SURGICAL ASPECT OF LARGE BOWEL

DISEASE
Ign.Riwanto MD PhD
Prof. of Digestive Surgery

SURFACE ANATOMY
1. LEFT LUMBAR:
Coecum, ascending
colon, hepatic flexure
2. UMBILICAL
Transverse colon
3. RIGHT LUMBAR:
Splenic flexure,
descending colon,
sigmoid
4. LEFT INGUINAL:
Sigmoid
5. HYPOGASTRIC:
Sigmoid & Rectum

ORGAN RELATED &

POSITION OF LARGE
BOWEL

- GASTRO-COLIC

LIGAMENT
- OMENTUM MAYUS
- Coecum: Intraperitoneal
-Ascending colon:
retroperitoneal
-Transverse colon:
intraperitoneal
-Descending colon:
retroperitoneal
- Sigmoid: intraperitoneal
-Rectum: retroperitoneal

DETAIL ANATOMY OF COLON

3-5 FEET IN LENGTH
ILEOCOECAL JUNCTION WITH
ILEOCOECAL VALVE
APPENDIX
COECUM IS WIDES,
PROGRESSIVELY NARROW
DISTALLY ANAL CANAL
3 TAENIA (CONDENSED OF
LONGITUDINAL MUSCLE
LAYER,CONVERGE AT THE
BASED OF APPENDIX AND
SPREAD AT RECTUM)
HAUSTRA
INCISURA
APPENDICES EPIPLOICAE

RECTUM
RETROPERITONEAL
12-15 CM IN LENGTH
ANORECTAL JUNCTION : ANGLE
DUE TO PUBO-RECTAL MUSCLE
WALDEYERS FASCIA:
RECTOSACRAL FASCIA
DENONVILLERS FASCIA:
ANTERIOR
LOWER THIRD OF RECTUM ,
RELATED TO THE PROSTAT (MALE)
AND VAGINA (FEMALE)

RECTUM & ANAL CANAL

3 RECTAL VALVE (INFERIOR, MIDLE &
SUPERIOR)
ANATOMICAL ANAL CANAL: ANAL CANAL SKIN
SURGICAL ANAL CANAL: ANAL CANAL SKIN &
MUCOSA
INTERNAL ANAL SPHINCTER (SMOOTH
MUSCLE FIBER CONTINUATION OF CIRCULAR
MUSCLE OF THE RECTUM, START FROM
ANORECTAL JUNCTION), 80% RESTING ANAL
CLOSING.
3 EXTERNAL ANAL SPHINCTER (STRIATED
MUSCLE FIBER), 100% SQUEEZING ANAL
CLOSING
INTERSPNCHTERIC GROVE
ANAL PAPILA & COLLUMNS OF MORGAGNI
ANAL CANAL CRYPT
ANAL CANAL GLAND
NO HAIR IN ANAL CANAL SKIN
INTERNAL & EXTERNAL HEMORRHOID PLEXUS

ARTERY
SUPERIOR MESENTERIC
ARTERY: Coecum, Ascending
colon & 2/3 transverse colon
(midgut)
INFERIOR MESENTERIC
ARTERY:
1/3 distal transverse colon,
sigmoid & rectum (hind gut)
MIDLE & INFERIOR RECTAL
ARTERY (branches from
INTERNAL ILEAC ARTERY):
rectum & anus

VENOUS SYSTEM
PORTAL SYSTEM
SUPERIOR MESENTERIC
VEIN & SPLENIC VEIN
form PORTAL VEIN, and
INFERIOR MESENTERIC
VEIN drain to SPLENIC VEIN
MIDLE & INFERIOR
RECTAL VEIN drain to
INTERNAL ILIAC VEIN
HEMORHOIDAL
COMPLEX: collateral
PORTAL- SYSTEMIC
SYSTEM

LYMPH ATIC SYSTEM

3 TYPES:

Epicolic
Paracolic
Intermediate (name according
artery they follow
Main/ principal : around SMA &
IMA
para-aortal cysterna chili
thoracic duct left sub-clavian
vein (Vircows node)
Distal rectum & anus : drain to
inguinal lymph node

INNERVATION
AUTONOMIC NERVOUS SYSTEM
SYMPATHETIC (Inhibit peristaltic):
- T7-T12 : RIGHT COLON &
- L1-L3 : LEFT COLON
PARA-SYMPATHETIC (stimulate peristaltic):
- VAGUS NERVE: RIGHT COLON
- SACRAL (S2-4): LEFT COLON
INTRINSIC INNERVATION:
MEISSNER;S PLEXUS: submucosal
AURBACH PLEXUS: circular
muscle layer

PHYSIOLOGY
Absorbtion of water & electrolyte :

especially right colon

Storage of feces
Fecal movement & delivery

COLON MOTILITY
RETROGRADE MOVEMENT: Transverse

colon coecum to facilitate the absorption water

& electrolyte
SEGMENTAL CONTRACTION: Simultaneous
segmental contraction of circular and longitudinal
muscle
MASS MOVEMENT: Contraction long segment,
30 seconds duration antegrade propulsion
feces at the rate 0.5-1 cm/sec, 3-4 times each day
after waking up & after eating.

DEFECATION
Mass movement feces move to rectum
Rectal distention involuntary relaxation of

internal sphincter
Voluntary relaxation external sphincter
pushes feces down to anal canal
Voluntary increase intra-abdominal pressure
propeling feces out of the anus

DISORDER MOTILITY OF COLON &

RECTUM

DISORDER MOTILITY
Iritable Bowel Syndrome (IBS)
Constipation
Diarrhea
Fecal incontinence

IRRITABLE BOWEL SYNDROME

Abnormal state of intestinal motility modified by

psychosocial factors, no anatomic cause

Male: female= 1:2
Incidence: Up to 17% (US)
Episode of altered bowel function (constipation, diarrhea or
both) intermittently over prolonged period with or without
pain
Treatment: reassurance, education, medical treatment for
anxiety/ depression

CONSTIPATION
< 3 stools/ week while consuming high fiber
Acute: persisten for < 3 months
Chronic: persistent > 3 months
Cause: Less fiber, less fluid, lack physical activity, medication

(opiate), IBS, DM, hypothyroidism, Hirsprung disease, depression,

Parkinson's disease, multiple sclerosis, rectocele, others.
Treatment: Stool softener, increasing fiber & fluid
Failure: colonic transit time, defecography , manometri
Fecal impaction: manual disimpaction
Surgery for rectocele, Hirsprung disease, prolong transit time

SCINTIGRAPHY

Normal: within 48
hours of ingestion much
of the radioisotope has
been passed from bowel

Severe constipation due

to prolonged transit
time, over the 4 days
radioisotope does not
progress beyond the
thansverse colon

RADIOLOGIC MARKER
Radio-opaque marker tablet
20 tablet, followed by serial daily

abdominal X-ray
Normal:
80% had passed by the end of 5th
days
TT through right colon 6.9-13.0
hours
TT through left colon 9.1-15 hours
TT through rectosigmoid 11-18.4
hours
More than 40% marker left in the
colon after 5 days considered
pathology.

Colonic
inertia

Hindgut
inertia

Outlet
obstruc
tion

 Rectocele: Anterior outpocketing of the rectal wall with incomplete evacuation

High incidence of ventral outpocketing
Vaginal bulging during straining & digitation for success defecation
Surgery: anterior levator mplasty

HIRSPRUNGS DISEASE
AGANGLIONIC IN THE NARROWING PART
DILATED PART: ACCUMULATION OF FECES & COMPENSATION
SURGERY

DIARRHEA
Passage of >3 loose stools/day
Surgery related: short bowel syndrome (less than 70 cm

of small intestine left)

Conservative: imodium, elemental diet, parentaral
nutrition
The rest of the small intestine will hypertrophy

FECAL INCONTINENCE
True: Complete loss of solid stools
Minor: Flatus or soilage undergarment from seepage or

urgency
Decreasing resting tone and squeeze pressure
Etiology: Sphincter injury, scleroderma, fecal impaction,
pudendal nerve injury.
Diagnosis: anal manometry, endoanal ultrasonography,
electtro-myography, Pudendal nerve motor latency.
Surgery: sphincter repair for sphincter injury.

COLITIS

COLITIS
Amoebic colitis: due to E histolytica, diagnosis based on fecal

microscopy or serum amoeba.

Pseudomembranous: (overgrowth Clostridium difficile after
using clindamycin, amphicillin or cephalosposin)
Actinomycosis: Rare infection of cecal region caused by A.
israelii, classically after appendectomy, may produce abscess &
fistulation that need surgical drainage & antibiotics
(tetracycline or penicillin)
Netropenic: colonic mucosal ulceration after chemotherapy in
cancer patients, may perforation surgery.
Radiation induced: after radio-therapy more than 5.000 cGy,
early presentation: bleeding & diarrhea, late presentation:
stricture & fistula need surgery
Ischemic: due to decrease perfusion or tromboembolism, if
conservatif treatment fail resection with colostomy

ULCERATIVE COLITIS vs CROHNS DISEASE

ULCERATIVE

CROHN

-Inflamation of the mucosa only

- Start in rectum

-Involve all bowel wall layers

-- rectal sparing 50%

-Continous lessions
-Rare
- Lead pipe colon

-Skip lesions
-Aphthous ulcer
- Cable stone appearance

Complication

- Perforation
- Stricture
- Megacolon

-Abscess
- Fistula
-Obstruction
-Perianal disease

Treatment

Mild to moderate : 5-ASA, corticosteroid p.o/ per rectum

Severe: IV steroid
Surgery: Failure medical theraphy & complication colon resection
or diverting colostomy

Pathology
Diagnosis
- Colonoscopy
- Colonography

DIVERTICULAR DISEASE

DIVERTICULAR DISEASE
Herniation of mucosa & sub-mucosa through sites where

arterioles penetrate outpouching (diverticula), in the

mesenterial side
Diverticulosis = multiple diverticula
Sigmoid most common
Old age & low fiber intake
Asymptomatic (80%), massive lower GI bleeding, pain
(diverticulitis), peri colic abscess formation, perforation
peritonitis
Dx: colonography, colonoscopy
Tx: high fiber & stool softener, antibiotics in diverticulitis,
surgery for failure of stop bleeding & complication

DIVERTICULOSIS vs ANGIODYSPLASIA
as the cause of Lower GI Bleeding
Diverticulosis

Angiodysplasia

Incidence

50% > 60 Yeras

25 % > 60 Years
Adult Men > adult women

Character

Painless
75% bleed from right colon

Coecum and ascending colon

Quantity and
rate

Massive and rapid

Slow

Sign & Sympt.

Melena and /or hematoschezia often with symptom of orthostasis

Dx

- NGT to rule out upper GI bleeding

- Identify bleed (colonoscopy, Tc sulfur colloid, Angiography)

Tx

1. Rescucitation
2. Octreotide, embolization, epinephrine, vasodestruction with alcohol,
coagulation/ coutery
3. Massive identified site segmental colectomy
4. Massive unidentified site total colectomy

COLONIC OBSTRUCTION

COLONIC OBSTRUCTION
Cause:
Cancer,
Vulvulus coecum
Volvulus Sigmoid
Pseudo-obstruction syndrome (Ogilvie Syndrome)

SIGN & SYMPTOM

Abdominal distention
Cramping abdominal pain
Nausea and vomiting
Obstipation
High pits Bowel Sound

DIAGNOSTIC
Abdominal X ray: distended proximal colon with air-fluid

level and no air distally

Coffe bean (kidney) appearance: Coecal , Sigmoid Volvulus
Colonography: to ruled out pseudo-obstruction
Colonoscopy: contra-indicated, but can be used to treat
pseudo-obstruction.

COLON OBSTRUCTION
PHOTO PA: LATERAL DISTENTION
HUSTRA-INCISURA,
PHOTO LEFT LATERAL DECUBITUS:
LONG AIR FLUID LEVEL
COLONOGRAPHY (WATER
SOLUBLE CONTRAS) : SPACE
OCCUPAYING LESSION

TREATMENT
NGT
Fluid & electrolyte correction
Pseudo obstruction:

- Neostigmin
- Decompressed by colonoscopy
- Coecal diameter more than 11 cm or sign peritonitis
Operation: ccoecostomy
Coecal volvulus: Right hemicolectomy
Sigmoid volvulus:
- Sigmoidoscopy to decompress followede by elective
resection
- Failure or sign of peritoneal iritation: emergency
resection
Cancer : resection or fecal diversion

ALGORITM
MANAGEMENT OF
COLON
OBSTRUCTION

HEMORRHOID

HEMORRHOID
Prolapse of the sub-mucosal vein ( 11,3,& 7

oclock)
Internal: covered by mucosa
External: covered by skin
Risk factor: constipation, excessive diarrhea,
pregnancy, increase pelvic pressure, portal
hypertension.

DEGREE OF INTERNAL HEMORROID

1st stage: congestive non

prolapsed hemorrhoids
2nd stage: prolapsing during
defecation, reducing
spontaneously at the end of
defecation,
3rd stage: prolapsing during
defecation and requiring manual
reduction
4th stage: permanently prolapsed
which cannot be reduced
manually

Abramowitz et al. Gastroenterologie June-July 2001.

RELATIONSHIP BETWEEN PATHOGENESIS AND

MODE OF TREATMENT
GENERAL: Ovoid/ minimizing the risk factors, anti-

inflammatory drugs, faeces softener

VASCULAR THEORY:
- Phlebotrophic drugs (micronized diosmin)
- Excision of hemorrhoidal tissue
INCREASE LAXITY OF HEMORRHOIDAL SUPPORT

TISSUE:
- Sclerotheraphy
- Rubber band ligation
- Longo hemorrhoidectomy
- Hemorrhoid artery ligation and Recto-anal repair
- Phlebotrophic drugs

GRADE OF INTERNAL HEMORRHOID & ITS

TREATMENT
Grade 1: Medical treatment
Grade 2: Medical and Ruber Band ligation or

Sclerotherapy
Grade 3: Medical and surgery
Grade 4. Medical and surgery

Excision of Hemorrhoidal tissue

OPEN METHOD
Morgan milligan

CLOSED METHOD
Fergusson
Park
White head

Morgan Milligan
Internal Hemorrhoid grade

II-IV
Removing anal cushion
including the skin
Left the wound open
Severe post operative pain

Fergusson
Internal Hemorrhoid grade

II-IV
Removing anal cushion
including the skin
Suturing the wound
Severe post operative pain

Park
Internal Hemorrhoid grade

II-IV
Submucous removing
Hemorrhoidal plexus
Suturing the wound
Post operative pain

before

Longos technique is based on

the theory of increase laxity of
hemorrhoidal support tissue
after

HEMORRHOID ARTERY LIGATION (HAL)

AND RECTO-ANAL REPAIR
HAL: first reported by Morinaga (Japan) 1995
Because the arteries carrying the blood inflow are ligated,

internal pressure of the plexus hemorrhoidalis is

decreased, shrink and become smaller.
HAL: high prolapse recurrence in grade IV 2005 RAR
(Recto-Anal Repair)
RAR = Proctoplasty/ mucopexy is lifting the hemorrhoid
back to where the belong.
The American Journal of Surgery, 2006

INSTRUMENT FOR HAL-RAR

Single system that has two

procedure options,
(Doppler Guided)
Hemorrhoidal Artery
Ligation and Recto Anal
Repair (Proctoplasty).

Step for Hemorrhoid Artery

Ligation (HAL)

Step for Recto-Anal Repair (RAR)

Prolaps Rektum

Epidemiologi
terjadi pada umur yang ekstrem, anak sampai umur 3 tahun

dan pada orang tua.

Lebih sering pada wanita tua dengan perbandingan 10-15:1
Pada anak laki & wanita sebanding

Anamnesa
Keluhan utama: - penonjolan rectum keluar anus pada
prolaps lengkap (3/4 kasus)
- pada pre-prolaps (intususepsi rektal) ada
rasa penuh dan terasa ada masa didalam
rektum yang menutup anus
Keluhan lain: - konstipasi
- inkontinensia alvi
- pengeluaran mukosa
Etiologi:
- kesulitan defekasi
- nulipara
- riwayat operasi sekitar anus:
hemorroidektomi, fistulektomi,
abdomino anal pullthrough

Pemeriksaan fisik
Inspeksi

Palpasi

: - penonjolan konsentrik mukosa rektum

berbeda dari hemmorroid prolaps dengan
adanya lobulus dengan sulkus
diantaranya, sementara dibedakan dari
polips yang prolaps dengan adanya tangkai
- terjadi strangulasi kehitaman
- kemungkinan bisa diidentifikasi polip
diujung prolaps sebagai penyebab
: - prolaps apakah bisa direposisi
- tonus sfingter ani, pada keadaan istirahat
(resting) dan kontraksi (squeezing),
kebanyakan kasus sfingter lemah
- pada pre-prolaps pada colok rektal, dengan
dibantu mengejan, akan teraba masa
seperti portio

PROLAPS RECTI

HEMORRHOID

Pemeriksaan penunjang
Rektosigmoidoskopi
- dilihat adanya polip atau karsinoma yang menjadi
titik awal dari prolaps
- dilihat derajat prolaps, hanya mukosa atau seluruh lapisan
- dilihat apakah ada solitary ulcer , berupa ulkus dengan
tepi hiperemik dikelilingi indurasi, akan tetapi bisa juga
dalam bentuk indurasi mukosa bahkan lesi polipoid
didinding depan rektum sekitar 6-8 cm dari anal verge.
Colon foto atau colonoskopi
- disarankan untuk orang tua sebelum merencanakan
operasi
Colon-transit time
- dilakukan bilamana terdapat konstipasi, untuk
memastikan apakah konstipasi tipe prolong transit time
atau outlet obstruction type.
Defecogram
- dilakukan pada partial prolaps, mungkin akan bisa dilihat
adanya intususepsi rectal, tumor (polip) rectum dan
rectocele.

PROLAPS REKTI

Internal
(Intususepsi rektal)

Eksternal (prolaps
lengkap)
gagal

Managemen medik

Toleransi
operasi besar
< baik

Necrose (-)

Toleransi
operasi besar
baik

Necrose (+)

Konstipasi (-)

Konstipasi (+),
sigmoid
redunden

*
**
Thiersch

Delorme

Express

* Dipilih bila beserta konstipasi / sigmoid redundan

Altemier

Ripstein

** Dipilih bl bsm rectocele

Laparoskopi
rektopeksi
ventral

Sigmoidekt
omi +
Ripstein

ANAL FISURA

ANAL FISSURE
Painful linear tear in anal canal skin (below dentate line)
Induced by constipation, excessive diarrhea, anal sex.
Painful defecation with bright red blood in the toilet tissue
Increase resting sphincter tone
Visible tear on examination
Tx:
medical: sitz bath, fiber diet, increase fluid intake,
Internal lateral spinchterotomy in case of medical Tx fail

SPHICHTEROTOMI INTERNA SUBCUTAN LATERALIS

PERI-ANAL ABSCESS & FISTULA

PERI-ANAL ABSCESS & FISTULA

Abscess caused by defect or obstruction of anal crypt

resulted in bacterial overgrowth in the anal glands

Tx Surgical drainage
May developed anal fistula (internal opening in the anal
crypt, external opening peri-anal)
Classification of fistula:
Intersphincteric (70%), Transsphincteric (25%),
Suprasphincteric (4%), Extrasphincteric (1%)
Tx: Fistulotomy, Seton for Supra & extrasphincteric.

Para-anal abscess

PARA-ANAL FISTULA

Goodsalls Rule
Tract anterior (A) berupa

garis lurus, sedangkan tract

posterior (P) berupa garis
lengkung
Secondary opening anterior
yang berjarak > 3 cm dari
anal margin, akan
membentuk garis lengkung
berhubungan dengan anal
gland posterior

Klasifikasi fistula ani menurut Parks

COLORECTAL CANCER

Age Standardized Minimum Incidence Rate (ASR) 5

prominent cancer in Semarang
(Tirtosugondo 1986)

1970-1974

1980-1981

Man
Location

Woman
ASR

Location

/100.000

Man
ASR

Woman

Location

ASR /

Location

ASR /

/100.000

100.000

100.000

Liver

5,2

Cervic

19,8

Liver

9,5

Cervic

27,9

Skin

4,3

Breast

10,2

Lung

7,6

Breast

13,0

Lung

4,0

Ovarium

5,1

6,1

Skin

6,7

Naso
pharynk
Colorectal

3,6

Skin

4,9

Naso
Pharynk
Skin

6,1

Ovarium

3,9

2,5

Colorectal

2,2

Colorectal

3,2

Colorectal

3,4

Increase incidence of colorectal cancer in Semarang

FAKTOR YANG BERPERAN TERHADAP HARAPAN

HIDUP PASIEN KANKER KOLON-REKTUM
1. Stadium penyakit
2. Derajat keganasan (histologik)
3. Komplikasi (tersumbat, pecah)
4. Dokter spesialis bedah (keputusan tindakan berdasarkan

stadium, pilihan pengobatan dan skill pembedahan)

5. Panas pasca-bedah
6. Tranfusi darah
7. Pengobatan tambahan
8. Petanda molekular (Mutasi K-ras respons chemoterapy
jelek)
9. Lain-lain

PERKEMBANGAN ALAMIAH KANKER

paparan
Perubahan biologik

gejala
waktu terdeteksi

sembuh/mati

A
Skrining faktor risiko

Periode

Periode

subklinis
Skining utk

klinis
diagnosis

deteksi

dini

dini

A: Skrining, B: Deteksi dini C: Diag.nosis dini D, Management & prognosis

Periode A dan B utamanya untuk kelompok

risiko tinggi
Umur
Penyakit
terkait

Riwayat
penyakit
Riwayat
keluarga

> 40 (>50) laki = wanita

Ulcerative colitis
Crohn disease
Peutz-jegher Syndrome
Kanker dan polip usus besar
Kanker kandungan dan buah dada
Juvenile polyp
Familial adenomatosis polyps
Familier polyposis syndrome
Kanker dan polip usus besar

SURVEILANCE COLONOSCOPI: POLIPEKTOMI ATAU BIOPSI

FLEXIBLE SIGMOIDOSCOPY
Kanker Rektum

& kolon kiri

70-80% kanker
kolo-rektal
Flexibel sigmoidoskopi

bisa mencapai fleksura lienalis, masih diperlukan kolon foto

untuk melihat sisa kolon

Kolonoskopi:
Diagnosis & Pengobatan

Colonoscopy and biopsy is the only way to make a definitive diagnosis of

colorectal cancer. A barium enema can be used in cases where colonoscopy is
difficult. (Adenis et al. Standards, options and recommendations: Carcinoma of the colon. Elec. J of
Oncol 2001)

Periode C. Diagnosis awal setelah muncul gejala klinis

Kolon kanan

Kolon kiri

Rektum

Nyeri perut samarsamar

gas pain cramps

Nyeri pada stadium

lanjut

Diare coklat/ hitam

Darah segar pada

kotoran

Darah segar pada

kotoran

Anemi

Tinja kaliber kecil

Tidak puas setelah

berak

Benjolan perut sisi

kanan

Perubahan
kebiasaan berak,
butuh pencahar

Nyeri sewaktu berak

dan berak sering

Tanda sumbatan

Morning diarea (lendir)

Pemeriksaan fisik
Tanda obstruksi atau peritonitis
Tumor masa intra abdomen (ukuran, lokasi, mobilitas,

konsistensi)
Pembesaran hepar
Sr Marie Nodule (nodule sekitar umbilicus): terdapat
peritoneal seeding
L.n. inguinal
Rectal toucher

RECTAL TOUCHER
Kanker dubur (rektum) >50% dari seluruh kanker usus besar)
Colok dubur: 2/3 distal dari dubur
Pasien diminta mengejan : tumor 1/3 proximal mobil dapat diraba
Diskripsikan: jarak dari anal verge, besar, lokasi thd lingkaran

rektum, kerapuhan, mobilitas terhadap dinding rektum dan

terhadap organ sekitar (mobile, tethered atau fixed) serta
limfonodi di mesorektum.

PROKTOSIGMOIDOSKOPI
Dilanjutkan foto kolon

dobel kontras untuk

melihat sisa kolon (adanya
synchronous tumor)
Deskripsi tumor
Jarak tumor dari anal verge
Biopsi/ polipektomi

FOTO KONTRAS USUS BESAR

Bukan tindakan pertama tetapi

disarankan sebagai kelanjutan

proktosigmoidoskopi, fleksibel
sigmoidoskopi atau kolonoskopi
yang tidak bisa melihat sekum
Foto kontras ganda pilihan terbaik
Perkembangan baru: Virtual CTColonography bisa melihat
kondisi intralumen colon yang diisi
kontras udara mendeteksi
polip/ tumor.

KANKER USUS BESAR,

TUMBUH KEDALAM, ATAU
MELINGKAR, PADA FOTO
AKAN NAMPAK KONTRAS
TISAK MENGISI PENUH
ATAU MENYEMPIT

SIFAT-SIFAT KANKER
1. Pertumbuhan cepat
2. Menyebar
3. Menerobos / Invasi
4. Bebenjol tidak rata
5. Selaput lendir berubah sifat
6. Rapuh mudah berdarah

LABORATORIUM
CEA: tidak akurat untuk diagnostik, baik untuk follow-up

menilai hasil pengobatan.

Alkali fosfatase: bisa meningkat pada metastase hepar, tetapi
tidak spesifik.

PRE-OPERATIVE STAGING FOR

COLORECTAL CANCER
Detect distant metastases (liver, lung, bone )
Detect lymph node involvement
Local staging: Deep of penetration and surrounding organ

infiltration
Chest X ray, USG, CT Scan, MRI
Endosonography

TUMOR YANG TUMBUH BESAR,

DINDING USUS MENEBAL DAN
LOBANG USUS MENYEMPIT

STAGING RECTAL CANCER

IMPORTANT TO KNOW THE DEPTH OF TUMOR

PENETRATION EVALUATE T
- ENDO ANAL ULTRASONOGRAPHY (EUS)
- CT SCAN or MRI
TO EVALUATE THE NODE (N):
- EUS, CT, MRI
TO EVAALUATE DISTANT METASTASES:
- CT
- CHEST X RAY

PREOPERATIVE STAGING FOR RECTAL

CANCER
Accurate information about infiltration of tumor is important for

deciding local excision, with or without preoperative chemo

radiation
The best modality for determining invasion into the layer of bowel
wall is endorectal ultrasonography
The best modality for visualization of endopelvic fascia
involvements is CT or MRI, with 92% agreement with histology.
T2 & T3 (distant to endopelvic fascia more than 2mm) need
preoperative chemoradiotherapy
Spiral CT scan: lung, liver, retroperitoneal and primary tumor can
all be visualized one-stop shop

Wiggers: Staging of rectal cancer. BJS 2003;90:895-896

TNM classification
q T= primary tumor

N= regional lymph nodes

Tx: primary tumour cannot be

assessed
T0: No evidence of primary tumour
Tis: Carinoma insitu
T1: Tumour invades submucosa
T2: Tumour invades muscularis
propria
T3: Tumour invades muscularis
propria into subserosa or
perirectal/ pericolic tissue non
peritoneal
T4. Tumor directly invades other organ
or perforated

Nx: Regional l.n. cannot be assessed

N0: No regional l.n. metastasis
N1: Metastasis in 1 to 3 reg. l.n.
N2: Metastasis in 4 or more reg. l.n.
M= Distant metastasis

Mx: Distant metastases cannot be assessed

M0: No distant metastasis
M1: Distant metastasis

TNM Classification
Stage 0

Tis, N0, M0

Stage I

T1 or T2, N0, M0

Stage II

T3 or T4, N0, M0

Stage III

All T, N1 or N2 , M0

Stage IV

All T, All N, M1

STAGE OF DISEASE AND SURGERY OF COLON CANCER

Stage
0
Stage
I
Stage
II
Stage
III
Stage
IV

Tis, N0, M0

Endoscopic mucosal
resection (EMR)/
polipectomy
T1 or T2, N0, Curative resection for T2
M0
(R0)
T3 or T4, N0, Curative or paliative
M0
resection (R0, R1 or R2)
All T, N1 or
May curative (R0) but
N2 , M0
mostly paliative resection
(R1 or R2)
All T, All N,
May be curative if M1 can
M1
be completely removed

CLINICAL STAGE & MODALITY OF TREATMENT IN RECTAL

CANCER
T1-N0 :

trans anal endoscopic mucosal resection

T2-N0:
trans-abdominal resection
T3, N0 or any T, N1-2: Preoperative chemoradiation followed by
transabdominal resection
T4 or metastatic disease:
resectable anorectal resection ,
unresectable diverting colostomy, stenting & chemoradiation
Total mesorectal excision
Sphincter preserving procedure for middle rectal cancer.

NCCN: Practice Guidelines in Oncology-v.3.2010 Rectal cancer

Radiotherapy in colorectal cancer.

Dutch Colorectal Cancer Group 1996-1999
924 patients preoperative radiotherapy (5Gy on each of 5 days)

followed by TME (Group I) vs 937 patients TME only (Group

II)
2 years survival: 82.0% vs 81.8%
Local reccurrence at 2 years: 2.4% vs 8.2% (P<0.001)
Postoperative radiotherapy was mandatory for patients with
positive circumferential margin.

Keus R.B. Radiotherapy in Colorectal cancer. Dutch foundation

postgraduate medical course 2004

TYPES OF SURGERY
RIGHT HEMICOLECTOMY

(EXTENDED) (A & B)
TRANSVERSECTOMY (C)
LEFT HEMICOLECTOMY (D)
EXTENDED LEFT
HEMICOLECTOMY (E)
SIGMOIDECTOMY (F)
SUBTOTAL/TOTAL
COLECTOMY (G)
ANTERIOR RESECTION
SPHINCTER PRESERVING
SURGERY
ABDOMINO-PERINEAL
RESECTION
INTERNAL DIVERSION
COLOSTOMY

Sphincter saving procedure:

after total mesorectal excision
folowed by distal irrigation,
resection and anastomosis

DEFUNCTIONING
ILEOSTOMY

CHEMOTHERAPY FOR COLORECTAL

CANCER
In-operable case
Residual tumor (+) or probable after resection
High grade malignancy