General Data:
Case Presentation and discussion on Gastrointestinal Tumor By: Roderick S. Mujer MD. 2nd Year Surgery Resident Ospital ng Maynila Medical Center
72 year-old male from San Andres Bukid Manila
History of Present Illness 3 months PTA
(+) Changes in bowel habits Pencil like stool Constipation (-) Consult (-) meds taken
3 days PTA
(+) Crampy Abdominal pain (+) Tenesmus (+) Vomiting (-) BM
2 days PTA
(+) ↑ Abdominal distension (- ) Flatus
Chief Complaint Abdominal Distension
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History of Present Illness 1 day PTA
Increasing severity Consulted at IM ER NGT: Fecaloid material
History of Present Illness Plain Film: Distended Bowel loops Up to descending colon
History of Present Illness Referred to Surgery ER
Past Medical History
Admission
Unremarkable
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Family History:
Personal & Social History
(+) prostate CA ( Father)
Non smoker non alcoholic beverage drinker
Abdomen:
Physical Examination General Survey:
distended hypoactive to absent bowel sounds (+) direct tenderness all over (+) muscle guarding
Conscious, coherent, oriented
Vital Signs: BP=110/80 HEENT: CHEST: CARDIAC:
CR=96
RR=26
T=37.8
Pink palpebral conjunctivae, Anicteric sclerae (-)NAD, (-) TPC, (-) CLA SCE, No retractions, clear and equal breath sounds Adynamic precordium, Tachycardic, regular rhythm, no murmur
Rectal: good sphincteric tone, rectal vault collapsed (+) mucoid feces on tactating finger
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Abdominal distension Severe generalized Abdominal pain X-Ray: Dilated bowel loops up to the descending colon Left sided Intestinal Obstruction
Salient Features: 72 years old, male, (+) abdominal distention (+) generalized abdominal pain (+) tenderness all over (+) muscle guarding (+) collapsed rectal vault (+) Fecaloid material/ NGT (+) dilated bowel loops up to descending colon
Tumor (65%)
Volvolus( 5%)
Diverticular dse (20%)
Pre-Treatment Diagnosis CONDITION
CERTAINTY
TREATMENT
PRIMARY
Intestinal Obstruction; 2ndry to tumor
90%
surgical
SECONDARY
Intestinal Obstruction 2ndry to a diverticulitis
10%
surgical
Do I Need a Paraclinical Diagnostic Procedure?
NO
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Treatment Options
Goal of Treatment • Resolve the underlying cause of obstruction • Restore bowel continuity
BENEFIT Main goal Colectomy With Intraoperative +++ Lavage And Anastomosis
Hartmann Procedure and delayed anastomosis Colectomy, colostomy, mucous fistula, and delayed anastomosis colostomy
Pre-Operative Preparation 1. Psychosocial
Preparation • Procedure explained to patient 2. Screening for associated medical problem • CXR 3. Optimizing physical condition • NGT placed • Antibiotics started • Fluid resuscitation 4. Preparation of operative needs • Blood prepared • Patient booked for emergency Explor-Lap
++
++
+
RISK
COST
Anaesthesia ≈ Leak rate 7% SWI 10.81%
5,000.007,000.00
0.6-17%
Anaesthesia ≈ Leak rate 4-16%
5,000.007,000.00
2-25%
0.6-17%
Anaesthesia ≈ Leak rate 4-16%
5,000.007,000.00
25-48%
31-41%
Anaesthesia ↓
5,000.00
Morbidity
Mortality
14-20%
6-11%
2-25%
AVAILABILITY
+ + + +
Intra Operative Findings • (+) generalized peritonitis • (+) gross fecal spillage • (+) sigmoid tumor perforation 6 cm from the peritoneal reflection • Resectable • (+) regional lymph node • (+) dilated proximal colon with heavy fecal load
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Intra Operative Findings
Goal Of Treatment 1. Resection of the tumor thereby achieving complete resolution of obstruction 2. Tumor Free margin of resection 3. Least morbidity and mortality
(+) Annular mass with 90% Luminal Obstruction
Treatment Options BENEFIT Main goal Morbidity
RISK
COST
AVAILABILITY
Mortality
Hartmann Procedure and delayed anastomosis
√
2-25%
0.6-17%
Anaesthesia ≈ 5,000.00Leak rate 7,000.00 4-16%
Sigmoidectomy with double barreled colostomy
√
2-25%
0.6-17%
Anaesthesia ≈ 5,000.00Leak rate 7,000.00 4-16%
√
√
Operation Done: Exploratory Laparotomy Sigmoidectomy Hartmann’s Procedure Reasons for Choice of Treatment: 1. Short distal stump 2. sigmoid tumor perforation 3. generalized peritonitis 4. gross fecal spillage
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Operative Technique • • • • • •
Patient supine Asepsis antisepsis Sterile drapes placed Midline incision carried down to the peritoneum Intraop findings noted Peritoneal lavage done
Operative Technique • Ligation and division of IMA • Sigmoidectomy 10 cm proximal margin 2 cm distal margin
Operative Technique • Liberation of the sigmoid and descending colon • Incision of the left paracolic gutter cepahalad to the splenic flexure
Operative Technique Hartmann’s Procedure
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Operative Technique • • • • • •
Peritoneal lavage Instrument and sponge checked Layer by layer closure Partial skin closure Colostomy bag applied Wound dressing
Final Diagnosis Intestinal Obstruction with Generalized Peritonitis 2ndry to a perforated Sigmoid carcinoma Stage III (T4N1M0) Dukes C
Post Op Care 1st POD
NGT maintained
Follow-Up Plan
Hydration continued IV Antibiotics
3rd POD
Catheter removed NGT removed
Goal of Post operative surveillance: Early detection of potentially resectable disease
Diet as tolerated 5th POD
IVF consumed Shifted to oral meds
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Follow-Up Plan • History and physical examination every 3-6 months for first 2 years • Either colonoscopy or Barium Enema every 6months for the first 2 years of Follow up If normal perform every 5 years
Follow-Up Plan Most common symptom of recurrent disease Intestinal obstruction Abdominal mass Gastrointestinal bleeding Anorexia & weight loss
Follow-Up Plan Adjuvant chemotherapy 5FU 425mg/m2 BSA + leucovorin 20mg/m2 BSA on days 1 to 5; every 4 weeks for 6 months
Thank You!!
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References: 1.
Cameron JL: Current surgical therapy: colorectal cancer 1998; (6)217-227.
2.
Naraynsingh V, Rampaul R, Maharaj D, et al. Prospective study of primary anastomosis without colonic lavage for patients with an obstructed left colon.
3.
De Salvo GL, Gava C, Pucciarelli S: Curative Surgery for obstruction from primary left colorectal carcinoma: primary or staged resection? (Cochrane Review). Coch Lib. 2004.
•
Zorcolo L, Covotta L, Carlomagno N, Bartolo DC. Safety of primary anastomosis in emergency colo-rectal surgery. Rev Gastroenterol Mex. 1999; 64(3):127-33.
References: 5.
6.
Wolmark N, Rockette H, Mamounas E, et al: Clinical trial to assess the relative efficacy of flurouracil and leucovorin, flurouracil and levamisole, and flurouracil, leucovorin, and levamisole in patients with Dukes’ B and C carcinoma of the colon: Results from National Surgical Adjuvant Breast and bowel Project C-04. J Clin Oncol 1999; 17:3553-3559 Tan SG, Nambiar R, Rauff A, Ngoi SS, Goh HS: Primary resection and anastomosis in obstructed descending colon due to cancer. Ir Med J.1996;89(4):138-9.
Risk Factors Discussion
• Age ≥50 years old • Increased risk – – – –
Adenomatous polyposis syndrome Familial adenomatous polyposis Family history of polyps or colorectal cancer Inflammatory bowel disease
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Etiology • Detoxification enzymes glutathione S transferase (GSH transferase) N- acetyltransferase protection from the effects of mutagen induced DNA damage
Etiology • Red meat intake heterocyclic amines (present in cooked meat) mutagenic compounds reactive molecules form adducts to DNA
Etiology
Etiology
• ↑ cholesterol intake → ↑bile acid production • Alcohol and tobacco intake 1.6-4.54% RR for adenoma formation
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Prevention • Dietary factors increase fiber intake dilution of mitogenic activity within the stool
Prevention • Dietary factors vitamin and mineral intake calcium → binds fatty acids & bile acids in the stool
↓ exposure of colonic mucosa to mutagens ↓ colonic mucosal proliferation
Prevention • Dietary factors vitamin and mineral intake vitamin A, C, E → Antioxidant
Prevention • Energy Intake, Physical Activity, and Obesity obesity & ↓physical activity alteration in intestinal prostaglandin activity correlate with colon cancer risk
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Spread of colorectal cancer • Liver most commonly involved organ colon drained by the portal venous system • Lungs via systemic circulation middle and inferior hemorrhoidal vein drains to the IVC
2003 AJCC Staging System TNM CLASSIFICATION Primary tumor (T) 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 the subserosa or into nonperitonealized pericolic or perirectal tissues T4 tumor directly invades other organs or structures and/or perforates visceral peritoneum
Spread of colorectal cancer • Vertebral involvement pelvis & lumbosacral spine vertebral venous plexus high pressure system open during special circumstances eg. Defecation allow tumor cells to invade vertebral bones & CNS using communications between portal system and paravertebral veins
2003 AJCC Staging System TNM CLASSIFICATION Regional Lymph Nodes (N) Nx regional lymph nodes cannot be assessed N0 no regional lymph node metastasis N1 metastasis in 1 to 3 regional lymph nodes N2 metastasis in 4 or more regional lymph nodes
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2003 AJCC Staging System TNM CLASSIFICATION
AJCC/UICC
Distant Metastasis (M) Mx Distant metastasis cannot be assessed M0 No distant metastasis M1 distant metastasis
Stage 0
Tis
N0
M0
-
Stage I
T1
N0
M0
A
T2
N0
M0
-
T3
N0
M0
B
T4
N0
M0
-
Any T
N1
M0
C
Any T
N2
M0
-
Any T
Any N
M1
-
Stage II
Stage III
Stage IV
Perforating Cancers • Perforation of the colon site of colon tumor itself bowel proximal to an obstructing tumor
65-82% 18-35%
• 5-year survival rate (localized perforation) • colorectal ca
44% 2-8%
Dukes
5 year surivival
90%
60-80%
20-50%