COLORECTAL CARCINOMA

Carcinoma of the large bowel is a major health hazard in most affluent countries. It is
the most common cancer of the gastrointestinal tract. In men, its frequency is
surpassed only by carcinoma of the lung and prostate. In women, it is outnumbered
only by breast cancer. Its frequency is higher in northern than southern Europe and
higher in North America than South America.

Colorectal cancer is the second commonest epithelial cancer in England and Wales,
and in the Western society as a whole it accounts for 9-20% of all cancer death. In
the United States, over 150,000 new cases of colon or rectum occur annually and
about 60,000 patients die each year from colorectal cancer. Its incidence rate has
changed little in the white population, but has increased appreciably in blacks.

Aetiology
The cause of colorectal cancer is unknown. Hereditary factors have been implicated
in some patients, but the overwhelming majority of cases appear to be related to extra
genetic factors,

Genetic Factors
In some patients, the genetic factor may be obvious. Inherited diseases associated
with large bowel cancer include various familial polyposis syndromes. Familial
Adenomatous Polyposis (FAP) has four variants:
• Typical FAP.
• Gardner’s syndrome.
• Turcot’s syndrome.
• Attenuated polyposis coli (AAPC).
Thus the polyps characteristic of familial polyposis coli, Gardner’s or Turcot’s
syndrome almost inevitably become malignant, giving rise to multiple tumours in the
colon and rectum. Of these syndromes the commonest is familial polyposis, which is
an inherited non-sex-linked autosomal dominant disease in which there are at least
100 adenomatous polyps throughout the entire large bowel. Symptoms of bowel
disturbance begin at an average age of 16 years and overt malignancy develops
within 15 years in most untreated patients by the time they reach early adult life.

FAP is classified as Gardner’s syndrome when the intestinal findings are

accompanied by certain extraintestinal growth including osteomas (particularly of
mandible or long bones), epidermoid cysts, dermoid tumours, and congenital
hypertrophy of the retinal pigment epithelium.
Turcot’s syndrome refers to intestinal polyposis in combination with brain tumours.
Dietary factors
Burkitt (1971) came up with the suggestion that the close relationship between bowel
cancer and other non-infective diseases of the bowel such as benign tumour,
diverticular disease and appendicitis indicates that these conditions may have a
common or related aetiology. The close association of carcinoma of the colon with
refined diet of the western civilization suggests that removal of dietary fibre may be
an aetiological factor. It is known that dietary fibre regulates the speed of intestinal
transit as well as the bulk and consistency of faeces, and along with other dietary
factors, fibre may be related to changes in bacterial flora of stool. It is postulated that
carcinogenic substances produced by the action of an abnormal bacterial flora, when
kept in contact with the bowel mucosa for a prolonged period of time in concentrated
form, may in part explain the high incidence of large bowel cancer in the
economically developed nations.

While most authorities support the mentioned hypothesis relating dietary factors to
colonic cancer, there is little agreement concerning which specific dietary item is
implicated. However, the hypothesis focuses on enzymatic activity of the intestinal
bacteria. A suggestion has been put forward that these enzymes could either activate
an ingested carcinogen and/or produce a carcinogen from dietary components or
intestinal secretions. Evidence mostly derived from animal studies indicates that the
important substrates are the bile acids which, secreted by the liver, are extensively
metabolised by the colonic bacteria, the principal metabolites being deoxycholic acid
and lithocholic acid.

A corollary of the bile acid-intestinal flora hypothesis of colonic cancer is the

observation that there is a two-fold increased risk of developing cancer of the right
colon after cholecystectomy. Absence of the gallbladder results in a continuous
circulation of the bile salt that prolongs the exposure of the bile salts to intestinal
bacteria. The conjugated bile acids are hydrolysed and subsequently transformed into
secondary bile acids, a step in the formation of known carcinogens.

Associated Diseases
Inflammatory Bowel Diseases
• Ulcerative Colitis.
Crohn and Rosenberg in 1925 first recognized the association between chronic
ulcerative colitis and large bowel carcinoma. Since then, thousands of cases of
adenocarcinoma complicating chronic non-specific ulcerative colitis have been
reported, and it is agreed generally that this disease is a true premalignant disease
of the colon and rectum. The incidence of malignancy is quoted to be about 5%
(range 1.7-13%). Factors present in the population at risk that might serve as clues
in screening for malignancy in ulcerative colitis include:
1. Total proctocolitis. The extent of the large bowel involved probably is
more important, with the other four being secondary. When confined to
 the rectum, rectosigmoid colon or the entire left side of the large bowel,
the risk of malignancy is substantially less than when the entire large
bowel is involved.
2. Long duration of colitis, longer than 10 years.
3. Onset of disease in youth.
4. Chronic continuous symptoms.
5. Clinically severe first attack colitis.
After identifying the patient with chronic ulcerative colitis who is at risk of
developing cancer, proper follow-up and the earliest possible diagnosis are essential.
While history is important for detection of colorectal cancer in the general
population, it is of little use in ulcerative colitis. Symptoms may be subtle changes in
the pattern of symptoms of chronic ulcerative colitis. These symptoms include:
1. A sudden exacerbation of disease especially when it has been relatively
quiescent;
2. A change in the pattern of diarrhoea, with more frequent bowel movements
and the passage of more blood;
3. Abdominal pain unrelated to bowel movements;
4. Constipation and symptoms of obstruction
5. Recent weight loss and
6. Symptoms of anaemia.
On examination, an abdominal mass or a rectal mass on digital examination often
represents advanced cancer and the failure to make an early diagnosis.

• Crohn’s Disease.
Clearly there is a moderate risk of large bowel malignancy developing in Crohn’s
colitis (granulomatous or transmural colitis). Possible risk factors include:
1. Long duration of Crohn’s disease, longer than 15 years;
2. Onset of colitis at 21 years or younger;
3. Total colonic involvement with Crohn’s disease and
4. A by-passed, excluded or obstructed large bowel.
Only a finding of a rectal mass on rectal examination is useful on examination of the
patient.

Other Conditions.
These include:
1. Radiation Proctocolitis. This association is well documented.
2. Following ureterosigmoidostomy. Patients who have had this procedure have
about 500 times greater risk of getting colon cancer than the age-matched
general population. The cancer develops in the sigmoid colon. The latency
period between ureterosigmoidostomy and the diagnosis of benign
adenomatous polyps depends upon the age of the patient at the time of urinary
diversion. In young patients undergoing the operation for benign conditions of
the bladder, the average age of diagnosis of benign adenomatous polyps was
 found to be 28 with a latency period of 29 years. Adenocarcinoma of the
sigmoid colon was diagnosed in patients who had ureterosigmoidostomy for
benign conditions of the bladder at an average age of 36.5 years with a latency
of 24 years. In contrast, older patients who had the procedure for malignant
conditions of the bladder had an average age of 64 years at the time of
diagnosis of either adenoma or adenocarcinoma of the sigmoid colon and a
latency period of only 7 years.
3. Schistosomiasis.
Several hundreds of cases of adenocarcinoma of the colon and rectum associated
with schistosomiasis have been documented in the Japanese and English literature.

Pathology.
The gross morphological features of the colonic primary cancer greatly influence the
clinical presentation of the disease. Regardless of the site of origin, colorectal
adenocarcinomas have a tendency to grow circumferentially. Because of the larger
luminal calibre in the right colon, these tumours are usually bulky and fungating,
with extensive projections into the bowel lumen. This is in contrast to the left colon
where more complete circumferential involvement occurs resulting into annular or
“napkin ring” tumours. The tumour can be classified into the following macroscopic
groups:
1. Polypoid (Papilliferous or Cauliflower).
2. Ulcerative.
3. Annular.
4. Diffuse Infiltrating.
5. Colloid.

Microscopy
Almost all colorectal carcinomas are adenocarcinomas. Histological features that
have been related to prognosis include:
• Grade of tumour,
• Character of margins,
• Presence or absence of lymphatic, vascular and perineural infiltration;
• The presence of an associated inflammatory response.
Grading system has been modified and adopted as:
a) Well differentiated (low grade),
b) Moderately differentiated (average grade) and
c) Poorly differentiated (high grade).
In addition, about 10 to 15 per cent of colorectal carcinomas produce mucin and are
called mucinous carcinomas. This type of cancer has more tendency to spread locally
and distantly and carries a poor prognosis. The signet-ring cell carcinoma, a rare
intracellular mucinous carcinoma, has also been found to have a poor prognosis.
Spread
1. Local. As the tumour continues to grow, it penetrates the deeper layers of the
bowel wall and may actually extend by contiguity into neighbouring structures
(small intestine, stomach, duodenum, liver, ureter, bladder, uterus, abdominal
wall, etc).
2. Lymphatic. To the regional lymph nodes, eventually spreading to the thoracic
duct, and may involve supraclavicular lymph nodes in the late stage. Lymph
nodes draining the colon are grouped as follows:
• N1 – Nodes in immediate vicinity of the bowel wall
• N2 – Nodes arranged along the ileocolic, right colic,
midcolic, left colic and sigmoid arteries.
• N3 - The apical lymph nodes around the superior and
inferior mesenteric vessels where they originate
the aorta.
3. Bloodstream spread. To the liver via the portal system, thence to the lungs.
4. Trans-coelomic spread. Gravitational metastases may occur at any time after
the has extended through the serosa of the bowel wall, allowing tumour cells to
break off and separate from the bowel wall and to be carried to distant sites
throughout the peritoneal cavity. Such seeding accounts for the generalized
abdominal carcimatosis that is occasionally encountered, as well as the shelf of
malignant tissue developing in the Pouch of Douglas, or in the female,
secondary deposits in the ovaries, the Krukenberg tumour. This means of
spread is also responsible for the “frozen pelvis”.
5. Trans-luminal spread. Tumour cells may be shed from the surface of the
carcinoma into the intestinal lumen. The importance of this mode of spread has
yet to be determined.

Distribution of colorectal cancer.

The distribution of large bowel tumours is as follows:
a) Caecum – 10-12%
b) Ascending colon – 5-8%
c) Hepatic flexure – 2%
d) Transverse colon – 5%
e) Splenic flexure – 3%
f) Descending colon – 4-6%
g) Sigmoid colon – 21%
h) Rectum – 38%
i) Anus – 2%.
The frequency of synchronous tumour is between 1-3%, excluding tumours
occurring as complications of familial polyposis and ulcerative colitis.
Staging of colorectal cancer
The staging of any tumour has three potential purposes. It may provide information
pertinent to therapeutic decisions, it may provide prognostic information for patient
consultation and it should provide a more or less uniform characterization of disease
type and extent on which treatment results may be compared. Staging may be done
with clinical, operative or pathologic findings or a combination of these.

In 1932, Dukes presented a pathological staging system for carcinoma of the rectum,
which was later applied to the colonic tumours as well. The original Duke’s
classification identified three groups of tumours . Those tumours confined to the
bowel wall were designated A, those penetrating the through the muscularis popria
into the surrounding fat and adventitia but with negative lymph nodes were
designated B and those tumours with lymph node metastases were designated C.
Modifications, putting into consideration presence or absence of distances is
currently in use as follows:
a) Stage A. Tumour limited to the mucosa.
b) Stage B. Tumour extension through the entire bowel wall into the paracolic
or pararectal tissues, but with no lymph nodal involvement.
c) Stage C. As with A and B but also with metastasis to the regional nodes.

Modification of Duke’s classification of colorectal cancer.

Stage Astler,Coller-1954 * Gunderson,Sosin-1974 **
A Tumour limited to mucosa. Tumour limited to mucosa
B1 Extension into muscularis Tumour extension through mucosa,
Popria but not through it but without nodal involvement.
B2 Penetrating through muscu- Tumour extension through entire wall with
laris popria but negative node. negative node.
B3 ____ Tumour adherent to or invading adjacent
organs, but with negative nodes.
C1 Tumour limited to bowel wall, Tumour limited to bowel wall, but nodes
with positive nodes. nonetheless positive.
C2 Tumour through entire bowel Tumour extension trough entire wall, nodes
wall, nodes also positive. also positive.
C3 ____ Tumour adherent to or invading adjacent
organs, nodes also positive.

* Modified from Astler V B and Coller F A.; Ann Surg 1954; 139:846.
**Gunderson L L and Sosin H.; Cancer 1974; 34:1278.

Relationship of Dukes’ Staging to survival ( Astler and Coller-1954*).

Stage 5-year survival, %
A 100.0
B1 66.6
B2 53.9
C1 42.8
C2 22.4
The relative frequency of patients in these categories when the condition is first
diagnosed in the Western nations is: Stage A, 15%; Stage B, 40%; Stage C, 45%.

Synchronous and Metachronous Cancer and Polyps.

Synchronous cancer of the colon and rectum is defined as a second cancer present at
the same time as the index cancer present at the same time as the index cancer. The
incidence is about 5 per cent. Most of the synchronous cancers are located in
different surgical segments that would not be removed with a standard pattern of
surgical excision of the primary tumour. Synchronous neoplastic polyps greater than
5 mm are encountered in 28% of patients. About two-thirds of these polyps are
remote from the planned surgical segment of the index cancer. Data from St. Mark’s
Hospital in London revealed that the second large bowel tumour was palpable at
operation in only 30% of cases.

Metachronous cancer refers to a second cancer occurring at some future date. The
incidence of metachronous cancer of the colon and rectum is approximately 2% with
up to twenty years follow-up. The incidence of metachronous polyps is around 5%.

Clinical Manifestation of Colorectal Cancer.

The clinical features of large bowel cancer are related to the tumour size and
location. The symptoms are non-specific. The classic symptoms of a change in bowel
habits and rectal bleeding may be the first symptom and sign, but do not necessarily
suggest an early lesion. The symptoms of abdominal pain and cramps, constipation,
bloating and diarrhoea are produced by partial intestinal obstruction. Carcinoma of
the rectum may cause a feeling of incomplete evacuation or tenesmus.

Bleeding per rectum is most often first noticed by the patient. The blood may be
bright red or dark, with or without clots. Most of the noticeable blood originates from
left-sided lesions while lesions of the transverse colon or right side is occult, unless
the bleeding is profuse. Weight loss and anorexia are often indicative on of advanced
malignancy.

Right-sided tumours
The symptoms associated with right-sided colonic tumours are determined by :
A. The macroscopic pathological features of the tumour. The majority are large
bulky polypoid and ulcerating tumours.
B. The wide diameter and distensibility of the right colon.
C. Its liquid faecal stream.
The more common symptoms of the right-sided colonic tumours include:
a) Vague abdominal pain that may be confused with gallbladder or peptic
ulcer disease, 80%.
 b) General malaise and lassitude associated with anaemia, 20%.
c) A palpable abdominal mass, 67%.
d) Symptoms and signs suggestive of an appendicular mass – this is
especially if subacute perforation occurs or should the tumour act as an
obstructing agent to the appendix itself, 20%.
e) When the tumour occurs in the hepatic flexure, or the caecum has failed
to descend, a perforating carcinoma may be misdiagnosed as acute
cholecystitis.
f) Malaena due to occult bleeding of an ulcerated tumour, 8%.
g) Weight loss, 48%.

Left-sided tumours

Tumours of the descending colon tend to be annular and because stool is semisolid,
the common symptom associated with left-sided colon tumours are:
a) Intermittent colicky lower abdominal pain, 50-70%.
b) Anorexia, fear to feed because eating may precipitate the onset of pain,
c) Change in bowel habits, 60%.
d) Bloody stool. Blood is mixed with stool, 10%.
e) Distension of the caecum due to intermittent obstruction presenting as a
right iliac fossa swelling.
g) Palpable mass, 45%.

In addition to these symptoms, left-sided colonic tumours may also present with the
following:
• Acute large bowel obstruction.
• Perforation. Rarely the tumour may present with perforation either into the
general peritoneal cavity or locally with the formation of a pericolic abscess,
or by fistulae into adjacent viscera e.g. a gastrocolic fistula or vesico-colic
fistula.
• Peritonitis due to perforation at the site of the tumour or perforation of the
colon proximal to the obstructing lesion due to stercoral ulceration.
• The effects of secondary deposit. The patient may present with jaundice, or
abdominal distension due to ascites, or with hepatomegaly.

Physical signs associated with colonic carcinoma.

Physical examination may reveal:

1. Clinical evidence of anaemia. This is normocytic and hypochromic and
associated with a low serum iron.
2. Wasting.
3. A Palpable mass. A palpable mass is most commonly associated with right-
sided tumours, a growth in this situation being palpable in about 50-75% of
 patients compared with 30-45% of patients with descending colonic tumours.
Tumours of the sigmoid colon may prolapse into the pouch of Douglas and
present with a palpable mass per rectum.
4. Abdominal distension and borborygmi in cases of chronic large bowel
obstruction.
5. Signs of local or general peritonitis may follow perforation of the tumour or a
stercoral ulcer if obstruction occurs.
6. Evidence of spread: hepatomegaly, ascitis, jaundice or supracondylar nodes.

Diagnosis

The diagnosis of carcinoma of the colon is made on the basis of the clinical history
and can usually be confirmed on the basis of special investigations.
Digital examination
This must be routine even. In the West, only a small percent of cancers of the colon
are within the reach of the finger. The examining finger on routine rectal examination
can palpate about 50% of the malignant lesions.

Procto-sigmoidoscopy
It is important to emphasize that approximately 50-75% of colorectal cancers occur
within the terminal 25 cm of the large bowel and thus are amenable to direct
visualization and biopsy via proctosigmoidoscopy.

Flexible proctosigmoidoscopy permits adequate visualization of the rectum, sigmoid

colon and often the descending colon.

Barium enema study

When proctosigmoidoscopy is negative, a barium enema is the next logical
investigation. The accuracy of this procedure has been greatly improved by the
introduction of double contrast technique by which the radiologist is now able to
easily demonstrate lesions in areas, which are difficult to visualize, such as the
overlapping parts of the sigmoid colon. A good study will pick up lesions 1 cm in
diameter or larger.

Barium enema will usually reveal the tumour as a stricture or filling defect. Lesions
involving the left colon are usually seen as filling defects and often demonstrate an
angular configuration, known as ‘the apple core’ deformity. Classically, the common
ulcerating tumour causes a filling defect with a typical ‘fingerprint’ deformity or
‘shouldering’ at its margins. The more schirrous type of growth may produce an
annular constricting lesion extending for a variable length along the bowel to produce
the typical ‘napkin-ring’ picture.
Other radiological investigations
These include:
• Chest x-ray. To rule out pulmonary metastases.
• IVP. In case there is evidence of obstructive uropathy or abnormal renal
function.
• Abdominal ultrasound.

Colonoscopy
This is currently is the most accurate and the most complete examination of the large
intestine. An experienced, well-trained colonoscopist can reach the caecum in 90% of
cases with little pain in most patients. Colonoscopy is extremely useful when:
a) When diagnosis remains doubtful following a barium enema.
b) Barium enema demonstrates a polypoid lesion.
Colonoscopy will allow opportunity for a biopsy of the lesion in question and
histological confirmation. In addition, the presence or absence of a synchronous
polyp or cancers can also be determined.

Depending on the colonoscopic expertise available at an institution, some authorities

feel that a barium enema is unnecessary and that, in any patient being evaluated for
colorectal cancer, colonoscopy alone is a sufficient diagnostic procedure. The only
contradiction to colonoscopy include:
• Acute, severe inflammatory disease with mucosal ulceration.
• Suspected perforation or presence of peritonitis.
• Recent injury to the bowel wall.

The disadvantages of colonoscopy are:

• Its cost is about twice as much as barium enema studies.
• Even an experienced colonoscopist cannot reach the caecum in all cases.
The main complications of colonoscopy are:
• Haemorrhage. This is most likely to occur after resection of polyps larger
than 2 cm in diameter.
• Perforation. Recorded in 0.1% of cases.
• Death. When it occurs, normally follows perforation.

Tumour markers
Carcino-embryonic Antigen (CEA).
CEA, more accurately known as the oncofetal antigen, is a glycoprotein antigen
normally absent in adults that is produced by the large bowel carcinoma. It is
 non-specific, since other conditions are also found to have an abnormal level.
These include:
• Malignancies of the stomach, breast and lung.
• Liver diseases.
• Pancreatitis.
• Ulcerative colitis.
• History of excessive smoking.
CEA has no value in screening or as a diagnostic tool for large bowel cancer, but it
has been shown to have prognostic value. A positive CEA test with an absolute
concentration higher than 2.5 ug/l is found in 70-805 of patients with colorectal
carcinoma. The levels tend to be higher with large tumours and higher still in the
presence of liver metastases. When preoperative CEA is abnormal, the chances of
subsequent recurrence or metastases are more than when the preoperative CEA is
normal. If it is elevated when the patient is first seen, it normally suggests that the
condition is incurable. Some surgeons advocate for a routine CEA determination in
large bowel cancer as a base-line investigation. Its main usefulness is for
postoperative follow up.

Routine laboratory tests

These tests are of little value in the workup of a patient with suspected colorectal
cancer. Studies of particular value, however, include haemoglobin determination and
tests to assess liver function.

Occult blood in stool

This procedure helps to detect cancers of the bowel at an early, curable stage. It is
recommended that this test be done yearly especially among those at high risk.

Treatment
Colorectal cancer is amenable to surgical excision. Although most tumours grow
relatively slowly and are late to metastasise, as high as 75% of the patients coming to
operation present with primary tumours that either have completely invaded the
bowel wall or are associated with lymphatic or more distant secondaries. Modern
surgical approach to colorectal cancer has to put into consideration the margins of
resection and the en bloc resection of the draining lymphatic tissue. Alternative
routes of tumour spread must be considered.

The operation of choice used is the one that allows a single-stage resection of the
colon with a wide resection of the mesentery and restoration of the bowel continuity
by end-to-end anastomosis. The nature of the operation used depends on the segment
of the colon that is involved as well as the presence or absence of complications and
the general condition of the patient. The treatment includes not only excision of the
cancer itself with sufficient margins on each side, but concomitant removal of areas
of lymphatic spread and direct (local) spread.
The essential surgical procedure underlying definite operation for large bowel
carcinoma therefore is:
• Wide resection of the cancer-bearing segment of the bowel.
• Wide excision of the lymphatics draining the affected part of the bowel.
It is important that the procedure is performed with minimal risk of contaminating
the peritoneal cavity with either bacteria or malignant cells. The abundant bacterial
flora in the colon represents a constant menace during surgery on this organ. The risk
of bacterial contamination can be minimized, although not totally eliminated by the
preoperative bowel preparation.

Preoperative large bowel preparation

A. MECHANICAL CLEANSING. Although the colon and rectum cannot be
sterilized completely, a complete mechanical cleansing of its content is the
most important method to decrease the bacterial count.
B. The conventional regimen of 3-days course of purgatives, enemas and dietary
restriction has been replaced by whole-gut lavage, which with polyethylene
glycol-electrolyte solution (Golytely or Colyte). With this method of
cleansing, the patient is allowed a light solid meal up to lunchtime of the day
prior to the operation. Metoclopramide, 10 mg, may be given half an hour to
an hour prior to starting bowel preparation to reduce nausea. The patient
drinks the solution or the solution is given through a nasogastric tube at the
rate of 250 mls every 10 minutes until the diarrhoeal effluent is clear. It may
take 3 to 10 hours to complete the process. It is convenient to start at 4.00 or
5.00 pm the evening before surgery.
C. ANTIBIOTIC PREPARATION. In addition to mechanical preparation,
nonabsorbable oral antibiotics have for a long time been given to achieve an
additional decrease in the bacterial flora of the colon; however this method
has been the subject of controversy. The antimicrobial drugs commonly in use
at the present time and which have been found highly effective in reducing the
incidence of postoperative sepsis in colorectal surgery are neomycin which is
particularly active against Escherichia coli and metronidazole more active
against Bacteroides fragilis. Both these organisms are commonly found in
wound infection.

A short course of prophylactic antibiotics has also been to markedly reduce

the infection rate. The choice of antibiotics is a matter of personal preference,
but in general the potent broad-spectrum broad-spectrum antibiotic should be
reserved for therapeutic use. A long-acting first generation cephalosporin
along with metronidazole given prior to abdominal incision is an effective
regimen. Another is to give a second-generation cephalosporin only. A
combination of gentamycin and clindamycin has also been found very
effective in prevention of sepsis following colorectal surgery. In the
 uncomplicated cases, the antibiotics may be continued for two more doses.
There is no benefit to prolonging the administration of prophylactic
antibiotics, it may be dangerous by promoting the production of antibiotic-
resistant bacteria.

Resection
The exact surgical procedure for a particular carcinoma depends on the location of
the tumour. Selection of the appropriate surgical procedure is influenced by:
• The degree of local tumour invasion.
• Tumour mobility.
• Accessibility.
• Size.
• Presence of involved lymph nodes.

Operative Technique.
In the conventional method of resection of colonic cancer, the segment having the
growth is mobilized first and its lymphovascular pedicle then divided. Turnbull et al
(1967) demonstrated that reversal of the order of these manoeuvres enhanced the
survival rate of patients with lymph node metastases. According to Turnbull’s “no
touch isolation” technique, the lymphatic and vascular channels of the involved
segment are ligated first, the colon divided at appropriate points second, and the
tumour-bearing segment mobilized last. This method gives maximal control of the
dissemination of malignant cells, known to occur during operative manipulation of
malignant tumours. (Turnbull R.B, Kyle K, Watson F.R, Spratt J. cancer of the colon.
The influence of the no-touch isolation technique on survival rates, Ann Surg 1967;
166:420.).

The following are the normally accepted limits of resection for the carcinomas in
various segments of the colon:
1. Carcinoma of the right colon including the hepatic flexure and right
transverse colon . Right hemicolectomy involving removal of about 10 to 12
cm of the terminal ileum together with the colon as far as the junction
between the right two-thirds with that of the left one-third of the transverse
colon. The branches of the superior mesenteric artery, including the middle
colic, right colic and inferior colic, together with the terminal branches of the
ileocolic vessel itself, are tied and divided at their origin from the main trunk.
The ileum is anastomosed to the left transverse colon by either hand or
stapling technique.
2. Carcinoma of the mid-transverse colon. This is managed by excision of the
whole transverse colon and mesocolon. The middle colic artery is divided at
its origin from the superior mesenteric artery. Another option is to do an
extended right hemicolectomy. The anastomosis is done between the terminal
ileum and the upper descending colon.
 3. Carcinoma of the splenic flexure, the left transverse colon and descending
colon. This is treated by left hemicolectomy and which involves excision of
the left third of the transverse colon, the splenic flexure, descending colon
and the sigmoid colon up to the rectosigmoid junction. This extensive surgery
involves division of the left branch of the middle colic artery along with the
left colic artery and the upper branch of the sigmoid artery.
4. Carcinoma of the sigmoid colon and rectosigmoid. This is treated by sigmoid
colectomy. All the branches of the sigmoid artery are divided close to their
origin from the inferior mesenteric artery.

Emergency operations
In cases where surgery is done on an unprepared bowel such as in obstruction,
perforation and haemorrhage or when the tumour is encountered unexpectedly at
surgery, most surgeons opt to go ahead with the definitive resection and anastomosis
if the lesion is in the right half of the colon. If the lesion is on the left side, one option
is to resect the tumour and exteorize the two cut ends of the colon. If the distal end is
two short to bring out, the Hartmann procedure is done.

Apart from situations where the general condition of the patient is considered too
risky and therefore a preliminary decompressive procedure for obstruction of the
distal colon due to carcinoma, the trend is towards primary resection plus or minus
immediate anastomosis. The choice is between the following:
a) Primary resection and anastomosis.
b) Primary resection without anastomosis.
c) Primary resection with anastomosis and proximal protective colostomy.
d) Subtotal colectomy with ileosigmoidostomy.
Primary resection and immediate anastomosis carries an average mortality of about
35% and probably should be performed by only in isolated situations by surgeons
with wide experience.

Adjuvant therapy

Radiotherapy has been used preoperatively, postoperatively and as a combination of

both preoperative and postoperative treatment.