Colorectal Carcinoma

and Polyps

SENG Jingjing
Department of General
Surgery
Surgical Anatomy
•Large intestine
•Cecum and the
ileocecal valve
•Ascending colon
and hepatic flexure
•Transverse colon
•Splenic flexure
•Descending colon
•Sigmoid colon
•Rectum
•Anus
Average Length:
135-150cm
The function of the
colon
•Water absorption
•Evacuation of fecal
waste
 Three Gross
Characteristic
•Taeniae coli
•Haustra
•Appendices epiploicae
 Taeniae coli
The outer
longitudinal
muscular coat is
concentrated into
three separate
longitudinal scrips
Haustra of the colon
Which are
sacculations or
protrusions of the
bowel wall between
the taeniae
 Appendices
epiploicae

Which are
extensions of
peritoneal fat
Their appearance on
simple radiographs of
the abdomen is
characteristic and often
allows distinction of the
colon from the small
intestine
Blood supply of the
colon
Ileocolic,right colic middle
colic branches of the
superior mesenteric
artery
the cecum assending
colon hepatic flexure and
proximal portion of the
transverse colon
 The inferior
mesenteric artery
distal transverse
colon,
splenic flexure
descending colon
 The left colic artery
and branches of the
sigmoid and superior
hemorrhoidal vessels
->sigmoid
 The middle
hemorrhoidal and
the inferior
hemorrhoidal
arteries
->rectum
 Colorectal
Carcinoma and
Polyps
 Introduction
Cancer of the colon and
rectum is the second most
common malignancy in men
and the third most common
in women in the western
world
Adenocarcinomas
majority
Carcinoid tumour
Others rare
• Lymphoma
• Squamous
carcinomas ----
anus and canal skin
Polyp
nasal polyps
endometrial polyps
polyps of peutz-
Jehger syndrome
Colorectal Polyps
•Polys are a common
finding in the large bowel
•Their great importance is
in relation to malignant
change
•Most colorectal
polyps are
adenomas and all of
these have potential
for malignant
change
 Pathological
Classification of
Colorectal Polyps
Neoplasms
Adenomas
Early Carcinomas
Lymphomas
Leiomyomas and leiomyosarcomas
Lipomas and liposarcomas
Carinoid Tumors
Hyperplasias
Metaplastic mucosal Polyps
Lymphoid Aggregations
Hamartomas
Angiomas
Juvenile Polyps
Inflammatory Polyps
 Adenomatous
polyps(adenomas)
Malignant potential
•Adenomas are
clinically important
because they
undergo malignant
change
 Histological
Patterns
•Tubular adenomas
•Villous adenomas
•Tubulo-villous
adenomas
 Familial
adenomatous
polyposis(FAP)
•When multiple tububar
adenomas occur
throughout the large
bowel ,in this inherited
condittion there is a
very high risk of early
malignant
transformation
Symptoms and signs
of coloretal polyps
Early stages:
no symptoms
Rectal bleeding
Anaemia
Tenesmus
Prolapse
 Diagnosis of
colorectal polyps
Colonoscopy and
Biopsy
Barium Enema
Examination
 Management
•Remove the
polyps
•Resect the bowel
Adenocarcinoma of
Colon and Rectum
Epidemiology
•The diease is rare
before the age of
40,but it is common
after the age of 60
•There is little
difference in
incidence between
the sexes
•First degree
relatives of patients
with colorectal
cancer have a two-
fold increased risk
of developing this
malignancy
•It is a disease of
developed
countries
•Western low-
fibre,high-fat diet
is the related factor
 Metastasis
•Lymphatic spread
•The bloodstream
spread-liver
Presentation
•The right colon is larger
in diameter and the
faecal stream more fluid
.therofore tumors of the
right colon rarely cause
obstruction unless the
ileo-caecal valve is
involved
•Occult bleeding from the
tumor surface commonly
causes iron deficiency
anaemia and these these
patients typically present
with anaemia and a
polyable mass in the right
iliac fossa
• The stool in the left colon is
more solid than on the right
and so left-sided cancers
usually present with a change
in bowel habit or precipitate
an emergency admission to
hospital with large bowel
obstruction which may be
partial or complete
•Blood is often visible
in the stool and the
character of the blood
and its mixing with
stool depends on how
far the lesion is from
the anus
•Lesions(carcinomas or polyps)
in the lower two-thirds of the
rectum may be preceired as a
mass of faeces. This
stimulates a persistent
defaecation response causing
the symptom of tenesmus
•A cancer eroding
through the bowel
wall may stimulate
a vigorous local
inflammatory
process resulting in
a pericolic abscess.
•This occurs in the recto-
sigmoid area and
usually presents with
left iliac fossa pain and
tenderness and a
swinging fever.
Differential diagnosis is
acute diverticulitis or
divertialar
•A carcinoma anywhere in
the colon may peritonitis .
Occasionally a malignant
fistula occurs into stomach
bladder,uterus,vagina or to
the skin
Clinical Signs
Rectal Examination

•Carcinomas occur in
the lowest 12cm of
the large bowel and
can be reached with
an examining finger.
 General
Examination
•Anaemia
•Obvious weight loss
•Supraclavicular
node enlargement
 Abdominal
examination
•Colonic mass
•Liver enlargement
due to metastases
or ascites
 Investigation
•Proctoscopy
•Sigmoidscopy
•Colonoscopy
•Barium enema
•Ultrasound or CT
scanning
•Many
patients,especially the
eldly,presents as
emergencies with
complete large bowel
obstruction ,often in the
sigmiod colon or recto-
sigmoid junction
 Differential diagnosis
• Benign tumours
• Ovarian or uterine tumours
• Extension from carcinoma of the
prostate or cervix
• Diverticular disease
• Endometriosis
• Lymphogranuloma inguinale
• Amoebic granuloma
• faeces
MANAGEMENT
•Surgical resection
is the main
treatment for
colorectal
carcinoma
 Rectum cancer
• Surgery depends upon
the distance of the
tumour from the anal
verge
• Uppers-third tumours can
be resected with
restorative anastomosis
between the sigmoid colon
and the lower
rectum(anterior resection)
• Lower-third tumours, less
than 5cm from the anal
verge, are usually treated
by abdomino-perineal
excision of the rectum,with
a terminal colostomy.
• Mid-third rectal tumours can
usually be treated by anterior
resection,provided that
satisfactory distal cleanrance can
be obtained.The operation is
easier in the female ,where the
wider pelvis facilitates
dissection.
•Adjuvant
radiotherapy and
chemotherapy are
sometimes used
but benefits are as
yet equivocal
Staging
Dukes’classification
 Dukes’A
•Tumour confined to
the bowel wall with no
extension in to the
extrarectal or
extracolic tissues and
no lymph node
metastases
 Dukes’B
•Tumour spread confined
to the extrarectal or
extracolic tissues by
direct continuity but
without lymph node
metastases
 Dukes’C
•lymph node
metastases
•C1 in which only a
few nodes are
involved near the
primary growth
,leaving proximal
nodes free from
metastases
•C2 in which there
is a continuous
string of involved
lymph nodes up to
the proximal limit
of resection
 Dukes’D
•This is a later
addition to duke’s
staging ,based on
clinical rather than
pathological
evidence.
•These patients are found
at operation to have
distant metastases or
such extensive local or
nodal spread that the
lesion is surgically
incurable whatever the
pathological staging
 5-year survival
rates
•Dukes’A 97%
•Dukes’B 80%
•Dukes’C1 65%
•Dukes’C2 35%
 Complications of
large bowel surgery
Early Complications
•Wound infections
•Intra-abdominal
abscess
•Systemic sepsis
and multi-organ
failure
•Anastomotic leak
breakdown
•Inadvertent
damage to other
organs
•Stoma problems
Later complications
 Diarrhoea
•Division of pelvic
parasympathetic
nerves small
bowel obstruction
 Bowel Cleaning
Techniques
1 、 Withdrawal of
solid foods
2 、 Purgation
3 、 Enemas and distal
bowel washouts.