Surgery
COLON CANCER
ANATOMY:
 The colon begins at the junction of the terminal ileum and
cecum and extends 3 to 5 feet to the rectum.
 The cecum is the widest diameter portion of the colon (normally
7.5–8.5 cm) and has the thinnest muscular wall.
o As a result, the cecum is most vulnerable to
perforation and least vulnerable to obstruction.
 The ascending colon is usually fixed to the retroperitoneum.
 The intraperitoneal transverse colon is relatively mobile
 The descending colon is relatively fixed to the
retroperitoneum.
 The sigmoid colon is the narrowest part of the large intestine
and is extremely mobile.
o Although the sigmoid colon is usually located in the
left lower quadrant, redundancy and mobility can
result in a portion of the sigmoid colon residing in the
right lower quadrant.
o The narrow caliber of the sigmoid colon makes this
segment of the large intestine the most vulnerable to
obstruction.
 BLOOD SUPPLY:
 Superior Mesenteric Artery
o Branches:
 Ileocolic artery (absent in up to 20% of
people)- Cecum and proximal ascending
colon
 Right colic artery- ascending colon
 Middle colic artery-transverse colon
 Inferior Mesenteric Artery
o Branches:
 Left colic artery- descending colon
 Sigmoidal branches- sigmoid colon
 Superior rectal artery- proximal rectum
 The terminal branches of each artery form anastomoses with
the terminal branches of the adjacent artery and communicate
via the marginal artery of Drummond. This arcade is
completein only 15% to 20% of people.
 LYMPHATIC DRAINAGE:
o The sentinel lymph nodes are the first one to four
lymph nodes to drain a specific segment of the colon
and are thought to be the first site of metastasis in
colon cancer.
 NERVE SUPPLY:
o Sympathetic nerves arise from T6-T12 and L1-L3.
o The parasympathetic innervation to the right and
transverse colon is from the vagus nerve; the
o parasympathetic nerves to the left colon arise from
sacral nerves S2-S4 to form the nervi erigentes.
INCIDENCE:
 Colorectal carcinoma is the most common malignancy of the
gastrointestinal tract.
 Colorectal Carcinoma is ranked 4th for both sexes in the
Philippines. (Philippine cancer society, 2010)
EPIDEMIOLOGY (RISK FACTORS):
 Aging
o Dominant risk factor for colorectal cancer
o More than 90% of cases diagnosed are in people
older than age 50 years.
 Hereditary Risk Factors
o Approximately 80% of colorectal cancers occur
sporadically, while 20% arise in patients with a
known family history of colorectal cancer.
 Environmental and Dietary Factors
o diets high in animal fat and low in fiber
o Animal studies suggest that fats may be directly toxic
to the colonic mucosa and thus may induce early
malignant changes.
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Inflammatory Bowel Disease
o It is hypothesized that chronic inflammation
predisposes the mucosa to malignant changes, and
there is some evidence that degree of inflammation
influences risk.
 Cigarette Smoking
o is associated with an increased risk of colonic
adenomas, especially after more than 35 years of
use.
PATHOGENESIS:
 Mutations may cause activation of oncogenes (K-ras) and/or
inactivation of tumor suppressor genes (APC, deleted in
colorectal carcinoma [DCC], p53).
 Colorectal carcinoma is thought to develop from adenomatous
polyps by accumulation of these mutations in what has come to
be known as the adenoma carcinoma sequence
Polyps:
 is a nonspecific clinical term that describes any projection from
the surface of the intestinal mucosa regardless of its histologic
nature.
 Neoplastic Polyps:
o Tubular adenomas are associated with malignancy
in only 5% of cases
o Villous adenomas may harbor cancer in up to 40%
o Tubulovillous adenomas are at intermediate risk
(22%)
o Although most neoplastic polyps do not evolve to
cancer, most colorectal cancers originate as a polyp.
o Polyps may be pedunculated or sessile.
 Hyperplastic Polyps:
o These polyps are usually small (<5 mm) and show
histologic characteristics of hyperplasia without any
dysplasia.
o Not considered premalignant
o Large hyperplastic polyps (>2 cm) may have a slight
risk of malignant degeneration.
 Serrated Polyps:
o Some of these polyps will develop into invasive
cancers
 Hamartomatous Polyps (Juvenile Polyps):
o Not premalignant
o These lesions are the characteristic polyps of
childhood but may occur at any age.
o Bleeding is a common symptom, and intussusception
and/or obstruction may occur.
o Because the gross appearance of these polyps is
identical to adenomatous polyps, these lesions
should also be treated by polypectomy.
o Mutation in PTEN
o Familial juvenile polyposis is an autosomal dominant
disorder in which patients develop hundreds of
polyps in the colon and rectum.
 Premalignant
 Annual screening should begin between
the ages of 10 and 12 years
 Inflammatory Polyps (Pseudopolyps):
o From Inflammatory bowel disease
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 o These lesions are not premalignant, but they cannot o A personal history of colorectal cancer or
be distinguished from adenomatous polyps based on adenomatous polyps
gross appearance and therefore should be removed. o A personal history of inflammatory bowel disease
(ulcerative colitis or Crohn’s disease)
Inherited Colorectal Carcinoma: o A strong family history of colorectal cancer or polyps
 Familial Adenomatous Polyposis (FAP): o A known family history of a hereditary colorectal
o This rare autosomal dominant condition accounts for cancer syndrome such as familial adenomatous
only about 1% of all colorectal adenocarcinomas. polyposis (FAP) or Lynch syndrome (hereditary non-
o Caused by mutation in APC gene polyposis colon cancer or HNPCC)
o Clinically, patients develop hundreds to thousands of
adenomatous polyps shortly after puberty.
o The lifetime risk of colorectal cancer in FAP patients
approaches 100% by age 50 years.
o Flexible sigmoidoscopy of first-degree relatives of
FAP patients beginning at age 10 to 15 years has
been the traditional mainstay of screening.
CLINICAL MANIFESTATIONS:
HISTORY:
 Typically asymptomatic for a long period of time; symptoms, if
present, depend on location and size
 RIGHT SIDED CANCERS:
o Occult bleeding with melena, iron deficiency anemia,
diarrhea and weakness
 LEFT SIDED CANCERS:
o Rectal bleeding, obstructive symptoms
(constipation), change in bowel habits and/or stool
caliber
 BOTH:
o Weight loss, anorexia, abdominal pain
PE: (Non specific)
 Abdominal tenderness, macroscopic rectal bleeding, palpable
abdominal mass, hepatomegaly, ascites
 Is rectal exam enough to screen for colorectal CA? (ACS) ROUTES OF SPREAD AND NATURAL HISTORY
o It’s not recommended as a stand-alone test for  Regional lymph node involvement is the most common form
colorectal cancer. This simple test, which is not of spread of colorectal carcinoma and usually precedes distant
usually painful, can find masses in the anal canal or metastasis or the development of carcinomatosis.
lower rectum. But by itself, it’s not a good test for  The T stage (depth of invasion) is the single most significant
detecting colorectal cancer because it only checks predictor of lymph node spread.
the lower rectum.  Four or more involved lymph nodes predict a poor prognosis.
 In colon cancer, lymphatic spread usually follows the major
PREVENTION: SCREENING AND SURVEILLANCE venous outflow from the involved segment of the colon.
 Lymphatic spread from the rectum follows two routes.
o In the upper rectum, drainage ascends along the
superior rectal vessels to the inferior mesenteric
nodes.
o In the lower rectum, lymphatic drainage may
course along the middle rectal vessels.
 The most common site of distant metastasis from colorectal
cancer is the liver.
o These metastases arise from hematogenous spread
via the portal venous system.
STAGING:

American Cancer Society (ACS) recommendations for colorectal

cancer early detection:
 People at average risk:
o asymptomatic, no family history of colorectal
carcinoma, no personal history of polyps or
colorectal carcinoma, no familial syndrome
 People at increased or high risk:
o need to start colorectal cancer screening before age
50 and/or be screened more often

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PREOPERATIVE MANAGEMENT:
 Surgery for colorectal cancer should be avoided if the hazards
are deemed to outweigh the potential benefits
 When it is decided that surgery is to proceed, certain
fundamental aspects of preparation should be considered.
These are listed below:
o a) Informed consent
o b) Preparation for stoma formation
o c) Cross-matching
o d) Bowel preparation
o e) Thromboembolism prophylaxis
o f) Antibiotic infection prophylaxis
o g) Enhanced recovery
STAGE-SPECIFIC THERAPY:
 Stage 0 (Tis, N0, M0)
o carry no risk of lymph node metastasis
o presence of high-grade dysplasia
o these polyps should be excised completely, and
pathologic margins should be free of dysplasia
o completely removed endoscopically
o followed with frequent colonoscopy
 Stage I: The Malignant Polyp (T1, N0, M0)
o based on the risk of local recurrence and the risk of
lymph node metastasis
o Invasive carcinoma in the head of a pedunculated
polyp with no stalk involvement carries a low risk
of metastasis (<1%) and may be completely resected
endoscopically.
o lymphovascular invasion, poorly differentiated
histology, or tumor within 1 mm of the resection
margin
 Segmental colectomy
o Invasive carcinoma arising in a sessile polyp
extends into the submucosa
 Segmental colectomy
 Stages I and II: Localized Colon Carcinoma (T1-3, N0, M0)
o Surgical resection
o Stage I: Rare to develop recurrence (Adjuvant
chemotherapy does not improve survival in these
patients)
o Stage II: Develop recurrence (adjuvant
chemotherapy has been suggested for selected
patients with stage II disease (young patients, tumors
with “high-risk” histologic findings)
 Stage III: Lymph Node Metastasis (T any, N1, M0).
o significant risk for both local and distant recurrence
o adjuvant chemotherapy has been recommended
routinely
o 5-Fluorouracil–based regimens (with leucovorin) and
oxaliplatin (FOLFOX) reduce recurrences and
improve survival in this patient population
 Stage IV: Distant Metastasis (T any, N any, M1)
o Survival is extremely limited
o The most common site of metastasis is the LIVER
o 20% are potentially resectable for cure. Survival is
improved in these patients (20% –40% 5-year
survival) when compared to patients who do not
undergo resection.
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o Hepatic resection of synchronous metastases from
colorectal carcinoma may be performed
o All patients require adjuvant chemotherapy
o The second most common site of metastasis is
the LUNG
o Although very few of these patients will be potentially
resectable, among those who are (about 1%–2% of
all colorectal cancer patients), long-term survival
benefit is approximately 30% to 40%.
o The remainder of patients with stage IV disease
cannot be cured surgically, and therefore, the
focus of treatment should be PALLIATION
 Lesions in the cecum and right colon
o right hemicolectomy 
o the ileocolic, right colic, and right branch of the
middle colic vessels are divided and removed
 Lesions in the proximal or middle transverse colon
o extended right hemicolectomy
o ileocolic, right colic, and middle colic vessels are
divided and the specimen is removed with its
mesentery
 Lesions in the splenic flexure and left colon
o left hemicolectomy
o The left branch of the middle colic vessels, the
inferior mesenteric vein, and the left colic vessels
along with their mesenteries are included with the
specimen.
 Sigmoid colon lesions
o sigmoid colectomy
 Total abdominal colectomy with ileorectal anastomosis
o Hereditary nonpolyposis colon cancer syndrome
(HNPCC)
o Attenuated familial adenomatous polyposis (FAP)
o Metachronous cancers in separate colon segment
POSTOPERATIVE MANAGEMENT:
• Monitor patient for signs of post-operative complications
• Controlling pain
• The patient is generally kept NPO until bowel function returns
• Fluid replacement
FOLLOW-UP and SURVEILLANCE:
 The goal of close follow- up observation is to detect
resectable recurrence and to improve survival.
 At risk for the development of recurrent disease (either locally
or systemically) or metachronous disease (a second primary
tumor)
 A colonoscopy should be performed within 12 months after the
diagnosis of the original cancer (or sooner if the colon was not
examined in its entirety prior to the original resection).
o If that study is normal, colonoscopy should be
repeated every 3 to 5 years thereafter.
o Most recurrences occur within 2 years of the
original diagnosis
PROGNOSIS:
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NOTE: Friends, yung colostomy e basahin niyo nalang sa book.
Wag niyo kalimutan basahin yun. Okay? 

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