Sei sulla pagina 1di 46

Penatalaksanaan medis Ca colon stadium III

Ca colon stadium III memiliki modalitas kuratif yaitu operasi, yang juga merupakan satu-satunya
modal kuratif. Kemoterapi adjuvant juga merupakan tatalaksana standar bagi pasien dengan ca
colon stadium III.
Lesi yang terletak di caecum dan kolon sebeleh kanan

Standard colectomies for adenocarcinoma of the colon.


For lesions in the cecum and right colon, a right hemicolectomy is indicated. During a
right hemicolectomy, the ileocolic, right colic, and right branch of the middle colic
vessels are divided and removed. Care must be taken to identify the right ureter, the
ovarian or testicular vessels, and the duodenum. If the omentum is attached to the
tumor, it should be removed en bloc with the specimen.
For lesions in the proximal or middle transverse colon, an extended right
hemicolectomy can be performed. In this procedure, the ileocolic, right colic, and
middle colic vessels are divided and the specimen is removed with its mesentery.
For lesions in the splenic flexure and left colon, a left hemicolectomy is indicated. The
left branch of the middle colic vessels, the inferior mesenteric vein, and the left colic
vessels along with their mesenteries are included with the specimen.
For sigmoid colon lesions, a sigmoid colectomy is appropriate. The inferior
mesenteric artery is divided at its origin, and dissection proceeds toward the pelvis
until adequate margins are obtained. Care must be taken during dissection to identify
the left ureter and the left ovarian or testicular vessels.
Total abdominal colectomy with ileorectal anastomosis may be required for patients
with any of the following:
Hereditary nonpolyposis colon cancer syndrome (HNPCC)

Attenuated familial adenomatous polyposis (FAP)


Metachronous cancers in separate colon segments
Total abdominal colectomy may also be indicated for some patients with acute
malignant colon obstructions in whom the status of the proximal bowel is unknown.
Laparoscopic surgery
The advent of laparoscopy has revolutionized the surgical approach to colonic
resections for cancers. Large prospective randomized trials have found no significant
differences between open and laparoscopic colectomy with regard to intraoperative or
postoperative complications, perioperative mortality rates, readmission or reoperation
rates, or rate of surgical wound recurrence. Oncologic outcomes (cause-specific
survival, disease recurrence, number of lymph nodes harvested) are likewise
comparable.[57, 58, 59, 60, 61, 62]
For example, the Clinical Outcomes of Surgical Therapy Study Group trial found no
significant differences between laparoscopic-assisted colectomy (LAC) or open
colectomy in terms of 5-year disease-free survival rate (69% versus 68% in the LAC
and open colectomy groups, respectively) or overall survival (76% versus 75%). [58] In
a study by Lacy et al with median followup of 95 months, LAC was more effective
than open colectomy, although the tendency toward higher cancer-related and overall
survival did not reach statistical significance. [61]
Metastatic colorectal cancer
Chemotherapy rather than surgery has been the standard management for patients with
metastatic colorectal cancer. The proper use of elective colon/rectal resections in
nonobstructed patients with stage IV disease is a source of continuing debate.
Medical oncologists properly note the major drawbacks to palliative resection, such as
loss of performance status and risks of surgical complications that potentially lead to
delay in chemotherapy. However, surgeons understand that elective operations have
lower morbidity than emergent operations on patients who are receiving
chemotherapy.
There is a trend toward nonsurgical management of patients with asymptomatic,
surgically incurable colorectal cancer, with studies showing that fewer than 10% of
these patients subsequently require surgery for obstruction or perforation. [63, 64] A
review by Venderbosch et al found that resection of the primary tumor appears to
improve survival in patients with stage IV colorectal cancer, but these researchers

concluded that prospective studies are warranted, given the potential bias of those
results.[65]
Curative-intent resections of liver metastases have significantly improved long-term
survival, with acceptable postoperative morbidity, including in older patients. [66] A
study by Brouquet et al found that resection of colorectal liver metastases after a
second-line chemotherapy regimen was safe and provided a modest hope for
definitive cure, making this approach viable in patients with advanced colorectal liver
metastases.[67]
Hepatic arterial infusion (HAI) of chemotherapeutic agents such as floxuridine
(FUDR) is a consideration following partial hepatectomy. A study by House et al
found that adjuvant HAI-FUDR combined with modern systemic chemotherapy
resulted in improved survival compared with adjuvant chemotherapy alone. [68]
During the past decade, colonic stents have introduced an effective method of
palliation for obstruction in patients with unresectable liver metastasis. However, a
study by van Hooft et al found that colonic stenting has no decisive clinical
advantages compared with emergency surgery. Although it may be used as an
alternative treatment in undefined sets of patients, concerns about tumor spread
caused by perforations remains.[69]
Previous
Next

Ablation
Although resection is the only potentially curative treatment for patients with colon
metastases, other therapeutic options for those who are not surgical candidates,
include thermal ablation techniques. Cryotherapy uses probes to freeze tumors and
surrounding hepatic parenchyma. It requires laparotomy and can potentially have
significant morbidity, including liver cracking, thrombocytopenia, and disseminated
intravascular coagulation (DIC).
Radiofrequency ablation (RFA) uses probes that heat liver tumors and the surrounding
margin of tissue to create coagulation necrosis. RFA can be performed percutaneously,
laparoscopically, or through an open approach. Although RFA has minimal morbidity,
local recurrence is a significant problem and is correlated with tumor size.
Adjuvant Chemotherapy

The standard therapy for patients with stage III and some patients with stage II colon
cancer for the last two decades consisted of 5-fluorouracil in combination with
adjuncts such as levamisole and leucovorin. [2, 3, 4] This approach has been tested in
several large randomized trials and has been shown to reduce individual 5-year risk of
cancer recurrence and death by about 30%.
In an observational study of 1291 patients with stage III colon cancer, adjuvant
chemotherapy reduced the risk of distant recurrence after surgery by about half.
Elderly patients benefited to a similar degree as younger patients. [70, 71]
Overall, 56% of the study participants received adjuvant chemotherapy, 31%
developed distant metastases, and 37% were 75 years of age or older. In the total
population, the use of adjuvant chemotherapy was associated with a significantly
reduced risk of distant recurrence. In separate analyses of patients 75 years of age
and those 75 years of age, the effect of adjuvant chemotherapy on recurrence risk
was similar in both age groups, with hazard ratios of 0.50 and 0.57, respectively.[70, 71]
Two large randomized trials (MOSAIC and NASBP-C06) investigated the addition of
oxaliplatin to fluorouracil (FOLFOX4 and FLOX, respectively) and demonstrated a
significant improvement in 3-year disease-free survival for patients with stage III
colon cancer. The addition of irinotecan to fluorouracil in the same patient population
provided no benefit based on the results from two large randomized trials (CALGB
89803 and PETACC 3).
Another randomized study, XACT, demonstrated noninferiority of capecitabine
(Xeloda) compared with fluorouracil/leucovorin as adjuvant therapy for patients with
stage III colon cancer. A large trial comparing capecitabine plus oxaliplatin (XELOX)
versus FOLFOX has completed accrual, but survival data have not yet been reported.
Although information on results of adjuvant therapy in stage II and III colon cancer is
limited, analysis of a data set assembled by the Adjuvant Colon Cancer Endpoints
group showed that adjuvant chemotherapy provides a significant disease-free survival
benefit because it reduces the recurrence rate. The benefit was particularly evident
within the first 2 years of adjuvant therapy but some benefit extended to years 3-4. [72]
Adjuvant therapy in stage II colon cancer
The role of adjuvant chemotherapy for stage II colon cancer is controversial. Surgery
alone is usually curative for stage II colon cancer, but approximately 20-30% of these
patients develop tumor recurrence and ultimately die of metastatic disease. The
American Society of Clinical Oncology does not recommend the routine use of

adjuvant chemotherapy for patients with stage II colon cancer, and instead
recommends encouraging these patients to participate in clinical trials. [73]
A large European trial (QUASAR) demonstrated small but significant benefit (3.6%)
in terms of absolute 5-year survival rate for those patients who received
fluorouracil/leucovorin versus those in the control group. [49] In contrast, a study by
OConnor et al found that in Medicare patients with stage II colon cancer, with or
without poor prognostic features, overall survival was not substantially improved by
adjuvant chemotherapy.[74]
Ongoing adjuvant trials are investigating additional risk stratification of stage II colon
cancer based on clinicopathological and molecular markers. For example, the ECOG
5202 trial is comparing two forms of adjuvant therapy (oxaliplatin, leucovorin, and
fluorouracil with or without bevacizumab) in high-risk patients, with low-risk patients
undergoing observation only.
In this trial, high-risk patients are defined as those with microsatellite stability (MSS)
or low-frequency microsatellite instability (MSI-L) and loss of heterozygosity at 18q.
Low-risk patients are those with MSS or MSI-L and retention of 18q, or highfrequency MSI with or without loss of heterozygosity at 18q.
Chemotherapy for Metastatic Disease
Combination regimens provide improved efficacy and prolonged progression-free
survival (PFS) in patients with metastatic colon cancer. The advent of new classes of
active drugs and biologics for colorectal cancer has pushed the expected survival for
patients with metastatic disease from 12 months two decades ago to about 22 months
currently.
In a phase III multicenter trial in patients with advanced colorectal carcinoma
refractory to fluorouracil, overall survival did not significantly differ between patients
treated with fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) (n=246) compared
with irinotecan (n=245); however, FOLFOX 4 improved response rate (RR) and time
to progression (TTP) compared with irinotecan (P=0.0009 for each RR and TTP).
FOLFOX4 was associated with more neutropenia and paresthesias. [75]
Although many patients with colorectal cancer are elderly, exclusion of these patients
from randomized controlled trials has impeded the creation of evidence-based
guidelines for this population. A study by Seymour et al demonstrated that elderly and
frail patients with untreated metastatic colorectal cancer can participate in a
randomized controlled trial. Study patients, who were considered unfit for full-dose

chemotherapy, underwent a comprehensive health assessment and were started on


chemotherapy at 80% of standard doses.[76]
Biologic Agents
Biologic agents used in the treatment of colon cancer include monoclonal antibodies
against vascular endothelial growth factor (VEGF) and epidermal growth factor
receptor (EGFR), as well as a kinase inhibitor and a decoy receptor for VEGF. Such
agents include the following:
Bevacizumab (Avastin)
Cetuximab (Erbitux)
Panitumumab (Vectibix)
Regorafenib (Stivarga)
Ziv-aflibercept (Zaltrap)
Bevacizumab
Bevacizumab is a humanized monoclonal antibody to VEGF. It was the first antiangiogenesis drug to be approved in clinical practice and its first indication was for
metastatic colorectal cancer. Approval was based on a pivotal trial that demonstrated
improved progression-free survival (PFS) and overall survival (OS) when
bevacizumab was added to chemotherapy with irinotecan, 5-fluorouracil, and
leucovorin (IFL).
Bevacizumab, in combination with fluorouracil-based chemotherapy, is indicated for
first- and second-line treatment of metastatic colorectal carcinoma. Bevacizumab is
also approved for second-line treatment in patients who have progressed on a first-line
bevacizumab-containing regimen.
Approval for continuation treatment was based on a study that showed maintenance of
VEGF inhibition with bevacizumab plus standard second-line chemotherapy. The risk
of death was reduced by 19% for those who received bevacizumab in combination
with standard chemotherapy in both the first- and second-line compared with those
who received chemotherapy alone (hazard ratio [HR]=0.81, P=0.0057). PFS improved
by 32% (HR=0.68, P < 0.0001).[77]

A pooled analysis of cohorts of older patients (aged 65 years or older) from two
randomized clinical trials concluded that adding bevacizumab to fluorouracil-based
chemotherapy for first-line treatment of metastatic colorectal cancer improved OS and
PFS in older patients as it does in younger patients, without increased risks of
treatment in the older age group. Median OS improved from 14.3 months to 19.3
months with the addition of bevacizumab, while median PFS improved from 6.2
months to 9.2 months.[78]
Results from the randomized CAIRO3 trial appear to show that, compared with
observation, maintenance therapy with capecitabine (Xeloda) and bevacizumab
significantly delayed disease progression in 558 previously untreated patients with
stable (or better) metastatic colorectal cancer after six cycles of induction therapy with
capecitabine, oxaliplatin, and bevacizumab (CAPOX-B). [79, 80] Patients in both groups
were treated with CAPOX-B at first progression until second progression.
At a median follow-up of 48 months, CAPOX-B was restarted in 48% of those in the
maintenance treatment group and 61% of patients in the observation group. [79,
80]
Median second progression after randomization occurred at 11.7 months in the
maintenance group and 8.5 months in the observation group, and median first
progression after randomization occurred at 8.5 months in the maintenance group
compared with 4.1 months in the observation group. [80]
In a study by Tebbutt et al, bevacizumab was found to be associated with a modestly
increased risk of arterial thromboembolism (ATE). However, safety was not
significantly worse in older patients or those with a history of ATE or other vascular
risk factors.[81]
Despite its role in the therapy of metastatic colon cancer, bevacizumab did not
significantly prolong disease-free survival in patients with stage II and III colon
cancer, when added to adjuvant chemotherapy (mFOLFOX6) in a randomized trial
(NASBP C-08).[82]
Cetuximab
Cetuximab is a chimeric monoclonal antibody against EGFR that is approved for
treatment of KRAS mutationnegative (wild-type), EGFR-expressing, metastatic
colorectal cancer. Cetuximab may be used as monotherapy or in combination with
irinotecan (Camptosar) in patients with metastatic colorectal cancer refractory to
fluoropyrimidine and oxaliplatin therapy.[83] Additionally, cetuximab is approved as
combination therapy with FOLFIRI (irinotecan, 5-fluorouracil, leucovorin). [84, 85]

KRAS mutations, which are present in about 40% of colon adenocarcinomas, affect
sensitivity to anti-EGFR treatment.[48] The addition of anti-EGFR antibody treatment
to standard chemotherapy regimens for patients with advanced colorectal cancer
improves progression-free survival for those with wild-type KRAS status, but not
those with mutant KRAS.[86]
The CRYSTAL trial, a large international trial exploring the benefit of adding
cetuximab to first-line chemotherapy with FOLFIRI, documented that only patients
with wild-type KRAS derived clinical benefit from cetuximab. In patients with
mutant KRAS, adding cetuximab to chemotherapy provided no clinical benefit and
resulted only in unnecessary toxicity.
Based on these results, testing for KRAS mutation was added to the cetuximab
indication by the European Medicines Agency (EMA). The US Food and Drug
Administration (FDA) approved the use of cetuximab in combination with FOLFIRI
for first-line treatment of patients with wild-type KRAS metastatic colorectal cancer,
as determined by FDA-approved tests, in July 2012.
Panitumumab
Panitumumab is a fully human monoclonal antibody against EGFR. This agent was
originally approved as monotherapy for patients with EGFR-expressing metastatic
colorectal cancer in whom combination chemotherapy with regimens containing
fluoropyrimidine, oxaliplatin, and irinotecan had failed or was not tolerated.
In May 2014, the FDA approved panitumumab for first-line treatment of patients with
wild-type KRAS (exon 2) metastatic colorectal carcinoma in combination with
fluorouracil, leucovorin, and oxaliplatin (FOLFOX4). [87] Approval was based on
results from the PRIME trial.[88]
The PRIME trial, a phase III study, showed that patients with wild-type KRAS tumors
achieved statistically significant improvement in PFS with panitumumab and
FOLFOX4 versus FOLFOX4 alone (9.6 versus 8.0 months, P=0.02) and a
nonsignificant improvement in OS versus FOLFOX4 alone (23.9 versus 19.7 months,
P =0.07). In contrast, patients with mutant KRAS had significantly reduced PFS with
panitumumab-FOLFOX4.[88]
Thus, panitumumab becomes an option, or an alternative to cetuximab, for patients
who have tumors with wild-type KRAS.[89, 90] However, Hecht et al reported that adding
panitumumab to bevacizumab and chemotherapy (oxaliplatin- and irinotecan-based)
as first-line treatment of metastatic colorectal cancer resulted in increased toxicity and
decreased PFS.[91]

In a randomized study of first-line treatment of metastatic colorectal cancer,


Bokemeyer et al concluded that the overall response rate for cetuximab plus
FOLFOX-4 was higher than with FOLFOX-4 alone. However, a statistically
significant increase was seen only in patients with KRAS wild-type tumors, for whom
the addition of cetuximab increased chance of response and lowered the risk of
disease progression.[92]
Douillard and colleagues reported that in addition to KRAS mutations in exon 2,
additional RAS mutations (KRAS exon 3 or 4; NRAS exon 2, 3, or 4; or BRAF exon
15) are associated with inferior PFS and OS with panitumumab-FOLFOX4 treatment.
[93]
Other mutations that involve some of the kinases downstream from KRAS (such
as BRAF and PI3K) are being investigated and may result in even more selective
methods to identify patients that may benefit from EGFR inhibition.
Regorafenib
Regorafenib, a kinase inhibitor, was approved in September 2012. It is indicated for
patients with metastatic colorectal cancer who have been previously treated with
fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy; anti-VEGF
therapy (eg, bevacizumab, ziv-aflibercept); and, if KRAS wild type, anti-EGFR
therapy (eg, cetuximab, panitumumab).[94]
Approval was based on a multicenter trial (n=760) that randomized patients at a 2:1
ratio to receive regorafenib in addition to best supportive care or placebo plus best
supportive care. Statistically significant benefit in OS and PFS was observed for
regorafenib over placebo in patients with metastatic colon cancer in whom all
approved standard therapies had failed.[95]
Ziv-aflibercept
Ziv-aflibercept is a fusion protein that acts as a decoy receptor for VEGF-A, VEGF-B,
and placental growth factor (PlGF). This agent was approved for use in combination
with FOLFIRI for the treatment of patients with metastatic colorectal cancer that is
resistant to or has progressed after an oxaliplatin-containing fluoropyrimidine-based
regimen.[96]
A phase III trial by Van Cutsem and colleagues in patients with metastatic colorectal
cancer previously treated with an oxaliplatin-based regimen found that the addition of
ziv-aflibercept fluorouracil, leucovorin, and irinotecan (FOLFIRI) improves survival.
Median survival time was 13.5 months with ziv-aflibercept plus FOLFIRI versus
12.06 months with FOLFIRI alone (P = O.0032); PFS was 6.90 versus 4.67 months,
respectively (P < 0.0001).[97]

Radiation Therapy
Although radiation therapy remains a standard modality for patients with rectal
cancer, it has only a limited role in colon cancer. Radiation therapy is not used in the
adjuvant setting, and in metastatic settings it is used only for palliative therapy in
selected metastatic sites such as bone or brain metastases.
Newer, more selective ways of administering radiation therapy, such as stereotactic
radiotherapy (CyberKnife) and tomotherapy, are currently being investigated. In the
future, these techniques may extend the indications for radiotherapy in the
management of colon cancer.
A prospective, multicenter, randomized phase III study by Hendlisz et al showed that
the addition of radioembolization with yttrium-90 significantly improved time to liver
progression and median time to tumor progression in patients with unresectable,
chemotherapy-refractory, liver-limited metastatic colorectal cancer. The study
compared treatment with fluorouracil alone with fluorouracil plus yttrium-90 resin,
which was injected into the hepatic artery.[98]
Deterrence/Prevention
Colorectal cancer prevention strategies fall into three categories:
Screening (see Workup)
Lifestyle measures
Pharmacologic prevention
Lifestyle measures
Abundant epidemiologic literature suggests an association of risk for developing
colorectal cancer with dietary habits, environmental exposures, and level of physical
activity. For example, a prospective cohort study in the general population of two
Danish cities concluded that if all participants had followed recommendations for five
lifestyle factors (physical activity, waist circumference, smoking, alcohol intake, and
diet), 23% of colorectal cancer cases might have been prevented. [99]
There is also evidence that diet and physical activity affect the risk for recurrence of
colon cancer. A prospective observational study involving patients with stage III colon
cancer from the CALGB 89803 adjuvant chemotherapy trial demonstrated adverse
effect with regards to risk for recurrence and increased mortality for patients

following a "Western" diet (high intake of red meat, refined grains, fat, and sweets)
versus a "prudent" diet (high intake of fruits and vegetables, poultry, and fish). [10]
In another observational study from the same cohort of patients, patients were
prospectively monitored and physical activity was recorded. The study concluded that
physical activity reduces the risk of recurrence and mortality in patients with resected
stage III colon cancer.[100]
Morikawa et al reported that in patients with colorectal cancer that tested negative for
cadherin-associated protein 1 (CTNNB1 or -catenin), high physical activity (18
metabolic equivalent task [MET] hours/week) after diagnosis was associated with
significantly better cancer-specific survival. No association between physical activity
and survival was seen in CTNNB1positive cases. [101]
In a study by Campbell et al, recreational physical activity before and after colorectal
cancer diagnosis was associated with lower mortality. These researchers determined
that 6 hours or more of sitting per day was associated with an increase in mortality
compared with sitting 3 hours or less per day. The findings suggest that increasing
physical activity helps reduce mortality in patients with colorectal cancer.[26]
Pharmacologic prevention
Pharmacologic prevention is based on the understanding of colorectal carcinogenesis
and the availability of pharmacologic agents that are effective yet minimally toxic.
The efficacy of these agents is usually first tested in high-risk populations.
Celecoxib (Celebrex), a selective cyclooxygenase-2 inhibitor, was first tested in
patients with familial adenomatous polyposis (FAP). Celecoxib was effective in
decreasing the number and size of polyps on serial colonoscopies, which was the
primary surrogate endpoint for this trial.[102] The drug was approved for FAP patients,
although it remains to be seen whether this intervention translates to reduced cancer
incidence and prolonged survival.
Enthusiasm for cyclooxygenase-2 inhibitors as chemopreventive agents has dampened
because of a high incidence of cardiovascular toxicity in trial patients, which led to
the removal of rofecoxib from the market. Other nonsteroidal anti-inflammatory drugs
(NSAIDs), such as sulindac and nonselective cyclooxygenase inhibitors, have been
tested in lower-risk populations.
Aspirin use has been shown to be effective in both primary prevention of colorectal
cancer (at doses of 300 mg or more daily for about 5 years [103] ) and secondary
prevention (at doses ranging from 81 to 325 mg daily[104] ) of colorectal adenomas. The

decrease in colon cancer risk with aspirin use may vary among population subgroups.
However, body mass index, physical activity, and plasma C-peptide levels were
shown to not have a significant impact on aspirins effect on colon cancer risk. [105]
Examination of questionnaire data collected from the Nurses Health Study and the
Health Professionals Follow-up Study showed regular aspirin use was associated with
lower risk of BRAF wild-type colorectal cancer (multivariable hazard ratio [HR],
0.73) but not with BRAF -mutated cancer risk (multivariable HR, 1.03). Status of
tumor PTGS2 expression or PIK3CA or KRAS mutation had no effect on this
association.[106]
A 2013 study showed that low-dose aspirin taken every other day lowers the risk for
colorectal cancer in middle-aged women. Nearly 40,000 women aged 45 and older
were randomized to low-dose aspirin (100 mg) or placebo every other day for roughly
10 years; 84% were followed for an additional 7 years after treatment ended. At
followup, colorectal cancer risk was lower in the aspirin group, mostly owing to a
reduction in proximal colon cancer; this reduction in risk emerged after 10 years. [107]
Some trials focused on combined inhibition of polyamine production and
cyclooxygenase inhibition. A report from a large randomized trial of a combination of
sulindac and dimethylformamine (DMFO), an inhibitor of ornithine decarboxylase
(ODC), described a dramatic effect of this combination in reducing polyp recurrence
in patients with prior history of colon polyps. Confirmatory trials are ongoing. [108]
Previous
Next

Consultations
Colorectal cancer, especially early stage disease, can be cured surgically. Following
diagnosis and staging, obtaining surgical consultation for the possibility of resection
may be appropriate. After surgery, the stage of the tumor may be advanced depending
on the operative findings (eg, lymph node involvement, palpable liver masses,
peritoneal spread).
In the care of patients with colorectal cancer and isolated liver metastases, consider
surgical consultation for possible resection. In some cases, resection of previously
unresectable liver metastases may become feasible after cytoreduction with
neoadjuvant chemotherapy. Therefore, ongoing involvement of the surgical oncologist
is very important in patient care, even if the tumor is not considered resectable at the
time of diagnosis. In patients with advanced disease, palliative surgery may be helpful
in cases of bleeding or obstruction.

Gastroenterology (GI) consultation is critical for screening of high-risk individuals


(ie, patients with a family history of colorectal cancer or polyposis syndromes) and
those individuals who are found to be inappropriately iron deficient or to have occult
blood on screening fecal examination. A colonoscopy or sigmoidoscopy is necessary
to visualize the colon endoscopically, to obtain biopsies, or to resect polyps.
GI consultation may also be necessary in the management of advanced disease. The
advent of colorectal stents allows a nonsurgical management of impending obstruction
in patients who present with unresectable, metastatic disease.
GI consultation is necessary in the follow-up of patients after surgical resection and
adjuvant chemotherapy. Patients must be screened for recurrent disease in the colon
by colonoscopic examination at 1 year after surgery and then every 3 years.
Previous
Next

Long-Term Monitoring
Pooled analysis from several large adjuvant trials showed that 85% of colon cancer
recurrences occur within 3 years after resection of primary tumor, with 95% occurring
within 5 years. Therefore, patients with resected colon cancer (stage II and III) should
undergo regular surveillance for at least 5 years following resection. [109] See Table 2
below.
Table 2. Surveillance recommendations for stage II and III colon cancer (Open Table
in a new window)
Parameter
History and
physical exam
CEA
Chest CT*
Colonoscopy**
Abdominal CT*

Organization
ESMO [JSMO](2013)
ASCO (2013)[109]
NCCN (2013)[111]
Every 3-6 mo for 3 y, then Every 3-6 mo for 3 y, then Every 3-6 mo for 2
every 6 -12 mo at 4 and 5 y every 6 mo to 5 y
y, then every 6 mo
to 5 y
Every 3-6 mo for 3 y, then Every 3 mo for 3 y*
Every 3-6 mo for 2
every 6 -12 mo at 4 and 5 y
y, then every 6 mo
to 5 y
Every 6-12 mo for first 3 y Every 1 y for 3 y
Every 1 y for 5 y
At y 1 after surgery, and
At 1 y, then every 5 y,
At 1 y, 3 y, and 5 y
every 3-5 y thereafter
dictated by the findings on if negative
the previous colonoscopy
Every 6-12 mo for first 3 y Every 1 y for 3 y
Every 1 y for 5 y;
scans to include
pelvis
[110]

ESMO = European Society of Medical Oncology; JSMO = Japanese Society of Medical


Oncology; ASCO = American Society of Clinical Oncology; NCCN = National Comprehensive
Cancer Network; CEA = carcinoembryonic antigen; CT = computed tomography

* For patients at high risk for recurrence (eg, lymphatic or venous invasion, or poorly
differentiated tumors).

**Colonoscopy should be performed 3-6 mo postoperatively if preoperative colonoscopy was


not done, due to an obstructing lesion; otherwise, colonoscopy in 1 y; if abnormal, repeat in 1
year; if no advanced adenoma (ie, villous polyp, polyp > 1 cm, or high-grade dysplasia), repeat
in 3 y, then every 5 y.

Followup should be guided by the patients presumed risk of recurrence and


functional status. Testing at the more frequent end of the range should be considered
for patients at high risk. Patients with severe comorbid conditions that make them
ineligible for surgery or systemic therapy should not undergo surveillance testing. [109]
Cancer Care Ontario published guidelines for the follow-up care of survivors of stages
II and III colorectal cancer, and these were endorsed by the American Society of
Clinical Oncology. The recommendations include the following [112, 109] :
Surveillance is especially important in the initial 2-4 years following treatment,
when most recurrences occur
Patients should be followed for 5 years, and regular reviews of medical history,
physical examination, and carcinoembryonic antigen testing should be
performed every 3-6 months
Annual computed tomography (CT) scanning of the abdomen and chest should
be performed for 3 years
Pelvic CT scanning should be performed in patients with rectal cancer annually
for 3-5 years
In patients who have not received pelvic radiation, a rectosigmoidoscopy
should be performed every 6 months for 2-5 years

A surveillance colonoscopy should be performed approximately 1 year after


initial surgery
Patients should be counseled to maintain a healthy body weight, be physically
active, and follow a healthy diet

Komplikasi pada pasien dengan kanker kolon yaitu:


1.

Pertumbuhan tumor dapat menyebabkan obstruksi usus

parsial atau lengkap.


2.

Metastase ke organ sekitar, melalui hematogen,

limfogen dan penyebaran langsung.


3.

Pertumbuhan dan ulserasi dapat juga menyerang

pembuluh darah sekitar kolon yang menyebabkan hemorragi.


4.

Perforasi usus dapat terjadi dan mengakibatkan

pembentukan abses.
5.

Peritonitis dan atau sepsis dapat menimbulkan syok.

6.

Pembentukan abses

F.

Pencegahan

Pencegahan Kanker Kolon.


1.

Konsumsi makanan berserat. Untuk memperlancar buang

air besar dan menurunkan derajat keasaman, kosentrasi

asam lemak, asam empedu, dan besi dalam usus besar.


2.

Asam lemak omega-3, yang terdapat dalam ikan

tertentu.
3.

Kosentrasi kalium, vitamin A, C, D, dan E dan

betakarotin.
4.

Susu yang mengandung lactobacillus acidophilus.

5.

Berolahraga dan banyak bergerak sehingga semakin

mudah dan teratur untuk buang air besar.


6.

Hidup rileks dan kurangi stress.

G.

Penatalaksanaan

1.

Penatalaksanaan medis

Pasien dengan gejala obstruksi usus diobati dengan cairan IV


dan pengisapan nasogastrik. Apabila terjadi perdarahan yang
cukup bermakna terapi komponen darah dapat diberikan.
Pengobatan medis untuk kanker kolorektal paling sering
dalam bentuk pendukung atau terapi ajufan. Terapi ajufan
biasanya diberikan selain pengobatan bedah. Pilihan
mencakup kemoterapi, terapi radiasi dan atau imunoterapi.
Kemoterapi yang diberikan ialah 5-flurourasil (5-FU).
Belakangan ini sering dikombinasi dengan leukovorin yang
dapat meningkatkan efektifitas terapi. Bahkan ada yang
memberikan 3 macam kombinasi yaitu: 5-FU, levamisol, dan
leuvocorin. Dari hasil penelitian, setelah dilakukan
pembedahan sebaiknya dilakukan radiasi dan kemoterapi

2.

Penatalaksanaan bedah

Pembedahan adalah tindakan primer untuk kebanyakan


kanker kolon dan rektal, pembedahan dapat bersifat kuratif
atau paliatif. Kanker yang terbatas pada satu sisi dapat
diangkat dengan kolonoskop. Kolostomi laparoskopik dengan
polipektomi merupakan suatu prosedur yang baru
dikembangkan untuk meminimalkan luasnya pembedahan pada
beberapa kasus. Laparoskop digunakan sebagai pedoman
dalam membuat keputusan dikolon, massa tumor kemudian di
eksisi. Reseksi usus diindikasikan untuk kebanyakan lesi kelas
A dan semua kelas B serta lesi C. Pembedahan kadang
dianjurkan untuk mengatasi kanker kolon kelas D. Tujuan
pembedahan dalam situasi ini adalah paliatif. Apabila tumor
sudah menyebar dan mencakup struktur vital sekitar, operasi
tidak dapat dilakukan.
Tipe pembedahan tergantung dari lokasi dan ukuran tumor.
3.

Penatalaksanaan Keperawatan

a)

Dukungan adaptasi dan kemandirian.

b)

Meningkatkan kenyamanan.

c)

Mempertahankan fungsi fisiologis optimal.

d)

Mencegah komplikasi.

e)

Memberikan informasi tentang proses/ kondisi penyakit,

prognosis, dan
4.

kebutuhan pengobatan.

Penatalaksanaan Diet

a)

Cukup mengkonsumsi serat, seperti sayur-sayuran dan

buah-buahan. Serat dapat melancarkan pencemaan dan buang


air besar sehingga berfungsi menghilangkan kotoran dan zat
yang tidak berguna di usus, karena kotoran yang terlalu lama
mengendap di usus akan menjadi racun yang memicu sel
kanker.
b)

Kacang-kacangan (lima porsi setiap hari)

c)

Menghindari makanan yang mengandung lemak jenuh dan

kolesterol tinggi terutama yang terdapat pada daging


hewan.
d)

Menghindari makanan yang diawetkan dan pewarna

sintetik, karena hal tersebut dapat memicu sel karsinogen /


sel kanker.
e)

Menghindari minuman beralkohol dan rokok yang

berlebihan.
f)

Melaksanakan aktivitas fisik atau olahraga secara

teratur
H.
a)

Pemeriksaan penunjang
Endoskopi. Pemeriksaan endoskopi perlu dikerjakan, baik

sigmoidoskopi maupun kolonoskopi. Gambaran yang khas


karsinoma atau ulkus akan dapat dilihat dengan jelas pada
endoskopi, dan untuk menegakkan diagnosis perlu dilakukan
biopsi.
b)

Radiologi. Pemeriksaan radiologi yang dapat dikerjakan

antara lain adalah : foto dada dan foto kolon (barium enema).
Pemeriksaan dengan enema barium mungkin dapat
memperjelas keadaan tumor dan mengidentifikasikan
letaknya. Tes ini mungkin menggambarkan adanya kebuntuan
pada isi perut, dimana terjadi pengurangan ukuran tumor
pada lumen. Luka yang kecil kemungkinan tidak
teridentifikasi dengan tes ini. Enema barium secara umum
dilakukan setelah sigmoidoscopy dan colonoscopy.
Computer Tomografi (CT) membantu memperjelas adanya
massa dan luas dari penyakit. Chest X-ray dan liver scan
mungkin dapat menemukan tempat yang jauh yang sudah
metastasis.
Pemeriksaan foto dada berguna selain untuk melihat ada
tidaknya metastasis kanker pada paru juga bisa digunakan
untuk persiapan tindakan pembedahan. Pada foto kolon dapat
dapat terlihat suatu filling defect pada suatu tempat atau
suatu striktura.
c)

Ultrasonografi (USG). Pemeriksaan ini berguna untuk

mendeteksi ada tidaknya metastasis kanker kelenjar getah


bening di abdomen dan di hati.
d)

Histopatologi/ Selain melakukan endoskopi sebaiknya

dilakukan biopsi di beberapa tempat untuk pemeriksaan


histopatologis guna menegakkan diagnosis. Gambaran
histopatologi karsinoma kolorektal ialah adenokarsinoma, dan

perlu ditentukan differensiasi sel.


e)

Laboratorium. Tidak ada petanda yang khas untuk

karsinoma kolorektal, walaupun demikian setiap pasien yang


mengalami perdarahan perlu diperiksa Hb. Tumor marker
(petanda tumor) yang biasa dipakai adalah CEA. Kadar CEA
lebih dari 5 mg/ ml biasanya ditemukan karsinoma kolorektal
yang sudah lanjut. Berdasarkan penelitian, CEA tidak bisa
digunakan untuk mendeteksi secara dini karsinoma
kolorektal, sebab ditemukan titer lebih dari 5 mg/ml hanya
pada sepertiga kasus stadium III. Pasien dengan buang air
besar lendir berdarah, perlu diperiksa tinjanya secara
bakteriologis terhadap shigella dan juga amoeba.
f)

Scan (misalnya, MR1. CZ: gallium) dan ultrasound:

Dilakukan untuk tujuan diagnostik, identifikasi metastatik,


dan evaluasi respons pada pengobatan.
g)

Biopsi (aspirasi, eksisi, jarum): Dilakukan untuk

diagnostik banding dan menggambarkan pengobatan dan


dapat dilakukan melalui sum-sum tulang, kulit, organ dan
sebagainya.
h)

Jumlah darah lengkap dengan diferensial dan trombosit:

Dapat menunjukkan anemia, perubahan pada sel darah merah


dan sel darah putih: trombosit meningkat atau berkurang.
i)

Sinar X dada: Menyelidiki penyakit paru metastatik atau

primer.

Keterbukaan mengenai tindakan bedah yang akan dilakukan,


pilihan anestesi, dan perubahan atau kejadian pasca operatif
yang diharapkan akan menghilangkan banyak tak berdasar
terhadap anestesi.

Bagi sebagian pasien, adalah suatu peristiwa hidup yang


bermakna.
Kemampuan perawat dan dokter untuk memandang pasien dan
keluarga sebagai manusia yang layak didengarkan dan
dimintai pendapat, ikut menentukan hasil pembedahan.
Egbert et al. (1963,dikutip gruendamann, 2006).
Memperliahatkan bahwa kecemasan pasien yang dikunjungi
dan dimintai pendapat sebelum dioperasi akan berkurang
saat tiba di kamar operasi dibandingkan mereka yang hanya
sekedar diberi pramedikasi dengan fenobarbital. Kelompok
yang mendapat premedikasi melaporkan rasa mengantuk,
tetapi tetap cemas.
Bantu pasien meningkatkan citra tubuh memberi kesempatan
pasien mengungkapkan perasaannya.

Perubahan yang

terjadi pada citra tubuh dan gaya hidup sering sangat


mengganggu, oleh karena itu pasien memerlukan dukungan
empatis dalam mencoba menyesuaikannya. Oleh karena stoma
ditempatkan pada abdomen pasien dapat berfikir bahwa
setiap orang akan melihat ostomi. Perawat dapat membantu
informasi aktual tentang prosedur pembedahan dan
pembentukan, serta penatalaksaan ostomi. Apabila pasien
menghendaki, diagram, foto dan slat dapat digunakan untuk
menjelaskan dan memperjelas. Pasien juga dapat mengalami

stres emosional, perawat perlu mengulang beberapa intonasi.


Berikan kesempatan pada pasien untuk mengajukan
pertanyaan.
Hadirkan pasien yang pernah dilakukan kolostomi.
Berdiskusi dengan individu yang berhasil menghadapi
kolostomi sering membantu menurunkan kecemasan pasien
pasca prabedah.
Berikan privasi untuk pasien dan orang terdekat.

Memberi

waktu untuk mengekplorasikan perasaan, menghilangkan


cemas dan perilaku adaptasi. Adanya kelurga dan temanteman yang dipilih pasien melayani aktifitas dan pengalihan
(membaca) akan menurunkan perasaan terisolasi.
Kolaborasi :
Beriak anti cemas sesuai indikasi contohnya diazepam.
Meningkatkan relaksasi dan menurunkan kecemasan.
Risiko injuri b.d. pasca-prosedur reseksi kolon
Tujuan : Dalam waktu 2 X 24 jam pascaintervensi reseksi
kolon, pasien tidak mengalami injuri.
Kriteria evaluasi:
-

TTV dalam batas normal

Kondisi kepatenan selang dada optimal

Tidak terjadi infeksi pada insisi.

Intervensi

Rasional

Kaji faktor-faktor yang meningkatkan risiko injuri.


Pascabedah pasien akan terdapat drain pada tubuh pasien.
Keterampilan keperawatan kritis diperlukan agar pengkajian
vital dapat sistematis dilakukan.
Monitor adanya komplikasi pasca bedah.

Perawat

memonitor adanya komplikasi pasca bedah seperti kebocoran


dari sisi anastomosis, prolaps stoma, perforasi, retraksi
stoma, inpaksi feka,l dan iritasi kulit, serta komplikasi paru
yang dihubungkan dengan abdomen. Andomen dipantau
terhadap tanda kembalinya peristaltil dan kaji karakteristik
feses.
Bantu ambulasi dini.

Paisen yang menjalani kolostomi

dibantu turun dari tempat tidur pada hari pertama


pascaoperatif dan didorong untuk mulai berpartisipasi dalam
menghadapi kolostomi.
Beri perhatian khusus pada pasien usia lanjut.

Pasien lansia

dapat mengalami penurunan penglihatan sampai beberapa


derajat dan kerusakan pendengaran, serta kesulitan
melakukan keterampilan yang memerlukan koordinasi motorik
halus. Oleh karenanya, membantu pasien memegang alat
ostomi pada periode praoperatif dan simulasi perbersihan
kulit periostomal, seta irigasi stoma akan membantu pasien.
Jatuh akibat ketidaksengajaan sering terjadi pada lansia.

Oleh karena itu, pengting untuk memastikan apakah pasien


dapat berjalan tanpa bantuan kekamar mandi.
Perawatan kulit adalah masalah utama untuk para lansia
dengan ostoma, karena pada lansia terjadi perubahan pada
kulit akibat proses penuaan. Lapisan lemak subkutan dan
epitel menjadi tipis dan kulit mudah teriritasi. Untuk
mencegah krusakan, perhatian khusus diberikan pada hygiene
kulit dan penempatan alat yang tepat. Arteri sklerosis
terjadi akibat penurunan aliran darah pada luka dan sisi
stoma.
Pertahankan status hemodinamik yang optimal.

Pasien akan

mendapat cairan intravena sebagai pemeliharaan status


hemodinamik
Monitor kondisi selang nasogatrik.

Secara umum pasien

pasca esofagektomi akan terpasang selang nasogatrik.


Perawat berusaha untuk tidak mengubah posisi, mengangkat,
memanipulasi, atau mengirigasi selang, kecuali memang
diperlukan untuk terapi.
Kolaborasi untuk pemberian antibiotic pasca bedah.
Antibiotik menurunkan risiko infeksi yang akan menimbulkan
reaksi inflamasi local dan dapat memeperlama proses
penyembuhan pasca-funduplikasi lambung.

Risiko tinggi infeksi b.d. adanya port de entre dari luka


pembedahaan
Tujuan : Dalam waktu 12 x 24 jam tidak terjadi infeksi,
terjadi perbaikan pada integritas jaringan lunak.
Kriteria evaluasi:

Jahitan dilepas pada hari ke-12 tanpa adanya tanda-

tanda infeksi dan peradangan pada area luka pembedahan

Leukosit dalam batas normal

TTV dalam batas normal

Intervensi

Rasional

Kaji jenis pembedahan, hari pembedahan, dan apakah adanya


order khusus dari tim dokter bedah dalam melakukan
perawatan luka.

Mengidentifikasi kemajuan atau

penyimpangan dari tujuan yang diharapkan.


Buat kondisi balutan dalam keadaan bersih dan kering.
Kondisi bersih dan kering akan menghindari kontaminasi
komensal dan akan menyebabkan respons inflamasi lokal,
serta akan memperlama penyembuhan luka.
Lakukan perawatan luka:

Lakukan perawatan luka steril pada hari kedua pasca

bedah dan diulang setiap dua hari sekali pada luka abdomen

Lakukan perawatan luka pada sekitar drain

Bersihkan luka dan drainase dengan cairan antiseptic,

jenis iodine providium dengan caraswabbing dari arah dalam


keluar.

Bersihkan bekas sisa iodine providium dengan alcohol

70% atau normal salin dengan cara swabbing dari arah dalam
keluar.

Tutup luka dengan kasa steril dan tuutp dengan plester

adhesive yang menyeluruh menutupi kasa.


Perawatan luka sebaiknya tidak setiap hari untuk menurunkan

kontak tikndakan dengan luka yang dalam kondisi steril


sehingga mencegah kontaminasi kuman ke luka bedah.
Drain pasca bedah merupakan material yang menjadi jalan
masuk kuman. Perawat melakukan perawatan luka setiap hari
atau disesuaikan dengan kondisi pembalut drain, apabila
kotor maka harus diganti.
Pembersihan debris (sisa fagositosis, jaringan mati) dan
kuman sekitar luka dengan mengoptimalkan kelebihan dari
iodine providium sebagai antiseptic dan dengan arah dari
dalam keluar sehingga dapat mencegah kontaminasi kuman ke
jaringan luka.
Antiseptic iodine providium mempunyai kelemahan dalam
menurunkan proses epitelisasi jaringan sehingga
memperlambat pertumbuhan luka, maka harus dibersihkan
dengan alcohol atau normal salin.
Penutupan secara menyeluruh dapat menghindari kontaminasi
dari benda atau udara yang bersentuhan dengan luka bedah.
Angkat drainase pascabedah sesuai pesanan medis.
Pelepasan sesuai indikasi bertujuan untuk menurunkan risiko
infeksi.

Kolaborasi penggunaan antibiotic.

Antibiotic injeksi

diberikan selama tiga hari pascabedah yang kemudian


dilanjutkan antibiotic oral sampai jahitan dilepas. Peran
perawat mengkaji adanya reaksi dan riwayat alergi
antibiotic, serta memberikan antibiotic sesuai pesanan
dokter.
4.

Evaluasi

Hasil yang Diharapkan


1.

Mempertahankan eliminasi usus adekuat.

2.

Mengalami sedikit nyeri.

3.

Meningkatkan toleransi aktivitas.

4.

Mencapai tingkat nutrisi optimal.

a.

Makan diet rendah residu, tinggi protein, dan tinggi

kalori.
b.

Kram abdomen berkurang.

5.

Keseimbangan cairan tercapai.

a.

Membatasi masukan makanan dan cairan oral bila terjadi

mual.
b.

Berkemih sedikitnya 1 liter per 24 jam.

6.

Mengalami penurunan ansietas.

a.

Mengungkapkan masalah dan rasa takut dengan bebas.

b.

Menggunakan tindakan koping untuk menghadapi stress.

7.

Memerlukan informasi tentang diagnosis, prosedur

bedah, dan perawatan diri setelah pulang.


a.

Mendiskusikan diagnosa, prosedur bedah, dan perawatan

diri pascaoperatif.
b.

Mendemonstrasikan teknik perawatan ostomi.

8.

Mempertahankan insisi tetap bersih, stoma, dan luka

perineal.
a.

Secara bertahap meningkatkan partisipasi dalam

perawatan stoma.
9.

Mengungkapkan perasaan dan masalah tentang diri

sendiri secara verbal.


10.

Tidak mengalami komplikasi.

a.

Menggunakan antibiotic oral sesuai resep.

b.

Bekerjasama dalam protocol pembersihan usus.

c.

Tidak demam.

d.

Bisisng usus ada.

e.

Lingkar abdomen dalam batas normal atau menurun.

f.

Tidak ada bukti perforasi atau pendarahan.

STUDI KASUS
PADA KANKER KOLON
Pengkajian
PENGKAJIAN KEPERAWATAN

Nama Perawat

: Ns. Cindra

Tanggal Pengkajian

: 05 Mei 2012

Jam Pengkajian
1.

: 08.00 WIB

Biodata :

Pasien
Nama

: Tn. A

Umur

: 35 th

Agama

: Islam

Pendidikan

: Sarjana

Pekerjaan

: PNS

Status Pernikahan
Alamat

: Menikah

: Kalirejo, Lampung Tengah

Tanggal Masuk RS

: Sabtu, 05 Mei 2012

Diagnosa Medis

: Ca. Colon

Penanggung Jawab
Nama
Agama

: Ny. B
: Islam

Pendidikan

: Sarjana

Pekerjaan

: PNS

Status Pernikahan
Alamat

: Kalirejo, Lampung Tengah

Hubungan dengan klien


2.

: Menikah
: Istri

Keluhan utama :

Nyeri hebat pada bagian perut

3.

Riwayat Kesehatan :

a.

Riwayat Penyakit Sekarang :

Klien masuk ke Rumah Sakit tanggal 5 Mei 2012 akibat


mengalami penyakit Ca. Colon. Klien datang ke RSUD
Pringsewu diantar oleh keluarganya melalui IGD, pada tanggal
5 Mei 2012, dengan keluhan nyeri pada abdomen, kram perut,
pola defekasi bermasalah, sering sembelit, feses berwarna
kehitaman dan kadang disertai darah merah segar, tidak
nafsu makan, penurunan berat badan, dan cepat letih.
b.

Riwayat Penyakit Dahulu :

Klien mengatakan tidak mempunyai alergi terhadap makanan


atau obat-obatan, hanya saja tidak terlalu suka sayuran. + 4
tahun yang lalu klien pernah terkena penyakit thypoid sampai
diopname. Klien pernah mengalami kecelakaan motor namun
tidak fatal. Keluarga klien mengatakan bahwa klien hampir
setiap hari mengkonsumsi daging hewan, jarang makan sayur,
dan klien mempunyai riwayat peminum / alkoholic.
c.

Riwayat Penyakit Keluarga

Keluarga klien menjelaskan anggota keluarganya tidak ada


yang menderita penyakit keturunan yang umumnya
menyerang, seperti DM, Asma, Hipertensi.
4.

Basic Promoting physiology of Health

a.

Aktifitas dan latihan

Pekerjaan Tn. A yaitu seorang PNS dan waktu luangnya diisi

dengan beristirahat di rumah dan berkumpul bersama


keluarga. Klien jarang berolahraga. Saat sakit, klien hanya
bisa berbaring di tempat tidur, aktifitas terbatas, dan klien
dibantu oleh keluarganya.
b.

Tidur dan istirahat

Sebelum sakit lama tidur klien 7-8 jam/hari, hanya


dipergunakan untuk tidur malam karena klien jarang sekali
tidur siang dan tidak ada gangguan dalam tidur. Saat sakit
lama tidur klien hanya 5 jam dengan tidur siang selama 1 jam.
Klien kadang-kadang kesulitan tidur di rumah sakit karena
nyeri yang dialami klien, klien tampak lemah.
c.

Kenyamanan dan nyeri

Klien merasakan nyeri pada perutnya dalam 2 bulan


belakangan ini. Nyeri akan lebih terasa menyakitkan jika
beraktifitas dan saat defekasi, dan akan berkurang saat
klien beristirahat. Region nyeri yaitu pada abdomen bagian
bawah (dessendens bawah). Skala nyeri klien 8, raut muka
klien tampak menahan nyeri.
d.

Nutrisi

Sebelum sakit, frekuensi makan Tn. A tidak teratur


dikarenakan kesibukan jam kerja yang mengakibatkan sering
telat makan. Berat badan klien 68 kg. Berat badan dalam 2
bulan terakhir turun drastis menjadi 57 kg. Jenis makanan
yang paling sering dikonsumsi klien yaitu daging hewan dan

makanan cepat saji (sate & gulai). Klien tidak suka sayuran,
dan tidak memiliki pantangan terhadap makanan apapun. Klien
tidak pernah mengalami operasi gastrointestinal. Saat sakit,
klien hanya mengkonsumsi nasi lembek, sayuran hijau, buah
tapi jarang habis karena klien mual, tidak nafsu makan, &
klien tidak makan yang pedas & berminyak. Diet di rumah
sakit adalah diet rendah lemak hewani dan tinggi serat.
Kebutuhan pemenuhan nutrisi dibantu oleh keluarganya.
e.

Cairan, elektrolit, dan asam basa

Sebelum sakit frekuensi minum klien 7-8 gelas/hari. Saat


sakit, frekuensi minum klien + 2-3 gelas/hari. Turgor kulit
tidak elastis. Klien mendapat support IV Line jenis RL 20
tetes/menit.
f.

Oksigenasi

Klien tidak mengalami sesak, tidak ada keluhan saat


bernafas, irama teratur, klien tidak batuk, klien tidak
merokok, klien tidak terpasang oksigen.
g.

Eliminasi fekal/bowel

Frekuensi BAB klien sebelum sakit 1x sehari di pagi hari.


Feses berwani kuning, konsistensi padat, berbau khas, warna
kuning kecoklatan, dan tidak ada keluhan.
Saat sakit, klien kesulitan BAB, mengalami sembelit, baru 1x
selama dirawat di RS, feses berwarna kehitaman, konsistensi
keras, kadang disertai darah merah segar, berbau anyir.

h.

Eliminasi urin

Frekuensi BAK klien 2x sehari. Klien tidak mengalami


perubahan pola berkemih. Klien tidak menggunakan kateter,
kebutuhan pemenuhan ADL dengan bantuan keluarga.
i.

Sensori, persepsi, dan kognitif

Klien tidak memiliki gangguan dan riwayat penyakit yang


menyangkut sensori, persepsi, dan kognitif

5. Pemeriksaan Fisik Head To Toe


a.

Keadaan Umum

Kesadaran klien composmentis, Vital Sign TD 110/90 mmHg,


Nadi 70x/menit, irama reguler kekuatan sedang, Respirasi
26x/menit, irama regular, Suhu 36,50 C
b.

Kepala : kulit kepala normal, tidak ada hematoma, lesi

atau kotor. Rambut mudah patah saat dicabut, hitam tanpa


uban, dan bersih.
Mata : mata klien secara umum normal, bentuk simetris,
konjungtiva tampak anemis, sklera tidak ikterik, pupil dapat
merespon terhadap cahaya, palpebra normal, tidak ada
oedema. Lensa mata normal, jernih, visus mata kanan dan kiri
normal. Tampak garis kehitaman pada kelopak mata klien

bagian bawah.
Hidung : Hidung klien simetris, tidak ada septum deviasi,
polip, epistaksis, gangguan indera pencium, atau secret.
Mulut : Mulut klien normal, dimana gigi klien normal, tidak
ada lubang, dan tidak ada gigi palsu. Bibir klien kering, tidak
stomatitis, dan tidak sianosis. Gusi klien berwarna merah,
lidah klien tampak kotor.
Telinga : telinga klien simetris, bersih, dan tidak ada
gangguan pendengaran.
Leher : leher klien normal, tidak ada pembesaran thyroid,
tidak ada kaku kuduk, tidak ada hematoma, tida ada lesi.
Tenggorokan klien normal, tidak ada nyeri tekan, tidak
hipremis, dan tidak ada pembesaran tonsil.
c.

Dada : bentuk dada klien normal

Pulmo : Inspeksi : pengembangan dada simetris. Palpasi :


Fremitus taktil kanan sama dengan kiri. Perkusi : pulmo kanan
dan kiri sonor. Auskultasi : vesikuler pada pulmo kanan dan
kiri
Cor : Inspeksi: ictus cordis tidak nampak. Palpasi : Ictus
cordis teraba pada mid clavicula sic 5, Perkusi : menunjukkan
batas jantung normal.
Auskultasi : Bunyi jantung I (SI) di ruang intercosta V
sebelah kiri, Bunyi jantung II (SII) di ruang intercosta II
sebelah kanan, Bunyi jantung III (SIII) tidak ada, murmur

tidak ada.
d.

Abdomen : inspeksi : bentuk agak cembung. Palpasi :

adanya nyeri tekan pada

perut bawah. Auskultasi :

peristaltik permenit.
e.

Genetalia : Laki-laki : normal, tidak ada perdarahan.

f.

Rektum : Normal, tidak ada hemoroid, tidak ada prolaps,

dan tidak ada tumor.


g.

Ekstremitas :

- atas : Kekuatan otot ka/ki : 6/6, ROM ka/ki : aktif/aktif


- bawah : kekuatan otot ka/ki: 6/6, ROM ka/ki : aktif/aktif
Psiko sosio budaya dan spiritual :
Psikologis :
Perasaan klien setelah mengalami masalah ini adalah gelisah.
Cara mengatasi gelisahnya klien dihibur keluarga. Dukungan
yang diberikan oleh keluarga sangat baik, keluarga
memberikan semangat kepada klien agar klien selalu berdoa
supaya cepat sembuh.
Rencana klien setelah masalah terselesaikan adalah istirahat
di rumah. Klien juga mengatakan sedikit cemas dengan
penyakitnya. Klien takut akan perubahan status
kesehatannya.
Sosial :
Aktivitas atau peran di masyarakat adalah sebagai anggota

RT 5 Kalirejo. Kebiasaan lingkungan yang tidak disukai adalah


lingkungan yang kotor. Cara mengatasinya dengan melakukan
kegiatan kerja bakti.
Budaya :
Budaya yang diikuti klien adalah budaya jawa. Kebudayaan
yang dianut tidak merugikan kesehatannya.
Spiritual :
Aktivitas ibadah sehari-hari sholat 5 waktu. Kegiatan
keagamaan yang biasa dilakukan adalah yasinan. Keyakinan
klien tentang masalah kesehatan yang sekarang sedang
dialami : klien yakin akan dirinya pasti sembuh.
6. Pemeriksaan Penunjang
Tes Diagnostik : (05 Mei 2012)
Hematologi
Hb

11,5

Ht/PVC

Hasil

Nilai Normal

12-18 g/dL
42

Leukosit
Trombosit

40-52%

7.000

Turun
Normal

4.000-10.000 /uL

253.000

Masa protrombin

13.0

Normal

150.000-450.000 /uL
11.0-17.0 detik

Radiologi :
Foto colon ( Barium Enema)
Colonoscopy

Interpretasi

Normal

Normal

7.

Terapi Medis

Bed rest

IVFD RL 20 tetes/menit

Th/oral :

Th/inj :

Kemoterapi

Leukovorin

5-FU, Levamisol, Leuvocorin

Pembedahan / Laparaskopi

ANALISA DATA
Nama Klien
Umur

: Tn. A
: 35 tahun

Ruang Rawat
TGL/JAM

No. Register
Diagnosa Medis

: Paviliun Asri 3
DATA FOKUS

Alamat

PROBLEM

: 123
: Ca. Colon
: Kalirejo

ETIOLOGI

05/05/12
08.00 WIB

DS :

Klien mengatakan perutnya sangat sakit bagian bawah

Klien mengatakan perutnya bertambah sakit saat

bergerak
-

Klien mengatakan nyeri hilang timbul

DO :
-

Klien tampak meringis kesakitan

Klien tampak gelisah

Skala nyeri klien 8

Klien tampak tidak nyaman dengan perutnya

akut

Nyeri

Obstruksi tumor pada usus dengan kemungkinan

menekan organ yang lain


06/05/12
13.00 WIB

DS :

Klien mengatakan nyeri pada daerah yang di insisi

Klien mengatakan tubuhnya masih lemah

DO :
-

Klien tampak lemah

Klien tampak menahan nyeri

Ekspresi wajah klien cemberut

Tampak kemerahan pada daerah bekas operasi

Nyeri akut

Agen cedera fisik (insisi pembedahan)

06/05/12
13.30 WIB
DS :
-

Klien mengatakan gatal pada daerah yang di insisi

Keluarga klien mengatakan badan klien hangat

DO :
-

Daerah pembedahan tampak masih baru dan terfiksasi

Leukosit : 15.000 /Ul

Suhu : 37,5 C

Risiko infeksi

Tindakan invasif, insisi post pembedahan


06/05/12
14.00 WIB

06/05/12
15.00 WIB

DS

Klien mengatakan punggungnya terasa panas

Klien mengatakan susah bergerak

Klien mengatakan tidak mampu beraktifitas secara

mandiri
DO :
-

Klien terlihat berbaring di tempat tidur

Klien tampak terpasang kateter

Aktifitas klien terlihat dibantu keluarga

Klien tampak lemah

Tampak adanya luka insisi pada perut klien

DS :
-

Klien mengatakan tidak nafsu makan

Klien mengatakan tubuhnya lemas

Keluarga klien mengatakan klien belum memakan apapun

pasca operasi
-

Klien mengatakan lidahnya terasa pahit

DO :
-

Klien tampak lemas

Bibir klien tampak kering & pucat

BB turun + 11 kg selama sakit


Intoleransi aktifitas

Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh


Kelemahan fisik

Ketidakmampuan untuk mencerna makanan


Diagnosa keperawatan yang mungkin muncul (NANDA):

Pre Operasi
Nyeri akut b.d obstruksi tumor pada usus dengan
kemungkinan menekan organ yang lain
Post Operasi
1.

Nyeri akut b.d agen cedera fisik (insisi pembedahan)

2.

Risiko infeksi b.d tindakan invasif, insisi post

pembedahan
3.

Intoleransi aktivitas b.d kelemahan fisik

4.

Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh

b.d ketidakmampuan untuk mencerna makanan