Transcript Surgical treatment of rectal cancer

Colorectal Disease
Jichao Qin
Department of Surgery
Tongji Hospital in HUST
[email protected]
Anatomy of the large intestine
Diameter: 7.5-2.5cm
Length: 150 cm
Anatomic landmark:
Haustra
Epiploic appendages
Taeniae coli
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
Lymphatics of large intestine
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
Anatomy of the Anal Canal
Anal Canal:
the end of the
digestive tract.
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
COLORECTAL CANCERs(CRCs)
Morbidity and risk factors for
CRC
Epidemiology
Colorectal Cancer (CRC),which include colon
cancer and rectal cancer, is one of the most
popular malignant carcinoma.
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the third most common in the whole World
the second most in USA
the third most common in China
High-risk groups for CRC
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gastrointestinal symptoms after the age of 50
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a history of Colorectal Adenomas, Ulcerative Colitis,
Schistosomiasis Colitis
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family history of Cancer and FAP (Familial
Adenomatous Polyposis)
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a history of pelvic Radiation Therapy
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a history of Cholecystectomy or Appendectomy
Colorectal cancer incidence by age in the US
Percent of adenomas containing invasive cancer
by size and histology
Probability of developing colorectal carcinoma in
patients with ulcerative colitis
an 0.5% cumulative incidence per year
The Percentage of CRCs in USA, but high% of
rectal cancer in China
Pathology of CRCs
Gross appearance of tumor
1． Endophytic (ulcerative)
——common type in Colorectal Cancer
2． Exophytic
——in right-sided tumors
3． Infiltrative
——in left-sided tumors
Exophytic (fungating)
Endophytic (ulcerative)
Infiltrative (linitis plastica)
Histological Classification
Adenocarcinoma 95%
Lymphoma
Squamous cell carcinoma
Development of Colorectal Carcinoma
Growth
 Malignant Transform
 Invade through the
bowl wall
 Spread to regional
lymph nodes
 Metastasize to distant
sites
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Cancer Staging System
TNM Staging System
Dukes Classfication System
How to diagnose CRCs
Signs & Symptoms
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Change in bowel
habits
Blood in Stool
Diarrhea
Constipation
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General abdominal
discomfort
Weight loss with no
explained reason
Constant tiredness
Vomiting
Diagnosis
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Biopsy
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Endoscopy
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Digital rectal exam
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Imaging examination
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Tumor markers
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Fecal Occult Blood Testing
More useful
for Diagnosis
Digital rectal exam (DRE)
Colonoscopy
Double-contrast barium enema
(DCBE)
apple core
CT image for hepatic metastasis
Tumor Markers (CEA)
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Relative with the extent of tumor.
Combined with CA199 for monitoring of
postoperative recurrence and evaluating
prognosis
Fecal Occult Blood Testing (FOBT)
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Detects blood from cancers or large
polyps
Bleeding increases with polyp size and
stage of cancer
Limited sensitivity: 30% - 50%
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
How to treat CRCs
 Surgery
 Chemotherapy
 Radiotherapy
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Surgical treatment of colon cancer
A：Right hemicolectomy
B：Transverse colectomy
C：Left hemicolectomy
D：Sigmoidectomy
Right hemicolectomy
greater omentum , 15cm terminal ileum, cecum, ascending colon,
hepatic flexure and right transverse colon and its mesentery
Transverse colectomy
the greater omentum , transverse colon, hepatic flexure splenic
flexure and its mesentery
Left hemicolectomy
the greater omentum, left transverse colon, splenic flexure ,
descending colon, its mesentery
Sigmoidectomy
Sigmoid colon and its mesentery
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
Surgical treatment of rectal cancer
Lower anterior resection (LAR)
Surgical treatment of rectal cancer
Abdominoperineal resection (APR) (shown with colostomy)
Surgical treatment of rectal cancer
Hartmann operation
Colostomy
(intestinal stoma)
Total Mesorectal Excision (TME)
TME has become the "gold standard"
treatment for rectal cancer
Devised at 1982
by Professor Bill Heald
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).
chemotherapy drugs
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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)
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
Combined therapy for stages II and III rectal cancer
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Summary
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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.
Other
Colorectal Disease
Sigmoid Volvulus
['vɔlvjuləs]
Sigmoid Volvulus
Polyps & Polyposis
Colon Polyps & Polyposis
Single polyps
Familial adenomatous polyposis
Surgery treatments for
Familial adenomatous polyposis
Different anastomosis
Surgery before the age of 20 (Rarely malignant transformation before 20)
The best age at surgery：14-15 years
Anal Fissure
[fɪʃɚ]
Excision of anal fissure
Perianorectal
Abscess
Perianal Abscess
Incision and drainage
Anal Fistula
Anal Fistula
LIFT Technique
（ligation of inter sphincteric fistula tract)
Hemorrhoids
Signs and symptoms
rectal pain (external hemorrhoids)
rectal bleeding (internal hemorrhoids)
prolapse
Prolapse
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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.
Conservative treatment
• Increasing dietary fiber
• Exercise
• non-steroidal anti-inflammatory drugs (NSAID)
• Sitz bath
Procedures
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Rubber band ligation
Sclerotherapy
Doppler guided transanal hemorrhoidal
dearterialization
Procedure for Prolapse and Hemorrhoids
(PPH)
Before and after PPH
Any questions, comments or suggestions?