The Surgical Management of Colon Cancer
Surgery remains the primary treatment modality for colon cancer. Prior to surgery, all patients should be clinically staged with a total colon exam; computed tomography scanning of the chest, abdomen, and pelvis; and measurement of serum CEA level. The pr
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Key Concepts • Complete clinical staging for colon cancer includes a total colon exam; computed tomography of the chest, abdomen, and pelvis; and a serum CEA level. • The principles of an oncologic resection include a total mesocolic resection, a ligation of the primary vessel at its origin, a wide mesenteric resection with >12 lymph nodes examined, and at least a 5 cm resection margin. • There is no difference in cancer-related outcomes for open and laparoscopic resections. • Anastomotic assessment for left-sided anastomosis is associated with a decreased leak rate. • Surgical resection is the most effective therapy for patients who present with obstruction colon cancers. • Endoscopic stenting of an obstructing colon cancer is an effective bridge to surgery within 72 h. • Perforated cancers should be treated with an oncologic resection. • First-line therapy for patients with metastatic colon cancer and an asymptomatic primary tumor is chemotherapy.
Introduction Our understanding of the pathogenesis, staging, and management of adenocarcinoma of the colon has evolved greatly over the last decade. Today, it is accepted that colorectal cancers develop via one of three distinct genetic pathways: (1) chromosomal instability, (2) mismatch repair, and (3) CpG island hypermethylation. This increased understanding of the genetics of colorectal cancer development has led to the identification of several putative molecular markers to predict their biologic and clinic behavior. However, pathologic staging using the TNM system remains the most valuable prognostic tool available, with depth of invasion (T stage) and lymph node involvement (N stage) being the best markers to risk stratifying regional and distant metastatic spread,
respectively. Preoperative imaging has allowed for more accurate clinical staging and earlier detection of metastatic disease that may impact the treatment of the patient. Advances in chemotherapy have allowed for improved outcomes for patients with selected stage II and stage III and IV cancers. Despite all of these advances, surgical resection remains the cornerstone and most important facet in the management of colon cancer. An intimate understanding of the anatomy of the colon, its vasculature, and the retroperitoneum are critical to performing an appropriate oncologic resection for colon cancer. This chapter will focus on the technical aspects of the principles of an oncologic resection such as the importance of total mesocolic resection, ligation of primary vasculature at its origin, obtaining an adequate lymph node harvest to ensure an examination of >12 lymph nodes, and obtaining appropriate distal and proximal margins for open and laparoscopic resections. Special topics such as laparoscopic colectomy for cancer, management of obstructing and perforated colon cancers, treatment of the primary tumor in the setting of metastatic disease, and the short-term and long-term outcomes for colectomy for cancer will be addressed.
Preoperative Preparation When preparing to take a patient to the operatin
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