CRC & other disease of the

colorectum

JM PLUMMER
GENERAL & COLORECTAL SURGEON
SENIOR LECTURER IN SURGERY, UWI
 Introduction

 CRC is the 3rd most common cancer in M & F in Ja

 JCR data gives 18 & 14 /100,000 for M & F
 It is the 2nd or 3rd leading cause of cancer related
mortality in Ja
 60 % of patients are diagnosed with regional or
distant metastasis
 50% of CRC patients will die from their disease
 Colon cancer and screening
5 year survival 90% for Dukes A disease, Deaths from CRC in the USA
68% with regional involvement and 10% decreasing, largely from screening (but
with metastatic disease not in blacks)

CRC lends itself to screening as the majority of CRC begin in adenomatous polyps

While the majority of polyps do not progress to invasive cancers, some do.
(depending on size, grade, and % of villous component.

Polyps being slow growing lends itself to the prevention of CRC, by their resection.
 Introduction

 CRC is attractive to various screening methods

 FOBT
 Flexible sigmoidoscopy

 CT colonography

 Colonoscopy

 ?DCBE

 Colonoscopy and biopsy is the standard diagnostic

test for all symptomatic patients and also those with
a positive screening test
 Risk Factors for CRC

 Adenomas
 Genetics (FAP, HNPCC, +ve FHx)
 Diet
 IBD
 ?Prior operations
 The ‘Genetics’ of CRC

Lynch HT et al.
 Lynch Syndrome
 LS is the most common hereditary form of CR
 LS results from germline mutations in DNA mismatch repair genes
MLH1, MSH2, MSH6 and PMS2.
 LS patients also have endometrial, gastric, ovarian, upper GU, small
bowel, brain and certain skin cancers
 The symptomatic patient

Right side lesions Left side lesions

 Anemia  Change in bowel habits

 Caecal mass  Haematochezia
 Metastatic disease (Rt  LBO
UQ pain)  Mucus pr and
 ?Abdominal pain tenesmus
 Spurious diarrhoea

Remember those presenting with mets and or detected by screening…

 Diagnosing the symptomatic patient

Diagnosis Staging

 Colonoscopy and  Contrast CT scan of the

biopsy abdomen/pelvis and
 or chest
 DCBE and flex. sig  Or
 Abdominal US and
 (synchronous lesions)
CXR

 CEA!

Remember some cases are diagnosed at laparotomy, having presented as emergency

Surgical approach

 Caecal and asc. colon –  Sigmoidectomy

Rt Hemicolectomy  Anterior resection
 Transverse colon-  Abdominoperineal
Ext. Rt hemicoloectmy or resection
Transverse colectomy
Desc colon Ca- left  Discuss…
hemicolectomy  (Hartmann’s procedure
vs Subtotal colectomy)
 Surgery in Stage IV Disease
• 17-25% of patients present
with Stage IV disease
• Majority of patients have
surgery (US = 66%)
• Morbidity and mortality
higher than average

Cook Ann Surg Onc 2005; 12:637-45

Temple JCO 2004; 22:3475-84
 Surgery for Palliation

 If surgery required, usually for obstruction

 Selected patients with Stage IV benefit from

hepatic or lung resections for cure

 5-year survival > 30-50% depending on the

series

Ruo J Am Coll Surg 2003; 196:722-8, Scoggins Ann Surg Onc 1999; 6:651-7, Muratore Ann Surg Onc
2007; 14:766-770; Poultsides JCO 2009; 27(15s)
 Operative Approach
• Laparoscopic approach
– Benefits in terms of LOS, pain and potentially hernia
formation
– Margins and node number equivalent

– No difference in cancer mortality

– Longer OR time

– Fewer wound and pulmonary complications but more

intraoperative complications
Operative Quality: Oncologic Resection
Lymphadenectomy
 Acceptable standard:
identification of at least 12
nodes
 Imperative: perform an
adequate mesenteric
resection and identify all
lymph nodes present
 Staging of CRC
 Why stage?
 Usually a pathologic
stage used…Dukes’
 A, B, C ‘and D’.
 Principles of surgery for rectal cancer for
mid and lower 1/3
• Adequate pre-operative
staging
• Neo-adjuvant therapy
• Qualified surgeon for
dissection
• Appropriate procedure
for the patient
 Surgery for Rectal cancer
• 24% of cancers occur in the  Surgeon an important
rectum
prognostic factor wrt
• Total Mesorectal Excision
the standard of care outcome
• Local recurrence 5-10%
with TME
• Leak rates higher in rectal
cancer (>10%)
• Temporary loop ileostomy
useful in selected cases
• Further reduction in local
recurrence with RTD
 Role of Pre-operative radiotherapy
3 RCT done and all show
preoperative RTD Ppppsuperior
to post-op RTD with
Better local control  Better local control
Better compliance
Lower treatment related toxicity  Better patient
? Increased survival compliance
3 RCT done and all show
preoperative RTD superior to
post-op RTD with  Less treatment related
Better local control toxicity
Better compliance
Lower treatment related toxicity
? Increased survival

Some patients may need post-op radiotherapy!

Consequences of restorative resection
Patients with lower 1/3 tumours treated with SSR are not
compromised with greater risk of LR or SR,
but functional disturbances affect > 50% of patients

restoraPPtiPve procedures do not compromise LR & SR in

patients wIith lower 1/3 lesions treated by SSR
P
BUT restative procedures create major persistent GI
functional disturbance in > 50% ofLAR
patients:
SYNDROME
● Increased frequency of BM↑ frequency of BM
(nocturn
● Clustering/Fragmentationcluster/fragmentation of
BM
LAR syndrome
● Urgency
 LAR Syndrome Prevention/Management
 Patient selection
1. Poor pre-op continence Colonic J pouch
 Some patients’ tumour maybe too low

 Pre-op education

 Bowel management
 Metamucil
 Imodium
coloplasty
 Enemas

 Colostomy (10%)

End-to-side
anastomosis
 Local excision for rectal cancer
Touchable (6 - 7 cm from AV)

• (mobile; well differentiated

• uT1No (occasional uT2No )

• Size (<40% of the circumference)
? anterior location
 Adjuvant therapy for colonic cancer
 Depends on the stage  5-Fu
 Dukes’s A- no benefit  Xeloda
• B- sometimes beneficial
 Oxaliplatin (FOLFOX)
• C- yes!
 Irinotecan
 Metastatic disease
 Chemotherapy  Biologic agents-
 Curative surgery bevacizumab/cetuxima
 Palliative treatments b
• Radiofrequency
ablation
• cryotherapy
 Post cancer surveillance

 2/3 of patients with CRC are treated with curative

intent with surgery
 30-50% will develop recurrent disease in 5 yrs
 80% will develop this in 3yrs
 Up to 8% will develop a metachronous CRC
 Symptomatic recurrence has poor prognosis
 Post CRC surveillance

Controversy remains as:

Not all patients benefit
Survival benefit not related to earlier detection and treatment of
recurrent disease
Optimal surveillance strategy unclear
 Post cancer surveillance

Hx and PE every 3-6/12 for 2 years then 6/12 for 5

years
Baseline CEA, then similar to clinical follow-up

Colonoscopy at 1,3 and 5 year after resection (or 3-

6/12 post-resection if emergency).

Annual chest, abdominal and pelvic CT for first 3-5

years post-resection
 Large bowel obstruction

 Causes
 Colon cancer
 Diverticular disease
 Sigmoid Volvulus
 Feacal impaction
 Pseudo-obstruction
 Presentation
• Constipation
• Abdominal distension
• Pain and vomiting
 Investigations
 Plain abdominal X-rays
 Single contrast Ba enema
 CT scan of the abdomen
 Management
 Surgery after establishing mechanical obstruction and resuscitation
Intestinal obstruction
 Sigmoid volvulus

 Most commonly seen in the elderly, institutionalized,

antipsychotic meds
 Short history, marked abdominal pain and
distension
 Diagnosis made on clinical and plain abdominal X-
rays
 Emergency sigmoidoscopic decompression, unless
ischemia present
Plain abdominal X-rays of a sigmoid volvulus; note the coffee bean sign.
Sigmoid volvulus treatment
 Acute diverticulitis

 40-75% of patients over 50 yrs have sigmoid

diverticulosis
 Diverticulitis results from perforation ~pericolic
infection (phlegmon/abscess/generalized peritonitis)
 Clinically- elderly patient with LLQ pain, fever, GI
upset, localized peritonitis.
 Investigations- A clinical diagnosis!
• US
• CT with contrast (investigation of choice)
• leucoytosis
Treatment- Admission/ IV fluids and antibiotics/
Analgesics/Drainage of abscess
Diverticular disease
Contrast CT features of acute diverticulitis
Questions?