large intestine

TSMU. Surgery Direction N1
Large intestineLarge intestine
 Obstruction of the colon;Obstruction of the colon;
 Diverticular disease of theDiverticular disease of the
coloncolon
 Ulcerative colitis;Ulcerative colitis;

Large intestine AnatomyLarge intestine Anatomy
 From the end of the ileum, toFrom the end of the ileum, to
the recrum;the recrum;
 The right colon: cecum,The right colon: cecum,
ascending colon, hepaticascending colon, hepatic
flexure, proximal transverseflexure, proximal transverse
colon;colon;
 The left colon: distalThe left colon: distal
transverse colon, splenictransverse colon, splenic
flexure, decending colon,flexure, decending colon,
sigmoid colon, rectosigmoid;sigmoid colon, rectosigmoid;

 Ascending & descendingAscending & descending
colons are fixed in thecolons are fixed in the
retroperit space;retroperit space;
 Transverse and sigmoidTransverse and sigmoid
colons are suspended bycolons are suspended by
their mesocolons.their mesocolons.
 4 layers: mucosa,4 layers: mucosa,
submucosa, muscular (innersubmucosa, muscular (inner
circular and outercircular and outer
longitudinal) and serosa;longitudinal) and serosa;

 The rectum: 12-15 cm inThe rectum: 12-15 cm in
length. The teniae coli arelength. The teniae coli are
not apparent distal to thenot apparent distal to the
rectosigmoid junction;rectosigmoid junction;
 The upper rectum posteriorlyThe upper rectum posteriorly
is retroperitoneal;is retroperitoneal;
 The anterior peritonealThe anterior peritoneal
reflection is 6-8 cm abovereflection is 6-8 cm above
the anal verge.the anal verge.

Large intestine PhysiologyLarge intestine Physiology
 Absorbtion (electrolytesAbsorbtion (electrolytes
and water in proximaland 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 cancerAn obstructing colon cancer
may demostrate dilatation ofmay demostrate dilatation of
the proximal colon, air-fluidthe proximal colon, air-fluid
level (Kloiber sign);level (Kloiber sign);
 Barium enema:Barium enema:
diverticulums, cancerdiverticulums, cancer
 Double-column bariumDouble-column barium
enema (barium+airenema (barium+air
insufflation): more sensitiveinsufflation): 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 ofCT: useful in the diagnosis of
masses, appendicitis andmasses, appendicitis and
diverticulitis.diverticulitis.
 CT colography (“virtualCT colography (“virtual
colonoscopy”): 3Dcolonoscopy”): 3D
ereconstruction of the airereconstruction of the air
distended colon;distended colon;
 MRI: better for cancerMRI: better for cancer
stagingstaging
 PET (positron emissionPET (positron emission
tomography) 95% sensitivetomography) 95% sensitive
and 98% specific in theand 98% specific in the
cancer recurrencecancer recurrence

Large intestine:Large intestine:
Fiberoptical colonoscopyFiberoptical 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, bleedingexcision of polyps, bleeding
control, foreign body removal,control, foreign body removal,
volvulus detorsion, stricturevolvulus detorsion, stricture
dilatation,dilatation,

Large intestine:Large intestine:
Fiberoptical colonoscopyFiberoptical colonoscopy
 Contraindications:Contraindications:
fulminant colitis andfulminant colitis and
suspected perforationsuspected 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 cmFlexible sigmoidoscopy (65 cm
length);length);
 Angiography(to detect bleedingAngiography(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 intestinal15% of all intestinal
obstructions.obstructions.
Reasons:Reasons:
 Carcinoma (65%)Carcinoma (65%)
 Volvulus (5%)Volvulus (5%)
 Diverticular diseaseDiverticular 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 ifPeristaltic 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 createsDistended colon creates
“picture frame” outlining“picture frame” outlining
abdominal cavity;abdominal cavity;
 Haustration can distinguishHaustration can distinguish
colon from small intestine;colon from small intestine;
 Contrast enemaContrast enema
 Barium must not be given orallyBarium 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 andGiving 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 causemay not cause
vomiting or latevomiting or late
vomiting;vomiting;
 Elderly patients withElderly patients with
no surgery or priorno surgery or prior
attacks of obstructionattacks of obstruction
often have carcinomaoften have carcinoma

Paralitic ileus:Paralitic ileus:
 Result of peritonitis orResult of peritonitis or
trauma to the back ortrauma to the back or
pelvis;pelvis;
 No crampingNo cramping
 Abdomen is silent;Abdomen is silent;
 Enema excludesEnema excludes
obstructionobstruction

Pseudo-obstruction (Ogilvie’sPseudo-obstruction (Ogilvie’s
syndrome):syndrome):
 Colonic distension in theColonic distension in the
absence of a mechanicalabsence of a mechanical
reason.reason.
 Extraintestinal illness: renal,Extraintestinal illness: renal,
cardiac, respiratory, traumacardiac, 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.

TreatmentTreatment
In case of obstruction,In case of obstruction,
operative treatment isoperative treatment is
required.required.
 Resection with primaryResection with primary
anastomosis;anastomosis;
 Resection withResection with
entero/colostomy (ileostoma,entero/colostomy (ileostoma,
cecostoma,cecostoma,
transversostoma,transversostoma,
sigmostoma). Temporary orsigmostoma). Temporary or
final;final;
 No resection with bypassNo resection with bypass

Resection and colostomyResection and colostomy

ResectionResection of Transversal Colonof 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 I
cancer 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 cancer
Stage 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 IV
cancer 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 growth5-15 years of silent growth
are required before aare required before a
cancer reachescancer reaches
symptom-producingsymptom-producing
size.size.
Routine screening sinceRoutine screening since
the age of 50.the age of 50.
1X10year1X10year

Right Colon:Right Colon:
 Unexplained weakness orUnexplained weakness or
anemia;anemia;
 Occult blood in feces;Occult blood in feces;
 Dyspeptic symptoms;Dyspeptic symptoms;
 Persistant right abdominalPersistant 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 orColonoscopy or
sigmoidoscopysigmoidoscopy

Rectum:Rectum:
 Rectal bleeding;Rectal bleeding;
 Alteration in bowelAlteration in bowel
habits;habits;
 Sensation of incompleteSensation of incomplete
evacuation;evacuation;
 Intrarectal palpableIntrarectal palpable
mass;mass;
 SigmoidoscopySigmoidoscopy

Ways of cancer spreading:Ways of cancer spreading:
 Direct extension (growsDirect extension (grows
circumferentially and nmay completelycircumferentially and nmay completely
encircle the bowel before it isencircle the bowel before it is
diagnosed);diagnosed);
 Hematogenous mts (hepatic, lungs,Hematogenous mts (hepatic, lungs,
ovaries, ..). Avoid mts producing byovaries, ..). Avoid mts producing by
minimizing manipulation of the tumorminimizing manipulation of the tumor
prior to ligation of the blood supply.prior to ligation of the blood supply.
 Regional lymph node mts (mostRegional lymph node mts (most
common form of tumor spread)common form of tumor spread)
 Transperitoneal mts (“seeding” whenTransperitoneal mts (“seeding” when
extended through serosa);extended through serosa);
 Intraluminal MTS (swept along in theIntraluminal MTS (swept along in the
fecal current).fecal current).

Diagnosis:Diagnosis:
 Lab finding. MostLab finding. Most
familiar marker forfamiliar marker for
cancer of the bowel iscancer of the bowel is
CEA (carcinoembryonicCEA (carcinoembryonic
antigen);antigen);
 Barium enemaBarium enema

TreatmentTreatment
 Wide resection of the colon withWide resection of the colon with
regional lymphatics;regional lymphatics;
 Resection indicated even in theResection indicated even in the
presence of distant MTS topresence of distant MTS to
avoid obstruction and bleeding;avoid obstruction and bleeding;
 The extent of resection of theThe extent of resection of the
colon for cancers in variouscolon for cancers in various
locations and the methods forlocations and the methods for
rstoration of continuityrstoration of continuity

Treatment Options for Colon CancerTreatment Options for Colon Cancer
Stage 0 (Carcinoma in Situ)Stage 0 (Carcinoma in Situ)
 Treatment of stage 0Treatment of stage 0
(carcinoma in situ) may(carcinoma in situ) may
include the following typesinclude the following types
of surgery:of surgery:
 Local excision or simpleLocal excision or simple
polypectomy.polypectomy.
 Resection/anastomosis.Resection/anastomosis.
This is done when theThis is done when the
tumor is too large totumor is too large to
remove by local excision.remove by local excision.

Treatment Options forTreatment Options for Stage I-IIStage I-II
Colon CancerColon Cancer
Stage I Colon CancerStage I Colon Cancer
 usuallyusually
resection/anastomosis.resection/anastomosis.
Stage II Colon CancerStage II Colon Cancer
 Resection/anastomosis.Resection/anastomosis.
 Clinical trials ofClinical trials of
chemotherapy, radiationchemotherapy, radiation
therapy, or biologictherapy, or biologic
therapy after surgery.therapy after surgery.
Right Hemicolectomy

Treatment Options forTreatment Options for Stage IIIStage III
Colon CancerColon Cancer
 Resection/anastomosis withResection/anastomosis with
chemotherapy.chemotherapy.
 Clinical trials of chemotherapy, radiationClinical trials of chemotherapy, radiation
therapy, and/or biologic therapy aftertherapy, and/or biologic therapy after
surgery.surgery.
 This summary section refers to specificThis summary section refers to specific
treatments under study in clinical trials,treatments under study in clinical trials,
but it may not mention every newbut it may not mention every new
treatment being studied. Informationtreatment being studied. Information
about ongoing clinical trials is availableabout ongoing clinical trials is available
from the NCI Web site.from the NCI Web site.
 Check for clinical trials from NCI's PDQCheck for clinical trials from NCI's PDQ
Cancer Clinical Trials Registry that areCancer Clinical Trials Registry that are
now accepting patients with stage IIInow accepting patients with stage III
colon cancer.colon cancer.
Left Hemicolectomy
Sigmoidectomy

Treatment Options forTreatment Options for Stage IVStage IV ColonColon
CancerCancer
 Resection/anastomosisResection/anastomosis (surgery to(surgery to
remove the cancer or bypass the tumor andremove 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, wheresuch 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 betherapy or chemotherapy may be
offered to some patients as palliativeoffered to some patients as palliative
therapy to relieve symptoms and improvetherapy to relieve symptoms and improve
quality of life.quality of life.
 Clinical trials ofClinical trials of chemotherapychemotherapy and/orand/or
biologic therapy.biologic therapy.
 Treatment of locally recurrent colon cancerTreatment of locally recurrent colon cancer
may bemay be local excisionlocal excision..
 Special treatments of cancer that hasSpecial treatments of cancer that has
spread to or recurred in the liver mayspread 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 hepaticClinical trials of hepatic
chemoembolizationchemoembolization with radiation therapy.with radiation therapy.

RadiofrequencyRadiofrequency
ablation:ablation:
 The use of a special probeThe use of a special probe
with tiny electrodes that killwith tiny electrodes that kill
cancer cells. Sometimescancer cells. Sometimes
the probe is insertedthe probe is inserted
directly through the skindirectly through the skin
and only local anesthesia isand only local anesthesia is
needed. In other cases, theneeded. In other cases, the
probe is inserted throughprobe is inserted through
an incision in the abdomen.an incision in the abdomen.
This is done in the hospitalThis is done in the hospital
with general anesthesia.with general anesthesia.

CryosurgeryCryosurgery
 NNew technique that can destroyew 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 isIt is the destruction of abnormalthe destruction of abnormal
tissue using sub-zero temperatures.tissue using sub-zero temperatures.
 The tumor is not removed and theThe tumor is not removed and the
destroyed cancer is left to bedestroyed cancer is left to be
reabsorbed by the body.reabsorbed by the body.
 Initial results in properly selectedInitial results in properly selected
patients with unresectable liverpatients with unresectable liver
tumors are equivalent to those oftumors are equivalent to those of
resection.resection.
 Cryosurgery involves the placementCryosurgery involves the placement
of a stainless steel probe into theof a stainless steel probe into the
center of the tumor. Liquid nitrogencenter of the tumor. Liquid nitrogen
is circulated through the end of thisis circulated through the end of this
device.device.

ChemotherapyChemotherapy
MMay be givenay be given before or afterbefore or after
operation, IV or intraperitoneqaly.operation, IV or intraperitoneqaly.
Followed byFollowed by radiation therapyradiation therapy oror
without. Ifwithout. If given after the surgery,given after the surgery,
is called adjuvant therapy.is called adjuvant therapy.
Chemotherapy is a cancerChemotherapy is a cancer
treatment that uses drugs to stoptreatment that uses drugs to stop
the growth of cancer cells, eitherthe growth of cancer cells, either
by killing the cells or by stoppingby killing the cells or by stopping
them from dividing.them from dividing.
SSystemic chemotherapyystemic chemotherapy:: ifif takentaken
per os or IVper os or IV..
RRegional chemotherapyegional chemotherapy: if: if
chemotherapy is placed directlychemotherapy is placed directly
into the spinal column, an organ,into the spinal column, an organ,
or a body cavity such as theor a body cavity such as the
abdomen, the drugs mainly affectabdomen, the drugs mainly affect
cancer cells in those areas.cancer cells in those areas.

ChemoembolizationChemoembolization
 What is chemoembolization?What is chemoembolization?
 AA palliative treatment forpalliative treatment for primary orprimary or
metastasizedmetastasized liverliver cancercancer
 During chemoembolization, three chemotherapyDuring chemoembolization, three chemotherapy
drugs are injected into the artery that suppliesdrugs are injected into the artery that supplies
blood to the tumor in the liver. The artery is thenblood to the tumor in the liver. The artery is then
blocked off ("embolized") with a mixture of oilblocked off ("embolized") with a mixture of oil
and tiny particles. This procedure accomplishesand tiny particles. This procedure accomplishes
four things:four things:
 The tumor becomes deprived of oxygen andThe 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 theBecause these drugs are injected directly at the
tumor site, this dosage is 20 to 200 timestumor site, this dosage is 20 to 200 times
greater than that achieved with standardgreater 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 washesBecause the artery is blocked, no blood washes
through the tumor. As a result, the drugs stay inthrough the tumor. As a result, the drugs stay in
the tumor for a much longer time - as long as athe tumor for a much longer time - as long as a
month.month.
 There is a decrease in side effects because theThere is a decrease in side effects because the
drugs are trapped in the liver instead ofdrugs are trapped in the liver instead of
circulating throughout the body.circulating throughout the body.

ChemoembolizationChemoembolization
 How does chemoembolizationHow does chemoembolization
work?work?
The liver is unique in having twoThe liver is unique in having two
blood supplies - the hepatic arteryblood supplies - the hepatic artery
and the portal vein. The normal liverand the portal vein. The normal liver
gets about 75% of its blood from thegets about 75% of its blood from the
hepatic artery.hepatic artery.
 When a tumor grows in the liver, itWhen a tumor grows in the liver, it
receives almost all of its blood supplyreceives almost all of its blood supply
from the hepatic artery. Therefore,from the hepatic artery. Therefore,
chemotherapy drugs injected into thechemotherapy drugs injected into the
hepatic artery at the liver reach thehepatic artery at the liver reach the
tumor very directly, sparing most oftumor 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 takennearly all of the blood supply is taken
away from the tumor, while the liveraway from the tumor, while the liver
continues to be supplied by bloodcontinues to be supplied by blood
from the portal vein.from the portal vein.

Radiation therapyRadiation therapy
 UUses high-energy x-rays or otherses high-energy x-rays or other
types of radiationtypes of radiation..
 TTargets rapidly dividing cells likeargets rapidly dividing cells like
cancer cells.cancer cells.
 PPrevents cell division and therevents cell division and the
replication of DNAreplication of DNA
 Two typesTwo types::
 ExternalExternal:: uses a machineuses a machine
outside the body to sendoutside the body to send
radiation toward the cancer.radiation toward the cancer.
 InternalInternal:: uses a radioactiveuses a radioactive
substance sealed in needles,substance sealed in needles,
seeds, wires, or catheters thatseeds, wires, or catheters that
are placed directly into or nearare placed directly into or near
the cancer.the cancer.
 The way the radiation therapy isThe way the radiation therapy is
given depends on the type andgiven depends on the type and
stage of the cancer.stage of the cancer.

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

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