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Colorectal Cancer and its Surgical Management Adam Gittins Surgical Oncology Teaching Series Clinical Teaching Fellow SOTS Russells Hall Hospital, DudleyWhat we will be covering • Epidemiology of colorectal cancer and associated risk factors • Pathology of colorectal cancer • Common presenting features of colorectal cancer • Diagnosis and staging of colorectal cancer • Management of colorectal cancer, with particular focus on surgical treatment • Perioperative management of colorectal cancer • Surgical treatment options for metastatic diseaseIntroduction th • 4 most common cancer in the UK. • 2 leading cause of cancer death. • 42,900 new cases are diagnosed in the UK each year. • to the ”Western lifestyle”.eloped countries, likely due Non-modifiable risk factors Modifiable risk factors • Age • Diet high in fat, processed meat and low • Genetic disorders in fibre • Associated conditions such as • Obesity inflammatory bowel disease • Inactivity • Smoking • Alcohol intakePathology • >90% of colorectal cancers are adenocarcinomas which arise from adenomatous polyps in the intestinal epithelium. Hyperplasia Dysplasia Neoplasia and invasion • Rarer types of colorectal cancer are neuroendocrine, squamous cell, adenosquamous, spindle cell and undifferentiated carcinomas.Hereditary Bowel Cancers Account for 5-10% of cases of colorectal cancer. Hereditary non-polyposis colorectal cancer (HNPCC) • Autosomal dominant condition caused by mutations in one of four genes in the DNA mismatch repair system. • Substantially increases risk of developing colorectal cancer before the age of 50. • Associated with other cancers such as endometrial and ovarian cancer as well. • Patients with known Lynch syndrome should have surveillance colonoscopy and upper GI endoscopy. Familial adenomatous polyposis (FAP) • Autosomal dominant condition caused by mutations in APC gene. • Development of hundreds to thousands of adenomatous colonic polyps which can become malignant. • Risk of colorectal cancer nearly 100% if untreated. • Patients with known FAP or a family history of FAP should have surveillance colonoscopy eryears. • Definitive treatment is with total colectomy +/- proctectomy.Presentation • Persistent(>6 weeks) change in bowel habit – diarrhoea or constipation • More common in cancers of the left colon and rectum • Rectal bleeding(visible or occult) • Iron deficiency anaemia, due to occult GI bleeding from the tumour • More common in cancers of the right colon • Abdominal pain • Unexplained weight lossDiagnosis • Patients presenting with red flag featuressuggestive of colorectal cancer should be referred on a 2-week-wait pathwayfora colonoscopy • Offers full visualisation of the colon and rectum. • Biopsy of any suspicious polyps for histological analysis. • Patients who do not meet 2 week-wait criteria but for whom there is clinical suspicion of colorectalcancer should have afaecaloccult blood test. • If the resultis positive, the patient is referred for colonoscopyBowel Cancer Screening • Up to a quarter of diagnoses of colorectal cancer in the UK are made as a result of screening of asymptomatic patients. • Adults aged 60-74 in the UK are offered a home faecaloccult blood test every two years. • 98% have negative results that require no further action. • 2% have positive results that warrant further investigation with colonoscopy. No further action ColonoscopyInvestigations Bloods • Full blood count • U&Es • Clotting profile Other • G&S / Crossmatch • CEA – useful in monitoring treatment response • Biopsy – usually taken at colonoscopy Imaging • Colonoscopy • CT colonography if patient is unsuitable for / refuses colonoscopy • CT TAP for staging • MRI rectum for tumours below peritoneal reflectionStaging TNM staging system Tumour Tis Carcinoma in situ Invading mucosa and T1 submucosa Invading muscularis T2 propria Invading into T3 subserosa Invading adjacent T4 structuresStaging TNM staging system Nodes No lymph nodes N0 containing cancer cells Cancer cells in 1-3 N1 nearby lymph nodes Cancer cells in 4+ N2 nearby lymph nodesStaging TNM staging system Metastasis M0 No metastasis Metastasis to one distant site with no M1a peritoneal spread Metastasis to 2+ distant sites with no M1b peritoneal spread Metastasis to distant sites with peritoneal M1c spreadStaging Duke’s staging system Duke’s stage Description A Confined to mucosa & submucosa B Invading muscle layers of the bowel Stage A Stage C Stage D C Spread to lymph nodes Stage B D Metastasis to distant organManagement • Curative treatment is achieved bysurgical resection. • Surgical procedure depends on stage and location of thetumour. • Resection with ≥ cm margin (both proximal and distal to the cancer) is recommended. • At least12 lymph nodesare resected along with the tumour for analysis. • Options for surgical approach are open, laparoscopic and robotic. • Resection specimen is sent for histological analysis to determine whether resection margins contain cancer cells (positive resection margin) or not (negative resection margin). • Survival rates can be improved by chemotherapy and/or radiotherapyalongside surgical resection. • Neoadjuvant treatment is given before surgical resection. • Adjuvant treatment is given after surgical resection.Open Surgery • Traditional approach to colorectal cancer resection. • Performed via a single long incision in the anterior abdominal wall for direct access to the abdominal cavity. • Scar is often large and unsightly, with significant risk of postoperative pain lengthening stay.Laparoscopic Surgery • approach for colorectalon cancer resection. • Minimally invasive technique. • abdominal wall for access to the abdominal cavity: • Instrument ports for operating. • Optical port for visualisation. • An additional incision is usually made (or a laparoscopic incision is site.ded) as an extractionLaparoscopic Surgery Advantages Disadvantages • Smaller surgical scars • May require open conversion • Better visualisation of the pelvis (e.g. in major bleeding) • Facilitates faster recovery and • Requires specialist training in shorter inpatient stay laparoscopic technique • Ergonomic challenges • Less intraoperative blood loss • Fewer postoperative complicationsErgonomics of Laparoscopic Surgery • Laparoscopic surgery presents an ergonomic challenge to the operating surgeons. • A manipulation angle (angle between two instrument ports) of 60° (±15°) is associated with optimal performance. • The Azimuth angle (angle between instrument and optical port) for instruments should be equal to ensure faster operating time. • Optimal monitor placement • Directly in front of operating surgeon • At hand levelRobotic Surgery • remotely operating a robot to perform surgical procedures. • Facilitates more precise movements than laparoscopic surgery. • Gaining popularity in colorectal cancer surgery. • Associated with a lower rate of conversion to open surgery than laparoscopic approach. • Operating time is currently significantly longer than laparoscopic surgery and operating costs are higher.Restoring Continuity: Anastomosis vs Stoma Anastomosis • Cut segments of bowel are joined to one another using sutures or staples. • Types of anastomosis • End-to-end anastomosis • End-to-side anastomosis • Side-to-side anastomosis • A successful anastomosis must have a good blood supply and minimal tension. • Better functional result for the patient. • May not always be safe or feasible due to risk of anastomotic failure (leak or dehiscence). • the emergency surgical setting.afe to perform in • Ileo-colic anastomosis has a much lower failure rate and is usually feasible, even in the emergency setting.Restoring Continuity: Anastomosis vs Stoma Stoma • Lumen of bowel is brought to the surface of the skin. • Types of stoma: • Ileostomy - higher output, spouted • Colostomy – lower output, more flush to skin Ileostomy • Functionally worse for patients than anastomosis. • Used if anastomosis is not safe or feasible. • Can sometimes be reversed (converted to anastomosis) later on. • Sometimes placed proximal to a primary anastomosis as a “defunctioning” stoma. • Diverts faeceswhile the anastomosis heals. ColostomyAnatomy RecapAnatomy Recap Blood supply to colon and rectum: • Superior mesenteric artery • Ileocolic artery • Right colic artery • Middle colic artery • Inferior mesenteric artery • Left colic artery • Sigmoid arteries • Superior rectal arteryRight Hemicolectomy • For tumours of the ascending colon • Removal of terminal ileum, caecum, ascending colon and hepatic flexure • Arteries ligated: • Ileo-colic artery • Right colic artery • Right branch of middle colic artery • Ileo-colic anastomosis can usually be formedExtended Right Hemicolectomy • For tumours of the transverse colon and splenic flexure • Right hemicolectomy + removal of transverse colon • Arteries ligated: • Ileo-colic artery • Right colic artery • Middle colic artery • Right branch of left colic arteryLeft Hemicolectomy • For tumours of the descending colon • Removal of splenic flexure, descending colon and proximal sigmoid colon • Artery ligated: • Inferior mesenteric artery • End-to-end colo-colic anastomosis can be done viatransanal circular staplerHigh Anterior Resection • For tumours of the sigmoid colon • Removal of distal descending colon, sigmoid colon and proximal part of rectum • Artery ligated: • Inferior mesenteric artery • End-to-end colo-rectal anastomosis can be done viatransanal circular staplerLow Anterior Resection • For tumours of the upper rectum • Must be >5cm from the anal verge • Artery ligated: • Superior rectal artery • Spares anal sphincter complex • Preserves faecalcontinence • Leaves a rectal stump to allow for end-to-end colo-rectal anastomosisAbdomino-Perineal Resection • For tumours of the lower rectum • <5cm from the anal verge • Removal of distal colon, rectum and anal sphincter complex • Artery ligated: • Superior rectal artery • Permanent colostomy must be formed (anastomosis is not possible)Total Mesorectal Excision (TME) • TME refers to excision of the surrounding mesorectum in rectal cancer surgery. • First described by RJ Heald in 1988. • It ensures removal of the tumour along with pararectal lymph nodes within the outside this plane such as pelvic nerves fibres. • Reduces local recurrence and improves survival. • Transanal TME was first described in 2010 and has been shown to be safe and effective in the treatment of rectal cancer.Enhanced Recovery After Surgery (ERAS) • ERAS is a nationally used protocol defining optimal care of patients undergoing elective surgery, through the preoperative, perioperative and postoperative phases. Preoperative Perioperative Postoperative • Hydration and carbohydrate- • Multimodal pain control • Earlymobilisation rich meals • Early nutrition • Antiemetics • Bowel prep • Fluid management • Multimodal pain control • Oral antibiotics • Antiemetics • NBM from midnight • Clearly defined discharge criteria • Through a multidisciplinary approach, ERAS can reduce length of hospital stay and improve outcomes.Metastatic Disease • Colorectal cancer most commonlymetastasises to the liver. • number of liver metastases.ossible if there are a limited • Where curative resection is not an option, patients may still benefit from surgical treatment to relieve obstruction: • Stenting • Bypass surgery • Diversion stomaSummary 1. Colorectal cancer is one of the most common cancers in the developed world. 2. It typically presents with a change in bowel habit, rectal bleeding and/or anaemia. 3. Dof diagnoses in the UK made as a result of the national screening programme. quarter 4. Curative treatment is achieved by surgical resection – surgical procedure depends on the site of the cancer. 5. Laparoscopic surgery is currently the gold standard approach for colorectal cancer resection, although robotic surgery is gaining popularity as it allows for more precise movements and is associated with a lower rate of open conversion. 6. Optimal perioperative care of elective colorectal cancer patients has been standardisedwith the Enhanced Recovery After Surgery (ERAS) protocol. 7. Patients with limited metastatic disease may still be eligible for curative treatment, but surgical options still exist for palliative colorectal cancer patients.References 1. Matsuda T, Yamashita K, Hasegawa H, et al.. Recent updates in the surgical treatment of colorectal cancer. Ann Gastroenterol Surg. 2018;2(2):12-136. 2. Supe AN, Kulkarni GV, Supe PA. Ergonomics in laparoscopic surgery. J Minim Access Surg. 2010;6(2):31-6 3. Sivathondan PC, Jayne DG. The role of robotics in colorectal surgery. Ann R Coll Surg Engl. 2018;100(Suppl 7):42-53. 4. Fleming M, Ravula S, TatishchevF, Wang HL. Colorectal carcinoma: Pathologic aspects. J Gastrointest Oncol. 2012 Sep;3(3):153-73. 5. Heald RJ. The ‘Holy Plane’ of rectal surgery. J R Soc Med. 1988;81(9):503-8. 6. KehletH. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606-17