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24 Colorectal Cancer: Preoperative Evaluation andStaging
447
tology, and poor/undifferentiated grade were associated
with a positive circumferential margin.
If involved CRM is suspected preoperatively, careful
surgical planning for extended resection and possible consideration for neoadjuvant multidrug chemotherapy are
warranted. With respect to rectal cancer, tumor involvement of the CRM is the most critical factor in predicting
local recurrence. For locally advanced rectal cancers, neoadjuvant therapy may result in downstaging, but if the
CRM is still positive, the risk of local recurrence is
increased. CRM is both an indicator of quality surgery and
the success of neoadjuvant therapy. The AJCC manual also
suggests that the surgeon mark the specimen on the nonperitonealized margins of resection with ink, especially in
the area with the deepest involvement of tumor, to allow
the pathologist to evaluate the radial margin and thus the
completeness of resection [12]. This should be done routinely for all cases where colon or rectal neoplasia (cancer
or polyp possibly containing cancer) is resected.
Tumor Location
It has been suggested that primary tumor location is a prognostic feature in colorectal cancer. With respect to colon cancer, tumors located distal to the splenic exure compared to
right-sided tumors have been associated with better prognosis independent of stage [82, 83]. However, it has also been
suggested that tumor location may be a proxy for tumor biology in that proximal tumors, being commonly associated
with β-RAF or KRAS mutations, are associated with poorer
prognosis. However, the relationship between tumor sidedness and prognosis is not straightforward and may be dependent on stage and histologic characteristics especially in
stage III disease [84].
With respect to rectal cancer, low tumors are associated
with a relatively poorer prognosis, partially due to the rigid,
narrow conguration of the pelvis and the technical challenges this poses intraoperatively. The consequence is a
lower rate of complete mesorectal excision and higher rate of
radial and distant margin positivity, as tumor location moves
more distally.
Conclusion
Once a diagnosis of colorectal cancer has been made, it is
essential that proper localization and staging be done to
assure that the patient will be assigned to the correct treatment protocol as determined by multidisciplinary tumor
boards. Doing so will enable the patient to receive optimal
management in order to effect the goals of long-term diseasefree and overall survival.
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Colon Cancer Surgical Treatment:
Principles ofColectomy
EvieH.Carchman andMatthewF.Kalady
25
Key Concepts
• Surgical resection of the primary tumor remains the cornerstone of treatment for stage I–III colon cancer and
plays a role in treating surgically resectable stage IV
disease.
• Extent of colectomy is based on the anatomic location of
the tumor.
• Goals of resection are to achieve negative circumferential
margins and to remove the mesentery at greatest risk for
lymphatic spread.
• Examination of lymph nodes allows for accurate cancer
staging, which is imperative for selection of patients for
adjuvant therapy.
Introduction
Colorectal cancer is among the most common cancers in the
United States, with an estimated 145,600 new cases and
51,020 associated deaths in 2019 (1). The 5-year survival
rate is 64.4%, based on data from 2009 to 2015. The most
accurate predictor of outcomes, based on the globally recognized TNM system for classication of malignant tumors, is
pathologic stage. Preoperative clinical staging with imaging
can determine the extent of local disease and detect distant
metastases, which may affect the treatment plan and sequence
of treatments. Surgical resection of the primary tumor
remains the cornerstone of treatment for stage I–III colon
cancer and plays a role in treating surgically resectable stage
IV disease. A clear understanding of anatomy, as well as the
E. H. Carchman (*)
University of Wisconsin, Department of General Surgery,
Madison, WI, USA
e-mail: carchman@surgery.wisc.edu
M. F. Kalady
Department of Surgery, Division of Colon and Rectal Surgery,
The Ohio State University, Columbus, OH, USA
e-mail: Matthew.Kalady@osumc.edu
appropriate extent of resection, guides the surgical approach
and has an important bearing on oncologic outcomes.
Preoperative Tumor Localization
When planning a colectomy, it is essential to determine the
precise location of the tumor. Typically, the diagnosis of neoplasia is made after identication and biopsy of the tumor on
colonoscopy, with note of the location of the tumor made on
the report. However, mislocalization of the tumor, based on
preoperative colonoscopy alone, occurs in 11–21% of cases
and can result in a different surgical procedure than originally planned in 11% of cases (2–5). This number may be
even higher when cecal and rectal tumors are excluded, due
to the lack of denitive landmarks in the distal ascending,
transverse and left colon, and variations in patient anatomy.
It should also be noted that localization based on “centimeters from the anal verge” should never be relied upon, as this
is often a highly inaccurate measurement when performed
during the course of exible colonoscopy. This is especially
important for tumors in the rectosigmoid, where misclassication of tumor location can lead to inappropriate treatment.
Many experienced colorectal surgeons will repeat exible
sigmoidoscopy on any patient referred to them with a neoplasm anywhere in the left colon, to avoid the mistake of
taking a patient with a rectal cancer directly to the operating
room for resection.
Preoperative computed tomography (CT) may demonstrate the exact location of the tumor. However, often the
tumor is too small to see denitively on CT, and thus other
localization methods should be considered. When a tumor is
encountered at colonoscopy, endoscopic tattoo placement
should be considered. Tattooing of the tumor facilitates
localization of the tumor intraoperatively, especially in cases
where palpation of the tumor is not possible such as during
minimally invasive colectomy. Effective tattooing has been
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S. R. Steele et al. (eds.), The ASCRS Textbook of Colon and Rectal Surgery, https://doi.org/10.1007/978-3-030-66049-9_25
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E. H. Carchman and M. F. Kalady
shown to reduce operating times and ensure that the correct
segment of colon is resected (6).
For most colonoscopically placed tattoos, India ink is
used. The goal is to inject into the submucosal plane. Fullthickness injection results in inadvertent spraying of tattoo
ink throughout the abdomen, which can make localization
difcult. One technique to more accurately and reliably conne the injection to the submucosa is to rst inject 0.5–
1.0mL of saline into the submucosa to create a bleb and then
insert the India ink into the saline bleb (0.75–1.0mL). It is
helpful to repeat this procedure in three or more quadrants to
avoid mesenteric injection only. It is also important to not
inject directly into the tumor but rather the opposite wall or
just distal to the tumor. One should note the placement of the
tattoo relative to the tumor in the colonoscopy procedure
note. It is preferable to inject tattoo only distal to the tumor,
rather than both proximal and distal, as occasionally only
one tattoo site can be identied intraoperatively. In addition,
usually it is the distal extent of the lesion that is most critical
for the surgeon when performing resection. An example of a
laparoscopic view of a colonoscopic tattoo is shown in
Fig.25.1.
Even with tattoo placement, the location of the tumor and
the tattoo can be sometimes difcult to discern, e.g., the tattoo ink is dispersed throughout the abdomen, or the surgeon
is unable to visualize the tattoo marks due to mesenteric
quadrant location placement, inadequate tattoo amount, obesity, or adhesions. Thus, when the tumor cannot be denitively identied on preoperative imaging, the patient and
surgeon should always be prepared for the possibility of
intraoperative colonoscopy for localization. Intraoperative
colonoscopy should ideally be performed using carbon dioxide as the insufation gas to limit bowel dilatation.
Another method of tumor localization is to place a
metallic clip adjacent to the tumor at the time of colonos-
Fig. 25.1 Intraoperative localization of a hepatic exure tumor by
identication of tattoo
copy. Plain radiographs in the supine position can be performed immediately post-colonoscopy. The colon is often
still lled with gas and the location of the clip relative to
the outline of the colon discernible. Alternatively, staging
CT of the abdomen and pelvis can be performed shortly
after colonoscopy and clip placement. If the clip remains
in situ, then the anatomic location of the tumor should be
readily visible on CT. This method may be especially
important when tattoo ink is unavailable at the time of
colonoscopy.
General Surgical Principles
Extent ofResection
In addition to removing the tumor itself, at least a 5-cm
margin should be obtained both proximally and distally,
and the feeding vessel should be taken at its origin. With
high ligation of the vessel, it is unlikely not to obtain 5-cm
margins due to resultant ischemia of the colon both proximally and distally. Adhering to 5-centimeter margins has
been shown to minimize anastomotic recurrences (7).
Proximal ligation of feeding vessels to the tumor should be
performed to maximize lymphadenectomy. Colectomy
specimens should have the non-peritonealized margins
marked with ink to assess for completeness of resection,
preferably by the surgeon, as is routine for proctectomy
specimens for rectal cancer.
For the treatment of sigmoid colon cancer, the level of
ligation of inferior mesenteric artery is controversial (high
ligation versus low ligation). There is increased lymph node
yield with high ligation over low ligation. However, studies
have shown no functional or oncologic differences between
high and low ligation (8–10). Unfortunately, there is not a
universally agreed upon nomenclature regarding the inferior
mesenteric artery (IMA) and its branches nor what is exactly
meant by “high” versus “low” ligation. Many experienced
surgeons consider the IMA to arise at the aorta and terminate
when it branches into the superior hemorrhoidal artery and
the left colic artery, which means that the average length of
the IMA is only a few centimeters. Other surgeons consider
the IMA to include what others would label the superior
hemorrhoidal artery, claiming that the IMA becomes the
superior hemorrhoidal artery when it crosses the common
iliac artery. This latter designation is problematic as it ignores
the principle of naming arteries based on their branch points
and because it is difcult to ascertain exactly where an artery
“crosses” another anatomically, especially after mobilization
of the mesosigmoid.
25 Colon Cancer Surgical Treatment: Principles ofColectomy
453
No-Touch Technique
The no-touch technique was developed due to concern about
dislodging tumor cells into the circulation during tumor
manipulation. This technique showed initial promise in
terms of prognosis (11). However, follow-up trials failed to
recapitulate these results (12). For this technique, the vascular pedicle is ligated prior to mobilization of the colon.
Garcia-Olmo et al. looked at blood samples to determine
whether release of circulating tumor cells (CTCs) occurred
during surgery and found no evidence of detachment with
tumor manipulation (13). A recent randomized controlled
trial of conventional colectomy versus no-touch for colon
cancer resection found no difference in disease-free survival,
overall survival, or recurrence-free survival in stages II and
III colon cancer patients (14).
Lymphadenectomy
When considering the surgical treatment of colon cancer, a
lymphadenectomy is considered adequate when feeding vessels are taken at their origin and at least 12 lymph nodes have
been harvested and examined histologically. Examination of
lymph nodes allows for accurate cancer staging. Adequate
surgical staging is imperative for selection of patients for
adjuvant therapy. The number of harvested lymph nodes and
the ratio of involved versus harvested nodes can be used as
markers of adequacy of surgical resection and are associated
with patient outcomes (15). There is no doubt that lymph
node excision is important to oncologic staging and outcomes; however, the extent of lymph node resection is
debated. Even more controversial is the role of extended
lymphadenectomy for synchronous extra-regional lymph
node metastasis, such as para-aortic lymph node metastasis
in colorectal cancer. One study demonstrated a benet for
highly selected patients, but this is not standard practice for
most colorectal surgeons (16).
found a signicant reduction in 5-year recurrence (9.7%
versus 17.9%, respectively). Another difference was the
number of lymph nodes harvested between the two groups
(median 38 versus 21, respectively) (17). The main benet
of a CME is the increased lymph node yield (18, 19).
Previous opinion on lymph node yield during lymphadenectomy was that it was mainly for prognostication; however,
recent studies bring into question its ability to improve
patient outcomes (survival) (20, 21). By performing a central ligation of the vessels, CME also obtains central and
apical lymph nodes and thus captures “skip lesions,” which
can occur in 5% of cases on average (22–24). Completion of
CME with an intact peritoneal lining has been demonstrated
to improve survival by 15% (25). The other theoretical
advantage of CME is that it standardizes surgical resection.
Drawbacks include the technical difculty of performing
CME compared to a standard colectomy, leading to longer
operative times. Further, given the increased dissection of
critical vascular structures (superior mesenteric artery
(SMA) and superior mesenteric vein (SMV)), there is a
potential for damage and signicant complications (26, 27).
The most feared complication during CME is damage to the
SMV, the main outow to the small intestines, shown to
occur in about 1.6% of right hemicolectomies (26). Several
studies have shown that laparoscopic CME is feasible and
safe (28–30). No functional differences have been noted
between patients who have undergone CME versus conventional colon surgery (31). Critically evaluating different surgical techniques is challenging, as there is no precise
denition of exactly what occurs during “conventional” surgery. It may be that some surgeons have been adhering to
the basic principles of CME long before the introduction of
the term. Ultimately, the major benet of CME may be refocusing surgeons of the basic principles of colectomy for
cancer–central ligation of vessels, removing the mesentery
at greatest risk for metastatic lymph node spread in its envelope, and achieving negative circumferential negative margins–just as “TME” did for rectal cancer.
Mesocolic Excision
The aim of the mesocolic resection is to remove the tumor,
its associated lymphovascular supply (including central vascular ligation), and mesocolon in an intact envelope of visceral peritoneum. There are no randomized controlled trials
comparing complete mesocolic excision (CME) to “standard” colon surgery. The rationale for CME comes from the
improvement in rectal cancer patient survival since the
introduction of “total mesorectal excision.” Initial retrospective studies have shown promising oncologic outcomes.
Bertelsen et al. reported 5-year outcomes for right-sided
colon cancer with CME versus standard resections and
Adjacent Tissue or Organ Invasion
Larger colon cancers may invade adjacent structures/organs.
The structures/organs most commonly involved are the
abdominal wall, bladder, duodenum, omentum, ovaries, peritoneum, retroperitoneum, small bowel, stomach, ureters, and
uterus. Surgical planning should include en bloc resection to
achieve negative circumferential margins. Adhesions from
the tumor to other structures are malignant in about 40% of
cases. If there is an uncertainty if there is direct invasion or
rather merely abutment, proceeding with en bloc resection is
favored. Without en bloc resection, patients are at higher risk
of recurrence and decreased survival (32).
454
E. H. Carchman and M. F. Kalady
For abdominal wall invasion, en bloc resection and then
reconstruction of the abdominal wall are recommended. For
other organ involvement, complete surgical resection should
be attempted if feasible and reconstruction of critical structures (ureters, iliac, etc.) if it can be performed. There can be
local invasion to the tail of the pancreas and spleen that
necessitates distal pancreatectomy and splenectomy. For
pancreatic or duodenal invasion, there are case reports of en
bloc pancreaticoduodenectomy (33).
Neoadjuvant systemic therapy can be considered for
locally advanced colon cancers. Data from the FOxTROT
Collaborative Group showed signicant tumor downstaging,
less apical node involvement, and fewer positive margins,
thus, favoring preoperative treatment in patients with locally
advanced, resectable colon cancer (34). Neoadjuvant chemotherapy was noted to be well tolerated and safe, with no
increase in perioperative morbidity and a trend toward fewer
serious postoperative complications. Evidence of disease
regression was noted in 59% of patients, including some
pathologic complete responses. The Collaborative Group
also noted a decrease in incomplete resection rate (abstract at
GI ASCO). The National Comprehensive Cancer Network
also recommends consideration of neoadjuvant therapy in
clinical T4b colon cancer, as this may improve survival (35).
Neoadjuvant chemoradiotherapy can be considered for
sigmoid tumors invading the bladder or other pelvic organs,
provided that the radiation dose to surrounding small bowel
can be limited. Neoadjuvant chemoradiotherapy has also
been administered to select patients with more proximal
colon tumors invading other vital structures such as duodenum and pancreas, although data are limited to case reports
and small series, and thus no denitive conclusions can be
made regarding relative efcacy.
Surgical Procedures Based onAnatomic
Location
Cecum andAscending Colon Cancer
For lesions of the cecum or ascending colon, a right hemicolectomy with ileocolic anastomosis is recommended. The
anatomic boundaries of the resection include approximately
10-cm proximal to the ileocecal valve and the proximal
transverse colon (Fig.25.2).
ing surgeon stands on the left side of the table. For an open
approach, a vertical midline or transverse/oblique incision is
made, using a self-retaining retractor of choice. The abdomen should be thoroughly inspected, especially the liver, for
evidence of metastatic disease. The tumor is assessed for
resectability, taking into account invasion of disease into the
duodenum or pancreas. The small bowel is retracted into the
left half of the abdomen, facilitated by tilting the table right
side up. The surgeon then identies the ileocolic artery and
performs a high ligation adjacent to the duodenum, after
ensuring that the duodenum is dissected free and protected
(Fig.25.3). The mesentery is then dissected off the retroperitoneum through this window. The right colic artery, if present, and the right branch of the middle colic artery and vein
are identied and ligated at their origins. The remaining mesentery to the transverse colon, including the marginal artery,
is taken. The remaining mesentery next to the planned transection point of the terminal ileum is also taken. The right
colon is dissected off the white line of Toldt to release the
remaining lateral attachments. The lesser sac is often opened
to mobilize the transverse colon and complete the mobilization of the hepatic exure. The terminal ileum and proximal
transverse colon are then divided, the specimen handed off
the table, and the anastomosis constructed per surgeon preference. There are a variety of ways to perform the anastomosis (intracorporeal or extracorporeal, hand-sewn or stapled,
side-to-side or end-to-side or end-to-end) with no one technique showing superiority over another. Closure of the mesenteric defect is controversial, as the defect is large and
unlikely to cause obstruction. The omentum of the hepatic
exure and transverse colon that is being resected is typically taken with the specimen. Reliable data indicate that
mobilization along anatomic planes is important and
improves prognosis (36).
In a lateral to medial approach, the surgeon rst transects
the white line of Toldt, usually starting at the cecum and
moving toward the hepatic exure. Then the colon and mesocolon are mobilized off the retroperitoneum and duodenum.
The hepatic exure is freed from the liver superiorly and
from the duodenum posteriorly. The ileocolic, right colic,
and right branch of the middle colic vessels are then ligated
at their origins. The remaining part of the procedure is similar to the procedure described above for a medial to lateral
approach.
Technical Aspects
Regardless of approach, most patients are positioned supine
on the operating table, unless intraoperative colonoscopy is
anticipated, whereas the patient should be in split leg position. It is helpful to tuck at least the patient’s left arm to allow
multiple individuals to stand on the left side, especially for
laparoscopic cases. For a medial to lateral technique, regardless of approach (laparoscopic, robotic, or open), the operat-
Hepatic Flexure Colon Cancer
For lesions in the hepatic exure, a right hemicolectomy may
be adequate if it is in the proximal hepatic exure, but
depending on location, an extended right hemicolectomy
may be required. For an extended right hemicolectomy, the
anatomic boundaries of resection are the terminal ileum to
distal transverse colon.
25 Colon Cancer Surgical Treatment: Principles ofColectomy
Fig. 25.2 Right
hemicolectomy
455
Fig. 25.3 Medial to lateral dissection of the right colon, identifying
and protecting the duodenum
Technical Aspects
Please refer to cecal and right colon cancer resection (above)
for a description of right hemicolectomy. In an extended
right hemicolectomy, the procedure is performed similar to a
right hemicolectomy, but the vascular division may include
the main middle colic arterial trunk provided that there is
adequate retrograde ow from the IMA to perfuse the splenic
exure (Fig.25.4). The lesser sac is opened along its entire
length, not just near the hepatic exure and proximal transverse colon. This allows visualization and access to the blood
supply. The splenic exure may need to be mobilized to create a tension-free anastomosis. The colon and the mesentery
are then resected according to the divided blood supply distribution. An ileocolic anastomosis is then created.
Removal of the spleen, either intentional or not, is associated with high morbidity and increased mortality (37).
Inadvertent splenectomies are usually a consequence of capsular tear due to inadequate exposure and aggressive retraction. The incidence of required splenectomy during splenic
exure mobilization is less than 1% (38). Varty et al. conducted a case control study that compared cancers requiring
splenectomy to cancers that did not. The authors found no
inuence on long-term survival but increased rates of postoperative sepsis (39).
456
Fig. 25.4 Extended right
hemicolectomy
E. H. Carchman and M. F. Kalady
Transverse Colon Cancer
It is often challenging to decide which surgical procedure to
utilize for cancer of the transverse colon, as the blood supply
comes from the middle colic, along with the right and left
colic vessels. The best procedure is the one that removes the
regional lymphatic drainage which is based on the arterial
supply and corresponding mesentery. The decision is inuenced by the location of the tumor within the transverse
colon and the anatomy in that individual. The more common
options include an extended right colectomy, extended left
colectomy, or a subtotal colectomy. Segmental transverse
colectomy is also sometimes utilized.
Technical Aspects
Proximal transverse colon cancers are typically managed
with an extended right colectomy, which is described above.
Lesions in the mid to distal aspect of the transverse colon
may be offered an extended right colectomy, extended left
colectomy, or segment transverse colectomy. An extended
left colectomy requires ligation of the middle colic artery
main branch in addition to the left colic artery as described
below (Fig.25.5). In the case of a mid-transverse colon cancer, a transverse colectomy may be considered. The principles of high ligation of the middle colic artery and drainage
of regional lymphatics remain the cornerstone of care. In
this case, the anastomosis is an ascending to descending
colon anastomosis which requires mobilization of both segments and can be challenging or awkward technically.
Segmental transverse colectomy is most appropriate for
patients with a tumor in the mid-transverse colon with a
redundant colon where mobility is not an issue. An end-toend colo-colonic anastomosis is usually performed due to
the risk of tension on a side-to-side anastomosis caused by
the two sides of the colon mesentery retracting back toward
their original position. There is also the concern regarding
the adequacy of the lymphadenectomy that occurs with a
segmental resection of the transverse colon. For these reasons, many surgeons treat mid-transverse colon lesions with
an extended right colectomy which is easier for mobilization of the small bowel for an ileocolic anastomosis. A limited segmental transverse colectomy can be offered for
palliative reasons or in frail patients that may not tolerate an
extended resection.