large intestine

TSMU. Surgery Direction N1

Large intestineLarge intestine

Obstruction of the colon;Obstruction of the colon; Diverticular disease of the Diverticular disease of the

coloncolon Ulcerative colitis;Ulcerative colitis;


Large intestine AnatomyLarge intestine Anatomy

From the end of the ileum, to From the end of the ileum, to the recrum;the recrum;

The right colon: cecum, The right colon: cecum, ascending colon, hepatic ascending colon, hepatic flexure, proximal transverse flexure, proximal transverse colon;colon;

The left colon: distal The left colon: distal transverse colon, splenic transverse colon, splenic flexure, decending colon, flexure, decending colon, sigmoid colon, rectosigmoid;sigmoid colon, rectosigmoid;



Ascending & descending Ascending & descending colons are fixed in the colons are fixed in the retroperit space;retroperit space;

Transverse and sigmoid Transverse and sigmoid colons are suspended by colons are suspended by their mesocolons.their mesocolons.

4 layers: mucosa, 4 layers: mucosa, submucosa, muscular (inner submucosa, muscular (inner circular and outer circular and outer longitudinal) and serosa;longitudinal) and serosa;



The rectum: 12-15 cm in The rectum: 12-15 cm in length. The teniae coli are length. The teniae coli are not apparent distal to the not apparent distal to the rectosigmoid junction;rectosigmoid junction;

The upper rectum posteriorly The upper rectum posteriorly is retroperitoneal;is retroperitoneal;

The anterior peritoneal The anterior peritoneal reflection is 6-8 cm above reflection is 6-8 cm above the anal verge. the anal verge.


Large intestine PhysiologyLarge intestine Physiology

Absorbtion (electrolytes Absorbtion (electrolytes and water in proximal and water in proximal colon), colon),

secretion, secretion, motility, motility, intraluminal digestion;intraluminal digestion;


Large intestine: X-rayLarge intestine: X-ray Plain films: gas distribution; Plain films: gas distribution; An obstructing colon cancer An obstructing colon cancer

may demostrate dilatation of may demostrate dilatation of the proximal colon, air-fluid the proximal colon, air-fluid level (Kloiber sign); level (Kloiber sign);

Barium enema: Barium enema: diverticulums, cancer diverticulums, cancer

Double-column barium Double-column barium enema (barium+air enema (barium+air insufflation): more sensitive insufflation): more sensitive for small lessions;for small lessions;

Barium enema procedure. The patient lies on an x-ray table. Barium liquid is put into the rectum and flows through the colon. X-rays are taken to look for abnormal areas.


Large intestine: CT & MRILarge intestine: CT & MRI CT: useful in the diagnosis of CT: useful in the diagnosis of

masses, appendicitis and masses, appendicitis and diverticulitis. diverticulitis.

CT colography (“virtual CT colography (“virtual colonoscopy”): 3D colonoscopy”): 3D ereconstruction of the air ereconstruction of the air distended colon; distended colon;

MRI: better for cancer MRI: better for cancer stagingstaging

PET (positron emission PET (positron emission tomography) 95% sensitive tomography) 95% sensitive and 98% specific in the and 98% specific in the cancer recurrencecancer recurrence


Large intestine:Large intestine: Fiberoptical colonoscopy Fiberoptical colonoscopy

direct vision of entire colon, direct vision of entire colon, biopsy, brushing;biopsy, brushing;

Diagnostic colonoscopy:Diagnostic colonoscopy: Therapeutic colonoscopy: Therapeutic colonoscopy:

excision of polyps, bleeding excision of polyps, bleeding control, foreign body removal, control, foreign body removal, volvulus detorsion, stricture volvulus detorsion, stricture dilatation, dilatation,


Large intestine:Large intestine: Fiberoptical colonoscopy Fiberoptical colonoscopy

Contraindications: Contraindications:

fulminant colitis and fulminant colitis and suspected perforation suspected perforation (relative);(relative);

Complication: Complication: perforation (0,1-0,2%), perforation (0,1-0,2%), bleeding (0,2%)bleeding (0,2%)

A colonoscope is inserted through the rectum into the colon. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples


Large intestine: other methodsLarge intestine: other methods

Proctosigmoidoscopy;Proctosigmoidoscopy; Flexible sigmoidoscopy (65 cm Flexible sigmoidoscopy (65 cm

length);length); Angiography(to detect bleeding Angiography(to detect bleeding

sites); sites);

Sigmoidoscopy. A thin, lighted tube is inserted through the anus and rectum and into the lower part of the colon to look for abnormal areas.


Obstruction of the Large intestineObstruction of the Large intestine

15% of all intestinal 15% of all intestinal obstructions.obstructions.

Reasons: Reasons: Carcinoma (65%)Carcinoma (65%) Volvulus (5%)Volvulus (5%) Diverticular disease Diverticular disease

(20%)(20%) Inflamatory disordersInflamatory disorders Benign tumorsBenign tumors Fecal impactionFecal impaction



Essentials of diagnosis:Essentials of diagnosis: Constipation;Constipation; Distension, tenderness;Distension, tenderness; Abdominal pain (severe, Abdominal pain (severe,

continuous in case of ischemia, continuous in case of ischemia, cramping “comes and goes”);cramping “comes and goes”);

Nausea, vomiting (late)Nausea, vomiting (late) X-ray findingsX-ray findings Peristaltic waves may be seen if Peristaltic waves may be seen if

abdominal wall is thin;abdominal wall is thin; High-pitched, metallic tinkles, High-pitched, metallic tinkles,

rushes, gurgles may be heard;rushes, gurgles may be heard; Tenderness, palpable massTenderness, palpable mass



Imaging studies:Imaging studies: Distended colon creates Distended colon creates

“picture frame” outlining “picture frame” outlining abdominal cavity;abdominal cavity;

Haustration can distinguish Haustration can distinguish colon from small intestine;colon from small intestine;

Contrast enemaContrast enema Barium must not be given orally Barium must not be given orally

if obstruction is suspected;if obstruction is suspected; CT is the most useful test. CT is the most useful test.

Giving info about location and Giving info about location and etiologyetiology


Obstruction of the Large intestine: Obstruction of the Large intestine: differential diagnosisdifferential diagnosis

Small vs large bowelSmall vs large bowel Slow in onset, Slow in onset, less pain, less pain, may not cause may not cause

vomiting or late vomiting or late vomiting;vomiting;

Elderly patients with Elderly patients with no surgery or prior no surgery or prior attacks of obstruction attacks of obstruction often have carcinomaoften have carcinoma



Paralitic ileus:Paralitic ileus: Result of peritonitis or Result of peritonitis or

trauma to the back or trauma to the back or pelvis; pelvis;

No crampingNo cramping Abdomen is silent;Abdomen is silent; Enema excludes Enema excludes

obstructionobstruction



Pseudo-obstruction (Ogilvie’s Pseudo-obstruction (Ogilvie’s syndrome):syndrome):

Colonic distension in the Colonic distension in the absence of a mechanical absence of a mechanical reason. reason.

Extraintestinal illness: renal, Extraintestinal illness: renal, cardiac, respiratory, trauma cardiac, respiratory, trauma (vertebral fracture)(vertebral fracture)

X-ray, enemaX-ray, enema Nasogastric suction, Nasogastric suction,

enemas, colon tubing, enemas, colon tubing, neostigmin is effectiveneostigmin is effective

Massive cecal dilatation (a hallmark of the Ogilvie syndrome) with dilatation of other parts of the colon.


Obstruction of the Large intestine: Obstruction of the Large intestine: TreatmentTreatment

In case of obstruction, In case of obstruction, operative treatment is operative treatment is required. required.

Resection with primary Resection with primary anastomosis;anastomosis;

Resection with Resection with entero/colostomy (ileostoma, entero/colostomy (ileostoma, cecostoma, cecostoma, transversostoma, transversostoma, sigmostoma). Temporary or sigmostoma). Temporary or final; final;

No resection with bypassNo resection with bypass


Resection and colostomy Resection and colostomy


Resection Resection of Transversal Colon of Transversal Colon with primary anastomosiswith primary anastomosis


Staging of colon CancerStaging of colon Cancer

From Stage 0 to IV

Stage 0 (Carcinoma in Situ)

abnormal cells are found in the innermost lining of

the colon. These abnormal cells may become cancer and spread into nearby

normal tissue.



Stage Icancer has formed and spread beyond

the innermost tissue layer of the colon wall to the middle layers.



Stage II.Stage IIA: Cancer has spread

beyond the middle tissue layers of the colon wall or

has spread to nearby tissues around the colon or rectum.

Stage IIB: Cancer has spread

beyond the colon wall into nearby organs and/or

through the peritoneum.



Stage III colon cancerStage IIIA: Cancer has spread from

the innermost tissue layer of the colon wall to the middle layers and has spread to as many as 3 lymph

nodes. Stage IIIB: Cancer has spread to as many as 3 nearby lymph nodes and

has spread: beyond the middle tissue layers

of the colon wall; or to nearby tissues around the

colon or rectum; or beyond the colon wall into

nearby organs and/or through the peritoneum.



Stage IIIC: Cancer has spread to 4 or more nearby lymph

nodes and has spread: to or beyond the middle tissue layers of the colon

wall; or to nearby tissues around the colon or rectum; or to nearby organs and/or through the peritoneum.

Stage III colon cancer is sometimes called Dukes C

colon cancer.



Stage IVcancer may have spread to nearby

lymph nodes and has spread to other parts of the body, such as the liver or lungs.


Cancer of the Large intestineCancer of the Large intestine

5-15 years of silent growth 5-15 years of silent growth are required before a are required before a cancer reaches cancer reaches symptom-producing symptom-producing size. size.

Routine screening since Routine screening since the age of 50.the age of 50. 1X10year1X10year



Right Colon: Right Colon: Unexplained weakness or Unexplained weakness or

anemia;anemia; Occult blood in feces;Occult blood in feces; Dyspeptic symptoms;Dyspeptic symptoms; Persistant right abdominal Persistant right abdominal

discomfort;discomfort; Palpable abdominal mass;Palpable abdominal mass; X-rayX-ray ColonoscopyColonoscopy



Left Colon: Left Colon: Change in bowel habits;Change in bowel habits; Gross blood in stool;Gross blood in stool; Obstructive symptoms;Obstructive symptoms; X-rayX-ray Colonoscopy or Colonoscopy or

sigmoidoscopysigmoidoscopy



Rectum: Rectum: Rectal bleeding;Rectal bleeding; Alteration in bowel Alteration in bowel

habits;habits; Sensation of incomplete Sensation of incomplete

evacuation;evacuation; Intrarectal palpable Intrarectal palpable

mass;mass; SigmoidoscopySigmoidoscopy



Ways of cancer spreading: Ways of cancer spreading: Direct extension (grows Direct extension (grows

circumferentially and nmay completely circumferentially and nmay completely encircle the bowel before it is encircle the bowel before it is diagnosed);diagnosed);

Hematogenous mts (hepatic, lungs, Hematogenous mts (hepatic, lungs, ovaries, ..). Avoid mts producing by ovaries, ..). Avoid mts producing by minimizing manipulation of the tumor minimizing manipulation of the tumor prior to ligation of the blood supply. prior to ligation of the blood supply.

Regional lymph node mts (most Regional lymph node mts (most common form of tumor spread)common form of tumor spread)

Transperitoneal mts (“seeding” when Transperitoneal mts (“seeding” when extended through serosa);extended through serosa);

Intraluminal MTS (swept along in the Intraluminal MTS (swept along in the fecal current). fecal current).



Diagnosis: Diagnosis: Lab finding. Most Lab finding. Most

familiar marker for familiar marker for cancer of the bowel is cancer of the bowel is CEA (carcinoembryonic CEA (carcinoembryonic antigen);antigen);

Barium enemaBarium enema


Cancer of the Large intestine Cancer of the Large intestine TreatmentTreatment

Wide resection of the colon with Wide resection of the colon with regional lymphatics;regional lymphatics;

Resection indicated even in the Resection indicated even in the presence of distant MTS to presence of distant MTS to avoid obstruction and bleeding;avoid obstruction and bleeding;

The extent of resection of the The extent of resection of the colon for cancers in various colon for cancers in various locations and the methods for locations and the methods for rstoration of continuityrstoration of continuity


Treatment Options for Colon CancerTreatment Options for Colon CancerStage 0 (Carcinoma in Situ)Stage 0 (Carcinoma in Situ)

Treatment of stage 0 Treatment of stage 0 (carcinoma in situ) may (carcinoma in situ) may include the following types include the following types of surgery:of surgery:

Local excision or simple Local excision or simple polypectomy. polypectomy.

Resection/anastomosis. Resection/anastomosis. This is done when the This is done when the tumor is too large to tumor is too large to remove by local excision.remove by local excision.


Treatment Options forTreatment Options for Stage I-II Stage I-II Colon CancerColon Cancer

Stage I Colon CancerStage I Colon Cancer usually usually

resection/anastomosis.resection/anastomosis.

Stage II Colon CancerStage II Colon Cancer Resection/anastomosis. Resection/anastomosis. Clinical trials of Clinical trials of

chemotherapy, radiation chemotherapy, radiation therapy, or biologic therapy, or biologic therapy after surgery.therapy after surgery.

Right Hemicolectomy

http://www.ispub.com/ispub/ijeicm/volume_7_number_1_3/acute_colonic_pseudo_obstruction_the_ogilvie_syndrome_a_case_report_and_review_of_literature/ogilvie-fig1.jpg


Treatment Options forTreatment Options for Stage III Stage III Colon CancerColon Cancer

Resection/anastomosis with Resection/anastomosis with chemotherapy. chemotherapy.

Clinical trials of chemotherapy, radiation Clinical trials of chemotherapy, radiation therapy, and/or biologic therapy after therapy, and/or biologic therapy after surgery.surgery.

This summary section refers to specific This summary section refers to specific treatments under study in clinical trials, treatments under study in clinical trials, but it may not mention every new but it may not mention every new treatment being studied. Information treatment being studied. Information about ongoing clinical trials is available about ongoing clinical trials is available from the NCI Web site.from the NCI Web site.

Check for clinical trials from NCI's PDQ Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are Cancer Clinical Trials Registry that are now accepting patients with stage III now accepting patients with stage III colon cancer.colon cancer.

Left Hemicolectomy

Sigmoidectomy


Treatment Options for Treatment Options for Stage IV Stage IV Colon Colon CancerCancer Resection/anastomosisResection/anastomosis (surgery to (surgery to

remove the cancer or bypass the tumor and remove the cancer or bypass the tumor and join the cut ends of the colon). join the cut ends of the colon).

Surgery to remove parts of other organs,Surgery to remove parts of other organs, such as the liver, lungs, and ovaries, where such as the liver, lungs, and ovaries, where the cancer may have recurred or spread. the cancer may have recurred or spread.

RadiationRadiation therapy or chemotherapy may be therapy or chemotherapy may be offered to some patients as palliative offered to some patients as palliative therapy to relieve symptoms and improve therapy to relieve symptoms and improve quality of life. quality of life.

Clinical trials of Clinical trials of chemotherapychemotherapy and/or and/or biologic therapy.biologic therapy.

Treatment of locally recurrent colon cancer Treatment of locally recurrent colon cancer may be may be local excisionlocal excision..

Special treatments of cancer that has Special treatments of cancer that has spread to or recurred in the liver may spread to or recurred in the liver may include the following:include the following:

ChemotherapyChemotherapy followed by resection. followed by resection. RadiofrequencyRadiofrequency ablation or cryosurgery. ablation or cryosurgery. Clinical trials of hepatic Clinical trials of hepatic

chemoembolizationchemoembolization with radiation therapy. with radiation therapy.


Radiofrequency Radiofrequency ablation:ablation:

The use of a special probe The use of a special probe with tiny electrodes that kill with tiny electrodes that kill cancer cells. Sometimes cancer cells. Sometimes the probe is inserted the probe is inserted directly through the skin directly through the skin and only local anesthesia is and only local anesthesia is needed. In other cases, the needed. In other cases, the probe is inserted through probe is inserted through an incision in the abdomen. an incision in the abdomen. This is done in the hospital This is done in the hospital with general anesthesia. with general anesthesia.

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CryosurgeryCryosurgery NNew technique that can destroy ew technique that can destroy tumors in a variety of sites (brain, tumors in a variety of sites (brain, breast, kidney, prostate, liver).breast, kidney, prostate, liver).

It is It is the destruction of abnormal the destruction of abnormal tissue using sub-zero temperatures. tissue using sub-zero temperatures.

The tumor is not removed and the The tumor is not removed and the destroyed cancer is left to be destroyed cancer is left to be reabsorbed by the body. reabsorbed by the body.

Initial results in properly selected Initial results in properly selected patients with unresectable liver patients with unresectable liver tumors are equivalent to those of tumors are equivalent to those of resection.resection.

Cryosurgery involves the placement Cryosurgery involves the placement of a stainless steel probe into the of a stainless steel probe into the center of the tumor. Liquid nitrogen center of the tumor. Liquid nitrogen is circulated through the end of this is circulated through the end of this device.device.


ChemotherapyChemotherapyMMay be given ay be given before or after before or after operation, IV or intraperitoneqaly. operation, IV or intraperitoneqaly. Followed by Followed by radiation therapy radiation therapy or or without. If without. If given after the surgery, given after the surgery, is called adjuvant therapy.is called adjuvant therapy.

Chemotherapy is a cancer Chemotherapy is a cancer treatment that uses drugs to stop treatment that uses drugs to stop the growth of cancer cells, either the growth of cancer cells, either by killing the cells or by stopping by killing the cells or by stopping them from dividing. them from dividing.

SSystemic chemotherapyystemic chemotherapy:: if if taken taken per os or IVper os or IV. .

RRegional chemotherapyegional chemotherapy: if: if chemotherapy is placed directly chemotherapy is placed directly into the spinal column, an organ, into the spinal column, an organ, or a body cavity such as the or a body cavity such as the abdomen, the drugs mainly affect abdomen, the drugs mainly affect cancer cells in those areas. cancer cells in those areas.


ChemoembolizationChemoembolization What is chemoembolization?What is chemoembolization? AA palliative treatment for palliative treatment for primary or primary or

metastasizedmetastasized liver liver cancercancer During chemoembolization, three chemotherapy During chemoembolization, three chemotherapy

drugs are injected into the artery that supplies drugs are injected into the artery that supplies blood to the tumor in the liver. The artery is then blood to the tumor in the liver. The artery is then blocked off ("embolized") with a mixture of oil blocked off ("embolized") with a mixture of oil and tiny particles. This procedure accomplishes and tiny particles. This procedure accomplishes four things: four things:

The tumor becomes deprived of oxygen and The tumor becomes deprived of oxygen and nutrients once the blood supply is blocked. nutrients once the blood supply is blocked.

Because these drugs are injected directly at the Because these drugs are injected directly at the tumor site, this dosage is 20 to 200 times tumor site, this dosage is 20 to 200 times greater than that achieved with standard greater than that achieved with standard chemotherapy injected into a vein in the arm. chemotherapy injected into a vein in the arm.

Because the artery is blocked, no blood washes Because the artery is blocked, no blood washes through the tumor. As a result, the drugs stay in through the tumor. As a result, the drugs stay in the tumor for a much longer time - as long as a the tumor for a much longer time - as long as a month. month.

There is a decrease in side effects because the There is a decrease in side effects because the drugs are trapped in the liver instead of drugs are trapped in the liver instead of circulating throughout the body. circulating throughout the body.


ChemoembolizationChemoembolization How does chemoembolization How does chemoembolization

work?work?The liver is unique in having two The liver is unique in having two blood supplies - the hepatic artery blood supplies - the hepatic artery and the portal vein. The normal liver and the portal vein. The normal liver gets about 75% of its blood from the gets about 75% of its blood from the hepatic artery. hepatic artery.

When a tumor grows in the liver, it When a tumor grows in the liver, it receives almost all of its blood supply receives almost all of its blood supply from the hepatic artery. Therefore, from the hepatic artery. Therefore, chemotherapy drugs injected into the chemotherapy drugs injected into the hepatic artery at the liver reach the hepatic artery at the liver reach the tumor very directly, sparing most of tumor very directly, sparing most of the healthy liver tissue.the healthy liver tissue.

Then, when the artery is blocked, Then, when the artery is blocked, nearly all of the blood supply is taken nearly all of the blood supply is taken away from the tumor, while the liver away from the tumor, while the liver continues to be supplied by blood continues to be supplied by blood from the portal vein.from the portal vein.


Radiation therapyRadiation therapy UUses high-energy x-rays or other ses high-energy x-rays or other

types of radiationtypes of radiation.. TTargets rapidly dividing cells like argets rapidly dividing cells like

cancer cells. cancer cells. PPrevents cell division and the revents cell division and the

replication of DNA replication of DNA Two typesTwo types::

ExternalExternal: : uses a machine uses a machine outside the body to send outside the body to send radiation toward the cancer. radiation toward the cancer.

InternalInternal:: uses a radioactive uses a radioactive substance sealed in needles, substance sealed in needles, seeds, wires, or catheters that seeds, wires, or catheters that are placed directly into or near are placed directly into or near the cancer. the cancer.

The way the radiation therapy is The way the radiation therapy is given depends on the type and given depends on the type and stage of the cancer. stage of the cancer.


Thank U 4 your Thank U 4 your attention. Questions?attention. Questions?

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