Tratamiento del cancer de colon localmente avanzadoPete SagarSt Jamess University Hospital,Leeds, England

Surgery for advanced colonic cancerPete SagarSt Jamess University Hospital,Leeds, England

Recent history

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Prone APER

MR in rectal cancer

Assessment of circumferential margins

The scan depictsan intermediate signal intensity (grey) upper third rectal tumour (outlined in white). The mesorectal fascia (red line) is shown as a thin low signal intensity (black) lineenveloping the mesorectum posteriorly with the peritoneal reflection anteriorly (yellow line). The scan shows a malignant lymph node (blue line) close to the mesorectalfascia. The potential circumferential margin is defined as clear on the scan because this distance is 2 mm. The tissue slice shows the malignant node (arrow) close tothe margin with a distance >1 mm. The margin is therefore clearFig*

Pre-operative radiotherapy

Colon cancer

Distant history

King John signs Magna Carta1215

Battle of Agincourt 1415

Battle of Waterloo1815

Battle with advanced colon cancerInvasion into adjacent organs

Invasion into abdominal wall

Tackling nodal challenges

Troublesome recurrences

Napoleons master plan:Strategy

Appreciation of terrain

Superb timing

Steady nerve

Espirit de corps

A Surgeons 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

Napoleons 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

Albert knight*

Direct involvement of abdominal wall

Biological mesh with vacuum assisted closure

Napoleons tactical artEngage..Then wait and see

R colon Ca : SMV & branches

Albert Knight arrow at site of branches from SMV (below the 3 or 4 vessels*

Napoleons 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

Napoleons master plan:Strategy

Appreciation of terrain

Superb timing

Steady nerve

Espirit de corps

A surgeons masterful planAppreciation of hazards

Timing & boldness

Team work

Bataillion carr

Right & left flanks attack

Central strike force

Flexibility

Manoeuvre sur les derriersDashes 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 & ureterVessels

NervesMuscles

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 review22 studies1575 patients87% primary, 13% recurrent64% 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 wallSmall bowelUreterPancreasBladderMultimodality treatment for locally advanced colon cancer

Problems with multivisceral resectionNot 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 cancerNeoadjuvant chemo used in oesophageal, gastric and rectal Ca

? Eradicates micrometastases

Multimodality treatment for locally advanced colon cancerMayo clinic N=25External & intraop radiotherapy, surgery, & chemotherapy

Median survival = 38.2 months5 year survival = 49%

Taylor et al Annals Surg Oncol 2002; 177-82

Classification of recurrent colon cancer

Harji fig

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 mistakeRule 1

Page 1

Book of war

Biggest mistake

Never march on Moscow

Colonic vessels

Splenic injuryGood exposure & visualisationAvoid unnecessary tractionPlace retractors carefullyTake care dividing adhesions

Bleeding from the inferior mesenteric vessels

Activit, activit, vitesse !

Watch the top end

Pack & go for coffee

Pack firmly, not roughly, to avoid shearing

Overstretch

ConclusionKnow the terrain high quality imaging

Be bold when necessary

Dont over reach

Have a get out plan

Never march on Moscow in winter

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The scan depictsan intermediate signal intensity (grey) upper third rectal tumour (outlined in white). The mesorectal fascia (red line) is shown as a thin low signal intensity (black) lineenveloping the mesorectum posteriorly with the peritoneal reflection anteriorly (yellow line). The scan shows a malignant lymph node (blue line) close to the mesorectalfascia. The potential circumferential margin is defined as clear on the scan because this distance is 2 mm. The tissue slice shows the malignant node (arrow) close tothe margin with a distance >1 mm. The margin is therefore clearFig*Albert knight*Albert Knight arrow at site of branches from SMV (below the 3 or 4 vessels*Harji fig