SURGICAL ASPECT OF LARGE BOWEL

DISEASE
Ign.Riwanto MD PhD
Prof. of Digestive Surgery
SURFACE ANATOMY
1.  LEFT LUMBAR:
Coecum, ascending
colon, hepatic flexure
2.  UMBILICAL
Transverse colon
3. RIGHT LUMBAR:
Splenic flexure,
descending colon,
sigmoid
4. LEFT INGUINAL:
Sigmoid
5. HYPOGASTRIC:
Sigmoid & Rectum
ORGAN RELATED & - GASTRO-COLIC
POSITION OF LARGE LIGAMENT
BOWEL - OMENTUM MAYUS
- Coecum: Intraperitoneal
- Ascending colon:
retroperitoneal
- Transverse colon:
intraperitoneal
- Descending colon:
retroperitoneal
- Sigmoid: intraperitoneal
- Rectum: retroperitoneal
DETAIL ANATOMY OF COLON

§ 3-5 FEET IN LENGTH

§ ILEOCOECAL JUNCTION WITH
ILEOCOECAL VALVE
§ APPENDIX
§ COECUM IS WIDES,
PROGRESSIVELY NARROW
DISTALLY à ANAL CANAL
§ 3 TAENIA (CONDENSED OF
LONGITUDINAL MUSCLE
LAYER,CONVERGE AT THE
BASED OF APPENDIX AND
SPREAD AT RECTUM)
§ HAUSTRA
§ INCISURA
§ APPENDICES EPIPLOICAE
 RECTUM

§  RETROPERITONEAL
§  12-15 CM IN LENGTH
§ ANORECTAL JUNCTION : ANGLE
DUE TO PUBO-RECTAL MUSCLE
§ WALDEYER’S FASCIA:
RECTOSACRAL FASCIA
§ DENONVILLERS’ FASCIA:
ANTERIOR
LOWER THIRD OF RECTUM ,
RELATED TO THE PROSTAT (MALE)
AND VAGINA (FEMALE)
 RECTUM & ANAL CANAL
§  3 RECTAL VALVE (INFERIOR, MIDLE &
SUPERIOR)
§  ANATOMICAL ANAL CANAL: ANAL CANAL SKIN
§  SURGICAL ANAL CANAL: ANAL CANAL SKIN &
MUCOSA
§  INTERNAL ANAL SPHINCTER (SMOOTH
MUSCLE FIBER CONTINUATION OF CIRCULAR
MUSCLE OF THE RECTUM, START FROM
ANORECTAL JUNCTION), 80% RESTING ANAL
CLOSING.
§  3 EXTERNAL ANAL SPHINCTER (STRIATED
MUSCLE FIBER), 100% SQUEEZING ANAL
CLOSING
§  INTERSPNCHTERIC GROVE
§  ANAL PAPILA & COLLUMNS OF MORGAGNI
§  ANAL CANAL CRYPT
§  ANAL CANAL GLAND
§  NO HAIR IN ANAL CANAL SKIN
§  INTERNAL & EXTERNAL HEMORRHOID PLEXUS
ARTERY
SUPERIOR MESENTERIC
ARTERY: Coecum, Ascending
colon & 2/3 transverse colon
(midgut)

INFERIOR MESENTERIC
ARTERY:
1/3 distal transverse colon,
sigmoid & rectum (hind gut)

MIDLE & INFERIOR RECTAL

ARTERY (branches from
INTERNAL ILEAC ARTERY):
rectum & anus
VENOUS SYSTEM

§  PORTAL SYSTEM

§  SUPERIOR MESENTERIC
VEIN & SPLENIC VEIN
form PORTAL VEIN, and
INFERIOR MESENTERIC
VEIN drain to SPLENIC VEIN
§  MIDLE & INFERIOR
RECTAL VEIN drain to
INTERNAL ILIAC VEIN
§  HEMORHOIDAL
COMPLEX: collateral
PORTAL- SYSTEMIC
SYSTEM
 LYMPH ATIC SYSTEM

3 TYPES:
Ø  Epicolic
Ø  Paracolic
Ø  Intermediate (name according
artery they follow
Ø Main/ principal : around SMA &
IMA

à para-aortal à cysterna chili à

thoracic duct à left sub-clavian
vein (Vircow’s node)

Distal rectum & anus : drain to

inguinal lymph node
INNERVATION
§ AUTONOMIC NERVOUS SYSTEM
§ SYMPATHETIC (Inhibit peristaltic):
- T7-T12 : RIGHT COLON &
- L1-L3 : LEFT COLON
§ PARA-SYMPATHETIC (stimulate peristaltic):
- VAGUS NERVE: RIGHT COLON
- SACRAL (S2-4): LEFT COLON

INTRINSIC INNERVATION:
MEISSNER;S PLEXUS: sub-
mucosal
AURBACH PLEXUS: circular
muscle layer
PHYSIOLOGY

— Absorbtion of water & electrolyte :

especially right colon
— Storage of feces
— Fecal movement & delivery
COLON MOTILITY
—  RETROGRADE MOVEMENT: Transverse
colonà coecum to facilitate the absorption water
& electrolyte
—  SEGMENTAL CONTRACTION: Simultaneous
segmental contraction of circular and longitudinal
muscle
—  MASS MOVEMENT: Contraction long segment,
30 seconds duration à antegrade propulsion
feces at the rate 0.5-1 cm/sec, 3-4 times each day
after waking up & after eating.
DEFECATION
—  Mass movement à feces move to rectum
—  Rectal distentionà involuntary relaxation of
internal sphincter
—  Voluntary relaxation external sphincter à
pushes feces down to anal canal
—  Voluntary increase intra-abdominal pressure à
propeling feces out of the anus
DISORDER MOTILITY OF COLON &
RECTUM
DISORDER MOTILITY

— Iritable Bowel Syndrome (IBS)

— Constipation
— Diarrhea
— Fecal incontinence
IRRITABLE BOWEL SYNDROME
—  Abnormal state of intestinal motility modified by
psychosocial factors, no anatomic cause
—  Male: female= 1:2
—  Incidence: Up to 17% (US)
—  Episode of altered bowel function (constipation, diarrhea or
both) intermittently over prolonged period with or without
pain
—  Treatment: reassurance, education, medical treatment for
anxiety/ depression
CONSTIPATION
—  < 3 stools/ week while consuming high fiber
—  Acute: persisten for < 3 months
—  Chronic: persistent > 3 months
—  Cause: Less fiber, less fluid, lack physical activity, medication
(opiate), IBS, DM, hypothyroidism, Hirsprung disease, depression,
Parkinson's disease, multiple sclerosis, rectocele, others.
—  Treatment: Stool softener, increasing fiber & fluid
—  Failure: colonic transit time, defecography , manometri
—  Fecal impaction: manual disimpaction
—  Surgery for rectocele, Hirsprung disease, prolong transit time
SCINTIGRAPHY

Normal: within 48
hours of ingestion much
of the radioisotope has
been passed from bowel

Severe constipation due

to prolonged transit
time, over the 4 days
radioisotope does not
progress beyond the
thansverse colon
RADIOLOGIC MARKER
—  Radio-opaque marker tablet
—  20 tablet, followed by serial daily
abdominal X-ray
—  Normal:
Ø  80% had passed by the end of 5th
days
Ø  TT through right colon 6.9-13.0
hours
Ø  TT through left colon 9.1-15 hours
Ø  TT through rectosigmoid 11-18.4
hours
—  More than 40% marker left in the
colon after 5 days considered
pathology.
Colonic Hindgut Outlet
inertia obstruc
inertia
tion
§  Rectocele: Anterior outpocketing of the rectal wall with incomplete evacuation
§  High incidence of ventral outpocketing
§  Vaginal bulging during straining & digitation for success defecation
§  Surgery: anterior levator mplasty
§ HIRSPRUNG’S DISEASE
§  AGANGLIONIC IN THE NARROWING PART
§  DILATED PART: ACCUMULATION OF FECES & COMPENSATION
§  SURGERY
DIARRHEA
—  Passage of >3 loose stools/day
—  Surgery related: short bowel syndrome (less than 70 cm
of small intestine left)
—  Conservative: imodium, elemental diet, parentaral
nutrition
—  The rest of the small intestine will hypertrophy
FECAL INCONTINENCE
—  True: Complete loss of solid stools
—  Minor: Flatus or soilage undergarment from seepage or
urgency
—  Decreasing resting tone and squeeze pressure
—  Etiology: Sphincter injury, scleroderma, fecal impaction,
pudendal nerve injury.
—  Diagnosis: anal manometry, endoanal ultrasonography,
electtro-myography, Pudendal nerve motor latency.
—  Surgery: sphincter repair for sphincter injury.
COLITIS
 COLITIS
—  Amoebic colitis: due to E histolytica, diagnosis based on fecal
microscopy or serum amoeba.
—  Pseudomembranous: (overgrowth Clostridium difficile after
using clindamycin, amphicillin or cephalosposin)
—  Actinomycosis: Rare infection of cecal region caused by A.
israelii, classically after appendectomy, may produce abscess &
fistulation that need surgical drainage & antibiotics
(tetracycline or penicillin)
—  Netropenic: colonic mucosal ulceration after chemotherapy in
cancer patients, may perforation à surgery.
—  Radiation induced: after radio-therapy more than 5.000 cGy,
early presentation: bleeding & diarrhea, late presentation:
stricture & fistula à need surgery
—  Ischemic: due to decrease perfusion or tromboembolism, if
conservatif treatment failà resection with colostomy
INFLAMMATORY BOWEL DISEASE
(IBD)
—  CROHN’S DISEASE
—  ULCERATIVE COLITIS

Ø  BOTH AUTO IMMUNE DISEASE

CROHN’S DISEASE ULCERAITIVE COLITIS

ULCERATIVE COLITIS vs CROHN’S DISEASE

ULCERATIVE CROHN
Pathology - Inflamation of the mucosa only - Involve all bowel wall layers
- Start in rectum - - rectal sparing 50%
Diagnosis
- Colonoscopy - Continous lessions - Skip lesions
- Rare - Aphthous ulcer
- Colonography -  Lead pipe colon -  Cable stone appearance
Complication -  Perforation - Abscess
-  Stricture -  Fistula
-  Megacolon - Obstruction
- Perianal disease
Treatment Mild to moderate : 5-ASA, corticosteroid p.o/ per rectum
Severe: IV steroid
Surgery: Failure medical theraphy, complication, dysplasia and
neoplasia à colon resection or diverting colostomy
DIVERTICULAR DISEASE
DIVERTICULAR DISEASE
—  Herniation of mucosa & sub-mucosa through sites where
arterioles penetrate à outpouching (diverticula), in the
mesenterial side
—  Diverticulosis = multiple diverticula
—  Sigmoid most common
—  Old age & low fiber intake
—  Asymptomatic (80%), massive lower GI bleeding, pain
(diverticulitis), peri colic abscess formation, perforationà
peritonitis
—  Dx: colonography, colonoscopy
—  Tx: high fiber & stool softener, antibiotics in diverticulitis,
surgery for failure of stop bleeding & complication
 DIVERTICULOSIS vs ANGIODYSPLASIA
as the cause of Lower GI Bleeding
Diverticulosis Angiodysplasia
Incidence 50% > 60 Yeras 25 % > 60 Years
Adult Men > adult women
Character Painless Coecum and ascending colon
75% bleed from right colon
Quantity and Massive and rapid Slow
rate
Sign & Sympt. Melena and /or hematoschezia often with symptom of orthostasis
Dx -  NGT to rule out upper GI bleeding
- Identify bleed (colonoscopy, Tc sulfur colloid, Angiography)
Tx 1.  Rescucitation
2.  Octreotide, embolization, epinephrine, vasodestruction with alcohol,
coagulation/ coutery
3.  Massive identified site à segmental colectomy
4.  Massive unidentified site à total colectomy
COLONIC OBSTRUCTION
COLONIC OBSTRUCTION
Cause:
—  Cancer,
—  Vulvulus coecum
—  Volvulus Sigmoid
—  Pseudo-obstruction syndrome (Ogilvie Syndrome)
SIGN & SYMPTOM
—  Abdominal distention
—  Cramping abdominal pain
—  Nausea and vomiting
—  Obstipation
—  High pits Bowel Sound
DIAGNOSTIC
—  Abdominal X ray: distended proximal colon with air-fluid
level and no air distally
—  Coffe bean (kidney) appearance: Coecal , Sigmoid Volvulus
—  Colonography: to ruled out pseudo-obstruction
—  Colonoscopy: contra-indicated, but can be used to treat
pseudo-obstruction.
ILEUS OBSTRUKSI RENDAH (COLON)
—  Kolik abdomen graduel
—  Gangguan bowel habit sebelumnya pada
keganasan kolon-rectum
—  Kembung seluruh perut dgn gambaran
& gerakan usus
—  Tidak bisa berak dan kentut
—  Mual, muntah bila sudah lanjut (fecal)
—  Perut kembung peristaltik meningkat
bisa ada suara metalik
—  RT kollaps (atau teraba tumor rektum)
—  BNO: dilatasi kolon (haustra &
incisura, air fluid level yang panjang di
kolon ascenden, bila val ileosekalis
inkompetent usus halus ikut melebar)
—  Colonografi/ CT scan dengan kontras
untuk menyingkirkan DD pseudo-
obstruksi
—  Terapi: pembedahan, kemungkinan
kolostomi perlu diinformasikan
CT scan abdomen

Obstruksi sigmoid oleh karena karsinoma (ada penyangatan pada

fase kontras)
Volvulus Sigmoid
—  Bentuk kronik dan akut
—  Nyeri perut mendadak dan
menetap karena iskemia (akut)
—  Bulging dan gambaran usus
—  Nyeri tekan
—  Defance muskuler bila telah
nekrosis/ perforasi
—  Foto: Cofee bean appearance
—  Coba konservatif dengan
rectoscopi decompresi dilanjutkan
pembedahan elektif untuk tipe
kronik
—  Gagal/ tanda nekrosis à operasi
segera
—  Tipe akut: laparatomi emergency
CT Scan

PSEUDO-OBSTRUKSI DI FLEKSURA LIENALIS

COLON
 ALGORITM
MANAGEMENT OF
COLON
OBSTRUCTION
TREATMENT
—  NGT
—  Fluid & electrolyte correction
—  Pseudo obstruction:
- Neostigmin
- Decompressed by colonoscopy
- Coecal diameter more than 11 cm or sign peritonitis à
Operation: ccoecostomy
—  Coecal volvulus: Right hemicolectomy
—  Sigmoid volvulus:
- Sigmoidoscopy to decompress followede by elective
resection
- Failure or sign of peritoneal iritation: emergency
resection
§  Cancer : resection or fecal diversion
HEMORRHOID
HEMORRHOID

—  Prolapse of the sub-mucosal vein ( 11,3,& 7

o’clock)
—  Internal: covered by mucosa
—  External: covered by skin
—  Risk factor: constipation, excessive diarrhea,
pregnancy, increase pelvic pressure, portal
hypertension.
DEGREE OF INTERNAL HEMORROID
—  1st stage: congestive non
prolapsed hemorrhoids
—  2nd stage: prolapsing during
defecation, reducing
spontaneously at the end of
defecation,
—  3rd stage: prolapsing during
defecation and requiring manual
reduction
—  4th stage: permanently prolapsed
which cannot be reduced
manually

Abramowitz et al. Gastroenterologie June-July 2001.

RELATIONSHIP BETWEEN PATHOGENESIS AND
MODE OF TREATMENT
—  GENERAL: Ovoid/ minimizing the risk factors, anti-
inflammatory drugs, faeces softener

—  VASCULAR THEORY:

Ø  - Phlebotrophic drugs (micronized diosmin)
Ø  - Excision of hemorrhoidal tissue

—  INCREASE LAXITY OF HEMORRHOIDAL SUPPORT

TISSUE:
Ø  - Sclerotheraphy
Ø  - Rubber band ligation
Ø  - Longo hemorrhoidectomy
Ø  - Hemorrhoid artery ligation and Recto-anal repair
Ø  - Phlebotrophic drugs
 GRADE OF INTERNAL HEMORRHOID & ITS
TREATMENT

—  Grade 1: Medical treatment

—  Grade 2: Medical and Ruber Band ligation or
Sclerotherapy
—  Grade 3: Medical and surgery
—  Grade 4. Medical and surgery
Excision of Hemorrhoidal tissue
—  OPEN METHOD
Ø Morgan milligan
—  CLOSED METHOD
Ø Fergusson
Ø Park
Ø White head
Morgan Milligan
—  Internal Hemorrhoid grade
II-IV
—  Removing anal cushion
including the skin
—  Left the wound open
—  Severe post operative pain
Fergusson
—  Internal Hemorrhoid grade
II-IV
—  Removing anal cushion
including the skin
—  Suturing the wound
—  Severe post operative pain
Park
—  Internal Hemorrhoid grade
II-IV
—  Submucous removing
Hemorrhoidal plexus
—  Suturing the wound
—  Post operative pain
before

Longo’s technique is based on

the theory of increase laxity of
hemorrhoidal support tissue
after
 HEMORRHOID ARTERY LIGATION (HAL)
AND RECTO-ANAL REPAIR

—  HAL: first reported by Morinaga (Japan) 1995

—  Because the arteries carrying the blood inflow are ligated,
internal pressure of the plexus hemorrhoidalis is
decreased, shrink and become smaller.
—  HAL: high prolapse recurrence in grade IV à 2005 RAR
(Recto-Anal Repair)
—  RAR = Proctoplasty/ mucopexy is lifting the hemorrhoid
back to where the belong.

The American Journal of Surgery, 2006

INSTRUMENT FOR HAL-RAR
—  Single system that has two
procedure options,
(Doppler Guided)
Hemorrhoidal Artery
Ligation and Recto Anal
Repair (Proctoplasty).
Step for Hemorrhoid Artery
Ligation (HAL)
Step for Recto-Anal Repair (RAR)
Prolaps Rektum
Epidemiologi
—  terjadi pada umur yang ekstrem, anak sampai umur 3 tahun
dan pada orang tua.
—  Lebih sering pada wanita tua dengan perbandingan 10-15:1
—  Pada anak laki & wanita sebanding
Anamnesa
Keluhan utama: - penonjolan rectum keluar anus pada
prolaps lengkap (3/4 kasus)
- pada pre-prolaps (intususepsi rektal) ada
rasa penuh dan terasa ada masa didalam
rektum yang menutup anus
Keluhan lain: - konstipasi
- inkontinensia alvi
- pengeluaran mukosa
Etiologi: - kesulitan defekasi
- nulipara
- riwayat operasi sekitar anus:
hemorroidektomi, fistulektomi,
“abdomino anal pullthrough”
 Pemeriksaan fisik
Inspeksi : - penonjolan konsentrik mukosa rektum
berbeda dari hemmorroid prolaps dengan
adanya lobulus dengan sulkus
diantaranya, sementara dibedakan dari
polips yang prolaps dengan adanya tangkai
- terjadi strangulasi à kehitaman
- kemungkinan bisa diidentifikasi polip
diujung prolaps sebagai penyebab
Palpasi : - prolaps apakah bisa direposisi
- tonus sfingter ani, pada keadaan istirahat
(resting) dan kontraksi (squeezing), PROLAPS RECTI
kebanyakan kasus sfingter lemah
- pada pre-prolaps pada colok rektal, dengan
dibantu mengejan, akan teraba masa
seperti portio

HEMORRHOID
Pemeriksaan penunjang
Rektosigmoidoskopi
- dilihat adanya polip atau karsinoma yang menjadi
titik awal dari prolaps
- dilihat derajat prolaps, hanya mukosa atau seluruh lapisan
- dilihat apakah ada “solitary ulcer” , berupa ulkus dengan
tepi hiperemik dikelilingi indurasi, akan tetapi bisa juga
dalam bentuk indurasi mukosa bahkan lesi polipoid
didinding depan rektum sekitar 6-8 cm dari anal verge.
Colon foto atau colonoskopi
- disarankan untuk orang tua sebelum merencanakan
operasi
Colon-transit time
- dilakukan bilamana terdapat konstipasi, untuk
memastikan apakah konstipasi tipe “prolong transit time”
atau “outlet obstruction type”.
Defecogram
- dilakukan pada partial prolaps, mungkin akan bisa dilihat
adanya intususepsi rectal, tumor (polip) rectum dan
rectocele.
 PROLAPS REKTI

Internal Eksternal (prolaps

(Intususepsi rektal) lengkap)

gagal

Managemen medik Toleransi Toleransi

operasi besar operasi besar
< baik baik

Konstipasi (+),
Necrose (-) Necrose (+) Konstipasi (-) sigmoid
redunden
*
**
Laparoskopi Sigmoidekt
Thiersch Delorme Express Altemier Ripstein rektopeksi omi +
ventral Ripstein
* Dipilih bila beserta konstipasi / sigmoid redundan ** Dipilih bl bsm rectocele
ANAL FISURA
ANAL FISSURE
—  Painful linear tear in anal canal skin (below dentate line)
—  Induced by constipation, excessive diarrhea, anal sex.
—  Painful defecation with bright red blood in the toilet tissue
—  Increase resting sphincter tone
—  Visible tear on examination
—  Tx:
—  medical: sitz bath, fiber diet, increase fluid intake,
—  Internal lateral spinchterotomy in case of medical Tx fail
SPHICHTEROTOMI INTERNA SUB-
CUTAN LATERALIS
PERI-ANAL ABSCESS & FISTULA
PERI-ANAL ABSCESS & FISTULA

—  Abscess caused by defect or obstruction of anal crypt

resulted in bacterial overgrowth in the anal glands
—  Tx Surgical drainage
—  May developed anal fistula (internal opening in the anal
crypt, external opening peri-anal)
—  Classification of fistula:
—  Intersphincteric (70%), Transsphincteric (25%),
Suprasphincteric (4%), Extrasphincteric (1%)
—  Tx: Fistulotomy, Seton for Supra & extrasphincteric.
 Para-anal abscess

PARA-ANAL FISTULA
Goodsall’s Rule
—  Tract anterior (A) berupa
garis lurus, sedangkan tract
posterior (P) berupa garis
lengkung
—  Secondary opening anterior
yang berjarak > 3 cm dari
anal margin, akan
membentuk garis lengkung
berhubungan dengan anal
gland posterior
Klasifikasi fistula ani menurut Parks
COLORECTAL CANCER
Age Standardized Minimum Incidence Rate (ASR) 5
prominent cancer in Semarang
(Tirtosugondo 1986)

1970-1974 1980-1981

Man Woman Man Woman

Location ASR Location ASR Location ASR / Location ASR /

/100.000 /100.000 100.000 100.000

Liver 5,2 Cervic 19,8 Liver 9,5 Cervic 27,9

Skin 4,3 Breast 10,2 Lung 7,6 Breast 13,0

Lung 4,0 Ovarium 5,1 Naso 6,1 Skin 6,7

Pharynk
Naso 3,6 Skin 4,9 Skin 6,1 Ovarium 3,9
pharynk
Colorec- 2,5 Colorec- 2,2 Colorec- 3,2 Colorec- 3,4
tal tal tal tal

Increase incidence of colorectal cancer in Semarang

FAKTOR YANG BERPERAN TERHADAP HARAPAN
HIDUP PASIEN KANKER KOLON-REKTUM

—  1. Stadium penyakit

—  2. Derajat keganasan (histologik)
—  3. Komplikasi (tersumbat, pecah)
—  4. Dokter spesialis bedah (keputusan tindakan berdasarkan
stadium, pilihan pengobatan dan skill pembedahan)
—  5. Panas pasca-bedah
—  6. Tranfusi darah
—  7. Pengobatan tambahan
—  8. Petanda molekular (Mutasi K-ras respons chemoterapy
jelek)
—  9. Lain-lain
PERKEMBANGAN ALAMIAH KANKER
paparan
Perubahan biologik
gejala
waktu terdeteksi
sembuh/mati
A B C D
Periode Periode
Skrining faktor risiko subklinis klinis
Skining utk diagnosis
deteksi dini
dini

A: Skrining, B: Deteksi dini C: Diag.nosis dini D, Management & prognosis

 Periode A dan B utamanya untuk kelompok
risiko tinggi
Umur > 40 (>50) laki = wanita
Penyakit Ulcerative colitis
terkait Crohn disease
Peutz-jegher Syndrome
Riwayat Kanker dan polip usus besar
penyakit Kanker kandungan dan buah dada
Riwayat Juvenile polyp
keluarga
Familial adenomatosis polyps
Familier polyposis syndrome
Kanker dan polip usus besar

SURVEILANCE COLONOSCOPI: POLIPEKTOMI ATAU BIOPSI

FLEXIBLE SIGMOIDOSCOPY
—  Kanker Rektum
& kolon kiri
70-80% kanker
kolo-rektal

—  Flexibel sigmoidoskopi

bisa mencapai fleksura lienalis, masih diperlukan kolon foto
untuk melihat sisa kolon
 Kolonoskopi:
Diagnosis & Pengobatan

Colonoscopy and biopsy is the only way to make a definitive diagnosis of

colorectal cancer. A barium enema can be used in cases where colonoscopy is
difficult. (Adenis et al. Standards, options and recommendations: Carcinoma of the colon. Elec. J of
Oncol 2001)
Periode C. Diagnosis awal setelah muncul gejala klinis
Kolon kanan Kolon kiri Rektum

Nyeri perut samar- “gas pain cramps” Nyeri pada stadium

samar lanjut
Diare coklat/ hitam Darah segar pada Darah segar pada
kotoran kotoran
Anemi Tinja kaliber kecil Tidak puas setelah
berak
Benjolan perut sisi Perubahan Nyeri sewaktu berak
kanan kebiasaan berak, dan berak sering
butuh pencahar
Tanda sumbatan Morning diarea (lendir)
Pemeriksaan fisik
—  Tanda obstruksi atau peritonitis
—  Tumor masa intra abdomen (ukuran, lokasi, mobilitas,
konsistensi)
—  Pembesaran hepar
—  Sr Marie Nodule (nodule sekitar umbilicus): terdapat
peritoneal seeding
—  L.n. inguinal
—  Rectal toucher
RECTAL TOUCHER
—  Kanker dubur (rektum) >50% dari seluruh kanker usus besar)
—  Colok dubur: 2/3 distal dari dubur
—  Pasien diminta mengejan : tumor 1/3 proximal mobil dapat diraba
—  Diskripsikan: jarak dari anal verge, besar, lokasi thd lingkaran
rektum, kerapuhan, mobilitas terhadap dinding rektum dan
terhadap organ sekitar (mobile, tethered atau fixed) serta
limfonodi di mesorektum.
PROKTOSIGMOIDOSKOPI
—  Dilanjutkan foto kolon
dobel kontras untuk
melihat sisa kolon (adanya
synchronous tumor)
—  Deskripsi tumor
—  Jarak tumor dari anal verge
—  Biopsi/ polipektomi
FOTO KONTRAS USUS BESAR
—  Bukan tindakan pertama tetapi
disarankan sebagai kelanjutan
proktosigmoidoskopi, fleksibel
sigmoidoskopi atau kolonoskopi
yang tidak bisa melihat sekum
—  Foto kontras ganda pilihan terbaik
—  Perkembangan baru: Virtual CT-
Colonography à bisa melihat
kondisi intralumen colon yang diisi
kontras udara à mendeteksi
polip/ tumor.
KANKER USUS BESAR,
TUMBUH KEDALAM, ATAU
MELINGKAR, PADA FOTO
AKAN NAMPAK KONTRAS
TISAK MENGISI PENUH
ATAU MENYEMPIT
SIFAT-SIFAT KANKER
1.  Pertumbuhan cepat
2.  Menyebar
3.  Menerobos / Invasi
4.  Bebenjol tidak rata
5.  Selaput lendir berubah sifat
6.  Rapuh mudah berdarah
LABORATORIUM
—  CEA: tidak akurat untuk diagnostik, baik untuk follow-up
menilai hasil pengobatan.
—  Alkali fosfatase: bisa meningkat pada metastase hepar, tetapi
tidak spesifik.
PRE-OPERATIVE STAGING FOR
COLORECTAL CANCER
—  Detect distant metastases (liver, lung, bone )
—  Detect lymph node involvement
—  Local staging: Deep of penetration and surrounding organ
infiltration

Ø  Chest X ray, USG, CT Scan, MRI

Ø  Endosonography
TUMOR YANG TUMBUH BESAR,
DINDING USUS MENEBAL DAN
LOBANG USUS MENYEMPIT
STAGING RECTAL CANCER

IMPORTANT TO KNOW THE DEPTH OF TUMOR

PENETRATION à EVALUATE T
- ENDO ANAL ULTRASONOGRAPHY (EUS)
- CT SCAN or MRI
TO EVALUATE THE NODE (N):
- EUS, CT, MRI
TO EVAALUATE DISTANT METASTASES:
- CT
- CHEST X RAY
PREOPERATIVE STAGING FOR RECTAL
CANCER
—  Accurate information about infiltration of tumor is important for
deciding local excision, with or without preoperative chemo
radiation
—  The best modality for determining invasion into the layer of bowel
wall is endorectal ultrasonography
—  The best modality for visualization of endopelvic fascia
involvements is CT or MRI, with 92% agreement with histology.
—  T2 & T3 (distant to endopelvic fascia more than 2mm) need
preoperative chemoradiotherapy
—  Spiral CT scan: lung, liver, retroperitoneal and primary tumor can
all be visualized à ‘one-stop shop’

Wiggers: Staging of rectal cancer. BJS 2003;90:895-896

TNM classification
q  T= primary tumor —  N= regional lymph nodes

Tx: primary tumour cannot be Nx: Regional l.n. cannot be assessed

assessed N0: No regional l.n. metastasis
T0: No evidence of primary tumour N1: Metastasis in 1 to 3 reg. l.n.
Tis: Carinoma insitu N2: Metastasis in 4 or more reg. l.n.
T1: Tumour invades submucosa
T2: Tumour invades muscularis —  M= Distant metastasis
propria
T3: Tumour invades muscularis Mx: Distant metastases cannot be assessed
propria into subserosa or M0: No distant metastasis
perirectal/ pericolic tissue non M1: Distant metastasis
peritoneal
T4. Tumor directly invades other organ
or perforated
TNM Classification
Stage 0 Tis, N0, M0

Stage I T1 or T2, N0, M0

Stage II T3 or T4, N0, M0

Stage III All T, N1 or N2 , M0

Stage IV All T, All N, M1

STAGE OF DISEASE AND SURGERY OF COLON CANCER
Stage Tis, N0, M0 Endoscopic mucosal
0 resection (EMR)/
polipectomy
Stage T1 or T2, N0, Curative resection for T2
I M0 (R0)
Stage T3 or T4, N0, Curative or paliative
II M0 resection (R0, R1 or R2)
Stage All T, N1 or May curative (R0) but
III N2 , M0 mostly paliative resection
(R1 or R2)
Stage All T, All N, May be curative if M1 can
IV M1 be completely removed
CLINICAL STAGE & MODALITY OF TREATMENT IN RECTAL
CANCER

—  T1-N0 : trans anal endoscopic mucosal resection

—  T2-N0: trans-abdominal resection
—  T3, N0 or any T, N1-2: Preoperative chemoradiation followed by
transabdominal resection
—  T4 or metastatic disease:
resectable à anorectal resection ,
unresectable à diverting colostomy, stenting & chemoradiation
§  Total mesorectal excision
§  Sphincter preserving procedure for middle rectal cancer.

NCCN: Practice Guidelines in Oncology-v.3.2010 Rectal cancer

 Radiotherapy in colorectal cancer.
Dutch Colorectal Cancer Group 1996-1999
—  924 patients preoperative radiotherapy (5Gy on each of 5 days)
followed by TME (Group I) vs 937 patients TME only (Group
II)
—  2 years survival: 82.0% vs 81.8%
—  Local reccurrence at 2 years: 2.4% vs 8.2% (P<0.001)
—  Postoperative radiotherapy was mandatory for patients with
positive circumferential margin.

Keus R.B. Radiotherapy in Colorectal cancer. Dutch foundation

postgraduate medical course 2004
 TYPES OF SURGERY

¨  RIGHT HEMICOLECTOMY

(EXTENDED) (A & B)
¨  TRANSVERSECTOMY (C)
¨  LEFT HEMICOLECTOMY (D)
¨  EXTENDED LEFT
HEMICOLECTOMY (E)
¨  SIGMOIDECTOMY (F)
¨  SUBTOTAL/TOTAL
COLECTOMY (G)
¨  ANTERIOR RESECTION
¨  SPHINCTER PRESERVING
SURGERY
¨  ABDOMINO-PERINEAL
RESECTION
¨  INTERNAL DIVERSION
¨  COLOSTOMY
Sphincter saving procedure:
after total mesorectal excision
folowed by distal irrigation,
resection and anastomosis
DEFUNCTIONING
ILEOSTOMY
CHEMOTHERAPY FOR COLORECTAL
CANCER

—  In-operable case

—  Residual tumor (+) or probable after resection
—  High grade malignancy