16/12/2012 Mr. Ravi-Kumar Stafford General Hospital1 ABC of CRC (Colo-Rectal Carcinoma) Mr...
-
Upload
morris-owen -
Category
Documents
-
view
217 -
download
0
Transcript of 16/12/2012 Mr. Ravi-Kumar Stafford General Hospital1 ABC of CRC (Colo-Rectal Carcinoma) Mr...
16/12/2012Mr. Ravi-Kumar Stafford General
Hospital 1
ABC of CRCABC of CRC(Colo-Rectal Carcinoma)(Colo-Rectal Carcinoma)
Mr Ravi-KumarMr Ravi-Kumar
Consultant SurgeonConsultant SurgeonColoproctology, Laparoscopy Coloproctology, Laparoscopy
& General& General
11/12/2012Mr. Ravi-Kumar Stafford General
Hospital 2
Incidence Aetiology Pathogenesis Heritable cancers/ FH Clinical presentation Role of screening Treatment options Recent advances
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 3
Colorectal cancer is second commonest cancer causing death in the UK
20,000 new cases per year in UK - 40% rectal and 60% colonic
Some cases are hereditary (5%) Most related to environmental factors - dietary
red meat, animal fat & lack of fibre Role of alcohol, smoking, obesity and lack of
exercise Role of micro-nutrients
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 4
Most cancers believed to arise within pre-existing adenomas
Risk of cancer greatest in villous adenoma Of all adenomas - 70% tubular, 10% villous and 20%
tubulo-villous Series of mutations results in epithelial changes from
normality, through dysplasia to invasion
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 5
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 6
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 7
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 8
1% due to Familial Adenomatous Polyposis coli (FAP)
4% due to Hereditary Non-Polyposis Colon Cancer (HNPCC)
Definition- at least 3 relatives affected (one of whom is a first degree relative of the other two)
At least one under the age of 50 Potential HNPCC- relatives of people with
CRC under 45 or multiple cases
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 9
Not a germ-line mutation Still a cluster of cases in various generation Not enough to fall under HNPCC or FAP Risk to be stratified and screened
accordingly
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 10
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 11
Age- disease of old age Peak age incidence 60-80 More & more younger patients are being
diagnosed with CRC (still makes only 5% of all cases)
Strong FH – younger age presentation IBD – increased incidence esp. With
extensive UC
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 12
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 13
Bleeding PR- o Mixed in with the stoolso Dark red in colouro Even one episode of bleeding may be
significant in the elderlyo Rarely massive lower GI bleed
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 14
Increased stool frequency Diarrhoea alternating with constipation Tenesmus Abdominal pain Incontinence
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 15
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 16
Abdominal pain Diarrhoea alternating with constipation
40% of all cancers present as a surgical emergency with either obstruction or perforation
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 17
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 18
Anaemia –iron deficiency Mass- RIF Increasing in incidence of right sided
tumours FH
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 19
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 20
May present with fistulation into nearby viscera- colovaginal, colovescical, coloenteral fistulae
Poor appetite Weight loss
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 21
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 22
FAST TRACK – FAXED REFERRAL
Bleeding PR lasting over 6/52 in anyone over the age of 60
Loose stools lasting over 6/52 in anyone over 60
Both symptoms in anyone even under 60
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 23
FAST TRACK – FAXED REFERRAL
Mass in the RIF Mass in the rectum Unexplained iron deficiency anaemia
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 24
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 25
To diagnose Colonoscopy – Gold standard
To Stage Contrast CT- Thorax, abdomen and Pelvis MRI Pelvis in addition to stage rectal cancer
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 26
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 27
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 28
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 29
Developed by Cuthbert Duke in 1932 for colorectal cancers
Dukes staging of colorectal cancer
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 30
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 31
TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: intraepithelial or invasion of lamina
propria T1 Tumor invades submucosa T2 Tumor invades muscularis propria T3 Tumor invades through the muscularis propria into
pericolorectal tissues T4a Tumor penetrates to the surface of the visceral
peritoneum T4b Tumor directly invades or is adherent to other organs
or structures
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 32
N0 No regional lymph node metastasis.
N1 Metastases in 1–3 regional lymph nodes. N2 Four or more regional lymph nodes.
NX Regional lymph nodes cannot be assessed.
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 33
M0 No distant metastasis.
M1 Distant metastasis.
M1a Metastasis confined to 1organ or site (e.g., liver, lung, ovary, non-regional node).
M1b Metastases in >1 organ/site or the peritoneum.
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 34
Little improvement over the last 30 years in general
How can we improve the prognosis? Considerable improvement achieved
recently in rectal cancer treatment Role of screening
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 35
TME- better surgical technique Better staging- MRI, EUS, CT Selective use of pre-operative
Radio/chemotherapy MDT
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 36
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 37
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 38
Right Hemicolectomy Ext. Right Hemicolectomy Transverse Colectomy Left Hemicolectomy Sigmoid colectomy Subtotal colectomy
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 39
www.websurg.com - is a very useful site for senior trainees and consultants
Free to register and thousands of video clips can be viewed for free
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 40
Laparoscopic vs. open Fast Track / enhanced post-op recovery
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 41
Pre-op- Counseling, Carbohydrate load Per-op – Less opiates, epidurals, Goal
directed fluid therapy, Transverse incision Post-op- Analgesic ladder, Less tubes, IVI for
less than 24 hours, early feeding and promote mobility
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 42
04/21/23Mr. Ravi-Kumar Stafford General
Hospital 43