Colectomy - Standard Treatment Guidelines
Sir William Arbuthnot was one of the early proponents of the usefulness of total colectomies. Colectomy is commonly performed for the treatment of colon cancer.
Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Colectomy. Following are the major recommendations :
Colectomy implies the surgical resection of any extent of the large intestine (colon). Based on the segment of colon removed colectomies are termed as
1. Right hemicolectomy.
2. Extended right hemicolectomy
3. Transverse colectomy
4. V resection
5. Left hemicolectomy
6. Extended left hemicolectomy
9. Total colectomy
10. Total proctocolectomy
11. Subtotal colectomy
Indian Incidence : not documented
- Inflammatory bowel disease-ulcerative colitis, Crohn’s disease
- Tuberculous stricture of the large bowel with obstruction
- Vascular malformations with lower gastro intestinal bleeding
In familiar situations like FAP & HNPCC early colectomy is advised.
It is important to understand the carcinogenesis in colorectal cancer & the associated molecular events.
Environmental Factors also pay an important role, particularly dietary factors & estrogen replacement.
Association between hyperplastic polyposis & colorectal cancer & adenomas called sporadic MIS tumuors
Colorectal cancers: are Sporadic in 75% cases & Genetic in 25% (younger age at diagnosis)
Positive Familial history is present in 15%-20%.
HNPCC (5%)-80% risk
FAP(less than 1%)-100% risk of development of CRC – prophylactic total colectomy/proctocolectomy
Predisposition Should be counselled & Screened For Colon Cancer.
Screening colonoscopy and polypectomy – reduces colon cancer mortality.
Optimal Diagnostic Criteria :
Anatomical locations and clinical manifestations of colon cancer
|Distribution %||Ascending / Caecum||Transverse||Descending/Sigmoid|
Low back pain
- Colonoscopy – investigation of choice
- - Biopsy & HPE
- - Brush cytology if biopsy is not possible
- X-ray abdomen – if patient presents with features of large bowel obstruction
- Double contrast barium enema :
- When colonoscopy is contra indicated or not available
- Findings – constant irregular filling defect
- Detects associated lesions
- Small ulcerative lesions can be diagnosed
- USG abdomen
- Endoluminal ultrasound – if available
- CECT – if available is used in large palpable abdominal masses
= To determine local invasion
- Urograms – when evidence of hydronephrosis on USG/ CT in left sided tumours
1. Pre op evaluation of staging, respectability, patient’s operative risks are mandatory.
2. Accurate localization of tumour – of particular importance.
- Sometimes known cancer may not be apparent on serosal aspect.
- Localization by tattooing during colonoscopy, Barium enema.
- Pre op CT, USG assessment of iver metastasis should be done
Pre OP Preparation :
Mechanical bowel preparation
Blood grouping and cross matching
Operative Techniques :
Resection should follow
Standard oncological principles:
- Proximal ligation of primary arterial supply at its margins
- Adequate proximal & distal margins(5 cm) determined by area supplied by the primary feeder artery
- Appropriate lymphadenectomy – harvesting of minimum 12 nodes
- Extent of resection is an important prognostic factor (SAGES guidelines 2000)
- Any tumour not removed intraoperatively strongly influences prognosis & therapy
Ro – absence of residual tumour, margins free histologically
R1 – no gross residual tumour but margins histologically positive
R2 – residual gross disease remains unresected
Radial Margin :
T4 lesions are a complex group & should be considered separate from other T groups
Radial tumour free margins should be resected. Radial margin should be histologically free of disease for resection to be curative.
Specimen labeling, marking are important for a good pathological report
R1 & R2 resection – incomplete resection for cure affects curability though TNM stage remains same
Lateral Circumferential Margin :
In addition to radial, proximal & distal margins, circumferential margins should also be pathologically assessed. Positive margins are associated with increased rate of local and distal failure.
Disease free survival and mortality significantly related to margin involvement after TME
ADJUVANT Ro stage:
Adjuvant therapies require complete resection
A case is not Ro if it is
- Non enbloc resection
- Radial margins positive for disease
- Bowel margin positive for disease
- Residual lymph node disease present or
- Nx (incomplete staging)
Should be radical (up to the level of origin of primary feeding artery)
Apical nodes positive for disease may have prognostic significance in addition to number of positive lymph nodes
ENBLOC RESECTION of adherent tumours : En bloc removal of adjacent organs locally invaded by cancer colon can achieve survival rates similar to patients with tumour that do not invade an adjacent organ, provided negatgive resection margins are achieved.
Perforation of Tumour Should be Avoided (Sages Guideline)
Inadvertent full thickness perforation of rectum would probably classify tumour as T4 and resection as R1
Perforation at the site of cancer, as opposed to an area remote from the tumour has a greater impact on survival & local recurrence.
Inadvertent local perforation predisposes to local recurrence and warrants post-operative radiotherapy.
Intraoperative Spillage :
Has AN Independentt Effect on Prognosis
Adjuvant radiotherapy may be considered to decrease rates of local recurrence
No Touch Technique :
Surgical Procedures :
Anatomical Resection of Colon Cancer
|Tumour location||Vascular Ligation||Colon resection||Anastamosis|
|Caecum, ascending colon||ileo-colic, right colic||Right hemicolectomy||ileotransverse colostomy|
|Hepatic flexure, Proximal transverse colon||ileocolic right, middle colic||Extended right hemicolectomy with omentectomy||iIeodescending colostomy|
|Distal transverse colon splenic flexure||ileocolic right, middle or left branch of middle colic, left colic||Extended right hemicolectomy with omentectomy or Left hemicolectomy||ileosigmoid colostomy or Transverse sigmoid colostomy|
|Descending colon||Inferior mesenteric or left colic||Left hemicolectomy||Transverse colorectal anastamosis|
|Sigmoid colon||Inferior mesenteric or sigmoid||Left colectomy or Sigmoid resection||Transverse colorectal anastamosis or descending colorectal anastamosis|
Colectomy may be performed by the
i) Conventional open technique
Patients suspected of colon cancer & biopsy proven should be referred to a higher centre for further evaluation and treatment when
1) Adequate surgical facilities are not available / surgeon does not have sufficient experience in colon cancer surgery.
2) Competent pathologist to report on malignant lesions as per standard oncological guidelines is not available.
3) For adjuvant / neo-adjuvant radio and chemo therapy
Patient requiring colectomy for biopsy proven cancer are best referred to a super specialty centre
In view of the need for multi modality treatment.
All investigations as in situation 1
- Spiral CT in elderly patients more than 80 years
- CT colonoscopy also called virtual colonoscopy – 6 mm polyps may be picked up effectively
- CEA – fetal glycoprotein
- Increased pre op CEA in node positive Ca – indication for chemotherapy
- MRI :
- PET : detection of metastasis
- SPECT – if single photon emission is studied, such as technetium or thallium
- FDG-PET – useful in evaluation of recurrent colorectal cancer
-Differentiates post op changes from recurrent / residual disease
-Useful diagnostic tool but prohibitive cost
- CT-PET – fusion tests provide the most powerful integrated images
- NUCLEAR MEDICINE IMAGING:
-Using 131 I , 111 In, 99m Tc bound to monoclonal antibodies, leucocytes & erythrocytes.
As outlined in situation 1.
Laparoscopic resection is gaining popularity. However it is not freely available & performed as per protocols.
A. Synchronous malignancies or polyps
Patients with synchronous malignancies should be considered for subtotal colectomy depending on the distance between lesions
Colonic cancer with multiple adenomatous polyps – subtotal colectomy
(Due to increased risk of metachronous lesion and to facilitate surveillance of the remaining colon)
Factors that influence the decision to perform prophylactic subtotal colectomy
- size of accompanying polyps
- compliance of patient
B. Cancer is a polyp
Complete endoscopic removal of polyp with cancer in situ – no further treatment
Histoplathology shows invasive carcinoma:
Ensure that endoscopic polypectomy was complete
Specimen was submitted with proper orientation to the pathologist for histopathology
Carcinoma at margin of resection requires formal resection
Carcinoma with free margins – a. thorough pathological review,
b. identification of adverse histological features
- poor differentiation,
- lymphatic or venous invasion
- invasion into the stock of the polyp – formal resection
It is difficult to locate the previous polypectomy site during surgery
Even if polyp is not removed it may be soft and difficult to palpate through the colon wall
Endoscopic distance (from anal verge or dentate line) misleading
Polypectomy site should be videotaped for later review and marked with vital dye that can be seen serosally at the time of surgery
C. Obstructing Cancers- 2% of colorectal cancers
Partial obstruction – Gentle bowel preparation over several days-Elective surgery
- Rt colon cancers – Rt Hemi colectomy – immediate ileocolostomy
- Lt colon cancers
1) Endoscopic decompression by laser passed beyond the obstructed
Segment – This allows mechanical preparation and elective resection.
- This is possible only when the narrowed lumen can be traversed by the endoscope.
- It is not possible when obstruction is complete
2) Primary resection and immediate anastamosis with ontable colonic washout with or without proximal colostomy.
3) Primary resection with colostomy. Anastamosis at second stage.
4) Subtotal colectomy with primary anastamosis
5) Decompressive colostomy followed by formal colonic resection
D. Adjacent organ involvement- 10%
Locally advanced tumours are potentially curable with multi organ resection.-Do not necessarily Portend a dismal prognosis.
- A non metastasizing variant of colon cancer grows to a large size without spreading to regional nodes
- Separation of adhesions adjacent to a malignancy can lead to dissemination of tumour cells.
- Enbloc resection of these tumours, depending on location can lead to five year survivals of 70% Hepatic metastases – 10% at the time of exploration
- Solitary metastasis amenable to –wedge resection with clear margins can be removed concomitantly.
- Formal hepatic lobectomy done as a second stage procedure.
E. Ovarian metastasis – 7% at the time of colon resection
Oophorectomy: at the time of colorectal surgery
- Large ovarian metastasis (Krukenbergt’s tumour) which are symptomatic (prevents second surgery for the metastasis, benefit of preventing primary ovarian cancer)
- Direct ovarian involvement
- Post menopausal women – prophylactic oophorectomy
F. Inadvertent Perforation
- Predisposes to local recurrence
- Warrants post op radiotherapy
Aim: Early detection of recurrence or metachronous lesion
History Physical examination
Faecal occult blood
CBC } every 3 months-first 3 years
LFT } every 6 months additional 2 years
Tumour markers (CEA) - monthly – 3 years, 3 monthly-next 2 years
Colonoscopy – first colonoscopy within 6-12 months of surgery, yearly-next 2 years, 2-3 yearly thereafter.
CT abdomen and pelvis – if primary loco regionally advanced
- LFT ↑
- CEA ↑
80-90% of recurrence of colon cancers occurs in the first two years.
All patients should be admitted when a colectomy is planned
WHO DOES WHAT?
- Surgeon: diagnosis & work up Pre operative planningOperative procedurePost operative follow up
- Radiotherapist : radiotherapy – neoadjuvant & adjuvant
- Medical oncologist : Chemotherapy
- Anesthetist: PAC, anesthesia, post op ICU management
- Siting of colostomy when required by some nurse
- Care of stoma
- Dressing of the wound
- Pre & post operative care
- Pre op equipment and drugs to be checked and kept ready
- Assist anesthetist in the OT
- Assist the surgeon, positioning of the patient
Resources Required For One Patient / Procedure (Patient weight 60 Kgs)
|1.||Surgeon – 1 Medical Officer / Assistant Surgeon – 1|
Anesthetist – 1 Pathologist – 1 Staff Nurse – 1 Technician – 1 Nursing Orderly – 1
Sweeper – 1
Urine Analysis Blood Sugar S. Electrolytes
X-Ray – Chest
Catheters Anesthetic drugs Dressings
|OT Table &|
|2.||Consultant – 1|
Residents – 1
Anesthetist – 1
Pathologist – 1
Medical Oncologist – 1
Radiotherapist – 1
Staff Nurse – 2
Stoma therapist – 1
Technician – 1
Nursing Orderly – 1
Sweeper - 1
|Same as above +|
|Same as above||Same as above +|
Guidelines by The Ministry of Health and Family Welfare :
Dr. Ajit Sinha & Dr. V. Ramesh