Surgery of the colon and rectum surgery

Currently, colorectal cancer is one of the leading cancers in the structure of cancer both in Russia and worldwide. The tumour can affect the rectum and different parts of the colon. Depending on the type of tumour and its structure, it can grow into the lumen of the intestine or it can grow into nearby organs and tissues.
The TNM staging system is used for staging, which reflects the depth of the tumour, metastasis to regional lymph nodes and distant metastasis. Based on TNM, the stage of the disease is determined, and an appropriate treatment strategy and prognosis are chosen.

"Cancer in situ."
Tumor of small size, most often a polyp that has not spread beyond the mucosa.

A tumor that has grown into the submucosa or into the muscular layer of the intestinal wall.

Tumor that grows into the deep layers of the intestinal wall (IIA), sprouts through it and spreads to neighboring organs (IIB). There are no metastases to regional lymph nodes. The symptoms at this stage are diverse: discomfort in the rectum, which some patients describe as a foreign body, discomfort in the lower abdomen, mucus and blood in the feces.
Stage III

Divided into three substages: IIIA, IIIB, and IIIC . In this stage, regional lymph nodes are affected. The substage is determined by the depth of the intestinal wall and the number of lymph node metastases. Patients note a worsening of the condition, the appearance of dyspeptic disorders:
Abdominal rumbling, bloating, false urges to defecation, cramps, pain, blood in the stool, alternating constipation and diarrhea. In the general condition, patients notice weakness, pallor, decreased appetite and performance.

The tumor grows into the deep layers of the intestinal wall (IIA), penetrates through it, and spreads to the neighboring organs (IIB). There are no metastases to regional lymph nodes. Metastasis to a single organ (most often the liver or lungs) or to a group of distant lymph nodes (IVA), there are metastases to more than one organ or group of lymph nodes (IVB), or the cancer has spread to the peritoneal surface (IVC). At this stage, the size of the primary tumor and depth of invasion are irrelevant. Among the most severe symptoms are intestinal obstruction, retention of feces and gases, vomiting, and increased pain in the abdomen as well as in those organs affected by the secondary tumor. Often there is emaciation, there is disruption of the central nervous system. A diagnosis of colorectal cancer needs to be made early, as this will increase the chance of effective treatment. The risk of occurrence is higher in men, especially in the age group over 70-75 years old.

Causes of rectal and colorectal cancer

There is no single cause associated with rectal and colon cancer. Scientists believe there are two main factors which influence the risk of developing these tumours: heredity and eating habits.
The eating habits that increase the risk of colorectal cancer are:

-frequent consumption of red meat and animal products
high fat content;
-Low dietary fibre content;
-The abuse of alcohol;
Constant overeating; -Incontinuous overeating
-Inappropriate drinking habits, which make regular emptying of the bowels difficult.

The hereditary predisposition to the disease has been proven by a number of studies in which scientists have studied the family history of patients with different forms of colorectal cancer. The MLH1 and MSH2 genes are the most frequently affected genes. Genetic mutations have been linked to the formation of polyposis and hereditary non-polyposis cancer.
Other causes of colorectal cancer include:
-The presence of adenomas, polyps, benign neoplasms of the rectum and colon;
-Chronic inflammatory bowel disease: ulcerative colitis, Crohn's disease;
-Immune system deficiencies;
-Infection with human papillomavirus;
-An oncological process in the breast or genital tissues in women;

Particular attention should be paid to polyps of the intestine, because if they are not removed in time, a malignant tumour may develop in this area.

Symptoms of colorectal cancer

In its initial stages, cancer may not manifest itself in any way. When the tumour increases in size and grows into the deeper layers of the intestine, the following symptoms may appear:
-bloody stool;
-Mucus discharge from the anus;
-Disorders in the stool - stool may become irregular, with constipation followed by diarrhoea;
Abdominal and anal pain; -Anxiety in the abdomen and anus area;
-unreasonable weight loss;
-Weakness;
-Signs of anaemia - palpitations, shortness of breath, pale skin, drowsiness and lethargy;
-Painful urges to defecate appear;
-meteorrhoea.
In the asymptomatic stage, a prophylactic colonoscopy is the only method of diagnosis. This is worth keeping in mind for patients older than 45-50 years of age, as well as for those who belong to a risk group and have a family history of cancer.

Diagnosis of rectal cancer

Screening has a special place in the diagnosis of rectal cancer. This is the early detection of cancer at stages when the disease does not bother the patient. Screening methods include:

-Finger examination of the rectum;
-Fecal occult blood test: Gregersen's test and FOBT (Fecal occult blood test);
-Endoscopic techniques.
Of the endoscopic methods, colonoscopy is used. It is used to diagnose not only cancer, but also precancerous lesions.

Confirmation of the diagnosis is only possible after a biopsy. For this purpose, a piece of tumour is taken for analysis and sent for histological analysis.
To determine the stage of the disease, methods are used to determine the extent of the tumour process:

-An abdominal and transrectal ultrasound;
-CT of the 3 zones with intravenous contrast;
-Pelvic magnetic resonance imaging (MRI).

Current treatment options for colorectal cancer

Screening has a special place in the diagnosis of colorectal cancer. It is the early detection of cancer at stages when the disease is not bothering the patient. Screening methods include:
-Rectal finger examination of the rectum;
-Fecal occult blood test: Gregersen's test and FOBT (Fecal occult blood test);
-Endoscopic techniques.
Of the endoscopic methods, colonoscopy is used. It is used to diagnose not only cancer, but also precancerous lesions.
Confirmation of the diagnosis is only possible after a biopsy. For this purpose, a piece of tumour is taken for analysis and sent for histological analysis.
To determine the stage of the disease, methods are used to determine the extent of the tumour process:
-An abdominal and transrectal ultrasound;
-CT of the 3 zones with intravenous contrast;
-Pelvic magnetic resonance imaging (MRI).

Surgical treatment

1. If the tumour is small and has not invaded the mucosa, submucosa, the intervention is endoscopic.
2. Transanal endoscopic endomicrosurgery is a modern treatment. It maximizes the preservation of the intestinal wall and is characterized by a maximally comfortable postoperative period.
3 If the tumour has reached the muscular layer, the entire intestine part involved is removed. The surrounding tissue and lymph nodes are also removed. Open or laparoscopic techniques may be used.
Most operations are performed using minimally invasive laparoscopic surgery. This type of surgery is the gold standard in most US and European clinics for localised tumours of all organs. In Russia these procedures are carried out only in a few clinics and these modern techniques are still inaccessible to the majority of cancer patients.
Laparoscopic surgery offers many advantages, including less pain in the post-operative period, reduced risk of infection, shorter hospital stays and less risk of scarring. The recovery period after laparoscopic surgery is 5-7 days, with the patient moving around the ward on his/her own in the first 24 hours.
In most cases, the localisation of the tumour makes it difficult to preserve the natural anus and requires a temporary or permanent colostomy. If the prognosis is favourable, the colostomy will be closed within a few months after surgery.
Combined operative interventions are required if several organs are involved. Distant metastases require staged removal. Metastases located in the liver are most often removed.
FAST-TRACK or fast-track surgery is used for all operations. This approach minimises postoperative complications, reduces pain and speeds up the patient's recovery and resumption of normal life.
After complex treatment it is necessary to visit a doctor and undergo the necessary examinations (blood for REA, CA-19, CT scan of 3 zones with contrast, small pelvis MRI, colonoscopy) once every 6 months in the first 2 years, and then once a year.

Examples of operations performed for colorectal cancer

-Removal of neuroendocrine and GIST bowel tumours
Removal of a dilated right-sided hemicolectomy with D3 lymphodissection and total mesocolonectomy
Laparoscopic left-sided hemicolectomy with total mesocolonectomy
-laparoscopically assisted abdominal-perineal extirpation
Laparoscopic right-sided hemicolectomy with D2 lymphodissection
-Laparoscopic left hemicolectomy with D2 lymph dissection
-Laparoscopic resection of the sigmoid colon
- Anterior rectal resection (preserving the anus)
-low anterior rectal resection (preserving the anus)
-Recto-abdominal resection (removal of the rectum with complete or partial preservation of the anus)
-abdominal perineal extirpation (removal of the rectum with complete removal of the anus)
-Hartman operation
-colostomy removal
-Reconstructive surgery to restore bowel continuity and closure of colostomies
-palliative surgery
-emergency surgery