Colon Cancer with Conor Delaney

General Surgery
Dr. Ponsky, professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery and Dr. Colon Delaney, chairman of digestive disease and institute and professor of surgery at Cleveland Clinic Lerner College of Medicine.

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Dr. Ponsky, professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery and Dr. Colon Delaney, chairman of digestive disease and institute and professor of surgery at Cleveland Clinic Lerner College of Medicine. 

01:04:09 Role of Colonoscopy for screening and for serrated polyps
In last five years we have found out that [hyperplastic polyps] are…serrated adenomas. There is good evidence they have genetic predisposition and may tie in with family cancer syndromes. These polyps have a really high risk of cancer. 

04:15:59 Rectal cancers at 6 cm in today’s era
6 cm from anal verge may be the anorectal ring or in a big person close to dentate. You might need to do an inter-sphincteric resection going in at the dentate line and do a hand sewn anastomosis or stapled colo-anal anastomosis to upper anal canal. So 6 cm doesn’t mean 6 cm. Instead consider margins and anastamosis...

08:17:45 Endoscopic ultrasound and preoperative radiation 
Distal staging is best with CT of chest abdomen and pelvis. The majority of local staging has transitioned to MRI. It is good at distinguishing T3 and T4 and circumferential margins. Endoscopic Ultrasound can be used selectively to distinguish T1 and T2 but it doesn’t measure circumferential resection margin, which allows you to determine if standard total mesorectal excision (TME) is best... Most accepted guidelines for neoadjuvant therapy are tumors that are outside of T3, outside of rectum or node positive.

13:05:22 Preoperative radiation in node negative cancer
If node negative and T1 or T2 then you will omit radiation. MRI is 90 to mid 90% accurate at T staging and high 80s to 90% accurate for nodal staging. EUS is only 70% accurate for nodal involvement.

14:08:53 Differences between T1a and T1b

Now people will often use trans-anal endoscopic microsurgery…But there is no level 1 data about better outcomes...For most people that are young and curable people will tend to favor radical resection with trans-anal resection as general rule kept for people not fit for bigger resection or for tumor so close to dentate line.

15:58:44 Endoscopic submucosal resection for rectal cancer
If it’s a rectal cancer it needs to be full thickness excision so you will never do ESD type procedure. You can use trans-anal platform to do that same procedure but if its cancer or high risk of cancer you are going to do full thickness resection trans-anally. 

17:18:09 Preoperative radiation for rectal cancer
Briefly for T3 or node positive disease. Not necessarily always for bulky disease. Consider it for close to anal rectum junction [or] threatened margin. Five times five grade given over 5 days and then you operate one or two weeks later. In US its 6 week forty to forty five grade given with chemotherapy staged over 6 weeks and then 6 to 8 week waiting period. 

18:57:32 Sigmoid cancer
You are looking for at least 5 cm proximal and distal margin… and second looking for at least 12 lymph nodes.…You need a complete mesocolic specimen.  For a mid-sigmoid cancer you can take mid-descending colon down to rectum. 

22:30:40 Approach to Cecal Cancer

Start with mesocolic excision close to SMA… and take the ileocolic close to origin. Lift up laparoscopically from medial to lateral in that same embryological plane between mesocolon and told’s fascia and go laterally, take down hepatic flexure so entire right colon is mobilized and take right colic at origin. If it’s near cecal valve take 10 cm of small bowel. If its mid ascending colon take 5 cm of small bowel...

23:57:48 Laparoscopic anastamosis
I do extracorporeal anastomosis through extraction site with 0.8% leak rate over 1000 cases

24:14:00 Genetic Workup
We are lucky to have Weiss center for hereditary colon cancer. They have biggest FAP and HNPCC database. If you think someone is high risk send them to a genetic specialist at your institution. 

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