COLORECTAL POLYPS AND COLORECTAL CARCINOMA

The colonic mucosa is now recognized to be a highly active epithelial lining

which is subjected to a prolonged exposure to a wide variety of environmental
stimuli.

Colorectal polyps
By definition a polyp can be described as a swelling arising from the colonic
mucosa on a single pedicle or stalk.
Polyps are a common finding in the large bowel. Their great importance is in
relation to malignant change.
The majority of colorectal polyps are adenomas (benign neoplasms) but all have
a malignant potential.
Furthermore a polyp may already have undergone malignant change yet still at
an early and potentially curable stage. Thus for practical purposes any
colorectal polyp must be considered malignant or premalignant until
proved otherwise.

Polyps typically present with rectal bleeding and sometimes iron deficiency
anemia due to occult blood loss. Distal lesions may occasionally produce
tenesmus or they may prolapse through the anus.
Many polyps cause no symptoms at least in their early stages and remain
undiagnosed or are found incidentally on barium enema examination.
Tenesmus is painful spasm of the anal sphincter along with an urgent desire to
defecate without the significant production of feces.
Prolapsed polyp is protrusion of the polyp through the anus and hence it
becomes visible outside the body.

Adenomatous polyps
Adenomas have two basic morphological forms: pedunculated polyps with
stalks of variable length and broad-based (sessile) lesions.
Histologically three patterns of growth are recognised: tubular adenomas, villous
adenomas and tubulo-villous adenomas.
Tubular adenomas
These are small pedunculated or sessile lesions in which the adenoma cells retain
a tubular form similar to normal colonic mucosa.
Tubular adenomas have the least potential for malignant transformation.
The exception is when multiple tubular adenomas occur throughout the large
bowel in the rare familial disorder of polyposis coli (adenomatous polyposis).
In this condition there is a very high risk of early malignant transformation.
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Villous adenomas
Villous adenomas are usually sessile and frond-like (papilliferous) lesions which
tend to secrete mucus. This may be so copious as to be the main presenting
complaint (passing stools with mucus).
Symptomatic hypokalaemia may develop (though rarely) because so much
potassium-containing mucus is lost.
There is a great potential for malignant change.
Tubulo-villous adenomas
These lesions are intermediate between tubular and villous adenomas and
include the majority of colonic polyps.

Most polyps are pedunculated the length of the stalk varies from about 1-10 cm.
and is probably due to peristalsis dragging the tumour mass distally.
The degree of epithelial dysplasia in adenomatous polyps is highly variable.
Early malignant change is represented by invasion of tumour cells through the
basement membrane and then into the muscularis mucosae and submucosa.
In apparently benign lesions, there may be small areas of frank malignancy and
careful histological examination is essential.
Adenomatous polyps may occur in any part of the large bowel, although three
quarters of them arise in the rectum and sigmoid colon.
This exactly parallels the distribution of carcinomas and provides strong
evidence to support the view that most cancers develop from polyps.

Adenomas are clinically important because they tend to cause rectal bleeding
loss (visible or occult) and because they may undergo malignant change.
If adenomatous polyps are discovered the whole large bowel must be examined,
preferably by fibre-optic colonoscopy.
As a general rule the larger the lesion the more likely it is to be malignant.
Patients with frank carcinoma often have benign polyps as well and these may
become malignant later. This explains why the whole colon should be examined
before colectomy wherever possible.

Diagnosis and management of colorectal polyps

Diagnosis may be made at rectoscopy, sigmoidoscopy; nearly half of all polyps
are within reach of the 25 cm. rigid instrument.
Fiberoptic sigmoidoscopy enables the left side of the colon to be examined as far
as the splenic flexure, the area of greatest risk and any polyps can be removed at
the same time by diathermy snare.
Barium enema examination reveals most polyps of significant size and is the
examination of first choice for the transverse and right side of colon.

Polyps can be excised using a diathermy snare around the stalk or sessile base.
Pedunculated lesions less than 2 cm. in diameter can usually be removed with
ease but larger ones or sessile may require snaring in several pieces.
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If a malignant polyp has been incompletely removed then bowel resection is

required. After removal of dysplastic or frankly malignant polyps most patients
are routinely endoscoped every one or two years.

Adenocarcinoma of the colon and rectum

Pathology and clinical presentation

Adenocarcinoma of the colon is initially exophytic (growing outwards from the
mucosa into the lumen) and later ulcerates and progressively invades the
muscular bowel wall.
The tumour invades next the serosa and surrounding structures. Stromal fibrosis
causes narrowing which is responsible for the common acute presentation of
large bowel obstruction.
Large bowel carcinomas metastases are produced mainly via lymphatics and via
the blood stream.
Lymphatic spread is sequential first to mesenteric nodes and then to para-aortic
nodes.
Occasionally lymph node involvement may be responsible for the clinical
presentation. For example, paraaortic nodes may present as a palpable mass or
cause duodenal obstruction. Other enlarged nodes may compress the bile ducts
in the porta hepatis causing jaundice.
Jaundice (icterus) - yellowing of the skin and the whites of the eyes caused by
an accumulation of bile pigment (bilirubin) in the blood

Hematogenous spread is predominantly to the liver. It usually follows lymphatic

spread and therefore a patient with only early lymph node involvement has a
better chance of avoiding liver metastases.
Occasionally hepatic involvement occurs without lymphatic spread.
Hematogenous spread to other sites such as lung or bone is uncommon.
By the time of diagnosis as many as 25% of patients with colorectal cancer
already have widespread metastases.

Mode of growth and clinical presentation of large bowel carcinoma depend

to some extent on the site of origin of the lesion.

1. Tumours of the large cecum may rarely cause obstruction and may grow
excessively before they produce symptoms. They usually cause occult bleeding
and typically present with iron deficiency anemia and a palpable mass in the
right iliac fossa.

2. Lesions elsewhere in the colon or rectum ulcerate earlier perhaps due to

intraluminal pressure and stool trauma.
Progressive encirclement of the bowel wall produces an annular stenosis. The
tumour usually presents with a change in bowel habit or as an emergency with
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large bowel obstruction, which may be partial or complete. There is usually

occult blood loss. Blood may be visible in the stool the appearance depending on
how far the lesion is from the anus.

3. Lesions (carcinomas or polyps) in the lower rectum may be perceived as a

mass of feces. This stimulates a persistent defecation response causing the
symptom of tenesmus.

4. A carcinoma anywhere in the colon (but rarely in the rectum) may perforate
and present as an emergency with fecal peritonitis. Occasionally a malignant
fistula occurs into the stomach (colo-gastric fistula), urinary bladder ( colo-
urinary fistula), uterus, vagina( colo-genital fistula) or to the skin ( colo-
cutaneous fistula).

Symptoms and signs of colorectal carcinoma

- cecal tumour - symptomless anemia
- diarrhea
- RIF palpable mass

- descending colon tumour - rectal blood loss

- change in bowel habit
- colicky pain
- perforation- fecal peritonitis

- rectal tumour - rectal bleeding

- tenesmus
- mucus diarrhea

Symptoms and signs due to secondary deposits

- enlarged lymph nodes porta hepatis - obstructive jaundice

- enlarged lymph nodes compressing- ureter – ureterohydronephrosis
-duodenum- high bowel obstruction

Systemic effects
- malaise
- anorexia
- weight loss

The etiology of most colorectal carcinomas is unknown but a small proportion

are secondary to malignant change in polyposis coli and long standing ulcerative
colitis.
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There is a belief that a low fiber diet high fat diet is in some way responsible. It
is well established that this diet results in a much slower transit time and
carcinogens in the stool maintain contact with the bowel mucosa for longer.

Investigations of suspected colorectal carcinoma

General examination may show features which suggest malignant disease;
obvious weight loss, anemia, abdominal distension, supraclavicular nodes,
hepatomegaly or an abdominal mass.
Rectal examination is mandatory as many carcinomas occur in the lowest third
of the large bowel and can be reached with an examining finger ( around 7 cm
from the anal verge).

In addition tumours in the sigmoid colon may be palpable through the rectal
wall.
The degree of fixation of a rectal tumour to surrounding structures can also be
evaluated digitally and this gives some indication of operative difficulty. Finally,
the glove should be inspected for blood and mucus and stool consistency.

Rigid sigmoidoscopy and proctoscopy are performed at the initial consultation;

proctoscopy may show local causes for rectal bleeding.
About 50% of colorectal cancer lie within reach of the rigid sigmoidoscope and
can be biopsied.

A barium enema should be arranged even if a tumour has been identified at

sigmoidoscopy because synchronous tumours or potentially malignant
adenomatous polyps may also be present.

Fiberoptic sigmoidoscopy or colonoscopy may be necessary to obtain a

histological diagnosis of more proximal lesions.

USS or CT scanning of the liver is often performed to seek metastases.

Finally if there is a risk of ureteric involvement by local spread an iv urography
is a useful preoperative investigation.

If there is a suspicion of duodenal compression a barium meal may confirm an

advanced tumour of the right colon into the duodenum.

Many patients, especially the elderly, present as emergencies with complete

large bowel obstruction. This typically takes several days to develop. Plain
abdominal x-rays often show bowel dilated gas above to the level of obstruction
and empty of gas beyond it.
Sigmoidoscopy may confirm the diagnosis of carcinoma; if not an
“instant”barium enema (without bowel preparation) will usually do so.
The cheapest and effective screening test for high-risk patients is occult fecal
blood test. Repeated positive tests represent an indication for colonoscopy.

Management of colorectal carcinoma

For resectable lesions surgical resection is the only curative therapeutic
modality.
Radiotherapy and chemotherapy are indicated as associated treatment. For
resectable rectal cancers, radiotherapy decreases loco-regional recurrence
especially when it is given preoperatively(neo-adjuvant) and or with added
systemic chemotherapy. For colonic cancers, chemotherapy is useful
postoperative treatment. Loco-regional recurrence is a cause of failure after
resection.

Loco-regional recurrence is usually defined as tumour re-growth at the

anastomosis or immediately within operative area. These local recurrences
may develop from either retained microscopic tissue in the lateral margins of
resection or microscopic positive lymph nodes left in the mesorectum.

In the randomised study ( a comparison study in which patients are assigned

randomly or by chance to separate treatment groups) of pre- versus
postoperative radiotherapy, the local recurrence rate was lower among those who
received pre- rather than postoperative radiotherapy but the postoperative
morbidity is higher amongst irradiated patients especially wound infection and
wound dehiscence.
For small tumours localized to the bowel wall, resection offers an excellent
chance of complete cure.

Even in very extensive tumours, palliative resection is usually still worthwhile to

relieve obstruction or prevent continuing blood loss.
Factors that significantly influence the surgical outcome in colorectal cancer are:
the age (young or very old), histological type (coloid type is worse), vascular and
lymphatic invasion, histological grade (poor differentiated is worst) and the
degree of wall invasion (Dukes classification).

Staging
Staging of colorectal cancers largely depends on the findings at laparotomy and
histological examination of the resected specimen. The most widely used system
is based on Duke’s classification.
Dukes’A- tumour confined to the bowel wall with no extension into the
extrarectal or extracolic tissues and no lymph node metastases.

Dukes’B- tumour spread into the extrarectal or extracolic tissues by direct

continuity but without lymph node metastases.
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Dukes’C- lymph node metastases

Dukes’D- distant metastases (liver, lung) or such extensive local or nodal spread
that the lesion is surgically incurable whatever the pathological staging.

Survival rates
Approximately half of all patients with colorectal cancer are incurable at
presentation; all of these die within 5 years. Out of the other half who undergoes
radical surgery with the aim of cure, 50% are alive and well 5 years later.
Very few patients surviving 5 years die later due to recurrent disease.

Operations for colorectal cancer

The principles of colorectal tumour resection are as follows:
- affected segment of bowel is removed with a margin of normal bowel.
A minimum of 5 cm clear each side of the tumour removes local lymphatics
likely to be involved. For rectal tumours, where lymphatic drainage is virtually
in a proximal direction a distal clearance of 1 cm is usually adequate.
This allows the anal sphincter to be preserved in many patients with rectal
cancer.
- lines of resection are determined by the distribution of mesenteric blood
vessels. There must be a good blood supply to the cut ends of bowel to ensure
healing. Many surgeons first perform proximal ligation of the venous drainage to
minimise the risk of tumour embolisation from handling during resection and
also ligation of the bowel lumen above and below the tumour.
This technique is known as “no touch, isolation”.
- wedge-shaped resection of mesentery allows en bloc lesion removal with its
primary field of lymphatic drainage. If there are obvious lymph node metastases,
these are usually included in the resection specimen.
- cut ends of bowel can be rejoined at the same operation without the need for a
colostomy.

The method used depends on the site of the anastomosis and whether there is
much disparity( different lumen size) in diameter between the bowel ends to be
joined.

Standard operations vary with the site of the tumour and each is modified
according to the operative findings.

Right colon tumour - right colectomy with ileocolic anastomosis.

Transverse colon tumour- segmental colectomy with colo-colic anastomosis.

Descending colon tumour- left colectomy with colorectal anastomosis.

Sigmoid colon tumour- sigmoidectomy with colorectal anastomosis
8.

Rectosigmoid tumour- low anterior resection of the rectum with colorectal

anastomosis.

Upper rectal tumour- low anterior resection of the rectum wih colorectal
anastomosis.

Low rectal tumour- abdominoperineal resection of the rectum.

Complicated rectosigmoid tumour (bowel obstruction)- Hartmann’s operation =

rectosigmoidectomy + closure of the rectal stump + end colostomy.

Management of advanced disease and recurrence

The primary tumour is usually resected to relieve local effects even when distant
metastases have been diagnosed. Most of these patients die within 1 year and
only about one in ten survives two or three years, none survives five years.
The commonest site of distant metastases is the liver. Liver metastases can be
discovered at operation (synchronous) or later on ultrasound or CT scanning
(metachronus). If metastases are confined in a lobe, a liver lobectomy associated
with resection of the primary tumour is advisable in fit patients.
Patients with liver metastases seldom become jaundiced since this only occurs
when parenchyma is almost completely destroyed or major bile ducts are
compressed.

Colorectal tumours sometimes metastasize to bones, particularly the lumbar

spine and painful lesions may be palliated by radiotherapy.
In colorectal carcinoma radiochemotherapy are sometimes successfully used.
Radiotherapy is useful for palliative treatment of recurrent pelvic cancer
following removal of the rectum. This is a common problem and causes
intractable perineal pain.

For unresectable right colon tumour the operation of choice to avoid bowel
obstruction is ileotransvere colon anastomosis (by-pass operation).

For unresectable left colon tumour-transverse colon- sigmoidostomy

For unresectable rectosigmoid tumour- sigmoid loop colostomyor end

colostomy.
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Familial polyposis coli

Polyposis coli (adenomatous polyposis) is a rare autosomal dominant disorder
characterized by multiple tubular adenomatous polyps throughout the colon and
rectum. The polyps first develop in adolescence. They are usually asymptomatic
but may present with rectal bleeding or change in bowel habit.
The polyps are initially benign but malignant change almost invariably occurs in
early adulthood often in more than one polyp at the same time.
Patients presenting with this condition should have all their close relatives
screened in adolescence if possible by sigmoidoscopy and barium enema
investigation to detect those affected by polyposis early.
Once familial polyposis coli has been diagnosed the whole colorectal segment
should be removed.
Panproctocolectomy (whole colon, rectum, anus removed)with definitive
ileostomy in the RIF is the standard surgical treatment.

An alternative to ileostomy is the creation of a Park’s pouch-in this operation a

reservoir of ileum is fashioned in the pelvis and connected to the anus. The anal
sphincter mechanism is preserved and thus the patient is usually continent and
can control evacuation.

Complication of large bowel surgery

Infection arising from fecal contamination is the main early complication of
large bowel surgery.
Contamination may result from perforation prior to operation, inadvertent fecal
spillage during the operation or anastomotic leak or breakdown postoperatively.

Three main types of infection occur: wound infection and dehiscence,

intraperitoneal abscess and generilized peritonitis.
Large bowel surgery has been associated with a high risk of complications
(morbidity), particularly in emergency operations but these have been
dramatically reduced by preoperative mechanical bowel cleansing and
prophylactic antibiotics.

Early complications
- wound infections- abscess and cellulitis
- intra-abdominal abscess at site of surgery, pelvic or subphrenic abscess
- anastomotic leak or breakdown with localized abscess or generalized
peritonitis.
- inadvertent damage to other organs such as ureters, bladder, duodenum or
spleen.
- stoma problems- ischemia, retraction, prolapse.

Later complications
- diarrhea- due to short bowel
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- division of pelvic parasympathetic nerves- causes impotence (abdomino-

perineal resection of the rectum)
- small bowel obstruction- due to pelvic peritoneal adhesions or.

Bowel cleansing techniques

The objective is to clear the bowel of all fecal material and to reduce the
bacterial flora. This is achieved by a combination of the following procedures:
- withdrawal of solid foods. The patient is limited to fluids or a low fibre diet for
a few days preoperatively.
- purgation with laxatives: picolax, magnesium sulphate, manitol, fortrans.
- enemas
- bowel “sterilisation” with non-absorbed oral antibacterial agents like neomycin.

Stomas
Indications and general principles
It is often necessary to divert the fecal stream onto the anterior abdominal wall
via a stoma. The effluent is collected in a removable plastic bag attached by
adhesive to the abdominal skin.
Stomas are named according to the part of the bowel opening onto the abdominal
wall: ileostomy or colostomy.
The majority of stomas are performed in cancer surgery although they are
sometimes necessary in inflammatory bowel disease and diverticular disease.
Stomas may be permanent or temporary. Wherever possible, the need for a
stoma should be anticipated before operation and discussed with the patient.
This is done to prepare the patient for what is often perceived as unacceptable.

Permanent stomas
This is necessary when there is no distal bowel segment remaining after
resection or for some reason the bowel cannot be rejoined.
A colostomy is required after abdominal perineal resection of a low rectal or anal
tumour.
An ileostomy is required after excision of the whole colon and rectum
(panproctocolectomy).
The usual indications are inflammatory bowel disease or familial polyposis coli.
Permenant stomas must be carefully sited to facilitate long-term management.
They are usually below the belt line. Permanent colostomies are usually
fashioned in the left iliac fossa and ileostomies in the right iliac fossa.

Temporary stomas
A stoma is often required temporarly to divert the fecal stream away from a more
distal part of the bowel. When the distal bowel problem has resolved the
colostomy is closed.
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Firstly, a colostomy may be created as an emergency measure to relieve

complete distal large bowel obstruction causing distal dilatation. The obstructing
lesion may be removed at the same operation or later as an elective procedure.
Secondly, a stoma may be used to protect a more distal anastomosis which is at
particular risk of leakage or breakdown. Common examples are:
- a technically difficult low anastomosis
- an anastomosis performed after resection of an obstructing lesion (distension
may compromise the blood supply)
- emergency resection involving unprepared bowel or elective surgery where the
bowel has not been adequately cleared of feces.
Thirdly, a temporary colostomy may be used to “rest” a more distal segment of
bowel involved in an inflammatory process such as a pericolic abscess, acute
Crohn’s disease or a colo-vesical or colo-vaginal fistula.

Types of stoma
The way in which a stoma is fashioned depends on its purpose.
Colonic stomas are designed with the bowel mucasa lying flush with the skin.
Small bowel stomas are fashioned with a “spout” of bowel protruding about 5
cm. to ensure that the irritant small bowel contents enter the ileostomy appliance
directly rather than flowing onto the skin.

1. Cecostomy
A connection is established between the skin and the cecum and is held open
with a large balloon catheter. Its sole function is to decompress the bowel of gas;
it is inappropriate for diversion of the fecal stream.
Cecostomy is rarely used because it frequently becomes blocked with feces and
requires regular irrigation to maintain patency.

2. Loop stoma (lateral colostomy)

This type of stoma is designed so that both the proximal and distal segments of
bowel drain onto the skin surface.
This deflects proximal effluent onto the skin and provides a “blow-off” valve for
the distal loop. A loop of bowel (transverse, sigmoid bowel) is brought through
a single skin incision and held above the skin surface by a “bridge” of plastic or
glass rod.
The “bridge” is usually removed after 1 week; this allows overspill of effluent
into the distal loop and re-establishes partial function.

3. End colostomy( terminal colostomy)

This type of stoma is used to divert the fecal stream onto the abdominal wall,
suturind the whole circumference of the colon to the abdominal fascia and skin.
It is a permanent stoma,performed after panproctocolectomy or abdomino-
perineal resection of the rectum.
12.

Complications of ileostomy and colostomy

Early complications
- mucosal sloughing or necrosis of the terminal bowel due to ischemia- requires
reoperation and refashioning of the stoma.
- obstruction of stoma due to edema or fecal impaction-relieved by exploration
with a gloved finger and sometimes softening enemas.
- persistent leakage between skin and appliance causing skin erosion and patient
distress- may require resiting operation.

Late complications
- prolapse of bowel- requires refashioning of stoma
- parastomal hernia- due to abdominal wall weakness- requires resiting of stoma
- retraction- requires reoperation.

Study questions
1. A 56 years old man presents 2 days history of rectal bleeding. He has no
other complaints. On physical examination he is fit and well, nothing
abnormal detected. BP=12/6, PR-80/min.regular. No relevant family
history or past medical history. He is on treatment with xanax for his
anxiety. What do you do with this man ?
2. A 62 years old female presents 5 days history of fever, chills, hypogastric
pain and pneumaturia. She is pale and in obvious pain. She is lost 5 Kg. in
the last month whilst she has had intermittent diarrhea and mild lower
abdominal pain? BP is 10/8 and PR 110/min. How would you manage this
patient?
3. What are the complications of a right colon cancer?
4. What is the best surgical procedure for sigmoid carcinoma with colo-
intestinal fistula formation?