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Common small and large intestinal surgical diseases Part II

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. Colorectal cancer. Outline. Definitions Polyps Basics of colorectal cancer Surgery Staging.

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Common small and large intestinal surgical diseases Part II

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

  2. Colorectal cancer 428 surgery team

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

  4. Perspective 428 surgery team

  5. 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

  6. 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

  7. Colon and Rectum 428 surgery team

  8. 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

  9. What is a polyp? 428 surgery team

  10. 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 riskof cancer • Tubular , Villus and Tubuloviilus are types of polyps . • Note:Villus histological feature have a high chance to develop carcinoma 40%. 428 surgery team

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

  14. Removing polyps prevents cancer Colonoscopy 428 surgery team

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

  16. 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

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

  18. Risk Factors • Genetics, Family history • 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

  19. 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

  20. 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

  21. 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

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  23. 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

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  25. 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

  26. 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

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

  28. Anterior resection Subtotal Colectomy Low Anterior resection 428 surgery team

  29. 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

  30. 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

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  35. 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

  36. 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

  37. Some notes mentioned about CEAIMP • 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

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

  39. 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

  40. 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

  41. TNM Staging • Stage 0 – Tis 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

  42. 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

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

  44. 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

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