Famlllal Famlllal aoenomatous aoenomatous polyposls polyposls & &

colonlc ca colonlc ca
POLYP:
POLYP ARE NODULAR LESION WHICH TAKES ORIGIN FROM
AN EPITH.SURFACE AND REMAIN ATTACHED TO IT BY
MEANS OF A STALK,SHORT OR LONG,IT MAY BE
INFLAMMATORY OR NEOPLASTIC,BUT PAPPILOMA ARE
ALWAYS NEOPLASTIC
POLPOSIS IS A MORPHOLOGIC TERM & no histologic
diagnosis is implied
polyposls polyposls
|t can occur:-
O Slngly
O Syncbronously ln a small numbers
O As a part ot a polyposls synorome
O |n FAP
More tban 100 aoenoma are present.
lassltlcatlon ot lassltlcatlon ot polyps polyps ot large gut ot large gut
class class variety variety
inflammatory inflammatory Pseudo polyp/benign lymphoid polyp Pseudo polyp/benign lymphoid polyp
metaplastic metaplastic Metaplastic or hyperplastic polyp Metaplastic or hyperplastic polyp
hamartomatous hamartomatous Peutz Peutz- -jeghers jeghers polyp/juvenile polyp polyp/juvenile polyp
neoplastic neoplastic 1.adenoma: 1.adenoma:- -(tubular/ (tubular/tubulovillous tubulovillous/villous /villous
adenoma) adenoma)
2.Adenocarcinoma 2.Adenocarcinoma
3.Carcinoid 3.Carcinoid tumour tumour
unclassified unclassified Hyperplastic Hyperplastic polyp polyp
miscellaneous miscellaneous Lipoma Lipoma//leiomyoma leiomyoma//carcinoid carcinoid
Polyposls Polyposls synorome synorome
Neoplastlc polyp specltlcally tubular varlety are
assoclateo wltb specltlc polyposls synorome.
1) tamlllal polyposls coll
2) garoner's synorome
3) turcoat's synorome
|ntlammatory polyp |ntlammatory polyp
Polyps are known as pseuoopolyp less tban 0.5cm ln
olameter & conslsts ot lntlameo mucosa &
submucosa.
Lam:-
1. Ulceratlve colltls
2. robn's ols
3. Dlvertlculltls
4. |n cbronlc oysentary
Famlllal Famlllal aoenomatous aoenomatous polyposls polyposls(FAP) (FAP)
Lssentlal teatures:-
1.Autosomal oomlnant
lnberlteo olsease oue to
mutatlon ot AP gene
2.More tban 100 colonlc
aoenoma are olagnostlc
3.Surgery ls tbe only means
ot preventlng colonlc
cancer
4.Polyps & mallgnant tumors
can oevelop ln tbe
ouooenum & small gut
.it is a general neoplastic
disorder of the intestine
6.it is rare but important
disease because colorectal
cancer can develop before
age 40 in nearly all
untreated patients
Lploemlology ot FAP Lploemlology ot FAP
1. Age:polyp beglns to appear at puberty
usually vlslble on slgmolooscopy by age
15 yrs.almost always vlslble by age
30yrs.a colon occur 10-20yrs atter
onset ot polyposls. | or more cancers
wlll alreaoy be present ln 2/3 ot tbose
pt presentlng wltb symtoms.
|t ln an lnvolveo tamlly polyp ooes not
oevelop even atter 40 years-ls not llkely
to oevelop later ln tbat partlcular
person
2. .se::-male & temale are equally attecteo
3. slte:large bowel ls attecteo. 8ut can
occur ln stomacb,ouooenum & small
gut.maln rlsk ls ln large gut cancer but
oouoenal & ampullary cancer bas been
reporteo
4. Genetlc:autosomal oomlnant apc gene
oetecteo ln sbort arm ot cbromosome -
5.also can occur sporaolcally by new
gene mutatlon
Patbology ot FAP Patbology ot FAP
O Myrlaos ot aoenomatous polyps
are trequently sltuateo ln slgmolo
colon & rectum. |t may cover tbe
entlre ot mucosa ot colon.otten
bunoreos ot tumors present.
O Tbere ls blgb lncloence ot
mallgnant transtormatlon.certaln
or multlple polyps may be
become cancerous concurrently
O .
Macroscopically::-
small pedunculated tubular
adenoma-1cm in
diameter.when closely
packed gives-flurry
appearance
Microscopically:-
neoplastic aggregation of
tubules & glands separated
by scant c.t septa.cell shows
poor differention into normal
cell type
Fap(multlple aoenomatous polyps ln a patlent ot Fap(multlple aoenomatous polyps ln a patlent ot
25 yrs). 25 yrs).
Mlcroscoplc vlew ot aoenomatous Mlcroscoplc vlew ot aoenomatous
polyp polyp
olonoscoplc vlew ot aoenomatous olonoscoplc vlew ot aoenomatous
polyp polyp
$ymptomatic: $ymptomatic:- -
(pts who have (pts who have
new mutation or a new mutation or a
member of an member of an
affected family affected family
not screened not screened
before) before)
Asymtomatic: Asymtomatic:- -
(usually member of an affected are (usually member of an affected are
screened) screened)
f no adenoma by age 30,fap is f no adenoma by age 30,fap is
unlikely. unlikely.
1.loose stool 1.loose stool
2.lower 2.lower
abdominal pain abdominal pain
3.diarrhoea 3.diarrhoea
4.Passage of 4.Passage of
blood & mucous blood & mucous
.wt loss .wt loss
1.Pigmented spots in 1.Pigmented spots in
retina.Congeital retina.Congeital hypertrophy of hypertrophy of
retinal pigment epithelium is present retinal pigment epithelium is present
as early as 3 months of age in as early as 3 months of age in
affected members of 2/3 rd of affected members of 2/3 rd of
families with FAP.(always families with FAP.(always
bilateral.more bilateral.more than 4 lesions on each than 4 lesions on each
side predict FAP with 97% sensitivity) side predict FAP with 97% sensitivity)
Ltracolonlc Ltracolonlc manltestatlon ot manltestatlon ot FAP FAP
benign benign
malignant malignant
1) 1) Gastric Gastric fundic fundic polyp polyp
2) 2) Duodenal adenoma Duodenal adenoma
3) 3) $mall bowel $mall bowel
adenoma adenoma
4) 4) Epidermoid Epidermoid cyst cyst
) ) Hypertrophic retinal Hypertrophic retinal
pigmentation pigmentation
6) 6) Endocrine adenoma Endocrine adenoma
1) 1) Gastric ca Gastric ca
2) 2) Duodenal carcinoma Duodenal carcinoma
3) 3) bile duct ca bile duct ca
4) 4) pancreatic pancreatic ca ca
) ) $mall bowel ca $mall bowel ca
6) 6) carcinoid carcinoid tumor of ileum tumor of ileum
7) 7) hepatoblastoma hepatoblastoma
8) 8) desmoid desmoid tumour tumour
9) 9) adrenal ca adrenal ca
10) 10) Medulloblastoma Medulloblastoma
11) 11) glioblastoma glioblastoma//
12) 12) thyroid ca thyroid ca
13) 13) osteogenic osteogenic sarcoma sarcoma
lnvestlgatlons lnvestlgatlons
1. slgmolooscopy
2. coloscoplc blopsy
to establlsb tbe number
to establlsb tbe blstologlcal types
lt more tban 100 aoenomas- olagnosls maoe contloently
3. once polyposls ls olagnoseo,upper glt enooscopy ls aovlseo
to look tor gastroouooenal leslons.
Screenlng pollcy Screenlng pollcy
1 all members ot tbe tamlly sboulo be eamlneo at tbe age ot 10-12 yrs
repeated every 1-2 yrs
2 most ot tbose wbo are golng to get polyp wlll bave tbem at age 20 &
tbese requlre operatlons.
3 lt tbere are no polyp at 20,contlnue 5 yearIy exaninations untll
age 50 yrs. |t tbere are stlll no polyps tbere ls probably no lnberlteo
gene
arclnomatous cbange may eceptlonally occur betore age ot 20.
Lamlnatlon ot blooo relatlves,cousln,nepbew,nlece are essentlal
treatment treatment
O 1. restoratlve proctocolectomy
wltb lleoanal poucb(most
commonly tor majorlty ot pts)
Aovantage:
1. |t ls oone ln pts wltb numerous
aoenomas ln rectum
2. Rlsks ot subsequent rectal
neoplasla ls essentlally nll
3. For pts llkely to be poor ln
attenolng tbe cllnlc
4. Done also ln pts wltb
establlsbeo cancer ot rectum &
slgmolo colon
Disadvantages:-
1. More complications
2. mpotency in young pts
R R conto conto
2.colectomy wltb lleorectal
anastomosls:-
Aovantages:-
1. Avolo permanent lleostomy
ln young pts .
2. Avolo rlsk ot pelvlc
olssectlon to nerve tunctlon
Neeo eamlnatlon &
oestructlon ot subsequent
oevelopment ot polyp by
snare or tulgaratlon
Follow up:-
1. Examination by flexible
sigmoidoscopy at 6 monthly
intervals is essential
A proportion of pts develop
ca in rectal stump, but
incidence is very rare
Prophylactic colectomy does
not alter the extra colonic
manifestations
2. Medical treatment after
surgery:- sulindac is used
3 synoromes ot juvenlle
polyposls bave been
oetlneo:-
1) [uvenlle polyposls coll
2) Generalzeo juvenlle
gastrolntestlnal
polyposls
3) runkblte canaoa
synorome
Garoner's synorome(oos)
Autosomal oomlnant
1) Polyposls(FAP)
2) Desmolo tumor
3) Osteomas pt manolble
or skull
4) Sebaclous cyst
5) Ltra colonlc
neoplasm occurs ln
skln,sebaclous
cyst,bone
%urcot's syndrome:-
Autosomal recessive
1. FAP
2. Medulloblastoma
3. glioma
OLON| ANLR OLON| ANLR
O General consloeratlons:-
1.age-peak lncloence 60-70yrs.lt ln young persons pre-
elstlng ulceratlve colltls or FAP to be suspecteo.
2.se:-ca rectum more common ln man
ca-rlgbt colon more common ln woman
3.race:-blgb lncloence ln attluent countrles llke
usa,canaoa,australla,sweoen.
low ln japan,soutb amerlca & atrlca
4.|ncloence 0.39/1000/year at 50 yrs
conto conto
Predisposing condition Predisposing condition Precancerous condn Precancerous condn
A high fat content(as from A high fat content(as from
meat) meat)
A low content of non A low content of non- -
absorbable vegetable absorbable vegetable
fibre fibre
A corresponding high A corresponding high
content of refined content of refined
carbohydrate carbohydrate
A decreased intake of A decreased intake of
protective micronutrients protective micronutrients
Ulcertive Ulcertive colitis colitis
Crohn's Crohn's disease disease
F.A.P F.A.P
Hereditary site specific colon Hereditary site specific colon
cancer( cancer(hsscc,lynch hsscc,lynch syndrome syndrome i i) )
Cancer family Cancer family
syndrome( syndrome(CF$,lynch CF$,lynch sydrome sydrome
ii) ii)
Colorectal polyp Colorectal polyp
ureterocolostomy ureterocolostomy
conto conto
Predisposing Predisposing condtn condtn Precancerous condn Precancerous condn
$moking $moking
High saturated fat intake High saturated fat intake
High intake of High intake of calory calory
Low dietary calcium Low dietary calcium
$chistosomal $chistosomal colitis colitis
Radiation colitis Radiation colitis
$uspected condition: $uspected condition:- -
Gastric surgery for Gastric surgery for
ulcer/ ulcer/cholecystectomy cholecystectomy//
barret barret esophagus/breast esophagus/breast
cancer cancer
Mecbanlsm: Mecbanlsm:- -
Reouceo tlbre content:-
1) sLool bulk
2) faecal LranslL Llme ln Lhe
bowel alLered bacLerlal
flora ln Lhe lnLesLlne
oLenLlally Loxlc blproducL of
CPC degradaLlon by bacLerla
are Lherefore presenL ln
hlgher concenLraLlon ln Lhe
small sLool are held ln
conLacL wlLh colonlc mucosa
for longer perlods of Llme
uleLary faL
Lnhances cholesLerol and blle
acld synLhesls by Lhe llver
Lhe amounL of Lhese sLerol
lncrease ln colonanaeroblc
bacLerla converL Lhese
compound Lo 2ndary blle acld
whlch are promoLer of
carclnogenesls
O |ngesteo calclum attects
colonlc epltbellal cell
prollteratlon toplcally &
by absorptlon lnto tbe
blooo stream
conto conto
O Syncbronous colonlc
cancer:-2 or more
carclnomas occurlng
slmultaneously-touno ln
5 ot pts
O Metacbronous cancer:-ls
a new prlmary leslon ln
a pt wbo bas bao a
prevlous resectlon tor
cancer- touno ln 2 ot
pts
Dlstrlbutlon Dlstrlbutlon
site site Frequency % Frequency %
Rectum Rectum
$igmoid colon $igmoid colon
Decending Decending colon colon
$plenic $plenic flexure flexure
%ransverse colon %ransverse colon
Hepatic flexure Hepatic flexure
Ascending colon Ascending colon
Caecum Caecum
appendix appendix
anus anus
38 38
21 21
4 4
3 3
. .
2 2

12 12
0. 0.
2 2
Otber varletles ot colon cancer: Otber varletles ot colon cancer:- -
Apart trom FAP, tbere are otber
groups ot pts wbo bave
bereoltary preolsposltlon to
oevelop large bowel cancer.
Tbere are 2 types ot autosomal
oomlnant :bereoltary non-
polyposls colorectal
cancer(HNP)
1. FS(lyncb synorome ||):early
onset/20-30 yrs/prolmal
oomlnance/assoclateo wltb
etracolonlc aoeno-ca. especlally
enoometrlal ca & breast
ca/syncbronous & metacbronous
tumor.
2.H$$CC(lynch syndrome
)(hereditary site specific colonic
cancer):-
same characteristics as CF$
except for the extracolonic
carcinomas
Macroscoplc varlety ot colonlc Macroscoplc varlety ot colonlc tumour tumour
1.annular(glve obstructlve synorome wltbln tbe
colonlc lumen)
2.tubular
3.ulceratlve(commonly lnvolve walls)
4.caulltlower(least mallgnant)
95 ot mallgnant tumour ot colon & rectum are
aoenocarclnoma
%he four common
macroscopic varieties of
carcinoma
of the colon( in
clockwise):-
(1)Annular;
(2)tubular;
(3) ulcer;
(4) cauliflower.
(3) (4)
(2)
(1)
Rt Rt colon cancer colon cancer
1. rlgbt colon bas large
callber
2.a tbln olstenslble wall
3.taecal content ls tlulo.
so cancer ot rlgbt colon may
attaln a large slze betore lt
ls olagnoseo
Uneplalneo mlcrocytlc
anemla- leaolng to
tatlgablllty & weakness ralse
tbe susplclon ot ca-rlgbt
colon
Lett colon cancer Lett colon cancer
1. Smaller lumen
2. Faeces are sollo &
seml llqulo
Tumor graoually occluoe
tbe colon. So teatures
ot obstructlon/cbange
ot bowel bablt are maln
teature
Spreao ot ca colon Spreao ot ca colon
|t ls comparatlvely slowly growlng neoplasm
1. local spreao(olrect etenslon)
2.lympbatlc spreao
3.blooo stream spreao
4.transperlteal
5.lntralumlnal spreao
Local spreao Local spreao
3 mooes ot spreao:-
A.lrcumterentlally
8.Longltuolnal submucosal
etenslon
.Raolal etenslon
lrcumterentlal etenslon-
may enclrcle bowel betore lt
ls olagnoseo
6montb to cover 1/4 tb ot
clrcumterence
18-24montb to cover
complete clrcumterence
conto conto
Longltuolnal etenslon:-
Rarely goes beyono 2cm tbe eoge ot tbe tumour unless tbere
ls concomltent spreao to lympb nooes
Raolal etenslon:-
As lt grows lt penetrate outer layers & lt may eteno by
congrulty lnto nelgbbourlng structures llke-llver/greater
curvature/oouoenum/small
bowel/pancreas/spleen/u.blaooer/vaglna/kloney/ureter/aboo
mlnal wall
conto conto
O a-rectum:- may lnvaoe vaglnal wall/u.blaooer/prostate /sacrum
Ulceratlve varlety more commonly lnvaoe locally & an lnternal tlstula
may result
Tbere may be local pertoratlon wltb abscess or an eternal taecal tlstula
may torm
LYMPHAT| SPRLAD,-
Most common torm ot spreao
Spreao to nooes ln tbe vlclnlty ot bowel wall, to reglonal nooes , to
mesenterlc nooes & para aortlc nooes
conto conto
O 8looo stream spreao:-
Accounts tor large proportlon ot late oeatb.
Tumour may lnvaoe tbe colonlc veln- carrleo by portal veln
to llver & sometlme causlng occult bepatlc metastasls
Tumour embollzatlon can occur tbrougb lumber & vertebral
vessel- to lungs & else wbere
Rectal cancer spreao vla bypogastrlc veln
Transperltoneal Transperltoneal spreao: spreao:- -
O Wben tumour eteno tbrougb serosa tumour cells
enter perltoneal cavlty proouclng:-
Local lmplant
Generallzeo aboomlnal carclnomatosls
Large metastatlc oeposlts ln pelvlc cul oe-sac are
palpable as baro sbelt.
|ntralumlnal |ntralumlnal spreao spreao
O Sbeo trom surtace ot tumor-swept along tbe tecal
current , lmplantatlon more olstally ln lntact mucosa
occur rarely
llnlcal consloeratlon llnlcal consloeratlon
O Aoenocarclnoma bas a meolan ooubllng tlme (tbe
tlme requlreo tor tbe tumor to oouble ln volume)
ot ---130oays
O Suggestlng at least 5yrs-otten 10-15yrs ot sllent
growtb ls requlreo betore a cancer reacbes
symptoms proouclng slze
Lssentlals ot olagnosls Lssentlals ot olagnosls
Right colon Right colon Left colon Left colon
Unexplained weakness Unexplained weakness
'' '' anemia '' '' anemia
Occult blood loss in faece Occult blood loss in faece
Dyspeptic symptoms Dyspeptic symptoms
Persistent abd. Discomfort Persistent abd. Discomfort
Palpable abd. Mass Palpable abd. Mass
Characteristic x Characteristic x- -ray & ray &
coloscopic findings coloscopic findings
Change in bowel habits Change in bowel habits
Loss of blood in stool Loss of blood in stool
Obstructive symptoms & Obstructive symptoms &
%enesmus %enesmus
Characteristic x Characteristic x- -ray & ray &
colonoscopic colonoscopic or or sigmoidoscopic sigmoidoscopic
finding finding
conto conto
Ca Ca- - caecum caecum Ca Ca- -tranverse colon tranverse colon
- -Mass in R..F Mass in R..F
- -Acute Acute
appendicitis(obstruction of appendicitis(obstruction of
lumen of appendix causing lumen of appendix causing
inflammation & gangrene) inflammation & gangrene)
- -Appendicular Appendicular
abscess(failure to resolve abscess(failure to resolve
app) app)
- -ntussusception ntussusception
- -%umour %umour in in epigastrium epigastrium( (mis mis
taken as ca taken as ca- - stomach) stomach)
Anaemia Anaemia & lassitude & lassitude
Ca Ca- -sigmoid colon sigmoid colon Ca Ca- -rectum rectum
$ome features of left $ome features of left
colon with colon with
Pain Pain- -colicky from the colicky from the
start start
%enesmus %enesmus- -
occassionally occassionally
accompanied by accompanied by
passage of mucous passage of mucous
&blood esp. in early &blood esp. in early
morning morning
Bladder symptoms Bladder symptoms
&some cases s/s of &some cases s/s of
colovesical fistula colovesical fistula
Rectal bleeding Rectal bleeding
$ensation of incomplete $ensation of incomplete
evacuation evacuation
ntrarectal ntrarectal palpable tumor palpable tumor
$igmoidoscopic $igmoidoscopic finding finding
Metastatlc olsease Metastatlc olsease
O [aunolce
O Ascltls
O Hepatomegaly
O Otber s/s trom rarer sltes ot metastasls
Macroscoplc vlew ot colon cancer Macroscoplc vlew ot colon cancer
conto conto
olonoscoplc vlew ot colonlc ca olonoscoplc vlew ot colonlc ca
lnvestlgatlons lnvestlgatlons
1) bc,U & L, Ltts, s.a ,serum
proteln & calclum
2) Urlne analysls
3) r
4) Ar
5) Double contrast enema ls
useo routlnely:-
|t sbows cancer ot colon e a
constant lrregular tllllng
oetect
|t ls also tbe lnvestn ot cbolce
ln pt ln wbom preoomlnant
cbange ln bowel bablt ls tbe
tbe presentlng symptom
lnvestn lnvestn
t aboomen:-
ls belptul ln assessment ln
etralumlnal etenslon ln rectal
cancer
Proctoslgmolooscopy:- pts prepareo
wltb a olsposable enema.seoatlon ls
not usually necessary
50-60 ca are eln reacb ot tlelble
slgmolooscope(60cm).20 ca seen
by rlglo slgmolooscope
Typlcal cancer ls:-
Ralseo,reo,centrally ulcerateo,bleeolng
sllgbtly,moblllty ot tumor can be
oetermlneo by manlpulatlon e tbe
tlp ot tbe lnstrument
Tumour slze sboulo be noteo,blopsy
to be taken,lnstrument passeo
beyono tbe tumor to cbeck tbe
prolmal bowel lt posslble
Colonoscopy:-
t is done in every case if there
is intension for curative
treatment:-
1. %o inspect synchronous
lesion
2. for biopsy
3. ultrasonography also can be
performed through colonoscopy
|nvestn |nvestn conto conto
O LA(carclnoembryonlc antlgen):-
Serum level ot cea ls olrectly relateo to
tbe slze ot tbe prlmary tumour
&lts etent ot spreao
O |n early leslon:LA ls +ve ln 19-40
|n large metastatlc leslon,+ve ln 100 cases
O |t tumor ls removeo :-LA level orops & olsappear
O Return ot LA posltlvlty ls blgbly rellable lnolcator ot recurrence ot tbe prlmary
neoplasm
O LA ls also +ve :-ln mallgnacncy
ca lung/ca breast/ca-ovary/prostatlc cancer/u.blaooer tumor/ca pancreas/ca-
stomacb.
|n non mallgnant conoltlon llke alcobollc clrrbosls/pancreatltls/ulceratlve colltls
Staglng ot colon cancer(ouke Staglng ot colon cancer(ouke astler astler- -coller coller
staglng) staglng)
stagin stagin
g g
criteria criteria yrs survival yrs survival
AA
BB- -1 1
BB- -2 2
C C- -1 1
C C- -2 2
D D
Limited to mucosa Limited to mucosa
nto nto muscularis muscularis propria propria
%hrough %hrough muscularis muscularis propria propria
nto nto muscularis muscularis propria+nodes propria+nodes
%hrough %hrough muscularis muscularis propria propria
+nodes +nodes
Distant metastasis Distant metastasis
More than 90 More than 90
70 70- -8 8
- -6 6
4 4- -
20 20- -30 30
Less than1 Less than1
O :es CIassification
O W Developeo by utbbert Duke ln 1932 tor rectal
cancers
O o Stage A - Tumour contlneo to tbe mucosa
O o Stage 8 - Tumour lntlltratlng tbrougb muscle
O o Stage - Lympb nooe metastases present
O W Flve year survlval - 90, 70 ano 30 tor Stages
A, 8 ano respectlvely
Dukes staglng ot colorectal cancer Dukes staglng ot colorectal cancer
Dltterentlal olagnosls: Dltterentlal olagnosls:- -
1) Dlvertlcllltls
2) a-stomacb
3) Appenolcular mass
4) Ulceratlve colltls
5) robn's colltls
6) |sbaemlc colltls
7) Haemorrbolo
8) Amoeblasls
9) Prlmary baematologlc olsoroer tor anaemla
10) Peptlc ulcer
11) Gb- stone
Treatment ot ca Treatment ot ca- -colon colon
Prlnclples ot management,-
O 1. assessment ot local &olstant tumour spreao sboulo be pertormeo
botb preoperatlvely & lntraoperatlvely to allow plannlng ot surgery
O 2.syncbronous tumour occur ln about 5 ot patlents & sboulo be
ecluoe preoperatlvely
O 3.operatlons are planneo to remove tbe prlmary tumour & lts
oralnlng locoreglonal lympb nooes
O 4.blstologlcal eamlnatlon ot resecteo tumours contrlbute to
oeclslon maklng regarolng tbe neeo tor aojuvent tberapby
Preoperatlve preparatlon Preoperatlve preparatlon
O Most commonly useo metboos:-
O Dletary restrlctlon to tlulo only tor 48 brs betore surgery
O 2 saccbets ot plcola(Na-plcosulpbate) are taken to purge tbe colon
on tbe oay betore operatlon & wltb rectal wasb out by enema
Alternatlvely,-
Prograoe lavage vla a nasogastrlc tube uslng water or balaceo
electrolytesolutlons.
Wben lntestlnal obstructlon present:
On table lavage tecnlque can be useo
Test ot operablllty Test ot operablllty
O 1.llver ls palpateo tor seconoary oeposlt
O 2.perltoneum: pelvlc perltoneum ls cbeckeo tor slgns ot small/wblte
seeo llke neoplastlc lmplantatlon. Slmllar cbange can occur ln tbe
omentum
O 3.groups ot lympb nooes tbat oraln tbe lnvolveo segment are palpateo
Lnlargeo lympb nooes may be oue to metastasls ln L.nooes or
reactlve byperplasla(lntlammatory reactlon)
4.Tbe neoplasm,- ls eamlneo tor moblllty &operablllty.
Local tlatlon ooes not always mean local lnvaslon because some tumor
eclte a brlsk lntlammatory response
Operatlons tor ca Operatlons tor ca- -colon colon
For electlve proceoure:-
O 1.caecum & rlgbt colon: rlgbt bemlcolectomy
O 2.transverse colon:etenoeo rlgbt bemlcolectomy
O 3.oecenolng colon:-lett bemlcolectomy
O 4.slgmolo colon: slgmolo colectomy
O 5.rectoslgmolo & upper rectum:anterlor resectlon wltb prlmary anastomosls
O 6.lower rectum:-aboomlnoperlneal eclslon ot ot tbe rectum sboulo be carrleo out
wltb a permanent colostomy
For any operatlon on lett sloe ot colon, tbe pt sboulo be warneo about a temporary
oetuntlonlng loop lleostomy untll tbe prlmary anastomosls bas bealeo
Operatlon Operatlon
O Lmergency operatlon tor colorectal cancer:-
|n conoltllon ot acute large gut obstructlon/pertoratlon wltb perltonotls/closeo loop
obstructlon e caecal olameter more tban 10cm on AXR
1.Flrst correct tlulo & electrolyte balance
2.For rlgbt sloeo tumorrlgbt bemlcolectomy wltb prlmary anastomosls ls tbe cbolce
3.Lower lett sloeo tumour---resectlon ot tbe tumor & bartmann's proceoure(closure
ot tbe rectal stump &tasblonlng ot an L|F eno lleostomy).contlnulty ot ot tbe bowel
ls reestabllsbeo some weeks later
Some surgeons carry out an on table colonlc lavage wltb resectlon ot tbe tumor
wltbprlmary anastomosls covereo by a loop lleostomy
Palllatlve proceoure ln ca Palllatlve proceoure ln ca - -colon colon
95 ot colonlc carclnomas are usually resectable.
For unresectable rectal cancer:-tbe tollowlng proceoure coulo be aoopteo
O Fulgaratlon(electrocoagulatlon)
O Laser pbotocoagulatlon
O Dlvertlng colostomy
O Hartmann proceoure
O Transverse colostomy
O Pelvlc colostomy
For ca- ascenolng colon:-
|leocollc anastomosls ls usually oone
Follow up Follow up
O Recurrence ls usually wltbln 2 yrs tollowlng curatlve
resectlon
1.Routlne pbyslcal eamlnatlon & LFTs tor every 3 montbs
tor 2yrs tben 6 montbly tor 2yrs tben yearly
2.XR 6 montbly tor 3 yrs net annually
3.LA every 2 montb tor 2 yrs ,tben every 4 montb tor 2 yrs
tben annually
4.olonoscopy every 2-3 montb tor 2 yrs tben annually tor 4
yrs, net every 2-3 yrs lnterval
Recurrent colorectal cancer Recurrent colorectal cancer
O Most colorectal cancer become cllnlcally recurrent by 3 year.
O Sltes :-
Local/llver/lung/braln
O Symptoms :-are usually not ot colon.wt loss/lassltuoe/low general bealtb/local
paln/cbest paln
O Slgns:-
bepatomegaly
lump ln aboomlnal wall or slte ot colonlc anastomosls,post vaglnal wall,base ot
U.blaooer,back ot prostate,sacrum
Ascltls
8etore operatlon searcb tor metastatlc lmplant ln cbest/braln/llver
|nvestn:- T.MR|,LA level,USG,8A-enema
R ot recurrent tumor R ot recurrent tumor
O 1. eclslon ot tumor lt posslble
O 2. tor bone paln-raolotberapby/local nerve block e
pbenol
O 3.cbemotberapby unoer trlal