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
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