Tratamiento del cancer de colon localmente avanzado

Pete SagarSt James’s University Hospital,

Leeds, England

Surgery for advanced colonic cancer

Pete SagarSt James’s University Hospital,

Leeds, England

Recent history

Prone APER

MR in rectal cancer

Assessment of circumferential margins

Pre-operative radiotherapy

Colon cancer

Distant history

King John signs Magna Carta1215

Battle of Agincourt 1415

Battle of Waterloo1815

Battle with advanced colon cancer

• Invasion into adjacent organs

• Invasion into abdominal wall

• Tackling nodal challenges

• Troublesome recurrences

Napoleon’s master plan:Strategy

• Appreciation of terrain

• Superb timing

• Steady nerve

• Espirit de corps

A Surgeon’s master plan:Strategy

• Appreciation of terrain

• Superb timing

• Steady nerve

• Espirit de corps

Behind the colon

Around the hepatic flexure

Blood supply

Blood supply to the left colon

Napoleon’s master plan:Strategy

• Appreciation of terrain

• Superb timing

• Steady nerve

• Espirit de corps

Locally advanced colon cancer

R colon Ca

R colon Ca about to fistulate

Direct involvement of abdominal wall

Biological mesh with vacuum assisted closure

Napoleon’s tactical art

Engage…..

Then wait and see

R colon Ca : SMV & branches

Napoleon’s master plan:Strategy

• Appreciation of terrain

• Superb timing

• Steady nerve

• Espirit de corps

Hepatic flexure invading duodenum

Hepatic flexure cancer invading pylorus, D1 and D2

Right colon Ca invading duodenum

Close to, but not invading, segment V of the liver

Splenic flexure Ca invading pancreas

Napoleon’s master plan:Strategy

• Appreciation of terrain

• Superb timing

• Steady nerve

• Espirit de corps

A surgeon’s masterful plan

• Appreciation of hazards

• Timing & boldness

• Team work

Bataillion carré

• Right & left flanks attack

• Central strike force

• Flexibility

Manoeuvre sur les derriers

• Dashes for Vienna in 1805 and 1809

• Get behind the enemy

Corps system

•“Converge all forces on the point I want to attack”

Locally advanced transverse colon cancer

Locally advanced transverse colon cancer

Locally advanced transverse colon cancer

The Sun of Austerlitz

• Iconic image of genius and luck

Splenic flexure cancer invading spleen, kidney tail of pancreas

Invasion into pancreas and kidney

Invasion into kidney and spleen

Spenic flexure cancer invading spleen , kidney tail of pancreas

Spenic flexure cancer invading spleen , kidney tail of pancreas

CT scan – caecal cancer

Caecal cancer with sacral involvement

Scalloping of the sacrum

Involved pelvic side wall

Tackling the pelvic side wallThink of the five layers

• Peritoneum & ureter• Vessels

• Nerves• Muscles

• Bones

1st layer – peritoneum & ureter

2nd layer - Iliac vessels

3rd layer - sacral nerves

4th layer – pelvic muscles

5th layer – pelvic bones

Multivisceral resection of colorectal cancer: Systematic review

• 22 studies• 1575 patients• 87% primary, 13% recurrent• 64% rectal, 36% colon

• Bladder and reproductive organs most common resection

Mohan et al Ann Surg Oncol 2013, 2929-36

Multivisceral resection

• Perioperative mortality = 4.2%• Postoperative morbidity = 42%• 5 year survival = 50.3%

• R0 resection strongest association with 5 year survival

• Main involved organs:– Abdominal wall– Small bowel– Ureter– Pancreas– Bladder

Multimodality treatment for locally advanced colon cancer

Problems with multivisceral resection

• Not always possible to identify need for MVR

• Distinguish inflammatory from invasion

• Significant morbidity

• USA – most patients with locally advanced colon ca not offered MVR

Preoperative chemotherapy for locally advanced colon cancer

• Neoadjuvant chemo used in oesophageal, gastric and rectal Ca

• ? Eradicates micrometastases

Multimodality treatment for locally advanced colon cancer

• Mayo clinic • N=25• External & intraop radiotherapy,

surgery, & chemotherapy

• Median survival = 38.2 months• 5 year survival = 49%

Taylor et al Annals Surg Oncol 2002; 177-82

Classification of recurrent colon cancer

Nodal deposit on renal fascia

Recurrence of colonic cancer

Recurrence invading iliacus/iliac bone

Colon ca recurrence invading symphysis pubis

MRI - mucinous drop metastasis

Colonic drop metastasis

Colonic drop metastasis

If discovered at operation….

• Describe findings in detail ….

• AND REFER !

Mistakes

Biggest mistake

• Rule 1

• Page 1

• Book of war

Biggest mistake

• Never march on Moscow

Colonic vessels

Splenic injury

• Good exposure & visualisation• Avoid unnecessary traction• Place retractors carefully• Take care dividing adhesions

Bleeding from the inferior mesenteric vessels

Activité, activité, vitesse !

Watch the top end

Pack & go for coffee

• Pack firmly, not roughly, to avoid shearing

Overstretch

Conclusion

• Know the terrain – high quality imaging

• Be bold when necessary

• Don’t over reach

• Have a get out plan

Never march on Moscow in winter