Approach to colorectal cancer
- 1. Approach to Colorectal Cancer & a bit about stomas Dr Elizabeth Brown Elizabeth.brown25@nhs.net
- 2. Clinical Presentation • Change in bowel habit – – – – Loose stool Frequent stool Rectal bleeding Tenesmus • Rectal/abdominal mass • Iron deficiency anaemia • Screening • Complications – Bowel Obstruction – Perforation • Secondaries – Liver metastases – jaundice, ascites, hepatomegal y • General effects of cancer (likely metastases) – Anaemia – Anorexia – Weight loss
- 3. Tumours disobey the rules, but generally… Left Colon Rectal Bleeding Change in bowel habit More present with obstruction Right Colon Anaemia Mass Pain Usually no change in bowel habit Less present with obstruction Rectal Tumours Tenesmus ‘Wet wind’ Rectal Bleeding
- 4. Risk factors for Colorectal Cancer • • • • Increasing age Colorectal polyps Inflammatory bowel disease – UC FHx – FAP – HNPCC – Any first degree relative • • • • Obesity Diet Smoking Acromegaly
- 5. Factors that may lower risk of Colorectal Cancer • Diet rich in vegetables, garlic, milk, calcium • Exercise • Low dose aspirin & NSAIDS
- 6. Examination • General signs – Anaemia – Evidence of weight loss • Abdomen – Evidence of obstruction – Palpable mass • Digital rectal examination – Rectal bleeding – Palpable mass in rectum/pouch of Douglas • Evidence of spread – – – – Hepatomegaly Jaundice Ascites Supraclavicular lymphadenopathy
- 7. GP referrals for suspected LGI Cancer: • When are you going to make an urgent referral? – Symptoms suggestive of LGI cancer – Age ≥40yrs with rectal bleeding + change in bowel habit for ≥ 6 weeks – Age ≥60yrs with rectal bleeding without change in bowel habit or anal symptoms for ≥ 6 weeks – Age ≥60yrs with change in bowel habit for ≥ 6 weeks – Any patient with RIF mass – Any patient with rectal mass – Iron deficiency anaemia <11 Males & <10 Females
- 8. • In borderline patients what important points in the history might sway you to refer urgently? – Particularly if Hx of Ulcerative Colitis or if FHx • What test can the GP do that will be useful to the Colorectal specialist? – Full Blood Count
- 9. Investigations • Gold standard = • Visualise tumour • Take biopsies • Alternatives: – Flexible sigmoidoscopy - & biopsies – Double contrast barium enema – CT colonography
- 10. Staging Investigations • CT with contrast – Chest, Abdomen & Pelvis – Probably the only staging investigation required • If another suspicious lesion found on CT, perhaps follow up with PET scan • Liver mets best investigated by MRI • If early rectal tumour (T1/T2) – endorectal USS (EUS)
- 11. Screening • General population – Faecal occult blood test (FOB) – Age 60-73yrs – 6 test cards every 2 years for FOB – If FOB +ve… • →Colonoscopy • High risk groups (strong FHx or UC) – Colonoscopy used for screening, not FOB
- 12. What is the role of serum CEA? • Not for diagnosis of colorectal Ca • Not for screening • Useful for follow up – if CEA ↑ suggests recurrence How do we follow up patients postcolorectal cancer? • Surveillance Colonoscopies
- 13. Dukes’ Classification - A – Tumour confined to mucosa & submucosa - >90% 5 year survival - B – Invasion of muscle wall - ~65% 5 year survival - C – Regional Lymph Nodes involved - ~30% 5 year survival - D – Distant spread e.g. liver, bladder
- 14. Spread of colorectal cancer • Local – Bladder & ureters • – Small bowel & stomach – Uterus/vagina or • prostate – Abdominal/Pelvic wall • Lymphatics – Mesenteric LNs – Groin LNs (rectal CA) – Supraclavicular LNs Blood – Portal vein → Liver – Lungs Transcoelomic – Peritoneal seedings
- 15. Surgery for bowel cancer • Principles: – Ideally empty bowel • Enemas & laxatives – Remove the tumour • Wide resection of growth – Lymphadenectomy • Regional LNs – Neo-adjuvant chemotherapy • Rectal Ca T1 or T2 only • Not colonic tumours • Aim to downsize tumour before surgery
- 16. Surgery for Colorectal Cancer Ascending colon tumour → Right Hemicolectomy
- 17. Surgery for Colorectal Cancer Transverse Colon Tumour → Transverse colectomy
- 18. Surgery for Colorectal Cancer Descending colon tumour → Left Hemicolectomy
- 19. Surgery for Colorectal Cancer Sigmoid Tumour → Sigmoid colectomy
- 20. Surgery for Colorectal Cancer Rectal Tumour → Abdominoperoneal (AP) resection
- 21. Synchronous Colon Cancers • 2 separate resections • Or subtotal colectomy:
- 22. Primary anastomosis • Primary anastomosis – If minimal contamination – Healthy tissue quality – Clinically stable
- 23. Anastomotic breakdown/Anastomotic leak: • High morbidity & mortality – – – – – – – – Can be subtle or obvious Fever Oliguria Ileus Raised WCC & CRP Peritonitis Drain/wound – enteric contents Usually non-specific examination unless peritonitic • NEEDS URGENT CT ABDOMEN & PELVIS • Small abscess/localised collection – CT guided drainage with broad spectrum antibiotics • IF GENERALISED PERITONITIS: NEEDS LAPAROTOMY
- 24. Stomas • Temporary stoma – Primary resection with proximal diversion – To decompress dilated colon before resection of obstructing lesion – Free perforation with peritonitis – Faecal contamination (unprepared bowel) – Poor nutrition – low albumin – For reversal procedure in future with anastomosis • Permanent stoma – AP resections – Ileostomy after subtotal colectomy (although ileorectal anastomosis is an option)
- 25. • A stoma is… – …surgically created communication between a hollow viscus and the skin or external environment – Ileostomies, Colostomies, Urostomies, technically a tracheostomy…
- 26. Colostomy • Usually left-sided • Bag contains more solid stool • Flush to skin
- 27. Ileostomy • Usually right-sided • Bag contains liquid stool • Spouted from skin – To protect against pancreatic enzyme secretions
- 28. Loop Ileostomy • 2 openings when examine stoma • Ileum brought to surface & antimesenteric boder opened • Rod is used to stop the opened bowel loop falling back inside • Simple to reverse so used for temporary diversion • Loop ileostomies preferable to loop colostomies as better blood supply
- 29. Early complications of stomas • Bleeding – unlikely to have large bleed – some blood in stoma bag acceptable • Ischaemia & necrosis – Dusky stoma colour – Needs resiting • Retraction – Risk of faecal peritonitis – Back to theatre • Obstruction – Due to oedema or hard stool – Examine stoma with gloves • High output ileostomy – Severe dehydration – Electrolyte disturbances • Parastomal dermatitis – Leaking ileostomy
- 30. Late complications of stomas • Parastomal hernia – Stoma/bowel obstruction – Strangulation – Stoma may need resiting • • • • • Prolapse Stenosis of stomal orifice Stomal diarrhoea Psychological problems Underlying disease e.g. Crohn’s peristomal fistulae
Editor's Notes
- #4: Tenesmus = sensation of incomplete emptyingWet wind – passing wind & mucus
- #7: Sigmoid tumour may prolapse down into the rectovaginal pouch so can palpate mass anteriorly on DRE
- #8: Urgent referrals by GP…2 week wait to local colorectal servicesChange in bowel habit = change to looser stools or more frequent stoolshttp://guidance.nice.org.uk/CG27/NICEGuidance/pdf/English
- #10: Colonoscopy is TOO MUCH for some patients to cope withIf comorbities prevent then patient should have flexible sigmoidoscopy followed by a barium enema.Ct colonography depending on local servicesAlternative investigations if comorbidities prevent colonoscopy
- #15: SupraclavicularLNs via thoracic duct
- #18: Cancer research uk – colorectal cancer – surgical resections = good diagrams
- #23: crucial for the prevention of mortality.1,3,4,5,6,7 The signs and symptoms can be subtle or obvious and include the presence of fever, oliguria, ileus, diarrhea, leukocytosis, and peritonitis. Once suspicion is raised, if the anastomosis is in the low pelvis, one can consider a digital rectal examination with the intent of feeling any defect or a mass. Otherwise, physical examination is generally nonspecific except in the setting of enteric contents draining from the wound or a drain. Water-soluble contrast enema, traditionally the first test used to evaluate a higher anastomosis, has been largely supplanted by a computed tomographic (CT) scan. A CT scan of the abdomen and pelvis can be done with intravenous, oral, or rectal contrast material and is particularly useful if a concomitant abscess is suspected. This can be not only diagnostic but also therapeutic, as if an abscess is found, it can often be drained percutaneously.
- #25: No nerve endings, patients must be careful not to injure it as won’t be able to feel the damageWhen perforation of uninvolved colon proximal to an obstructing tumor has occurred, whenever possible, resection of the tumor following the oncological principles outlined above should be performed in addition to resection of the perforated segment. In most instances, an ostomy will provide effective fecal diversion and allow for patient recovery until the acute peritonitis has resolved. If the perforation occurs at the site of the tumor but is contained by adjacent structures, resection should ideally incorporate the adjacent structures en bloc. In cases of free perforation with peritonitis, the involved segment should be resected and proximal fecal diversion constructed. A primary anastomosis (with/without proximal diversion) may be considered in selected patients with minimal contamination, healthy tissue quality, and clinical stability.ObstructionThe management of patients with an obstructing cancer should be individualized but may include a definitive surgical resection with primary anastomosis. Grade of Recommendation: 1BOptions for the treatment of obstructing tumors depend on the site of obstruction and the presence of proximal colonic distention with fecal load. Options for treatment may include resection with or without anastomosis (e.g., Hartmann resection), resection of the distended bowel (e.g., subtotal/total colectomy), or temporary relief of obstruction and fecal load (e.g., preoperative stenting as a bridge to resection).