duc m. vo, md - peacehealth · pdf filecolorectal cancer pathway pre-op teaching intra-op...
TRANSCRIPT
Duc M. Vo, MD
None
Scenario 1 – colon cancer Preop eval, Treatment
Scenario 2 – rectal cancer Preop eval, Treatment
Colorectal cancer pathway Pre-op teaching Intra-op management Post-op care
35 year old man with a 1 week history of severe abdominal pain. CT scan showed mass in the ascending colon, no liver masses. Colonoscopy confirmed near obstructing adenocarcinoma
H&P Colonoscopy Imaging of chest, abdomen, pelvis Basic labs CEA
If no evidence metastatic disease Surgery
56 year with rectal bleeding. Colonoscopy shows a rectal cancer at 7 cm.
Preop eval H&P Colonoscopy Imaging of chest, abdomen, pelvis Basic labs CEA No evidence metastatic disease
T1, select T2, no evidence of nodal or metastatic disease local excision +/- adjuvant treatment Radical resection
If T3/T4 or evidence of nodal disease neoadjuvant treatment (because high risk of locoregional recurrence)
5 ½ weeks of radiation and chemotherapy 6-8 weeks recovery Low anterior resection vs APR with diverting
ileostomy (3 months after diagnosis) 6 month of adjuvant chemotherapy Ileostomy reversal (9 months after starting
treatment)
Better local control Better vascularized and oxygenated tissue is more
sensitive to radiation Decreased toxicity Downstaging tumor More likely to preserve sphincters
Decrease radiation injury to small intestine Remove irradiated tissue Sterilizing tumor, decrease risk of tumor spillage
Decreased length of stay No difference in mortality or morbidity Increased satisfaction in patients, supportive
staff, and physicians
Components Preop, Intraop, Postop
Managing expectations (preop classes) Early feeding Early ambulation Expected discharge in 2-3 days Multimodality analgesia- not pain free
Preop tylenol and gabapentin
Prepare for marathon Nutritional optimization Carbo loading +/- bowel prep
Meeting with enterostomal therapist
Control surgical stress Minimizing incision Laparoscopic when indicated
Maintain euvolemia Goal directed fluid administration Preventing bowel edema- obstruction/ileus
No postop nasogastric tubes Avoid drains
Ambulating 6 hours postop Clears and crackers 4 hours postop Tylenol, NSAIDS and Neurontin if appropriate Epidural
Narcotics prn Foley removal within 24 hours
good pain control with oral analgesia taking solid food, no intravenous fluids independently mobile or same level as prior to willing to go home
Scenario 1: pT2 N0 (20 lymph nodes negative), home on POD 2
Scenario 2: ypT0 N1 (2 of 10 lymph nodes positive), home on POD 2
Decreased length of stay on average 2 days Mortality: zero Morbidity: same as prior to implementation Satisfaction Patients, nurses, dieticians, ostomal therapists,
surgeons