1. Tongji Hospital in HUST
Colorectal 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.

2. Anatomy of the large intestine
Diameter: cm
Length: 150 cm
Anatomic landmark:
Haustra
Epiploic appendages
Taeniae coli 2
The First, We have a review of anatomy[əˈnætəmi] of large intestine. The colon is the last part of the digestive system. The colon consists of four sections:
the ascending colon,
the transverse colon,
the descending colon,
the sigmoid[ˈsiɡmɔid] colon.
The colon, cecum
[ˈsi:kəm] , appendix, and rectum make up the large intestine.
The colon is about 4.9 feet (1.5 m) long with the diameter of 7.5 to 2.5 centimeters.
The colon has three anatomic landmarks: haustra, Taeniae coli, Epiploic appendages[əˈpendɪdʒz] .
Taeniae/ˈtiniə/ coli[ˈkəulai] – three bands of smooth muscle
Haustra –small pouches on colon
Epiploic appendages – small fat accumulations outside the colon wall

3. Blood supply of the Large intestine
SMA(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.

5. Anatomy of the Rectum
The rectum, along with the sigmoid colon, is 12 to 15 cm in length.
Rectum is divided into two parts,the upper and lower section, by Pelvic peritoneal reflection
The rectum, along with the sigmoid colon, is 12 to 15 cm in length.
Rectum is divided into two parts, the upper and lower section,
by Pelvic[ˈpɛlvɪk] peritoneal [ˌperitə'ni:əm] reflection

6. Anatomy of the Anal Canal
Anal Canal: the end of the digestive tract. 6
Anal ['einəl] Canal [kə'næl]: the end of the digestive tract.
The pectinate ['pektineit] line (dentate ['denteit] line) is a line which divides the upper 2/3 and lower 1/3 of the anal canal.

7. Blood supply of Rectum and Anal Canal (post view)
Above the dentate line ：
Superior rectal artery
inferior rectal artery
middle rectal artery
Below the dentate line：
Anal artery 7
Blood supply of Rectum and Anal Canal.
Iliac/ˈɪliˌæk/ artery

8. COLORECTAL CANCERs(CRCs)8
And Now!
Let’s come to the main part of the course: Colorectal Cancer.

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 CRC
gastrointestinal 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

15. The Percentage of CRCs in USA, but high% of rectal cancer in China
Pathology of colorectal cancer

16. Pathology of CRCs

17. Gross appearance of tumor
1． Endophytic (ulcerative)
——common type in Colorectal Cancer
2． Exophytic
——in right-sided tumors
3． Infiltrative
——in left-sided tumors 15
Gross appearance of tumor

18. Exophytic (fungating)16
Exophytic

19. Endophytic (ulcerative)17
Endophytic

20. Infiltrative (linitis plastica)18
Infiltrative

21. Histological Classification
Adenocarcinoma 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 Carcinoma
Growth
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 System
Cancer 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 habits
Weight 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 Endoscopy
Digital 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]

27. Digital rectal exam (DRE)24
The digital rectal examination (DRE) is a relatively simple procedure.
The doctor inserts a finger into the rectum to feel for abnormal areas. It only detects tumors large enough to be felt in the distal part of the rectum but is useful as an screening test.

28. Colonoscopy 25
Colonoscopy [ˌkoləˈnɑskəpi] is the gold standard for establishing the diagnosis of colon cancer. It permits biopsy of the tumor

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 with
FOBT (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 cancer
A：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 35
Sigmoidectomy Resection should include Sigmoid colon and its mesentery ['mesəntəri]
Sigmoid colon and its mesentery

40. Surgical treatment of rectal cancer
Surgery 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

44. Colostomy (intestinal stoma)40
Colostomy (also named as intestinal stoma ['stəumə])
A colostomy bag helps patient to collect the feces [ˈfisiz]

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 cancer
Necessity :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]

53. Sigmoid Volvulus 49
Sigmoid Volvulus cause colon obstruction and expansion of colon

54. Polyps & Polyposis 50
Polyps & Polyposis

55. Colon Polyps & Polyposis51
Single polyp and FAP thousands of of polyposis
Single polyps
Familial adenomatous 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

58. 54
A picture of anal fissure [ˈfiʃə]

59. Excision of anal fissure54
A picture of anal fissure [ˈfiʃə]

60. Perianorectal Abscess57
Perianorectal Abscess

61. Perianal Abscess 58 A picture of Perianorectal Abscess
ischium[ˈɪskiəm]

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]

64. Anal Fistula 61
2 pictures of anal Fistula

65. LIFT Technique （ligation of inter sphincteric fistula tract)62
LIFT Technique for Anal Fistula

66. Hemorrhoids 63
Hemorrhoids

67. Signs and symptoms rectal pain (external hemorrhoids)
rectal bleeding (internal hemorrhoids)
prolapse 64
Signs and symptoms of Hemorrhoids

68. Prolapse Grade I: No prolapse.
Grade II: Prolapse upon defecation but spontaneously reduce.
Grade III: Prolapse upon defecation and must be manually reduced.
Grade IV: Prolapsed and cannot be manually reduced. 65
the degree of Prolapse [prəu'læps] has 4 Grade
Grade I: No prolapse.
Grade II: Prolapse upon defecation [ˌdefə'keiʃən] but spontaneously [spɔn'teiniəsli] reduce.
Grade III: Prolapse upon defecation and must be manually reduced.
Grade IV: Prolapsed and cannot be manually reduced.

69. Conservative treatment
Increasing dietary fiber
Exercise
non-steroidal anti-inflammatory drugs  (NSAID)
Sitz bath 66
Conservative treatment

70. Procedures Rubber band ligation Sclerotherapy
Doppler guided transanal hemorrhoidal dearterialization
Procedure for Prolapse and Hemorrhoids (PPH) 67
Procedures

71. 68
PPH is a new procedure for hemorrhoids

72. Before and after PPH 69
Before and after PPH, significant change.

73. Any questions, comments or suggestions?71
That all, Thank you!