (without other organs involved) Stage II - BT4 N0 M0T4: Tumor invades adjacent organs or perforates the visceral peritoneumperitoneum Stage III- AT1-2 N1 M0N1: Metastasis to 1 to 3 regional lymph nodes. T1 or T2.lymph nodes Stage III - BT3-4 N1 M0N1: Metastasis to 1 to 3 regional lymph nodes. T3 or T4. Stage III - Cany T, N2 M0N2: Metastasis to 4 or more regional lymph nodes. Any T. Stage IVany T, any N, M1M1: Distant metastases present. Any T, any N.

Management plan Diagnosis - colonoscopy, Staging Operability Optimum treatment strategy

Treatment Stage 0 – complete excision of the polyps Stage I malignant polyp – segmental colectomy Stage I and II Localized colon Carcinoma - Surgical resection + adjuvant chemotherapy Stage IV Distant Metastasis – Surgical resection, hepatic resection of synchronous metastasis and adjuvant chemotherapy

Optimum Treatment Strategy Surgery is the only hope for CURE Adjuvant chemotherapy for Colon CA – > Stage 111 disease – High risk Stage 11 disease Obstruction / Perforation High grade histology Adjuvant chemo-radiotherapy for Rectal CA – > Stage 11 disease – Either pre-operative or post-operative

Objectives in Treatment To remove the primary tumor along with its lymphovascular supply Any organ or tissue that has been invaded should be resected en – bloc with the tumor Presence of synchronous cancers or adenomas or a strong family history - subtotal or total colectomy

What do you think should be performed? Family history : Father died of colon cancer at age 50 Aunt died of colon cancer at age 52 Two cousins have abdominal cancer and undergoing chemotherapy Total or subtotal colectomy

Preparations for Surgery Cardiopulmonary status – Anemia Co-morbid conditions – Nutritional status – Renal function – Liver function

A subtotal colectomy is performed. Histopath reveals a full thickness moderately differentiated adenocarcinoma with 2 out of 16 positive pericolic lymph nodes. Both lines of resection are negative for tumor. Full thickness Adenocarcinima – T3 Metastasis to 2 pericolic lymph node – N1 Presence of distant metastasis cannot be assessed – ? T3 N1 M – Stage III

Further Plans Currently recommended standard adjuvant therapy for stage III colon cancer : INH Consensus Conference 1. Postoperative day 21-35: Begin levamisole 50 mg orally three times daily for three consecutive days, repeated every two weeks for one year. 2. Postoperative day 21-35: FU 450 mg/m2/day by rapid intravenous injection for five consecutive days beginning simultaneously with levamisole. 3. Twenty-eight days after the start of chemotherapy, begin weekly FU 450 mg/m2 by rapid intravenous injection for 48 weeks.

Follow up Aim : to diagnose in the earliest possible stage any metastasis or tumors that develop later but did not originate from the original cancer Medical exam and physical exam - every 3 to 6 months for 2 years, then every 6 months for 5 years. CEA antigen blood level measurements CT- scan of the chest, abdomen and pelvis annually for the first 3 years Colonoscopy after 1 year