CARCINOMA COLON

RECTUM
SURGICAL ASPECT
 INCIDENCE CANCER COLON RECTUM

MALES
COUNTRIES FEMALES
ASR

Australia 65.66
New Zealand 74.13 Indonesia
Japan 60.51 22.000-30.000
Hongkong 60.40 NEW CRC/YEAR
Singapore 44.65
China 29.34
Rep.of Korea 15.11
Malaysia 40.70
Phillipine 22.01 Colon and rectal cancer age
Vietnam 29.71 standarized incidence
Papua New Guinea 15.08 Rates per 100.000 in countries
(1990)
 LOCATIONS OF CANCER COLON RECTUM
INDONESIA

LOCATION SUMANTI WARTATMO PHILLIPPI SUDJATMIKO SUDARSA

MANADO JOGJAKARTA JAKARTA SURABAYA DENPASAR
1990-1995 1994-1996 1991-1993 1990-1995

Caecum 3 (3.3) - 29 (25) 8 (6.1) 5 (4.0)

C.Asc 9 (9.8) 3 (1.5) - 13 (9.9) 8 (6.5)
C.Transv 5 (5.4) - 11 (10) 3 (3.0) 5 (4.0)
C.Desc 10 (10.9) 8 (4.1) 17 (15) 12 (9.2) 6 (15.3)
Sigmoid 15 (16.3) 41 (20.9) 23 (20) 12 (9.2) 19 (15.3)
Rectum 50 (54.2) 144 (73.5) 34 (30) 53 (52.6) 81 (65.3)

TOTAL 92 196 114 131 124

SURVIVAL CARCINOMA COLON RECTUM

USA : 5YSR st I/II (37%) 90 %

st III 65 %
st IV 8%
SURABAYA 5YSR 50 %
SEMARANG 5YSR st I/II 70 %

RECURRENT 80 % WITHIN 2 YEARS

HEPATIC 50 %
LUNG 20 %
LOCAL 33 %
PERITONEAL SEEDING 22 %

STATISTIC USA 2001 AMERICAN CANCER SOCIETY

 Colon Resection

Totalresection
Negative proximal
distal
radial
Extended lymphadenectomy
Reanastomosis end to end
 COLON RESECTION
ARTERIAL & LYMPHATIC DRAINAGE
COLON RESECTION
VENOUS DRAINAGE
COLON RESECTION
 COLON RESECTION

PREOPERATIVE
NUTRITIONAL STATUS
BOWEL STERILIZATION
 COLON RESECTION
RIGHT COLON : DUODENUM
RIGHT URETER
RIGHT GONAD VESEL
LEFT COLON : LEFT URETER
LEFT GONAD VESEL
SPLEEN

END TO END ANASTOMOSE

NO TENSION
T4 --- en bloc resection
No touch technique
 BOWEL OBSTRUCTION

LAVAGE INTRA OPERATIVE

LEFT COLON IN HARTMANN /

DOUBT ILEOSTOMY
 TME

Bladder

Penis Prostate

Sacrum

Anus Rectum
Coccyx
Surgical TME technique of APR

Cilindrical resection
"coning in"
 CARCINOMA RECTUM

MULTIMODALITY
PREVENTION OF
COMBINED THERAPY
LOCAL RECCURENCE (MCT)
TOTAL MESORECTAL
QUALITY OF LIFE EXCISION
(SOCIAL LIFE) (TME)
SPHINCTER SAVING
PROCEDURE
(STAPLES)
 CARCINOMA RECTUM
TOTAL MESORECTAL EXCISION

1982 HEALD (GREAT BRITAIN)

METASTASE LATERAL (RADIAL) > DISTAL

TME
2 CM DISTAL STUMP SPHINCTER SAVING
(FROZEN SECTION)

PRESERVE AUTONOMIC NERVE

BOWEL, BLADDER, SEXUAL FUNCTION
 Norwegian Rectal Cancer Project
N = 3319
Conventional surgery TME

Local recurrence 12% 6%

Overall survival 60% 73%

Wibe et al. Dis Colon Rectum 2002; 45:857-66

TOTAL MESORECTAL EXCISION
TOTAL MESORECTAL EXCISION
TOTAL MESORECTAL EXCISION
CARCINOMA COLON RECTUM
REANASTOMOSIS
 CARCINOMA COLON RECTUM

PREOPERATIVE CHEMORADIATION
MULTIMODALITY THERAPY ?!

4-6 CHEMORADIATION
wks
5FU + LEUCOVORIN
3-6 wks 4000cGY

DOWN STAGING
RESECTABILITY SURGERY
LOCAL RECURRENCE
CHEMORADIATION
 PREOPERATIVE ASSESSMENT
OF RECTAL CANCER

ANTERIOR RESECTION
> 15 CM

10-15
PARTIAL TME
CM
LOCAL EXCISION
CLINICAL T1 N0 M0
TME
CLINICAL T2 N0 M0
PRE-OP CHEMORADIATION
1-10 CM CHEMORADIATION + TME
CLINICAL T3 N any M0
POST-OP CHEMORADIATION
PRE-OP CHEMORADIATION +
CLINICAL T4 N any M0
APR
<1 CM APR
CARCINOMA COLON RECTUM

FUTURE
LAPAROSCOPY
CHEMOTHERAPY
BIOMOLECULAR THERAPY
SCREENING - DIAGNOSTIC
 CONCLUSION

SURGICAL AUDIT
TO IMPROVE SURVIVAL
IMPROVE SURGICAL TECHNIQUE
CHEMORADIATION PERIOPERATIVE
REFER TO A BETTER CENTRE