Transcript MR Staging of Rectal Cancer

Surgery for Inflammatory Bowel disease
E .Condon
Beaumont Hospital/ RCSI, Dublin.
Colorectal Department
Colorectal Surgery Department
Overview
Types
1. Diverticular disease
2. Ulcerative colitis
3. Crohns Disease
4. Ischemic colitis
5. Amoebiasis
6. Pseudomembranous colitis
7. Radiation enterocolitis
Colorectal Surgery Department
Diverticular disease
• Definition ; Herniation of bowel mucosa through the
bowel wall (Blood vessels)
• Sites sigmoid and descending colon
• Raised intraluminal pressure
• Segmental contraction
• 30% of all patients over 60 in the western world
Colorectal Surgery Department
Presentations
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Acute diverticulitis
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Chronic diverticulitis
Complications of diverticulitis
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Obstruction
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Abscess formation
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Diffuse peritonitis
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Fistula
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Haemorrhage
Colorectal Surgery Department
Diagnosis
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Bloods
CT
Barium
Colonoscopy
Colorectal Surgery Department
Indications for surgery
• Acute diverticulitis- all complications except abscess
• Chronic diverticulitis – Persistent Pain /anemia
• 2 episodes of mild diveriticulitis
Colorectal Surgery Department
Surgical options
• Laparoscopy
• Sigmoid colectomy
• Hartmans
• Anterior resection
• Transverse colostomy and peritoneal toilet
Colorectal Surgery Department
Operating theatre
Colorectal Surgery Department
Best operation to Do??
• Sigmoid colectomy
• Anterior resection
• Hartmans
Colorectal Surgery Department
Ulcerative colitis
• Definition; disease of unknown cause charecterised by
non specific and diffuse inflammatory changes of the
mucosa of the rectum and the large bowel
• Causes
• Infection
• Allergy
• Autoimmunity
Colorectal Surgery Department
UC
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Disease is mucosal
Serosa – no serositis
Segment usually descending colon
Mucosa reddened friable
Pseudopolyps
Microscopic – inflammatory cellular infiltration of
mucosa and the submucosa crypt abscesses dysplasia
transmural inflammation
Colorectal Surgery Department
Symptoms
• Bloody diarrhoea
• Abdominal discomfort
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Diagnosis – colonoscopy barium enema
Treatment
Steroids local systemic
NSAIDS
Bowel rest
Colorectal Surgery Department
Indications for surgery
• Relative indications
– Chronic invalidisim- severe colitis few years chronic ill
health anemia
– Relapsing colitis 2 severe episodes in 3years
– Persistent steroids – the complications of roids
• Absolute indications
– Failure of medical therapy in acute severe attack
– Perforation
– Toxic megacolon
Colorectal Surgery Department
Operating theatre
Colorectal Surgery Department
Surgical Options
• 1. ileostomy
• 2.Proctocolectomy- permanent ileosotmy
• 3.Total colectomy- later ileorectal anastomosis
• 4.Pouch 2 stage / 3 stage
• 5. Total colectomy with ileostomy
Colorectal Surgery Department
Best Surgery
• Pouch 3 stage
• Proctocolectomy- permanent
ileostomy
Colorectal Surgery Department
Pouchs
• J Pouchs
• Advantages no stoma / continence
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Complications
Infertility
Pouchitis
Pouch failure 10 years 18 %
crohns
Colorectal Surgery Department
Crohns
• Definition ; regional enteritis granulomatous
entercolitis
• Unknown cause ( toothpaste)
• Characterised by discontinuous full thickness
inflammation anywhere in the GI tract
• Common sites ileocaecal skip lesions in the ileum and
perianal suppuration
Colorectal Surgery Department
Crohns
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Key histological differences
Granulomas
Fibrosis
Full thickness
Fistulas
Colorectal Surgery Department
Presentation
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Usually regional ileitis
Like appendicitis
Mass RIF
Diarrhoea
Obstruction
Perforation
Fistula
Perianal Crohns
Anemia
Colorectal Surgery Department
Indication for Surgery
• Surgery nearly always treatment of choice 80-90% of
cases ultimately require surgery
• Perianal disease and fistulas
Colorectal Surgery Department
Operating theatre
Colorectal Surgery Department
Surgical options
• Regional ileitis
– Ileal resection primary reanastomosis
– Right Hemicolectomy
• Colonic crohns
– Panproctocolectomy and permanent ileostomy
– Perianal crohns fistulotomy
Colorectal Surgery Department
Colorectal Surgery Department
Colorectal Surgery Department
Colorectal Surgery Department
Ischemic colitis
• Inflammatory response in the colon following an
ischemic episodeowing to occlusion or narrowing of
the inferior mesenteric artery
• Causes
atheroma
embolism
surgery/ trauma
Severity depends on the duration and the patency of the
marginal arteryColorectal Surgery Department
Presentations
• 2 phases
– Mucosal gangrene
– Secondary invasion with organisims which accelerate the
gangerenous process
• Ischemic colitis with gangerene
• Transient ischemic colitis
• Stricture
Colorectal Surgery Department
Surgical options
• Transient ischemic colitis –mesenteric angiogram
stenting of affected segment – primary vascular repair
excision of the affected segment
Ischemic colitis with gangarene excision total colectomy
with permanent ileosotomy 80% mortality
Colorectal Surgery Department
Amoebiasis
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Entamoeba histolytica
Cyst water /faecal oral /sexual
Colitis
Transmural colitis with perforation
Infamatory mass
Hepatic abscess
Stool exam ct scan -flagyl
Perforation -resection
Colorectal Surgery Department
Pseudomembranous colitis
• C difficile – cephalosporins
• Diarrhea
• Bowel rest / flagyl/ vancomycin ORALLY
• Toxic dilatation > 6 cm impending perforation
• PFA CT
• Proctocoletomy end ielostomy
Colorectal Surgery Department
Radiation enteritis
• Usually SB following therapeutic radiation less
common now
• Diarrhoea /obstruction
• Ileitis /proctitis
• Treatment NSAIDS steroid rarely resect except for
Colorectal Surgery Department
strictures
General Advise
• Categorise youre answers
eg intestinal obstruction
in the lumen
outside the lumen
in the wall
in medical
Be logical and organised
Colorectal Surgery Department
Answer questions
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Definition
Pathology
Classification
Causes
Differential diagnosis
Symptoms signs
Complications S&S of complications
Investigations bloods radiology surgical
Management medical/ surgical
prognosis
Colorectal Surgery Department
Questions?
Good Luck!!
Colorectal Surgery Department
Preoperative MRI
• Preop MRI scanning allows
selection of patients who will
benefit from a course of
preoperative radiotherapy
• T3 or T4 primary tumour or node
positive patients
lymph node
Colorectal Surgery Department
MRI
• Main indication in rectal cancer T3 or not T3
• Every patient with rectal CA should have pre-op MRI
to decide whether or not neoadjuvant therapy is
indicated
Colorectal Surgery Department
PET Scanning
Local recurrence at
the splenic flexure
Colorectal Surgery Department
Current indications for PET Scanning
• FDG PET is approved detection and localisation of
recurrent colorectal cancer in patients with rising CEA
levels and indeterminate findings on standard imaging
studies
• Indications may expand in the future but its final role
is still to be determined
• Radilogical imaging modalities in the diagnosis and management of colorectal cancer ,
Heamatology clinics of north america 202 16;90 875-95
Colorectal Surgery Department
Virtual Colonoscopy
Colorectal Surgery Department
Virtual colonoscopy – how does it work
• Virtual Colonoscopy is a promising new method for
detecting colorectal polyps and cancers. Air is
insufflated into a cleansed colon, and high resolution,
thinly-collimated spiral CT slices are acquired. The
two dimensional slices, as well as the post-processed
"fly-through" virtual colonoscopic images, are
examined for polyps and tumors.
Colorectal Surgery Department
Virtual Colonoscopy- advantages
• Advantages of Virtual Colonoscopy
Virtual Colonoscopy is minimally invasive, and does
not carry the low but real (1 in 1500) risk of
perforation associated with Conventional Colonoscopy.
It is well tolerated by patients and does not require
sedation. It is capable of evaluating the colon upstream
from obstructing lesions that prevent passage of an
endoscope. Virtual Colonoscopy is significantly less
expensive than Conventional Colonoscopy.
Colorectal Surgery Department
Virtual Colonoscopy-Disadvantages
• The dose of ionizing radiation is less than that of a
conventional abdominal CT, and is comparable to
obtaining a supine and upright plain film exam of the
abdomen.
• Colonoscopy by CT does not provide the same
information as Conventional Colonoscopy. Mucosal
detail and color is not visible which limits the
characterization of lesions. In addition, the detection of
small polyps is inferior
Colorectal Surgery Department
Virtual colonoscopy-disadvantages
• As with any procedure, including Conventional
Colonoscopy, there are no guarantees that all
clinically significant growths will be detected. It
should be remembered than between 10 and 20% of
all polyps, and up to 5% of colon cancers are missed,
even on Conventional Colonoscopy.
• Virtual Colonoscopy (like the Barium Enema) is a
diagnostic not therapeutic technique. All patients in
whom polyps are identified would need to undergo
Conventional Colonoscopy for removal.
Colorectal Surgery Department
Virtual Colonoscopy Current indications
• Frail elderly patients
• Occlusive cancer for detection of other lesions
• Previous incomplete colonoscopy
Colorectal Surgery Department
Surgical Advances
• LOCAL RESECTION
• TOTAL MESORECTAL EXCISION(TME)
• COLOANAL POUCH ANASTOMOSIS
• LAPAROSCOPIC SURGERY
Colorectal Surgery Department
Local Resection of low rectal tumours
Transanal resection or TEMS (Trans anal endoscopic
microsurgery) allows anal sphincter preservation while
avoiding the risks of abdominal surgery
- but its oncologic acceptability remains controversial.
- No randomised trials exist
- Safe application of this technique requires accurate
preoperative staging, careful transanal resection, and
meticulous histological examination. Factors that increase the
risk of recurrence following local resection include T stage,
poor histological grade, lymphovascular invasion, and positive
excision margins
Colorectal Surgery Department
Local resection for low rectal tumours
• Recent meta-analysis indicates that local recurrence
occurs in
• 9.7% of patients (range 0%-24%) of patients with T1
tumors
• 25% (range 0%-67%) of those with T2 tumors
• 38% (range 0%-100%) of those with T3 tumors
• Sengupta S,Tjandra JJ. Local excision of rectal cancer: what is the
evidence? Dis Colon Rectum. 2001;44:1345-1361.
Colorectal Surgery Department
Transanal Endoscopic Microsurgery
Colorectal Surgery Department
Total Mesorectal Excision
Colorectal Surgery Department
Total Mesorectal Excision
• Definition; en bloc resection of the rectum and its
enveloping mesentery to the level of the pelvic floor
with a negative distal and radial resection margin.
• reduces the incidence of local recurrence to less than
10% without the use of adjuvant treatment. Martling AL,
Holm T, Rutqvist LE, et al. Stockholm Colorectal Cancer Study Group,
Basingstoke Bowel Cancer Research Project. Lancet. 2000;356:93-96
Colorectal Surgery Department
Total Mesorectal Excision
Colorectal Surgery Department
Coloanal J pouch
Colorectal Surgery Department
Criteria necessary for successful sphincter
preservation in rectal cancer
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No pre-operative alteration of sphincter mechanism.
TME and nerve sparing surgery.
No damage to levator ani.
Preservation of at least half of the internal sphincter.
Low rate of anastomotic leakage.
Low rate of pelvic sepsis.
Low rate of anastomotic stricture.
Allow good bowel function.
Colorectal Surgery Department
How can we improve function?
• Rectal cancer surgery may result in
poor post-operative quality of life in
survivors as a result of frequency,
urgency and faecal soiling.
McDonald et al BJS 1983
• Postoperative function and
continence after low anterior
resection are significantly improved
by a colonic pouch.
Parc et al BJS 1986
Lazorthes et al BJS 1986
Mantyh et al DCR 2001
Colorectal Surgery Department
Coloanal J pouch vs. direct low anastomosis
• Lower morbidity.
• Better early function.
• Improvement of function persists with time.
Lazorthes F. et al. Br J Surg 1997
Dehni N. et al. Dis Colon Rectum 1998
Harris G.J.C. et al. Br J Surg 2001
• Age not a contra-indication.
Dehni N. et al. Am J Surg 1998
Colorectal Surgery Department
Coloanal J pouch: functional results
• Bowel movements
• Continence
– Perfect or good
– Soiling
– Frequent fecal incontinence
2.1 per 24 h
82%
14%
4%
• Protecting PAD
– Never
– As a safety
– Needed
71%
11%
18%
Colorectal Surgery Department
Coloanal J pouch: functional results
• Normal discrimination between
flatus and stool
• Urgency
• Fragmentation of stools
• Suppository or enema
to elicit evacuation
Colorectal Surgery Department
95%
4%
21%
20%
Conclusion
• Preoperative radiotherapy is
followed by only minor
deterioration in post-op
anorectal function if colonic
pouch anal anastomosis is
performed.
• Reconstructive technique of
choice in preoperatively
irradiated patients.
transanal
rectal
mucosectomy
Colorectal Surgery Department
exclusion of
anal sphincter
from field of
radiation
Laparoscopic Surgery
% Laparoscopic
100
*78.9%
50
Cholecystectomy
Colorectal Cancer
Resection
*27.2%
0
88 89 90 91 92 93 94 95 96 97 98 99
*Nair RG et al. British Journal of Surgery 1997;84:1369-98
Colorectal Surgery Department
Laparoscopic colectomy -Essential
Questions
Is it safe?
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Clinically
Technically
Economically
Oncologically
Colorectal Surgery Department
Laparoscopic Colorectal Surgery
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Potential advantages
Early mobilisation
Shorter ileus
Reduced opiate requirement
Lower cardiorespiratory morbidity
Reduced hospital stay
Cosmetically better
Colorectal Surgery Department
Laparoscopic Colorectal Surgery
Potential disadvantages
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Technically demanding
Difficult orientation
Increased operative time
Increased tumour dissemination
Increased postoperative morbidity
Colorectal Surgery Department
Patterns of Recurrence and Survival
after Laparoscopic and Conventional
Resections for Colorectal Carcinoma
John E Hartley, et al
Annals of Surgery 2001;132:181-186
Colorectal Surgery Department
Methods 3 - Lap. Assisted
Operative Technique
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“Laparoscopic principles are Open principles”
Laparoscopic Mobilisation
Intracoporeal vessel division
Intra /Extracorporeal bowel division
Extracorporeal stapled anastomosis
Colorectal Surgery Department
Results 1 - Demographics
Laparoscopic
n
Age
Sex M:F
Stage
Dukes A
Dukes B
Dukes C
Dukes D
Open
58
53
70 (51-87)
38:20
72 (36-90)
42:11
12
19
22
5
10
15
21
7
Colorectal Surgery Department
Results 2 - Operative
Laparoscopic
Operative Time
185 (80-330)
Open
122 (70-285)*
*p<0.05
CONVERSIONS n=20 (34%)
3
Mann Whitney
Tumour Fixity
10
Obesity
Adhesions
2
Bowel perforation
Small bowel obstrucion
2
1
1
1
Ureter not identified
Equipment failure
Crude Survival - Kaplan-Meier
1
p=0.6264. Log Rank Test
.8
Probability
of
.6
Survival
.4
Open
.2
Laparoscopic
0
10
Number 58
at risk
53
20
30
40
50
60
47
40
11
2
43
28
9
2
MONTHS
Recurrence
Open
Lap.
Assisted
Rectal Cancer
n
27
Local + distant recurrence
Local recurrence in isolation
Total
(7.1%)
Wound recurrence (all patients)
(1.7%)
28
2
1
3 (11.1%)
2
3 (5.6%)
1
Colorectal Surgery Department
1
1
Recurrence
• Rectal Cancer
Local recurrence
3 of 27 open
2 of 28 lap. assisted
11.1%
7.1%
3 of 53
1 of 58
5.6%
1.7%
• Wound recurrence
Open
Lap. assisted
Colorectal Surgery Department
Conclusions
• Oncological outcome at two years is not compromised
by an “all-comers” laparoscopic assisted approach
• Wound recurrence is a feature of both open and
laparoscopic surgery for advanced disease
Colorectal Surgery Department
Conclusions - Current status
• Laparoscopic surgery for cancer is still in the
development phase
• Convincing data that it is safe and new suggestions that
survival may be improved
• Very operator dependant
• Needs strict control - ongoing audit and supervision.
Colorectal Surgery Department
“The Ongoing Randomized Trials”
NIH
COLOR
CLASICC
BARCELONA
SINGAPORE
? 2003 AD
Colorectal Surgery Department
Single Positive Randomised Trial
Laparoscopy-assisted colectomy versus open
colectomy for treatment of non-metastatic colon
cancer: a randomised trial.
Lacy AM et al
Lancet 2002 Jun 29;359(9325):2224-9
Multicentre trials not yet reported CLASICC etc
Colorectal Surgery Department
Lacy trial continued
• 219 patients (111 laparoscopic)
• Improved short term variables and
• Improved survival in laparoscopic group particularly
for Stage III (ie node +ve) cancers
• Very significant data if can be replicated.
– Single centre with enthusiast
– Small numbers
Colorectal Surgery Department
Consensus Statements
• “The use of laparoscopic surgery in the curative
treatment of colorectal cancer remains controversial.
However, assuming appropriate adherence to the
principles of surgical oncology there appears to be no
difference in the adequacy of tumour resection and
adjacent lymph nodes. In addition, the short term
outcome appears comparable to open surgery in
respect of morbidity, mortality and cancer recurrence
including wound deposits.”
ACPGBI & AESGBI
Colorectal Surgery Department
Laparoscopic Assisted Colectomy
• Three port technique
• Laparoscopic
• identification of anatomy
• division of vascular pedicle
• mobilisation of colon, mesentery
and relevant flexure
• Extracorporeal
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delivery of specimen
determination of margins
anastomosis
closure of mesenteric defect
Colorectal Surgery Department
Colorectal Surgery Department
Operating theatre
Colorectal Surgery Department